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Member since Jun-04-08 · Last seen Jul-22-14
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.

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 2014, 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 and Capablanca 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.

Instead, it is the frequencies of a few middlegame pawn structures 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.

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)

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 6453 times to chessgames   [more...]
   Jul-22-14 visayanbraindoctor chessforum
visayanbraindoctor: <And patients probably aren't always conscious so you can't ask for.. perhaps excessive headaches. Or are there specific symptoms, I don't know: eyes doing strange things.> <Annie K.: <dakkie> intracranial pressure can also be caused by blockages (not ...
   Jul-17-14 Kramnik vs D Baramidze, 2014
visayanbraindoctor: <Captain Hindsight: Better would have been <28.fxg7+ Kg8 29.Qf4! >> That's outright winning for White. It threatens both Q takes rook and Qh6. One has to think only three moves ahead. How can Kramnik miss that?
   Jul-12-14 Vladimir Kramnik (replies)
visayanbraindoctor: Kramnik was again unrecognizable in his game against Meier. There was nothing much tactical about the game; from a bad opening Kramnik emerged into a positionally lost middle game. He has been blundering pretty badly lately. But now it's as though even his positional ...
   Jul-06-14 Saemisch vs Nimzowitsch, 1925 (replies)
visayanbraindoctor: <perfidious: <visayan> Then came scarlet fever for Alekhine in 1943, and he was not at the same level thereafter; possibly Alekhine's age should have led to a decline in his play in any event, but he was decidedly not the same player.> I did not know he had a ...
   Jun-30-14 waustad chessforum (replies)
visayanbraindoctor: <waustad: Is he related to Andronico Yap who I met with Murray Chandler when they played in the World Junior Championship in Austria in 1977 or 78?> I don't think so. IM Andronico Yap (whom I have played in tournaments and whom I believe was one of the strongest ...
   Jun-30-14 Kasparov - Kramnik World Championship Match (2000) (replies)
visayanbraindoctor: <john barleycorn: <To some extent now I of course regret that I acted too nobly just trying to follow my principles> wow!!!> <RookFile: Tell that to Shirov.> GKK is the strongest player ever since the machine-like Fischer of 1969 - 1972, and IMO the most
   Jun-13-14 67th Russian Championship Higher League (2014) (replies)
visayanbraindoctor: 'The 9 round Swiss Open had a qualifying character for the Russian Superfinal 2014. GM Igor Lysyj, GM Vadim Zvjagintsev, GM Dmitry Jakovenko, GM Denis Khismatullin and GM Boris Grachev were the top five to earn spots in the prestigious Superfinal.' ...
   Jun-07-14 Caruana vs A Giri, 2014 (replies)
visayanbraindoctor: Trying to control weak squares, a basic chess principle. Just a round earlier, Giri as White lost a similar positional game to Kramnik, when he lost control of his f3 square to a Knight. Kramnik was willing to sac a pawn in order to control the f3 square. Now Giri is ...
   Jun-06-14 Carlsen vs Caruana, 2014 (replies)
visayanbraindoctor: 3. f3 For the third game in a row in this tournament, Carlsen avoids mainlines. Caruana had no doubt prepared for the more common Grunfeld lines, but Carlsen as is his wont cleverly sidestep it. Carlsen ends up with a substantial advantage out of the opening.
   Jun-05-14 Norway Chess Tournament (2014) (replies)
visayanbraindoctor: <Chris321: didn't call Fischer"the masjine",they said"he play like a masjine" for nothing,especially meaning his endgames was so accurate!.> They called Fischer like so because he was so accurate. The Fischer of 1969 to 1972 IMO would probably be world champion ...
(replies) indicates a reply to the comment.

Kibitzer's Corner
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Jul-15-14  SugarDom: Do you get paid for the home visits?
Premium Chessgames Member
  visayanbraindoctor: <SugarDom: Do you get paid for the home visits?> My 'home visit' is actually conducted in the OPD of a public hospital. Half of my post-op patients come from this province. Each one would spend a thousand pesos to see me in my city for follow up check up and suture removal. So I have made an arrangement with that public hospital that I could sit in their OPD to see my post-op patients in that province. In return I see new OPD patients there for free. In effect it's a free clinic for OPD patients in that province.

However, most of my old post-op patients still owe me and they usually give me some cash which they would normally spend in the travel to my city. Myself traveling to their province allows them to save that money, and they give some of it to me in order to partly settle their debts to me.

So no, the OPD patients there don't pay me anything. And yes, my old post-op patients try to partially settle their debts to me by paying me some cash.

Premium Chessgames Member
  visayanbraindoctor: 16 July 2014. Entry 1. I usually do suturing of clean woulds and debridement of infected scalp wounds in the CiH in the ward, at bedside. It takes some arrangement for me to schedule these patients in the OR. What can be safely done in the ward, I do in the ward.

This morning I had to debride a large infected scalp wound. It was sutured by a resident doctor and he inadvertently sutured in some contaminated hair into the wound. My metabolic rate increases whenever I operate, and without air-conditioning or electric fans in the ward, I was soon sweating profusely. I just noticed that after I had excised off the infected tissue, washed the wound with a liter of normal saline, and closed it. The other patients were saying 'Doc basa na ka sa singhot' (Doctor, you're drenched wet in sweat.)

Premium Chessgames Member
  visayanbraindoctor: 17 July 2014. Entry 1. A midnight referral gone tragic. 6:30pm, a man and his young granddaughter, 6F, fell off a motorcycle in a small neighboring city. At first 6F was awake, but then began to deteriorate. The family decided to transfer to my city. 9:30pm, 6F arrived in my small city in a hired PUV. At the ER of PrH1, they were advised CT scan. However, the mother had no money. No CT scan. 11:30 pm, someone arrived with some cash. The CT scan proceeded. By then 6F had begun dozing off.

Midnight, I was informed of 6F. 12:30am, I saw her at the ER of PrH2, where they had transferred. She was comatose, right pupil dilated. The CT scan plate showed a huge right temporo-parietal epidural hematoma, at least 70cc. I immediately intubated her. I wanted to do a craniectomy right then and there, but private hospitals don't allow such major operations before money down first. No money, no entry.

I asked them to transfer to the public CiH.

1:30am, we arrive almost simultaneously at CiH ER. Shortly after, 6F went on CP arrest in the ER. Cardio-pulmonary resuscitation follows. 2am early this morning, I pronounce 6F dead.

Premium Chessgames Member
  WannaBe: Yikes!!! In (most of) these cases that you see/handle, would an earlier diagnose via X-ray or CT help to avoid such death?
Jul-17-14  SugarDom: No health insurance, no money for emergencies, no free hospital is a 3rd world problem in the Philippines. 4th World, the good doctor will say.

Can your forum allow you to state your opinion on Pnoy's performance as president? And who would you vote in 2016? Duterte, Miriam, Bongbong, Binay or another?

Premium Chessgames Member
  visayanbraindoctor: <SugarDom: No health insurance, no money for emergencies, no free hospital is a 3rd world problem in the Philippines. 4th World, the good doctor will say.

Can your forum allow you to state your opinion on Pnoy's performance as president? And who would you vote in 2016? Duterte, Miriam, Bongbong, Binay or another?>

Unfortunately no.

Premium Chessgames Member
  visayanbraindoctor: <WannaBe: Yikes!!! In (most of) these cases that you see/handle, would an earlier diagnose via X-ray or CT help to avoid such death?>

She would have been alive.

I stuck around for 20 minutes in the ER over the child's dead body, in a kind of denial stage.

Premium Chessgames Member
  WannaBe: Thank you.
Premium Chessgames Member
  visayanbraindoctor: 18 July 2014. Entry 1. Another child was referred yesterday afternoon, 5F. She had a 2 day history of sensorial deterioration. The Oracle showed a large right occipito-parietal intracerebral hemorrhage. There was no history of trauma that I could gather.

So I thought a small congenital arteriovenous malformation (AVM) in the posterior cerebral circulation might have ruptured. I saw her yesterday evening in the public CiH, and fortunately the family had procured OR needs and blood by the morning.

I opened up the back of her skull, did a cortisectomy on the posterior parietal lobe way behind the somesthetic cortex, and suctioned out 60 cc of clotted blood. I could not see the vessel that ruptured. Probably a small 'burned out' clotted AVM. I left behind a firm clot that resisted suctioning; it could be part of the clotted AVM, and removing it forcibly would reopen the bleeding vessel. I just packed the bed of the cavity previously occupied by the blood clot with hemostatic absorbable gelatin sponge. Post-op 5F is OK.

In the past when I was able to do an angiogram of such cases, there was no AVM detected post-op. Both my trainer and my old master believe that this kind of AVM's contents clot entirely, thus effecting a permanent cure for itself. No need to clip or cauterize as is often the case in large AVMs. The same case can be said for very small micro-aneurysms, such as the lenticulo-striate micro-aneurysms theorized as causing hypertensive basal ganglia hemorrhages.

Funny incident just as 5F was about to be anesthesized. Pre-op I had give her large doses of Mannitol in order to temporarily decrease the intra-cranial pressure, and she responded by becoming more awake. When the orderly clipped the pulse oximeter (a common, cheap, and useful device that measures the blood's oxygen saturation) to her big toe, she suddenly woke up and yelled 'Ayaw ko paaka'. Don't bite me! All the OR nurses smiled and laughed.

Premium Chessgames Member
  dakgootje: Hey doc :)

Got a question, hope you can shed some light when you've got some time to burn :)

I'm curious about intracranial pressure. From reading some of your posts over time, it seems like they tend to be due to a cerebral blood clot - and the remedy Mannitol for a shorttime solution, followed by removing the blood clot.

Are there other reasons [and solutions] for intracranial pressure? Presumably in movies they'd drill a hole in the skull - but I suppose that might be outdated :) And, what I wondered about more: How do you know there's pressure? I wouldn't know how to measure it. And patients probably aren't always conscious so you can't ask for.. perhaps excessive headaches. Or are there specific symptoms, I don't know: eyes doing strange things.

As always it's an honor reading your transcripts. One day I'll grab my neuroscience book and reread them all :)

Premium Chessgames Member
  Annie K.: <dakkie> intracranial pressure can also be caused by blockages (not necessarily blood clots - tumors, whether malignant or benign, are also a possibility) that cause a local accumulation of CSF, that then starts pressing on adjacent brain areas. Symptoms can include headaches, vision peculiarities, loss of balance, and other malfunctions of the brain centers being pressed. But I'll leave it to the doc to give a more complete answer. ;)

<Sri doc> how is the baby girl with meningitis doing, please?

Premium Chessgames Member
  dakgootje: Yeah I thought about those symptoms - but they still require some interaction. Which isn't possible when someone fell off their motorbike and is unconscious :P

But thanks for the preliminary answer :)

Premium Chessgames Member
  Annie K.: Well yes, when somebody falls off their motorcycle, then traumas and blood clots are much more likely to be involved, and they are much more likely to be unconscious and to have arrived without relatives who know their medical background.

In *other* cases, though, the patient is often not only conscious but rational, despite physical malfunctions, plus you have family to question. ;)

Premium Chessgames Member
  dakgootje: People are rational? Man, I have to emigrate ;D
Premium Chessgames Member
  Annie K.: <dakkie> oh, don't get carried away now! That just means, in context, "not less rational than under normal health conditions". :p

Anyhoo, you were asking about other reasons for intracranial pressure (than blood), and these other reasons are mostly found in non-motorcycle-accident , or other physical trauma, circumstances.

And yes, AFAIK neurologists usually go straight for the eyes when they want to know how your intracranial pressure is doing. ;)

Premium Chessgames Member
  visayanbraindoctor: <dakgootje, Annie K.> Will try to answer your questions in more detail when I am not too busy. The baby girl has been discharged and is doing fine. I did not have to do a VP shunt, or any lumbar taps.
Premium Chessgames Member
  visayanbraindoctor: 19 July 2014. Entry 1. Strong winds in the night. Looks like another typhoon.
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  Annie K.: <Doc> thanks much. :) Take care.
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  visayanbraindoctor: 20 July 2014. Entry 1. Brown out the all day, 7am to 7pm. I guess they're doing repairs on typhoon damage. I do not pay any particular attention to typhoons if flooding does not occur in my locality. It seems that two typhoons (Glenda and Henry) have already hit the country.

If strong winds occur, I just stay inside. If I have to go out, I get into a car/SUV or a PUV. When I was a kid during a strong typhoon, I saw something flying in the winds which I imagined to be a galvanized rooftop panel. Ever since then, whenever typhoon winds begin to pick up and I am outside, I irrationally keep looking around for a flying roof that might come out of nowhere and hit me.

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  WannaBe: Reminds me of the line from the movie "Twister"

"Look, Another cow."

"No, I think it's the same cow."

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  visayanbraindoctor: 21 July 2014. Entry 1. Uneventful day.
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  visayanbraindoctor: 22 July 2014. Entry 1. Uneventful day. Except for some trouble with my computer.
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  visayanbraindoctor: <dakgootje: I'm curious about intracranial pressure. From reading some of your posts over time, it seems like they tend to be due to a cerebral blood clot>

Not always. Sometimes it's too much CSF, hydrocephalus. Sometimes it's a contused brain that's swelling. Like you hit your foot on the sidewalk and it starts to swell. You can take off your shoes, but in case of the brain, you can't take off your skull to relieve the pressure. Or as you say:

<Are there other reasons [and solutions] for intracranial pressure? Presumably in movies they'd drill a hole in the skull - but I suppose that might be outdated>

You are probably referring to a burr hole or a trepanation. Which I do all the time. To make the hole bigger, you can saw a line connecting 3 or 4 burr holes with a gigli saw (or a craniotome) and then remove the bone inside the sawed off lines. I don't think it's outdated at all.

If the intracranial pressure is increasing significantly, there's hardly any other solution than to remove part of the skull. Imagine s swelling foot inside a shoe made of a rigid calcium-phosphate mineral. You just have to saw off part of the shoe if you hope to save the foot from being squashed inside its rigid casing.

<How do you know there's pressure? I wouldn't know how to measure it.>

When I insert a tube into the frontal horn in a tube ventriculostomy operation, I can actually measure the intracranial pressure 'manually', in terms of centimeters water. I just watch CSF flow up the tube, and measure it's height from the external auditory meatus (your ear hole). It should be about 15 to 18 cm. Anything above 20cm is probably indicative of increased intracranial pressure. In the first world, the Neurosurgeons may place a device outside the skull but connected into the ventricular system by which to measure the intracranial pressure. They still have to do a burr hole in order to insert the tube inside the brain. These devices are way too expensive for the local population. To be frank, I don't think they're really that much needed here. What's needed is money just to do a CT scan and to procure basic OR needs for craniectomies.

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  visayanbraindoctor: <And patients probably aren't always conscious so you can't ask for.. perhaps excessive headaches. Or are there specific symptoms, I don't know: eyes doing strange things.>

<Annie K.: <dakkie> intracranial pressure can also be caused by blockages (not necessarily blood clots - tumors, whether malignant or benign, are also a possibility) that cause a local accumulation of CSF, that then starts pressing on adjacent brain areas. Symptoms can include headaches, vision peculiarities, loss of balance, and other malfunctions of the brain centers being pressed.>

Annie K. basically answered that question.

Further on the topic of increased ICP, mostly I rely on observations on the patient's sensorium. In general, if a patients is stuporous or comatose, I assume there is increased intracranial pressure. A CT scan can confirm this.

Caveat: there are cases in which there is no increased ICP, yet the patient is still comatose. Commonly these are usually patients that have depressant drugs in their system (the usual one being alcohol from a drinking session), infarcts affecting the ascending reticular activating system, and encephalopathies.

The CT scan of patients with increased intracranial pressure usually shows effaced sulci, bowing of the frontal horns, outright midline shifts (the midline septum pellucidum is pushed to the right or to the left, when it should be located exactly midline). Most feared of all is obliterated paramesencephalic cisterns. That's a small space around your midbrain (mesencephalon). If this is obliterated, the pressure has already pushed the temporal lobe's uncus into herniating into the tentorial notch and onto the midbrain. If both uncus have herniated, the the patient is doomed. You can see all of these in a CT scan.

Without a CT scan, an uncus pushing against the midbrain can be detected by looking at the pupils. CN III (oculomotor nerve), has a part of it that is located between the uncus and the midbrain. Aside from moving the eyes around, it causes the ipsilateral pupil to constrict. If compressed, the opposite happens; the ipsilateral (on the same side) pupil dilates.

As you note, that's why Neurologists and Neurosurgeons and trained ER personnel seem obsessed into peering into patients' eyes.

If you review some of my entries, you can note the urgency implied in my writings whenever I see a patient with one pupil dilating. It's still possible to save many of them, especially for epidural hematoma cases. Not so when biuncal herniation has occurred, clinically when both pupils dilate.

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