✓ The first successful operation ever on a parasagittal meningioma was performed in 1910 by Harvey Cushing. The operation turned out to be a critical event in his career as a neurosurgeon and made him confident about the possibilities of brain surgery. The patient was Leonard Wood, Major General and Chief of Staff of the United States Army, who was a military surgeon turned career officer. In the election campaign for the president to succeed Woodrow Wilson in 1920, Leonard Wood, the personification of competence, became the Republican favorite. General Wood was, however, eliminated from the presidential election campaign by complicated intrigues. From the next year on, General Wood experienced increasing warning signs of a recurrent tumor, which he unfortunately neglected. Not until 1927 did Wood again come under the care of Dr. Cushing, who had just returned from Britain, where in the course of a single month he had been awarded no less than seven distinctions from different medical societies. Deeply concerned at Wood's condition, Cushing decided to attempt extirpation of the recurrent tumor. General Wood died a few hours after the operation. No tragedy caused Cushing more distress than the death of General Wood, who 7 years earlier had been on the verge of being nominated President of the United States.
✓ Herbert Olivecrona (1891–1980) singlehandedly founded Swedish neurosurgery. At the International Congress in Neurology in Bern in August, 1931, Harvey Cushing invited the cream of the world's medical society to a private banquet. Among the 28 specially invited guests was Herbert Olivecrona. At 40 years old, Olivecrona took his seat with pioneers such as Otfrid Foerster, Percival Bailey, Hugh Cairns, Geoffrey Jefferson, and Sir Charles Sherrington. This suggests that Cushing was impressed by the Swedish aristocrat's didactic deeds when he visited the Serafimer Hospital in Stockholm 2 years earlier. During the mid-1920's, the radiologist Erik Lysholm greatly improved the technique of ventriculography and, challenged by Olivecrona, his diagnostic neuroradiology became of superior quality. In the early 1930's, utilizing technical innovations of his own, Lysholm became a master at demonstrating and localizing posterior fossa tumors, which Olivecrona then operated on. Olivecrona's clinic became the mecca to which many scholars, thirsting for more knowledge, went on a pilgrimage. The international reputation of the clinic was founded, not on epoch-making discoveries, but by the resolute and practical application of methods already launched elsewhere and the exemplary organization that Olivecrona had established in collaboration with Lysholm. In spite of hardships and primitive working conditions, the clinic at the Serafimer Hospital gradually developed into the ideal prototype for a modern neurosurgical department. Olivecrona trained many colorful personalities who later were to lay the foundation for neurosurgery in their home countries; these included Wilhelm Tönnis of Germany, Edvard Busch of Denmark, and Aarno Snellman of Finland. Olivecrona was a true pioneer who made major contributions in practically all fields of conventional neurosurgery.
Ib Søgaard and Bengt Ljunggren
✓ Hans Adolf Sølling (1879–1945), working completely on his own in the small town of Horsens, was Denmark's first neurosurgeon. Sølling was an admirable and talented man who performed major intracranial operations on more than 130 patients suffering from trigeminal neuralgia, as well as treating epilepsy, craniotrauma, brain tumors, glossopharyngeal neuralgia, and myelomeningoceles. Although not in the same league as Harvey Cushing (1869–1939), Vilhelm Magnus in Norway (1871–1929), and Herbert Olivecrona in Sweden (1891–1980), Sølling was a true Danish pioneer.
Lennart Brandt and Bengt Ljunggren
✓ The authors describe a new instrument for placement of bone dowels in procedures for anterior cervical interbody fusion.
Harald Fodstad, Bengt Ljunggren and Kristian Kristiansen
✓ In parallel with but completely independent from Harvey Cushing, Norway had its own giant in the establishment of the special field of neurological surgery. Vilhelm Magnus (1871–1929), born in the United States in Fillmore County, Minnesota, was Norway's pioneering neurosurgeon. Following graduation in Oslo, he started his clinical training in neurology and became an early member of the small group of neurologists of the time who were dissatisfied with the therapeutic nihilism generally accepted in relation to diseases of the nervous system. After working with Victor Horsley, whom he held in high esteem, Magnus devoted himself to surgically treatable lesions in the nervous system. During a quarter of a century he single-handedly established the special field of neurological surgery in Norway. Magnus was a far-seeing and brilliant surgeon with a broad intellectual mind, a startling diligence, and wide research activities. He published his first scientific paper in 1899 and his total contribution to the literature amounted to 70 papers. In 1901 he was able to demonstrate the importance of the corpus luteum in the first 3 weeks of pregnancy. As early as 1903 Magnus manifested his interest in the surgical treatment of brain tumors. In 1926 his surgical material comprised 216 patients, with an 8% operative mortality rate among 161 cases of supratentorial tumor versus 17% for 55 cases of infratentorial tumors, including 14 cases of acoustic tumor. Vilhelm Magnus, who visited Harvey Cushing in 1928, has hitherto not been given the attention he merits.
Bengt Ljunggren, Bengt Sonesson, Hans Säveland and Lennart Brandt
✓ The mortality rate has recently been reduced to only a small percentage of patients selected for early aneurysm surgery. Despite recovery without neurological deficits, however, a diffuse encephalopathy may remain, with emotional and psychological sequelae that will interfere with rehabilitation and social reintegration. The present study evaluates quality of life, degree of cognitive dysfunction, and adjustment of patients with a satisfactory neurological recovery after aneurysm operation in the acute stage following a major subarachnoid hemorrhage (SAH). Of 118 patients with a good neurological recovery, 40 patients were randomly sampled for a cross-sectional study and subjected to a questionnaire relating to their symptoms, a clinical interview, and a comprehensive neuropsychological investigation. The time interval between SAH and assessment varied between 14 months and 7 years, averaging 3½ years. By means of standardized psychometric testing of intellectual capacity, memory functions, visuo-spatial abilities, perceptual speed and accuracy, and concept formation, degrees of cognitive impairment ranging from slight to severe dysfunction were identified. The results suggest that these disturbances may be permanent. The degree of impairment appeared to correlate with the patients' age. Interview data revealed substantial post-hemorrhagic maladjustment with respect to vitality, social management, self-assertion, emotional control, temperament, mood, and cognitive abilities. These findings were considerably at variance with the symptoms reported. It is stressed that, in the absence of gross neurological deficits, vital information on post-hemorrhage adjustment and impairment may easily be overlooked due to psychological defensive measures. It remains an open question whether post-SAH encephalopathy is enhanced by surgery performed in the acute stage.
Lennart Brandt, Bengt Ljunggren, Karl-Erik Andersson and Bengt Hindfelt
✓ The capricious appearance of delayed cerebral vasospasm in some but not all patients with an aneurysmal subarachnoid hemorrhage (SAH) was the stimulus for studying the reactivity of human cerebral arterioles in vitro to various vasoactive agents (prostaglandin F2a, noradrenaline, serotonin, human plasma, and cerebrospinal fluid from patients with aneurysmal SAH). There was a marked variability in response between arterioles from different individuals. The finding of a markedly individual profile in terms of reactivity toward vasoactive substances emphasizes the importance of a human cerebral vessel wall factor in the pathogenesis of cerebral vasospasm.
Hans Säveland, Bengt Sonesson, Bengt Ljunggren, Lennart Brandt, Tore Uski, Stefan Zygmunt and Bengt Hindfelt
✓ Seventy-eight individuals among a population of 1.46 million suffered aneurysmal subarachnoid hemorrhage (SAH) during 1983. Within 24 hours after the bleed, 32 of the 78 patients were in Hunt and Hess neurological Grades I to II, 13 were in Grade III, 21 were in Grades IV to V, and 12 were dead on admission to a hospital or forensic department. When the amount of blood visualized on computerized tomography (CT) scanning was integrated with the Hunt and Hess neurological classification in order to improve prediction of prognosis, only 16 patients were considered to have a good prognosis (CT-modified Grades I to II), 21 had a less favorable prognosis (CT-modified Grade III), and 29 had a poor prognosis (CT-modified Grades IV to V).
Assessment at 1 year revealed that only 32 patients (41%) had a good physical recovery. The physical morbidity rate was 22%, and the overall mortality rate was 37%. Twenty-six individuals with a good neurological outcome and five with a fair outcome also underwent reexamination 1 year or more post-SAH, which included a comprehensive evaluation of the quality of life, assessment of cognitive dysfunction, and determination of general adjustment. Five of the patients with a good neurological outcome and all five with a fair outcome (four of whom had had a poor prognosis in the acute stage) showed severe psychosocial and cognitive incapacitation. When functional morbidity, based upon persistent severe cognitive and psychosocial impairment, was included in the outcome assessment, only 33% of the total series was considered to have a favorable outcome. Approximately 60% of the initially good-risk patients (Grades I and II) showed a good physical outcome without concomitant indications of severe cognitive dysfunction and/or psychosocial impairment. Among the good-risk patients with a CT-modified grade, the figure was 70%. It is suggested that in any outcome grading system, persistent cognitive and psychosocial disturbances be taken into account.
Bertil Romner, Bengt Ljunggren, Lennart Brandt and Hans Saveland
✓ Thirty-six patients with a proven first subarachnoid hemorrhage (SAH) from a ruptured supratentorial aneurysm were subjected to repeated transcranial Doppler sonography assessments. Eighteen individuals (Group A) were operated on within 48 hours, while the other 18 (Group B) had surgery between 49 and 96 hours after SAH. The patients represented two clinically comparable groups. In the first 72 hours post-SAH, no increased flow velocities suggestive of arterial narrowing or vasospasm were recorded. There was no significant difference in preoperative flow velocities between the groups. Postoperative flow velocities were significantly lower in patients operated on within 48 hours (p < 0.001). Two patients, who had surgery on Day 4 post-SAH and who showed the highest recorded postoperative flow velocities, died from cerebral vasospasm and infarction. The results favor a referral system which enables early surgical intervention not only to prevent rebleeds but also aimed at reducing delayed ischemic dysfunction.