The early argument for prefrontal leucotomy: the collision of frontal lobe theory and psychosurgery at the 1935 International Neurological Congress in London.

The pathophysiology of mental illness and its relationship to the frontal lobe were subjects of immense interest in the latter half of the 19th century. Numerous studies emerged during this time on cortical localization and frontal lobe theory, drawing upon various ideas from neurology and psychiatry. Reflecting the intense interest in this region of the brain, the 1935 International Neurological Congress in London hosted a special session on the frontal lobe. Among other presentations, Yale physiologists John Fulton and Carlyle Jacobsen presented a study on frontal lobectomy in primates, and neurologist Richard Brickner presented a case of frontal ablation for olfactory meningioma performed by the Johns Hopkins neurosurgeon Walter Dandy. Both occurrences are said to have influenced Portuguese neurologist Egas Moniz (1874-1955) to commence performing leucotomies on patients beginning in late 1935. Here the authors review the relevant events related to frontal lobe theory leading up to the 1935 Neurological Congress as well as the extent of this meeting's role in the genesis of the modern era of psychosurgery.

Review of seizure outcomes after surgical resection of dysembryoplastic neuroepithelial tumors.

Dysembryoplastic neuroepithelial tumors (DNETs) are rare tumors that present with seizures in the majority of cases. We report the results of a review of seizure freedom rates following resection of these benign lesions. We searched the English literature using PubMed for articles presenting seizure freedom rates for DNETs as a unique entity. Patient demographics, tumor characteristics, and operative variables were assessed across selected studies. Twenty-nine articles were included in the analysis. The mean age at surgery across studies was a median of 18 years (interquartile range 11-25 years). The mean duration of epilepsy pre-operatively was a median 7 years (interquartile range 3-11 years). Median reported gross-total resection rate across studies was 79% (interquartile range 62-92%). Authors variously chose lesionectomy or extended lesionectomy operations within and across studies. The median seizure freedom rate was 86% (interquartile range 77-93%) with only one study reporting fewer than 60% of patients seizure free. Seizure outcomes were either reported at 1 year of follow-up or at last follow-up, which occurred at a median of 4 years (interquartile range 3-7 years). The number of seizure-free patients who discontinued anti-epileptic drugs varied widely from zero to all patients. Greater extent of resection was associated with seizure freedom in four studies.

Hitler's parkinsonism.

Of the multitude of medical and psychiatric conditions ascribed to Hitler both in his lifetime and since his suicide in April 1945, few are more substantiated than parkinsonism. While the timeline of the development of this condition, as well as its etiology, are debated, there is clear evidence for classic manifestations of the disease, most prominently a resting tremor but also stooped posture, bradykinesia, micrographia, and masked facial expressions, with progression steadily seen over his final years. Though ultimately speculation, some have suggested that Hitler suffered from progressive cognitive and mood disturbances, possibly due to parkinsonism, that affected the course of events in the war. Here, the authors discuss Hitler's parkinsonism in the context of the Third Reich and its eventual destruction, maintaining that ultimately his disease had little effect on the end result.

Maternal and neonatal outcomes following SARS-CoV-2 infection.

Infection with SARS-CoV-2 causing COVID-19 in pregnancy is known to confer risks to both the pregnant patient and fetus. A review of the current literature demonstrates that pregnant individuals with SARS-CoV-2 infection are at risk for higher composite morbidity, intensive care unit admission, ventilatory support, pre-eclampsia, preterm birth, and neonatal intensive care unit admissions compared to pregnant individuals without SARS-CoV-2. Worse obstetric morbidity and mortality generally correlate with the severity of COVID-19. Comorbidities such as diabetes increase the risk of severe COVID-19. An increased risk of stillbirth appears to be predominantly confined to pregnancies affected in the Delta variant time period. Further, vaccination against SARS-CoV-2 has been demonstrated to be safe and effective in pregnancy and while breastfeeding. Therefore, continued counseling encouraging vaccination remains imperative. The long-term maternal and neonatal consequences of pregnancies affected by SARS-CoV-2 remain unknown, and therefore continued research in this regard is warranted.

Neonatal and Childhood Outcomes Following Preterm Premature Rupture of Membranes.

Preterm premature rupture of membranes (PPROM) is almost uniformly associated with preterm birth and thus sequelae of prematurity explain many of the complications associated with this condition. However, the unique inflammatory environment and oligohydramnios associated with PPROM may impart unique neonatal and childhood morbidity compared with other preterm birth pathways.

Intracranial Epidural Metastases of Adrenal Pheochromocytoma: A Rare Entity.

BACKGROUND: Pheochromocytomas are uncommon neuroendocrine tumors of the adrenal medulla. Malignant behavior is seen in approximately 10% of these lesions, evidenced by distant metastasis to sites without chromaffin tissue. Here we report a rare case of intracranial epidural metastases of an adrenal pheochromocytoma in a 24-year-old man. CASE DESCRIPTION: The patient originally presented at age 10 years with adrenal pheochromocytoma and subsequently developed extensive metastatic bone and lung disease. He was monitored in the intervening years until recent imaging demonstrated an enlarging right parietal mass. On surgical resection of the parietal lesion, the tumor was highly vascularized and confined to the epidural space. CONCLUSIONS: To the best of our knowledge, this is the first reported case of metastatic epidural spread of pheochromocytoma without concomitant subdural or intraparenchymal extension.

Anatomy and white matter connections of the orbitofrontal gyrus.

OBJECTIVE The orbitofrontal cortex (OFC) is understood to have a role in outcome evaluation and risk assessment and is commonly involved with infiltrative tumors. A detailed understanding of the exact location and nature of associated white matter tracts could significantly improve postoperative morbidity related to declining capacity. Through diffusion tensor imaging-based fiber tracking validated by gross anatomical dissection as ground truth, the authors have characterized these connections based on relationships to other well-known structures. METHODS Diffusion imaging from the Human Connectome Project for 10 healthy adult controls was used for tractography analysis. The OFC was evaluated as a whole based on connectivity with other regions. All OFC tracts were mapped in both hemispheres, and a lateralization index was calculated with resultant tract volumes. Ten postmortem dissections were then performed using a modified Klingler technique to demonstrate the location of major tracts. RESULTS The authors identified 3 major connections of the OFC: a bundle to the thalamus and anterior cingulate gyrus, passing inferior to the caudate and medial to the vertical fibers of the thalamic projections; a bundle to the brainstem, traveling lateral to the caudate and medial to the internal capsule; and radiations to the parietal and occipital lobes traveling with the inferior fronto-occipital fasciculus. CONCLUSIONS The OFC is an important center for processing visual, spatial, and emotional information. Subtle differences in executive functioning following surgery for frontal lobe tumors may be better understood in the context of the fiber-bundle anatomy highlighted by this study.

A Simplified Method of Accurate Postprocessing of Diffusion Tensor Imaging for Use in Brain Tumor Resection.

BACKGROUND: Use of diffusion tensor imaging (DTI) in brain tumor resection has been limited in part by a perceived difficulty in implementing the techniques into neurosurgical practice. OBJECTIVE: To demonstrate a simple DTI postprocessing method performed without a neuroscientist and to share results in preserving patient function while aggressively resecting tumors. METHODS: DTI data are obtained in all patients with tumors located within presumed eloquent cortices. Relevant white matter tracts are mapped and integrated with neuronavigation by a nonexpert in < 20 minutes. We report operative results in 43 consecutive awake craniotomy patients from January 2014 to December 2014 undergoing resection of intracranial lesions. We compare DTI-expected findings with stimulation mapping results for the corticospinal tract, superior longitudinal fasciculus, and inferior fronto-occipital fasciculus. RESULTS: Twenty-eight patients (65%) underwent surgery for high-grade gliomas and 11 patients (26%) for low-grade gliomas. Seventeen patients had posterior temporal lesions; 10 had posterior frontal lesions; 8 had parietal-temporal-occipital junction lesions; and 8 had insular lesions. With DTI-defined tracts used as a guide, a combined 65 positive maps and 60 negative maps were found via stimulation mapping. Overall sensitivity and specificity of DTI were 98% and 95%, respectively. Permanent speech worsening occurred in 1 patient (2%), and permanent weakness occurred in 3 patients (7%). Greater than 90% resection was achieved in 32 cases (74%). CONCLUSION: Accurate DTI is easily obtained, postprocessed, and implemented into neuronavigation within routine neurosurgical workflow. This information aids in resecting tumors while preserving eloquent cortices and subcortical networks.

Rates of Seizure Freedom After Surgical Resection of Diffuse Low-Grade Gliomas.

OBJECTIVE: Patients with diffuse low-grade gliomas (DLGGs) typically present with seizures. We sought to review the neurosurgical literature for seizure outcome after resection of these tumors. METHODS: Using PubMed, we identified surgical series reporting seizure freedom rates for grade II astrocytoma, oligoastrocytoma, and oligodendroglioma. Inclusion criteria included seizure outcomes reported specifically for DLGGs and at least 10 patients with follow-up data. RESULTS: Twelve articles met the inclusion criteria. The median seizure-free rate after surgery in these patients was 71%, with an interquartile range of 64%-82%. In 10 studies, more than 60% of patients were seizure free. Studies used varying reporting times for seizure outcome determination. In the 6 studies that reported postoperative antiepileptic medication use, 5%-69% of seizure-free patients were weaned off these agents (median, 32%). The durability of seizure freedom has not been clearly studied to date. The most commonly reported prognostic factor for seizure freedom after resection was increasing extent of resection. CONCLUSIONS: Among articles reporting seizure outcomes after resection of DLGG, the median seizure-free rate was 71% (interquartile range, 64%-82%). Seizure freedom is likely associated with extent of resection.

White matter connections of the inferior parietal lobule: A study of surgical anatomy.

INTRODUCTION: Interest in the function of the inferior parietal lobule (IPL) has resulted in increased understanding of its involvement in visuospatial and cognitive functioning, and its role in semantic networks. A basic understanding of the nuanced white-matter anatomy in this region may be useful in improving outcomes when operating in this region of the brain. We sought to derive the surgical relationship between the IPL and underlying major white-matter bundles by characterizing macroscopic connectivity. METHODS: Data of 10 healthy adult controls from the Human Connectome Project were used for tractography analysis. All IPL connections were mapped in both hemispheres, and distances were recorded between cortical landmarks and major tracts. Ten postmortem dissections were then performed using a modified Klingler technique to serve as ground truth. RESULTS: We identified three major types of connections of the IPL. (1) Short association fibers connect the supramarginal and angular gyri, and connect both of these gyri to the superior parietal lobule. (2) Fiber bundles from the IPL connect to the frontal lobe by joining the superior longitudinal fasciculus near the termination of the Sylvian fissure. (3) Fiber bundles from the IPL connect to the temporal lobe by joining the middle longitudinal fasciculus just inferior to the margin of the superior temporal sulcus. CONCLUSIONS: We present a summary of the relevant anatomy of the IPL as part of a larger effort to understand the anatomic connections of related networks. This study highlights the principle white-matter pathways and highlights key underlying connections.

Histology and molecular aspects of central neurocytoma.

Central neurocytoma (CN) is a well-differentiated tumor of neural cells occurring within the ventricles. It is composed of monomorphic cells with round, regular nuclei within clear cytoplasm and must be distinguished from other clear cell tumors. Immunohistochemical markers of CN that aid in diagnosis include synaptophysin and neuronal nuclear antigen. The molecular biology of these tumors is becoming increasingly elucidated, particularly with the use of microarray analyses. Several oncogenic pathways have been suggested by these studies. Although progress continues to be made, knowledge of CN has yet to dictate targeted therapies in treating patients with these tumors.

Operative results of keyhole supracerebellar-infratentorial approach to the pineal region.

The supracerebellar-infratentorial approach to the pineal region is typically accomplished with a craniotomy that extends to at least the rim of the foramen magnum. Minimally invasive techniques that limit the inferior extent of the craniotomy have been described for this approach but, to our knowledge, no operative results have been published demonstrating the feasibility and safety of such techniques. We present a series of patients who underwent surgical resection of pineal region lesions using the minimally invasive method at our institution. Clinical, radiologic, and operative data were prospectively collected on patients treated for lesions of the pineal region by the senior author from January 2012 to July 2014. Seven patients were identified. The sitting position was employed in each patient. Keyhole craniotomies were limited to a maximum diameter of 2.5 cm. Adequate working corridors were attained, and in no patient was resection limited by the exposure. No neurological or systemic complications were seen in the perioperative and early follow-up periods. In this feasibility study, we demonstrate that it is not necessary to extend a craniotomy inferiorly to the rim of the foramen magnum in order to gain access to the pineal region via relaxation of the cerebellum. The same surgical goals can be safely accomplished with a smaller craniotomy.

Seizure Freedom Rates and Prognostic Indicators After Resection of Gangliogliomas: A Review.

Gangliogliomas are rare tumors that comprise up to 40% of lesional epilepsy. Seizure control represents an important quality-of-life determinant in patients with these tumors. Here we present results of a literature review addressing rates of seizure freedom in in patients with gangliogliomas. Across studies, seizure freedom occurred in 63%-100% of patients. Many studies included follow-up times of greater than 5 years, suggesting that the responses are durable. We discuss potential prognostic factors associated with seizure freedom, including the duration of epilepsy, patient age, frequency and semiology of seizures, tumor location, extent of surgical resection, and operative strategy, including surgical approach and use of invasive monitoring. Although significant differences in study populations and treatments preclude meta-analysis, we discuss prognostic factors identified in individual studies. Increased extent of resection, lesser duration of epilepsy, and younger age at surgery have been associated with increased seizure freedom rates in at least 2 studies each. Although all studies were retrospective in nature and are consequently limited by the weaknesses inherent to such investigations, the literature suggests that surgery is able to relieve most ganglioglioma patients--regardless of patient demographics, tumor characteristics, and operative variables--of seizures.