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To the editor
Surg Neurol 1990;33:157-60
157
Editorial
Surgical Neurology is proud to have reprinted the 1981 Sano Lecture that Paul Bucy gave. Dr. Bucy was very perceptive, as always, and very understanding of many of those who have gone before. However, one quotation from his paper [1], Just over 100 years ago, a young man, William Macewen, 31 years of age, in one of the backwaters of the world, Glasgow, Scotland, removed the first brain tumor localized purely by neurological signs and symptoms. Since then, many advances have been made in the diagnosis and treatment of brain tumors, but in terms of mortality, we can do no better today than Macewen did more than 100 years ago.
has s t i m u l a t e d an a p p r o p r i a t e r e v e r b e r a t i o n f r o m o n e o f o u r e d i t o r s f r o m Scotland, w h i c h w e are p r o u d to p u b lish. D r . M i l l e r is n o t o n l y a scholar, b u t an e m i n e n t historian as well. Eben Alexander, Jr., M.D., Editor
Reference 1. Bucy PC. Sano Lecture. "Ancora Imparo"--I continue to learn. Surg Neurol 1989;32:195-9.
Letters to the Editor
To the Editor: In his Sano Lecture (SURGICALNEUROLOGY 1989;32:195--9), Dr. Bucy describes Glasgow, Scotland, as "one of the backwaters of the world." H o w unkind, how untrue, and how ironic that such a remark should be made by an American, since it was the emergence of the United States that propelled Glasgow to world status. One hundred years ago, the time of which Dr. Bucy speaks, Glasgow, with 750,000 inhabitants, was the Second City of the British Empire, grown rich from its position as European leader in the trade in tobacco, sugar, and cotton from America; a major port from which Sir Thomas Lipton sent his tea clippers across the oceans; a cathedral city 700 years old; a city with a great university founded many years before Columbus "sailed the ocean blue." Two hundred years ago, its professors included Joseph Black (latent heat), William Cullen (the nervous system in disease), and Adam Smith (The Wealth of Nations). One hundred years ago, William Thomson (Lord Kelvin) occupied the Chair of Natural Philosophy and Joseph (Lord) Lister, having developed antiseptic surgery, had vacated the Regius Chair of Surgery. This is the city in which William Macewen worked, one of the great cities of the Victorian world. When Osier and Flexner sought a candidate for the Foundation Chair of Surgery for the new Johns Hopkins Medical School in Baltimore, it was to Glasgow that they looked. What of Macewen himself? N o t only was he a pioneer of cranial and spinal neurosurgery, he was the originator of aseptic surgery and he developed the prototype of today's all-metal sterilizable surgical instruments and steam sterilizers. H e was a pioneer of endotracheal intubation for airway obstruction, of hernia repair, of the first successful pneumonectomy, and master of the © 1990 by ElsevierSciencePublishing Co., Inc.
operations of mastoidectomy and femoral osteotomy [ 1]. Only after Macewen had thrice declined the offer of the Chair at Johns Hopkins was William Halsted appointed to the post. Could Harvey Cushing have achieved his neurosurgical fame working with this surgical giant from Glasgow as he did with Halsted? We shall never know, but we do know that the Glasgow of Sir William Macewen was no backwater. J. Douglas Miller
Edinburgh, Scotland Reference 1. Miller JD. William Macewen--master of surgery. Virginia Medicine 1979;106:362-8.
To the Editor: We read with interest the report of Solomon and Correll [6] recently published in this journal. This is an important contribution, since it is the first reported case documenting the rupture of an intracranial aneurysm observed to have been less than 10 mm in angiographic diameter prior to subarachnoid hemorrhage. That this is the only such case ever reported appears to be consistent with previous observations that unruptured saccular aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture [7,8]. It is important to point out, however, that this rupture may not have been entirely spontaneous and that the size of the aneurysm may have been misleading. The 6-ram asymptomatic aneurysm was distal to a "moderate-sized right internal 0090-3019/90/$3.50
158
Surg Neurol 1990;33:157-60
carotid origin plaque," which normally indicates approximately 50% to 60% linear stenosis (or about 80% crosssectional area stenosis). Such a lesion would decrease pressure in that carotid system, and this could have decreased the size of the aneurysm. Autopsy data by McCormick and AcostaRua [2] demonstrated an increase of 30% to 60% in aneurysmal size during infusion of the intracranial arteries with normal saline under a pressure of 70 mm Hg compared to their unfixed collapsed size. This does not allow any precise calculation of potential decreases in aneurysmal size created by carotid stenosis but illustrates that changes in mean pressure within the carotid system may affect aneurysmal size. Even more interesting was the observation that the aneurysm ruptured approximately 3 months subsequent to ipsilateral carotid endarterectomy. We are familiar with another case of an 11-mm unruptured aneurysm discovered incidentally in a patient without prior subarachnoid hemorrhage that ruptured approximately 1 month after ipsilateral carotid endarterectomy. At least 15 previous cases involving endarterectomy in patients with intracranial aneurysms have been reported [1,35]. Three of the 15 cases involved patients with prior subarachnoid hemorrhage, and each of these patients had rerupture of an intracranial aneurysm at intervals of 2 days, 1 week, and 10 months after contralateral endarterectomy. Among the 12 cases with prior unruptured aneurysms, 1 had rupture of a 10-mm right superior cerebellar artery aneurysm 3 months after right carotid endarterectomy. Eleven other cases with carotid endarterectomy and carotid system aneurysm (six ipsilateral and five contralateral) had no ruptures over a mean follow-up period of 13 months. Three of these cases had elective aneurysm repair between 2 and 3 months after endarterectomy. The sudden change of hemodynamics in the distal carotid system from correcting a pressure significant stenosis may be a factor predisposing to enlargement and/or rupture of a previously unruptured intracranial saccular aneurysm. Even endarterectomy for nonpressure significant stenosis could cause significant distal carotid system pressure alterations at clamping and unclamping. It should be emphasized that none of the existing natural history data on unruptured aneurysms may be applicable to patients undergoing ipsilateral carotid endarterectomy proximal to the aneurysm and that such procedures may predispose patients to an increased risk of rupture. David O. Wiebers, M.D. Jack P. Whisnant, M.D. Rochester, Minnesota
References 1. Fields WS, Weibel J. Coincidental internal carotid stenosis and intracranial saccular aneurysm. Trans Am Neurol Assoc 1970; 95:237-8. 2. McCormick WF, Acosta-Rua GJ. The size of intracranial saccular aneurysms. An autopsy study. J Neurosurg 1970;33:422-7. 3. Poole JL, Potts DG. Aneurysms and arteriovenous anomalies of the brain. Diagnosis and treatment. New York: Harper & Row, 1965:417.
Letters to the Editor
4. Orecchia PM, Clagett GP, Youkey JR, Brigham RA, Fisher DF, Fry RF, McDonald PT, Collins GJ, Rich NM. Management of patients with symptomatic extracranial carotid artery disease and incidental intracranial berry aneurysm. J Vasc Surg 1985; 2(1):158-64. 5. Pormoy HD, Avellanosa A. Carotid aneurysm and contralateral carotid stenosis with successful surgical treatment of both lesions--a case report. J Neurosurg 1976;32:476-82. 6. Solomon RA, Correll JW. Rupture of a previously documented asymptomatic aneurysm enhances the argument for prophylactic surgical intervention. Surg Neurol 1988;30:321-3. 7. Wiebers DO, Whisnant JP, O'Fallon WM. The natural history of unruptured intracranial aneurysms. N Engl J Med 1981;304: 696-8. 8. Wiebers DO, Whisnant JP, Sundt TM, Jr, O'Fallon WM. The significance of unruptured intracranial saccular aneurysms. J Neurosurg 1987;66:23-9.
To the Editor: I read with interest your article about the McKenzie Reservoir
(SURGICALNEUROLOGY, 1989;31:476). I thought that you might be interested to know that by the time I had arrived on the unit, the structure of the reservoir had changed. Instead of using a condom, a rubber glove was used to provide the diaphragm because of its extra strength and its ability to withstand multiple punctures. The reservoir was made by taking the top of a plastic pill container, which in those days consisted ofa knurled top and a hollow protrusion which fitted into the neck of the glass bottle. The hollow extruded portion was exactly the size of a burr hole made with the McKenzie burr. If one cut off the knurled top, it left a small cup of plastic. A hole was drilled in the flat bottom of the cup and a straight piece of plastic tubing of the appropriate length was fused by heat to the hole. A piece of rubber glove was then stretched over the open surface of the cup and tied in place and trimmed. Very often we made our own in the operating room from the top of a pill bottle, a rubber glove and a piece of polyethylene tubing. The reservoir really worked quite well and by shaving off the bottom of the pill bottle cap, we could adjust it to various thicknesses of the skull. I was most pleased to read the article, because it brought back memories of the evenings in D O.R. sitting around the table discussing patients and developing new techniques or preparing pieces of equipment for surgery the following morning. It was a good time and I feel nowadays that our resident staff lack this family atmosphere which seemed to be such a rewarding part of the rotation through the McKenzie service. E. Bruce Hendrick, M.D. Toronto, Ontario, Canada
To the Editor: I read with great interest the report of Drs. Vertosick and Sekhar of a case of adult aqueductal stenosis representing with double incontinence (SURGICALNEUROLOGY, 1989;31:387-
157
Editorial
Surgical Neurology is proud to have reprinted the 1981 Sano Lecture that Paul Bucy gave. Dr. Bucy was very perceptive, as always, and very understanding of many of those who have gone before. However, one quotation from his paper [1], Just over 100 years ago, a young man, William Macewen, 31 years of age, in one of the backwaters of the world, Glasgow, Scotland, removed the first brain tumor localized purely by neurological signs and symptoms. Since then, many advances have been made in the diagnosis and treatment of brain tumors, but in terms of mortality, we can do no better today than Macewen did more than 100 years ago.
has s t i m u l a t e d an a p p r o p r i a t e r e v e r b e r a t i o n f r o m o n e o f o u r e d i t o r s f r o m Scotland, w h i c h w e are p r o u d to p u b lish. D r . M i l l e r is n o t o n l y a scholar, b u t an e m i n e n t historian as well. Eben Alexander, Jr., M.D., Editor
Reference 1. Bucy PC. Sano Lecture. "Ancora Imparo"--I continue to learn. Surg Neurol 1989;32:195-9.
Letters to the Editor
To the Editor: In his Sano Lecture (SURGICALNEUROLOGY 1989;32:195--9), Dr. Bucy describes Glasgow, Scotland, as "one of the backwaters of the world." H o w unkind, how untrue, and how ironic that such a remark should be made by an American, since it was the emergence of the United States that propelled Glasgow to world status. One hundred years ago, the time of which Dr. Bucy speaks, Glasgow, with 750,000 inhabitants, was the Second City of the British Empire, grown rich from its position as European leader in the trade in tobacco, sugar, and cotton from America; a major port from which Sir Thomas Lipton sent his tea clippers across the oceans; a cathedral city 700 years old; a city with a great university founded many years before Columbus "sailed the ocean blue." Two hundred years ago, its professors included Joseph Black (latent heat), William Cullen (the nervous system in disease), and Adam Smith (The Wealth of Nations). One hundred years ago, William Thomson (Lord Kelvin) occupied the Chair of Natural Philosophy and Joseph (Lord) Lister, having developed antiseptic surgery, had vacated the Regius Chair of Surgery. This is the city in which William Macewen worked, one of the great cities of the Victorian world. When Osier and Flexner sought a candidate for the Foundation Chair of Surgery for the new Johns Hopkins Medical School in Baltimore, it was to Glasgow that they looked. What of Macewen himself? N o t only was he a pioneer of cranial and spinal neurosurgery, he was the originator of aseptic surgery and he developed the prototype of today's all-metal sterilizable surgical instruments and steam sterilizers. H e was a pioneer of endotracheal intubation for airway obstruction, of hernia repair, of the first successful pneumonectomy, and master of the © 1990 by ElsevierSciencePublishing Co., Inc.
operations of mastoidectomy and femoral osteotomy [ 1]. Only after Macewen had thrice declined the offer of the Chair at Johns Hopkins was William Halsted appointed to the post. Could Harvey Cushing have achieved his neurosurgical fame working with this surgical giant from Glasgow as he did with Halsted? We shall never know, but we do know that the Glasgow of Sir William Macewen was no backwater. J. Douglas Miller
Edinburgh, Scotland Reference 1. Miller JD. William Macewen--master of surgery. Virginia Medicine 1979;106:362-8.
To the Editor: We read with interest the report of Solomon and Correll [6] recently published in this journal. This is an important contribution, since it is the first reported case documenting the rupture of an intracranial aneurysm observed to have been less than 10 mm in angiographic diameter prior to subarachnoid hemorrhage. That this is the only such case ever reported appears to be consistent with previous observations that unruptured saccular aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture [7,8]. It is important to point out, however, that this rupture may not have been entirely spontaneous and that the size of the aneurysm may have been misleading. The 6-ram asymptomatic aneurysm was distal to a "moderate-sized right internal 0090-3019/90/$3.50
158
Surg Neurol 1990;33:157-60
carotid origin plaque," which normally indicates approximately 50% to 60% linear stenosis (or about 80% crosssectional area stenosis). Such a lesion would decrease pressure in that carotid system, and this could have decreased the size of the aneurysm. Autopsy data by McCormick and AcostaRua [2] demonstrated an increase of 30% to 60% in aneurysmal size during infusion of the intracranial arteries with normal saline under a pressure of 70 mm Hg compared to their unfixed collapsed size. This does not allow any precise calculation of potential decreases in aneurysmal size created by carotid stenosis but illustrates that changes in mean pressure within the carotid system may affect aneurysmal size. Even more interesting was the observation that the aneurysm ruptured approximately 3 months subsequent to ipsilateral carotid endarterectomy. We are familiar with another case of an 11-mm unruptured aneurysm discovered incidentally in a patient without prior subarachnoid hemorrhage that ruptured approximately 1 month after ipsilateral carotid endarterectomy. At least 15 previous cases involving endarterectomy in patients with intracranial aneurysms have been reported [1,35]. Three of the 15 cases involved patients with prior subarachnoid hemorrhage, and each of these patients had rerupture of an intracranial aneurysm at intervals of 2 days, 1 week, and 10 months after contralateral endarterectomy. Among the 12 cases with prior unruptured aneurysms, 1 had rupture of a 10-mm right superior cerebellar artery aneurysm 3 months after right carotid endarterectomy. Eleven other cases with carotid endarterectomy and carotid system aneurysm (six ipsilateral and five contralateral) had no ruptures over a mean follow-up period of 13 months. Three of these cases had elective aneurysm repair between 2 and 3 months after endarterectomy. The sudden change of hemodynamics in the distal carotid system from correcting a pressure significant stenosis may be a factor predisposing to enlargement and/or rupture of a previously unruptured intracranial saccular aneurysm. Even endarterectomy for nonpressure significant stenosis could cause significant distal carotid system pressure alterations at clamping and unclamping. It should be emphasized that none of the existing natural history data on unruptured aneurysms may be applicable to patients undergoing ipsilateral carotid endarterectomy proximal to the aneurysm and that such procedures may predispose patients to an increased risk of rupture. David O. Wiebers, M.D. Jack P. Whisnant, M.D. Rochester, Minnesota
References 1. Fields WS, Weibel J. Coincidental internal carotid stenosis and intracranial saccular aneurysm. Trans Am Neurol Assoc 1970; 95:237-8. 2. McCormick WF, Acosta-Rua GJ. The size of intracranial saccular aneurysms. An autopsy study. J Neurosurg 1970;33:422-7. 3. Poole JL, Potts DG. Aneurysms and arteriovenous anomalies of the brain. Diagnosis and treatment. New York: Harper & Row, 1965:417.
Letters to the Editor
4. Orecchia PM, Clagett GP, Youkey JR, Brigham RA, Fisher DF, Fry RF, McDonald PT, Collins GJ, Rich NM. Management of patients with symptomatic extracranial carotid artery disease and incidental intracranial berry aneurysm. J Vasc Surg 1985; 2(1):158-64. 5. Pormoy HD, Avellanosa A. Carotid aneurysm and contralateral carotid stenosis with successful surgical treatment of both lesions--a case report. J Neurosurg 1976;32:476-82. 6. Solomon RA, Correll JW. Rupture of a previously documented asymptomatic aneurysm enhances the argument for prophylactic surgical intervention. Surg Neurol 1988;30:321-3. 7. Wiebers DO, Whisnant JP, O'Fallon WM. The natural history of unruptured intracranial aneurysms. N Engl J Med 1981;304: 696-8. 8. Wiebers DO, Whisnant JP, Sundt TM, Jr, O'Fallon WM. The significance of unruptured intracranial saccular aneurysms. J Neurosurg 1987;66:23-9.
To the Editor: I read with interest your article about the McKenzie Reservoir
(SURGICALNEUROLOGY, 1989;31:476). I thought that you might be interested to know that by the time I had arrived on the unit, the structure of the reservoir had changed. Instead of using a condom, a rubber glove was used to provide the diaphragm because of its extra strength and its ability to withstand multiple punctures. The reservoir was made by taking the top of a plastic pill container, which in those days consisted ofa knurled top and a hollow protrusion which fitted into the neck of the glass bottle. The hollow extruded portion was exactly the size of a burr hole made with the McKenzie burr. If one cut off the knurled top, it left a small cup of plastic. A hole was drilled in the flat bottom of the cup and a straight piece of plastic tubing of the appropriate length was fused by heat to the hole. A piece of rubber glove was then stretched over the open surface of the cup and tied in place and trimmed. Very often we made our own in the operating room from the top of a pill bottle, a rubber glove and a piece of polyethylene tubing. The reservoir really worked quite well and by shaving off the bottom of the pill bottle cap, we could adjust it to various thicknesses of the skull. I was most pleased to read the article, because it brought back memories of the evenings in D O.R. sitting around the table discussing patients and developing new techniques or preparing pieces of equipment for surgery the following morning. It was a good time and I feel nowadays that our resident staff lack this family atmosphere which seemed to be such a rewarding part of the rotation through the McKenzie service. E. Bruce Hendrick, M.D. Toronto, Ontario, Canada
To the Editor: I read with great interest the report of Drs. Vertosick and Sekhar of a case of adult aqueductal stenosis representing with double incontinence (SURGICALNEUROLOGY, 1989;31:387-