Happy Birthday "One Flew Over the Cuckoo's Nest": A Momentous Tale in the Quest for an Effective and Ethical Approach to Psychosurgery.

The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.

Psychiatric Co-Morbidities in Post-Traumatic Stress Disorder: Detailed Findings from the Adult Psychiatric Morbidity Survey in the English Population.

Post Traumatic Stress Disorder (PTSD) is a condition which causes great sufferance to the individuals affected. The occurrence of comorbidities in PTSD is a frequent event with a negative impact on outcome. This study investigated the frequency of PTSD in relation to comorbidities by analyzing the results of the 2007 'Adult Psychiatric Morbidity Survey' in the English population, which included data on comorbidities. A population study conducted in the United Kingdom, this survey investigated the frequency of PTSD in the community and the relationship to comorbidities by adopting a random design to minimize selection bias, stratified by region and socioeconomic characteristics, and weighted according to design and non-response. The survey interviewed 7403 adults living in private households. Socio-demographic characteristics and psychiatric morbidity were systematically assessed. Results indicated that PTSD prevalence was 2.9%, with an excess in women (3.3%) compared to men (2.4%) as reported by the 2007 survey. Comorbidity was a very frequent occurrence in PTSD reaching 78.5% in affected cases. Major depression was the commonest condition and its frequency increased with symptoms severity up to 54%. Among anxiety disorders, social phobia was the most frequent, followed by generalized anxiety disorder, obsessive-compulsive disorder, agoraphobia and panic disorder. Substance use disorders were also common. The presence of psychotic symptoms was particularly significant with over 30% prevalence in PTSD. These results indicate that attention needs to be devoted to the presence of comorbidities. In view of the impact of comorbidities on PTSD severity, chronicity and functional impairment, early detection and treatment are likely to improve outcome.

Six-item cognitive impairment test (6CIT): pragmatic diagnostic accuracy study for dementia and MCI.

BACKGROUND: The six-item cognitive impairment test (6CIT) is a brief cognitive screening instrument (CSI) recommended for use in primary care settings. There are very few studies of 6CIT performance in secondary care settings. METHODS: We undertook a pragmatic diagnostic accuracy study of 6CIT in consecutive patients referred over the course of one year to a neurology-led cognitive function clinic, and compared its performance for the diagnosis of dementia and mild cognitive impairment (MCI) to that of the simultaneously administered Mini-Mental State Examination (MMSE). RESULTS: In a cohort of 245 patients with dementia prevalence around 20%, 6CIT proved quick and easy to use and acceptable to patients. It had good sensitivity (0.88) and specificity (0.78) for dementia diagnosis; it was more sensitive than MMSE (0.59) but less specific (0.85). For MCI diagnosis, 6CIT was again more sensitive (0.66) than MMSE (0.51) but less specific (0.70 vs. 0.75). Weighted comparisons showed net benefit for 6CIT compared to MMSE for both dementia and MCI diagnosis. 6CIT effect sizes (Cohen's d) were large for dementia diagnosis and moderate for MCI diagnosis. CONCLUSIONS: 6CIT is an acceptable and accurate test for the assessment of cognitive problems, its performance being more sensitive than the MMSE. 6CIT use should be considered as a viable alternative to MMSE in the secondary care setting.

A comprehensive assessment of cerebellar damage in multiple sclerosis using diffusion tractography and volumetric analysis.

BACKGROUND: White matter (WM) and grey matter (GM) brain damage in multiple sclerosis (MS) is widespread, but the extent of cerebellar involvement and impact on disability needs to be clarified. OBJECTIVE: This study aimed to assess cerebellar WM and GM atrophy and the degree of fibre coherence in the main cerebellar connections, and their contribution to disability in relapsing-remitting MS (RRMS) and primary progressive MS (PPMS). METHODS: Fourteen patients with RRMS, 12 patients with PPMS and 16 healthy controls were recruited. Cerebellar WM and GM volumes and tractography-derived measures from the middle and superior cerebellar peduncles, including fractional anisotropy (FA), mean diffusivity (MD), and directional diffusivities, were quantified from magnetic resonance imaging (MRI). Patients were assessed on clinical scores, including the MS Functional Composite score subtests. Linear regression models were used to compare imaging measures between 12 RRMS, 11 PPMS and 16 controls, and investigate their association with clinical scores. RESULTS: Patients with PPMS showed reduced FA and increased radial diffusivity in the middle cerebellar peduncle compared with controls and patients with RRMS. In PPMS, lower cerebellar WM volume was associated with worse performance on the upper limb test. In the same patient group, we found significant relationships between superior cerebellar peduncle FA and upper limb function, and between superior cerebellar peduncle FA, MD and radial diffusivity and speed of walking. CONCLUSION: These findings indicate reduced fibre coherence in the main cerebellar connections, and link damage in the whole cerebellar WM, and, in particular, in the superior cerebellar peduncle, to motor deficit in PPMS.

Petroclival meningiomas: predictive parameters for transpetrosal approaches.

OBJECTIVE: To determine parameters that influence the selection of the proper petrosal approach or combined approaches for the excision of petroclival meningiomas. METHODS: We dissected 15 cadaver heads, inspected the petroclival region in 50 dry human skulls, and performed a retrospective analysis of the cases of 35 patients with petroclival meningiomas who underwent surgery via transpetrosal approaches. RESULTS: The petroclival region was divided into three "zones" based on the extent of surgical exposure achieved via the petrosal approaches with microscopic dissection of 15 preserved and silicone-injected cadaveric heads and with the measurements of 50 dry skulls. Zone I, defined as the area from the dorsum sellae to the internal auditory canal, is accessible via the anterior petrosal approach. Zone II, defined as the area from the internal auditory canal to the upper border of the jugular tubercle, is easily accessible in its lateral portion via the posterior petrosal approach. The medial portion of Zone II, the "central clival depression," is accessible only with cochlear resection and posterior facial nerve transposition. Zone III, defined as the area from the upper border of the jugular tubercle to the lower edge of the foramen magnum, is accessible via a suboccipital/transcondylar approach. The retrospective analysis of the cases of 35 patients who underwent transpetrosal resection of petroclival meningiomas between 1991 and 1998 was used to determine the predictive value of these anatomic parameters. The degree of tumor resection was analyzed with a novel grading scale combining the percentage of resection and the percentage of brainstem reexpansion. Total excision was achieved in 37% of the patients and complete brainstem reexpansion was achieved in an additional 40%. Residual tumor was concentrated in the central clival depression in Zone II, as predicted by anatomic parameters, and around infiltrated neurovascular structures. New cranial nerve deficit occurred in 31% of the patients in the early postoperative period and improved to 17% at 6 months. Major morbidity occurred in 9% of the patients, and mortality was 0%. Early Karnofsky scores were reduced in 37% of the patients, but 6-month Karnofsky scores were equal to preoperative baseline scores or improved in 91%. CONCLUSION: Anatomic parameters can predict the resectability of petroclival meningiomas. Judicious application of cytoreductive surgery in selected patients maintains an acceptable morbidity and achieves adequate brainstem reexpansion.

Colored silicone injection for use in neurosurgical dissections: anatomic technical note.

OBJECTIVE: The dissection of cadaveric specimens is very important for a more sophisticated understanding of neurosurgical anatomic features and approaches. Teaching known approaches to residents or learning new approaches is best performed in a cadaveric laboratory. The utility of neurosurgical cadaveric dissections can be improved by injecting the intracranial vascular tree with colored silicone. The vascular anatomic features, which are integral to neurosurgical procedures, are much more clearly defined in injected specimens. METHODS: Self-curing colored silicone rubber is used to inject the arteries and veins (red and blue, respectively) of the head. This process is described in a step-by-step format. Six steps are required and can be summarized as follows: 1) exposure of the great vessels, 2) cannulation of the great vessels, 3) irrigation of the head, 4) preparation of the colored silicone, 5) injection of the colored silicone, and 6) evaluation of the final specimen. CONCLUSION: Injection of colored silicone into the vascular tree can enhance the educational value of cadaveric head dissections. This report describes the technique of vascular injection that is used in the Goodyear Microsurgical Laboratory, the University of Cincinnati, and the Mayfield Clinic.

Primary lymphoma of Meckel's cave mimicking trigeminal schwannoma: case report.

OBJECTIVE AND IMPORTANCE: We report the first case of primary lymphoma of Meckel's cave. The ability of a lymphoma to mimic a trigeminal schwannoma, both clinically and radiographically, resulted in misdiagnosis and flawed surgical strategy. We discuss the characteristics of a Meckel's cave lymphoma on magnetic resonance images, the predisposing medical conditions that should cause the neurosurgeon to add lymphoma to the normal differential diagnosis, and appropriate management strategies. CLINICAL PRESENTATION: A 40-year-old African-American woman presented with a 5-month history of progressive facial numbness and pain in all three divisions of the left trigeminal nerve. Magnetic resonance imaging revealed a mass in the left side of Meckel's cave, with extension into the lateral compartment of the cavernous sinus, without encasement of the internal carotid artery, through the foramen rotundum into the posterior aspect of the maxillary sinus, and through the foramen ovale into the pterygopalatine fossa. The diagnosis, based on clinical history and radiographic imaging, was schwannoma of Meckel's cave. The patient had a history of systemic lupus erythematosus that had been treated with intermittent steroid therapy. INTERVENTION: The surgical approach selected was a frontotemporal craniotomy with orbitozygomatic osteotomy and anterior petrosectomy. The lesion was totally excised, although the gross intraoperative appearance of the lesion was inconsistent with the preoperative diagnosis, and the pathological examination was unable to establish a histological diagnosis on the basis of frozen sections. Histological diagnosis was confirmed on permanent section after surgery as B-cell lymphoma. Evaluation for other primary sites produced negative results. The patient was then treated with cyclophosphamide (Cytotoxan; Bristol-Myers Oncology, Princeton, NJ), doxorubicin (Adriamycin; Pharmacia & Upjohn, Kalamazoo, MI), vincristine, and prednisone chemotherapy every 3 weeks for six cycles and then by radiation therapy to the affected area. CONCLUSION: The diagnosis of lymphoma should be considered for lesions affecting Meckel's cave in high-risk immunocompromised patients. The presence of an apparent dural tail in an otherwise typical schwannoma is the distinguishing characteristic of a lymphoma. The absence of hyperostosis helps differentiate it from a meningioma. At this point, the preferred surgical strategy is biopsy for diagnosis and then radiotherapy and chemotherapy rather than major cranial base surgery for total resection.