Search

To the Editor.— The 5% mortality for patients with intracranial aneurysms reported by Ballenger et al (237:1845, 1977) is a tribute to the care their patients receive. I would question, however, whether this low rate can be attributed to surgery. Ballenger et al state that of patients who have survived the first subarachnoid hemorrhage (SAH), "more than 40% will suffer a recurrence within the first eight weeks, and 60% of these second hemorrhages will prove to be fatal. The overwhelming majority of such instances will occur in the first two weeks after the initial hemorrhage. One day after the initial SAH, a conservatively treated patient in good condition has only a 50% chance of surviving one year. The chief advantage of intracranial surgery over alternative forms of treatment is that it offers the patient definitive protection from recurrent hemorrhage with its attendant mortality." Or does it? The average time to

By the expression "cerebral hemorrhage," is meant bleeding in the substance of the brain or into the cavity of the ventricles. Until very recently such cases have been regarded as beyond the pale of surgical interference. Indeed, only a few years ago Jacobson declared he could find but ten cases recorded as having beeen operated upon, and even Horsley—one of the boldest of cerebral operators— as late as July, 1890, advised tying the common carotid in every case of bad cerebral hemorrhage seen within four hours after the attack. But recently quite a number of operations have been reported with improvement in most cases, and surgeons are beginning to realize the brilliant possibilities of certain classes of hemorrhages, viz., cortical or surface hemorrhages, subcortical and ingravescent or progressive apoplexy. Most authorities have, until lately, advised against operation for the reason (as expressed by Starr, of New York) that "when a

The need for clear vision in the depth of a small field is well recognized by every neurosurgeon. Operations on the brain and spinal cord must be performed within a very limited area, such as the transfrontal approach to the pituitary body, the section of the posterior root of the trigeminus, and certain suboccipital operations involving the cerebellopontile angle. The lighted retractor has proved invaluable in exploring these deep recesses below the brain. The great problem at present concerns the matter of sponging within the depths of the wound, so as to give a clear view of the structures and landmarks presenting during the operation. The extreme friability of the cortical vessels has made it necessary to use the softest cotton pledgets, small enough to be introduced into the limited space concerned. A small amount of hemorrhage in the depth of the wound arrests the progress of the operation

Suppuration in the brain does not differ from abscess in other parts of the body, except in the symptoms which arise from the peculiar location of the pus. Formerly, abscess of the brain and cerebral softening were regarded as synonymous terms; but now we know that softening is the result of the death of brain tissue from interference with the blood supply—a purely passive process, the creamy mass possessing none of the characteristics of pus excepting the resemblance in consistency and color; on the other hand, abscess is the result of an active process, inflammation, and in the broken-down tissues are found the distinctive microorganisms of true pus, and the same rule for the treatment holds good as in abscess elsewhere; let the pus out as soon as its location can be determined. MORTALITY. Abscess of the brain, from a surgical standpoint, is more favorable than almost any other form

• Hypotension induced with trimethaphan has been used in connection with ether anesthesia in a series of 295 craniotomies. This series was compared with another of 201 cases in which hypotension was not induced. Blood pressures below 60 mm. Hg were associated with higher morbidity and mortality rates ascribed to cerebral damage due to stagnant anoxia. Prolongation of hypotension at levels of 70 to 100 mm. Hg did not increase morbidity or mortality. It probably facilitated operative procedure by decreasing the bleeding from small vessels and may be advisable when massive bleeding is anticipated. In the two series, however, operating times were practically equal, as were the percentages of patients requiring transfusions of 2,000 cc. or more of blood.

( e .) Insanity due to softening. That portion of the cortical substance most prone to embolic and thrombotic softening is that which is supplied by the parieto-sphenoidal branch of the middle cerebral, or Sylvian artery, the left being much more frequently affected than the right. That softening of the brain —even of quite limited extent—often gives rise to insanity has for many years been a well-established fact; but the proposition to trephine in such cases is, so far as I know, wholly original with me, as I can nowhere find record of cases similar to my own. By the term "softening," I do not mean cerebral abscess —all surgeons would trephine for abscess if its location could be determined—nor to that condition formerly called "red softening," which is in reality only the initial stage of a suppurative inflammation and which if not arrested leads to destruction of the nerve fibers and

This volume represents a series of papers presented at the Neurosurgical Section of the American College of Surgeons' Meeting in 1966 on subjects having to do with cranial and intracranial infection. The list of nine contributors includes some of the most illustrious names in neurosurgery, and by and large the volume reads easily and smoothly. In view of the rapidly changing field of antibiotic therapy and ever-changing spectrum of organisms which produce intracranial infection, a good deal of the information is of mainly historical interest. The excellent chapter by R. Lewis Wright of the Neurological Service of the Massachusetts General Hospital and the Department of Surgery at the Harvard Medical School, on "Septic Complications of Intracranial Surgery," is probably the outstanding contribution to the monograph and deserves careful reading and rereading by all of those interested in the problem. One might question his statistics as to the rate of infection

To the Editor.— The paper on "Intracranial Suppurative Disease" (218: 1542, 1971) would lead one to believe that something new had been developed to obviate intracranial surgery for brain abscess. It should be pointed out that a focal intracranial lesion is not necessarily "surgical lesion." The fact that the carotid angiograms were normal in six cases initially bears this out. However, in cases 3 and 7, when carotid angiography disclosed a mass lesion, surgery was carried out in the conventional manner. In case 1, it is stated that "the strongest deterrent to craniotomy was fear of hemorrhage." I could see no indication for craniotomy with normal angiogram and sonoencephalogram. Competent hematologists assure me that plasma thromboplastin component deficiency can be controlled readily by the administration of factor IX at time of surgery. In short, this article emphasizes a dogma taught me as a resident: "... in central nervous system sepsis mass

Neither from the earliest collation of cases nor even from the more recent ones do we seem in a position to estimate accurately the frequency of hypophyseal tumors. The cases are reported from such widely different premises, most often according to points of special clinical significance. Thus we find it necessary to search the records of ophthalmology, treatises on acromegaly, contributions to intracranial surgery, journals devoted to radiography, and so forth, in getting at information bearing on the pathology. Mindful of this difficulty encountered in making up an exhaustive tabulation of cases, I think we may, nevertheless, assume that tumors of the hypophysis and infundibulum are quite rare. As concerns the variety of neoplasms, we meet with simple hyperplasia, adenoma, glioma, sarcoma, carcinoma and teratoma. The teratomata of the gland are, indeed, a very rare form of tumor. Boyce and Beadles, in their large collection of cases, include three of

Ether, administered by inhalation, has three serious liabilities in intracranial surgery. It causes (1) swelling of the brain, (2) postoperative vomiting and (3) pneumonia. Together, these three effects are alone responsible for quite a high percentage of the mortality associated with operations on the brain. Doubtless much of the swelling of the brain results from venous cerebral congestion incident to respiratory embarrassment during induction, but the direct irritating effects of the ether on the brain is also probably an important factor. Although the degree of swelling of the brain is variable, it is always present and is always an added hazard. Occasionally it may be so extreme as to resemble the pressure of an intracranial tumor and prevent closure of the dura and replacement of the bone flap. For operations beneath the surface of the brain, such as for hypophyseal, pineal, cerebellopontile, olfactory groove and other tumors, sufficient exposure for

No one can have experience of intracranial surgery without perceiving how difficult it may be to localize an intracranial tumor, and how frequently operation is performed without the tumor being found. The object of this paper is to show that surgical intervention which falls short of removal of the tumor may so alter the signs and symptoms of the tumor as to enable a more accurate localization of its position to be made. Changes of a similar nature sometimes occur in cases of tumor of the spinal cord after lumbar puncture has been performed. These are easy to interpret and may therefore be conveniently considered before the more complicated changes that attend surgical intervention in cases of intracranial tumor. THE EFFECT OF LUMBAR PUNCTURE IN TUMORS OF THE SPINAL CORD It is well known that withdrawal of cerebrospinal fluid by lumbar puncture may aggravate the signs and symptoms of a

Although cranial surgery was undoubtedly practiced by prehistoric man and by his descendants, little progress was made, and this type of surgery, apart from the relief of demons in individuals suffering from epilepsy and psychoses, was confined to the treatment of wounds and fractures and of other externally visible conditions until the last quarter of the last century. At that time a renaissance of interest in the nervous system was initiated by Fritsch and Hitzig in Germany and by a band of eager spirits in England, which included Jackson, Ferrier and Horsley, to mention only a few. Their studies provided that minimum of information necessary to the beginning of the surgical treatment of those intracranial lesions not visible externally; to permit of the localization of such lesions by deductive reasoning. This beginning was made by Alexander Hughes Bennett, who first so localized an intracranial tumor and persuaded Godlee to operate on it. Sir Victor Horsley, who himself had no small part in the actual experiments which made this development possible, was, however, the first to establish intracranial surgery on a firm basis. Unfortunately, although Horsley's main interest was concerned with the nervous system rather than with surgery, his successors, imitators and pupils were, in the main, general surgeons with little or no interest in the nervous system. They were thus neither interested nor capable of advancing this field of medicine. It is not