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Bernardo Borovich, Marcel Mayer, Baruch Gellei, Eli Peyser and Mordechai Yahel

✓ A case is presented in which two separate concurrent astrocytomas of the brain in the same patient were successfully operated on. The patient has been followed for 3 years and remains well. The authors believe that the diagnosis of multifocal tumors can be established on clinical grounds when the tumors are remote from each other, and when there has been no recurrence of neoplasm between the lesions after a long follow-up period. It is felt that a more optimistic approach to the treatment of multifocal tumors may yield good results.

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Bernardo Borovich, Jacob Braun, Silvia Honigman, Henry Z. Joachims and Eli Peyser

✓ A case is presented in which computerized tomography (CT) demonstrated a supratentorial and parafalcial purulent collection. However, neither carotid angiography nor CT revealed the small scattered pockets of pus that were found over the convexity at operation. The entire subdural space was exposed by a wide craniectomy, permitting adequate subdural drainage and decompression of the brain. It is thought that thorough drainage of the entire subdural space is crucial for the attainment of a successful result in a singlestage operation.

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Menashe Zaaroor, Bernardo Borovich, Lucyna Bassan, Yaffa Doron and Jan Gruszkiewicz

✓ A case of cutaneous extravertebral meningioma is presented. It was diagnosed in infancy as a lumbar meningocele. Operation was initially refused but was subsequently demanded for cosmetic reasons. The findings were a very thick corrugated skin and a cutaneous meningioma connected by a fibrous tract to the dura mater. The presence of a fibrous stalk linking the tumor to the dura mater might have been the pathogenetic connection between the meningocele and cutaneous meningioma.

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Bernardo Borovich, Jacob Braun, Joseph N. Guilburd, Menashe Zaaroor, Michel Michich, Lion Levy, Anshel Lemberger, Ian Grushkiewicz, Moshe Feinsod and Izu Schächter

✓ During a 4½-year period, seven patients with delayed onset of an extradural hematoma were seen among 80 consecutively treated cases of extradural hematoma for a frequency of 8.75%. The hematomas were insignificant or not present on initial computerized tomography (CT) scanning. Repeat CT scans within 24 hours of admission showed sizeable hemorrhages. Six hematomas were evacuated, and one was reabsorbed spontaneously. In only one patient did neurological deterioration herald the onset of the extradural hematoma, four patients remained unchanged, and two improved before diagnosis. Intracranial pressure (ICP) was monitored in five patients, four of whom showed intermittent rise in pressure despite preventive treatment. Intracranial hypotension and rapid recovery from peripheral vascular collapse seemed to be contributory factors in the delayed onset of an extradural hematoma. Awareness of this entity, a high degree of vigilance, ICP monitoring, and repeat CT scanning within 24 hours of injury are strongly recommended in these cases, especially after decompression by either surgical or medical means, recovery from shock, or whenever there is evidence of even minimal bleeding under a skull fracture on the initial CT scan.

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Bernardo Borovich and Yaffa Doron

✓ Meningiomas are regarded as benign dural tumors that can be totally removed; however, after a resection that appears to the naked eye to be total, their recurrence rate is high. Malignancy in a few cases and an erroneous belief in many others that the excision was total are among the most accepted explanations. Few studies have mentioned multicentricity as a cause of “relapse.” Therefore, the authors decided to examine the dura mater around globular meningiomas for evidence of regional multifocality. A radial strip of dura was removed from the line of attachment of globular meningiomas in 14 consecutive patients. Meningotheliomatous cell aggregates were demonstrated in 100% of these dural strips in the form of either intradural clusters or nodes protruding from the inner aspect of the dura. The benign appearance of the cells and the great prevalence in this study of the benign types of meningioma seem to exclude malignancy; the intradural position of the clusters and their independence from blood vessels apparently negate seeding and dural metastasis. Control strips of convexity dura mater taken from 10 neurosurgical patients without meningioma failed to show these meningotheliomatous conglomerates. These findings indicate that solitary globular meningiomas represent only the most visible growth in the midst of a neoplastic field change spreading over a wide area of dura mater. The authors believe that this can explain some unexpected “recurrences,” and that a wide resection of dura around globular meningiomas, whenever possible, could reduce the incidence of clinical growth after true total excision of the most visible lesion. It remains to be determined what factors cause the acceleration of growth of these cell aggregates after removal of the dominant tumor.

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Bernardo Borovich, Yaffa Doron, Jacob Braun, Joseph N. Guilburd, Menashe Zaaroor, Dorit Goldsher, Anshel Lemberger, Jan Gruszkiewicz and Moshe Feinsod

check; Globular single meningiomas are generally regarded as benign tumors that can be completely removed. Nevertheless, after a total macroscopic resection including the insertion zone (Grade 1 operation according to Simpson's classification), the incidence of recurrence ranged from 9% to 14% at the 5-year follow-up review. The authors have shown that single meningiomas represent only the visible predominant growth in the midst of a wide neoplastic field in the dura mater. Regional multiplicity in meningiomas would thus seem to be the rule. With this in mind, the authors propose to divide recurrences after Grade 1 operations into 1) true local and 2) false regional. A local recurrence is defined as a regrowth within the limits of the previous dural flap. Regional recurrence is when new growth develops outside the previous craniotomy site; this should not be considered as a recurrence but as a new primary site. These regional recurrences might explain some unexpected late tumor growth occurring after a Grade 1 operation. Five illustrative cases in which regional recurrence was detected by computerized tomography are presented. The authors also propose to add a supplementary grade to Simpson's surgical grading: Grade 0. This operation would entail a wide resection of the dura around the attachment zone of the meningioma. The authors hope that with a Grade 0 operation the incidence of recurrence might be reduced.

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Bernardo Borovich, Elizabeth Johnston and Edgardo Spagnuolo

✓ Infratentorial subdural empyemas are rare. The authors report three cases encountered between 1979 and 1988, representing a 3% incidence among all subdural empyemas. The common source was an ear infection. Clinical presentation encompassed a systemic febrile illness, headaches, and a stiff neck. Only one patient had an inconspicuous focal neurological deficit that suggested a cerebral location. Initial diagnosis was acute meningitis in each case. A lumbar puncture was ordered in all three cases but was actually performed in two without developing tonsillar herniation. Cerebrospinal fluid analysis confirmed the diagnosis of meningitis in one but was normal in the other. Computerized tomography allowed a precise diagnosis and localization of the pathology. All three patients received aggressive antibiotic therapy plus suboccipital craniectomy and aspiration of pus; catheter drainage was performed in two. Cultures were positive in one case and negative in the others. Two patients were cured without sequelae; the third patient was moribund at surgery and died. Although it is known that subdural empyemas may localize in the posterior fossa, only one previous report was found. Infratentorial subdural empyema may sometimes be an unrecognized companion of acute meningitis and is cured with antibiotic therapy alone.

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Alberto A. Biestro, Ricardo A. Alberti, Ana E. Soca, Mario Cancela, Corina B. Puppo and Bernardo Borovich

✓ The effect of indomethacin, a cyclooxygenase inhibitor, was studied in the treatment of 10 patients with head injury and one patient with spontaneous subarachnoid hemorrhage, each of whom presented with high intracranial pressure (ICP) (34.4 ± 13.1 mm Hg) and cerebral perfusion pressure (CPP) impairment (67.0 ± 15.4 mm Hg), which did not improve with standard therapy using mannitol, hyperventilation, and barbiturates. The patients had Glasgow Coma Scale scores of 8 or less. Recordings were made of the patients' ICP and mean arterial blood pressure from the nurse's end-hour recording at the bedside, as well as of their CPP, rectal temperature, and standard therapy regimens. The authors assessed the effects of an indomethacin bolus (50 mg in 20 minutes) on ICP and CPP; an indomethacin infusion (21.5 ± 11 mg/hour over 30 ± 9 hours) on ICP, CPP, rectal temperature, and standard therapy regimens (matching the values before and during infusion in a similar time interval); and discontinuation of indomethacin treatment on ICP, CPP, and rectal temperature.

The indomethacin bolus was very effective in lowering ICP (p < 0.0005) and improving CPP (p < 0.006). The indomethacin infusion decreased ICP (p < 0.02), but did not improve CPP and rectal temperature. The effects of standard therapy regimens before and during indomethacin infusion showed no significant changes, except in three patients in whom mannitol reestablished its action on ICP and CPP. Sudden discontinuation of indomethacin treatment was followed by significant ICP rebound. The authors suggest that indomethacin may be considered one of the frontline agents for raised ICP and CPP impairment.