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We report the case of 63 year old man found to have a calcified right frontal mass at the site of an 11 year old skull fracture. We present this case in support of the origin of some meningiomas from post-traumatic head injuries. In this case, the point of injury was precisely the site from which the tumour was removed and correlated directly with the traumatic injury to the inner table of the calvarium.
It is of no small consequence that Cushing felt strongly that meningiomas were caused by trauma to the calvarium with resultant meningeal irritation. The well published cases of some of his patients correlated the occurrence of these tumours with prior trauma to the skull and meninges.1 This association was highlighted by the well publicised case of General Leonard Wood and the patient’s first craniotomy performed by Cushing in 1909.1 2 The successful removal of a “a brain tumour” on an eminent, public figure ensconced neurosurgery in the public’s eye as a specialty in which surgery could be performed safely on the brain and people could survive.3 It was Dr Cushing’s success that helped raise neurosurgery to new and distinguished heights and enabled him to become one of the most outstanding men in medical history.
This 63 year old black man presented to the hospital after a witnessed grand mal seizure. Eleven years earlier he had had a focal skull injury to the right frontal bone with an open laceration after being struck by a full beer bottle while on a fishing trip. Physical examination disclosed only a mild asymmetric motor weakness in the left arm and leg. Skull radiography showed a right frontal bone lytic lesion about 2 cm in diameter, hyperostosis, and an extra-axial calcified density (ill defined) directly beneath the lesion. Head CT disclosed a right frontal mass with a lytic focus involving the inner table.
A bicoronal incision and right frontal craniotomy was performed. A right frontal meningioma was found, producing full thickness skull erosion associated with a healed depressed skull fracture. The meningioma was resected with adherent dura and then sent for frozen section. The dura was closed primarily and a cranioplasty was performed using titanium mesh and methylmethalcrylate. Histopathological examination confirmed the diagnosis of meningioma (figure).
This case lends credence to the monumental work of Cushing over 75 years ago, who noted multiple cases of tumour formation after blunt or sharp head trauma. He cited 24 cases “in which evidence of an injury in the nature of a swelling, cicatrix, or depressed fracture corresponded with the tumor’s obvious point of origin”. Cushing noted that trauma as “an aetiological factor...is inescapable”.4 The celebrated case of General Leonard Wood highlighted Cushing’s strong belief on the aetiology of meningiomas.3 General Leonard Wood, Major General and Chief of Staff of the United States Army, developed a parasagittal meningioma 12 years after hitting his head on a chandelier. Cushing first examined General Wood in 1909, at a time when the diagnosis of suspected brain tumour still relied predominantly on clinical findings. After an “initial wait and see” policy, Cushing decided to perform the operation in two stages, 4 days apart. The surgery was a tremendous success and the patient was walking around his room 11 days after the procedure. This was the first time that Cushing had successfully removed a parasagittal meningioma.1 This procedure catapulted Cushing’s career and he was soon promoted to Surgeon in Chief of the new Peter Bent Brigham Hospital in Boston. Additionally, it invigorated the fledgling specialty of neurosurgery and instilled a positive attitude by the public towards brain surgery and the possibility of survival from such operations.
Our case is reminiscent of the General Wood case described by Cushing.3 Our patient was fishing on a causeway when he was struck on the right frontal skull by a full beer bottle thrown from a passing car. The patient sustained a large laceration which bled profusely. At the time, he was seen by emergency room personnel and the laceration was sutured. He remained symptom free for 11 years, until the last admission. Examination of the patient disclosed a healed scar over the 11 year old laceration. The presence of disrupted bone and remoulding with hyperostosis as well as lysis of bone matrix at the point of injury supports a direct causal relation. The histological confirmation of cicatrix adjacent to tumour implicates scar formation as the oncogenic factor in meningioma formation. The leptomeningeal formation of this partially calcified meningioma and the precise correlation with the wound corroborates Cushing’s original premise.
We present a case supporting Cushing’s hypothesis that a causal relation exists between head trauma, resultant scar formation, and the development of meningiomas.
We thank Dr Archinto P Anzil and Dr Chandrakant Rao of the Department of Pathology for their invaluable assistance in the preparation of this manuscript. This work and the paper were funded in part by the Harry Arthur Kaplan Neurosurgical Foundation.