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Neurological and Architectural Sinuosities: The Niemeyer Brothers In a family of 7 siblings in Rio de Janeiro, Brazil, 2 of the most remarkable national personalities decided to follow different fields at the beginning of the 20th century. Their life’s work would, however, intersect in at least 2 respects: the quest for innovation and a passion for sinuosity. The achievements of Paulo and Oscar Niemeyer are landmarks in the history of neurosurgery and architecture in Brazil. Among his many innovations in neurosurgery, Paulo Niemeyer first described the transventricular amygdalohippo- campectomy in 1957 and introduced the operating microscope to neurosurgery in Brazil in 1971. His brother Oscar became a world-renowned representative of the modern architecture movement, sculpting graceful curves from concrete. KEY WORDS: Amygdalohippocampectomy, Epilepsy, Modern architecture, Neurosurgical history, Oscar Niemeyer, Paulo Niemeyer Neurosurgery 67:1167–1179, 2010 DOI: 10.1227/NEU.0b013e3181ef27d3 www.neurosurgery-online.com B orn in the same family in Rio de Janeiro at the beginning of the 20th century, 2 re- markable personalities pursued different fields. Their careers, however, intersected in at least 2 respects: the quest for innovation and a passion for the exploration of sinuous struc- tures. The achievements of Paulo and Oscar Niemeyer are landmarks in the history of neu- rosurgery and architecture (Figure 1). We review the historical implications of the brothers’ careers, the similarities of their approaches to problems, the contents of their endeavors, and their remarkable influence on their respective fields. THE INCIPIENT CAREERS Paulo Niemeyer Paulo Niemeyer was born on April 14, 1914, in Rio de Janeiro (Figure 2). He was the youngest of 7 siblings. He graduated from the Medical School of the Federal University of Rio de Janeiro in 1936, an institution more than 200 years old and the first medical school in Brazil. He completed his training in general surgery at the Santa Casa de Miserico ´rdia Hospital of Rio de Janeiro, a philanthropic institution, where he dedicated almost 70 years of his life. Niemeyer performed the first gastrectomy at this institution. 1 In 1938, he performed the first stored-blood transfusion in Brazil. 2 Initially a general surgeon, Niemeyer gradually switched his interest to neurosurgery in the late 1930s. Surgeries of the sympathetic system, pri- marily periarterial sympathectomies, were com- monly indicated in the management of pain, and Leriche’s textbook, La Chirurgie de la Douleur, held Paulo’s interest. 3-6 He not only performed these surgeries, he also reported the results of his experiments involving the sympathetic system. 7,8 In 1939, he joined the Souza Aguiar Municipal Hospital (formerly the Hospital de Pronto- Socorro), where he directed his attention to brain injury. There, in 1945, he founded the first Department of Neurosurgery devoted to neuro- trauma in Latin America, at a time when traumatic brain injury was almost exclusively managed by general surgeons. 1,9 This department became a remarkable center for teaching neuro- traumatology. 1 As early as 1948, he reported the management and outcome of his first 1000 traumatic brain injury cases. 10 In 1949, Niemeyer presented his experience with 1500 such injuries at the IVth International Congress of Neurology in Paris. 11 In 1942, Paulo founded the Department of Neurosurgery at the Santa Casa de Miserico ´rdia Hospital of Rio de Janeiro. Eight years later, he also founded the Department of Neurosurgery at the Casa de Sau ´de Dr. Eiras in Rio de Janeiro. At this private institution, he established a multiprofessional team with the neurologists Daniel D. Cavalcanti, MD Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Jose ´ Antonio D. Guasti, MD Department of Neurosurgery, Hospital Geral de Bonsucesso, Rio de Janeiro, Brazil Mark C. Preul, MD Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Reprint requests: Mark C. Preul, MD, c/o Neuroscience Publications, Barrow Neurological Institute, 350 W. Thomas Road, Phoenix, AZ 85013. E-mail: [email protected] Received, September 17, 2009. Accepted, January 15, 2010. Copyright ª 2010 by the Congress of Neurological Surgeons NEUROSURGERY VOLUME 67 | NUMBER 5 | NOVEMBER 2010 | 1167 LEGACY—INSTITUTIONS AND PEOPLE Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
Transcript

Neurological and Architectural Sinuosities: TheNiemeyer Brothers

In a family of 7 siblings in Rio de Janeiro, Brazil, 2 of the most remarkable nationalpersonalities decided to follow different fields at the beginning of the 20th century. Theirlife’s work would, however, intersect in at least 2 respects: the quest for innovation anda passion for sinuosity. The achievements of Paulo and Oscar Niemeyer are landmarks inthe history of neurosurgery and architecture in Brazil. Among his many innovations inneurosurgery, Paulo Niemeyer first described the transventricular amygdalohippo-campectomy in 1957 and introduced the operating microscope to neurosurgery in Brazilin 1971. His brother Oscar became a world-renowned representative of the modernarchitecture movement, sculpting graceful curves from concrete.

KEY WORDS: Amygdalohippocampectomy, Epilepsy, Modern architecture, Neurosurgical history, Oscar

Niemeyer, Paulo Niemeyer

Neurosurgery 67:1167–1179, 2010 DOI: 10.1227/NEU.0b013e3181ef27d3 www.neurosurgery-online.com

Born in the same family in Rio de Janeiro atthe beginning of the 20th century, 2 re-markable personalities pursued different

fields. Their careers, however, intersected in atleast 2 respects: the quest for innovation anda passion for the exploration of sinuous struc-tures. The achievements of Paulo and OscarNiemeyer are landmarks in the history of neu-rosurgery and architecture (Figure 1). We reviewthe historical implications of the brothers’careers, the similarities of their approaches toproblems, the contents of their endeavors, andtheir remarkable influence on their respectivefields.

THE INCIPIENT CAREERS

Paulo Niemeyer

Paulo Niemeyer was born on April 14, 1914,in Rio de Janeiro (Figure 2). He was theyoungest of 7 siblings. He graduated from theMedical School of the Federal University of Riode Janeiro in 1936, an institution more than 200years old and the first medical school in Brazil.He completed his training in general surgeryat the Santa Casa de Misericordia Hospital ofRio de Janeiro, a philanthropic institution,where he dedicated almost 70 years of his life.Niemeyer performed the first gastrectomy at thisinstitution.1 In 1938, he performed the firststored-blood transfusion in Brazil.2

Initially a general surgeon, Niemeyer graduallyswitched his interest to neurosurgery in the late1930s. Surgeries of the sympathetic system, pri-marily periarterial sympathectomies, were com-monly indicated in the management of pain, andLeriche’s textbook, La Chirurgie de la Douleur,held Paulo’s interest.3-6 He not only performedthese surgeries, he also reported the results of hisexperiments involving the sympathetic system.7,8

In 1939, he joined the Souza Aguiar MunicipalHospital (formerly the Hospital de Pronto-Socorro), where he directed his attention to braininjury. There, in 1945, he founded the firstDepartment of Neurosurgery devoted to neuro-trauma in Latin America, at a time when traumaticbrain injury was almost exclusively managedby general surgeons.1,9 This department becamea remarkable center for teaching neuro-traumatology.1 As early as 1948, he reportedthe management and outcome of his first 1000traumatic brain injury cases.10 In 1949, Niemeyerpresented his experience with 1500 such injuriesat the IVth International Congress of Neurologyin Paris.11

In 1942, Paulo founded the Department ofNeurosurgery at the Santa Casa de MisericordiaHospital of Rio de Janeiro. Eight years later, healso founded the Department of Neurosurgeryat the Casa de Saude Dr. Eiras in Rio de Janeiro.At this private institution, he establisheda multiprofessional team with the neurologists

Daniel D. Cavalcanti, MD

Division of Neurological Surgery,

Barrow Neurological Institute,

St. Joseph’s Hospital and Medical Center,

Phoenix, Arizona

Jose Antonio D. Guasti, MD

Department of Neurosurgery,

Hospital Geral de Bonsucesso,

Rio de Janeiro, Brazil

Mark C. Preul, MD

Division of Neurological Surgery,

Barrow Neurological Institute,

St. Joseph’s Hospital and Medical Center,

Phoenix, Arizona

Reprint requests:

Mark C. Preul, MD,

c/o Neuroscience Publications,

Barrow Neurological Institute,

350 W. Thomas Road,

Phoenix, AZ 85013.

E-mail: [email protected]

Received, September 17, 2009.

Accepted, January 15, 2010.

Copyright ª 2010 by the

Congress of Neurological Surgeons

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LEGACY—INSTITUTIONS AND PEOPLE

Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

Abrahao Akerman and Benedito Mettre and the neurophysi-ologist Helio Bello.12 In a few years, these 2 departmentsbecame the standard for neurosurgery in Brazil.13 At Santa Casade Misericordia and Casa de Saude Dr. Eiras, Paulo also startedfunctional surgery and later introduced microsurgery. Impor-tant figures in the neurosciences, including MacdonaldCritchley, Charles Drake, Murray Falconer, Henri Gastaut,Guy Lazorthes, Peter Janneta, Wilhelm Tonnis, and EarlWalker (Figure 3), came to Brazil to participate in conferencesand symposia under Niemeyer’s direction.

Believing that the application of technology was crucial forneurosurgery’s advancement, Paulo performed the first electro-corticographies in Brazil and reinforced the use of electroenceph-alography and electrocorticography as regular diagnostic tools fortumor resections, movement disorders, and epilepsy surgeries.14-16

Because of Brazil’s close cultural ties to Portugal, Paulo wasaware of the early explorations of angiography in that country. Inthe late 1940s, he was one of the first to use angiography sys-tematically as a diagnostic procedure for brain tumors and vas-cular lesions as he worked on establishing vascular neurosurgeryin South America.13,17,18 In 1947, 19 years after the first cerebralangiography was performed in the Americas by Egas Moniz andAugusto Brandao Filho in Rio de Janeiro, Niemeyer introducedthe technique of percutaneous cerebral angiography in Bra-zil.17,19-21 After visiting Thomas Olivecrona in 1949, Niemeyerpublished an extensive review in Portuguese on the clinicor-adiological features and surgical management of arteriovenousmalformations. The review included his first 10 cases and wascited in significant international publications (Figure 4).22-25 In1953, Paulo published a detailed article on the angiographicfeatures of brain herniation.25-28 The next year he introduced aningenious modification for the challenging percutaneous cathe-terization of the horizontal segment of the vertebral artery(V3).29,30 He demonstrated the angiographic technique inworkshops and congresses across Brazil and South America.

Oscar Niemeyer

Oscar Niemeyer was born in Rio de Janeiro 7 years beforePaulo (Figure 5). Oscar graduated from the National School ofFine Arts in Rio de Janeiro in 1934. He then joined a team ofBrazilian architects collaborating with the Swiss-born Frencharchitect Le Corbusier on a new building for the Ministry ofEducation and Health in Rio de Janeiro. Niemeyer worked onthis project with Lucio Costa and Le Corbusier until 1938.Murals of Candido Portinari rendering Brazilian economiccycles, a sculpture by cubist artist Jacques Lipchitz, and BurleMarx’s landscapes enriched the construction, which became anarchitectural milestone.31 In the Brazil Builds exhibition atNew York’s Museum of Modern Art in 1943, the architectPhilip S. Goodwin stated that ‘‘Brazil has had the courage tobreak away from the safe and easy path with the result that Riocan boast the most beautiful government building in theWestern hemisphere.’’32 Together, Niemeyer and Costadesigned the Brazilian Pavilion for the 1939 World’s Fair inNew York City.31 Their innovative ideas ignited interest inarchitectural design in South America.Awarded projects from sectors of West Berlin and suburbs of

Havana to the Caracas Museum of Modern Art, Oscar’s in-ternational career quickly progressed. In 1947, the Americanarchitect Wallace Harrison invited Oscar to join a commissionin charge of designing the United Nations headquarters in NewYork and to submit a proposal.33 Niemeyer’s project was selectedunanimously (Figure 6A).34 In deference to his mentor,Le Corbusier, also a member of the architects’ commission, Oscar

FIGURE 2. Paulo Niemeyer in the early 1940s.Courtesy of Paulo Niemeyer Filho.

FIGURE 1. A, Oscar Niemeyer. With permission of JulianaZucolotto. B, Paulo Niemeyer. Courtesy of Paulo Niemeyer Filho.

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modified the original sketches slightly, primarily in the location ofthe General Assembly building and the terrain. Perhaps wishinghis ideas had been accepted without change by the committee,Oscar stated: ‘‘But it doesn’t stop me from feeling a bit sad when Isee the photo of the built complex. Oh. . .the United NationsSquare that I designed is missing so much!’’34 Nonetheless, thecomplex was inaugurated in 1950 with international recognitionthat it was Oscar Niemeyer’s conception (Figure 6B).

LANDMARKS IN FUNCTIONAL SURGERY

In the early 1940s, with an abiding interest in neurophysiol-ogy, Paulo Niemeyer started to manage movement disorderssurgically, using Putnam’s pyramidotomy35 and cortical extir-pation, as advocated by Bucy36 and Klemme.37 These destructivelesions of the pyramidal tract offered satisfactory relief of tremorbut affected motor strength adversely. In 1945, Niemeyer re-ported positive results in 14 patients, primarily patients withParkinson’s disease. Nine patients underwent pyramidotomy and2 underwent cortical extirpation of Brodmann area 4.15,38 In 1 ofthese 2 latter cases, he identified an area that suppressed motorresponses during stimulation of the premotor cortex. Tremor wasthereby eliminated, and the electrical cortical activity observedon electrocorticography of area 4 was reduced significantly. Hetried to demonstrate, as described in animal studies, the exis-tence of cortical spreading depression in the human brain.39,40

Garol and Bucy41 first identified the suppressor strip in humansjust anterior to the precentral gyrus. In 1946, Paulo16,42 publishedthe related study of suppression of the motor response and theelectrical cortical activity in humans. Penfield43 cited this study inhis textbook Epilepsy and Functional Anatomy of the Brain.In 1955, Paulo44 reported a larger series of patients with

movement disorders with a longer follow-up. Patients withspasmodic torticollis who underwent anterior radicotomy at thecervical level and those with torsion dystonia who underwentanterior cordotomy and bilateral anterior cervical radicotomyimproved. Athetotic patients did not respond to extirpation ofBrodmann area 6. He also stated that parkinsonian patients couldnot be cured, but cortical extirpation provided more lastingtremor control than pyramidotomy. Paulo was not satisfied withhis results, which confirmed those of other contemporary series.Such outcomes led Bucy to state that cortical extirpation ‘‘shouldnot be undertaken unless the tremor is so severe that hemiparesiswill be welcome in its place.’’44,45 Accordingly, Paulo44 alsostated that ‘‘it is now unacceptable for an operative technique toaim to treat a symptom—the tremor—and to cause a new illness,the hemiparesis.’’Traugott Riechert offered Niemeyer a stereotactic frame,

which allowed Paulo to perform the first stereotactic surgery forParkinson’s disease in Latin America in 1954 (Figure 7).44 In 1 year,he performed 16 stereotactic surgeries, including 6 pallidotomies.44

The management of these last 6 cases was detailed in the studyentitled ‘‘Surgical Treatment for Dyskinesias’’ published in 195544

and later cited by Ernest Spiegel and Henry Wycis.38,46

FIGURE 3. Exponents from different generations andsubspecialties visited Niemeyer’s departments and gave lec-tures in Rio de Janeiro. A, James L. Poppen is in the center ofthe photograph and Paulo Niemeyer is at his left at SantaCasa de Misericordia Hospital of Rio de Janeiro, 1952. B,from left to right in the front row: the neurologist AbrahaoAkerman, Macdonald Crichtley, and Paulo Niemeyer amonghis assistants at Santa Casa de Misericordia Hospital of Riode Janeiro, 1955. C, the International Colloquium ofElectrocorticography organized by the Brazilian branch of theInternational League Against Epilepsy. Carlos Villavicenciois presenting his lecture entitled ‘‘EEG in Non-epilepticPatients.’’ Henri Gastaut sits on his left, and Earl Walker sitsat the other extreme of the table. Niemeyer is the first on theleft in the front row. Rio de Janeiro, 1955. Courtesy of PauloNiemeyer Filho.

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Throughout the 1940s and 1950s, neurosurgeons, neurolo-gists, and neurophysiologists attempted to elucidate the patho-physiology of temporal lobe epilepsy.47-49 These years witnessedthe first use of electroencephalography to localize epilepticfoci,50,51 the identification of clinical epilepsy subtypes,47,52 thefirst epilepsy surgery based on electroencephalographic localiza-tion of pathological electrical activity,47,53,54 and explorations ofelectrical potentials recorded from the cortical surface that wereactually arising from ‘‘underlying cortical areas, eg, the cornuammonis’’55 or ‘‘underlying rhinencephalic structures.’’56,57

In 1948, Gibbs et al58 confirmed the temporal origin ofseizures in a large series of patients with psychomotor epilepsy.They stressed that the response to antiepileptic drugs was poor,which instigated the surgical management of this entity at dif-ferent centers.54,59-61 These early series involved anterolateraltemporal corticectomies and provided limited results; the absenceof pathology of the tissue resected was frequently noted.47 Baileyet al62 stated that the chance to obtain seizure control was greaterin the presence of a pathological lesion rather than based onelectroencephalographic findings alone. Crucial experimentalstudies reproducing psychomotor seizures had unveiled the role ofthe mesiotemporal lobe and its association with cortical seizureactivity.63–66 Niemeyer, with the help of Bello, used electro-corticography to study the epileptogenic activity of the hippo-campus and detailed the correlated cortical activity.67

Importantly, Niemeyer reported a 44-year-old woman with

psychomotor seizures at late follow-up after undergoing a tem-poral lobectomy for a posterior communicating artery aneu-rysm.67 Seizure control was achieved after the hippocampus andparahippocampal gyrus were resected.It was recognized that a temporal lobectomy should include the

uncus, amygdala, and hippocampus. Subsequently, Penfield andBaldwin68 described their subtotal temporal lobectomy, identifyingthe pathological evidence (‘‘incisural sclerosis’’) in the surgical speci-mens and relating it to temporal lobe epilepsy. In 1956, Morris69

reported that 78% of his patients were free of psychomotor seizuresusing a similar technique. Citing improved outcomes, Paulo preferreden bloc resection of the temporal cortex, parahippocampal gyrus,amygdala, and hippocampus.67 Gastaut49 commented on these sur-gical procedures: ‘‘These findings suggest that the operation does notalways remove all the structures responsible for the attacks and that insome cases it merely removes structures playing a secondary part in thecourse of its clinical or electroencephalographic manifestation.’’Niemeyer67 believed that psychomotor epilepsy had its origin in the‘‘nucleus amygdalae, in the temporo-insular cortex or in the hippo-campus’’ and these structures formed a ‘‘functional unit, responsiblefor the production of psychomotor attacks, leaving in the majority ofcases the temporal cortex in a secondary place.’’ Based on his neu-rophysiological results, Paulo showed ‘‘astrocytic gliosis, particularly inthe areas H2 and H3 of the hippocampus, which were the beststudied ones, marginal and perivascular gliosis and cellular rarefaction’’in his surgical specimens,70–72 which he claimed supported theprobable secondary role of the temporal lobe. Based on these findings,Paulo tailored a procedure in which the amygdala and hippocampal

FIGURE 4. Many of Paulo Niemeyer’s studieswere cited in important textbooks. This patient’scase was reproduced in Olivecrona’s CongenitalArteriovenous Aneurysms of the Carotis and Ver-tebral Arterial Systems.23 With permission ofSpringer Science+Business Media.

FIGURE 5. The architect Oscar Niemeyer. In1947, he was selected as a member of the architect’scommission in charge of the design for the UnitedNations headquarters in New York. This photo-graph shows Niemeyer presenting his project.ªTime & Life Pictures/Getty Images.

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FIGURE 6. A, Niemeyer is greeted by the international architect’s commission after hisproject for the United Nations headquarters was chosen unanimously. From left to right:the architects Le Corbusier, Vladimir Bodiansky, Ssu-ch’eng Liang, Harrison, Niemeyer,Gyle Sailleux, Nikolai D. Bassov, Abramovitz, Ernest Cormier, Ernest Weissman, andMatthew Nowicki. Courtesy of the Fundacxao Oscar Niemeyer. B, United Nationsheadquarters, New York, 1966. Courtesy of the Library of Congress, Prints & Photo-graphs Division, HABS NY, 31- NEYO, 151-1.

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complex could be resected selectively to preserve the temporal cortex.In a letter mailed to Gastaut, Niemeyer explained the technique:

Rio de Janeiro, November 16, 1956My dear friend Gastaut,

I would like to ask your impression of a new operation that Ihave used for psychomotor epilepsy, based on your studies. For anatomic,physiologic, and experimental reasons and because the focus of thisepilepsy is usually in the nucleus amygdalae, in Ammon’s horn, or in thehippocampus of gyrus, I resected these 3 structures via a transventricularapproach, almost without touching the temporal cortex.

During the procedure, I stimulated the hippocampus and sawthat the temporal cortex appeared to be in synchrony with the hippo-campal discharges, the sharp waves and spikes, almost exactly where thespontaneous focal anomalies had been, giving the impression that theywere secondary.

I have called this operation a transventricular amygdalohippo-campectomy, and I presented the first seven cases at the InteramericanCongress of Surgery, November 9th, in Sao Paulo. All the patientsimproved; two still have a few crises, but from a mental perspective theresults were excellent. Two others underwent surgery too recently (30 and15 days, without crises) to draw any conclusions. But it appears to methat after surgery, the EEG returned to normal in almost all cases.

I think that one of the advantages of this operation is that itpermits more adequate resection of the hippocampus than can be ob-tained solely with an extensive lobectomy. The resected Ammon’s hornsdemonstrated the histological lesions so well discussed at the MarseillesColloquium, especially the gliosis in areas H1, H2 and H3. The em-ployed technique does not allow anatomic study of the nucleus amygdalaeand hippocampus, which are aspirated by suction.

I will present this study at the next Congress of the League, inBrussels, but I would very much like to have your critique.

Please, my friend, accept my best regards.

Gastaut answered as follows:

December 3, 1956Dear Paulo,Your letter interested me so much that I have already writtenthe organizers of the Washington Colloquium on temporalepilepsy to see if it would be possible to invite you to present thework on the intraventricular amygdalo-hippocampectomy. If Iobtain a positive response, I will let you know immediately butit is probable that they will write you directly.Anyway, I am aware of your findings. Do not hesitate topresent this work in Brussels because I think that this approachto the temporal physiopathogeny is extremely interesting.Best regards, Henri Gastaut

In 1957, as a special guest and the only representative of SouthAmerica, Paulo participated in the Second International Collo-quium on Temporal Lobe Epilepsy, sponsored by the NationalInstitutes of Neurological Diseases and Blindness in Bethesda.73

Paulo presented the study ‘‘The Transventricular Amygdalo-Hippocampectomy in Temporal Lobe Epilepsy,’’ which was thenpublished in 1958 in the book Temporal Lobe Epilepsy.67 Paulodescribed the approach as follows:

The transventricular amygdalo-hippocampectomy was employed onlywhen the temporal cortex was grossly normal. A 2-cm incision wasmade on the second temporal gyrus, avoiding injury to cortical vessels.The temporal horn of the lateral ventricle is opened and the hip-pocampus exposed. After the electrographic study, the hippocampus isablated in an extension of 3 cm, and the n. amygdalae and gyrushippocampi are removed by subpial suction, until the basal arachnoidappears on the whole extension of the exposed ventricular floor. Bytransparency through the arachnoid, we can see the tentorium and thecommunicating and posterior cerebral arteries.67

In 1973, Niemeyer and Bello presented the use of microsur-gical techniques to refine the operation at the Fifth InternationalCongress of Neurological Surgery in Tokyo.74 Later, Wieser andYasargil75 described the selective amygdalohippocampectomyusing the transsylvian approach, and Olivier76,77 modified thesurgery via the superior temporal sulcus.During the 1950s, the intense interchange between Gastaut

and Niemeyer through frequent visits to Rio de Janeiro and atinternational meetings was elemental in the development of bothselective amygdalohippocampectomy and epilepsy research inBrazil.9 Gastaut addressed a series of conferences on epilepsyhosted by Niemeyer in Rio de Janeiro between 1954 and 1955.Gastaut attended the International Symposium on Electro-corticography in 1955 in Rio. The meeting was organized byNiemeyer and presided by Earl Walker, with Bartolome Fuster,Leao, Mosovich, and Villavicencio on the faculty.78 Moreover,Bello himself observed important experiments in Marseilles onelectrical stimulation of the amygdala and hippocampus.14,64,79

Years later, Niemeyer and Gastaut exchanged letters on this topic,celebrating their experiments and the increased application of theselective amygdalohippocampectomy:

FIGURE 7. Operating room at the Santa Casa de MisericordiaHospital of Rio de Janeiro, 1955. A patient with the stereotacticframe given to Niemeyer by Riechert is being assessed with electro-encephalography. The conventional C-arm radiography and theneurostimulation systems completed the surgical apparatus necessaryfor the practice of functional surgery at that time. In 1955, Niemeyerperformed the first stereotactic surgery for Parkinson’s disease in LatinAmerica. Courtesy of Paulo Niemeyer Filho.

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Marseille, April 16, 1991Dear Niemeyer,I was both surprised and touched to receive news after thirty

years of silence. I am quite happy knowing that your operativetechnique ‘‘transventricular amygdalo-hippo-campectomy’’ derivedfrom my own studies finally found the success it deserved.

I am in good health and continue to manage some epilepticpatients, but I do no more research.

Thank you again for your kind letter.All my best regards, dear Niemeyer.Professor Henri Gastaut

PIONEERING MICROSURGERY IN BRAZIL

Along with leading Brazilian neurosurgeons Jose Ribe Portugaland Elyseu Paglioli, Niemeyer was one of the founders of theBrazilian Society of Neurosurgery, which was organized on July 26,1957, during the First International Congress of NeurologicalSurgeons20 in Brussels.

In 1970, Niemeyer visited the microsurgical laboratory headed byM. Gazi Yasargil at the Department of Neurosurgery at the Universityof Zurich. He was impressed by the advantages offered by the mi-croscope during neurosurgical procedures and enthusiastic about theimpact of such a tool on patient outcomes. When the microscopetechnology could not be imported to Brazil during the militarydictatorship from 1964 to 1985, Paulo cooperated with D. F. Vas-concellos S.A. from Sao Paulo to develop an operating microscope forneurosurgery1,80 in Brazil.1,12,80 This microscope was subsequentlyused in the majority of neurosurgery departments in South America.

Applying the improvements offered by magnification andillumination, Niemeyer performed the first extracranial-to-in-tracranial arterial bypass in South America in 1971, completinga superficial temporal artery-to-middle cerebral artery anasto-mosis. Four years later, he reported the successful treatment of8 patients who underwent cerebral revascularization.80 Hehandcrafted his own aneurysm clips using steel fishhooks anda custom-made machine (Figure 8).1,80 Paulo’s81 series of 54intracranial aneurysms clipped with his home-made clips waspublished in 1974 and quoted in Yasargil’s82 Microsurgery andother significant publications.83,84 In the same year after visitingArmando Basso in Argentina, Niemeyer introduced microsur-gical transsphenoidal hypophysectomy in Brazil.80 He promotedthis procedure in courses and congresses across the country,often inviting international figures, including Jules Hardy andthe Nobel laureate Andrew Schally, to share their experiences.Paulo reinforced the advantages of microsurgical training when hearranged for former Brazilian president Ernesto Geisel to in-augurate the first microsurgical laboratory in Brazil at Santa Casa deMisericordia Hospital of Rio de Janeiro in 1976 (Figure 9).

LANDMARKS IN ARCHITECTURAL MODERNISM

Oscar Niemeyer was a pioneer in exploring the constructivepossibilities of reinforced concrete. His buildings are composed

of rectangles, semicircles, harmonic curves, ellipses, hyperbolas,and abstract forms that impart a sensation of equilibrium. Thelines of his buildings are futuristic and gravity defying. He statedthe following: ‘‘If you think of the Renaissance, you think ofbuildings heavy on the bottom and light on top. I don’t believein this.’’85

In 1956, the former Brazilian president Juscelino Kubitschekboldly planned a new capital for Brazil to move it from Rio deJaneiro to the hinterland. Niemeyer, Costa, and Marx becameresponsible for building this new city from scratch (Figure 10).Oscar designed the government buildings in the capital Brasilia,which was founded in 1960. The National Congress, PresidentialPalace, Metropolitan Cathedral of Brasilia, and the ItamaratyPalace are among his main conceptions (Figure 11). The politicalsignificance of this architectural creation on Brazil has beenstunning—the development of a new region where millions ofpeople live and one of the main tourist attractions of the country.Oscar’s influence reverberated in different projects around theworld. The Metropolitan Opera House at Lincoln Center in NewYork was designed by Wallace Harrison with a distinct Niemeyerinfluence.85

After Brazil’s military dictatorship took power in 1964, Oscarspent 21 years in exile in France. The exhibition Oscar Niemeyer:L’Architecte de Brasilia was organized in Paris in 1965.86 In 1967, hewas authorized by Charles de Gaulle to practice architecture inFrance. Oscar’s reputation for achievement is preserved in the Frenchpopular and architectural vision. He designed many projects inFrance such as the French Communist Party headquarters in Paris(Figure 11E), the Bobigny Labor Exchange, Le Volcan, and theheadquarters of l’Humanite in Saint-Denis.86 The Algerian gov-ernment commissioned Oscar to design the University of Con-stantine, which was completed in 1968. During the same period, hedesigned another masterpiece, the headquarters for the MondadoriGroup in Milan (Figure 11F).34

Oscar also designed the Sambodromo, the venue for Rio deJaneiro’s Carnival, built in 1984.34 Designed in 1991 and openedin 1996, the Niteroi Museum of Contemporary Art is regarded asone of his masterpieces (Figure 11G). He also conceived of theOscar Niemeyer Museum in Curitiba, which was inaugurated in2002 (Figure 11H). The renowned architect Zaha Hadid statedthat Oscar’s temporary pavilion for the Serpentine Gallery inHyde Park in London in 2003 was ‘‘a postcard of Brazil in themiddle of Hyde Park’’ (Figure 11I).85

ENDLESS ENDEAVOR

At the 1997 World Federation of Neurosurgical SocietiesMeeting in Amsterdam, the Committee on the Medals ofHonor nominated 5 neurosurgeons for their contributions toneurosurgery: Jules Hardy, Paulo Niemeyer, Kenichiro Sugita,Arnoud de Vet, and Mahmut Gazi Yasargil.87 By pioneeringmany techniques in South America, providing a uniqueneurosurgical literature in Portuguese, and visiting or inviting

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surgeons and scientists of leading centers in different sub-specialties, Dr. Niemeyer instructed numerous residents andcontributed his experience to the formative years of variousresidents and generations of Brazilian and South Americanneurosurgeons, including his son, Paulo Niemeyer Filho whois an active neurosurgeon in Brazil. Paulo and his wife wereknown for their Saturday open houses, where guests felt athome and knowledge was discussed. These events, aside fromformal scientific meetings, were important for connecting andinfluencing the younger generation of neurosurgeons in Brazil.Paulo worked actively at his office until he died at the age of 89in 2003.In 1988, Oscar was honored with the Pritzker Architecture

Prize.88 He celebrated his 100th birthday in 2007 and is stillworking on several projects. The Niemeyer Cultural Center,which is being erected in Aviles, Spain, and the Oscar NiemeyerAuditorium in Ravello, Italy, constitute the 2 major projects inprocess. He still works everyday at his office on the top floor ofa building overlooking Copacabana beach.

FIGURE 8. Paulo Niemeyer handcrafted the majority of aneurysm clips that he used in the early 1970s.Front (A) and side (B) views of a small hand crank apparatus used in the process to bend aneurysm clips. C,custom-made steel aneurysm clips crafted using fish hooks. Courtesy of Paulo Niemeyer Filho.

FIGURE 9. Paulo Niemeyer and the former Brazilian presidentErnesto Geisel inaugurating the first microsurgical laboratory inBrazil. Rio de Janeiro, 1976. Courtesy of Paulo Niemeyer Filho.

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CONCLUSION

Although in different fields, the Niemeyer brothers had severaltraits in common: they were inventive, creative, and motivated, and

both had an innate sense of spatial relationships. Neurosurgeonsmust develop an acute sense of 3-dimensional space to remainoriented when approaching surgical targets from odd, non-orthogonal angles. Architects must conceive of space in the same

FIGURE 10. A, Oscar Niemeyer’s sketch of the National Congress building in Brasilia. Courtesy of the FundacxaoOscar Niemeyer. B, construction of the Brazilian National Congress building. In 1956, the former Brazilianpresident Juscelino Kubitschek commissioned Oscar Niemeyer to design the governmental buildings for the newBrazilian capital, Brasilia, which was built from scratch near the geographic center of the country. In April 1960, thecapital of Brazil was transferred from Rio de Janeiro to Brasilia. ªTime & Life Pictures/Getty Images.

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way—they must see in the mind’s eye every line, edge, curve, anddimension of a building that may only be on paper and comprehendits composition and framework as neurosurgeons must comprehendthe structure of the brain. Paulo and Oscar each labored in complexspaces that they created. Although Paulo’s greatest contribution toneurosurgery may have been through the gentle curves and sym-metry of the gyri, sulci, and the mesiotemporal lobe brain structures,Oscar’s contribution lies in the curves, dimensions, materials, and

symmetry of some of the most impressive and pleasing architecturethat the world has known (Figure 12). In many ways the Niemeyerbrothers’ visions for space, volume, and dimension were sim-ilar—just in different environments—this cannot be by chance. Thebrothers evolved in comparable scale and their work reached in-ternational prestige. Through their explorations of sinuosity, eachbrother significantly influenced the world for human improvementand comfort (Figure 13).

FIGURE 11. Oscar Niemeyer’s buildings in Brazil and the world. A, Brazilian National Congress building. Courtesy of Stuart L. Weibel, PhD. B,Presidential Palace. C, Metropolitan Cathedral of Brasilia. B and C, Courtesy of Sergio Viana, MD.ªwww.vianaphotography.com D, ItamaratyPalace. Courtesy of Xenıa Antunes. E, French Communist Party headquarters in Paris. Courtesy of Daniel Dunham. F, the Mondadori Groupheadquarters in Segrate, Italy, was inaugurated in 1975. Courtesy of Roberto Dulio.G, the Museum of Contemporary Art was constructed in the cityof Niteroi. It is situated just across the Guanabara Bay from the city of Rio de Janeiro. Courtesy of Leonardo Paris.H, the Oscar Niemeyer Museumwas inaugurated in 2002. It is located in Curitiba, Brazil. Courtesy of Petra Patitucci Photography. I, the 2003 Serpentine Gallery Pavilion inHyde Park in London, UK. Courtesy of David Robertson/drparchitecture.

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Disclosure

The authors have no personal financial or institutional interest in any of thedrugs, materials, or devices described in the article.

Acknowledgments

We thank Dr Paulo Niemeyer Filho for providing valuabledocuments and photographs that greatly assisted our study. Allletters reproduced here were generously provided by PauloNiemeyer’s son, Paulo Niemeyer Filho, and were translated bythe first author. Part of this study was presented at the 2009AANS Annual Meeting in San Diego, where it was awarded FirstPlace Scientific Eposter in the category of History.

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FIGURE 12. Paulo Niemeyer’s schematic illustration demonstrating the transventricular amygdalohippo-campectomy. A, the approach to the temporal horn after a 2-cm corticectomy through the medial temporalgyrus. B, surgical resection of the hippocampus and subpial suction of the amygdala and parahippocampalgyrus. C, extension of mesiotemporal lobe resection and preservation of the temporal cortex.67 D, OscarNiemeyer’s sketch of the Niteroi Contemporary Art Museum. D, courtesy of the Fundacxao Oscar Niemeyer.

FIGURE 13. Paulo (left) and Oscar (right)Niemeyer at the National Academy of Medicine inRio de Janeiro, 2000. Courtesy of Paulo NiemeyerFilho.

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