The vascular hypothesis held that posttraumatic epilepsy results from reflex vasoconstriction of cortical arteries around a cerebral scar. Penfield’s initial support and eventual refutation of the vascular hypothesis is the subject of this paper, which is based on a review of his clinical charts, operative and electrocorticographic reports, and brain maps held in the Montreal Neurological Institute archives. Penfield and his collaborators discovered that posttraumatic cortical scars are composed of astro-glial fibers, collagen fibrils, and a neo-vascular plexus that anastomoses with the surrounding cortical arteries. He hypothesized that the contracting scar applied traction to these arteries, which caused epileptic seizures. This was supported by his observations that cortical arteries constrict during an epileptic seizure. Penfield’s subsequent investigations led to the discovery that parasympathetic nerves innervate the intracranial arteries, that experimental vasospasm can produce cortical infarction, and that cerebral blood flow (CBF) is coupled to cerebral metabolism. In fact, Penfield found that CBF increases in the epileptogenic zone around a cortical scar, contrary to what the hypothesis had predicted. Despite this, Penfield’s investigations shed new light on the dynamics of the cerebral circulation that were not fully understood until decades later.
Harvey Cushing and Wilder Penfield enjoyed a unique professional and personal relationship. Shortly before his retirement from Harvard University in 1933, Cushing sent Penfield 8 sketches that he drew in 1902 and 1903 while he was at Johns Hopkins Hospital. The first series of 3 sketches illustrate the relationship between a cortical hemorrhagic lesion and the motor strip in a patient with focal motor seizures. The second series also comprises 3 sketches. These depict the operative findings in a patient in whom Cushing had electrically stimulated the precentral gyrus, before resecting the cortex subserving motility of the upper extremity to control painful dyskinetic movements. The third series consists of 2 sketches that illustrate the results of stimulation of the motor strip as an aid in the safe resection of an epileptogenic focus in a patient with Jacksonian seizures. These sketches are the subjects of this paper. They add to the relatively sparse record of Cushing’s activities in cortical stimulation and in the treatment of functional disorders.
The localization of articulate language (speech) to the posterior third of the third left frontal convolution—Broca’s area—did not occur to Broca as he reported the case of his first aphasic patient in 1861. Initially Broca localized articulate language to both frontal lobes, a position that he maintained for 4 years after publishing his first case. In the interval, the Academy of Medicine in Paris had received a copy of a paper authored in 1836 by Marc Dax, in which Dax claimed that the ability to speak resides within the left hemisphere alone. The Academy of Medicine convened in the spring of 1865 to adjudicate the issue. All of the distinguished speakers argued against Dax’s contention by citing the prevailing paradigm, that bilaterally symmetrical organs, such as the eyes and ears, and the hemispheres of the brain, must perform the same function. The lone dissenting voice was that of Jules Baillarger, the discoverer of the laminar organization of the cerebral cortex, whose argument in favor of what he called “Dax’s law” was so lucid that it carried the day. During his address to the Academy, Baillarger not only supported left-hemisphere dominance for speech, but for the first time described two forms of aphasia, fluent and nonfluent, now referred to as Wernicke’s and Broca’s aphasias, respectively, as well as the ability of aphasics to speak during emotional outbursts, to which we now refer as Baillarger-Jackson aphasia. It was 9 days after Baillarger’s address that Broca, for the first time, unequivocally localized speech to the left frontal lobe.
This paper is based on the author’s reading of Dax’s and Broca’s original texts and of the texts read before the Academy of Medicine meeting held at the National Library of France between April 4, 1865, and June 13, 1865. From these primary sources it is concluded that the Academy of Medicine’s debate was the last serious challenge to left-hemisphere dominance for speech and to the localization of articulate language to the left frontal lobe—and that Jules Baillarger played a pivotal role in what was a defining moment in neurobiology.
Andrés M. Lozano and Richard Leblanc
✓ The authors report seven individuals from two families, all of whom had aneurysmal subarachnoid hemorrhage. These cases and all reported cases of familial aneurysms (243 aneurysms in 177 patients from 74 families) were submitted to computer-aided multivariate analysis to determine if the aneurysms or the patients who harbor them differ from sporadic aneurysm cases. Familial aneurysms rupture at a smaller size (mean diameter 10.5 mm), and when the patient is younger (mean age 42.3 years and decennial age at peak incidence 40 to 49 years). There is a similar sex distribution (male to female ratio 48:52), a similar incidence of multiple aneurysms (21.5%), and a similar predominance of females over males with multiple aneurysms (2.2:1). Anterior communicating artery aneurysms occur less often in familial cases (19%) than in sporadic cases. In sibling pairs the aneurysms occur at the same or at mirror sites, and rupture within the same decade twice as frequently as randomly selected nonfamilial aneurysm patient pairs. The occurrence of aneurysms at identical and mirror sites is more frequent in familial cases and appears to be a function of the degree of kinship between affected individuals. These observations suggest a genetic basis for the pathogenesis of familial intracranial aneurysms.
Richard Leblanc and Ernst Meyer
✓ A case is presented which represents the first instance of the use of functional positron emission tomography (PET) scanning to precisely localize a structural brain lesion to the precentral gyrus, and the first validation of functional PET scanning by intraoperative cortical mapping. The lesion was a 3-cm arteriovenous malformation (AVM) that had produced a generalized seizure in an otherwise asymptomatic young woman. A first, resting H215O PET scan identified the AVM. A second PET scan, performed during vibrotactile stimulation of the contralateral hand, identified the somatosensory area of the hand region and localized the AVM to that part of the precentral gyrus immediately in front of it. This relationship and localization were confirmed by cortical mapping at the time of craniotomy under local anesthesia. Functional PET scanning may prove to be useful to localize cortical lesions precisely and to help in determining preoperatively the best form of treatment for lesions, especially AVM's, in functionally important cortex.
Eric W. Peterson, Roger Searle, Francis F. Mandy and Richard Leblanc
✓ Topical dibutyryl cyclic adenosine monophosphate (AMP) was used to reverse experimental cerebral vasospasm of the basilar artery in the cat. The combination of dibutyryl cyclic AMP and theophylline caused prolonged dilatation of the basilar artery. Dibutyryl cyclic AMP seems to be specific as a topical vasodilator, which may be useful in the postoperative management of subarachnoid hemorrhage.