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James P. Caruso and Jason P. Sheehan

At the peak of his career, Walter J. Freeman II was a celebrated physician and scientist. He served as the first chairman of the Department of Neurology at George Washington University and was a tireless advocate of surgical treatment for mental illness. His eccentric appearance, engaging personality during interviews, and theatrical demonstrations of his surgical techniques gained him substantial popularity with local and national media, and he performed more than 3000 prefrontal and transorbital lobotomies between 1930 and 1960. However, poor patient outcomes, unfavorable portrayals of the lobotomy in literature and film, and increased regulatory scrutiny contributed to the lobotomy’s decline in popularity. The development of antipsychotic medications eventually relegated the lobotomy to rare circumstances, and Freeman’s reputation deteriorated. Today, despite significant advancements in technique, oversight, and ethical scrutiny, neurosurgical treatment of mental illness still carries a degree of social stigma.

This review presents a historical account of Walter Freeman’s life and career, and the popularization of the lobotomy in the US. Additionally, the authors pay special attention to the influence of popular literature and film on the public’s perception of psychosurgery. Aided by an understanding of this pivotal period in medical history, neurosurgeons are poised to confront the ethical and sociological questions facing psychosurgery as it continues to evolve.

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Jason P. Sheehan and Jay Jagannathan

Intracranial radiosurgery has been proved effective for the treatment of brain metastasis. The treatment of paraspinal and spinal metastasis with spinal radiosurgery represents a natural extension of the principles of intracranial radiosurgery. However, spinal radiosurgery is a far more complicated process than intracranial radiosurgery. Larger treatment volumes, numerous organs at risk, and the inability to utilize rigid, frame-based immobilization all contribute to the substantially more complex process of spinal radiosurgery.

Beyond the convenience of a shorter duration of treatment for the patient, spinal radiosurgery affords a greater biological equivalent dose to a metastatic lesion than conventional radiotherapy fractionation schemes. This appears to translate into a high rate of tumor control and fast pain relief for patients. The minimally invasive nature of this approach is consistent with trends in open spinal surgery and helps to maintain or improve a patient's quality of life. Spinal radiosurgery has expanded the neurosurgical treatment armamentarium for patients with spinal and paraspinal metastasis.

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Jason P. Sheehan, Gregory A. Helm, Jonas M. Sheehan, and John A. Jane Sr.

Lumbar spinal stenosis can be effectively treated by performing an extensive ipsilateral spinal decompression, including a partial pediculotomy, and contralateral posterior bone fusion. Infrequently, complications can arise following radical decompression to alleviate symptoms of stenosis, and one such complication is a pedicle fracture. Three reports of pedicle fractures following extensive spinal decompression and contralateral posterior fusion are detailed. This complication is emphasized, and interventions are discussed.

Three patients presented with symptoms attributable to lumbar stenosis; they were initially treated with an ipsilateral decompression, achieved in part, through a partial pediculotomy followed by contralateral autologous bone fusion. Initially, all three patients improved postoperatively; however, they later developed neurological symptoms ipsilateral to the side of spinal decompression. Computerized tomography scanning demonstrated pedicle fractures on the decompressed side. This complication has not yet been reported in association with decompression and fusion for lumbar stenosis.

Two of the patients developed leg pain necessitating reoperation whereas the third experienced only mild transient symptoms. The fractured pedicle was removed in one patient; laminar and spinous process fusion was performed again. Another patient underwent a total laminectomy, removal of the fractured pedicle, and bilateral transverse process fusion. Reoperation yielded satisfactory outcomes. The third patient's symptoms resolved without intervention.

Pedicle fractures are a potential complication of extensive lumbar decompression and contralateral posterior fusion. Loading forces from the facets or transverse processes are possibly the cause of such fractures. Removal of the fractured pedicle, additional decompression, and enhanced bone fusion are recommended when the symptoms warrant surgical intervention.

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Intramedullary spinal cysticercosis

Case report and review of the literature

Jason P. Sheehan, Jonas Sheehan, M. Beatriz Lopes, and John A. Jane Sr.

Cysticercosis is the most common parasitic infection of the central nervous system. It infrequently affects the spine, but when it does, it can present with symptoms similar to other more common spinal diseases. The authors present a case of isolated intramedullary cysticercosis of the cervical spine and review the literature.

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Jay Jagannathan, Jason P. Sheehan, and John A. Jane Jr.

✓ The treatment of patients with Cushing disease and without magnetic resonance (MR) imaging evidence of Cushing disease (that is, negative MR imaging) is discussed in this paper. Magnetic resonance imaging is the diagnostic modality of choice in Cushing disease, but in up to 40% of these patients negative imaging can be caused by tumor-related factors and limitations in imaging techniques. In cases in which the MR imaging is negative, it is critical to make sure that the diagnosis of Cushing disease is correct. This can be accomplished by performing a complete laboratory and imaging workup, including dexamethasone suppression tests, imaging of the adrenal glands, and inferior petrosal sinus sampling when appropriate. If these evaluations suggest a pituitary source of the hypercortisolemia, then transsphenoidal surgery remains the treatment of choice. The authors favor the endoscopic approach because it gives a wider and more magnified view of the sella and allows inspection of the medial cavernous sinus walls. Radiosurgery is an effective treatment option in patients with persistent Cushing disease. When a target cannot be found on MR imaging, one can target the entire sellar region with radiosurgery.

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R. Webster Crowley, Nader Pouratian, and Jason P. Sheehan

✓ Despite the implementation of increasingly aggressive surgery, chemotherapy, and fractionated radiotherapy for the treatment of glioblastoma multiforme (GBM), most therapeutic regimens have resulted in only modest improvements in patient survival. Gamma knife surgery (GKS) has become an indispensable tool in the primary and adjuvant management of many intracranial pathologies, including meningiomas, pituitary tumors, and arteriovenous malformations. Although it would seem that radiosurgical techniques, which produce steep radiation dose fall-off around the target, would not be well suited to treat these infiltrative lesions, a limited number of institutional series suggest that GKS might provide a survival benefit when used as part of the comprehensive management of GBM. This may largely be attributed to the observation that tumors typically recur within a 2-cm margin of the tumor resection cavity. Despite these encouraging results, enthusiasm for radiosurgery as a primary treatment for GBM is significantly tempered by the failure of the only randomized trial that has been conducted to yield any benefit for patients with GBM who were treated with radiosurgery. In this paper, the authors review the pathophysiological mechanisms of GKS and its applications for GBM management.

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Jason P. Sheehan, Douglas Kondziolka, John Flickinger, and L. Dade Lunsford

Object

Nonfunctioning pituitary adenomas comprise approximately 30% of all pituitary tumors. The purpose of this retrospective study was to evaluate the efficacy and role of gamma knife surgery (GKS) in the treatment of these lesions.

Methods

The authors conducted a review of cases in which GKS was performed at the University of Pittsburgh between 1987 and 2001. Forty-six patients with nonfunctioning pituitary adenomas and with at least 6 months of follow-up data were identified. In 41 of these patients some form of prior treatment such as transsphenoidal resection, craniotomy and resection, or conventional radiation therapy had been conducted. Five patients were deemed ineligible for microsurgery, and GKS served as the primary treatment modality. Endocrinological, ophthalmological, and radiological responses were evaluated. The mean radiation dose to the margin was 16 Gy.

In all patients with microadenomas and 91% of those with macroadenomas tumor control was demonstrated after radiosurgery. Gamma knife surgery had essentially equal efficacy in terms of achieving tumor control in cases of adenomas with cavernous sinus invasion and suprasellar extension. No new endocrinopathies were noted following radiosurgery. In two patients, however, tumor growth and decline in visual function occurred.

Conclusions

Gamma knife surgery is safe and effective in treating nonfunctioning pituitary adenomas. Radiosurgery may serve as a primary treatment modality in some or as a salvage treatment in others. Treatment must be tailored to meet the patient's symptoms, overall health, and tumor morphometry.

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Rupa Gopalan, Kasandra Dassoulas, Jessica Rainey, Jonathan H. Sherman, and Jason P. Sheehan

✓ The management of craniopharyngioma involves balancing adequate reduction in tumor volume and prevention of recurrence while minimizing damage to delicate surrounding structures. Because of the lesion's proximity to the optic chiasm and its relationship to the hypothalamic–pituitary axis, morbidity rates following treatment can be high. Gamma Knife surgery (GKS) is now being considered as a viable method of providing tumor control while ensuring minimal side effects. The authors conducted a literature review of 10 studies in which GKS was used to treat craniopharyngioma; some lesions had been previously treated and some had not. The mean marginal dose ranged from 5 to 16.4 Gy (mean 12.3 Gy). Tumor control was achieved in 75% of cases overall and varied with tumor subtype (cystic, solid, mixed). Control was seen in 90% of solid, 80% of cystic, and 59% of mixed tumors. The overall morbidity rate resulting from radiosurgery was 4% and the overall mortality rate was 0.5%. These results suggest that GKS may provide a favorable benefit-to-risk profile for many patients with craniopharyngiomas.

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Jason P. Sheehan, John A. Jane Jr., Dibyendu K. Ray, and Howard P. Goodkin

✓ Although it is uncommon, pediatric brain abscess remains a serious, life-threatening neurological problem. Those with congenital heart disease, an ongoing infection, or an immunocompromised state are particularly at risk. The symptoms on presentation may include those associated with a space-occupying lesion in the brain, and neuroimaging has made the diagnosis of brain abscess more reliable. Prompt diagnosis and treatment are required to lessen neurological morbidity and the risk of death. Treatment includes medical management with appropriate and specific antimicrobials. Although the effectiveness of medical management has improved and some children may be treated with antimicrobial therapy alone, surgical evaluation remains an important component of the treatment algorithm for most pediatric patients.

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Corey Raffel