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Member since Jun-04-08 · Last seen Feb-13-16
Good Day to All! Ma-ayong adlaw sa tanan. And my thanks to for this excellent website. Salamat Opinions:

1. World Chess Championship

The true Chess World Champions are the holders of the Traditional Title that originated with Steinitz & passed on in faithful succession to Lasker, Capablanca, Alekhine, Euwe, Botvinnik, Smyslov, Tal, Petrosian, Spassky, Fischer, Karpov, Kasparov, Kramnik, Anand, and Carlsen. The sacredness of this Title is what makes it so valuable.

And how does one become the true Chess World Champion? In general, by beating the previous Titleholder one on one in a Match! Matches are preferred over Tournaments because of the Tradition of the WC Succession & because the chance for pre-arranging a Tournament result is more likely. The only exceptions to this rule:

A. In case where the Candidates and World Champion participate in an event that all the participants agree to be a World Championship event because of extraordinary circumstances.

Thus, the 1948 World Championship Tournament was justifiable because of the death of the Title holder Alekhine.

Likewise, the 2007 WC Tournament was justifiable under the extraordinary circumstances of the Chessworld trying to heal its internal rift over the 1993 Kasparov Schism. Anand himself became the World Champion in this 2007 Tournament & not in 2000 when he won a knock-out FIDE Tournament. Caveat: Some chess fans deem the 2007 WC Tournament as illegitimate, considering that Anand became the World Champion only in 2008, when he beat the previous Titleholder Kramnik in a WC match. From this perspective Anand only became the Undisputed World Champion in 2008.

Karpov lost his Title to Kasparov in 1985, & never regained it in the 1990s events that FIDE labeled as 'world championships'. All solely FIDE Champions that emerged outside WC Traditional Succession elaborated on above, strong as they were, were not true World Champions (eg., Bogolyubov 1928, Khalifman 1999, Ponomariov 2002, Kasimdzhanov 2004, Topalov 2005).//

B. In case the previous Titleholder defaults an event that the Chessworld largely deems as a World Championship event in the Tradition of the World Championship Succession. Thus, Karpov was the true successor to Fischer who defaulted their WC Match in 1975.

2. The strongest chess events in different eras of chess history?

Because of the brain's limitations explained below, the best professional (amateurs don't matter much in top level chess) chess players of each generation beginning in the Lasker era have always played at a similar level - near the maximum allowed by human standards. Now there are larger cohorts of chess professionals post WW2 than preWW2 thanks to government state funding in the Soviet era and presently corporate funding. The result is that large preWW2 tournaments had numerous 'bunnies', relatively weak players. By the Kasparov era, super-tournaments that featured most of the top ten, and no bunnies, had became more common. However, the top 4 or 5 since Lasker's time have always been very strong.

Consequently the smaller the top-player-only tournament, the stronger it gets. For any era. If there was a double round robin tournament in 1914 featuring Lasker, Capablanca, Alekhine, and Rubinstein, and no other, it would be as strong as any present day super-tournament.

Now weed out everyone except the two strongest players in the world. What we (usually) get is the chess World Championship match.

There has been talk of elite tournaments, composed only of the strongest top masters and no weaker bunnies replacing the World Championship match in prestige, probably because of the assumption that they would be the strongest chess events possible. False assumption. The strongest chess events in chess history generally have been World Championship matches. Even the strongest masters in each generation usually do not match the world champion and challenger in chess strength. In a World Championship match, the contestant has to meet the monster champion or challenger over and over again, with no weaker master in between. Capablanca vs Lasker 1921 was just as strong a chess event as the recent Carlsen vs Anand 2013, and far stronger than Zurich 2014. (Imagine having to play 14 straight games with a computer-like errorless Capablanca at his peak.)

3. The strongest chess players in chess history?

IMO the 1919 version of Capablanca & the 1971 version of Fischer, both of whom played practically error-free chess, are it; updated in opening theory, they should beat anyone in a match.

If computers were self-aware, I have no doubt that they would unanimously choose the 1916 to 1924 Capablanca as the strongest chess player in history. And please no red herring remark that Capa played only 'simple' chess. This young Capablanca played some of the most complicated, sharp, double edged, and bizarre positions possible; and played them without making a single losing error (and by all accounts with unsurpassed quickness), something that has always befuddled my mind when I got to peruse through his games.

We have to take this question in the context of the limits of the human Anatomy and Physiology. A concrete example would be the one hundred meter dash. The human body is designed such that the limit it can run is about 9 seconds. In order for a human being to run faster, we would have to redesign the human anatomy into that of say a cheetah. One can rev up the human Anatomy and Physiology, say with steroids, but this regimen would hit an eventual Stonewall too; the same way that we could rev up human proficiency to learn openings with computer assistance.

Since the Nervous System has physiological limits (example of a limit- neuronal action potential speed don't go up much more than 100 m/s) and so limits the human chess playing ability, increasing the number human chess players, thus expanding the normal curve of players, simply creates more possibilities of players playing like a Fischer in his prime, but will not create a mental superman who plays chess at computer levels. This explains why human and computer analysis indicate that Lasker was playing on a qualitatively similar level as more recent WCs.

'Worse' in chess, any computer assistance ends once the opening is over. After a computer-assisted opening prep, every GM today has to play the game the way Lasker did a hundred years ago, relying on himself alone, with the same fundamental chess rules and chess clock. An Encyclopedic opening repertoire is not a necessity to be a top player. In fact, there are World Champions who did not do deep opening prep; they just played quiet but sound openings that got them into playable middlegames and then beat their opponents in the midlegame or endgame. Just look at Capablanca, Spassky, Karpov, and now Carlsen.

Because of subconscious adherence to the narcissistic generation syndrome, the belief that everything that is the best can only exist in the here and now, many kibitzers would not agree to the above theses. While it is true that there have been more active chess professionals and consequently larger cohorts of top chess masters on a yearly basis since WW2 thanks to Soviet state funding and present corporate funding, the very top chess masters since Lasker's time have always played at a similar level- within the limits imposed by the human brain. There is no physical law that bars a pre-WW2 chess master from playing chess as well as today's generation. The human brain has not changed in any fundamental manner in the past tens of thousands of years.

4. The greatest chess players in history?

A related question is who is the greatest chess player in history. The answer depends on the criteria one uses. Since I place great emphasis on the ability to play world class chess for the longest period of time, Lasker would be it. He was playing at peak form from 1890 age 22 (when he began a remarkable run of match victories over Bird, Mieses, Blackburne, Showalter, and culminating in his two massacres of Steinitz) until 1925 at age 57 (when he nearly won Moscow after winning new York 1924). Kasparov (high plateau from 1980 to 2005) and Karpov (high plateau from 1972 to 1996) would follow. (At their very peak though, I believe that Kasparov was stronger than Karpov, and both were stronger than Lasker; and the peak Capablanca and Fischer were stronger than any of them.)

5. Computers vs Humans, who is stronger?

Another related question is how history's top masters would fare against computers. It's obvious from Kasparov's time that computers would totally crush them all. Opening knowledge would not matter much. Computers swamp human opponents in the middle game, simply by calculating more variations more rapidly by several orders of magnitude. Peak Capablanca probably would have the best score among humans. Talk about another level of playing is fans' subjective and IMO wrong words for their favorite players, unless one talks about chess computers. Chess computers do play at a higher level.

6. On the game and chess players young and old, past and present:

The proposition that an older player would not be able to adjust to the openings and methods of a younger generation is false, as evidenced by the observation of strong masters whose careers happened to span generations beating the tar out of weaker masters of the next generations. Lasker provides a classic example; he was beating Mieses, Blackburne, and Steinitz in the 1890s, and crushing masters versed in the hyper-modern teaching of controlling the center indirectly- Reti, Bogolyubov, and Euwe in the 1920s. In more recent times, we have Victor the Terrible, who learned most of his chess in the 1940s and 1950s, whom we have seen competing successfully with the so-called computer generation even at an advanced age.

This 'inter generational knowledge/theory leveling phenomenon' holds true today and will probably still hold true two decades from now. As of the end of 2015, Kramnik, Anand and Topalov, and a couple of years ago Gelfand are living smoking gun proofs that the speculation that the older generation cannot adopt to newer openings is false. Older players have always adapted and will always adapt to the latest openings in the vogue. The present day young players will do the same 20 years from now, faced with a future generation of rising chess players.

The notion that computers are more advantageous to younger players IMO is not quite right. Younger players should have more energy and stamina in studying chess openings and endgames for long hours everyday compared to older players without computers, but the use of computers would tend to make the learning process easier for every one including the older ones.

As a corollary, computers also make it easier today for very young players in their early teens to peak at a younger age than in past eras, although they tend to level off in their early 20s to their high plateau, defined by their inborn talents and determination.

In brief. computers tend to level chess learning for everyone, young and old.

This is not a rigid rule. The best games I have ever seen played by a 12-13 year old are Capablanca's; and Tal, Karpov, and Kasparov reached their high plateau in their early 20s in a computer-less era, similar to computer age Carlsen. However let it be noted that Carlsen reached his peak sidestepping intensive computer-prepped tactical openings and beating his competitors in the old fashioned way in the middlegame and endgame. These masters peaked early not because of computers by because of their immense chess talent. Perhaps normal rules do not apply to these geniuses.

Another false notion is that the nature of the middlegame today is somehow different from the middlegame in the past. The easiest way to prove the wrongness of this proposition is by observing CG's daily puzzles. Do not peek at the names of the players that played these puzzles, and don't look at the dates. Can you glean from the middlegame play and combinations in the puzzles the date they were played? You can't. You would not know if it was played in 2016, 2000, 1950, or 1900. Chess combinations don't just suddenly change their stripes just because a hundred years have passed.

Another observation is that when the best masters of the past, Lasker, Capablanca, and Alekhine met the occasional 'modern' structures of the Sicilian Scheveningen and Dragon, KID, Modern Benoni, Benko Gambit, they played strategically perfectly, in just the way these opening structures should be played. So how did these masters play openings and the resulting middlegame structures that are deemed incomprehensible to them by some of today's dogmatically 'modern' kibitzers? The answer is that chess rules and principles have not changed. Center, rapid development, open files and diagonals, holes, weak pawns, piece activity, initiative and attack, positional sacrifices and all types of combinations were as familiar to them as to us.

Note that it is the frequencies of a few middlegame pawn structures that have changed since WW2. Not the Ruy Lopez or QGD, but obviously Sicilians and KIDs are much more common post-WW2. Since so many games nowadays begin with the Sicilian and KID, people associate these with being 'modern' (which is a rather vague undefined term IMO). But certainly Lasker and Capablanca understood the middlegame principles behind them and when they did get these positions they played them excellently, like the top masters they are.

Moreover, Keres is another smoking gun, bomb proof evidence of the fallacy of Watson's speculation that 'the best players of old were weaker and more dogmatic than the best players today', and Larsen's assertion that he would crush everyone in the 1920s. The glaring fact is that Keres is a pre-WW2 master who began his career in the late 1920s, and played competitively up to the 1970s, and he did learn (and contributed) to the newer opening variations (the most famous of which is the Keres attack which he invented in 1943). The ideal way for Watson and Larsen to prove their statements is to beat a top pre WW2 master such as Keres. They failed. Tellingly enough an aging Keres beat both a rising Watson and a peak Larsen when they happened play each other.

7. On ratings:

Elo ratings reflect relative and not absolute chess strength.

Chessplayers are naturally arranged in populations partitioned by geopolitical regions & time periods that have infrequent contacts with one another. Within such a population, players get to play each other more frequently, thus forming a quasi-equilibrium group wherein individual ratings would tend to equilibrate quickly; but not with outside groups. With caveats & in the proper context, FIDE/Elo ratings are simply fallible descriptors & predictors of an active player's near-past & near-future performances against other rated players, & only within the same quasi-equilibrium group.

As corollaries: the best way to evaluate a player's strength is to analyze his games & not his ratings; one cannot use ratings to accurately compare the quality of play of players from the past and present, or even the same player say a decade ago and today; & care should be taken in the use of ratings as a criterion in choosing which players to seed into the upper levels of the WC cycle. All the above often entail comparisons between players from different quasi-equilibrium groups separated by space and/or time.

Regarding inflation deniers, they imply that Elo ratings reflect absolute and not relative chess strength. Professor Elo himself would condemn their view. If the top 20 players were to suffer a serious brain injury and begin playing like patzers, but play no one else for the next decade, they would more or less retain their 2700s ratings, although they would be playing terrible patzerish chess.

8. Best Qualifiers?

The credible, fair, tried & tested Zonals - Interzonals - Candidates (with known strong players directly seeded into the Interzonals & Candidates; & here ratings may be used with caveats) over the random World Cup and the elitist Grand Prix. If possible long Candidate matches and 16 to 24 game World Championship matches. However, with the passing of the state-funded chess era of Soviet times, I begin to doubt if the strict money guzzling qualification process above can be re-installed.

9. The 1993 Chess Rift and Kramnik:

Regarding the Rift in the chessworld after Kasparov split in 1993, I believe that Kramnik has done more than any other individual in helping heal it by concrete actions - agreeing to a WC Match with Topalov in 2006 & not walking out when he could have done so with the support of most of the world's top GMs after getting accused of cheating; & agreeing to Defend his Title in a WC Tournament in 2007, the first time a living Titleholder has agreed to do so in chess history. My eternal gratitude to him.

10. Finances of a would-be Challenger:

Regarding all kinds of problems chessplayers outside of Europe & the USA face in their quest for the Title, Capablanca & Anand have proven it's possible for a non-European non-USA chessplayer to be World Champion; but apparently only if you have the chess talent of a Capablanca or Anand! For others, I guess they would have to try to get monetary support & good seconds somewhere to have some hope for a Title shot.

11. Ducking a World Championship re-match:

Alekhine vs. Capablanca - Not definitively resolved. If pushed, I would tend to favor Capablanca given that pre-WW 2, there was no definitive cycle to choose the Challenger &, after all is said and done, it was the Champion who set the conditions & who chose his Challenger. AAA could & should have chosen Capa; & there was ample time, more than a decade, to do so before WW2. On the other hand, Capa's pride may have caused him to behave arrogantly & thus offend AAA. The issue is very much debatable. //

Kramnik vs. Kasparov - For me, it's resolved. Kudos to Kramnik for trying his best to install a decent Qualifying Event. Kasparov for his reasons clearly did not want to go through the Qualifying Event that he himself had pledged before losing his Title; & did not even seem serious in playing the solely FIDE champions. Why? I can only speculate that Kasparov would rather retire than risk a loss in a Qualifier or a match to either a FIDE champion or to Kramnik. If he regained his Title, he would be the greatest Champion in history, but there was risk involved. If he retired, he would still be the greatest Champion in history, but there would be no risk involved. Kasparov chose the latter & no one should blame him for that decision; & more so don't blame Kramnik!

12. Predictions for Hypothetical World Championship Matches:

Lasker vs. Pillsbury, Rubinstein, Maroczy - Lasker wins 2, loses 1 match //

Lasker vs. Capablanca (inexperienced) 1914 - Lasker close win //

Capablanca (not overconfident & not having TIAs) 1929 to 1937 vs. Alekhine or any other master - Capa win //

Alekhine (sober & prepared) vs. Capablanca (w/ severe HPN & numerous past strokes), Botvinnik, Keres, Fine, Reshevsky, Flohr 1939 - Alekhine win //

Alekhine (alcoholic, ill, & depressed) vs. Botvinnik 1946 - Botvinnik win //

Fischer (inactive for 3 years) vs. Karpov 1975 - Karpov win//

Kasparov vs. Shirov 2000 - Kasparov win. (But GKK should still have given it to Shirov. And don't blame Kramnik. Had Kramnik declined, GKK would have chosen another; & Shirov would still be frustrated.)


I have opened a <'multi-experimental' forum> below. Its nature is that of several secret social and psychological experiments, whose objectives and parameters, and the rules that follow, are strictly defined and which I may or may not reveal. Readers of this forum might be able to deduce some of these rules. Accordingly messages shall be retained or removed with or without explanation, even those from my dear friends here in CG, although I am making it clear here that absolutely no offense is intended to any one in this experiment. I may or may not respond to certain questions and messages, also according to the rules. To my friends: Please bear with me in this matter. There can be a certain amount of disinformation and propaganda in the messages that are retained.

The title of this <'multi-experimental' forum> is:

Biased Journal of a Fourth World Brain Operator

Some abbreviations

CiH = the public City Hospital

PrvH = Private Hospital. There are three main ones. So PrvH 1, PrvH 2, PrvH 3.

ProvH = the public Provincial Hospital

SOL = Space Occupying Lesion

SQ = Subcutaneous tissue layer of the skin or scalp

CVA = Cerebrovascular accident = stroke

EDH = Epidural Hematoma, blood above the dura mater, the outer covering of the brain, and beneath the skull.

SDH = Subdural Hematoma, blood beneath the dura mater.

ASDH = Acute Subdural Hematoma, SDH incurred recently, usually less than a week

CSDH = Chronic Subdural Hematoma, SDH that is more than two weeks old

HCP = Hydrocephalus, too much CSF in the brain's ventricular system

CSF = Cerebrospinal Fluid

CNS = Central Nervous System

CAB = Continuous ambubagging

ETT = Endotracheal tube (for airway purposes)

NGT = Nasogastric tube (for feeding purposes)

NOD = Nurse on duty

The Oracle = personification of the CT (computed tomography) scan.

Magic mirror = the computer monitor where one can see CT scan images.

Witching Hour Admissions or Referrals = 12 midnight to 5am

MF = Motorcycle Fall

Craniectomy = neurosurgical procedure that involves removing a portion of the skull

Tracheostomy = a surgical procedure to create an opening through the neck into the trachea (windpipe)

INTUBATE: To put a tube in, commonly used to refer to the insertion of a breathing tube into the trachea for mechanical ventilation

EXTUBATION: the removal of a tube especially from the larynx after intubationócalled also detubation.

EBRTL: Equally briskly reactive to light.

SRTL: Slowly or sluggishly reactive to light.

NRTL: Non reactive to light.

NSS: Normal Saline Solution

Uneventful day = Most likely still a busy day, making daily rounds in the hospitals, following up post-op patients, seeing patients in the OPD, answering referrals, admitting all kinds of patients in the hospitals; nevertheless a day in which nothing interesting has caught my attention.

>> Click here to see visayanbraindoctor's game collections. Full Member

   visayanbraindoctor has kibitzed 7877 times to chessgames   [more...]
   Feb-13-16 twinlark chessforum
visayanbraindoctor: The success of YPG based in the isolated Kurdish enclave of Afrin in North West Syria is quite puzzling. They have been consistently winning battles against Islamist proxy forces of Turkey, in just the area where these forces are strongest and their logistical supply ...
   Feb-12-16 J A Blanco vs Capablanca, 1901
visayanbraindoctor: A super GM endgame. Played by a 12 year old! Capablanca demonstrates how to handle the N side in a N vs R game. He exploits the holes in his opponents' position where his Knight can't be dislodged by his opponent's Rook. In such positions, the chess principle <There ...
   Feb-12-16 Alexander Alekhine
visayanbraindoctor: <Fischer improved his rook endings specifically by <studying to acquire knowledge of them>, just as any top player today needs to study to acquire whatever knowledge is important for competetiveness today.> I agree. In the context of Watson's pronouncements,
   Feb-12-16 Jose Raul Capablanca (replies)
visayanbraindoctor: <TheFocus> Thank you for all the info that you write in players' pages. It seems that there were a lot of quick game tournaments in the old days. Most of them are probably not well recorded at all. The young Capablanca must also have played a lot of these quick ...
   Feb-12-16 visayanbraindoctor chessforum
visayanbraindoctor: 12 February 2016. 48M was referred to me yesterday in PrH2 ICU, comatose at GCS 8. CT scan showed a huge right frontal hemorrhage that looks like an AVM (worm-like hyperdense structures). Most AVMs occur before 40, so I also had to consider an anterior cerebral artery ...
   Feb-12-16 Jonathan Sarfati chessforum
visayanbraindoctor: I just did an AVM operation. You could read it up in my forum.
   Feb-06-16 Ivan Bukavshin
visayanbraindoctor: <Jonathan Sarfati: Why would a 20ya GM die of a stroke? Ivan Bukavshin> Probably an arterio-venous malformation. My condolences.
   Feb-05-16 Alekhine vs A Rabinovich, 1918
visayanbraindoctor: <Lidador: I love this game... Specially the move 13.Bb2!! atacking the queen..> Alekhine's imaginative powers in full swing. He lures Rabinovich into making not a Pawn grab but a Bishop grab! The sac deflects Black's Queen away from the defense of the Kingside, ...
   Feb-03-16 Vladimir Kramnik (replies)
visayanbraindoctor: <devere> Prognosis is good for some diseases in the sense that patients don't die of it, nor are they disabled to the point of being bedridden. However, a patient gets these little aches and a feeling of discomfort that would affect him if he were to engage in ...
   Feb-01-16 Capablanca - Alekhine World Championship Match (1927) (replies)
visayanbraindoctor: <Jonathan Sarfati: <TheFocus>, as indicated. If Capa had won the clearly winning position in Game 27 as well as the actual win in #29, he would have been tied at 4-4. Likewise, Capa at his best would surely have won #31, which also would have tied the match.> ...
(replies) indicates a reply to the comment.

Kibitzer's Corner
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Premium Chessgames Member
  visayanbraindoctor: 25 January 2016.

I was attending a small closed meeting of language translators with City Government officials. The translators want to preserve the local dying indigenous language in my area. One of the speakers got her Ph.D by making a grammar book meant to teach one of the dying Philippine languages. I was quite pleased at this info; there are many Ph.D's who study a dying language but don't do a thing to preserve it. I was invited since I have made grammar books also meant to teach non Tagalog Philippine languages. This was deeply appreciated by the speakers. In the middle of the meeting, my cell phone began to ring rather loudly and obviously in the small meting room. I offed it and texted- Tex ra! (Text only). My CP just kept on ringing. The MS in Anthropology and Ph.D in Linguistics speakers, two Reverends from local churches who were members of our city's native dying ethno-linguistic people, and the Mayor of our city, who was sitting right next to my left, pretended they were not being disturbed. After the fourth ring, I had to excuse myself out of the meeting,

I rushed to PrH2 ER. there was a kid, 11M comatose at GCS 6, who had been run over by a private vehicle, already being CT scanned. Just a small 5cc right temporal EDH. The ROD had already intubated him. He was in severe respiratory distress and upon each cough was spurting out fresh red blood out of his endotracheal tube. Without a more secure airway 11M could go into CP arrest anytime from a clogged ETT. I don't hesitate in these cases.

(Emergency Tracheostomy 1/25/16 9 am to 9:20 am. No BT. Under LA in the ER.)

In my local setting, I am the number one practitioner of tracheostomies. I do them anywhere- OR, ER, bedside, as long as there is a source of bright light (even a large flashlight), and the materials. I estimate it takes less than 30 seconds for a blocked airway to cause a Neuro patient's brain to begin swelling. A patient who can't breathe for 3 minutes becomes brain dead.

Afterward, an ER nurse tried to resume ambubagging. I stopped him since I thought 11M may have had a tension pneumothorax. Positive pressure makes it worse. I referred 11M to a General Surgeon. He did a right chest thoracostomy, relieving the hemopneumothorax.

I went back to the meeting. The GS to whom I referred to who did the thoracostomy is a member of a small also dying minority people from the adjacent southern province, and I called him on my CP to see if he had finished the procedure. I wanted to invite him over to the meeting as he had previously helped me translate Department of Education materials into his native language. Unfortunately the meeting was about to end by the time I arrived, so I told him sorry never mind the meeting has just finished.

Premium Chessgames Member
  visayanbraindoctor: 26 January 2015.

Entry 1.

I returned the skull bone of 62M, whom I had previously operated on 23 November 2014 for bifrontal hygromas after he was hit by a motorcycle while walking.

(Replacement of bones bi frontal 1/26/16 9:12 am to 9:57 am.)

I encountered an unusual problem. I had removed two bones, one from each of 62M's frontal areas, I found out that they had fused while being stord in his left abdominal subcutaneous layer. They had been there for more than a year.

I had to get a chisel and mallet and cleaved the fused bones into their two original parts. Unfortunately one of the bones had 'stolen' a piece of the other bone. Subsequently, when I returned the bones to 62M's skull, the left frontal area bulged slightly more than the left. It's only quite a small bulge so I don't think it will be noticeable.

Entry 2.

<13 January 2016.

Entry 1.

19M drove his motorcycle into a parked truck 3 days ago in a neighboring province. Comatose, he was referred next day to me. I intubated him in PrH2 ER and transferred him to the public CiH because of lack of family finances. He exhibited the rare Kernohan's sign. He had an acute subdural hematoma on his right hemisphere, yet his left pupil was more dilated than his right (3mm and 2.5mm respectively).

His family could not buy the necessary OR needs right away and I managed to operate on him only after 2 more days. Pre-op his right pupil had dilated to 5mm while his left was at 3mm. This indicates that the right uncus had herniated into the tentorial notch.

(Right fronto-parietal craniectomy, evacuation of acute subdural hematoma, bone transplant to left hemi-abdomen SQ layer. 1/13/16 2:32 pm to 3:22 pm. No BT.)

Post-op, no change in pupillary size. Bad prognosis. He is not expected to survive.>

17M only went into CP arrest today after being brain dead, hypotensive, and on Dopamine, and inotropic that forces the heart to keep on beating, even if the patient is brain dead. His heart had kept on beating for 13 days!

Entry 3.

<19 December 2015.

Entry 2.

Another hemorrhagic stroke! 59F is another bad case. Comatose with a huge right to mid cerebellar bleed that had ruptured into the 4th ventricle thus also causing hydrocephalus.

Operation 1: (Tube ventriculostomy right frontal. 12/19/15 9:28 to 9:58 pm. No BT.)

I did this operation while the patient is supine. I usually do an initial tube ventriculostomy in order to release CSF and decompress, or else placing the patient in prone position risks a sudden lowering of the BP in these posterior fossa cases. The medulla is in the posterior fossa. It's the control center for our body's BP, and even slightly compressing it more while turning the patient around causes a drop in BP.

For the next operation, done in the same OR setting and GA, I turn the patient over to a prone position.

(Bi-suboccipital craniectomy, cortisectomy right cerebellum, evacuation of right to mid cerebellar hemorrhage. 12/19/15 10:30 pm to 11:29 pm. No BT.)

I did these operations quickly because I feared she would herniate anytime. Post-op she remained comatose at GCS 6. Poor prognosis.>

Surprise! 59F made it. She can now communicate by signs. She still has a tracheostomy tube on her throat and so can't speak, but I am discharging her. I will remove the trach tube after a month, when her gag reflex has improved.

Premium Chessgames Member
  visayanbraindoctor: <Jonathan Sarfati: Normal saline solution = 1 mol/l NaCl? I thought there could be danger of sympathetic ophthalmitis if a damaged eye were left in too long.>

My incision is separate and away from the eyes. I never touch the eyes myself if there is no Ophthalmologist around in the OR. Sometimes the alcohol, Betadine, and NSS that I use to prep the head of my patients get into the eyes and irritate them (you can see the sclerae area vessels turn red). However, this has never happened to my patients in years, ever since I began to always place a thick paste of antibiotic ophthalmic ointment on both eyes before prepping. I even apply the ointment on the external auditory meatuses thus plugging them, so that Betadine and other prepping liquids do not enter into the ear canal. The traditional way to protect the eyes is to close them with a piece of atraumatic tape, and the ears by plugging them with cotton. These methods sometimes still fail. So I experimented and have switched to the above more effective method.

Premium Chessgames Member
  visayanbraindoctor: I misunderstood you. I think you were asking about sympathetic blindness.

Yes, and that's why the damaged eye is routinely removed. However, I can't speak for the Ophthalmologist to whom I referred to. I think she eventually will do it, but on her own time. (Things such as PF and materials have to be settled in elective surgeries.)

Jan-27-16  GreenLantern: <27M is brain dead.>

Did the unfortunate young man's cancer metastasize? Did he have no other medical options?

Premium Chessgames Member
  visayanbraindoctor: <GreenLantern: <27M is brain dead.>

Did the unfortunate young man's cancer metastasize? Did he have no other medical options?>

I really don't know. A whole body CT scan might prove useful, but what's the purpose in a brain dead patient from an impoverished family; it's just additional costs for them.

Amputation maybe.

Premium Chessgames Member
  visayanbraindoctor: 28 January 2016.

<15 January 2016.

57M, motorcycle fall, driver, hit another motorcycle, 5 days ago in a neighboring province. He was later referred to me, stuporous on admission at GCS 9.

(Right fronto parietal craniectomy, evacuation of subdural hygroma, bone transplant to left hemi-abdomen SQ layer. 1/15/16 9:56 am to 10:53 am. No BT.)>

57M woke up after a week and was communicative, but then developed pneumonia, which seems to be more of a tendency in chronic alcoholics. I referred to the internists. Antibiotics and nebulization were given, but the pneumonia grew worse since 57M had difficulty in expectorating. While on noon rounds, I noted tachypnea with RR of at least 30 per minute. I thought of intubating him, but he was fully awake and would struggle, Best to do it in the OR under GA and I then would proceed with a tracheostomy.

I contacted my Anesthesiologist and we agreed to schedule 57M at 3pm, giving his family time to buy the tracheostomy tube and OR needs. I left CiH at around 1pm in order to get my scrub suit. When I came back at 2:30pm I found out that 57M had died. The nurses told me that shortly after I left, he suddenly just stopped breathing.

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  visayanbraindoctor: 2 February 2016.

A group of young men ganged up on 66M. During the fight, he stabbed and killed one of them, but he got hacked on the head.

(Right temporo-parietal craniectomy (outer table only). 2/2/16 10:04 am to 10:18 am. No BT.)

The hacked wound did not penetrate into the brain. I removed the damaged outer table of the skull bone, and washed with a litter of NSS + Betadine.

There are always policemen around near him because he is a murder suspect. The police wanted me to sign a waiver so 66M could appear in court. I told them not now, but only after he is discharged.

Feb-03-16  SugarDom: Varsity young chess player died because of 2 day delay. RIP.
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  Jonathan Sarfati: Why is 66M a murder suspect? Looks like an open-and-shut case of self-defence to me.
Premium Chessgames Member
  perfidious: Seems that way to me as well, but the laws here vary greatly from one state to another; moreover, in my opinion, the idea that one may, while under potentially deadly threat, be fully capable of gauging such situations seems nebulous indeed.
Feb-03-16  SugarDom: No Jonathan, 66m was already a murder suspect before the incident.
Premium Chessgames Member
  visayanbraindoctor: Regarding the case above, I just write what the patient and the patient's family says. The truth in such cases is investigated by the police and prosecutors. So I really don't know what happened. I should have placed <as alleged by the patient and his relatives>.

The only definitive thing I can say is that the laceration was caused by a machete-like instrument, and that the hack came in from right to left in front of the patient. The evidence? It was a large laceration of about 20cm, and the scalp on the lateral right side was avulsed. So if whoever hacked him was standing in front of him, he probably was right handed and delivered the blow from right to left. Alternatively, if the blow came from the back, it came from left to right, and the assailant was probably left handed.

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  visayanbraindoctor: <Jonathan Sarfati: I suppose that poor little 7yo girl will need her right eye removed> I forgot to tell you. The child eventually became cooperative, and to my surprise, she could still see from her right eye!

It's often difficult to assess vision and hearing in children, especially after they have suffered from severe trauma, because they simply refuse to speak to me. Sometimes they get into tantrums and do such uncomfortable things as lashing out with arms and feet. Even removing sutures can prove to be difficult. That's why I use absorbable Vicryl or Dexon for skin closure. If the child keeps on pulling her head back if I attempt to remove sutures with small scissors, I could just end up cutting the skin and wounding the child. In such cases, I just instruct the parents to clean the site daily with cheap alcohol, and the subdermal part of the sutures get absorbed after about 2 months and the exposed parts then drop off.

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  Jonathan Sarfati: Good news about that little girl!
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  Jonathan Sarfati: Why would a 20ya GM die of a stroke?

Ivan Bukavshin

Premium Chessgames Member
  visayanbraindoctor: <Jonathan Sarfati: Why would a 20ya GM die of a stroke?

Ivan Bukavshin>

Probably an arterio venous malformation.

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  Jonathan Sarfati: Oh dear, so he was basically born with this ticking time bomb in his brain, but the ticks were undetectable unless there had been a reason to perform CT or MRI?
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  visayanbraindoctor: <Jonathan Sarfati: Oh dear, so he was basically born with this ticking time bomb in his brain, but the ticks were undetectable unless there had been a reason to perform CT or MRI?>

I do not know exactly what disease GM Bukavsin suffered from. Based on what I have read from his page, He had a stroke. A stroke below age 40 is regarded as 'stroke in the young', and the most common lethal one is an arterio-venous malformation.

Unfortunately you are right. It's a congenital ticking time bomb in an apparently healthy person. A CT scan usually shows mass of whitish worm-like structures inside the brain.

I see them sporadically and have operated on perhaps a dozen or so (can't recall the exact number anymore). When you open up the brain, you see large abnormal vessels that spurt out blood if you cut them. The book recommends clipping them, and I did so when I was a resident. In my place, there are no clips, but I have found out that cauterizing the feeder vessels carefully with bipolar suffices to control the bleeding. The hard part is to visually expose these vessels properly. If you cut them while they are still buried deep in brain tissue, you will have blood spurting out and painting your field an opaque red. You realize to your horror that you don't know exactly where the bleeding is coming from, and that you can't cauterize what you do not accurately see. You just have to suction the blood as fast as you can and brain tissue as well in order to visually expose the buried vessels, before your patient dies on you of exsanguination. What I do is to suction a bit of brain around the undisturbed vessels in order to visually expose them properly and make sure I don't cut them by accident or carelessness.

As a rule, the patient is young, more males than females, and leading a normal life, often quite active as most young people are. Then they get intolerable headaches, and lose consciousness. In the worst cases, they just drop down unconscious without any warning sign.

If GM Bukavshin, had an AVM, then he could have been one of those who never even made it to the hospital in time for an operation.

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  visayanbraindoctor: 4 February 2016.

One of those cases that makes me (temporarily) think of quitting my job.

Young 13M has a one month history of progressive headache and drowsiness. When I first saw him 5 days ago he was stuporous at GCS 9. CT scan showed a deeply located medial to left frontal brain tumor that also impinges on the ventricle, thus causing hydrocephalus. I placed him on Mannitol and Dexamethasone (a steroid that lessens the vasogenic brain edema caused by tumors). He woke up in a couple of days (GCS 15). I then transferred him to the public CiH for financial reasons.

(Bi fronto-parietal craniectomy, right frontal tube ventriculostomy and CSF drainage, bone transplant to left hemi-abdomen SQ layer. 2/4/16 10:54 am to 1 pm. BT 2 units FWB.)

Since I had decided to remove parts of both fronto parietal bones for decompression. I knew I had to cross the midline where the sagittal sinus is located. This is the major drainage vein for the cerebral hemispheres and is located on the midline just beneath the bone, running antero posteriorly where it joins the torcula of Herophili. Any operation that removes bone on the midline always carries the risk of heavy bleeding from the sagittal sinus and the adjacent venous lakes.

Thus pre-op, I had two units of fresh whole blood properly typed and cross matched prepared and standing by in the hospital blood bank.

My Anesthesiologist requested for the blood to be brought shortly after I began cutting. The OR nurse called up the ward nurse two times. By the time I lifted the bone from the sagittal sinus, there was still no blood. Profuse bleeding had already begun.

Then my Anesthesiologist announced: "The O2 sat is dropping."

Another call to the ward nurses: "Hurry up with the blood."

Still no blood.

Anesthesiologist: "Pulse oximeter says there is no 02 sat."

Then: "I can't detect any BP anymore."

I quickly placed absorbable hemostatic gel sponge and OS on top of the sagittal sinus and temporarily closed the scalp with towel clips in order to tamponade the bleeding.

In the panicky haze that ensued, the OR nurses kept calling the ward nurses to deliver the blood. My Anesthesiologist gave several ampules of epinephrine just to keep the heart beating. I had 500cc of Voluven (a synthetic colloid used in plasma volume replacement) fast dripped into the patient. One of the ward nurses finally went to the hospital blood bank to get one unit. I had it transfused ASAP. I went out and called in the ward nurses - Why were they sitting on the order to bring in blood? Another one went to get the second unit. When I went back inside the OR, CPR was being done on the patient.

I thought- It's over. An unnecessary table death. Just because the prepared blood already sitting in the hospital blood bank could not be brought up to the OR in time.

I went out into the OR corridor again and asked the assembled ward nurses: Who was receiving the calls from the OR and why were they sitting on the order. No clear answer. I went back to the OR.

To my relief, the Anesthesiologist tells me that O2 sat was back to 70 and climbing, and the pulse was strong. After a few more minutes, he announces that BP was back at 100.

I waited for the first unit of FWB BT to be done. Then I removed the towel clips and reopened the scalp. The sponge had soaked up with coagulated blood and was sticking on the sagittal sinus, thus stopping the bleeding. I proceeded with a tube ventriculostomy, and then closed up. The second unit of FWB arrived and my Anesthesiologist immediately began transfusing it.

13M much to the relief of every one woke up post op. I told the family I might do a ventriculo peritoneal shunting procedure after a week, but that the tumor operation will have to wait for three more months in order to allow their child to recover.

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  visayanbraindoctor: 7 February 2016.

51F, on a PUV hit by a 10 wheeler truck, stuporous on admission at GCS 12.

(Right temporo-fronto-parietal craniectomy, evacuation of acute subdural hematoma, bone transplant to left hemi-abdomen SQ layer. 2/7/16 12:15 pm to 1:20 pm. No BT.)

Post-op, woke up.

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  WannaBe: Why can't the procedure begin, after the (back up) blood was in th OR.

Because of temperature?

Premium Chessgames Member
  visayanbraindoctor: <WannaBe: Why can't the procedure begin, after the (back up) blood was in th OR.

Because of temperature?> No that's not a problem.

But I should have done what you say. I was relying too much on the ward nurses to bring up the blood after I started cutting.

The usual protocol in my hospitals is that the blood stays in the blood bank and is brought up only after cutting commences. Sometimes, after the patient is already in the OR the operation does not proceed. (For example, the Anesthesiologist may notice that an elective patient has rales and has lots of tracheal secretions. The surgeon may opt to postpone the operation until the patient recovers from pneumonia. No use for blood if this happens.)

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  visayanbraindoctor: 8 February 2016.

Entry 1.

I returned the skull bone of 33M, whom I had previously operated on 9/22/15 for an ASDH following a motorcycle fall.

(Replacement of bone left occipito-parieto, 2/8/16 11:11 am to 11:27 am.)

Entry 2.

I returned the skull bone of 36M, whom I had previously operated on 6/21/15 for an ASDH following a motorcycle fall.

(Replacement of bone left occipito-parieto, 2/8/16 12:07 pm to 12:44 pm.)

Premium Chessgames Member
  visayanbraindoctor: 12 February 2016.

48M was referred to me yesterday in PrH2 ICU, comatose at GCS 8. CT scan showed a huge right frontal hemorrhage that looks like an AVM (worm-like hyperdense structures). Most AVMs occur before 40, so I also had to consider an anterior cerebral artery infarct that underwent hemorrhagic conversion.

The family refused an operation. I intubated the patient bedside in the ICU, but with no consent I could not operate.

Today I went back to the ICU and noticed that the patient had markedly deteriorated (GCS 6).

Still no consent.

In the evening I received a call from the ICU. The family had finally consented.

(Right fronto-parietal craniectomy, excision of arterio-venous malformation, evacuation of intracerebral hemorrhage, right frontal partial lobectomy, bone transplant to left hemi-abdomen SQ layer. 2/12/16 10:37 pm to 11:40 pm. No BT.)

Just before cutting, I peeked at 48M's pupils. Already dilated, both at 5mm. I informed the family I will proceed but that prognosis is poor. I was hoping the biuncal brain herniation that the dilated pupils indicated was occurring had just begun, and that there was still time to reverse it. So I operated fast.

When I opened up the brain, there it was, a mass of abnormally large vessels, indicative of an AVM. The vessels were already thrombosed and the brain was non pulsating. So I had an AVM surrounded by infarcted dead brain. This actually makes the operation easier, because dead brain doesn't bleed much. It comes out like melted butter. I used bipolar forceps cautery in order to cauterize all feeding vessels that I could see on the sides of the AVM, steadily going deeper. Once I was sure that these were all properly cauterized, I suctioned off the hemorrhage that had seeped into the surrounding brain, and all the dead brain too. I ended up suctioning off a significant portion of the infarcted right frontal lobe.

Post-op, to my surprise, both pupils had contracted to 2mm. Prognosis while having improved is still poor IMO.

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