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Daniel L. Peterson, Peter J. Sheridan and Willis E. Brown Jr.

✓ The scientific understanding of the biology of human brain tumors has advanced in large part through the use of animal models. For most of this century, investigators have been evaluating the inciting factors in brain tumor development, and applying this knowledge to direct tumor growth in laboratory animals. Virus-induced, carcinogen-induced, and transplant-based models have been vigorously investigated. As knowledge of the molecular biology of neoplasia has advanced, transgenic technology has been introduced. The authors review the development of animal models for brain tumor, and focus on the role of transgenic models in elucidating the complex process of central nervous system neoplasia.

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Subclavian steal syndrome

Part 1: Proximal vertebral to common carotid artery transposition in three patients, and historical review

George L. Bohmfalk, Jim L. Story, Willis E. Brown Jr. and Arthur E. Marlin

✓ Three patients with central nervous system symptoms due to subclavian steal syndrome were treated with proximal vertebral to common carotid artery transposition. Neurological symptoms were relieved or improved in all three, with no decrease in blood pressure or pulse in the ipsilateral upper extremity. The colorful history of this syndrome is reviewed, and the various surgical approaches to its treatment are discussed. Although the literature suggests that the commonly used carotid to subclavian artery bypass graft and other similar extrathoracic procedures are generally safe and effective for relief of symptoms of the steal, there is also evidence that these bypasses may fail to restore antegrade flow in the vertebral artery, and, in fact, may steal from the carotid artery. Thus, the blood flow provided to the brain by these procedures may be hardly more than that provided by vertebral artery ligation, whereas the principal effect is to restore blood flow into the upper extremity. Vertebral artery ligation alone has been used in 20 patients, with neurological improvement in all cases and production of persistent intermittent brachial claudication in only one. These considerations and our patient experience suggest that a relatively simple operation, proximal vertebral to common carotid artery transposition, which emphasizes restoration of flow to the brain rather than to the upper extremity, may be preferable for most patients with neurological symptoms of subclavian steal syndrome.

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David A. Cavanaugh, Jim L. Story, Willis E. Brown Jr., Lee V. Ansell and Holger E. I. Skerhut

✓ Eight patients undergoing an end-to-side vertebral artery (VA) to common carotid artery transposition between August, 1979, and July, 1982, had a polytetrafluoroethylene (PTFE) interposition graft placed when a direct anastomosis was believed not to be satisfactory. Five of these patients are living; clinical and radiographic follow-up studies over periods ranging between 54 and 82 months show that their transpositions are patent. Two patients died perioperatively, one from an acute anterior myocardial infarction and the other from acute VA occlusion with a propagating thrombus. A third patient died of myocardial infarction 20 months after graft placement; the anastomosis had been found patent at 12 months. This report gives the clinical and radiographic follow-up results in a previously reported group of patients with PTFE interposition grafts. Some of these patients have been followed for over 6 years after surgery: the average radiographic follow-up period in the five survivors is 60 months, and all grafts are patent without evidence of progressive stenosis. Expanded PTFE appears to be an acceptable material for short interposition grafts in operations involving the VA; however, direct artery-to-artery anastomosis is preferred. The results of longer PTFE grafts in reconstructive cerebrovascular surgery have not been adequately studied.

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Moustapha Abou-Samra, Arthur E. Marlin, Jim L. Story and Willis E. Brown Jr.

✓ The authors present a case of cranial epidermoid tumor that caused a subacute epidural hematoma after minor trauma. The radiological, operative, and pathological findings are described, and indications for elective excision of cranial epidermoid tumor are discussed.

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Subclavian steal syndrome

Part 2: Intraoperative vertebral artery blood flow measurement

George L. Bohmfalk, Jim L. Story, Willis E. Brown Jr. and Arthur E. Marlin

✓ Intraoperative vertebral artery blood flow was measured in two patients with symptomatic subclavian steal syndrome, before and after proximal end-to-side vertebral to common carotid artery transposition. This confirmed retrograde flow in the vertebral artery before transposition, and antegrade flow after transposition. The measured flow rates were compared to values in other series involving different operative procedures for correction of symptomatic subclavian steal. The greatest mean antegrade flow rates in the vertebral artery were restored by proximal end-to-side vertebral to common carotid artery transposition.

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George L. Bohmfalk, Jim L. Story, John P. Wissinger and Willis E. Brown Jr.

✓ The authors tabulate and analyze cases of bacterial intracranial aneurysm documented since 1954, and add four of their own. In 85 cases the overall mortality was 46%. Elimination of patients dying before reaching the hospital makes this figure spuriously low. Figures for patients hospitalized for endocarditis before neurological symptoms occurred suggest a true mortality of 80% from aneurysms that rupture and 30% if the aneurysm remains intact. Multiple reports of spontaneously resolving, enlarging, diminishing, multiple, and sequentially appearing aneurysms, all of which occurred in our fourth case, clarify the need for complete and sequential angiography. Computerized tomographic (CT) scanning in this disease has not been reported, but our experience with these scans demonstrates considerable potential value.

A protocol of complete cerebral angiography and CT scanning of these neurologically asymptomatic patients is proposed, in order to assess the true incidence of bacterial intracranial aneurysm, to learn more of its natural history, and to prevent some neurological catastrophes.

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Cauda equina syndrome of long-standing ankylosing spondylitis

Case report and review of the literature

Micam W. Tullous, Holger E. I. Skerhut, Jim L. Story, Willis E. Brown Jr., Eduardo Eidelberg, Mohammad R. Dadsetan and John R. Jinkins

✓ Cauda equina syndrome as a neurological complication of long-standing ankylosing spondylitis was first reported in 1961. The syndrome is relatively uncommon and its pathophysiology is still poorly understood. Based on their experience with such a case, the authors review the clinical, electrographic, histological, and radiographic features of the syndrome, including the findings of magnetic resonance (MR) imaging. The addition of MR imaging to the evaluation of patients with ankylosing spondylitis and the cauda equina syndrome not only aids in the diagnosis of the syndrome but may also provide valuable insight into the pathophysiology of this condition.