Intracranial extension and spontaneous hemorrhage of a sphenoid plasmacytoma

A 71-year-old woman with IgG multiple myeloma presented initially with a compression fracture of the thoracic spine. She responded to radiation therapy and chemotherapy with melphalan and prednisone. One year later, she died from a plasmacytoma eroding intracranially from the greater wing of the sphenoid bone with an associated subdural hematoma. Uncal herniation had been preceded for several weeks by facial numbness. Cranial and intracranial plasmacytomas may occur as isolated lesions or as part of multiple myeloma and can present clinically in a variety of ways, most frequently with cranial nerve palsies. Large intracranial extensions may produce cerebral compression and spontaneous hemorrhage similar to that seen with other malignant intracranial neoplasms. The differential diagnosis of changes in level of consciousness in myeloma patients should include increased intracranial extension and spontaneous hemorrhage.

Dopaminergic mechanisms regulating prolactin secretion in patients with prolactin-secreting pituitary adenoma. Long-term studies after selective transsphenoidal surgery

Twenty-seven female patients with prolactin-secreting pituitary microadenoma, were studied at different intervals following selective transsphenoidal removal of the tumor. Postoperatively, all patients had normal prolactin (PRL) levels and regular menstrual cycles were restored. Sixteen of 27 patients showed positive responses to TRH and metoclopramide (MCP) within 1 mo after surgery. On the contrary, 9 patients showed evaluation of these patients demonstrated that normal neuroendocrine relationships were restored after several months since positive PRL responses to TRH and MCP could be elicited in such patients. The remaining 2 patients who showed basal PRL levels in the upper range of normal, exhibited negative responses to TRH and MCP. These patients had progressively to TRH and MCP exhibited 10-20 mo after surgery a normal decrease in PRL levels following administration of carbidopa plus L-Dopa. Negative responses to carbidopa plus L-Dopa were instead obtained in 6 postoperative patients with elevated PRL levels and negative responses to TRH and MCP. These results suggest that: 1) Hyperprolactinemia induced by "autonomous" pituitary adenomas increases hypothaLamic dopamine (DA) secretion, which in turn inhibits PRL secretion by nonadenomatous lactotropes. 2) Total selective removal of the microadenoma acutely decreases PRL concentration, but a functional inhibition of the normal lactotrope can persist for a period of few months following surgery in a certain number of patients. 3) Prolonged reduction of PRL concentration is accompanied to a normal DA tone with reestablishment of normal neuroendocrine relationships.

[Treatment of acromegaly by the surgical approach through the sphenoid bone. I. Clinical results]

Forty-five cases of pituitary adenomas with clinical characteristics of acromegaly treated surgically from an approach through the nose and sphenoid sinus are presented. After the operation the somatic features of acromegaly decreased in 66% of cases, headaches regressed in 88%, visual field defects disappeared in 20% of cases. Selective removal of pituitary microadenoma caused return of regular menstrual cycles in 12 women and in 3 of them successful pregnancy and labour resulted. In cases of extrasellar growth of the tumour no satisfactory clinical remission was obtained.

[Computed tomography of the nasopharynx and fossa pterygopalatina ]

CT is--especially since the introduction of thin slice technique--the method of choice for the diagnosis of nasopharyngeal tumors. This method provides better results than the conventional film tomography in determining intracranial tumor extension, osseous destruction of the base of the skull, and involvement of the orbit. Tumor infiltration into the pterygoid fossa is also well seen by the third generation of CT. In particular CT scans are superior to conventional tomography in delineating tumor extension to the parapharyngeal and retromaxillary space as well as in recognition of cervical lymph node involvement.

Hyperostosing meningiomas of the sphenoid ridge--clinical features, surgical therapy, and long-term observations: review of 49 cases

Thirty-three patients with en plaque, 9 with en masse (but with extensive bone involvement), and 7 with recurrent hyperostosing meningiomas of the sphenoid ridge were operated on. All patients underwent large extradural resection of the base of the skull as well as extirpation of the intradural tumors or adjacent plaques. The periorbita was involved in 13 patients (26.5%). Seventeen patients (34.7%) needed reconstruction of the base of the skull. This was achieved with autogenous bone grafts. In all but 3 patients, invasion of the bone by meningiomatous tissue was demonstrated histologically. Operative mortality was 4%. Total removal was possible in 91% of the patients with meningiomas located at the pterion or middle third of the sphenoid ridge. More difficult was the total removal of meningiomas of the inner third or of the entire sphenoid ridge (47%). However, long-term results have proved to be satisfying. Early surgical therapy should always be considered as the treatment of choice for such meningiomas.

Transsphenoidal injection of silicone for the production of communicating or obstructive hydrocephalus in dogs

A technique for the insertion of a spinal needle through the soft palate and sphenoid bone into the suprasellar cistern of dogs is described. Instillation of room-temperature-curing silastic elastomer via the needle causes an increased resistance to the flow of cerebrospinal fluid in the basal subarachnoid spaces above the tentorium, for the production of communicating hydrocephalus. If the needle is advanced farther, the same material can be injected directly into the third ventricle for the production of obstructive hydrocephalus. Twenty-five of 34 dogs (74%) developed hydrocephalus and survived to undergo subsequent experimentation.

Role of endocrine function tests in the evaluation of transsphenoidal hypophysectomy for advanced breast cancer

Forty-three women underwent transsphenoidal hypophysectomy for metastatic breast cancer. Endocrine tests (luteinizing hormone, follicle-stimulating hormone, thyrotropin, prolactin and growth hormone) were done in 28 patients to evaluate the completeness of the procedure. Response of the metastatic breast cancer and duration of survival after hypophysectomy were determined and statistically compared with the posthypophysectomy hormone levels. Only one patient had an endocrinologically complete hypophysectomy, but the objective remission rate (32 percent) is comparable to the 30 to 40 percent objective remission rate reported in other studies that claim to have achieved complete hypophysectomy. No statistically significant associations were found between the levels of the hormones measured and the type of response (objective, subjective or none) to hypophysectomy. However, objective responders survived longer than nonresponders (p = 0.01). When analyzing the associations of the various hormone levels with the duration of survival after hypophysectomy, a positive correlation (p less than 0.05) of peak thyrotropin levels with duration of survival was found. Our data indicate that the clinical benefit advanced breast cancer patients received from an endocrinologically incomplete hypophysectomy is probably as great as that received from an endocrinologically complete hypophysectomy. It appears that a nonspecific disturbance of the hormonal milieu may adversely affect the growth of breast cancer. More studies are needed to elucidate the nature of the endocrine disturbance produced by hypophysectomy and its effects on hormone-sensitive tumors.

Visual loss from cavernous hemangiomas of the middle cranial fossa

We studied a case of cavernous hemangioma of the middle cranial fossa. This rare tumor, of which only nine prior cases have been recorded, is characterized by insidious visual loss, multiple cranial nerve pareses, proptosis, papilledema, and bitemporal hemianopsia. Pituitary dysfunction has been noted in the more advanced cases. The female-male ratio has been 8:2; ages ranged from 30 to 62 years. The hemangiomas may occur on either side. Contrast-enhanced computed tomography can clearly demonstrate the presence of these lesions, but is not diagnostically specific. High-quality angiograms using magnification and subtraction techniques may show areas of dye retention in the cavernous spaces of the lesion. This tumor is amenable to successful excision, and early removal may prevent progressive visual loss.

Role of radiation therapy in the management of meningioma

Surgery is the accepted form of treatment of meningioma; the role of radiotherapy has not been clearly established. With this in mind, we have reviewed our experience with radiation therapy in the management of meningiomas at New York University Medical Center. Sixty-eight patients fell into three groups. Forty-three (Group A) underwent operation followed by radiation therapy, 14 patients (Group B) had radiation for recurrence after operation, and 11 patients (Group C) had radiation therapy as the primary treatment. In Group A, 41 of 43 are alive. During a follow-up of 1 to 10 years, only 2 have deteriorated. Five of 14 Group B patients showed neurological improvement and 7 showed deterioration, including 5 who died of tumor. All 11 patients in Group C are alive with follow-up periods of 3 to 6 years; 9 of these show improvement in neurological function. Eleven patients had malignant meningioma, of whom 8 are alive and stable. We present 4 case reports, including computed tomographic scans that show evidence of tumor necrosis after radiation therapy. Pathological verification of tumor necrosis is presented in 1 case. We believe that radiation therapy has an established role in the treatment of incompletely excised, recurrent, or malignant meningiomas and, in some cases, as the initial management of meningiomas. Indications for treatment and guidelines are presented.

Morphogenetic potential of rat growth cartilages as isogeneic transplants in the interparietal suture area

The proximal end of the tibia or the spheno-occipital synchondrosis with some adjoining bone were isogeneically transplanted across the interparietal suture of 10-day-old rats. As a sham procedure, a piece of calvarium traversed by a part of the interparietal suture was interchanged between pairs of animals. Untreated rats served as controls. The animals, injected with Alizarin red S, were killed 25-75 days after the operation, 10 in each group. The transverse dimensions of the neurocranium were larger in the rats with the cartilage transplants than in the controls, particularly at 25 days after the operation; the differences persisted longer in the animals with the synchondroseal transplant. The orientation of the bone interdigitation at the anterior lambdoidal suture changed temporarily in response to the excessive lateral displacement of the parietal bones. The observations indicate that basicranial synchondroses, like epiphyseal cartilage, are endowed with a tissue-separating property that may persist for a prolonged period under transplant conditions. As such cartilaginous structures may also be affected by environmental influences, there must be a two-way interaction between the synchondroses and their immediate environment.

Meningiomas of the anterior visual system

Meningiomas, whether primary in the orbit, optic canal or intracranial area, typically cause slowly progressive loss of vision covering months to years. They usually occur in white women of middle age. Tumors in the orbit or optic canal almost always affect vision unilaterally; intracranial tumors, while usually causing unilateral visual loss initially, eventually cause bilateral loss of vision, often with blindness in one eye. Depending upon the size and location of the tumor, the ocular signs and symptoms of meningiomas may include visual field abnormalities, optic atrophy, edema of the ipsilateral optic disc, papilledema, diplopia, and proptosis. The diagnosis of meningiomas in all locations has been greatly facilitated by recent advances in computer assisted tomography. However, tumors confined to the optic canal or its foramina are small when vision is first lost and therefore are still difficult to detect. Hypocycloidal polytomography may be useful; other neuroradiologic studies rarely are. Treatment is surgical. Based on a review of more than 3000 meningiomas reported in the literature, the frequency and characteristics of the signs and symptoms of meningiomas in each location are discussed, as are the anatomy, pathology, natural history, and probable mechanisms.

Maffucci's syndrome complicated by an intracranial chondrosarcoma and a carotid body tumor. Case report

✓ A patient with Maffucci's syndrome who had undergone multiple surgical procedures presented with blindness due to chondrosarcoma of the left sphenoid bone. A carotid body tumor was discovered, a coexistent tumor previously unreported in this syndrome.