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Ernest Joseph Barthélemy, Christopher A. Sarkiss, James Lee, and Raj K. Shrivastava

The historical origin of the meningioma nomenclature unravels interesting social and political aspects about the development of neurosurgery in the late 19th century. The meningioma terminology itself was the subject of nationalistic pride and coincided with the advancement in the rise of medicine in Continental Europe as a professional social enterprise. Progress in naming and understanding these types of tumor was most evident in the nations that successively assumed global leadership in medicine and biomedical science throughout the 19th and 20th centuries, that is, France, Germany, and the United States. In this vignette, the authors delineate the uniqueness of the term “meningioma” as it developed within the historical framework of Continental European concepts of tumor genesis, disease states, and neurosurgery as an emerging discipline culminating in Cushing's Meningiomas text.

During the intellectual apogee of the French Enlightenment, Antoine Louis published the first known scientific treatise on meningiomas. Like his father, Jean-Baptiste Louis, Antoine Louis was a renowned military surgeon whose accomplishments were honored with an admission to the Académie royale de chirurgie in 1749. His treatise, Sur les tumeurs fongueuses de la duremère, appeared in 1774. Following this era, growing economic depression affecting a frustrated bourgeoisie triggered a tumultuous revolutionary period that destroyed France's Ancien Régime and abolished its university and medical systems. The resulting anarchy was eventually quelled through legislation aiming to satisfy Napoleon's need for qualified military professionals, including physicians and surgeons. These laws laid the foundations for the subsequent flourishing of French medicine throughout the mid-19th century. Subsequent changes to the meningioma nomenclature were authored by intellectual giants of this postrevolutionary period, for example, by the Limogesborn pathologist Jean Cruveilhier known for the term “tumeurs cancéreuses de la duremère,” and the work of histopathologists, such as Hermann Lebert, who were influenced by Pasteur's germ theory and by Bernard's experimental medicine.

The final development of the meningioma nomenclature corresponded to the rise of American neurosurgery as a formal academic discipline. This historical period of growth is chronicled in Cushing's text Meningiomas, and it set the scientific stage for the modern developments in meningioma research and surgery that are conducted and employed today.

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Lee Kesterson, Edward Benzel, William Orrison, and James Coleman

✓ Although several large series of atlas fractures have been reported recently, none has concentrated on the evaluation and treatment of atlas burst fractures (Jefferson fractures). The treatment of this fracture is challenging. Its diagnosis may easily be missed due to concerns about associated trauma and absence of neurological signs. In addition, the open-mouth anteroposterior x-ray study, which is usually pathognomonic for the diagnosis, is often inadequate or not obtained. In order to clarify the diagnosis and treatment of this disorder, 17 cases of Jefferson fracture treated between 1982 and 1989 at the Louisiana State University Affiliated Hospitals are presented.

The diagnosis was delayed in three patients because of a low index of suspicion and inadequate x-ray films. Four patients were noted to have unstable Jefferson fractures; all of these had an associated Type II odontoid fracture and were treated with occiput-C-2 wiring and fusion. The remainder of the patients had stable Jefferson fractures and were managed with Minerva jackets or rigid collar stabilization. No significant complications related to the treatment of the Jefferson fracture occurred in this series. One patient died from associated injuries: however, the remaining patients enjoyed an excellent long-term result with the acquisition of spinal stability and the resolution of subjective complaints.

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James Rodney Feild, Ling Lee, and Robert F. McBurney

✓ Of 1000 patients who had 1202 brachial and 1099 carotid arteriograms between 1966–1970, 52 had mild and 15 severe complications. Cerebrovascular disease was most frequently encountered. There were 11 patients undergoing simultaneous carotid and brachial arteriography in whom complications could not be localized to an individual artery. Including this group the complication rate for brachial arteriograms was 3.99% and excluding this group the complication rate was 3.08%. There were 3.32% mild and 0.60% severe complications of brachial arteriography and a mortality rate of 0.21%. A serious complication occurred at a rate of one per 152 brachial arteriograms. The complication rate of brachial arteriography with carotid vascular disease was 2.70% and 6.41% with basilar artery disease. The total complication rate of brachial arteriography in cerebrovascular disease was 12.17%. The most common local complication was a transient loss of the radial pulse. The most common cerebral complication was a transient motor deficit.

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A. Lee Dellon, James N. Campbell, and David Cornblath

✓ Although sharp and blunt injury to the spinal accessory nerve has been well-documented, stretch or traction-type injury has not been reported previously. Such a case, treated successfully with nerve grafting, is described.

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W. Craig Clark, Thomas Callihan, Lee Schwartzberg, and James Fontanesi

✓ A very rare case of primary intracranial Hodgkin's lymphoma without dural attachment is reported. Based on a review of the literature and the clinical results in the present case, recommended therapy consists of surgical excision whenever possible, followed by radiotherapy.

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Supratentorial ependymomas

Neuroimaging and clinicopathological correlation

Ricardo S. Centeno, Arthur A. Lee, James Winter, and David Barba

✓ In 10 patients with supratentorial ependymomas, the tumors exhibited hyperdensity on computerized tomography (CT) scanning prior to contrast infusion and, with one exception, all tumors were mixed lesions with the low densities suggesting cystic or necrotic portions. Eighty percent of the tumors contained small calcifications. Characteristically, the tumors were well demarcated and demonstrated moderate to marked enhancement after the intravenous administration of contrast material. Angiograms obtained in some patients showed mild hypervascular tumor staining and absence of large feeding arteries. The degree of contrast enhancement, angiographic vascularity, and tumor stain was compared to the pathological anaplasia of the tumors. No correlation was observed. Of four patients who were still alive during a follow-up period of 4 years or longer, three had recurrences with inoperable tumors; the remaining patient is without recurrence after craniospinal radiation. This same patient belonged to a group of five patients with a diagnosis of high-grade ependymoma, four of whom had recurrence. Follow-up CT accurately recorded the clinical course of each patient. Annual routine follow-up examinations are proposed for patients with low-grade ependymomas, and for those with high-grade ependymomas follow-up CT should be performed every 6 months. The characteristic appearance and behavior of these tumors include several distinctive features on angiographic and CT images.

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Superficial temporal-middle cerebral artery bypass

A detailed analysis of multiple pre- and postoperative angiograms in 40 consecutive patients

Richard E. Latchaw, James I. Ausman, and Myoung C. Lee

✓ Pre- and postoperative angiograms on 40 patients undergoing superficial temporal-middle cerebral artery (STA-MCA) bypass surgery have been examined in detail. Multiple postoperative angiograms have been obtained to evaluate the change in both the bypass circuit and the intracranial circulation over time. A reproducible system for evaluating the degree of intracranial vascular filling via the bypass is introduced.

The study shows that the STA and its anastomotic branch increase in size over time, measured in months, in the majority of patients. This is paralleled by a progressive increase in the degree of intracranial vascular filling. These changes are proportional to the severity of the vascular disease before surgery. The pattern of preoperative collateral circulation may change over time following the addition of the bypass circuit. The progressive change over time suggests that a static analysis at one time may belie the true effect of the surgery. The change of collateral circulation, with augmentation of blood supply to areas of the brain other than those affected by the recent ischemic event, means that a total cerebral evaluation including neuropsychological testing may be necessary for adequate evaluation of the effect of the bypass surgery.

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Chang-Hyun Lee, Jaebong Lee, James D. Kang, Seung-Jae Hyun, Ki-Jeong Kim, Tae-Ahn Jahng, and Hyun-Jib Kim

OBJECT

Posterior cervical surgery, expansive laminoplasty (EL) or laminectomy followed by fusion (LF), is usually performed in patients with multilevel (≥ 3) cervical spondylotic myelopathy (CSM). However, the superiority of either of these techniques is still open to debate. The aim of this study was to compare clinical outcomes and postoperative kyphosis in patients undergoing EL versus LF by performing a meta-analysis.

METHODS

Included in the meta-analysis were all studies of EL versus LF in adults with multilevel CSM in MEDLINE (PubMed), EMBASE, and the Cochrane library. A random-effects model was applied to pool data using the mean difference (MD) for continuous outcomes, such as the Japanese Orthopaedic Association (JOA) grade, the cervical curvature index (CCI), and the visual analog scale (VAS) score for neck pain.

RESULTS

Seven studies comprising 302 and 290 patients treated with EL and LF, respectively, were included in the final analyses. Both treatment groups showed slight cervical lordosis and moderate neck pain in the baseline state. Both groups were similarly improved in JOA grade (MD 0.09, 95% CI −0.37 to 0.54, p = 0.07) and neck pain VAS score (MD −0.33, 95% CI −1.50 to 0.84, p = 0.58). Both groups evenly lost cervical lordosis. In the LF group lordosis seemed to be preserved in long-term follow-up studies, although the difference between the 2 treatment groups was not statistically significant.

CONCLUSIONS

Both EL and LF lead to clinical improvement and loss of lordosis evenly. There is no evidence to support EL over LF in the treatment of multilevel CSM. Any superiority between EL and LF remains in question, although the LF group shows favorable long-term results.

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James Lee, George I. Jallo, Michael Guarnieri, Benjamin S. Carson Sr., and Margret B. Penno

Object

Survival rates for high-grade brainstem tumors are approximately 10% and optimal therapy has yet to be determined. Development of a satisfactory brainstem tumor model is necessary for testing new therapeutic paradigms that may prolong survival. The authors report the technique, functional progression, radiological appearance, and histopathological features of a novel brainstem tumor model in rats.

Methods

Thirty female Fischer 344 rats were randomized (10 animals/group) to receive an injection of either 3 μl of 9L gliosarcoma cells (100,000 cells), 3 μl of F98 glioma cells (100,000 cells), or 3 μl of medium (Dulbecco modified Eagle medium) into the pontine tegmentum of the brainstem. Using a cannulated guide screw system implanted in the skull of the animal, rats in each group were injected at coordinates 1.4 mm to the right of the sagittal and 1 mm anterior to the lambdoid sutures, at a depth of 7 mm from the dura mater. The angle of the syringe during injection was anteflexed 5° from the vertical. Postoperatively, the rats were evaluated for neurological deficits by using an automated rotarod test. High-resolution [18F]fluorodeoxyglucose–positron emission tomography (FDG-PET) fused with computerized tomography (CT) scans were acquired pre- and postoperatively through the onset of hemiparesis and correlated accordingly. Kaplan–Meier curves were generated for survival and disease progression, and brains were processed postmortem for histopathological investigation.

The 9L and F98 tumor cells grew in 95% of the animals in which they were injected and resulted in a statistically significant mean onset of hemiparesis of 16.5 ± 0.56 days (p = 0.001, log-rank test), compared with animals in the control group, which had no neurological deficits by Day 45. The FDG-PET studies coregistered with CT scans demonstrated space-occupying brainstem lesions, and this finding was confirmed by histological studies. Animals in the control group showed no functional, radiological, or pathological signs of tumor.

Conclusions

Progression to hemiparesis was consistent in all tumor-injected animals, with predictable onset of symptoms occurring approximately 17 days postsurgery. The histopathological and radiological characteristics of the 9L and F98 brainstem tumors were comparable to those of aggressive primary human brainstem tumors. Establishment of this animal tumor model will facilitate the testing of new therapeutic paradigms for the treatment of these lesions.

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Christopher B. Michael, Andrew G. Lee, James R. Patrinely, Samuel Stal, and J. Bob Blacklock

✓ The authors present a case of visual loss associated with fibrous dysplasia of the anterior skull base and the surgical management of this case. Preoperative computerized tomography scanning in this patient demonstrated a patent optic foramen and a rapidly growing cystic mass within the orbit, which was responsible for the patient's visual loss. A literature review revealed that this case is typical, in that cystic mass lesions of various types are frequently responsible for visual loss associated with fibrous dysplasia. The authors did not find significant evidence in the literature to support the notion that visual loss associated with fibrous dysplasia is the result of progressive optic canal stenosis, thus raising questions about the value of prophylactic optic canal decompression. Instead, as demonstrated by this case and those uncovered in the literature review, most instances of visual loss result from the rapid growth of mass lesions of cystic fibrous dysplasia, mucoceles, or hemorrhage. Findings of the literature review and the present case of fibrous dysplasia of the anterior skull base support a role for extensive surgical resection in these cases and indicate a need for additional prospective analysis of a larger number of patients with this disease.