The First CT Scan of the Brain: Entering the Neurologic Information Age.

Computed tomography (CT) scan of the brain transitioned clinical neurology from the educated-guess world to the real computer-age world. One of the first CT scans-published by the British neuroradiologist James Ambrose-showed an intracranial hemorrhage and also suggested the use of iodine to demonstrate abnormal blood-brain barrier. In the USA, CT scans were rapidly commercialized and first placed at Mayo Clinic and Massachusetts General Hospital in the summer of 1973. CT scanning of the brain has revolutionized diagnostic acute neurology and neurosurgery and was the overture to an even larger revolution-magnetic resonance imaging. This historical vignette discusses the development of CT scanning of the brain and its connection with neurocritical care.

Walter Edward Dandy (1886-1946): The epitome of adroitness and dexterity in Neurosurgery.

Walter Edward Dandy did pioneering work in Neurosurgery in the early part of the 19th century. He worked all his life at the Johns Hopkins Hospital in USA and contributed extensively to research in hydrocephalus, the physiology of the cerebrospinal fluid and devised the technique of pneumoencephalography, apart from performing the first clipping operation in cerebral aneurysm and the division of the trigeminal nerve in neuralgic pain. This article summarizes his immense contributions in the field of Neurosurgery.

Pneumoencephalography in the workup of neuropsychiatric illnesses: a historical perspective.

Throughout history, neurosurgical procedures have been fundamental in advancing neuroscience; however, this has not always been without deleterious side effects or harmful consequences. While critical to the progression of clinical neuroscience during the early 20th century, yet, at the same time, poorly tolerated by patients, pneumoencephalography is one such procedure that exemplifies this juxtaposition. Presented herein are historical perspectives and reflections on the role of the pneumoencephalography in the diagnosis and treatment of neuropsychiatric illnesses.

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea.

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30% following head injury and 15% were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60%) followed in frequency by the cribriform plate and the sphenoid sinus (20% each). Follow-up period was 12-24 months. We have achieved a 95% success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100% success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.

Neuroradiology investigations before scanning.

Coaxial tomography (CT) and magnetic resonance imaging (MRI) scans are so much part of neurological investigation these days and provide such detailed information that even thorough neurological clinical examination may be neglected. The investigations in common use forty years ago were pneumoencephalography, ventriculography in babies with hydrocephalus, and carotid angiography with the injection of X-ray contrast to outline the arteries.

Retained foreign body in ethmoid with bilateral pneumoencephaly.

Intracranial penetrating injury through the nose is rare. We present a case of a 79 year-old patient who had intracranial penetrating injury with a wooden object accompanied by massive bilateral pneumoencephaly with the presence of a foreign body in the ethmoid bone with fracture and displacement of crista galli. This is a hitherto unreported retained foreign body with fractured ethmoid resulting in bilateral pneumoencephaly.

Neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra / Pneumocephalus as a Complication of Regional Epidural Block Due to Lumbosacral Radiculopathy

Introducción: El neumoencéfalo (sinonimia: aerocele o neumatocele intracerebral), se define como la presencia de gas dentro de cualquiera de los compartimentos intracraneales (intraventricular, intraparenquimatosa, subaracnoidea, subdural y epidural). Objetivo: Describir los hallazgos clínicos, estudios complementarios, conducta terapéutica y evolución de un caso con neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra. Presentación de caso: Se presentó un paciente masculino de 57 años de edad que comenzó con un cuadro súbito de desorientación, excitabilidad psicomotriz y convulsiones tónico-clónicas, a partir de una inyección epidural de metilprednisolona como método analgésico. Conclusiones: El caso presentado exhibió manifestaciones neurológicas inespecíficas, la aparición súbita posterior al proceder invasivo hizo sospechar en un evento neurológico agudo o fenómeno tromboembólico. Los estudios complementarios como la tomografía axial computarizada craneal simple, permitió su diagnóstico para tener una conducta consecuente. El manejo conservador del neumoencéfalo como complicación del uso de anestesia epidural, constituyó una conducta terapéutica eficaz y repercutió en la satisfactoria evolución del paciente(AU)

Introduction: Pneumocephalus (synonym: aerocele or intracerebral pneumatocele), is defined as the presence of gas within any of the intracranial compartments (intraventricular, intraparenchymal, subarachnoid, subdural and epidural). Objective: To describe the clinical findings, complementary studies, therapeutic conduct and evolution of a case with pneumocephalus as a complication of regional epidural block due to lumbosacral radiculopathy Case presentation: A 57-year-old male patient was presented who began with a sudden episode of disorientation, psychomotor excitability and tonic-clonic seizures, following an epidural injection of methylprednisolone as an analgesic method. Conclusions: The case presented exhibited non-specific neurological manifestations, the sudden appearance after the invasive procedure raised suspicion of an acute neurological event or thromboembolic phenomenon. Complementary studies such as simple cranial computed axial tomography, allowed its diagnosis to have a consistent conduct. The conservative management of pneumocephalus as a complication of the use of epidural anesthesia constituted an effective therapeutic approach and had an impact on the patient's satisfactory evolution(AU)

Predicting the outcome of shunt surgery in normal pressure hydrocephalus.

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

Differential diagnosis of the infundibular dilation and aneurysm of internal carotid artery: assessment with fusion imaging of 3D MR cisternography/angiography.

Fusion imaging of 3D MR cisternography/angiography was used for the assessment of the vascular bulging finding detected by MR angiography from the viewpoint of the outer wall configuration of the corresponding internal carotid artery depicted by MR cisternography. With a fusion image, useful information was obtained to distinguish an infundibular dilation and enlarged origin of the normal posterior communicating artery from an aneurysm. This imaging technique can be a feasible addition to a noninvasive screening of cerebrovascular lesions with MR angiography alone.

Hydrocephalus associated with Guillain-Barre syndrome.

A 68-year-old man developed progressive four-limb weakness and areflexia 17 days after an influenza vaccination. He was diagnosed with Guillain-Barre syndrome (GBS), and remained ventilator dependent and bed-bound for 3 months, despite plasmapheresis and immunoglobulin infusion. However, cognitive impairment, excessive daytime sleepiness, and motor disability were still present, even when he was no longer ventilator dependent. Brain computerized tomography scan and isotope cisternography was consistent with normal pressure hydrocephalus. His motor control and cognitive function recovered almost completely after insertion of a ventriculoperitoneal shunt. Although hydrocephalus is not frequently associated with GBS, our case report indicates that brain imaging is necessary in GBS patients whose cognitive functions deteriorates after disease onset.

Trigeminal neuralgia associated with an anomalous artery originating from the persistent primitive trigeminal artery.

A 31-year-old man presented with typical trigeminal neuralgia caused by an anomalous variant type of anterior inferior cerebellar artery (AICA) directly branching from the primitive trigeminal artery (PTA). Three-dimensional computed tomography angiography, magnetic resonance angiography, and magnetic resonance cisternography disclosed that this anomalous artery originated from the PTA and coursed to the AICA territory of the cerebellum. Microvascular decompression surgery disclosed the trigeminal nerve compressed by this AICA variant together with the superior cerebellar artery. These arteries were successfully transpositioned to decompress the nerve. Careful and thorough inspection around the trigeminal nerve verified that the PTA did not conflict with the nerve. This unusual case was caused by compression of the trigeminal nerve from the AICA directly originating from the PTA, without the more common involvement of the PTA.

Evaluation of the abnormal sella turcica.

Current neurodiagnostic and endocrine evaluation for pituitary tumors, empty sella syndrome, and parasellar lesions includes new techniques. Multidirectional polytomography of the sella turcica in detecting very small pituitary adenomas is important. Also, the role of computerized axial tomography (CT scanning) in defining size and extent of sellar and parasellar lesions is increasing. There has been a decline in the use of cerebral angiography and pneumoencephalography, especially the latter, in the diagnostic workup of these patients since the introduction of CT scanning.

Pituitary tumors and hyperprolactinemia.

Hyperprolactinemia was demonstrated in eight of nine patients with clinical evidence of pituitary tumors without acromegaly or Cushing syndrome. Hourly sampling for 24 hours disclosed elevation of serum prolactin concentrations, whereas, measurable serum growth hormone levels were found rarely. Although eight of these patients were hypersecreting prolactin, only four of them were lactating. Prolactin secretion was characterized by moderate hourly fluctuations of serum levels and absence or blunting of the normal sleep-related augmentation of secretion. Patients with the highest serum prolactin concentrations tended to have the largest pituitary tumors, as indicated by pneumoencephalography. In two patients followed-up with serum prolactin determinations after treatment, a fall in serum prolactin concentrations correlated with clinical improvement. Future study will hopefully establish the value of serum prolactin determinations in following tumor growth before and after pituitary ablative therapy.

Galactorrhea, amenorrhea, and hyperprolactinemia as manifestations of parasellar meningioma.

We describe two women with amenorrhea, galactorrhea, and cranial nerve palsy. Elevated serum prolactin levels were found in both patients before and after administration of protirelin. Both patients had an abnormal sella turcica with suprasellar mass. A prolactin-secreting tumor with suprasellar extension was considered, but further investigation and surgical exploration showed that both patients had parasellar meningiomas. These findings indicate that parasellar meningioma can produce hypothalamic-pituitary dysfunction and should be considered in the differential diagnosis of women with galactorrhea and amenorrhea.

Abnormal sella turcica. A tumor board review of the clinical significance.

Sixty of 146 patients with intracranial neoplasms or arterial aneurysms had roentgenographic abnormalities of the sella turcica. These abnormalities were most commonly due to chromophobe adenoma, craniopharygioma, and acromegaly, but ten of them were caused by lesions arising distant to the sella. There were also three cases of empty sella syndrome. Headache, visual disturbance, and sexual dysfunction were the most frequent presenting complaints, with visual field abnormality being most common. Pituitary dysfunction was manifested most frequently by alterations in growth hormone level and gonadotrophin secretion and less frequently by hypothyroidism and adrenocortical insufficiency. When the abnormal sella was associated with evidence of symptomatic intracranial disease, endocrine dysfunction, or visual field compromise as evidence of an anatomically aggressive intracranial neoplasm, specialized neuroroentgenographic localizing procedures were usually positive, and treatment for most of the causative lesions was highly effective.

Demonstration of cerebrospinal fluid leakage on radionuclide cisternography by SPECT/CT.

We report a case of a 37-year-old woman with severe headache provoked by postural changes who was referred to the nuclear medicine department for radionuclide cisternography to demonstrate suspected cerebrospinal fluid leakage. There was an increased uptake laterally on the left paraspinal region of upper thoracal spine and posteriorly on the upper cervical region. Fused SPECT/CT images located the exact leakage site as at the first costovertebral junction level on the left side laterally and on the posterior region of the first and second cervical spine. The treatment with epidural blood patch was successful.

Melatonin concentration in human blood and cerebrospinal fluid: relationship to stress.

In 35 daytime paired blood and cerebrospinal fluid (CSF) samples from 15 patients, melatonin levels in CSF were undetectable or detectable but not higher than blood levels. During pneumoencephalography in 6 patients, no significant elevation of blood melatonin levels was observed, whereas cortisol concentration increased.

Penumoencephalographic findings in parkinsonism.

Pneumoencephalograms of 19 patients with unilateral parkinsonism, and of 26 patients with symptoms of generalized parkinsonism were studied. Cortical atrophy was found in 46.7% (21), while central (ventricular) atrophy occurred in 77.8% (35) of the patients. The percentage of patients with cortical atrophy, or with enlargement of ventricular body span (VBS) and septum-caudate distance (S-C), was smaller in the hemiparkinsonism group. No substantial correlation was found between enlargement of frontal horn width (FH), S-C and third ventricle width (3V), and the duration of illness. Likewise, no noteworthy correlation could be seen between the degree of central atrophy and the severity of the clinical symptoms. The FH/S-C ratio of the group of unilateral parkinsonism patients was higher than in the generalized parkinsonism group. The FH/S-C ratios in parkinsonism and in Huntington chorea patients varied. A ratio of greater than 1.40 was found in 73.3% of the patients with parkinsonism, and in an earlier study, it was found that 96.4% of the patients with Huntington chorea had a ratio less than 1.40. It is suggested that a FH/S-C ratio less than or equal to 1.40 is compatible with the diagnosis of Huntington chorea, although 26.7% (12) patients with parkinsonism have a ratio less than or equal to 1.40.