Showing papers in "Journal of Neurosurgery in 1968"

Surgical Risk as Related to Time of Intervention in the Repair of Intracranial Aneurysms

Abstract: I T IS generally agreed that the surgical risk in intracranial aneurysm is closely related to the patient 's condition at the time of surgery, as well as to other factors such as age, associated disease, and the location of the aneurysm. Many criteria have been proposed 1,2,5 for the determination of surgical risk; some are based upon whether or not the patient is \"conscious,\" others upon the number of days that have passed since the last hemorrhage, and still others upon the patient 's age. We have felt that the intensity of the meningeal inflammatory reaction, the severity of neurological deficit, and the presence or absence of significant associated disease should provide the best clinical criteria for the estimate of surgical risk. Our modification of Botterell's classification 3 has been applied to 275 consecutive cases of intracranial aneurysm treated by the faculty and resident staff of the Ohio State University and affiliated hospitals over a 12year period (Table 1). In this series, a lmost all cases were graded at admission and again just prior to operation. I t is recognized that such classifications are arbi trary and that the margins between categories may be ill defined. We are, nevertheless, of the opinion that a fairly sharp differentiation is possible among patients who have few or no meningeal signs, patients who have welldefined meningeal signs but no neurological deficit, and patients who show neurological malfunction. Associated disease was sufficient to change the graded risk when it was unequivocally present and, in the judgment of the surgeon, severe enough to influence the patient 's operative or postoperative course. We did not consider it necessary for the patient to have recovered completely from all symptoms and signs of the hemorrhage to be considered an optimal or Grade I risk. Table 2 shows the relative distribution of

Anatomical variations in the pituitary gland and adjacent structures in 225 human autopsy cases.

Abstract: O BSERVATIONS in over 1,000 intracranial operations for tumors of the pituitary or for its palliative ablation by various members of the Neurosurgical Department at The New York Hospital-Cornell Medical Center have produced evidence of several hitherto unrecognized variations both in the gland and in the surrounding anatomy. To define these anatomical variations, the pituitary gland and adjacent structures were removed en bloc with a motor saw from 225 fresh autopsy cases, measured in detail, drawn, photographed, and embedded in plastic. None of these cases had had a recognized pituitary disease or operation. Attention was directed to the optic chiasm, the arachnoid cisterns, the diaphragm of the sella, the cavernous and intercanvernous sinuses, the carotid siphon, the surrounding bones, and the size and shape of the pituitary itself.

Vascular malformations ("angiomas") of the brain, with special reference to those occurring in the posterior fossa

Abstract: LTHOUGH vascular malformations (\"angiomas\") within the posterior fossa have been considered uncommon, or even rare, 2,3A2AS,26'27,32,37'38,4~ one of us has recently shown that such is not the caseY 2 This report gives our experience with certain major pathological features of 164 angiomas of the posterior fossa. In addition, the major pathological and demographical features of 330 patients with 346 cerebral angiomas and two dural angiomas are compared. Many of these cases had detailed gross examinations, and all were studied microscopically. These malformations were characterized according to the detailed morphological classification recently published by one of usY 1 The dural angiomas have been reported separately. 28

Abnormal myelograms in asymptomatic patients.

Abstract: I N THE evaluation of the patient with back, neck, arm, or leg pain, great reliance has been placed on the results of myelography. Occasionally, difficulties arise in the correlation of the results of this study with the clinical examination. The myelogram may be normal in the face of a clear-cut clinical syndrome, or defects in the positive contrast column may be found at levels other than those thought to be involved. Accordingly, more information has been needed relative to the incidence of myelographic abnormalities in the asymptomatic patient. This paper reports the incidence of myelographic abnormalities in 300 patients who were studied by posterior fossa myelography to establish a diagnosis of acoustic tumor. Myelograms of the spinal axis were obtained even though these patients had no symptoms of cervical or lumbar nerve root compression at the time of the examination.

Chronic Deafferentation of Human Spinal Cord Neurons

Abstract: T HE study of focal cortical epilepsy has led us to the belief that epileptic neurons are partially deafferentY The validity of this hypothesis has been demonstrated in the cat spinal cord where rhizotomy or hemi-cordotomy result in neuronal firing patterns that are similar to those seen in an epileptic focus. 1 Other work in our laboratories has shown that certain epileptogenic agents, when injected into the spinal cord of the cat, can produce unusual sensory states suggestive of pain and the neuronal firing patterns typical of epilepsy? It is our hypothesis that many of the central pain states that occur after nerve or spinal cord injury may be due to chronic deafferentation and subsequent hyperactivity at the segmental level. This report describes a paraplegic patient whose spinal cord neuronal activity was sampled.

Abnormal Cerebrovascular Network Related to the Internal Carotid Arteries

Abstract: APANESE neurosurgeons have recently observed in patients of their own race a variety of neurological disorders which are often transient and appear most frequently in young people. The typical angiographic appearance is that of narrowing or occlusion of both internal carotid arteries at the level of the siphon (C-1) together with a hemangiomatous network at the base of the brain (Fig. 1). These patients were initially reported as having a type of occlusive disease of the internal carotid artery. 1~ The entity has also been reported by other Japanese authors as occlusion of the circle of Willis, 3 telangiectasia, 1,11 or vascular malformation. ~,9 In 1964 we collected 21 case reports from the Japanese literature, added three of our own, r and concluded that the entity was unique to the Japanese. We reported the entity as "hemangiomatous malformation of bilateral internal carotid arteries at the base of the brain" and noted the similarity of the abnormal vasculature to the vascular network in the embryo. We noted, too, that the malformation was primarily limited to the distribution of the internal carotid arteries, s The term "cerebral rete mirabile" has some descriptive value although it is probably not entirely appropriate. The Western literature yielded only one similar case with bilateral involvement, and this patient was a Japanese woman. 1'~ Taveras and Wood ~ reported comparable cases in non-Japanese patients, but the occlusions were unilateral. Since our paper 6 in 1964, numerous other reports have appeared in the Japanese literature. Adding these to an additional number collected by writing all the neurosurgical clinics in Japan, we are now reporting a total of 96 cases. Analysis of the Cases

The effect of radiofrequency current and heat on peripheral nerve action potential in the cat.

Abstract: T HE use of radiofrequency (rf) current to produce cord lesions in percutaneous cordotomy 1~ prompted this study. The purpose was to see if the diameter of nerve fibers determined their sensitivity to rf current. Such differential sensitivity of nerve fibers to other forms of energy and manipulat ion is documented. Compression, 4,~'~'~~ cold/' '7 and anodal polarization ~1 all block the large A fibers first. By contrast, high voltage alternating current ~ and local anesthetics ';,s,', depress C fibers before the A group. Evidence indicates that peripheral nerve fibers maintain their size ranges in post-synaptic spinal cord projections? Thus, it is probable that any demonstrable relationship between fiber size and sensitivity to rf current in peripheral nerve would hold true for spinal cord. Since the effect of rf current is due to the heat that is generated, 1 the effect of graded hyper themia was also examined.

Factors affecting the clinical corse of patients with severe head injuries. 1. Influence of biological factors. 2. Significance of posttraumatic coma.

Abstract: T HE clinical developments that follow closed head injuries can be described in accordance with the flow chart in Fig. 1, which focuses on loss of consciousness. The inconstant \"epiphenomena\" related to brain concussion, ~1 such as focal lesions and hematomas, have not been considered in this approach to the problem. Some of the injured will die from the immediate or delayed effects of the cerebral damage, usually without regaining consciousness. Those who survive can remain in coma or eventually regain consciousness after some time. Psychic functions are presumably always disturbed to a variable degree during the initial phase after awakening from coma, but mental restitution is possible in time. In some cases, however, persistent dementia may be the final outcome. Thus it is possible to delimit three alternative clinical courses in the evolution of events, namely, the lethal course, the coma course, and the course that leads to a mental recovery. The physiological mechanisms that determine these developments are essentially unknown, even though it may be possible to identify some probable components. This paper reports an analysis of a series of severe brain injuries resulting from blunt head trauma according to the three categories above. Its purpose is to define some of the characteristics of the underlying biological factors and pathophysiological processes.

Lumbar Intraspinal Extradural Ganglion Cyst

Abstract: G ANGLION cysts are commonly found about the wrist and hand. z,'~ Theoretically, they can occur at any site in the body where periarticular connective tissue is present. Reports by others have indicated common involvement of various joint regions such as the shoulder, elbow, 2,5 hip, 9'1~ knee, 2,5 ankle, 2 and axillaY These cysts may cause pressure on adjacent peripheral nerves to produce a variety of neurological symptomsY ,1~ Recently, two patients consulted us for symptoms suggesting a protruded lumbar intervertebral disc; in each an extradural ganglion cyst was uncovered and removed at operation. Subsequently, an asymptomatic ganglion cyst was found in a third patient.

A Lateral Approach to the Cervical Spine: Technique and Indications*

Abstract: T HE lateral surgical approach to the cervical spine is a relatively recent development. Kiit tner u in 1917 described a technique for exposing the vertebral artery between the transverse processes. In his paper he mentioned that Helferich had suggested removal of the anterior rim of the foramen transversarium, but no further details of this technique were given until Henry's 8 precise description of the exposure of the second portion of the vertebral artery. This procedure was also used by Elkin and Harris 3 for traumatic vertebral arteriovenous fistulae. We had occasion to perform this operation for a spontaneous vertebral arteriovenous fistula, following Henry 's procedure. The vertebral artery was lifted from its bed by means of tapes applied above and below the lesion, and the abnormal communications could be occluded while the artery remained patentY 1 As we viewed the operative exposure, it occurred to us that this procedure provided excellent access to the lateral aspects of the cervical vertebral bodies, the intervertebral foramina, and the port ion of the anterior rami of the brachial plexus lying in the neural grooves of the transverse processes. Since then, we have used this approach (Figs. 1-3) on a small number of patients who had lateral bony spurs compressing the vertebral artery, arthritic spurs compressing cervical nerve roots, lateral rupture of a cervical disc, or damage to the upper portion of the brachial plexus near the transverse processes. All operations were performed under the control of an x-ray image intensifier and a television monitor to facilitate identification of the level of the lesion.

Study of functional recovery produced by delayed localized cooling after spinal cord injury in primates.

Abstract: N SPITE of the sophisticated advances in modern surgical therapy, the present day management of spinal cord trauma generally remains unsatisfactory. 6,~,:3 Current methods used in the treatment of spinal cord trauma consist of immobilization with skeletal traction, surgical decompression with or without incision of dural coverings, and immediate or delayed bony fusion to provide stabilization. Controversy even exists as to the merits of "conservative" treatment versus surgical decompression. s,'~,1'-1:~,1~,~7,:~~ Even among those favoring early laminectomy in patients displaying sensory-motor paralysis associated with a spinal fluid block, there is no unanimity of opinion whether the dura should be opened or left intact. In reviewing other approaches to the problem of spinal cord injury, we were impressed with some of the work relating to the protective effect of cold on brain. It has been shown that hypothermia will decrease the cerebral metabolic demand, reduce brain volume, bring about a reduction in the inflammatory response to brain injury, and allow the brain to tolerate extended periods of circulatory arrest? 4,1a-2u24,~'~,~'J,33 It has also been demonstrated that total body cooling to 30~ will protect the spinal cord of the dog during occlusion of the thoracic aorta? 5,16 Because of the accessibility of the injured segment of the spinal cord during surgical laminectomy, an attempt has been made to assess the practical advantages of direct

Pinealomas and Tumors of the Posterior Portion of the Third Ventricle

Abstract: T HIS is a review of 45 patients with tumors in the region of the pineal body and posterior third ventricle treated in the Department of Neurosurgery of the Lahey Clinic Foundation from 1934 to 1965. The pinealomas referred to in this report cannot be considered separately from other tumors of the posterior portion of the third ventricle for most of the diagnoses were unverified and based mainly upon clinical and radiologic findings. Tumors of the surrounding regions are not considered.

Control of Hydrocephalus by Valve-Regulated Venous Shunt: Avoidance of Complications in Prolonged Shunt Maintenance

Abstract: N A previous paper the technical measures necessary for ideal placement of the Holter valve-controlled shunt from ventricle to venous system were described. 16 Our accumulated experience with 140 venous shunts for progressive hydrocephalus in infancy from 1956 to 1966 now provides a basis for understanding and preventing shunt dysfunction or infection which often necessitate shunt removal. Cases in which shunts were used in the management of a known neoplasm are not included in this series. Prior experience with simple check valves for venous shunts first performed in 1949 had pointed up the problems resulting from overdrainage of ventricular fluid? s Check valves of proper resistance were simultaneously developed by Pudenz, et al., 2~ and SpitzY In considering this artificial but mechanically effective method for controlling ventricular pressure and size, three principles have gradually established themselves and now form the basis of our philosophy and plan of management. First, severe uncomplicated infantile hydrocephalus, when properly treated, clearly can be followed by normal brain development much more frequently than has been taught in the past. 6a4,15 Second, the ultimate result, although related in part to the original cause and severity of the hydrocephalus, is strongly affected by the adequacy of continued mechanical palliation. Even children who are apparently tolerating a shunt blockade will often be found to have re-enlarged ventricles with sufficient elevation of pressure to prevent optimal development, a,5 Third, the many technical problems posed by continuous maintenance of shunt function in the rapidly growing infant can be minimized by expert planning. In this paper we will deal primarily with

Intracranial arterial spasm: a clinical analysis.

Abstract: I T HAS become apparent during the past two decades that patients suffering from spontaneous subarachnoid hemorrhage frequently also have intracranial arterial spasm, a complicating factor that adversely affects their neurological status and prognosis, w-'''~''~,s,~ ~,16'z~ ,9,~3 ~,,,~7 Despite the common occurrence of this phenomenon, its exact etiology and pathogenesis are not known. Intracranial arterial spasm in humans can be induced by mechanical stimuli such as surgical trauma to the cerebral arteries, but the mechanisms that produce preoperative spasm are less well understood. This type of spasm has been found to have the following characteristics: it is seen most frequently in association with subarachnoid hemorrhage; it is usually most marked in the major cerebral arteries ipsilateral to a ruptured aneurysm and involves primarily the parent artery; it is almost exclusively an intradural phenomenon; it usually lasts for days to weeks and does not seem to vary in severity from minute to minute; and it does not appear to be caused by arteriography. Because of these clinical features, as well as the results of various laboratory investigations, 6,14,33,47,51'~7'59 it has been postulated that preoperative intracranial arterial spasm originates locally as a result of arterial distortion and irritation by aneurysmal rupture and perivascular clot formation, and is propagated to other areas by the nerves and smooth muscle fibers of the involved cerebral arteriesY ~ Our recent clinical experience with intracranial arterial spasm, as analyzed in the present paper, adds further support to this concept.

Anterior Cervical Fusion by the Smith-Robinson Approach*

Abstract: E ARE presenting our personal experiences in treating cervical disc disease and spondylosis by the Smith-Robinson technique of discectomy and anterior cervical fusion. 5,s Based upon careful analysis of the results, it is our feeling that this operative method is superior to those commonly used for these conditions in the past. Modifications of the posterior approach have usually been used to treat various conditions of the cervical spine, depending upon the condition expected. One might treat a nerve root compressed by osteophytes by a foraminotomy; ~ a soft posterolateral disc protrusion by partial excision through an interlaminar approach; :~ spinal cord impingement from a ventral ridge by total laminectomy, perhaps combined with dentate ligament section; ~ and midline disc herniation by laminectomy and transdural resection5 We believe that all of these conditions can be effectively treated by a single operation, without variation, consisting of total disc excision from an anterior approach followed by interbody bone grafting. We have utilized it in a series of 86 patients with disc protrusion and/or spondylosis of various kinds. Our resuits indicate that this operation has been successful for all of these conditions.

Increased Intracranial Pressure and Pulmonary Edema

Abstract: CARD1OVASCULAR response to raised intracranial pressure was first noted in the nineteenth century. 1~ Cushing gave meaning to this response when he demonstrated that the diastolic blood pressure always rose to a level slightly greater than that of the intracranial pressure5 This pressor response thus serves to maintain the circulation within the cranial cavity. Several groups of investigators have further characterized aspects of the hemodynamic response to increases in intracranial pressure; 2-4'(;'7'1j'I ~'16''-'~' however, none has studied the cardiovascular response that occurs with graded elevations in intracranial pressure. We have recently encountered 11 patients with pulmonary edema associated with increased intracranial pressure in the absence of concomitant cardiovascular or pulmonary disease. ~ These patients were all young, ranging in age from 12 to 44 years. Our laboratory experience has indicated that pulmonary edema can be elicited in about 20% of normal dogs and monkeys by the sustained elevation of intracranial pressure." The present experiments were performed to delineate both the systemic and pulmonary hemodynamic responses of higher primates to graded increases in intracranial pressure and thereby to understand both the Cushing reflex and the finding of pulmonary edema.

Cerebral arterial spasm. 2. Experimental evaluation of mechanical and humoral factors in pathogenesis.

Abstract: ONSTRICTION of arteries has been considered one of the physiological mechanisms for the control of hemorrhage since the time of John Hunter? 3 The occurrence of this phenomenon, termed spasm, in association with ruptured intracranial aneurysms has, however, been recognized for only 18 years. ='~ During this time surgeons have come to agree that ischemia of the brain, secondary to arterial spasm, is one of the principal causes of the morbidity and mortality in patients with subarachnoid hemorrhage, and some have stated that spasm is the greatest single problem in aneurysm surgery today. Arterial spasm, in addition to being an important clinical problem, remains one of the least understood of the physiological mechanisms for hemostasis. The arteries at the base of the brain are especially suited for study of the phenomenon, for it is only here that arteries are found bathed by clear fluid and covered by an avascular membrane which can be incised without exposing the outside of the artery to blood. These vessels also present a column of bright red blood outlined against the white tissue of the brain, a situation ideal for photography. From the work of others we know that cerebral arteries constrict in response to mechanical and electrical stimulation, and the topical application of autogenous blood or a variety of chemical compounds includ

Experimental improvements in the use of Silastic cuff for peripheral nerve repair.

Abstract: F OR nearly 90 years experimental and clinical evidence has favored structural support about a nerve repair 7,~7 with a material that permitted direct and reproducible maximal axonal spanning without axonal disorganization or connective tissue build-up. Only during the past year has such a material become available. 4 This material, Silastic, formed into thin, elastic tubes was tested in chimpanzees against thicker tubes of the same material, wraps of millipore, collagen, or silicone, and against standard epineural suturing without wrapping. The results have been promising? However, ill-fitting tubes, regardless of the material, can strangulate a nerve anastomosis if too tight or fail to support it if too loose. 13 Therefore, establishing the best cuff dimensions, including such specifications as the proper ratio between the cross-section area of the nerve and the tube, became an important prerequisite to clinical trials. This report describes refinements in the technical details of nerve repair utilizing a Silastic cuff.

Antifibrinolytic Therapy for Intracranial Aneurysms

Abstract: I T HAS long been known and it has been recently documented in an admirable fashion 7 that patients who sustain a subarachnoid hemorrhage from a ruptured berry aneurysm have a tendency to rebleed, that this tendency is minimal during the first 2 days, rises to a maximum about the end of the first week, falls to a relatively low level during the third week, and to a very low figure after the third month. Pathologically speaking, what does this mean? It probably means that the initial hemorrhage stops by means of the formation of a blood clot (possibly aided by arterial spasm), that this blood clot is intact for 2 days and then shows evidence of dissolution. Dissolution may allow a second hemorrhage to occur. If the second hemorrhage does not occur early, fibrous tissue and endothelial repair take place, thus providing the patient once more with a reasonable, if perhaps restricted, life expectancy. Therapeutically, there is little that can be done for the patient's initial hemorrhage beyond good medical and nursing care and the occasional evacuation of an intracranial hematoma. Most effort has been directed toward preventing the incidence and consequent mortality and morbidity of the second and subsequent hemorrhages. The classical surgical methods of clip, ligature, and encapsulation are well known. Medical reduction of blood pressure has also been advocated. 17 Another reasonable method that suggests itself is a prolongation of the duration of the naturally occurring hemostatic blood clot within and about the wall of the aneurysm. This prolongation might be expected to provide protection against hemorrhage while fibrous tissue and endothelial repair got under way. In the course of experimental work u designed to induce controlled thrombosis within intracranial aneurysms, we noted that electrically induced thrombi in the femoral artery

Further experience with surgical treatment of aneurysm of the basilar artery

Abstract: I T SEEMS CLEAR that, in regard to surgical treatment, aneurysms of the basilar artery should be considered in two groups, those along the trunk of the vessel and those at the bifurcation. As a result of previous experience in 14 cases, '~.'~ it was stated that: 1) most saccular aneurysms along the trunk of the vessel could be approached and obliterated by clip or ligature with reasonable safety, and 2) aneurysms at the bifurcation were particularly dangerous because of the hazard of injury to the leash of vital perforating vessels intimately applied to the sac posteriorly and irrigating the midbrain and diencephalon. These conclusions can he modified in view of further experience with 17 cases in which there were no operative deaths, while significant morbidity occurred only in two patients although ultimately it caused the death of one. The subtemporal approach previously described '~'~ appears to give the most direct access to these aneurysms whether they lie above or below the tentorium. We have not used hypothermia since 19627 Moderate (systolic pressure 70-80 mm Hg) or, preferably, deep or profound hypotension (systolic pressure 40-50 mm Hg) is used routinely at normal body temperature as the major surgical adjunct-. The pressure is measured through a cannula placed in the radial or femoral arteries. The reduction of pressure is induced with Arfonad and occasionally deepening of anaesthesia and change of posture. That perfusion of the brain and vital organs is adequate is evidenced by the fact that pressures of 45 mm Hg seem to be tolerated for 1 hour or more without demonstrable effect, even in patients over 60. The chief asset with this degree of hypotension is that the aneurysm is soft and can be

Increased intracranial pressure and pulmonary edema. 1. Clinical study of 11 patients.

Abstract: p ULMONARY abnormalities such as pulmonary edema, bacterial and viral pneumonia, and aspiration pneumonitis have frequently been reported in association with intracranial disease. Pulmonary edema often arises as a pathophysiological hemodynamic response to the intracranial disease without the complication of other etiologic agents. This report is an analysis of 11 such cases. All were young patients without primary cardiopulmonary disease.

Experimental study of patterns of brain distortion and ischemia produced by an intracranial mass.

Abstract: E XPANDING intracranial masses can cause neuronal dysfunction by several possible mechanisms. A rapidly expanding mass lesion may produce vascular compression and ischemia of brain tissue adjacent to the lesion. Brain substance remote from the mass also can be rendered ischemic because of the particular vulnerability of its blood supply to distortion and compression2 A notable example is compression of the posterior cerebral artery against the edge of the tentorium. A third mechanism to be considered is alteration of the electrical and chemical properties of neurons by distortion of their architectural arrangement. This is particularly pertinent in evaluating the significance of brainstem displacement and distortion. The purposes of the present investigation were to study displacement and distortion of the brain and intracranial vascular compression produced by acute expansion of an extracerebral balloon, and to correlate these effects with pressure measurements from various intracranial compartments. Particular attention was directed to gross morphological changes in the brain stem.