CHAPTER Neuroanatomical Studies of Cerebral Hemisphere Tumors: A Theory Concerning the Relationship of the Association Areas and Pathways to Space Sickness* RICHARD c. SCHNEIDER, M.D. INTRODUCTION For many years man has been intrigued by the localization of cerebral function so that at first through pure conjecture and then by gradually progressive scientific research by manyinvestigators much knowledge has been accumulated. Slightly more than 150 years ago, phrenology, the study of physiognomy, was introduced by Gall and Spurzheim (31, 32) suggesting that by studying the conformation of the skull, one could identify the localization of the 'sites of mental functions and character traits (Fig. 4.1). Prior to World War I, Baillarger (1840) (1) and Broca (6) A Chart of Phrenology. 1 Amativeness; 2 Philoprogenitive- ness; 3 Concen tra tiveness; 3 a Inhabitativeness; 4 Adhesiveness; 5 Combativeness; 6 Destructiveness; 6 a Alimentiveness; 7 Secretiveness; FIG. 4.1. Phrenology diagram localizing mental faculties and traits of character based upon conformation of the skull. (From F. J. Gall and J. C. Spurzheim (31, 32).) * This publication was supported by the Begole- Brownell Neurosurgical Research Fund. The author is indebted to the donors of that fund for their kind gifts, which have made this study possible. A portion of this material has been reproduced from the 3rd edition of Correlative Neurosurgery, published by Charles C Thomas, Springfield, Ill. 21 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 4 4 17 20 FIG. 4.2. Brodmann's map of cerebral localization areas based upon cytoarchitecture of the brain. (From K. Brodmann (7,8». Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 10 ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 23 Sr-nsorv hornuncu lu-. A Motor hornuuculus. B FIG. 4.3. Penfield's sensory (A) and motor (B) cerebral localization protrayed in the homunculi based on electrical stimulation of the brain in man. (From W. Penfield and T. Rasmussen (48). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 in France, Brodmann (1903-1925) (7, 8), and Vogt and Vogt (65) in Germany, Campbell (1904 and 1905) in Scotland (12, 13), and Ramon Y Cajal (1911) in Spain (49) contributed cytoarchitectural maps of the cerebral cortex. Of these, the most commonly used is that of Brodmann's (Fig. 4.2), which has been revised so many times that some of the designations of the original areas almost have been lost. There were other major contributions from neurosurgery and neurophysiology. Over the years, many experimentalists and surgeons such as Ferrier (1874) in Scotland (24), Fritsch and Hitzig (1870) in Germany (27), Leyton and Sherrington (1917) in England (15,41, 64), Dejerine and Dejerine-Klumke in France (1895-1901) (21), Economo and Koskinas (1925) in Italy (23), Foerster (1931) and Monakow in Germany (25,44), Penfield et al. (1954) in Canada (47, 48), Jackson (1870) in England (36), and Fulton (1932) in the United States (30) provided a basis for modern experimental and clinical studies of the cortex. In 1954 Penfield stimulated the human cerebral cortex and developed the classical pattern of his homunculus in man (Fig. 4.3) (47). In recent years, the discovery of the second or socalled supplementary motor areas have been demonstrated by Foerster (1931) (25), and French and associates (26), Penfield and associates (1954) (47), Crosby and associates (Fig. 4.4) (17, 19, 20, 22, 56) and other investigators. They have greatly expanded our knowledge of cerebral localization and function. It is truly remarkable that such excellent observations were made independently by these early workers, who did not have the advantage of fine instruments and lacked communication with each other. The identification and understanding of the importance of certain sites, pools, or nodal points on the lateral and medial aspects of the cerebral central fissure I.e. A. fac~ (h) fac~ (h) u.e.\bJ I.e. \b') u.e. \h} ~,~.,,;'··::,,~:a 4 I.e.{c) . u.e. (c ) face (h) trunk face( (b) u e. Ii) fac~(h), neck u.e.(h) c. face(h) neck face(h) FIG. 4.4. The supplementary motor areas in man. Diagram of the lateral (A) and the medial (C) surfaces and the insular region (B) of the macaque left hemisphere, locating certain supplementary motor areas and indicating the patterns of movement elicitable from them (17, 19, 54). The pattern on the midtemporal area is based on the work by DeJonge and Crosby (22) and that on the island has been elicited more or less completely by several Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 face (c) u,e. ( c ) ______ ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 25 hemisphere from which certain sensory (45), motor, and psychological responses have been obtained have been intriguing (Fig. 4.5). The vestibular symptoms of dizziness due to temporal operculum involvement or dizziness with the illusion of inversion of body image from irritation of the temporoparietal area (58,59) and the circling episodes resulting from stimulation of the areas (11, 58, 59, 61, 62) adjacent (18, 20) to and in the island of Rei! are but a few examples. Time does not permit further expansion on the merit of these many contributions by many investigators (5). observers (19). The supplementary motor regions here indicated are: area 6 (Foerster, Penfield & Welch, Travis); areas 5 and 7 (Fleming and Crosby); areas 23 and 24 (Kaada, Showers and Crosby, Showers and Lauer); the island region (C, Hand L; Frontera, Lauer, Showers and Lauer); the temporal areas (DeJonge, Lemmen, Rieck, Schneider and Crosby); and also areas 3,1,2 (a somesthetic sensory field) which is regarded as either a supplementary motor area (Glees) or an extension of the motor cortex (Penfield and Rasmussen). All of these have been studied by many workers. b, bilateral responses; c, contralateral responses; h, homolateral responses; l.e., lower extremity, u.e., upper extremity. (Discussion and complete references to individual authors are presented in references (19,55).) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.5. The lateral aspect of the left cerebral hemisphere is shown with a part of the frontal operculum cut away to show the buried cortex of the island of Reil. Dizziness may be obtained with stimulation of the temporal operculum vestibular association area. When this symptom is associated with inversion of body schema or disorientation in space, it is secondary to stimulation of the parietotemporooccipital region as noted in "space sickness." 26 CLINICAL NEUROSURGERY FIG. 4.6. Dr. Elizabeth C. Crosby delivering one of her memorable scientific papers at the 3rd International Meeting of Neurobiologists, Frankfurt, Germany, 1964. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 For 30 years the speaker has had the privilege and pleasure of being associated, first as a student and then as a staff man; with Dr. Elizabeth C. Crosby (Fig. 4.6), our world-famous neuroanatomist and neurosurgical consultant, who simultaneously is Emeritus Professor of Neuroanatomy at the Universities of Michigan and Alabama, actively dividing her time between the 2 schools. She has contributed importantly not only to her own field of neuroanatomy but also has added magnificently to neurosurgery, based on her outstanding knowledge of the anatomy of the central nervous system. Without her brilliant teaching, kindness, understanding, and selflessness, the author, many of his peers, and thousands of medical students would never have had the opportunity to understand, and perhaps unravel, some of the mysteries of the central nervous system. One of the joint efforts of Dr. Crosby and this author has been the investigation of the association areas and their connecting association ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 27 Case L] Five weeks prior to admission to the hospital, a middle-aged, right-handed housewife struck her left mastoid region but did not lose consciousness. Shortly thereafter she developed severe bifrontal and occipital headaches accompanied by nuchal rigidity, nausea, and vomiting. Hallucinations recurred at intervals. There were noises like the whistling sound of wind. Occasionally, there were olfactory hallucinations similar to foul cigar smoke. Her visual hallucinations, consisting of distorted headless people with weirdly shaped arms in place of heads and flashes of light in the form of circles or bars or colored butterflies, were seen in the right temporal field. Later, symptoms of numbness and tingling of the fingers of the right hand became a source of annoyance. At no time did she display a true Jacksonian march in her seizures. Previously, there had been an attack of meningitis, which had left her with partial visual impairment. Five years prior to this hospitalization, she had been in an automobile accident resulting in enucleation of the left eye, which was compensated for by a left orbital prosthesis. Chorioretinitis and a high myopia caused partial impairment of central vision in the right eye. The remainder of her neurologic examination, her lumbar puncture studies, and the x-rays of the chest and skull were all normal. The EEG revealed high voltage delta waves bifrontally, in the left anterior temporal, midtemporal and, to a lesser degree, in the occipital regions (Fig. 4.7, A and B). The left anterior cerebral artery was displaced to the right on the anterior view of the left internal carotid arteriogram, and on the lateral view there was no distortion of the vessels in the temporal region (Fig. 4.7, C and D). Thus the arteriogram suggested primarily a left frontal lesion. Ventriculography demonstrated good filling of the left temporal horn, diminishing the likelihood of a left temporal expanding lesion (Fig. 4.7, E and F), but the frontal horn of the left lateral ventricle was shifted posteriorly by an expanding lesion at the base of the brain. Under local anesthesia with adjuvant drugs, a left frontotemporal osteoplastic craniotomy was performed, exposing the left temporal and frontal regions. Electrocorticography and depth electrode studies could be carried out, since there was no increased intracranial pressure. The pattern was one of delta waves bifrontally and in the left temporal area, without evidence of spike activity. Attempts made to stimulate the left temporal lobe to reproduce the patient's symptoms had to be abandoned because the patient became too uncooperative. The left anterior and superior frontal and the midtemporal gyri were evaluated with depth electrodes. A flat line was obtained from the depth of the left midfrontal gyrus, a normal alpha pattern was obtained from the left superior frontal area, and delta waves were obtained from the left temporal region. A depth electrode in the anterior-inferior frontal area confirmed the presence of a firm mass at a depth of 2 em., just lateral to the midline. An encapsulated brain abscess, 2 em. in diameter, was resected from the tip of the left frontal lobe (Fig. 4.7G). The postexcision electrocorticogram demonstrated some improvement in the pattern. The operative field is shown with the falx medially, the left olfactory nerve, the stalk protruding from the orbital roof, and the abscess at the tip of the left frontal lobe (Fig. 4.7H). The osteomyelitic bone of the left t (From R. C. Schneider, E. C. Crosby, and S. M. Farhat (62). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 fiber pathways, with regard to their location and functional significance (19). A brief condensation of some of this material is illustrated by the presentation of the case histories of 3 patients with expanding intracranial lesions. They have been selected from our small series of 120 patients at the University of Michigan, who have had extensive studies and surgical treatment for their severe intractable convulsive seizures. There have been only 12 of these patients who have had preoperatively diagnosed intracranial neoplasms. P RE -OPERATIVE EEG RF-RM LM- Lant T RM - Rant T Lmid.T-LM RmidT -RM LT-LO RT -RO ~50,.v EEG 26775 6-17-59 A SEVEN MONTHS POST -OPERATIVE LF- LM L M- L ant T ,..-J"Y\I'"'rAJ1fVV\'\~~~.JHI'fJ~'WtJ~""""~AJ~~~~~ RM- Rant T 14.-y~~~~ANVI./~~~~WW~rvJ'l\.~~~N'tr.,.J~ --.!....!!LJ 50 JAV EEG 28190 2-3-60 D.S. Age 30 B FIG. 4.7. (A) Case 1. Preoperative EEG. The preoperative EEG showed delta waves in the bifrontal, left anterior, and to a lesser degree, in the left midtemporal regions, suggesting a focal left frontotemporal expanding intracranial lesion. (From R. C. Schneider, E. C. Crosby, B. K. Bagchi, and H. D. Calhoun (59). Published with permission.) (B) Case 1. Postoperative EEG. The EEG made 7 months postoperatively showed resolution of the slow waves in the bifrontal, left anterior and middle temporal areas. In the originally abnormal sites on the left side, these waves were replaced by some spike activity probably Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 LF-LM ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 29 FIG. 4.7. (E) Case 1. The posteroanterior view of the ventriculogram showed a well-filled left temporal horn (which was on the side of the lesion). The right temporal horn did not fill well. The study helped to exclude a possible abscess in the left temporal lobe. (F) Case 1. The brow-up film illustrated posterior displacement of the frontal horn of the left lateral ventricle. There was no apparent displacement of the left temporal horn. (From R. C. Schneider, E. C. Crosby, B. K. Bagchi, and H. D. Calhoun (59). Published with permission.) due to scarring. There was no evidence of any focal expanding intracranial lesion. The overall electrical background of the brain seemed to be markedly improved. (From R. C. Schneider, E. C. Crosby, and S. M. Farhat (62). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.7. (C) Case 1. Left internal carotid arteriogram showed definite displacement of left anterior middle cerebral artery across midline toward right side of brain. No inward or upward displacement of left middle cerebral artery is evident to suggest a temporal lobe lesion on this view. (D) Case 1. Lateral view of left internal carotid arteriogram shows an area of some frontal lobe vascularity and, possibly, posterior displacement of right anterior cerebral artery. Equivocal elevation of the left middle cerebral vessel is seen, with a clumping together of branches indicating possibility of frontotemporal extension of lesion. (From R. C. Schneider, E. C. Crosby, B. K. Bagchi, and H. D. Calhoun (59). Published with permission.) FIG. 4.7. (If) The picture shows the abscess bed at the tip of the left frontal pole. (From R. C. Schneider, E. C. Crosby, B. K. Bagchi, and H. D. Calhoun (59). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.7. (G) Case 1. The abscess has been sectioned, and pus exuded around the periphery. (From R. C. Schneider, E. C. Crosby, B. K. Bagchi, and H. D. Calhoun (59). Published with permission.) ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 31 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 orbital roof was removed. The defect through which the stalk of the abscess had projected was excised, this bony cavity was plugged with muscle, and a pericranial graft was applied to the dural aperture. The wound was closed in layers. After a stormy convalescence complicated by a staphylococcic infection despite antibiotic therapy, the osteoplastic flap had to be excised, and a large extradural abscess was evacuated. An EEG made 7 months postoperatively demonstrated regression of the delta waves with replacement by a low to moderate voltage fast activity pattern (Fig. 4.7B). Pneumoencephalography revealed relocation of the left frontal horn of the ventricle, and the skull defect was repaired by an acrylic cranioplasty. The patient has remained seizure-free with no hallucinations since the initial excision of her left frontal lobe abscess 18 years ago. This patient therefore had firing of the auditory recall area, the olfactory region of the hippocampal gyrus, the temporal lobe visual recall area for formed hallucinations, and also the somesthetic cortex. This diagram shows the uncinate fasciculus with a ventral leafprojecting to the region of the amygdala and hippocampal gyrus, with the dorsal leaf of the uncinate fasciculus discharging by long and short association bundles ofthe inferior occipitofrontal fasciculus into the occipital lobe (Fig. 4.71). Professor Kubik of the Anatomisches Institut, Zurich, Switzerland, has provided this beautiful dissection of these fiber pathways (Fig. 4.7J). Mere excision ofthe small abscess from the frontal lobe tip was sufficient to cause complete regression of the abnormal frontal and temporal EEG pattern and the disappearance of the patient's seizures. The uncinate fasciculus coupled with the inferior occipitofrontal fasciculus is a two-way street. Schneider, Crosby and associates (59-62) have seen lesions in the midtemporal region, which have in turn fired the frontal area and provided the clinical picture of a frontal lobe tumor. Case 2.t A 19 year old right-handed man was admitted to the University Hospital on September 25, 1968, with a 4 year history of a neurological problem. Originally, as a boy, he had sustained dizziness and then held onto things for support, but this symptom disappeared after a few months. He subsequently would hear a peculiar indescribable noise, which was followed by a grand mal seizure, but eventually the pattern changed, with the noise vanishing, and the grand mal seizures were converted into a controversive type, turning of the head to the left and clonic movements of the right arm and leg. Eventually, these symptoms were replaced by psychomotor seizures. While watching television, he took offhis shoes and circled toward the right side 3 or 4 times in succession. Once, when he entered an employment office to apply for a job as a stock mover, he arose from his chair, circled around the room, walked out of the door, ended up in another room, and lost his job. He developed severe temper tantrums, striking members of his family with his fists. He withdrew from society, so that he had few friends and had a belligerent affect which might have been related to his asocial attitude. An inability to drive a car, coupled with his aggressive personality and his seizures, prevented him from holding most jobs, so that his only successful employment was the breaking of wild horses! The patient was the product of a difficult forceps delivery, but he had sustained no natal respiratory distress. His anticonvulsant regime had consisted ofprimidone, 250 mg, and phenobarbital, 32 mg, 3 times daily, and diazepam 5 mg, twice a day. All of the neurological and psychological examinations revealed no abnormality, except that his full scale I.Q. was only 84. His vocabulary and conversation were commensurate with a grade school education. The skull x-rays were normal but his repeat EEG examinations demonstrated a delta focus in the right frontotemporal junction (Fig. 4.8A). Metrazol (Knoll Pharmaceutical Co., Whippany, N. J.) injections were used in an endeavor to produce his circling seizures, but this was unsatisfactory, despite the use of electroencephalographic telemetry. His brain scan and right carotid arteriogram were not abnormal, but the pneumoencephalogram exhibited a somewhat dilated right temporal ventricular horn. 32 CLINICAL NEUROSURGERY I Frontal Cortex Uncinate Fasciculus Thalamoorbital Fibers Dorsomedial Nucleus Inferior Frontooccipital Fasciculus FIG. 4.7. (1) The fiber pathways are superimposed on the brain, showing the uncinate fasciculus with the ventral leaf extending from the orbital surface of the frontal lobe to the amygdala and the dorsal leaf connecting the middle frontal gyrus to the anterior temporal region. Impulses may project to the midtemporal and occipital areas by the inferior frontooccipital fasciculus. (From E. C. Crosby, T. Humphrey, and E. W. Lauer (19). Published with permission.) On October 7, 1968, he had a right frontotemporal osteoplastic craniotomy with electrocorticography. Upon opening the dura, a gelatinous-appearing material was found superficially far forward on the cortex in the right frontotemporal junction, which was pathologically identified as a tiny arteriovenous anomaly. Electrocorticographic and subcortical studies revealed spike wave foci in the temporal and frontal regions superimposed on delta activity (Fig. 4.8C). Six centimeters of the right temporal lobe were resected, with no gross evidence of tumor. The postexcision electrocorticogram showed spike waves in the right frontal area (Fig. 4.8D). Subsequently, with further investigation of the temporal lobe specimen, a diagnosis was made of a mixed low grade type of infiltrative glioma. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 Superior Longitudinal Fasciculus Cingulum Corpus Callosum Anterior Thalamic Radiations J FIG. 4.7. (J) The actual dissection of the uncinate fasciculus demonstrates the dorsal and ventral leaves connecting the frontal and temporal lobes joining with the inferior frontooccipital fasciculus extending to the temporal and occipital areas. The fibers of the cingulum, just above the corpus callosum, are also well exhibited. (The author is indebted to Prof. S. Kubik, Anatomisches Institut, Universitat Zurich, Zurich, Switzerland, for this beautiful dissection.) "f:;:N~f-.rV'-.r-JO'~/IJ·-~~~ LM- ~,~~~ RM- ...Nvv'v--J'.A/'~~VV\.'.vJ'v''\f'Iif.f.v-..f\....fI(\''f'vv-/\rv'~~ to- ~r".-J'vJI!'v'..,JAJ~~ RP- ~vJ'~~I,/\--/'''~-v-J'",.,'''\~..J'N'"'\"",/\~ RanfT- ~ 1\ /\ , ~ \," "V~u'~\0\,/r-,,'·0/-f.~' L post T- ~,~~''V''-.~--''-....r- ~,l~~~,'"\~~ ~':::::':::/\v/,/\/'v'J\~,...r\.~\fv'.~rl\r~. /'I;v(\~·.,I·-.J'<\/\~"V' ~ RmidT- RM l~pV ~~w~--yvv-J~v WR A9.' 19 EEG 53675 I~o"v ~ II••. ~ ~I.e~c~ B A FIG. 4.8. (A) Case 2. The preoperative EEG reveals spike waves and high voltage paroxysmal slow activity in the right midtemporal and posterior temporal areas along with diffuse bisynchronous discharges. (B) Case 2. Postoperatively, paroxysmal activity is absent; the pattern is essentially normal. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 Uncinate Fasciculus 34 CLINICAL NEUROSURGERY [CoG 10-7-" FIG. 4.8. (C) Case 2. The electrocorticogram reveals frequent high voltage polyspike waves, picked up widely over the temporal lobe (Ist strip), as well as repetitive spikes and spike waves in the low frontal area (2nd strip). Comment During the next 15 months, he had only 1 generalized convulsive seizure, at which time he did not lose consciousness. This episode occurred when the primidone was removed abruptly from his postoperative anticonvulsant regime, but with its restoration he became seizure-free. Following the operation, his temper tantrums disappeared, and he was gainfully employed. His last EEG (Fig. 4.8B), which was made 6 months postoperatively, was borderline, with a slight excess of theta activity, but there were no localizing or paroxysmal abnormalities. His episodes of rage no doubt indicated the direct participation and the indirect discharge to the amygdala and hypothalamus. Eight years postoperatively, he remained free of his seizures and associated symptoms. He is happily married and employed at hard labor, despite only subtotal removal of his slow-growing tumor. This young man exhibited the typical frontotemporal march of symptoms associated with some tumors, as described by Schneider and Crosby Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 W.1l C ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 35 14-13 I\/'-.rvr "'-\ ~ .J~\/\,,~~ 13- 2 2-7 r"'i~ 7 - I~ POST EXCISION ~~ 11-12 ~ W.R. o CORTICAL LEADS FIG. 4.8. (D) Case 2. The electrocorticogram after right temporal lobectomy. Following excision of the temporal lobe, the tracing shows only rare spikes in the frontal area. (Fig.4.8E) (58,61). As the tumor grew, it stimulated the vestibular area on the inner aspect of the temporal operculum and the island causing dizziness (Fig. 4.8E, 1). With further growth and destruction of this region, this symptom disappeared, and now the lesion irritated the auditory area along the more posterior portion of the temporal operculum, resulting in the hallucination of hearing a peculiar noise (Fig. 4.8E, 2), followed by a spread of impulses and a grand mal seizure. These symptoms vanished with further destruction of this area by the neoplasm, and then manifestations of irritation of the island of Hell appeared in the form of controversive seizures. At about this time, he had his circling seizures (Fig. 4.8E, 3), a type which had been reported from this Clinic (11, 18,54, Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 4-14 36 CLINICAL NEUROSURGERY 55, 60, 61) and which Crosby and Augustine (17) demonstrated so beautifully in the monkey on the stimulation of island area with spread through extrapyramidal pathways to the lower centers of the midbrain and spinal cord (16). The rage attacks were the last to appear with firing of the amygdala (Fig. 4.8E, 4). The careful chronological development of the patient's history, with special attention to the symptomatology and the consideration of the location of the sites or nodal points of involvement by the physician, will often disclose such a chronic frontotemporal march of seizures associated with slowly expanding and usually infiltrative brain tumors (58,60,61). This region of the brain is the best source of such a march, due to the fact that so many pools or nodal points for various functions are in close proximity to each other. Case 3.* A six year old right-handed boy was admitted to University Hospital on January 3, 1966, with a history offour years duration of having had left-sided focal facial seizures with a sensation of spinning spells. If standing, he would assume a wide stance and would weave but not fall. If sedentary, he might exclaim, "There goes my face again. I will be all right in a couple of minutes." His hands would then drop limply into his plate and when asked to watch where his hands were, he would say, "I can't see them." At times he would see himself upside down. The patient did not lose consciousness, was oriented, and was fully aware of his environment during these episodes. He complained *From R. C. Schneider and E. C. Crosby (58). Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.8. (E) Case 2. The chronic march of seizures was noted with stimulation of area 1, the temporal operculum with dizziness; with destruction this symptom disappeared. Successively areas 2, 3, and 4 were subsequently first irritated and then destroyed, causing symptoms to appear and then disappear as the tumor grew. ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 37 FIG. 4.9. (A) Case 3. The skull x-ray exhibited a marked erosion of the inner and outer tables of the skull. (From E. A. Kahn, E. C. Crosby, R. C. Schneider, and J. A. Taren (60). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 almost daily of frontal headaches. His mother noted that he could not skip rope with his left foot very well, and there was clumsiness of the left hand. The child was a product of a full term forceps delivery, complicated by having the cord around the neck. Spontaneous respirations did not occur, and the child was revived only after artificial respiration and oxygen were administered. Skull x-rays had demonstrated a thinning of the inner table and a bulging of the outer table of the skull in the posterior area (Fig. 4.9A). Skull x-rays taken two years later showed a further ballooning of this area. His radioactive mercury brain scan was regarded as probably normal. An electroencephalogram was definitely abnormal and paroxysmal, with high voltage spikes and serial rhythmic delta waves over the right posterior quadrant suggesting a possible atrophic lesion in the posterior quadrant of the right hemisphere (Fig. 4.9, B and C). Unfortunately, the right percutaneous arteriogram was deemed unsatisfactory, and a pneumoencephalogram was reported as "normal." On January 19, 1966, a right parietooccipital craniotomy was performed by Dr. Edgar A. Kahn, with gross total removal of a right parietooccipital astrocytoma, Grade II, followed by an acrylic cranioplasty. Postoperatively, the patient was well except for a left homonymous hemianopsia. 38 CLINICAL NEUROSURGERY Comment LF-BE LF-LE RF- RF- LM- RM- RM- RO- LP- RT- RP- RP- LO- RAT- RO- RPT- P.J. B AgI'6 EEG 44647 C 1-3-66 FIG. 4.9. (B) Case 3. The EEG shows focal spikes and spike waves in the right occipital region and (C) disorganization and slowing of intrinsic patterns in the right parietooccipital area. Interpretive Cortex and Speech Cortex (see also Figure 8). D FIG. 4.9. (D) Case 3. Penfield demonstrated the interpretive cortex bilaterally in the temporoparietal area with a tendency to more space orientation occurring on the right side and speech on the left in a right-handed person. (From W. Penfield and T. Rasmussen (48). Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 Initially, the tumor irritated the vestibular area in the right parietooccipital region, causing dizziness (Fig. 4.9D). With further growth the tumor very likely fired the cingulum discharging to the midtemporal visual recall region. Discharges to the occipital association areas 18 and ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 39 DISCUSSION Much of the experimental interest related to temporal lobe lesions in the macaque was triggered by Bucy and Kluver (9, 10), and this was followed by the painstaking excellent observations in man by Penfield and his associates (47,48), as well as by many other investigators. Some years ago, after a presentation of some of our material on the association areas and the association pathways at a joint meeting of the British Neurosurgical Society and the Neurosurgical Society of America (59), one of our British hosts politely commented as follows: "This is a very interesting paper. You know, I have always wondered what all of those fiber pathways were used for other than a framework upon which to hang the cortex." To the speaker, it seemed that there are other important implications regarding the functions of these neuroanatomical structures and localization sites in the temporoparietooccipital regions of the brain. The Possible Relationship of These Sites, Nodes, or Pools to the Symptoms of "Motion Sickness" in Space Flight Life was never to be quite the same on earth after July 20, 1969, when 3 young American astronauts made their historic space flight (Fig. 4.10A), looked back at the earth (Fig. 4.10B), and landed on the moon, with Neil Armstrong taking that "one small step for man and one gigantic stride for mankind" (Fig. 4.10C). Like the millions of people in the awestruck television audience, this author had followed the Russian and American space flights with more than a passing interest. During the early phases of space exploration, he had observed the reports of the cosmonauts and the astronauts sustaining "motion sickness," the symptoms of which were variously described as "dizziness, nausea, vomiting, flashes of light, formed hallucinations, or illusions of inversion of image or disorientation in space" (34). Hallucinations may be due to many causes (39,40,46,66), but all of these symptoms reportedly associated in space flight were very similar to those experienced by the 3 patients with the expanding lesions of the brain reported here, and by numerous other such patients, who had symptoms referable to the lateral and medial aspects of the temporoparietooccipital portions of the cerebral hemispheres. A few of the excerpts on several space flights are presented from the news media, and Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 19 caused a transient failure of vision, possibly secondary to a seizure with postictal cortical exhaustion, and finally, with a further increase in growth of the lesion, there was disorientation in space and inversion of body image, as had been described by Penfield and Rasmussen (48). Eleven years after operation, examination disclosed merely the persistent visual field defect, but the patient has been seizure-free, except for some occasional slightly antagonistic behavior, which seemed to be related to situational familial problems. 40 CLINICAL NEUROSURGERY these are supported by the scientific data from official aerospace reports (4, 28, 29, 33, 35) or from aviation medical publications (14, 34, 35, 42, 43). The classical example of motion sickness was that of Titov, who felt that he was flying upside down and "became motion sick, the first recorded instance in space flight" (35). In 1964 newspaper headlines in Associated Press reports mention "space sickness" as a cause for return of the Russian cosmonauts to earth sooner than had been expected (Fig. 4.10D). Some excerpts from the Detroit Free Press article were: "They experienced a reaction similar to sea sickness and had hallucinations." Yegorov, the doctor-cosmonaut, "developed a vestibular vegetative reaction of the sea sickness type." An another note revealed: "One spaceman imagined he was half-crouched and facing downward, and the other thought he was hanging upside down, Tass said." Although this is apparently an unofficial report, the problems related to motion sickness have been substantiated by subsequent official reports. According to Graybiel and associates (35) at the Skylab Life Sciences Symposium in 1974: "Postural illusions were experienced immediately after transition into orbit, and while short-lived, some cosmonauts continued to experience the illusion until the G-Ioad reappeared that was associated with re-entry." Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.10. (A) The three astronauts, Armstrong, Aldrin, and Collins, following their successful flight to the moon on July 20, 1969. (From NASA, Houston, Texas; published with permission.) ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 41 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.10. (B) The astronauts' view of the earth as they traveled through outer space. (From NASA, Houston, Texas; published with permission.) 42 CLINICAL NEUROSURGERY In the Russian manned space flight programs, there were 4 of 24 cosmonauts who suffered motion sickness, an incidence of 17% (Table 1) (35). Berry (4) has contributed much to the medical aspects of space flight literature and has reported on the Apollo series. According to the Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.10. (C) "One small step for man, one gigantic stride for mankind." (From NASA, Houston, Texas; published with permission.) ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 43 Space 'Seasickness' Ended Red Probe Early MOSCOW (AP) - The Sovietjthc announcement when it wa~lno discomfort. Union's three-man spaceship I sent up. . Tass said Yegorov and Feokapparently was brought back to; Tass made no mention of lhelH~tov fcl~ giddy d~ring, the , th ted I early landing but said Konstan- flight, which lasted little more earth earI ier an expec as t' F kti t th . . than 24 hours year because two of the cosmo- In eo IS ov, . e scientist . nauts got sick. ,a~~rd, and BorIS Yegerov, the Yegorov had symptoms of . . ship s doctor-cosmonaut, " - space sickness on the second A report on. postflight medical v v tibular ve etative orbit and suffered from nausea checks, publi~bed Sunday by e seasic ess and lack of appetite. Feoktistov T~ss, the ~V1et News agency,!m.::' bad the same trouble to a lesser saId the s~leDtist a~d the doc~or - 'rile end organs of the vestibu- extent, Tass said. o~ ,the fliJht had • reaction lar sense are located in the tn- Orie waceman imared he sfmilar,to seasickness an expe- ner ear and are affected by the was ha-crouched faCing ~.~ hal1uclnabons. pull of gravity. downward, ano tbe~ The spacesblp Voskhod 1 The medical report noted that thought he was ·~)iii!ii. uPiRle came down Oct. 13, 1964, after Col. Vladimir Komarov, the' own, asssaTa.' The re ort did 16 orbits. It had been scheduled commander of Voskhod 1 and no sa W IC one su ere for "a lonz flizht." accordina to an experienced fighter pilot, felf: W ich j usion. tl an D FIG. 4.10. (D) An Associated Press newspaper account of the aborted Russian space flight by Voskhod 1 on October 13, 1964, due to space "seasickness." (From the Detroit Free Press.) TABLE 4.1 Manned Space Flight Programs Russia Program Number of Space Pilots Incidence of Motion Sickness Vostok Voskhod Soyuz 6 5 13 1 3 0 From A. Graybiel, E. F. Miller, II, and J. L. Homich (35). (Published with permission.) Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 Associated Press report, he had commented that the Apollo 12 mission was marked by "medical mysteries." Brilliant flashes of light were observed by the astronauts when they closed their eyes, and these were "thought to be caused by charged particles or rays from the sun or from space penetrating the astronaut's eyelids." Could these be unformed images due to irritation of the occipital cortex? According to Skylab Life Sciences Symposium (35), "motion sickness" in the American space flight program was found in 9 of 59 pilots, an incidence of 15% (Table 2). It is interesting to observe that as recently as the Skylab Life Sciences Symposium Proceedings 3 years ago, there seemed to be little mention that the brain might be involved in the symptoms of motion sickness. In 44 CLINICAL NEUROSURGERY 4.2 United States Program M~~ Gemini Apollo command module Apollo lunar landing Number of Space Pilots Incidence of Motion Sickness 6 16 25 12 0 0 9 0 From A. Graybiel, E. F. Miller, III, and J. L. Homich (35). (Published with permission.) these Proceedings, Graybiel and associates had observed that no state ment had been made about motion sickness aloft until the Apollo mission (35). During this Symposium on the Skylab Space Missions, one crewmai of Skylab 4 crew, Gibson (33), observed that, "being upside down in th. wardroom made it look like a different room than what we were used tc When I started to rotate back and got approximately 45 degrees or so 0 the attitude which we normally call "up", the attitude in which we hat been trained, there was a very sharp transition in my mind from a rOOD that was sort of familiar to one which was intimately familiar. It all of ~ sudden was a room in which we felt very much at home and comfortabli with. It wasn't a gradual thing, it was a very sharp transition." Thessymptoms might be akin to a sudden deja vu phenomenon seen ir temporal lobe lesions. Gibson added that "I also noted the feeling 0 'down.' We all experienced light flashes. Bill, Pogue and I also saw th« ones which looked like polywogs. I also saw one green flash. Not a slightlj green flash but a good old St. Patrick's Day green flash and exceptionallj bright." Kerwin (38) of the Skylab 2 crew reported that "Our crew was fortunate enough not to run into the motion sickness problem in any clinical 0] full-blown form. Therefore our first pleasant or different impressions were the impressions of a very changed relationship between ourselves and the outside world. And, in my own words, I would say there was ne vestibular sense of the upright whatsoever. I certainly had no idea where the earth was at any time unless I happened to be looking at it. I had nc idea of the relationship between one compartment of the spacecraft and the other in terms of a feeling for up and down, and this has some peculiar effects when one passes from one compartment to another and the walls tum into ceilings and the ceilings turn into floors in a very arbitrary way. But all one has to do is to rotate one's body to the comfortable orientation and whamo! what one thinks is up, is up." Finally, Graybiel and associates stated that "In the Apollo command module, where stimulus conditions were far more favorable for eliciting motion sickness than in the Mercury program, on the moon, or in the Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 TABLE Manned Space Flight Programs ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 45 Daedalus and his son, l carus, are two earliest recorded flyers. They were Athenians and went to the Island. of Crete to build a labyrinth. Eventua'l!'y, they themselves were imprisoned there. In order to escape, Daedalus mode a pair of wings for each, which were held to the body b'y some form of 'War. Daedalus warned his son Icarus not to get too near the sun as the wax would melt. They both escaped from the labyrinth, but Icarus did not obey htiJ father's warnilli[J and, as a result of flying too high and getting too near the sum, he fell into the sea and droumed. Daedalus, on the Dither hand} arrived safely 1m. Sicily. These are early examples of both faulty engineering, although Doedalus probably used the best materials that were aoailoble, and pilot failure in that Icarus did nOlt obey the instructions 01 his father, the engineer, who kneui of the weakness W1. the flying equipment which he had designed. E FIG. 4.10. (E) An interesting variation of the famous fable applied to space flight by Dr. Charles A. Berry, former Medical Director of the N 4~SA program. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 Gemini command module, 9 among the 25 Apollo astronauts were motion sick (35). In the Mercury spacecraft the astronauts were restrained in their couches, helmets (which were removed only occasionally) prevented quick head movements and the visual clues were adequate and plentiful. In the Gemini spacecraft helmets were not worn but there was limited opportunity for free floating activities." It could be that rather slight alterations in blood pressure due to vascular insufficiency in the distribution of the posterior cerebral artery secondary to postural change could have effected these symptoms of "motion sickness," which in this author's opinion really is often a misnomer for "space sickness." An interesting excerpt from a paper by Dr. Charles Berry, formerly Medical Director of the NASA program, retells the story of Daedalus and his son, Icarus (Fig. 4.10E), and in the last sentence faults pilot error in not taking engineering advice as the cause of the catastrophe. From this author's observations, perhaps in the modern version of the story one might include other persons dealing with the central nervous system. 46 CLINICAL NEUROSURGERY Case 4.§ On December 18, 1975, a 50 year old right-handed professional pilot aru woman astronaut candidate had sustained severe headache, neck pain, nausea, aru vomiting (Fig. 4.11A). When the pain did not subside, she had an osteopathic adjustmen without any relief, and at a local hospital 3 days later she was found to have a blood; lumbar puncture. On the following day she was admitted to the University Hospital where the neurological examination was normal. An angiogram demonstrated a righ parietal arteriovenous (A "I anomaly, which was fed by both the right anterior and righ posterior cerebral arteries (Fig. 4.11, B and C). On December 29, 1975, she had a righ. parietooccipital craniotomy with apparent total removal of the lesion by Dr. Bennie Scot, and this author. Immediately postoperatively, she had dysconjugate gaze, a left homony mous hemianopsia, and a left hemiparesis. On the day after the operation her visual fields demonstrated the left homonymous hemianopsia and marked right homonymous impair ment (Fig. 4.11D), but 2 weeks postoperatively there was marked improvement (Fig. 4.11~ and at 3 months after operation her visual fields were almost normal (Fig. 4.11F). A postoperative angiogram demonstrated complete obliteration of the arteriooenotu (Al1 anomaly on anterior posterior and lateral views (Fig. 4.11, G and H). Five months after operation she began to have psychomotor seizures with unformed hallucinations ir the left homonymous field, micropsia, and the sensation of seeing herself in a mirror. He} electroencephalogram showed some delta waves and a few spike discharges in the riglu parasagittal temporoparietoccipital area suggesting irritation due to possible postopera tive scar formation. This was an amazing set of coincidences, that the lesion should be ir the region of the cerebrum which we have been discussing. Comment This well-known professional woman pilot had at one time won the "Powder Puff Derby" and been the victor in "The Angel Derby" twice the latter is a race which originates or terminates outside the continenta United States. She was a logical and excellent candidate for a position as a woman astronaut. In the rigorous simulated flight tests at WrightPatterson Field she had been carried to 32,000 feet without oxygen-s-ane had not ruptured her AV anomaly. If she had become an astronaut anc had her subarachnoid hemorrhage in space while she was perhaps piloting a command module circling the moon waiting to pluck 2 fellow astronauts from its surface, or carrying out some other vital duty in space, it might have resulted in tragedy for an entire mission. A computerized tomographic (CT) scan was not performed because ol this patient's acute subarachnoid hemorrhage, but it should have readily demonstrated a lesion prior to rupture of the anomaly. However, such ~ scan currently would not demonstrate a tiny aneurysm or perhaps ~ smaller vascular anomaly. In a mission so fraught with danger and sc extremely expensive it would seem that a 4-vessel arteriogram and a C1 scan would be almost an essential part of a prespace flight examinatior for an astronaut, so as to preclude the possibility of these 2 dangerous § (From R. C. Schneider, E. C. Crosby, and H. Calhoun (60). Published with permission. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 A clinician, such as a neurologist or neurosurgeon, might be madi available for evaluation of space sickness and other symptoms sustainer in space. ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 47 intracranial lesions. Careful consideration must be given as to whether the risks of the invasive techniques, such as arteriography, or the incidence of discovery of a significant number of vascular lesions justifies their use. For example, Liske, a neurologist, and Crowley (42,43) studied 5,500 medical charts over a 10 year period (1955-1965) at the Aerospace Medical School and found that 96 of the personnel complained of headache. Only a single patient complaining of headache had a bloody cerebrospinal fluid on lumbar puncture, and 4-vessel cerebral angiography was normal (43). Although the EEG has been used satisfactorily to exclude latent convulsive seizure disorders and to monitor the astronauts' ability to sleep in space (28), it, of course, will prove of little value in preflight evaluation unless a distinctly abnormal brain wave pattern leads to arteriography for a large AV anomaly. "Motion Sickness" vs. "Space Sickness" This speaker believes it is necessary to clearly define 2 types of sickness in space. Both of these may have manifestations of nausea, vomiting, headache, and dizziness, but these symptoms are primarily "motion sickness" related to the peripheral organ, the inner ear. This may be contrasted to "space sickness," which may have all of those primary Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.11. (A) Case 4. Picture of the patient, a professional pilot and one of the early group of woman astronaut candidates. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.11. (B and C) Case 4. The right carotid arteriogram showing the AV anomaly in the right parietooccipital region fed by the anterior and posterior cerebral arteries. 49 ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS OD 20/20 oa20L20 2 W/IOOO 12/30/75 Reg. No. NS 1143486 8.5. Address H.205605 E os 00 TANGENT SCREEN RECORD OD20/20 oaELm 2 WIIOOO 1/14/76 Reg. No. Nome NS 1143486 8. S. Address H.205605 os 00 FIG. 4.11. (D and E) Case 4. The patient's visual fields postoperatively. (D) Twenty-four hours after operation. (E) Two weeks following her surgery. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 D TANGENT SCREEN RECORD CLINICAL NEUROSURGERY 50 3/12/76 20/20 I Reg No 1143486 OD O.~ 3W/IOOO I Nome I Addres_s H.205605 NS B.S. _ os FIG. 4.11. (F) Case 4. These visual fields were made 3 months postoperatively. symptoms of "motion sickness," but in addition may have central or interpretive vestibular cerebral mechanisms related to the disorientation ofthe body or objects in space by the temporoparietal region, flashes of unformed images from the occipital area and formed ones from the midtemporal portion of the brain. In his fairly extensive reading on the topic this author has not found such a distinction clearly stated, but the information could have been missed in the voluminous literature related to aerospace problems. The difference is depicted in a cartoon from the Saturday Evening Post. Motion sickness is visualized on the right; space sickness is visualized on the left (Fig. 4.12). This author's initial conclusion was that space sickness, somehow, was simply related to vascular insufficiency (2, 3, 37, 50-53, 57, 63) in the temporoparietooccipital association areas or in the regions of the brain fired by the association bundles. Time and space and the more recent acquisition of further knowledge make it appropriate that considerable expansion of this discussion should be assigned to the following chapter. This will involve the histories, surgery, and treatment of 3 patients, who had posterior fossa tumors with transient postoperative cerebral hemisphere symptoms, with a theory concerning the etiology of "space sickness." Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 F TANGENT SCREEN RECORD Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.11. (G and H) Case 4. The postoperative arteriogram reveals an apparently successful complete excision of the right parietooccipital AV anomaly. 52 CLINICAL NEUROSURGERY SUMMARY Cerebral localization is profoundly influenced by the association areas and association fiber pathways. Association sites, or rather pools or nodal points, for certain functions may be fired either directly or indirectly through impulses along the association bundles. The type and extent to which these nodal points will respond will depend on the character of adjacent points and their degree of stimulation, or extent of destruction, as is shown in the 3 cases of expanding lesions cited above. The chronic march of infiltrative brain tumors, particularly in the frontotemporal area, may be identified by a carefully taken chronological history based on the knowledge of the anatomical and functional characteristics of these regions. Although complete removal of a considerable number of such infiltrative neoplasms has not been possible, the remarkable relief of related intractable seizures may often be achieved for long Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 FIG. 4.12. This cartoon depicts to some degree the difference between "motion sickness" and "space sickness." Both may have associated dizziness, nausea and vomiting. On the right it is suggested that "motion sickness," dizziness, etc., such as going up in an elevator, is a symptom complex associated with the peripheral organ function, the inner ear. On the left is "space sickness"-dizziness, etc., with inversion of body image in space, perhaps associated with formed or unformed visual hallucinations, requiring evaluation by the interpretive cortex of the temporoparietooccipital regions of the brain. (Reprinted with permission © 1977 The Saturday Evening Post Company.) ANATOMICAL STUDIES OF CEREBRAL HEMISPHERE TUMORS 53 REFERENCES 1. Baillarger, J. G. F. Recherches sur la structure de la couche corticale des circonvolutions du cerveau. Memoires de l'Academie Royale de Medicine, 8: 149-183,1840. 2. Benson, D. F., and Tomlinson, E. B. Hemiplegic syndrome of the posterior cerebral artery. Stroke, 2: 559-564, 1971. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/25/CN_suppl_1/21/4099680 by guest on 05 December 2019 periods of time by interruption of the fiber pathways which have been stimulated by the neoplasm. The vestibular symptoms of dizziness arising from irritation of the temporal operculum and the circling motor components have been reported previously by this author and his associates (11, 18,54,55,60,61). They have also confirmed the presence of dizziness with the illusion of inversion of body image and disorientation in space, as noted by other observers, due to stimulation of the temporoparietooccipital region. Associated with such lesions, there may be formed or unformed visual hallucinations from the temporal or occipital lobes, respectively. The symptoms noted above were so reminiscent of those experienced by the cosmonauts and astronauts that it called their motion or space sickness to the attention of this author, who wondered whether vascular insufficiency in the distribution of posterior cerebral artery and its branches might be responsible for this symptomatology. A case report on a woman flyer, an astronaut candidate who had a spontaneous subarachnoid hemorrhage from a temporoparietal AV anomaly, has been presented. The fact that she had successfully passed the rigorous simulated tests for space flight as a candidate for the astronaut program may suggest that a CT scan and a transfemoral 4vessel cerebral arteriogram perhaps might be considered in the screening of applicants for the space program. Although the AV anomaly might be seen in the former type of study, at this time a small aneurysm might be missed, spelling tragedy for the individual and the mission unless an arteriogram could be performed to rule out such a smaller vascular vascular lesion. In the case presented, the total excision of the lesion with "cure" of the AV anomaly was achieved, but the patient had visual hallucinations with micropsia and difficulty with depth perception, both of which seem to have been controlled successfully with anticonvulsant medication. Finally, this author believes that although there are symptoms common to motion and space sickness, a distinction should be made between them (Fig. 4.12). 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