"Triple cross" of the hypoglossal nerve and its microsurgical impact to entrapment disorders

OBJECTIVE

Cadaveric dissections were performed to review the intracranial and extracranial course of the hypoglossal nerve. The neurological significance of a newly defined "triple cross" of the hypoglossal nerve is discussed.

MATERIALS AND METHODS

10 cadaveric heads (left and right; 20 sides) were dissected using microsurgical techniques.

RESULTS

In the cisternal segment of hypoglossal nerve, the diameter of the rostral trunk amounted to 155-680 microm (mean 435 microm), and the caudal trunk to 210-820 microm (mean 482 microm). The roots formed three trunks in 20% of the hypoglossal nerves and two trunks in the rest. As a first cross, the anterior medullary segment of the vertebral artery crossed the hypoglossal nerve roots in 14 of 20 sides (70%). As a rare variation, the vertebral artery extended medial to the nerve (25%) or between its roots (5%). The second cross was found between the descendens hypoglossus and the occipital artery (75%), sternocleidomastoid artery and vein complex (15%) and external carotid artery (10%). The third cross was shown in the submandibular triangle between the lingual hypoglossus and its drainage vein; vena committans nervus hypoglossus.

CONCLUSION

Throughout its way, the hypoglossal nerve passes over vascular structures in three crossing points which may serve as a probable cause of hypoglossal nerve entrapment disorders.

Fiber dissection technique: lateral aspect of the brain

OBJECTIVE

The fiber dissection technique involves peeling away the white matter tracts of the brain to display its three-dimensional anatomic organization. Early anatomists demonstrated many tracts and fasciculi of the brain using this technique. The complexities of the preparation of the brain and the execution of fiber dissection have led to the neglect of this method, particularly since the development of the microtome and histological techniques. Nevertheless, the fiber dissection technique is a very relevant and reliable method for neurosurgeons to study the details of brain anatomic features.

METHODS

Twenty previously frozen, formalin-fixed human brains were dissected from the lateral surface to the medial surface, using the operating microscope. Each stage of the process is described. The primary dissection tools were handmade, thin, wooden spatulas with tips of various sizes.

RESULTS

We exposed and studied the myelinated fiber bundles of the brain and acquired a comprehensive understanding of their configurations and locations.

CONCLUSION

The complex structures of the brain can be more clearly defined and understood when the fiber dissection technique is used. This knowledge can be incorporated into the preoperative planning process and applied to surgical strategies. Fiber dissection is time-consuming and complex, but it greatly adds to our knowledge of brain anatomic features and thus helps improve the quality of microneurosurgery. Because other anatomic techniques fail to provide a true understanding of the complex internal structures of the brain, the reestablishment of fiber dissection of white matter as a standard study method is recommended.

Arteries of the insula

OBJECT

The insula is located at the base of the sylvian fissure and is a potential site for pathological processes such as tumors and vascular malformations. Knowledge of insular anatomy and vascularization is essential to perform accurate microsurgical procedures in this region.

METHODS

Arterial vascularization of the insula was studied in 20 human cadaver brains (40 hemispheres). The cerebral arteries were perfused with red latex to enhance their visibility, and they were dissected with the aid of an operating microscope. Arteries supplying the insula numbered an average of 96 (range 77-112). Their mean diameter measured 0.23 mm (range 0.1-0.8 mm), and the origin of each artery could be traced to the middle cerebral artery (MCA), predominantly the M2 segment. In 22 hemispheres (55%), one to six insular arteries arose from the M1 segment of the MCA and supplied the region of the limen insulae. In an additional 10 hemispheres (25%), one or two insular arteries arose from the M3 segment of the MCA and supplied the region of either the superior or inferior periinsular sulcus. The insular arteries primarily supply the insular cortex, extreme capsule, and, occasionally, the claustrum and external capsule, but not the putamen, globus pallidus, or internal capsule, which are vascularized by the lateral lenticulostriate arteries (LLAs). However, an average of 9.9 (range four-14) insular arteries in each hemisphere, mostly in the posterior insular region, were similar to perforating arteries and some of these supplied the corona radiata. Larger, more prominent insular arteries (insuloopercular arteries) were also observed (an average of 3.5 per hemisphere, range one-seven). These coursed across the surface of the insula and then looped laterally, extending branches to the medial surfaces of the opercula.

CONCLUSIONS

Complete comprehension of the intricate vascularization patterns associated with the insula, as well as proficiency in insular anatomy, are prerequisites to accomplishing appropriate surgical planning and, ultimately, to completing successful exploration and removal of pathological lesions in this region.

A legacy of microneurosurgery: memoirs, lessons, and axioms

This article is written at the request of the editor. It contains my autobiographical sketch, professional memories, lessons, axioms, and reflections on the present problems in neurodiagnosis and neurotherapy. The combination of microsurgical techniques, the bipolar coagulation technique, the concept of arachnoidal exploration, and the concept of segmental and compartmental occurrence of vascular and neoplastic lesions of the central nervous system, with their predilection sites, allowed microneurosurgery to gradually unfold and proceed within the last 30 years as a continuation of conventional neurosurgical principles established by the founder generation. Today, the lesions in each region of the central nervous system can be accessed without using computer-assisted targeting and navigation technology and can be selectively eliminated ("pure lesionectomy") with acceptable outcomes; the mortality and morbidity rates have been reduced remarkably. Further scientific and technological advances will promote the ongoing evolution in neurodiagnosis and neurotherapy. Competitive neurospecialties are welcomed in the interest of patients, medical sciences, and surgical advances. The younger generation of neurosurgeons will have spent more time in laboratory training, deepening their knowledge of neuroanatomy and gaining experience in surgical techniques. The achievements, limits, and problems of neurosurgery in relation to technology, medical and surgical standards, and controversial treatment options have been presented thoroughly in numerous professional publications. However, the relationship of neurosurgery to the evolution of integral neurophysiology and biochemistry has hitherto been inadequately evaluated. The advances in microbiology, anesthesiology, and topographic neurology have been viewed as essential components of neurosurgery's foundations. A critical analysis proves that this is only partially true. The turning point in the development from craniospinal surgery to physiological neurosurgery began with the research of Th. Kocher, V. Horsley, H. Cushing, and W. Dandy concerning the importance of the cerebrospinal fluid system. This was the first step in a trend toward integral neurophysiology, which initiated neurosurgical procedures on a routine basis. The intensive research on the hypothalamus by R.W. Hess and associates led to intensified studies on the autoregulated integral functional units of the central nervous system ("dynamic homeostasis," in the words of W.B. Cannon). This slowly developing but exciting history of neurophysiology requires patient study to seek out solutions for the present difficulties in neurodiagnosis and neurotherapy, which constitute a similar situation to that encountered by the pioneer surgeons at the end of the last century. In pertinent sections, my personal opinions relating to observations and experiences with a large number of operated patients with vascular and neoplastic lesions are presented. The predilection sites of brain tumors in the neopallial and paleopallial (limbic-paralimbic) areas and brainstem, and their expansive but usually not infiltrative growth, are discussed and documented. The current hypothesis of infiltrative growth of gliomas is opposed. The microsurgical technique for the treatment of various types of lesions is summarized. The principal microsurgical instruments and apparatus are presented with some remarks relating to their conception and manufacture.

Topographic anatomy of the insular region

OBJECT

The insula is one of the paralimbic structures and constitutes the invaginated portion of the cerebral cortex, forming the base of the sylvian fissure. The authors provide a detailed anatomical study of the insular region to assist in the process of conceptualizing a reliable surgical approach to allow for a successful course of surgery.

METHODS

The topographic anatomy of the insular region was studied in 25 formalin-fixed brain specimens (50 hemispheres). The periinsular sulci (anterior, superior, and inferior) define the limits of the frontoorbital, frontoparietal, and temporal opercula, respectively. The opercula cover and enclose the insula. The limen insula is located in the depths of the sylvian fissure and constitutes the anterobasal portion of the insula. A central insular sulcus divides the insula into two portions, the anterior insula (larger) and the posterior insula (smaller). The anterior insula is composed of three principal short insular gyri (anterior, middle, and posterior) as well as the accessory and transverse insular gyri. All five gyri converge at the insular apex, which represents the most superficial aspect of the insula. The posterior insula is composed of the anterior and posterior long insular gyri and the postcentral insular sulcus, which separates them. The anterior insula was found to be connected exclusively to the frontal lobe, whereas the posterior insula was connected to both the parietal and temporal lobes. Opercular gyri and sulci were observed to interdigitate within the opercula and to interdigitate the gyri and sulci of the insula. Using the fiber dissection technique, various unique anatomical features and relationships of the insula were determined.

CONCLUSIONS

The topographic anatomy of the insular region is described in this article, and a practical terminology for gyral and sulcal patterns of surgical significance is presented. This study clarifies and supplements the information presently available to help develop a more coherent surgical concept.

The endovascular treatment of brain arteriovenous malformations

Advances in superselective microcatheterization techniques, which took place in the past decade, established superselective endovascular exploration as an integral and indispensable tool in the pretherapeutic evaluation of brain AVMs. The strict and routine application of superselective angiography furthered our knowledge on the angioarchitecture of brain AVMs, including vascular composition of the nidus, types of feeding arteries and types and patterns of venous drainage. In addition, various types of weak angioarchitectural elements, such as flow-related aneurysms, intranidal vascular cavities and varix formation proximal to high-grade stenosis of draining veins, could be identified as factors predisposing for AVM rupture. A wide spectrum of secondary angiomorphological changes induced by the arteriovenous shunt of the nidus and occurring up- and downstream of the nidus have been identified as manifestations of high-flow angiopathy. These data help to better predict the natural history, understand the widely variable clinical presentation and to define therapeutic targets of brain AVMs. Correlation of the topography of the AVM as demonstrated by MR with the angioarchitecture as demonstrated by superselective angiography provided a system for topographic-vascular classification of brain AVMs, which proved very useful for patient selection and definition of therapeutic goals. This study showed, that 40% of patients with brain AVMs can be cured by embolization alone with a severe morbidity of 1.3% and a mortality of 1.3%. Part of theses patients can, however, be cured equally effective by microsurgery or radiosurgery. Which modality will be chosen for a particular patient will mainly depend on the locally available expertise and experience, but also on the preference of the patient following its comprehensive information about the chances for cure and the risks associated with each of these therapeutic modalities. Embolization has a significant role in the multimodality treatment of brain AVMs, by either enabling or facilitating subsequent microsurgical or radiosurgical treatment. Appropriately targeted embolization in otherwise untreatable AVMs represents a reasonable form of palliative treatment of either ameliorating the clinical condition of the patient or reducing the potential risk of hemorrhage. Regarding the practical aspects of the endovascular treatment the following conclusions could be drawn from the experience obtained with this series of 387 patients with a brain AVM: (1) The goal of endovascular treatment should be defined prior to the procedure. This does not preclude a change in the goal, if additional information obtained during the procedure make this necessary. (2) The result of endovascular treatment of a brain AVM in terms of the degree of obliteration achieved and complication rate depends mainly on the endovascular strategy developed and the technique applied. These depend on the specific angioarchitecture and topography of the individual AVM, on the past history and clinical presentation of the patient and on the predefined goal of embolization. The strategy should include the definition of embolization targets, the selection of the most appropriate approach for endovascular navigation, the determination of the sequence of catheterization of individual feeding arteries, the selection of the type of catheters and microcatheters, the selection of the appropriate embolic materials as well as the site and mode of their delivery. Thereafter, every endovascular move should be, as in a chess game, the result of a logical plan. (3) Atraumatic superselective microcatheterization is a key point in the endovascular treatment of brain AVMs. It requires manual skills, knowledge of anatomy and respect for the vascular wall. (4) All locations of brain AVMs should be regarded as eloquent, and no distinction should be made between eloquent and non-eloquent areas of the brain when deciding on the execution of embolizatio

The transcallosal-transforaminal approach to the third ventricle with regard to the venous variations in this region

Surgical approaches to lesions located in the anterior and middle portions of the third ventricle are challenging, even for experienced neurosurgeons. Various exposures involving the foramen of Monro, the choroidal fissure, the fornices, and the lamina terminalis have been advocated in numerous publications. The authors conducted a microsurgical anatomical study in 20 cadaveric brain specimens (40 hemispheres) to identify an exposure of the third ventricle that would avoid compromising vital structures. An investigation of the variations in the subependymal veins of the lateral ventricle in the region of the foramen of Monro was performed, as these structures are intimately associated with the surgical exposure of the third ventricle. In 16 (80%) of the brain specimens studied, 19 (47.5%) of the hemispheres displayed a posterior location of the anterior septal vein-internal cerebral vein (ASV-ICV) junction, 3 to 13 mm (average 6 mm) beyond the foramen of Monro within the velum interpositum, not adjacent to the posterior margin of the foramen of Monro (the classic description). Based on this finding, the authors advocate opening the choroidal fissure as far as the ASV-ICV junction to enlarge the foramen of Monro posteriorly. This technique achieves adequate access to the anterior and middle portions of the third ventricle without causing injury to vital neural or vascular structures. The high incidence of posteriorly located ASV-ICV junctions is a significant factor influencing the successful course of surgery. Precise planning of the surgical approach is possible, because the location of the junction is revealed on preoperative neuroradiological studies, in particular on magnetic resonance venography. It can therefore be determined in advance which foramen of Monro qualifies for posterior enlargement to gain the widest possible access to the third ventricle. This technique was applied in three patients with a third ventricular tumor, and knowledge of the venous variations in this region was an important resource in guiding the operative exposure.

Is there a superior occipitofrontal fasciculus? A microsurgical anatomic study

OBJECTIVE

Using a fiber-dissection technique, our aim was to expose and study the myelinated fiber bundles of the brain to achieve a clearer conception of their configurations and locations. During the course of our study, the superior occipitofrontal fasciculus became the focus of our interest. Many publications have defined this as a bundle of association fibers, located between the corpus callosum and the caudate nucleus, that connects the frontal and occipital lobes. By examining this area using fiber dissection, we realized that the descriptions of the anatomy are inadequate; thus, we focused on the elucidation of the anatomic structures of this region and, in particular, that known as the superior occipitofrontal fasciculus.

METHODS

Twenty previously frozen, formalin-fixed human brains were dissected under the operating microscope using the fiber-dissection technique.

RESULTS

On coronal sections of the brain, a structure on the superolateral aspect of the caudate nucleus usually has been identified as the superior occipitofrontal fasciculus. However, our fiber dissections revealed that this structure is the superior thalamic peduncle, that it is composed of projection fibers rather than association fibers, and that it does not interconnect the occipital and frontal lobes.

CONCLUSION

The structures of the brain are better understood when the fiber-dissection technique is used to explore their configurations and locations. The resulting information is especially beneficial for planning strategies and tactics of neurosurgical procedures.

The arteries of the corpus callosum: a microsurgical anatomic study

OBJECTIVE

The corpus callosum is the major commissural pathway connecting the hemispheres of the human brain. It is particularly important, because various tumors and vascular lesions can be located in and around the corpus callosum, and it is a route through which pass several surgical approaches. Performing accurate surgery in this region and avoiding damage to normal structures require that the neurosurgeon have adequate knowledge of the anatomy of the intricate blood supply to this area.

METHODS

In 20 cadaver brains, the arteries of the corpus callosum were examined under the operating microscope, with particular attention to the origin, course, anastomoses, number, and caliber of the arteries.

RESULTS

In all specimens, the pericallosal and posterior pericallosal arteries were found to be the main sources of blood supply to the corpus callosum. In 80% of the specimens, the anterior communicating artery gave rise to either a subcallosal artery or a median callosal artery, each of which made a substantial contribution to the blood supply of the corpus callosum. A detailed examination of the anatomic features of all the main arteries of supply revealed anastomoses within the callosal sulcus that formed the pericallosal pial plexus. This network supplied the corpus callosum, the radiation of the corpus callosum, and the cingulate gyrus.

CONCLUSION

Familiarity with the details of the vascularity of the corpus callosum is crucial when performing surgery in this region. The additional, significant data described expands the knowledge of this anatomy, which can enhance the surgeon's ability to accomplish a more accurate and successful exploration.

Association of epidermal growth factor receptor gene amplification with loss of chromosome 10 in human glioblastoma multiforme

Although the loss of tumor suppressor genes and the activation of oncogenes have been established as two of the fundamental mechanisms of tumorigenesis in human cancer, little is known about the possible interactions between these two mechanisms. Loss of genetic material on chromosome 10 and amplification of the epidermal growth factor receptor (EGFR) gene are the most frequently reported genetic abnormalities in glioblastoma multiforme. In order to examine a possible correlation between these two genetic aberrations, the authors studied 106 gliomas (58 glioblastomas, 14 anaplastic astrocytomas, five astrocytomas, nine pilocytic astrocytomas, seven mixed gliomas, six oligodendrogliomas, two ependymomas, one subependymoma, one subependymal giant-cell astrocytoma, and three gangliogliomas) with Southern blot analysis for loss of heterozygosity on both arms of chromosome 10 and for amplification of the EGFR gene. Both the loss of genetic material on chromosome 10 and EGFR gene amplification were restricted to the glioblastomas. Of the 58 glioblastoma patients, 72% showed loss of chromosome 10 and 38% showed EGFR gene amplification. The remaining 28% had neither loss of chromosome 10 nor EGFR gene amplification. Without exception, the glioblastomas that exhibited EGFR gene amplification had also lost genetic material on chromosome 10 (p less than 0.001). This invariable association suggests a relationship between the two genetic events. Moreover, the presence of 15 cases of glioblastoma with loss of chromosome 10 but without EGFR gene amplification may further imply that the loss of a tumor suppressor gene (or genes) on chromosome 10 precedes EGFR gene amplification in glioblastoma tumorigenesis.

Tumours of the limbic and paralimbic system

240 patients with tumours of the limbic and paralimbic areas are presented. The following tumour growth patterns have been observed: they remain isolated to areas within the allocortex; they spread throughout allocortical regions; they spread from allocortical to mesocortical zones. With the exception of advanced malignant tumours there seems to be a tendency for tumours to spare the adjacent neocortical and medial structures. The tumours can be approached and extirpated using the trans-Sylvian approach and microneurosurgical technique. 56% have been histologically benign. 60% were below 40 years of age. Seizures were the leading manifestation (77%). In 95% the postoperative results were good. There was no peri-operative mortality.

Tumours of the limbic and paralimbic systems

Clinical manifestations, findings, management and outcome of a series of 177 cases with tumours of the limbic and paralimbic systems are presented. There was no operative mortality. Postoperatively 95% of them had no or only minor neurological deficits. Most of them were able to resume work. Pre-operatively 77% of the patients had epilepsy, but 84% became seizure-free after tumour removal. All 77 cases with malignant tumours died within 1-5 years. In the past many neurosurgeons were reluctant to attempt complete tumour removal in these areas. This series demonstrates the efficacy of highly skilled microneurosurgery.

Intracranial venous hypertension and the effects of venous outflow obstruction in a rat model of arteriovenous fistula

A model of rat arteriovenous fistula (AVF) was created using a proximal common carotid artery to distal external jugular vein anastomosis. Anatomical dissections revealed that the external jugular vein is the primary vessel draining intracranial venous blood. Physiological measurements were made with the AVF open and closed, and during venous outflow occlusion of the contralateral external jugular vein. Opening the AVF increased torcular pressure from 6.5 +/- 0.6 to 13.5 +/- 1.1 mm Hg and decreased mean arterial pressure from 82.7 +/- 1.8 to 62.8 +/- 1.8 mm Hg (both P less than .05), decreasing cerebral perfusion pressure from 76.2 +/- 1.7 to 49.3 +/- 2.2 mm Hg (P less than .05). Middle cerebral artery blood flow velocity (MCA BFV) decreased from 6.8 +/- 1.1 to 4.2 +/- 0.7 cm/s (P less than 0.05). In rats with an AVF, occlusion of venous outflow increased torcular pressure to 34.8 +/- 3.1 mm Hg (P less than 0.05), MCA BFV decreased to 1.8 +/- 0.5 cm/s (P less than 0.05), and severe ischemic changes were seen on the electroencephalogram. Under this condition, torcular pressure and systemic arterial pressure had a positive linear relationship (P less than 0.05), whereas in control rats torcular pressure and arterial pressure had no relationship. Restoration of cerebral perfusion pressure by release of venous outflow occlusion and AVF closure transiently increased MCA BFV to 69% above baseline (P less than 0.05). Histological examination 1 week after permanent venous outflow occlusion revealed venous infarction, subarachnoid hemorrhage, and severe brain edema in rats with an AVF but not in control rats without an AVF. This model of cerebrovascular steal with venous hypertension reproduces both hemodynamic and hemorrhagic complications of human AVF and emphasizes the importance of venous outflow obstruction and venous hypertension in the pathophysiology of these lesions.

Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients

The clinical features, perioperative course, and postoperative outcomes of 144 patients who underwent microsurgical resection of craniopharyngioma were reviewed. Overall, 90% of the tumors were completely resected and 7% recurred. Evaluation of those patients who underwent primary resection revealed much better results. The operative techniques and approaches are reviewed in detail. The results of this series suggest that primary total removal of craniopharyngiomas yields the best long-term outcome for the patient. Experience has shown that the larger the tumor the greater will be the damage, both preoperatively and intraoperatively, to vital intracranial structures. Consequently, early diagnosis, at a stage when the tumor is still small, improves the chances of accomplishing complete removal and of achieving good operative results. The early diagnosis of craniopharyngioma, before it can produce devastating neurological defects, continues to be the principal goal of our medical and pediatric colleagues.

Correlation of clinical and pathological features in surgically treated craniopharyngiomas

Surgical specimens of 104 craniopharyngiomas from 93 patients were reviewed and characterized histopathologically. They were found to have either a classic adamantinous or a squamous papillary structure. The clinical features of each group were then assessed. The frequently solid (50%), always uncalcified squamous papillary tumor type was found in one-third of the adult patients (greater than or equal to 20 years) but did not occur in children. It was associated with a good functional postoperative outcome (84.6%). There have been no cases of tumor recurrence in the squamous papillary group. However, in the group with the adamantinous type of craniopharyngioma, the recurrence rate was 13% in adult patients and 9% in children. When compared to the adult adamantinous cases, the incidence of visual deficits was lower in the squamous papillary group (75% vs. 84%) but the incidence of endocrine abnormalities was higher (75% vs. 52%). Thus, the preoperative, operative, and postoperative features of the two types of craniopharyngioma were found to be distinctly different in adults and children.

Microneurosurgical treatment of intracranial dermoid and epidermoid tumors

Forty-three patients with intracranial, intradural dermoid (8) and epidermoid (35) tumors underwent radical surgical resection utilizing strict microneurosurgical technique. The average age was 37.3 years for the patients with epidermoid tumors and 36.2 years for the patients with dermoid tumors. The male to female ratio was 3:2 for the epidermoid group and 3:1 for the dermoid group. Common clinical presentations included cerebellar dysfunction, cranial nerve impairment, and seizures. Typically, computed tomography scans revealed the epidermoid tumors (30 cases studied) as nonhomogeneous hypodense lesions with irregular borders and without contrast enhancement. The dermoid tumors (7 cases studied) had a similar appearance, but with a wider range of attenuation values. Magnetic resonance imaging findings for the epidermoid tumors (6 cases studied) consisted of increased T1 and increased T2 relaxation times. Supratentorial tumors were excised by the pterional (frontosphenotemporal) approach, mesencephalic tumors by either a supratentorial posterior interhemispheric transtentorial approach or an infratentorial/supracerebellar method, and posterior fossa tumors by either a medially or laterally positioned suboccipital osteoplastic craniotomy. One epidermoid tumor and one dermoid tumor were considered to be subtotally resected because of dense adherences left attached to vital structures; the remaining 41 tumors were completely excised. The most frequent complications were aseptic/chemical meningitis and transient cranial nerve palsies. There were no perioperative deaths. Mean follow-up was 5.2 years. Eighty-six percent of patients reported good to excellent results. No patient had experienced symptomatic or radiographic evidence of recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial mixed germ cell tumor with syncytiotrophoblastic giant cells and precocious puberty

A 9-year-old male patient developed a germ cell tumor in the right basal ganglia which secreted beta-human chorionic gonadotropin (beta-HCG) and caused precocious puberty. Histology and immunohistochemical staining for placental alkaline phosphatase (PLAP), alpha-fetoprotein (alpha-FP), and beta-HCG showed a mixed population of neoplastic germinocytes, embryonal carcinoma, and syncytiotrophoblastic giant cells (STGC). Immunohistochemical double-staining for alpha-FP and beta-HCG revealed that these two markers were produced by different subsets of cells. Expression of the proliferation marker Ki-67 showed a growth fraction of 53% for the neoplastic germinocytes and embryonal carcinoma cells, but only 21% for the STGC.

Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article

The pterional craniotomy as described previously by the first author requires creation of a special flap over the temporalis muscle for increased visibility. Topographical variations of the course taken by the frontal branches of the facial nerve were studied and are described in this report.

The terminal vascular bed in the superficial cortex of the rat. An SEM study of corrosion casts

The capillaries in the vascular bed of the rat brain have been investigated by means of scanning electron microscopy of corrosion casts. A technique is described that allowed the finer ramifications to be observed. A series of representative sites from the arteriovenous terminal pathway are described in detail. Contrary to previous reports, the dichotomic pattern of vessel distribution is shown to prevail over the network pattern. Arteriovenous shunts of discrete size were not seen. "Thoroughfare channels" could be recognized. The findings are considered in light of current physiological knowledge, and their significance for microcerebrovascular flow is indicated.

Primary intracranial germ-cell tumors. A clinicopathological study of 14 cases

Fourteen cases of primary intracranial germ-cell tumors are presented. Histologically, there were eight germinomas, three teratomas, and three germ-cell tumors of more than one histological type. Immunohistochemical studies revealed alpha-fetoprotein in yolk-sac tumor components in two cases and beta human choriogonadotropin in syncytiotrophoblastic giant cells in one case. One teratoma contained an unusual pleomorphic sarcomatous portion with features of early myoblastic differentiation. Comparison of intracranial with gonadal germ-cell tumors shows that the same subtypes are found in both locations with comparable incidence and similar biological behavior. The detailed World Health Organization classification of testicular germ-cell tumors should be applied to the histopathological classification of intracranial germ-cell tumors. Despite the critical location of intracranial germ-cell tumors, a good outcome can be achieved by optimal surgical excision. A primary microsurgical approach provides a histopathological diagnosis, which is indispensable for the proper choice of postoperative management.

Arteriovenous malformations of the spinal cord

The operative experience in Zürich of forty-one cases of spinal AVM with major intramedullary components showed that it was possible, with the aid of precise microsurgical techniques, to remove completely 60% of these lesions with improvement, or, at least, without deterioration in neurological condition. A further 12% could be apparently effectively palliated by subtotal removal. Radical surgery may be justified in patients with irreversible neurological deficits to treat pain and to prevent fatal SAH. The best results have generally been obtained in patients with less severe neurological deficits and with lesions in the cervical region rather than the thoracolumbar region. The natural history of intramedullary spinal AVMs--that of deterioration after recurrent haemorrhage--is analogous to that of intracranial aneurysms--and the need for earlier diagnosis and for early preventive surgery is the same for both. It would, perhaps, be preferable to treat all cases of spinal AVM by transvascular occlusion to obviate the risk of open surgery and of spinal deformity, but some AVMs will remain impossible to treat by this means and the long term results of embolization still require full analysis before it can be accepted as definitive treatment. Comprehensive and exact superselective spinal angiography is a mandatory prerequisite to surgery and preoperative partial embolization may facilitate operation considerably in the future. However, even the most careful angiographic studies do not always totally define the lesion and the surgeon must be prepared to find unexpected vascular relationships at operation. A simple classification of intramedullary and mixed extra/intramedullary lesions is described. The experiences with dural arteriovenous malformations in Queen Square again show that the best results are obtained in patients who have mild or moderate neurological deficit preoperatively. There is no doubt that progressive neurological deficits finally become irreversible and it is therefore clear that once the diagnosis is suspected, it should be definitively established and operation should follow immediately. The prime, indeed the only, necessary investigation is selective spinal angiography, which demands a high degree of radiological skill and experience, but given these prerequisites, may be performed with little hazard. While embolization of these lesions is possible, the simple surgical disconnection of the nidus of the shunt from the coronal venous plexus is effective in most cases, apparently permanently, and is substantially without risk.

The radiological diagnosis of cerebral venous angioma: cerebral angiography and computed tomography

The angiographic and CT findings in seven cases of cerebral venous angioma are presented and analyzed. Two cases were also examined with dynamic CT. The radiological literature on the subject is reviewed and a new classification of cerebral venous angioma based on its pattern of drainage is proposed. It is concluded that with the use of thin slices and coronal cuts both the angioma and its pattern of venous drainage can be identified on CT in a high proportion of cases. In addition, with dynamic CT the specificity of CT in diagnosing cerebral venous angioma may further increase.

4-Aminopyridine and fiber potentials in rat and human hippocampal slices

Compound fiber action potentials of stratum radiatum afferents in slices from human and rat hippocampus are shown to be prolonged by 4-aminopyridine (4-AP). This action can explain the enormous increase in synaptic transmitter release caused by 4-AP.

Auditory brain stem responses in patients with posterior fossa tumors

Twenty patients suffering from space-occupying lesions of the posterior fossa were investigated with the help of brain stem auditory evoked potentials. The results were compared with the findings of computerized tomography (CT) and with the operative findings. In large cerebellopontine angle tumors, there was severe attenuation of all components ipsilateral to the lesion, which may or may not include wave I. In patients with intrinsic pontine tumors, severe degradation of the components subsequent to wave III was found. In cerebellar tumors, caudal distortion of the brain stem seems to cause an increase of the interpeak separation of III-V, whereas rostral compression did not alter the responses. No consistent pattern appears to be recorded in extrinsic brain stem tumors. In only 2 of 8 patients in whom postoperative observations were made did the postoperative responses parallel the overall clinical course of the early postoperative period.

Selective amygdalohippocampectomy as a surgical treatment of mesiobasal limbic epilepsy

We report indications and techniques as well as preliminary results of a new microsurgical method of treatment for patients with drug-resistant psychomotor epilepsy in whom mesiobasal temporal lobe epilepsy has been diagnosed. The most important reason for surgical intervention in our series of 27 patients was their epilepsy. In 12 patients a tumor of the amygdala and/or hippocampal formation was suspected or had been proved. In 13 patients the amygdala and/or hippocampus had been delineated as the epileptogenic area by long-term monitored stereo-electroencephalography. In the remaining 2 patients, clear-cut ictal findings on surface electroencephalography allowed operation. Preliminary results of this selective surgical procedure are very promising. They indicate that this type of psychomotor epilepsy can be treated more successfully in ths new way than by the classic removal of the temporal lobe or by stereotactic methods. After 6 to 73 months of follow-up (mean = 21), 22 patients were free of seizures. The postoperative neuropsychological follow-up studies showed better results than those for patients who underwent large temporal lobe resections. In more than half of the patients a clear-cut general improvement in tests of intellectual performance was found. Learning and memory impairments were also much less pronounced or even undetectable.

Microsurgical treatment of cerebral aneurysms at the bifurcation of the internal carotid artery

With microtechnique, meticulous dissection and identification of critical anatomical structures become realities, contributing substantially to the improved results in the treatment of internal carotid artery bifurcation aneurysms.

Brain vascularization by transplanted omentum: a possible treatment of cerebral ischemia

The authors report their experience with experimental brain vascularization with the use of transplanted omentum majus. The possibility of treating cerebral ischemia with this method is discussed.

Association of middle cerebral artery anomalies with saccular aneurysms and Moyamoya disease

Two cases are reported in which accessory middle cerebral arteries were associated with stenoses around the internal carotid artery bifurcation, aneurysms and collateral vascularization similar to Moyamoya disease. The findings are discussed.

Cerebral cavernous haemangiomas or cavernomas. Incidence, pathology, localization, diagnosis, clinical features and treatment. Review of the literature and report of an unusual case

Reviewing the literature and adding one unusual case the features of 164 cerebral cavernous haemangiomas are described with special reference to incidence, localization, diagnosis and clinical findings. Cavernomas may be found in every age group including the neonatal period. The sex incidence is equal. In 126 cases (76.8%) the cavernomas were of supratentorial, in 34 cases (20.7%) of infratentorial site, and in 4 more cases (2.5%) there was multiple occurence of supratentorial and posterior fossa cavernous haemangiomas. A specific clinical syndrome could not be defined: but the course is usually acute or subacute, and initial symptoms are commonly epileptic fits, acute headache and subarachnoid or intracerebral haemorrhage. Macroscopic calcifications of cerebral cavernomas were found only in 18 cases (11%). Cerebral angiography was done in 31 cases (18.9%). In 9 cases angiography was totally normal, and in 11 cases the cavernoma presented only as an avascular mass. In the remaining cases there was no conformity in the angiographic appearance of cerebral cavernous haemangiomas. Operative extirpation is the treatment of choice if a solitary lesion is favourably located. In addition to our patient there are now 21 cases (12.8%) in which cavernomas were treated successfully by operative extirpation.

Complete microsurgical excision of cervical extramedullary and intramedullary vascular malformations

Eleven patients with vascular malformations of the cervical spinal cord have been operated upon at the University of Zürich. Total microsurgical excision was achieved in all. One patient had a lesion which was entirely intramedullary. Nine patients had combined lesions, intramedullary and extramedullary. Only one patient had a lesion which was entirely extramedullary. There was one operative death from meningitis. Another patient improved slightly postoperatively, but eventually died of urological complications. One patient had the operation immediately following his only subarachnoid hemorrhage, and has thus been protected from neurological damage. One patient has had postoperative reversal of his progressive neurological deterioration and severe pain. Six patients severely impaired preoperatively improved dramatically. One patient who was quadriplegic preoperatively has regained function in her upper extremities. The treatment of choice in lesions such as these is complete microsurgical excision.

Experimental intracranial transplantation of autogenic omentum majus

✓ The authors report the technique and successful results of experimental intracranial free transplantation of the greater omentum in dogs by microsurgery. The absorptive capacity of the omentum is demonstrated.

Saccular aneurysms of the distal anterior cerebral artery

✓ A series of 13 patients with saccular aneurysms of the distal anterior cerebral artery, operated on by the same surgeon with microtechniques, is reviewed. The incidence of aneurysms in this location was 3.4%, the median age of the patients 44 years, and the median time from most recent hemorrhage to surgery 13 days. There were five cases of multiple aneurysms. No operative mortality occurred; the operative morbidity was 15%. Because of their multiplicity, characteristic broad base, and the small subarachnoid space in the interhemispheric fissure, these aneurysms are judged technically difficult.

Microsurgical treatment of intracranial saccular aneurysms

✓ A consecutive series of 250 patients with cerebral aneurysms operated on with microsurgical techniques is presented. Good results were obtained in 83% of the entire series and in 94% of patients who were Grades 1, 2, and 3 preoperatively. The overall mortality rate was 5%; it was 1.6% for Grades 1, 2, and 3 patients, and there were no deaths in the 112 patients in Grades 1 and 2. The microsurgical techniques and the preoperative and operative factors that influenced the results are discussed.