Sanger Brown and Edward Schäfer before Heinrich Klüver and Paul Bucy: their observations on bilateral temporal lobe ablations.

Fifty years before a report on the complete bitemporal lobectomy syndrome in primates, known as the Klüver-Bucy syndrome, was published, 2 talented investigators working at the University College in London, England-neurologist Sanger Brown and physiologist Edward Schäfer-also made this discovery. The title of their work was "An investigation into the functions of the occipital and temporal lobes of the monkey's brain," and it involved excisional brain surgery in 12 monkeys. They were particularly interested in the then-disputed primary cortical locations relating to vision and hearing. However, following extensive bilateral temporal lobe excisions in 2 monkeys, they noted peculiar behavior including apparent loss of memory and intelligence resembling "idiocy." These investigators recognized most of the behavioral findings that later came to be known as the Klüver-Bucy syndrome. However, they were working within the late-19th-century framework of cerebral cortical localizations of basic motor and sensory functions. Details of the Brown and Schäfer study and a glimpse of the neurological thinking of that period is presented. In the decades following the pivotal work of Klüver and Bucy in the late 1930s, in which they used a more advanced neurosurgical technique, tools of behavioral observations, and analysis of brain sections after euthanasia, investigators have elaborated the full components of the clinical syndrome and the extent of their resections. Other neuroscientists sought to isolate and determine the specific temporal neocortical, medial temporal, and deep limbic structures responsible for various visual and complex behavioral deficits. No doubt, Klüver and Bucy's contribution led to a great expansion in attention given to the limbic system's role in action, perception, emotion, and affect-a tide that continues to the present time.

Frontolateral pins for halo ring placement: reassessment of a common neurosurgical procedure with CT measurements of skull thickness.

OBJECT: Halo orthosis placement is a common neurosurgical procedure for the treatment of cervical spine injuries. Frontal sinus puncture by the anterior pins may occur using standard techniques, and up to 30% are dissatisfied with forehead scarring, especially women and African Americans. METHODS: The authors describe a frontolateral (FL) anterior pin site placement supported by high-resolution CT scan skull thickness measurements. The standard supraorbital (SO) pin site is several centimeters above the lateral orbit, whereas the FL pin site is 2-3 cm posterolateral to the SO site. Frontolateral placement is just anterior to the temporalis muscle close to a triangular anterior projection of the temporal hairline. For quantitative information on skull thickness at the SO and FT pin sites, thin 0.625-mm CT scan measurements of the outer table, diploic space, and inner table were obtained in 40 adults (80 sites). RESULTS: The mean values for total skull thickness at the SO and FT sites were not significantly different. The inner table was significantly thicker at the FL site in both males and females, buttressed by the nearby greater sphenoid wing. The mean total skull thickness was significantly less in females than in males, but the values were not significantly different at the SO and FL sites. CONCLUSIONS: The FL and SO anterior pin sites are comparable with respect to skull thickness CT measurements, with a significantly thicker inner table at the FL site. In the senior author's experience, the FL anterior pin site yielded secure fixation without skull perforation, neurovascular injury, or propensity to infection. The cosmetic result of the FL site is more acceptable, and the authors recommend its general usage be adopted.

Chronic epilepsy due to low grade temporal lobe tumors and due to hippocampal sclerosis: do they differ in post-surgical outcome?

Chronic seizures as a presenting feature of low grade temporal lobe gliomas and hippocampal sclerosis (HS) are reported to have similar outcomes although the prognostic indicators may not be the same. This study seeks to identify the variables that are associated with poor surgical outcome in both conditions. A retrospective analysis from our epilepsy data base was performed. All low-grade temporal lobe gliomas were selected and relevant variables were compared to the same variables in HS patients. There were 34 tumors (out of 233 cases of chronic temporal lobe epilepsy = 14.6 %) with a mean age of onset of 19 years, and the preoperative duration was 12.3 years. When compared to 120 HS patients both of these factors were significantly different (p < 0.001). Age at the time of surgery for tumors was 31.08 (p = 0.5). Tumors were left sided in 20 patients. In tumor cases amygdala resection was complete in 75 %, for hippocampus 24 % were complete and 39 % partial. Astrocytoma, ganglioglioma and oligodendroglioma constituted 80 % of tumor cases. Good outcome (Engel's Class I) was achieved in 88.2 % of tumor cases and 71 % of HS cases while poor outcome (Class III + IV) was seen in 5.9 and 16.7 % respectively. The follow up period for the two groups was not significantly different. In multivariate logistic regression analysis, the groups differed significantly in preoperative delay (between diagnosis and surgery) and in epilepsy outcome. Chronic temporal lobe epilepsy due to low-grade tumors had significantly better surgical outcome with considerably less preoperative delay. The age of onset of seizures was younger in HS patients but a delay in surgical treatment was significantly longer. Given that the diagnosis of treatment-resistant TLE secondary to HS can be established after two failed AED trials at optimal doses, shortening the interval between diagnosis and surgery may improve epilepsy outcome.

Temporal lobe gangliogliomas associated with chronic epilepsy: long-term surgical outcomes.

OBJECTIVE: To review the clinical features and surgical outcome in patients with temporal lobe gangliogliomas associated with intractable chronic epilepsy. METHODS: The Rush University Surgical Epilepsy Database was queried to identify patients with chronic intractable epilepsy who underwent resection of temporal lobe gangliogliomas at Rush University Medical Center. Medical records were reviewed for age of seizure onset, delay to referral for surgery, seizure frequency and characteristics, pre-operative MRI results, extent of resection, pathological diagnosis, complications, length of follow-up, and seizure improvement. RESULTS: Fifteen patients were identified. Average duration between seizure onset and surgery was 14.3 years. Complex partial seizures were the most common presenting symptom. Detailed operative data was available for 11 patients - of these, 90.9% underwent complete resection of the amygdala and either partial or complete resection of the hippocampus, in addition to lesionectomy. Average follow-up was 10.4 years (range 1.6-27.5 years), with 14 patients improving to Engel's class I and one patient to Engel's class III. There were no recurrences, and permanent complications were noted in one patient. CONCLUSIONS: Long-term follow-up of patients with temporal lobe gangliogliomas associated with chronic intractable epilepsy demonstrates excellent results in seizure improvement with surgery and increasingly low incidence of complications with improvements in microsurgical techniques.

Repositioning of supraorbital nerve stimulation electrode using retrograde needle insertion: a technical note.

INTRODUCTION: With growing interest and acceptance of peripheral nerve stimulation (PNS) approach, there is now an increasing need in developing clear procedural details to resolve frequent complications and minimize associated tissue injury. Migration and suboptimal positioning of PNS electrodes are one of the most commonly observed complications of PNS approach. MATERIALS AND METHODS: We present a simple technique for repositioning a supraorbital electrode using retrograde insertion of introducer needle that allows one to place percutaneous (cylindrical) PNS electrode into appropriate anatomical location with minimal additional injury to surrounding tissues. RESULTS: This approach has been successfully used in multiple cases. An illustrative case of electrode revision with proposed technique is described in detail. CONCLUSION: This technically simple approach to repositioning of cylindrical supraorbital electrodes using retrograde needle insertion eliminates the need for a more elaborate and invasive procedure. The technique can be used for electrode repositioning in most PNS applications.

Evaluation of the prognostic indicators of giant intracranial aneurysms.

The indicators of poor outcome in giant intracranial aneurysms have been the subject of several studies in the literature. We conducted a retrospective analysis to evaluate the predictors of poor outcome in giant intracranial aneurysms. We studied consecutive cases with aneurysms admitted over a 9-year period in our institution. All the aneurysms were treated with clipping. Patient demographics, clinical profile, and aneurysm characteristics were evaluated in a multivariate analysis as probable indicators of Glasgow Outcome Scale (GOS) score. The outcome of the aneurysms (GOS score) was compared with the remaining non-giant aneurysms. A total of 41 giant and 348 non-giant aneurysms were identified in our series. In the multivariate analysis, the indicators of poor outcome were identified as poor clinical grade (p < 0.0004), intraoperative rupture (p < 0.007), and posterior circulation of the aneurysms (p < 0.01). Non-giant aneurysms had a better outcome compared with the giant aneurysms (p < 0.01). Giant aneurysms impose a relatively higher risk of morbidity and mortality to the patients. The predictors of the postsurgical outcome of the giant aneurysms include the clinical condition of the patient, location of the aneurysm, and intraoperative rupture.

Cerebral ischemia as a presenting feature of intracranial aneurysms: a negative prognostic indicator in the management of aneurysms.

OBJECTIVE: Cerebral ischemia (stroke) can be a presenting clinical feature of intracranial aneurysms and may herald poor prognosis. METHODS: A retrospective review of admissions for aneurysms over a 6-year period revealed that 12 patients (5%) had stroke or stroke-like presentations among 236 patients with intracranial aneurysms. Patient demographics, characteristics of aneurysms, and management were analyzed. RESULTS: Of 12 patients reviewed, nine had anterior circulation aneurysms. Two patients presented with subarachnoid hemorrhage and 10 with unruptured aneurysms. Eleven patients had stroke at the time of presentation, and five had a previous history of transient ischemic attacks. Ten patients had hypertension and eight were active smokers. The mean size of 10 aneurysms was 11.8 mm. Surgical extirpation of the aneurysms was performed in all cases. Four cases revealed thrombus in the aneurysm and one was atherosclerotic. The 6-month outcome was good in seven patients (58%) and fair in four patients (33%). One patient died. This outcome was significantly worse (P < 0.01) compared to that of good grade aneurysms in our database. Hypertension was a significant indicator of poor outcome (P < 0.02). CONCLUSION: Ischemic episodes as a presenting feature of intracranial aneurysms could be indicators of poor prognosis. Routine evaluation of stroke patients for aneurysms may help in early diagnosis. In addition, surgical obliteration of aneurysms could prevent subsequent strokes and neurological deficits.

Management of carotid artery injuries: Louisiana State University Shreveport experience.

BACKGROUND: Traumatic carotid artery injury is an infrequently encountered surgical entity. Carotid artery injuries in polytrauma patients can be easily missed in the absence of clinical findings and/or presence of confounding concurrent injuries. METHODS: Between 1991 and 1998, 23 patients were diagnosed with various carotid artery injuries at the trauma center of Louisiana State University Health Sciences Center, Shreveport, Louisiana. Injuries were assessed by angiography and/or surgical exploration of the neck. Clinical presentations, radiologic features, management strategies, and neurologic outcomes were statistically analyzed and compared with the existing literature. RESULTS: Twelve patients (52%) had penetrating carotid artery injuries, while 11 (48%) had blunt trauma. The diagnosis of carotid injury was significantly delayed in the group with blunt trauma as opposed to those with penetrating wounds. Surgical repair was performed in 6 (26%) patients; 2 (8%) underwent balloon occlusion, while ligation was conducted in 2 (8%) patients. Thirteen patients (57%) were treated conservatively with anticoagulants. Six patients (26%) died, while another 6 (26%) had permanent neurologic deficit. Mortality and morbidity was significantly higher in the group with penetrating injuries. A statistical analysis showed that multi-level carotid injury (p < 0.002) and increasing age (p < 0.001) had a significantly higher mortality. CONCLUSIONS: Injury to carotid arteries results in significant mortality and morbidity. Our results indicate that penetrating carotid injury at more than one level carries higher mortality and morbidity rates than blunt injury. Furthermore, early identification of the injured segment may favorably influence the outcome for such patients.

Selective intraoperative angiography in intracranial aneurysm surgery: intraoperative factors associated with aneurysmal remnants and vessel occlusions.

BACKGROUND: The objective of this study was to assess the role of selective intraoperative angiography and to analyze the factors associated with faulty clip application. METHODS: Two hundred thirty-eight patients undergoing surgery for intracranial aneurysms were studied consecutively for intraoperative angiography (IOA)-related events. The procedure was performed in 155 operations. Demographic details, clinical grade of the patient, location and size of the aneurysm, intraoperative rupture, application of the temporary clip, IOA findings, and final outcome were analyzed. RESULTS: In the 155 patients in the series, there were 125 anterior circulation aneurysms and 30 on the vertebrobasilar system. Aneurysms were smaller than 10 mm in 63% of the patients, and 19 were giant aneurysms. Thirty-eight percent were unruptured, 36% were Hunt and Hess Grades I and II, 21% were Grade III, and 5% were Grades IV and V. An intraoperative rupture occurred in 18 operations. Intraoperative angiography was normal in 88%; in 11 cases (7%) there was a residual neck, and in 8 (5%), occlusion of the artery was observed. An incomplete clipping was significantly related to intraoperative rupture of the aneurysm (p < 0.008) and anterior location of the aneurysm (p = 0.05), whereas vessel occlusion had a significant association with posterior location of the aneurysm (p < 0.0005). An eventful IOA had significant association with poor outcome (p < 0.003). CONCLUSION: Intraoperative rupture and a posterior location of the aneurysm had a significant correlation with residual aneurysm and vessel occlusion, respectively. The use of IOA is justified in aneurysms associated with these factors.

Primary cerebral sarcoid granuloma: the importance of definitive diagnosis in the high-risk patient population.

Sarcoidosis of the central nervous system has been variously reported in 5-15% of all sarcoid patients. However, presentation of sarcoidosis as an isolated 'intracranial tumor' is rare. A 35-year-old African-American woman presented with intractable headaches. Neuroimaging revealed a tumor that was suggestive of a glioma or meningioma or metastasis. The symptoms did not respond to steroids, and an open biopsy of the lesion revealed non-caseating granuloma. A thorough work-up for systemic sarcoidosis was negative. The patient remains symptom-free at a 2-year follow-up. Primary sarcoid granuloma of the brain is rare. Once systemic disease has been excluded, early tissue diagnosis is crucial. This is particularly relevant for patients in the high-risk population before considering empirical radiosurgery.

Far-lateral approach to intradural lesions of the foramen magnum without resection of the occipital condyle.

OBJECT: The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads. METHODS: During the last 6 years at Louisiana State University Health Sciences Center-Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9 degrees visibility, and removal of one half produced a mean increase of 19.9 degrees. CONCLUSIONS: On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.