IntroductionBrain tumours frequently cause language impairments and are also likely to co-occur with localised abnormal slow-wave brain activity. However, it is unclear whether this applies specifically to low-grade brain tumours. We investigate slow-wave activity in resting-state electroencephalography in low-grade glioma and meningioma patients, and its relation to pre- and postoperative language functioning.MethodPatients with a glioma infiltrating the language-dominant hemisphere and patients with a meningioma with mass effect on this hemisphere underwent extensive language testing before and 1 year after (...) surgery. EEG was registered preoperatively, postoperatively, and once in healthy individuals. Slow-wave activity in delta- and theta- frequency bands was evaluated visually and quantitatively by spectral power at three levels over the scalp: the whole brain, the affected hemisphere, and the affected region.ResultsGlioma patients had increased delta activity and increased theta activity before and after surgery. In these patients, increased preoperative theta activity was related to the presence of language impairment, especially to poor word retrieval and grammatical performance. Preoperative slow-wave activity was also related to postoperative language outcomes. Meningioma patients showed no significant increase in EEG slow-wave activity compared to healthy individuals, but they presented with word retrieval, grammatical, and writing problems preoperatively, as well as with writing impairments postoperatively.DiscussionAlthough the brain-tumour pathology in low-grade gliomas and meningiomas has a different effect on resting-state brain activity, patients with low-grade gliomas and meningiomas both suffer from language impairments. Increased theta activity in glioma patients can be considered as a language-impairment marker, with prognostic value for language outcome after surgery. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Difficult Patient':A Reflective EssayDaniel McFarlandThe patient who sat across from me knew too much about all brain tumors. According to her, she would never know enough about the one sitting uncomfortably close to her brain's temporal lobe. In her quest for the 'right' answer to her meningioma problem, she became certain that its surgical removal would upend her life, leaving her in neurological taters.She was a small business (...) owner of a practice dedicated to medical massage. Indubitably, she had helped countless clients heal themselves of medical mishaps and avoid or recover from the tyranny of [End Page E13] a medical community that did not always provide respectable, hospitable care. She was certain a craniotomy would end her business, nullifying everything she had spent her life building. She became fluent in the legalese needed to transfer or sell her business in anticipation of surgery. To stave off losing her life's work from a surgical mishap, she sought opinions from a dozen neurosurgeons. They reassured her that a routine surgery like this would be effective with little chance of neurological collateral damage. She did not believe them. In her business she had treated numerous exhausted professionals. Many surgeons with whom she worked professionally frequently referred patients to her. She had seen the poor self-care that many surgeons and doctors brought on themselves in the form of unrelenting stress, drinking, bad eating habits, and even drugs. This made her nervous and untrusting about the care she could receive at the hands of an overworked or impaired surgeon. She scheduled appointments with every neurosurgeon she could find and interviewed them relentlessly, looking for the slightest sign of incompetence, unprofessionalism, antipathy, or lapse in compassion. Given her insistence and dogged nature, she usually found what she was looking for. She would bring her research to the appointments and interview the neurosurgeons on what other doctors had opined. If they were incredulous of research she brought or a technique on which she inquired, they were summarily dismissed.At first glance, which is likely all that she got from many of her visits, these encounters put a spotlight on a 'difficult' patient refusing care. The deeper look that my patient deserved revealed a personal narrative of the oldest child who survived a broken home riddled with drug use and prostitution. She learned to rely on only herself for protection. She took unapologetic control of her fate. Her own mother had at one time offered my patient work as a prostitute. Her father was no better in providing protection and a decent upbringing. He had left her as an eight-year-old with the neglectful mother and four younger siblings to fend for herself, which she did against the odds. She suffered physical, emotional, and spiritual abuse.As an adult, her strong sense of selfhood and boundaries allowed her to have a guarded relationship with both of her parents at a comfortable emotional distance. Her mission and passionate drive to help others heal saved her life. In healing others, she was healing herself. Importantly, her experience marked for her indelibly that while she could do this for herself, others were not reliable and could not heal her. She had only ever trusted and relied upon herself. She was the only one who had never let her down. She was terrified that this might be the first time. The potential surgery risked her cognition, physical capacities, and ability to care for herself. The risk was too great.We met numerous times, uncovering her past, reliving the stories of her tumultuous background, and examining how she established her place in the world away from the horrors of her insecure childhood. She took in my reaction to her stories and saw the horror on my face when I tried to imagine a world where one's parents were not only neglectful but the source of danger. Through my reaction, she may have begun to have some compassion for her own story and put the pieces together. One several occasions, she became enraged when I didn't meet her expectations, or I didn't entertain the diatribe of neurosurgical scholarly work.On one of those... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Life is GoodAnnette ChacosI live in Hervey Bay. I’m a member of several social groups. I have adult children and grandchildren, and many lovely friends. I love to write. Most importantly I love The Lord Jesus Who has been my strength, bringing me through the good times, the not so good times, and the, ‘I’m throwing in the towel’ times.I was first diagnosed with a brain tumour in 1997. (...) Prior to knowing about the tumour and for some time after its removal I had little or no memory of events. The tumour was a left Frontal Meningioma (benign). For some time afterward I was partially [End Page 189] paralyzed. Now there is only some weakness on the right side of my body. Epilepsy too became part of my life. There are different types of seizures, which are rarely, if ever, amusing.Humour is very important. If you can’t laugh at the things that happen life would be a constant tale of woe. I’m very blessed. There are so many people who are much worse off than myself.My storyIn July 1997 my husband went to see if everything was okay because I wasn’t up out of bed yet. I was lying across the bed in a disheveled state. After being cleaned up I was taken to the local hospital. The duty doctor, who hadn’t even seen me, told my son that he didn’t think there was much wrong and to take me home. My sons refused and insisted that the doctor admit me. He did.I was diagnosed with a urinary tract infection. My memories of this are scattered. I learned some time later that I had had a Tonic Clonic seizure (formerly known as “grand mal” seizures which are commonly associated with epilepsy). After I came out of hospital I saw my general practitioner (GP). She sent me for an x–ray, and then to see a Neurosurgeon. An MRI was taken and there was a large tumour in my brain.My memory of this time is poor. I do recall a friend phoning and I told her I was going into hospital to have a brain tumour removed. After fifteen years she is still saying I was so matter of fact about it. I now know that my emotions, like my memory, was at a very low ebb due to the tumour. There was no caring or worrying. If there was, in the next minute, probably second, it was forgotten.Before going into hospital my late husband said to the kids “better take a photograph of your mother in case she dies.” I was told about that comment some time later. What a comfort! Then one day the photo turned up. It was so ugly I tore it up. You’ll note I said the photo was ugly!The operation took place in Canberra hospital, at the end of August. It was to be earlier but they deferred it because an emergency came in. They were going to defer it again, by which time I was mute and non–responsive. My daughter Maria arrived from Melbourne and my daughter Katrina and her husband Kevin came from America with their 3–month–old baby. My son Libe arrived from Sydney. Marcus, my youngest, lived locally, as did my daughter Tania. On hearing the operation was to be deferred again they took action informing hospital staff they were going to the local MP and the A Current Affair television show. So l had the operation—it was much easier to put me under the scalpel than battle the bureaucracy!I have only one film from that MRI. Where the others are I don’t know. According to Dr C, the tumour was very large. But to me, what does size matter—it was no longer there. Most importantly, I survived. The ten days I was in hospital are mostly forgotten. The few people I remember are like snapshots. No one moved, or so it seemed to me.In 2006, the second tumour was removed. It was discovered by the same lovely GP, who found the first one. I was... (shrink)

Asomatognosia designates the experience that one’s body has faded from awareness. It is typically a somaesthetic experience but may target the visual modality. Frequently associated symptoms are the loss of ownership or agency over a limb. Here, we elaborate on the rigorous nosographic classification of asomatognosia and introduce a structured interview to capture both its core symptoms and associated signs of bodily estrangement. We additionally report the case of a pure left-sided hemiasomatognosia occurring after surgical removal of a meningioma (...) in the right atrium. Despite the wide lesions of the right angular gyrus and of the temporo-parietal junction, the patient did not present visuospatial deficits or bodily awareness disorders other than hemiasomatognosia. The patient and 10 matched controls’ motor imagery was formally assessed with a limb laterality task in which they had to decide whether hands and feet presented under different angles of rotation depicted a left or a right limb. Bayesian statistics showed that patient’s reaction times were significantly impaired exclusively for the left foot and especially for mental rotations requiring somatomotor rather than visual limb representations. This was in accordance with a more enduring left-sided hemiasomatognosia for the lower limbs confined to the somesthetic modality. Our findings shed new light on motor imagery in asomatognosia and encourage the future use of the structured interview introduced here. In addition, the limb laterality task may capture phenomenological elements of a case by chronometric means. This allows a more standardized reporting of phenomenological detail and improves communication across different clinical facilities. (shrink)

Objective: To investigate the differences between patients returning to work and those who did not after brain tumor surgery.Methods: Patients were evaluated before surgery and after 3 months. The Montreal Cognitive Assessment test, Trail-Making Test, 15-word Rey–Osterrieth Word List, F-A-S tests, and Karnosfky Performance Status were used to assess cognitive status, attention, executive functions, memory, word fluency, and functional status. Patient-reported outcome measures used to evaluate emotional distress and disability were the Hospital Anxiety and Depression Scale and World Health Organization (...) Disability Assessment Schedule. Clinical and work-related variables, PROMs, and cognitive tests were compared using chi-squared, t-test or Mann–Whitney U test.Results: Sixty patients were included. Patients returning to work were 61.3 and 31.0% among people with meningioma and glioma, respectively. They reported lower postoperative disability and lesser home-to-work travel time. Patients with meningioma also showed better preoperative and postoperative attention and executive functions, better postoperative functional and cognitive status, and lower frequency of treatments.Conclusions: These variables should be considered in a clinical context to plan interventions for people who need support during return to work and in future research to investigate preoperative and postoperative predictive factors of going back to work. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Oldest and Most Respected Uniform in the World1Zelig R. Weinstein“And all the peoples of the earth shall see that the name of the LORD is called upon thee; and they shall be afraid of thee.”(Deuteronomy 28:10)Rabbi Eliezer the Great says that this verse alludes to the Tefillin Shel Rosh, the small leather box containing Biblical verses that are worn by Jewish men on their head. During Talmudic times (...) and for centuries after, devout Jewish men would wear Tefillin the entire day. This practice is now only rarely seen. Since the 1960s, there has been a resurgence of public display of one’s adherence to traditional Jewish practices. It is increasingly common to see Jewish men wearing a yarmulke at work and in public spheres. There are perhaps thousands of Jewish doctors who don’t hesitate to wear their yarmulke in their places of practice–hospital, clinic, private practice.In the 1980s I joined the staff of the Department of Radiology at the Bethesda Naval Hospital as the Director of Neuroradiology and Interventional Radiology. As the hospital’s Neuroradiologist I presented the radiological findings for the cases presented at the bimonthly “brain cutting” sessions. These sessions were well attended by staff, residents and medical students from the Departments of Neurosurgery, Neurology, Neuropathology and Radiology. I was the only traditional Orthodox Jew at the hospital, clearly recognizable as such by the yarmulke I always wore (very unusual in the early 1980s). My yarmulke would provoke occasional good–natured kidding particularly from the neurosurgery staff and residents. [End Page 212]During one of these sessions, kidding about my yarmulke from a small group of residents was reaching a crescendo. The kidding came to a sudden halt when the Chief Resident of Neuro-surgery, a born and bred Louisianan, demanded everyone’s attention. When it quieted down he very sternly ordered everyone to carefully look at their uniforms. Everyone seemed perplexed but all followed suit. Almost a half–minute passed before the Chief Resident, with his thick Southern drawl, spoke. “Our [naval] uniforms are, at most, a couple of hundred years old.” He then pointed toward my yarmulke and said: “Dr. Weinstein’s uniform is thousands of years old and a lot more respected than our uniforms.”This was my initiation into the alluring, usually positive and unexpected fascination and respect that my obvious religiosity had on my patients, their families and my many colleagues during the almost seven years I spent at Bethesda.The story I will tell is very poignant. It involved the family of one of the most senior Chief Petty Officers of the United States Navy.Late one Sunday evening, I received a call from the Chief Resident, Dr. Steve Henning, informing me that the family matriarch had been admitted to Bethesda with relatively acute onset of significant neurological findings. The emergent workup confirmed the presence of a large mass, a meningioma, of the frontal lobe region with significant surrounding edema and mass effect. Neurosurgery requested embolization of the feeding vessels prior to surgery. The interventional procedure and possible serious complications were fully explained to the patient, her husband and her two daughters. Consent was signed and early Monday morning the patient was brought to Special Procedures to have the tumor embolized.Prior to the procedure I introduced myself to the patient’s family and spoke to them about the procedure. The patient’s husband and two daughters, one of whom was an active duty Navy nurse the other a minister of a fundamentalist church in the South, were very attentive and expressed concern about the procedure and its outcome. I tried to reassure them and told them I would speak to them during and after the procedure.All went well. Medically, the patient did well during and after the procedure. She was discharged from our care to neurosurgery. The patient and her family thanked us.After the patient left the Special Procedures area the Chief Technologist, Al, approached me and very cryptically asked if I was aware of what happened when the Chief Resident, Dr. Henning, spoke with the patient and family the night before. I was puzzled and replied, no. He... (shrink)

High-resolution neuroimaging modalities are used often in studies involving healthy volunteers. Subsequently, a significant increase in the incidental discovery of asymptomatic intracranial abnormalities raised the important ethical issues of when follow-up and treatment may be necessary. We examined the literature to establish a practical set of criteria for approaching incidental findings. Our objective is to develop an algorithm for when follow-up may be important and to provide recommendations that would increase the likelihood of follow-up. A systematic literature search was performed (...) using the PubMed and MEDLINE databases to identify articles describing brain tumors and intracranial aneurysms. The treatment algorithm we present suggests that incidental intracranial masses suspicious for glioma should be biopsied or resected, while other masses are to be followed with serial imaging based on the expected growth pattern. Lack of follow-up can result in adverse outcomes that can be mitigated by using technology to facilitate communication and improve follow-up care. The importance of training physicians to be good communicators is also stressed. New technology including automated telephone systems, texting and email will improve access to patients and hopefully encourage compliance and follow-up. (shrink)