Cheng-Mei Shaw and Ellsworth C. Alvord, Jr


The history of Neuropathology is inseparable from that of Neurosurgery. Since the creation of Cushing's Tumor Registry, it has been apparent that neurosurgeons should understand the elements of diagnostic neuropathology. Over the past few decades, there have been extensive developments in histologic tools requiring lengthy specialized training for neuropathologists. The new diagnostic imaging techniques enable clinicians to discover and locate numerous lesions other than tumors and abscesses. The imaging advances also allow the evolution of the lesions to be studied. This chapter focuses on the neuropathologic approaches that neurosurgical trainees should understand. The following three questions should be answered, (1) How is histo-pathologic diagnosis made? (2) How can one understand the changing diagnostic terminology? (3) What are the limitations of histopathologic diagnosis of surgical specimens?

When the young Harvey Cushing arrived at Johns Hopkins Hospital as an assistant resident in William Halsted's Surgical Service, he knew very little about pathology and bacteriology. However, it was the responsibility of the house officers to carry out all of the clinical bacteriological and pathological studies for every patient under their charge. Years later, Cushing wrote that he owed to this system what little he knew of histological pathology and admitted that his early bacteriological studies, some of which got into print, would otherwise never have been made.

In the early 1900s, Cushing operated unsuccessfully on a 14-year-old girl who presented with headache, failing vision, obesity and lack of secondary sexual development. The patient died several days after examination of the posterior cranial fossa followed by occipital exploration and decompression. Autopsy showed a large pituitary cyst, which William Welch called a "teratoma", but which was probably a "Rathke's cleft cyst" in today's terminology. The importance of this case was not fully appreciated until several years later, when Cushing asked the pathology department for the tissue; it could not be found. From then on, Cushing was insistent that he should be responsible for the pathological study of all specimens from the patients under his care. His insistence rightfully caused some difficulties with his colleagues but was granted because he was fortunate to have understanding friends, such as William Welch and W.G. MacCallum. After he moved to Harvard, he made a similar request and more difficulties were encountered, but he was unyielding. His insistence resulted in the development of his own neuropathological laboratory under the supervision of Percival Bailey, who had had unusual training in the techniques of the microscopic study of the nervous system. The renowned "Cushing Tumor Registry", a

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