Early gene expression in the rat cortex after experimental traumatic brain injury and hypotension.

To determine c-fos and egr-1 mRNA levels in the rat cortex after traumatic brain injury (TBI) and TBI plus hemorrhagic hypotension (HH). Sprague-Dawley rats were subjected to TBI. HH was induced by removing 5 ml of blood from the jugular vein for a duration of 20 min. Cortical tissue was harvested at 0 and 120 min, and mRNA levels of the immediate early genes c-fos, egr-1 were obtained. Rats that sustained TBI alone had increased c-fos and egr-1 mRNA expression at 120 min that was significant. Additionally, c-fos mRNA levels after TBI alone were significantly higher than c-fos mRNA levels after TBI+HH at 120 min. Levels of egr-1 mRNA after TBI alone at 120 min were not significantly higher than egr-1 mRNA levels after TBI+HH at 120 min.

The treatment of wartime brain wounds: traditional versus minimal debridement.

BACKGROUND: Since World War II, surgeons in Western armies dealing with brain wounds have generally advocated thorough missile track debridement, and many have urged meticulous dural closure to prevent cerebral spinal fluid (CSF) leakage and subsequent infection. For the last decade some reports have appeared wherein wartime brain wounds have been treated by minimal brain debridement with little or no attention to tight dural closure. This report compares and contrasts postdebridement complications reported with each method. METHODS: I reviewed the pertinent neurosurgical papers from Vietnam, the Israeli war in Lebanon, and the Iran-Iraq war and compared the results of traditional debridement and water-tight dural closure to those following minimal debridement without close attention to dural closure. RESULTS: Minimal brain debridements without tight dural closure were up to 20 to 30 times more likely to require additional debridement, had a 10-15 times higher incidence of life-threatening CSF leakage, a fivefold increase in postdebridement meningitis, and a 2.5 times greater risk of fatal meningitis. CONCLUSIONS: Compared to thorough brain debridement and watertight dural closure, minimal debridements and nonwatertight dural closure give inferior results.

Major Harvey Cushing's difficulties with the British and American armies during World War I.

This historical review explores Harvey Cushing's difficulties with both the British and American armies during his World War I service to definitively examine the rumor of his possible court martial. It also provides a further understanding of Cushing the man. While in France during World War I, Cushing was initially assigned to British hospital units. This service began in May 1917 and ended abruptly in May 1918 when the British cashiered him for repeated censorship violations. Returning to American command, he feared court martial. The army file on this matter (retrieved from the United States National Archives) indicates that US Army authorities recommended that Cushing be reprimanded and returned to the US for his violations. The army carried out neither recommendation, and no evidence exists that a court martial was considered. Cushing's army career and possible future academic life were protected by the actions of his surgical peers and Merritte Ireland, Chief Surgeon of the US Army in France. After this censorship episode, Cushing was made a neurosurgical consultant but was also sternly warned that further rule violations would not be tolerated by the US Army. Thereafter, despite the onset of a severe peripheral neuropathy, probably Guillian Barré's syndrome, Cushing was indefatigable in ministering to neurosurgical needs in the US sector in France. Cushing's repeated defying of censorship regulations reveals poor judgment plus an initial inability to be a "team player." The explanations he offered for his censorship violations showed an ability to bend the truth. Cushing's war journal is unclear as to exactly what transpired between him and the British and US armies. It also shows no recognition of the help he received from others who were instrumental in preventing his ignominious removal from service in France. Had that happened, his academic future and ability to train future neurosurgical leaders may have been seriously threatened. Cushing's foibles notwithstanding, all realized that he contributed greatly to both British and US war neurosurgery. United States Army surgeons who operated upon brain wounds in France recognized Cushing as their leader.

Botulinum toxin injections for simple partial motor seizures associated with pain.

Intractable epilepsy with painful partial motor seizures is a relatively rare and difficult disorder to treat. We evaluated the usefulness of botulinum toxin to reduce ictal pain. Two patients received two or four botulinum toxin (BTX) injections at one-to-two-month intervals. Patient 1 had painful seizures of the right arm and hand. Patient 2 had painful seizures involving the left foot and leg. Injections were discontinued after improved seizure control following resective surgery. Both patients received significant pain relief from the injections with analgesia lasting at least two months. Seizure severity was reduced, but seizure frequency and duration were unaffected. For these patients, BTX was effective in temporarily relieving pain associated with muscle contraction in simple partial motor seizures. Our findings do not support the hypothesis that modulation of motor end-organ feedback affects focal seizure generation. BTX is a safe and reversible treatment that should be considered as part of adjunctive therapy after failure to achieve control of painful partial motor seizures.

Cushing and the treatment of brain wounds during World War I.

Harvey Cushing, perhaps the most important founder of American neurosurgery, was an Army neurosurgeon in France from 1917 to 1918. Over a 3-month period in 1917 he and his team operated on 133 soldiers with a brain wound. The operative mortality rate for their last 45 patients was 29%, considerably lower than the usual postoperative mortality rate of approximately 50% for those with a brain wound. This accomplishment was lauded at the time and eventually, for some, it was Cushing who was responsible for lowering the postoperative mortality rate of brain wounds during World War I. As the decades passed he was eventually credited as the "originator of brain wound care." This report shows that these attributions are misplaced. Cushing merely followed the enlightened surgical precepts of the time developed by Continental (European) surgeons. It also examines Cushing's writings to ascertain how these misperceptions concerning his originality might have been generated.