The lost art of localization: Franc Ingraham's legacy in pediatric neurosurgery.

The authors describe an 8-year-old girl who underwent emergency posterior fossa surgery for resection of a large cerebellar astrocytoma in November 1939. The surgery was carried out by Franc D. Ingraham at Boston Children's Hospital a decade after he established the first pediatric neurosurgical service in the world at the same institution. Four years later the tumor recurred and the patient underwent repeat resection followed by external-beam radiation therapy. The pathological diagnosis by Sidney Farber was fibrillary astrocytoma. The young girl is currently a healthy, functional 82-year-old woman. The authors believe that this 74-year follow-up represents one of the longest in history, if not the longest, of a patient undergoing resection of a brain tumor. A recent MRI study shows postoperative changes with no evidence of residual or recurrent tumor. The original block tissue specimen had been preserved. It was restained and examined, revealing the pathological diagnosis to be juvenile pilocytic astrocytoma. The case is analyzed in the context of Ingraham's powerful and lasting impact on the field of pediatric neurosurgery.

Cognitive deficits from a cerebellar tumour: a historical case report from Luria's Laboratory.

In 1964 an original case report from A.R. Luria's Laboratory of Neuropsychology was published in Cortex, being one of the first to draw a link between cerebellum and cognition, by highlighting the manifestation of 'pseudo-frontal' symptoms resulting from a cerebellar tumour. The findings of Luria and his team seem more consistent with modern views about cerebellar interactions with the frontal lobe and its contributions to behaviour than the views prevalent at the time of publication. The paper was originally submitted in Russian, and translated into Italian for its publication by Cortex. However, Cortex did not preserve the original manuscript in Russian. With the passage of time, and available only to the Italian readership, this case report inevitably fell into obscurity. Hence, we present a translation in English based on the published Italian version of the manuscript and discuss it in the context of Luria's general thinking about information processing in the brain and our current understanding of cortico-cerebellar system. The publication of this article gives readers an opportunity to consider the substantial influence of Soviet neuropsychology on the field internationally under Luria's leadership in the 1960s. It also shows that time is the best judge of ones scientific endeavours, and what may seem implausible today might prove to be valid and worthy of exploration tomorrow.

Unique challenges faced by pediatric neurosurgeon Harvey Cushing in 1909 at Johns Hopkins: a choroid plexus tumor of the lateral ventricle mimicking a cerebellar lesion.

INTRODUCTION: At the turn of the twentieth century, diagnosis of pediatric intracranial lesions frequently relied exclusively on the subtle, nonspecific signs associated with these pathologies. In absence of detailed neuroimaging, erroneous diagnoses and misdirected operative explorations were common within pediatric populations. METHODS: Following institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the surgical files from the Johns Hopkins Hospital for the years 1896-1912. Harvey Cushing's neurosurgical cases were collected and further analyzed. RESULTS: A 9-year-old boy presented with a year-long history of headaches and blindness. His neurological examination was remarkable for focal cranial nerve deficits and cerebellar signs. Cushing diagnosed a cerebellar tumor with hydrocephalus and performed two suboccipital explorations with negative results. The patient died prior to further operative intervention, and the postmortem examination revealed a large choroid plexus tumor within the left lateral ventricle. CONCLUSIONS: Early neurosurgical diagnosis and operative planning was fraught with difficulties, and surgeons relied solely on history and physical examination for localization of intracranial lesions. Here we report a case of a choroid plexus tumor of the lateral ventricle, which was misdiagnosed by Cushing. This case serves to emphasize the unique challenges faced by pediatric neurosurgeons at the turn of the twentieth century, who relied solely on history and examination to localize intracranial lesions.

Transotic approach to the cerebellopontine angle. 1992.

The transotic approach to the cerebellopontine angle has been developed at the University of Zurich for the removal of acoustic tumors in an effort to increase operative exposure and enhance facial nerve preservation and reconstruction. Key steps involve the total removal of all pneumatic cell tracts with middle ear and eustachian tube obliteration, followed by complete otic capsule removal for tumor exposure. This article discusses the advantages, disadvantages, and technique of this approach.

Inauguration of pediatric neurosurgery by Harvey W. Cushing: his contributions to the surgery of posterior fossa tumors in children. Historical vignette.

Development of posterior fossa surgery remains Harvey Cushing's hallmark contribution to pediatric neurosurgery. During the era before Cushing, posterior fossa lesions were considered inoperable, and only osseous decompressive surgery was offered. The evolution of Cushing's surgical expertise from subtemporal decompressions to total extirpation of vascular fourth ventricular tumors, combined with a dramatic decrease in his operative mortality rate, reflects the maturation of modern neurosurgical techniques. A comprehensive review of the medical records of Cushing's pediatric patients treated between 1912 and 1932 revealed that procedures such as lateral ventricular puncture (to decrease cerebellar herniation), transvermian approach to midline tumors, and electrocoagulation were the key factors punctuating the path to his pioneering achievements in posterior fossa surgery. The outcome of such operations was improved by his recognition of the importance of tumor mural nodule in cyst recurrence, as well as elucidation of the histogenesis of pediatric posterior fossa tumors to tailor treatment including radiotherapy.

The influence of Harvey Cushing on neuroradiologic therapy.

Harvey Cushing was largely responsible for the establishment of neurosurgery as a separate discipline. He demonstrated how careful attention to technique could make surgery acceptably safe, established classifications and clinical-pathologic correlations of a wide variety of tumors, and trained dozens of future neurosurgical department heads. Less well known, however, is Cushing's contribution to the early clinical use of radiation therapy for a variety of intracranial disorders. With the aid of his meticulous clinical follow-up, large case volume, and willingness to try new treatment methods, he demonstrated the utility of therapeutic radiation in patients with pituitary tumor, medulloblastoma, and arteriovenous malformation. His less impressive results with the irradiation of patients with glioma are also worthy of note and include trials of brachytherapy. Neurosurgeons and radiation oncologists exploring new methods of delivering therapeutic radiation to the central nervous system should be aware of the lessons learned from Cushing's experience.