Prevalence of psychologic disorders after surgical treatment of seizures

To investigate whether surgical treatment of refractory epilepsy is associated with increased risk for serious psychopathology, 25 treated patients were compared with 25 current candidates for surgery matched on demographic and neuroepileptic characteristics. Diagnoses were made by the National Institute of Mental Health Diagnostic Interview Schedule. No differences between groups in lifetime or point prevalence rates were significant. The rate of psychosis in the postoperative group (8%) approximated the lower estimates in previous studies. Thus, surgical treatment of seizures did not increase the risk for psychopathology. However, patients with temporal lobe electroencephalogram foci or tumor as the epileptogenic lesion were more likely to have serious disorders than other patients. Also, anxiety disorders were more prevalent in our patient groups than in the general population.

[Experimental validation of the use of an ultrasonic surgical instrument in neurophysiology]

The effect of ultrasonic and surgical instruments on nervous tissue in chronic experiments on the cats were investigated with electrophysiological and morphological methods. The authors compared the results of removal of the neocortex zones using ultrasonic and surgical instruments or routine methods. Electrophysiological and morphological studies have shown small injury effects made by ultrasonic and surgical instruments on the surrounding brain tissue.

Incidence and cardiac effects of systemic venous air embolism. Echocardiographic evidence of arterial embolization via noncardiac shunt

Central nervous system dysfunction in venous air embolism may result from air entering the arterial circulation. Using two-dimensional and pulsed-wave Doppler echocardiography, this study not only documented the frequent presence of air in the right heart chambers of patients undergoing upright neurosurgery or pacemaker insertion, but also documented the presence of air in the left atrium and left ventricle of one patient via noncardiac shunt. Studies in dogs confirmed paradoxical air embolism in the absence of anatomic communications between right and left heart chambers. Systemic venous air also produced a dose-dependent increase in pulmonary artery pressure and diastolic flattening of the ventricular septum with increase in left ventricular filling pressure despite preserved systolic function.

[Treatment of post-traumatic and post-neurosurgical bacterial meningitis with ceftriaxone alone or in combination with fosfomycin]

From 1984 to 1986, 13 patients (10 adults, 3 children) with bacterial meningitis following neurosurgery or traumatism were given ceftriaxone alone 6 times at a dose of 40 mg/kg one IV injection per day, or in association 7 times with fosfomycin at a dose of 200 mg/kg/day, 3 IV perfusions every 4 h. The bacteriological diagnosis was confirmed in 9 cases (3 Staphylococcus aureus, 4 Streptococcus pneumoniae, 1 Klebsiella, 1 Peptococcus). In vitro neither synergy nor antagonism were observed between the two antimicrobial agents. The acute infections episode resolved in all patients except on who died with a negative CSF culture. One superinfection meningitis with Achromobacter was seen. CSF concentrations of ceftriaxone were assayed and found to be comparable with those reported by most authors. Tolerance was excellent for all our patients.

Acute brain swelling during evacuation of subdural hematoma caused by delayed contralateral extradural hematoma: report of two cases

Two patients experienced severe brain swelling during the evacuation of acute subdural hematomas. Postoperative computed tomographic (CT) scans revealed delayed extradural hematomas on the sides opposite the subdural hematomas. Extradural bleeding occurred in the area of the fractured skull. One patient improved neurologically after evacuation of the extradural hematoma, and the other was not operated because he was moribund. Drilling exploratory burr holes in the fractured area may have been a better strategy than awaiting a postoperative CT scan. The reduction of intracranial pressure after the removal of subdural hematoma was postulated to be the most important factor contributing to the formation of the extradural hematoma.

Bilateral hearing loss after unilateral removal of an acoustic neuroma by the suboccipital approach: case report

Contralateral hearing loss is a very rare complication of acoustic neuroma surgery. A case of immediate postoperative contralateral hearing loss is reported. Possible causes and the pertinent literature are reviewed.

Bacterial infections of the central nervous system in neurosurgery

CNS infections following clean neurosurgery are uncommon but occur with increased frequency following neurotrauma and placement of CSF shunts and ventriculostomies. When faced with the possibility of meningitis or brain abscess in these settings, the clinician must aggressively seek definitive diagnostic information by means of CT scanning and cell counts, Gram stain, and culture of the CSF. Appropriate empiric therapy should then be administered promptly to achieve cidal activity in the CSF against the most likely infecting pathogens. Prophylaxis for clean neurosurgery and for placement of CSF shunts has been advocated by several investigators. However, regimens are many, and data are few and conflicting. When given, prophylaxis should be administered only during the intraoperative period. There is, at best, a weak scientific basis for what remains a widespread practice.

Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position

Because venous air embolism (VAE) has been considered to be a major deterrent to use of the sitting position, records of 255 patients undergoing neurosurgery in the sitting position from 1975 to 1982 were reviewed to determine the nature of morbidity and mortality in relation to the surgical procedure as well as to the occurrence of VAE. Complications were classified as surgical or anesthetic during joint review by a neurosurgeon and two neuroanesthesiologists. Outcome was classified on the basis of postoperative hospital course and discharge examination. The incidence of VAE was 30%. Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE. The episodes of VAE did not seem to be significant factors in the perioperative morbidity and mortality in our series of patients operated upon in the sitting position. Two case reports are discussed in detail.

Traumatic bilateral epidural hematomas presenting at different times in a patient with large ventricles

In a patient with large ventricles, a huge epidural hematoma of venous origin developed after removal of a contralateral traumatic epidural clot which was produced by the tearing of the middle meningeal artery. The possible pathophysiologic characteristics of such hematomas are discussed.

Some inquiries in neuroanesthesia and neurological supportive care

Complications of performing neurosurgery in the sitting position have been well defined, and include cardiac and respiratory effects, air embolism, and pneumocephalus. Prophylactic measures and early diagnosis allow prompt therapy with minimal residual sequelae. All anesthetic agents and techniques alter the intracranial dynamics. A clear understanding of drug effects and the pathology involved allow a rational choice of anesthetic management to maximize the potential for a good outcome. Patients with cerebrovascular disorders frequently have multisystem disease, and careful preanesthetic assessment and preparation ensure a more stable intraoperative and postoperative course. Many chemical and mechanical reactions follow an ischemic hypoxic insult, but appropriate therapeutic intervention and early establishment of cardiorespiratory support measures have shown promise in improving the neurological outcome in these patients.

Meningitis caused by gram-negative bacilli

Thirty adults with meningitis caused by gram-negative bacilli were observed from 1968 to 1978 at four hospitals associated with Boston University School of Medicine. Equal numbers of two distinct types of gram-negative bacillary meningitis--spontaneously occurring meningitis and meningitis after neurosurgery--were found. Spontaneously occurring meningitis appeared to be caused most often by Escherichia coli and Haemophilus influenzae. Meningitis occurring after neurosurgical procedures was more insidious in onset, more protracted in course, and more often caused by organisms resistant to multilple antibiotics. Approaches to therapy are based on the differences in character of these two types of meningitis.

[Microtopography of cerebellopontine angle structures in acoustic neuroma]

The structures of the cerebellopontine angle in neurinoma of the auditory nerve were studied in autopsy material and during surgical intervention with the use of an operative microscope. Principally different variants of the relationships between the cerebellopontine angle structures and the neurinoma capsule in intra- and extracisternal localization of the tumor were revealed. The greatest difficulties occur in exposure of the capsule of an intracisternal neurinoma which is tightly connected with the structures of the cerebellopontine angle by means of strong connective-tissue trabeculae. In extracisternal localization of the tumor its capsule is easily separated from the arachnoid, which is pushed to the brain stem, because there are no trabeculae between these structures. The main source of blood supply to the tumor irrespective of its localization is the anterior inferior cerebellar artery.

Usefulness of gamma-aminobutyric acid (GABA) therapy in pathologies of neurosurgical competence

The Authors, after giving some theoretical and pharmacodynamic opinions on GABA, report their clinical experience for 18 consecutive years with the use of gamma-aminobutyric acid in cases of central comas, psycho-organic post-operative syndromes, Parkinson's Disease. The drug, in the various above listed pathologies, shows respectively a wakening effect, with actual rising of the level of consciousness, a re-equilibrating action towards psycho-organic involutions, especially acute ones, and a considerable antiakinetic activity. After analyzing the original results obtained, considered especially in the light of the most modern researches on the importance of GABA-ergic mediation on the basal ganglia, some interesting neurofunctional hypotheses are put forward, which are connected with the problem of nervous conduction in human pathology. According to said hypotheses the aminoacid works clinically, owing to its role of inhibiting mediator (rather than of oxidable substrata), and is involved in extrapyramidal nigro-striatal lesions.

The phenomenon of ipsilateral innervation. One case report

A patient with an anterior communicating artery aneurysm successfully treated surgically by occluding its major feeding vessel, the left anterior cerebral artery, displayed a homolateral hemiparesis. The possibility of ipsilateral innervation is strongly suggested based on clinical grounds and the post operative follow-up angiographic studies, EEG and PEG.

Secondary aneurysm due to arterial injury during surgical procedures

Most secondary aneurysms following trauma to the cerebral artery were reported as a complication of head injury. Three cases of aneurysm due to arterial injury during operations are reported. A search of the world literature revealed ten other cases. The responsible surgical procedure and the location of these aneurysms varied. Rupture of these aneurysms was observed in four cases at 10 to 23 days following the primary operation. Only two patients died.

Bilateral trigeminal nerve sensory deficits and nasal deformity

A nasal deformity developed in a woman with bilateral trigeminal sensory deficits. A comparison of the clinical and pathologic features of this case with those of several other cases that have been reported previously suggests a relationship between the bilateral fifth nerve lesions and the nasal damage. The aforementioned clinical combination does not appear to be pathognomonic of any specific nosologic entity. However, it probably should be accorded the status of a clinical syndrome since the nasal degeneration apparently occurs only if both fifth nerves are affected.

Cerebral revascularization

Cerebral vascular insufficiency due to occlusive lesions regarded as inaccessible is a common problem. The degree of cerebral dysfunction associated with such lesions is dependent in part on the amount of collateral circulation present. By anastomosing the superficial temporal artery to a branch of the middle cerebral artery an increase in collateral circulation is provided to the affected hemisphere. This report describes the results of twenty such procedures. Postoperative angiography demonstrates a 90% patency rate. There is frequent neurological improvement following surgery, and the rate of new TIA's or strokes seems less than would be expected. The most damaging complication of the procedure ist intracerebral haemorrhage. The indications for, and the complications of, such procedures are discussed.

Organismic states and their effect on recovery from neurosurgery: a new perspective with implications for a general theory

The authors examine and review current research on recovery of function following brain damage. Emphasis is placed upon the physiological and neurochemical states of the organism prior to neurosurgery and their influences on behavioral recovery of function. It is proposed that the consequences of a given neurosurgical procedure depend not only on its neuroanatomical locus but also on the organismic state of the brain substrate at the time of such a procedure. The brain substrate can be modified prior to a given manipulation, resulting in an alternation of the effects of the manipulation. The implications of this new perspective for both basic research and clinical medicine are discussed.

Physiological considerations important for the management of vasospasm

The physiological mechanisms of known importance in the control of cerebral blood flow (CBF) and smooth muscle contraction and relaxation are reviewed. The pathophysiology of vasospasm following subarachnoid hemorrhage (SAH) is correlated with an alteration of these mechanisms. It is emphasized that smooth muscle relaxation is an energy-dependent process and that vasodilators require a functional smooth muscle membrane that may be severely impaired in ischemia or subarachnoid hemorrhage. The temporal profile of ischemia from spasm is correlated with the pathophysiology of altered metabolism of smooth muscle. The relevance of this complication to the timing of aneurysm surgery in 337 cases operated by one surgeon is considered along with various drug regimens suggested for its management.

[Neurosurgery of chiasma syndromes (author's transl)]

The conditions for the success of surgical interventions within the chiasmal region are careful preparation of the patient, ideal general anesthesia, precise surgical technique especially improved by the use of the microscope and bipolar coagulation. The surgical results also depend on the age of the patient, on his general condition, on the volume of the tumoral lesion and on the extent and kind of implication of the vascular and nervous structures of this region. The lesions are classified into extraparenchymatous lesions, intraparenchymatous lesions, giant aneurysms and inflammatory lesions. The extensive extraparenchymatous lesions represent the most important group: they comprise the pituitary adenomas, the cranio-pharyngiomas, the meningiomas and finally rarer tumors like the chordomas, or other tumors of the sphenoid. In these regions the choice of access is extremely important: transphenoidal, subfrontal intracranial or mixed. Among the intraparenchymatous lesions one has to mention first of all the gliomas of the chiasm and then the ectopic pinealomas. The giant aneurysm in older persons is improved the symptomatology by ligation of the internal carotid. The inflammatory arachnoidal lesions of the chiasm (specific or nonspecific) generally profit from an intervention aiming to disconnect the adhesions. X-ray therapy represents very often an indispensable component of the surgical treatment of the tumoral lesions. Apart from death the complications are postoperative infection, aggravation of the neuro-ophthalmological symptoms, the neuro-psychological consequences and the endocrinological and hypothalamic complications. Early diagnosis represents the best means to diminish the importance of the complications. An alternative complication is the tumor recurrence.

An unusual entrance site of venous air embolism during operations in the sitting position

Embolism of air into the venous system occurs during approximately 25% of neurosurgical operations performed with the patient in the sitting position. The present report calls attention to an unusual entry site for such air embolism-the punctures in the scalp made by a neurosurgical pin-type head holder.

Computed tomography in the postoperative care of neurosurgical patients

By its ability to differentiate the densities of various intracranial tissues, computed tomography is an ideal tool to investigate the postoperative course and complications of neurosurgical patients. The most important immediate postoperative complications are intracerebral edema and epidural, subdural or intracerebral hematomas. The extent of surgical resection of neoplasms can also be studied easily by CT. The method of investigation and representative cases are described.

[Lumbar arachno-epiduritis. Study of 20 cases]

The authors report twenty cases of lumbar arachnitis, from the clinical, biological, and neuroradiological points of view; a discussion is developed in connexion with various etiological factors centred, on the one hand, on the responsibility of the contrast media used in neuro-radiology and, on the other hand, on that of the act of surgery, a factor that was encountered in half of the cases reported. The possibilities of therapy are also discussed.

[The value of direct blood transfusion in brain tumor surgery]

An analysis of 93 direct transfusions of the blood to 53 patients operated upon in connection with brain tumours is offered. The effectiveness of direct hemotransfusions both during surgery in cases of an acute hemorrhage and an abrupt fall of the arterial pressure and in the post-operative period, due to untoward changes in the biochemical blood indices and post-operative anemia, is demonstrated. Direct hemotransfusions produce a high therapeutic effect in cases of the blood-clotting system disorders and also in suppurative-inflammatory processes during the post-operative period. The practice of direct hemotransfusions made it possible to more effectively control the described disorders and to improve the outcomes of surgical treatment in dealing with brain tumours.

[Akinetic mutism and bicingular softening. 3 anatomo-clinical cases]

The authors describe three pathological cases of akinetic mutism with, as a common basic lesion, bilateral infarction of the cingulate gyrus secondary to aneurysm of the anterior communicating artery (case n degrees 1), to a huge olfactory meningioma (case n degrees 2), both operated on, and to atheromatous occlusion of the anterior cerebral arterial system (case n degrees 3). These three cases enable a variety of "anterior and waking" akinetic mutism to be described which is unusual enough to be compared with other mesencephalic and diencephalic aspects of this syndrome. It is in fact an akinetic mutism characterized by: a certain dissociation in its non-response to various stimuli, a particularly marked appearance of wakefulness when day-time alertness is considered, conservation of the waking-sleeping rhythm, perception and reaction unpredictable and paradoxical in both degree and quality, complete absence of any spontaneous verbal communication in contrast to relative break-down of solicited communication which is infrequent, uncertain and unresponsive to the usual methods of stimulation, without any possibility of a code. In addition, there is a remarkable mimic and segmental general akinesia, resistant to the usual nociceptive stimuli, but sensitive to slight excitation of the manual and oral zones. Besides this special akinetic mutism, there are variously systematised signs, mostly asymmetrical, indicating lesion of the cortico-sub-cortical frontal structures bordering on the gyrus cinguli. This unusual behaviour pattern corresponds in these three cases to extensive anterior bilateral ischemic lesions of the cingulate gyrus regularly associated with bilateral infarctions confined to the medial aspect of F1 in the superficial territory of the two anterior cerebral arteries, to possible neurosurgical changes (ablation of the right frontal pole) and to compressive or ischaemic lesions of the gyrus rectus. These exclusively cortico-sub-cortical associated lesions are in contrast with the remarkably intact caudate nuclei, the pallidal, thalamic, hypothalamic and septal formations and the anterior pillars of the fornix. These findings compared with the results of experimental research carried out by M. Kennard, help, if help is needed, to resolve the apparent contradictions between the effects of therapeutic cingulectomies or cingulotomies and the scanty pathological data already available in cerebral vascular pathology.

Late results of radical excision of craniopharyngiomas in children

The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented. The patients are analyzed in regard to survival and quality of survival. While 22 of 34 children so treated at the initial operation are presently alive and tumor-free, high mortality and morbidity followed in cases where reoperation was performed. Properly treated endocrinological deficits need not be a serious problem, but persistent hyperosmolality carried a grave prognosis. No predictive criteria are yet available to determine which tumors are amenable to radical surgical excision.

Neonatal craniopharyngioma. Case report

The authors report a case of craniopharyngioma in a newborn infant. Marked hydrocephalus of the fetal head was recognized in the pelvimetric roentgenograms of the mother and massive suprasellar calcification was seen in the plain skull films.

Retrieval of detached shunt catheter from the heart. Case report

✓ A method of removing a detached ventriculoatrial shunt catheter from the heart is described.