A history of neurological surgery at the University of California, San Francisco.

Over a span of 80 years and four chairmanships, and now beginning the fifth chairmanship, the Department of Neurological Surgery at the University of California, San Francisco has held a position of renown among academic institutions serving neurological surgery. This article attributes this reputation to the qualities of the chairmen, an unforgettable group including Howard Naffziger, Edwin Boldrey, John Adams, and Charles Wilson. Some of their accomplishments are described.

The Krause operations.

Some of Fedor Krause's contributions to operative technique are reviewed and portrayed as fundamental steps in the progress of neurological surgery. The approaches he devised, the "Krause operations," are exposure of the trigeminal ganglion and root, of the cerebellopontine angle, and of the pituitary (transfrontal) and the pineal (supracerebellar) regions. This review recalls the significance of the aggregate body of Krause's work, which has not been fully appreciated except by his compatriots.

Nonoperative treatment of spinal epidural infections.

Spinal epidural infections were diagnosed before the onset of neurological deficits in six patients and treated nonsurgically. The diagnosis was based on the clinical presentation and on the results of myelography and computerized tomography scanning. Positive cultures were obtained from blood in all six patients, from aspiration of a paraspinous infection in two, and from a skin abscess and a pulmonary empyema in one patient each. Staphylococcus aureus was the causative organism in five cases. All patients were treated with intravenous antibiotics and remained neurologically intact throughout the course of treatment. Five patients have had no recurrence of their symptoms. One patient eventually required surgery for persistent discitis.

Differentiation of aseptic and bacterial meningitis in postoperative neurosurgical patients.

The differentiation of bacterial from aseptic meningitis in postoperative neurosurgical patients has traditionally been based on the clinical setting, a recent history of steroid administration, and cerebrospinal fluid (CSF) studies, including the total and differential leukocyte counts, Gram stain, glucose, and total protein. Recent reports questioning both the validity of a relative CSF lymphocytosis in excluding bacterial meningitis and the usefulness of standard CSF testing prompted the authors to reevaluate these standard criteria. The type of operation, the presence of a foreign body, use of steroids, postoperative day on which symptoms developed, altered mental status, neck stiffness, headache, and nausea were not helpful in the differential diagnosis. High fever, new neurological deficits, an active CSF leak, and elevated leukocyte counts in the CSF and peripheral blood favored a bacterial etiology. The CSF glucose level and the differential leukocyte count were less helpful. No criterion or combination of criteria was sensitive and specific enough to reliably differentiate aseptic from bacterial meningitis in the majority of patients. The possibility of improving diagnostic accuracy with newer tests, such as CSF lactate, ferritin, total amino acids, C-reactive protein, and amyloid-A, should be assessed.

Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery: case report.

We report the case of a patient with cervical monoradiculopathy secondary to a pseudoaneurysm of the vertebral artery caused by a knife wound to the neck.

Subarachnoid hemorrhage from a peripheral intracranial aneurysm associated with malignant glioma: report of a case.

The case of a patient who initially presented with a subarachnoid hemorrhage from an aneurysm of the distal left middle cerebral artery is reported. The aneurysm was later found to have occurred within a malignant glioma. Histological analysis showed tumor infiltrating the wall of the aneurysm. A causal relationship between growth of the tumor and development and rupture of the aneurysm is postulated.

Cushing's legacy to transsphenoidal surgery.

Cushing's experience with the surgical treatment of pituitary adenomas and other lesions producing the chiasmal syndrome is reviewed. The conclusion is that his ultimate rejection of the transsphenoidal route was not due to his dissatisfaction with this procedure, but rather came about because of the transfrontal route provided him with access to the pituitary and, at the same time, enabled him to verify all suprasellar tumors if the preoperative diagnosis was uncertain. Until he gave it up in 1929, Cushing used the transsphenoidal route preferentially when the sella was large. Some of his assistants in the clinic, notably Norman Dott, came away with a high and lasting regard for the operation, and Dott's subsequent influence on Gérard Guiot is a crucial link in the return of transsphenoidal surgery to its current preeminent position.

Resection of multiple nocardial brain abscesses: diagnostic role of computerized tomography.

We present a case of multiple brain lesions in which the preoperative computerized tomographic (CT) scan suggested the presence of brain abscesses rather than metastatic tumors. The patient presented with symptoms of left frontal and right cerebellar mass lesions, confirmed by carotid and vertebral arteriography and a radionuclide brain scan. A CT scan revealed multiple contiguous ring-enhancing lesions of various sizes at both sites. With the exception of a prior mild pulmonary infection, no findings suggested underlying malignancy, immunosuppression, or medical illness. We based our decision to administer antibiotics preoperatively on the presumed presence of abscess. We found and totally removed two multiloculated abscesses during one operation and initiated sulfa drug therapy (sulfisoxazole) immediately after identification of the Nocardia organism. The patient experienced no postoperative complications and at 6-months follow-up is clinically free of disease.