✓ The authors present the case of a young patient in whom the spontaneous rupture of a known, long-standing middle fossa arachnoid cyst into the subdural space was documented. This spontaneous rupture was followed by gradual diminution of the cyst to near-complete resolution.
Anatoly Rakier and Moshe Feinsod
Gideon Findler and Moshe Feinsod
✓ A patient with hydrocephalus due to aqueductal stenosis suffered facial pain which was relieved after the insertion of a ventriculoperitoneal shunt. The trigeminal somatosensory evoked response (TSER) of the affected side showed lower amplitudes and longer latencies as compared to the unaffected side. Following surgery, the waves regained higher amplitudes and shorter latencies. An episode of shunt malfunction was accompanied by recurrent facial pain and impairment of the TSER. Both improved after revision of the shunt. The possible etiology of facial pain in patients with hydrocephalus is discussed.
Gideon Findler and Moshe Feinsod
✓ Electrical stimulation of the upper and lower lips of normal subjects evoked a consistent response recorded from over the face area of the ipsi- and contralateral hemispheres. This response consisted of seven discrete waves. Peak latencies ranged from as early as 8 msec to 115 msec. Stimulation of the lower lip evoked a response of lower amplitude and reversed polarity, as compared to the upper lip stimulation response. The data support the validity of the trigeminal sensory evoked response in the evaluation of the trigeminal pathways. Previously reported methods are reviewed and compared.
Gideon Findler, Moshe Feinsod, Graciela Lijovetzky and Moshe Hadani
✓ A patient in whom transient global amnesia (TGA) led to the diagnosis of a metastasis of a transition-cell carcinoma of the bladder to the non-dominant hemisphere is described. In previously reported cases of TGA associated with brain tumors, the tumors involved either the dominant or both hemispheres. The etiology of TGA associated with a brain tumor is most likely vascular, as suggested by the sudden development and the transitory character of the event. In contrast to the “common” form of TGA (where both temporal lobes suffer temporary ischemia), in these patients only one side of the limbic system is affected, because a brain tumor has already compromised the other limbic area. Therefore, the dominance of the hemisphere with the tumor is of no consequence, as both hemispheres have been involved. It is concluded that the TGA in these patients is not due to, but is rather associated with, a unilateral brain tumor.
Gideon Findler, Amiram Aldor, Moshe Hadani, Abraham Sahar and Moshe Feinsod
✓ Children with rare coagulation disorders are at high risk from intracranial bleeding with even minor head injury. Treatment by transfusion of fresh frozen plasma is limited because of the large volumes required for restoring the missing coagulation factor. Furthermore, even when concentrates of such a factor are available, their use may prove ineffective due to circulating specific antibodies. Three patients with rare coagulation disorders are presented who suffered head injury complicated by intracranial hemorrhage.
Analysis of a less aggressive surgical approach
Benny Brandvold, Lion Levi, Moshe Feinsod and Eugene D. George
✓ From June, 1982, through June, 1985, 113 patients were evacuated to Rambam Maimonides Medical Center with penetrating craniocerebral injuries sustained in ongoing military hostilities in Lebanon. Two factors distinguished this group of patients from those presenting in earlier conflicts: 1) this was the first large series in which computerized tomography (CT) was routinely used to initially evaluate combat head injuries; and 2) in an effort to preserve maximum cerebral tissue, intracranial debridement was significantly less vigorous than that advocated during the Korean or Vietnam conflicts. No efforts were made to locate or remove indriven bone or metal fragments visualized on CT unless they readily presented themselves on gentle irrigation. In fact, it was elected to treat a number of patients without intracranial hematomas nonoperatively. The acute outcome was quite similar to that reported in Vietnam series in respect to both complications and mortality.
Of the 83 survivors, 46 were Israeli citizens and thus were available for follow-up review. These 46 patients were reevaluated in late 1988, a mean follow-up period of 5.9 years. None had died in the interim; 10 had developed chronic seizure disorders, and there was one case of delayed meningitis in a patient with no retained fragments. Repeat CT scans were performed on 43 patients; 22 (51%) were found to have retained intracranial bone fragments. No relationship existed between the presence of retained fragments and the development of either a seizure disorder or an infection of the central nervous system. These findings suggest that not only is it unnecessary to reoperate for retained bone fragments, but it may also be possible to temper the initial debridement in an effort to preserve additional cerebral tissue.
Moshe Feinsod, John B. Selhorst, William F. Hoyt and Charles B. Wilson
✓ During surgical removal of a pituitary adenoma, conduction in the anterior visual pathways was monitored by continuous recording of visual evoked responses (VER). The method employed a scleral contact lens with an embedded flashing diode for delivery of visual stimuli. Evoked potentials of nearly normal latency, amplitude, and form were recorded from occipital scalp electrodes immediately after the optic nerves were decompressed. Restoration of the VER was correlated with restoration of normal vision.
Part 2: Clinical and radiological aspects
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.
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.