High dose glucocorticoids in the management of severe head injury

Eighty-eight patients with a Glasgow coma score of 8 or less 6 hours after nonpenetrating head trauma were given either high dose methylprednisolone sodium succinate (30 mg/kg q6h X2, then 250 mg q6h X6, then tapering over 8 days), low dose methylprednisolone (1.5 mg/kg q6h X2, then 25 mg q6h X6, then tapering over 8 days), or placebo. Standard care including the removal of traumatic hematomas, assisted ventilation, and intracranial pressure monitoring and control was carried out. Follow-up assessments were performed on all surviving patients at 6 months and were graded according to the Glascow outcome scale. No statistically significant difference in outcome was seen between the low dose group and the placebo group. The high dose group experienced a mortality of 39% as compared to a 52% mortality in the low dose and placebo groups (P less than 0.05). Mortality differences were most marked in patients less than 40 years old, with the high dose group experiencing a mortality of 6% as compared to a 43% mortality for the low dose and placebo groups (P less than 0.05). For patients under 50 years old, the incidence of recovery of speech was 62% compared to 36% in the low dose and placebo groups (P less than 0.5). The increased survival in those treated with high dose corticoids, however, was associated with an increase in the poorer outcome categories.

Computed tomographic guidance stereotaxis in the management of lesions of the third ventricular region

The initial management strategies for lesions of the 3rd ventricular region are often controversial. Current techniques for computed tomographic guidance stereotaxis allow accurate access to any intracranial point. A Brown-Roberts-Wells stereotactic system was used as a technical adjunct in the initial management of 42 mass lesions of the 3rd ventricular region. Objectives included biopsy, culture, aspiration, visualization, and installment of drainage conduits. Forty-five point placements were accomplished, and 140 tissue specimens were retrieved without complication. The pathological diagnosis was substantiated in all cases and included lesions of developmental (1 case), neoplastic (31 cases), and infectious (10 cases) origins. Information based on stereotactic assessment provided a rational substrate for the initiation of management, which included craniotomy, cerebrospinal fluid diversion, radiotherapy, chemotherapy, and antibiotic or antiviral therapies. Based on this experience, it is apparent that these methods offer acceptably safe and accurate access to lesions of the entire 3rd ventricular region. Histological or microbiological diagnosis without the need for craniotomy may be readily realized and offers logical guidance for therapeutic strategies. Dependent on the pathological condition, definitive treatment may be achieved.

Surgical considerations in treatment of intraventricular cysticercosis. An analysis of 45 cases

Infestations of the human brain with the larval stage of Taenia solium, once an infrequent diagnosis in the United States, is now a more frequently encountered clinical entity especially in population centers with high immigrant flux. During a recent 5-year period 45 cases of intraventricular cysticerosis have been evaluated and treated. Modes of involvement included isolated cyst formation, ependymitis, or combinations of both. Evidence of associated parenchymatous involvement was present in 20% of cases. Sites of infestation included the lateral ventricle (five cases), third ventricle (12 cases), Sylvian aqueduct (four cases), and fourth ventricle (24 cases). Mean post-therapy follow-up periods for this series exceed 36 months. This experience indicates that direct excision is the treatment of choice for ventricular cystic lesions, but that management, operative planning, and expectations should be influenced by considerations of: 1) the potential for acute clinical deterioration (38%); 2) the potential for cyst migration; 3) attendant ependymitis, defined by computerized tomography or verified at surgery; 4) the potential for increase in cyst volume with local mass effect; 5) selection and institution of corridors of surgical access that establish alternative routes of cerebrospinal fluid flow; and 6) the possibility of cyst excision by a stereotaxic endoscopic procedure.

Sellar glomangioma

A glomangioma (glomus tumor) arising in the pituitary region is described. The histologic and ultrastructural features were characteristic. The tumor was composed of epithelioid cells arranged in an organoid fashion around vascular channels and contained scattered mast cells. Electron microscopy revealed tumor cells that showed features of smooth muscle differentiation. Immunocytology demonstrated the presence of actin, desmin, and myoglobin within tumor cells and basement membrane antigen surrounding them; factor VIII was localized in endothelial cells and not within tumor cells. Pituitary hormones were not detected in the tumor by the immunoperoxidase technique. This is the first report of a glomangioma of the sella turcica. The gomitoli of the hypophyseal portal vessels are structures that resemble glomera found in other sites. Derivation of this tumor from gomitoli is suggested.

Bromocriptine treatment of prolactin-secreting tumors: surgical implications

Ten of 19 patients with Stage III-IV prolactin-secreting tumors experienced significant reduction in the size of the tumor when treated with therapeutic doses of bromocriptine. Those tumors that responded favorably to preoperative pharmacological manipulation were found to have an improved surgical cure rate. These preliminary data suggest that a preoperative effort to reduce the size of large prolactin-secreting tumors may result in significant improvement of our surgical ventures.

Natural history of microprolactinomas: six-year follow-up

A 6-year follow-up of patients harboring microprolactinomas suggests that few patients (3 of 27) demonstrate significant growth of their tumor during this time. The major hazard for such patients who are not treated seems to be their risk for the development of premature osteoporosis in the face of sustained hyperprolactinemia. The risks of this complication may exceed the risks of early surgical intervention in selected patients. This short term risk of tumor growth (about 10%) must be weighed in the decision about therapeutic endeavors.

Elevated levels of smooth muscle autoantibodies in patients with acromegaly

Screening of sera from patients with central nervous system (CNS) tumors for serum antibodies to tumor and normal tissue antigens revealed that the sera from a significant percentage of patients with pituitary adenoma demonstrated reactivity for smooth muscle antibodies (SMA) at a serum titer (1/25) at which other CNS tumors are devoid of this reaction. The sera were assessed by an indirect immunofluorescent antibody assay on fresh cryostat sections of rat kidney, liver, diaphragm, and stomach tissue. Absorption of SMA-positive sera with extracts containing smooth muscle tissue abolished the reaction. The overall incidence of SMA among patients harboring pituitary tumors was 30% (12/40). Assessment of the functional types of the tumor revealed a distinct predilection for such findings among patients with clinical acromegaly. Among patients with hypersecretion of growth hormone (CA) 90% (9/10) have SMA (both IgG and IgM type) whereas SMA was positive in only 10% (3/30) of corresponding group of patients with pituitary tumors resulting in hypercortisolemia or those that did not result in a hyperfunctional endocrine state.

Mammosomatotroph cell adenoma of the human pituitary: a morphologic entity

Nine cases of a hitherto undescribed morphologic entity, termed mammosomatotroph cell adenoma of the human pituitary, are reported. These tumors, occurring mostly in men, are invariably associated with acromegaly (or gigantism) and high-normal or slightly elevated blood prolactin levels, and it cannot be distinguished clinically from well-differentiated growth hormone cell or mixed growth hormone cell-prolactin cell adenomas. They show a slow growth rate and usually exhibit a diffuse pattern and intense cytoplasmic acidophilia by histology. The immunoperoxidase technique detects both growth hormone and prolactin within the same cells. Electron microscopy reveals monomorphous tumors with a fine structure markedly similar to that of well-differentiated, densely granulated growth hormone cell adenomas. An added feature and diagnostic marker of mammosomatotroph cell adenoma is the presence of extracellular deposits of secretory material. One tumor shows a marked abnormality of hormone packaging and storage, resulting in the cytoplasmic accumulation of pleomorphic bodies containing semicrystalline secretory material.

Cerebrospinal fluid drainage as influenced by ventricular pressure in the rabbit

Artificial cerebrospinal fluid (CSF) containing radioisotope iodinated (125I) serum albumin (RISA) and either blue dextran or indigo carmine was given to white New Zealand rabbits over 4 hours. In one group it was given by ventriculocisternal perfusion, in one by ventricular infusion, and in one by cisterna magna infusion. Blood was sampled continuously from the superior sagittal sinus (SSS) or intermittently from the systemic arterial circulation. Removal of CSF from the cisterna magna during the ventriculocisternal perfusion kept the intracranial pressure (ICP) at 0 to 5 torr, whereas ventricular or cisterna magna infusion raised the ICP to 20 to 30 torr and 15 to 20 torr, respectively. In the two groups with raised ICP, an increased concentration of RISA was present in the optic nerves, olfactory bulbs, episcleral tissue, and deep cervical lymph nodes; but this was not found in the group with normal ICP. In all three groups, the concentration of RISA in the SSS blood was the same as in the systemic arterial blood. The concentration gradient of RISA across the cerebral cortex was similar in both the ventriculocisternal perfusion and the ventricular infusion groups. With cisterna magna infusion, the concentration of RISA was the same on the cortical surface and less in the ventricles compared with the ventricular infusion. It is concluded that, with elevated ICP, CSF drained via pathways that are less evident under normal pressure. Drainage of CSF was similar irrespective of whether the infusion site was the ventricles or cisterna magna. It did not appear that acute dilatation of the ventricles during ventricular infusion compromised the subarachnoid space over the surface of the hemisphere, as the concentration of RISA on the convexities and in the SSS blood did not significantly differ between the groups. Transcortical bulk transfer of CSF was not evident with raised ICP.

Transcallosal, interfornicial approaches for lesions affecting the third ventricle: surgical considerations and consequences

A group of 11 patients with a variety of lesions affecting the 3rd ventricle have been treated using a direct transcallosal interfornicial approach to the region. In 3 patients, no attendant hydrocephalus was present. In an effort to minimize potential cortical injury related to the approach, we studied the venous anatomy in the region of the coronal suture. Based on this study, appropriate flap placement and interhemispheric entry points were defined. Although no lasting, clinically apparent morbidity was observed in any of the 11 cases, we performed more sophisticated studies of the interhemispheric transfer of somesthetic and perceptual motor tasks, as well as psychometric testing related to parameters of intelligence and memory, 3 to 8 months postoperatively in 6 cases. The results and clinical material indicate that this surgical technique is a safe, feasible alternative in the management of a wide spectrum of pathological lesions within this region. A transcallosal, interfornicial approach offers excellent visualization of the entire 3rd ventricle without the dependence on hydrocephalus or an extensive extra-axial mass to enhance the exposure. With proper planning and technique, it may be accomplished with a minimum of physiological consequence.

Adenoma of the human pituitary producing growth hormone and thyrotropin. A histologic, immunocytologic and fine-structural study

A pituitary adenoma removed by surgery from a 22-year-old man was studied by histology, immunocytology, transmission electron microscopy and immunoelectron microscopy. Clinically, the patient had acromegaly and euthyroidism with elevated blood GH concentrations. Blood TSH and T4 levels were within the normal range. Histologically, the adenoma was chromophobic and exhibited no PAS, lead hematoxylin, aldehyde thionin or Grimelius silver positivity. By the immunoperoxidase technique GH, beta-TSH and alpha-subunit but no PRL, ACTH, alpha-endorphin, beta-FSH or beta-LH were demonstrated in the adenoma cells. Electron microscopy revealed adenoma cells which were similar to TSH cells and showed no resemblance to GH cells of nontumorous pituitaries or GH-secreting tumors. Immunoelectron microscopy demonstrated GH and beta-TSH in the secretory granules. It is concluded that pituitary adenomas composed of TSH-like cells may secret GH, resulting in acromegaly. Production of GH by adenomatous TSH cells cannot be explained on the basis of the one cell- one hormone theory. The question is raised whether bihormonal or multihormonal clones, capable of synthesizing more than one hormone, exist in the human pituitary. These cells are apparently dormant under normal conditions, but in the course of neoplastic transformation may undergo functional dedifferentiation and acquire the ability to produce two or more different hormones.

The utilization of native glioma antigens in the assessment of cellular and humoral immune responses in malignant glioma patients

Cellular and humoral components of the immune response have been studied preoperatively, concurrently, and serially in patients with malignant glial neoplasms. In order to assess titres of circulating antibodies to tumour cell constituents an indirect immunofluorescent technique was applied to single cell suspensions and snap frozen cell smears. In an allogeneic system, 49% of 47 test and 7% of 124 control sera gave a positive response to cytoplasmic components. The leucocyte adherence inhibition assay was applied to study 39 test and 64 control patients. Significant non-adherence of leukocytes was observed in 77% of test cases. Control parameters indicated specificity of the response. Simultaneous assessment in 28 test patients yielded a positive response for one or both assays in 89% of cases..

Acidophil stem cell adenoma of the human pituitary: clinicopathologic analysis of 15 cases

In material of 347 surgically removed pituitary adenomas, 15 tumors (4.3%) were diagnosed as acidophil stem cell adenomas. These are immature neoplasms, assumed to derive from the common progenitor of growth hormone and prolactin cells, and usually containing both hormones by the immunoperoxidase technique. Clinically, they are regularly associated with hyperprolactinemia. Some patients may exhibit physical stigmata of acromegaly without biochemical evidence of the disease ("fugitive acromegaly"). The entity is also characterized by (1) relatively short clinical history; (2) large (grade III--IV), locally invasive adenoma, and (3) relatively low hormonal activity. By electron microscopy, these tumors are unicellular with immature cytoplasm, exhibiting some features of adenomatous growth hormone and prolactin with immature cytoplasm, exhibiting some features of adenomatous growth hormone and prolactin cells and frequently mitochondrial abnormalities as well. They are more aggressive than the well-differentiated adenomas of the "acidophil" cell line--a fact to be considered in postoperative management.

Monolayer and suspension culture of human prolactin-secreting pituitary adenoma

In order to study the hormonal characteristics of human prolactin-secreting pituitary adenomas, in vitro monolayer and suspension cultures from human pituitary glands were established. Optimal conditions for cultures included enzymatic dispersion into viable single-cell suspensions with the use of 1% collagenase in phosphate-buffered saline solution. After pelleting the dispersed cells by centrifugation (800 rpm for 10 minutes), they were cultured in RPMI medium that contained 20% fetal calf serum and then incubated at 37degrees C in 5% CO2. Cells were subcultured weekly at a ratio of one plate to two. In an attempt to establish whether bromocriptine has a direct inhibitory effect on pituitary secretion of prolactin (PRL), variable doses of bromocriptine were added to duplicate plates. The addition of bromocriptine to the culture medium induced suppression of PRL within 7 days. In conclusion, this study demonstrated that either monolayer of suspension cultures of human PRL secreting adenomas can be established, and that bromocriptine in doses of 1 ng/plate or more has a direct inhibitory effect on the secretion of PRL.

Correlative ultrastructural morphometry of human prolactin-producing adenomas

Ultrastructural morphometry was applied to 24 surgically removed human sparsely granulated prolactin cell adenomas in an attempt to correlate the measurements with blood prolactin levels, size of tumour, and age and sex of patient. No correlation was apparent. However, further evaluation revealed that correlation existed between size of tumour and blood prolactin levels, indicating that tumour mass, and not subcellular morphology, was related to the amount of prolactin released.

Gunshot wounds to the brain--a civilian experience

A study involving 79 patients who were considered for surgical treatment for craniocerebral gunshot injuries between 1972 and 1978 was carried out to develop criteria for radiographic assessment and surgical operation, as well as to improve operative techniques and preoperative planning. The study focused on differences between military and civilian injuries, as well as criteria for gross prediction of outcome. Of note in the overall perspective of the series were (1) the predominance of low-velocity missiles, (2) the high rate of self-inflicted injuries (34 percent), (3) the overall mortality of 23 percent with the rate for persons older than 60 being approximately 70 percent, (4) the correlation between preoperative patient assessment and mortality, (5) complications predominated by cerebrospinal fluid fistulas (10 percent), (6) the value of computerized axial tomographic (CAT) scanning in patient assessment and operative strategy and (7) the ultimate employability rate in survivors (78 percent). An historical review of the development of management principles based on operative experience in the military sector as well as other recent civilian literature also deserves consideration.

Checkerboard visual evoked response in evaluation and management of pituitary tumors

As a routine part of the evaluation of patients with pituitary tumor, visual evoked responses (VERs) to checkerboard pattern reversal were recorded from 83 patients with tomographically documented pituitary tumor. VER tests were correlated with examinations of visual acuity, color perception, and visual fields and with computerized tomographic scan evidence of suprasellar extension of the tumor. The purpose of the VER recording was to determine the presence of visual system compression by the tumor and thus contribute to the decision of whether surgery was necessary. Each of the patients who had suprasellar extension of the tumor sufficient to produce a visual field abnormality also had an abnormal VER. In addition, some patients with suprasellar extension had normal visual fields but abnormal visual evoked responses. Thus, the VER provided earlier evidence of suprasellar extension causing visual system compromise than did conventional visual tests.

Definition of cellular immune responses to brain antigens in human head trauma

Cellular immune responses to brain antigens in patients with head injury were studied by applying the leukocyte adherence inhibition (LAI) assay. The investigation was conducted in three phases. 1) In the initial phase, evaluation of a series of 22 test and 25 control cases obtained at random during a 2- to 6-week time frame following a traumatic event indicated significant non-adherence of leukocytes (NAL) in 77% of the test group and 20% of the control group in the presence of brain antigen. 2) In a second phase, larger test population was divided into four groups of different posttraumatic intervals. This study measured NAL in the presence of normal heart of normal brain antigen. Assays revealed an initial significant NAL in the presence of both antigens; however, after the first week following injury the majority of cases manifested significant NAL only with brain antigen. These values of NAL persisted over a 6- to 8-week period. 3) As a final phase of investigation, analysis of a sequential series of assays in 12 patients over a 90-day period indicated significant NAL in the presence of brain antigen within the first week of injury, this was followed by a drop in NAL in most of the cases. Studies at 7 to 60 days posttrauma demonstrated significant NAL with brain antigen alone, with a subsequent drop by 90 days. These observations are interpreted to represent sensitization of leukocyte subgroups to brain proteins that are immunologically recognized following the traumatic event.

Specific cellular immune responses in patients with malignant gliomas

The leukocyte adherence inhibition assay was used to measure cell-mediated immunity in 26 patients with malignant glial neoplasms and 41 control subjects. A significant inhibition of leukocyte adherence was observed in 21 of 26 (80%) glioma patients in the presence of a 3 M KCl extract of glioma tissue, as compared to that of normal brain extract. Among the control group, no significant difference in the percentage of nonadherent leukocytes was noted in the presence of either antigen. To study the specificity of the reaction, a 3 M KCl extract of meningioma, pituitary tumor, carcinomas of breast, and lung, melanoma, brain, and heart tissues were used as nonspecific antigens. Such studies revealed significantly lower values of nonadherent leukocytes. These data indicate that patients with malignant glial neoplasms manifest a cellular immune response to glioma-associated antigens which can be measured by the tube leukocyte adherence inhibition assay and that leukocyte adherence inhibition assay may render additional useful information in diagnostic and prognostic evaluation of malignant glial neoplasms.

Preoperative cell-mediated immune status of patients with malignant glial tumors

The leukocyte adherence inhibition assay (LAI) was used to measure cell-mediated immunity in 26 patients with malignant glial neoplasms and in 41 control subjects. A significant inhibition of leukocyte adherence was observed in 21 out of 26 (80%) patients with malignant astrocytic gliomas in the presence of a 3M KC1 extract of glioma tissue compared to that of normal brain extract. Among the control group, no significant difference in the percentage of nonadherent leukocytes (NAL) was noted in the presence of either antigen. To study the specificity of the reaction, 3M KC1 extracts of meningioma, pituitary tumor, carcinoma of breast, carcinomas of lung, melanoma, brain, and heart tissues were employed as non-specific antigens. Such studies revealed significantly lower values of NAL. These data indicate that patients with malignant glial neoplasms manifest a cellularimmune response to glioma-associated antigens that can be measured by the tube LAI assay and that LAI assay may render additional useful information in the diagnostic and prognostic evaluation of malignant glial neoplasms.

Influence of nitroprusside on cerebral pressure autoregulation

The authors studied 10 cats to assess the question of abolition of cerebral autoregulation attendant on the use of nitroprusside for hypotensive anesthesia. After the establishment of stable base line parameters, a continuous infusion of sodium nitroprusside was begun in a dose sufficient to maintain a mean systemic arterial pressure of 65 mm Hg. Infusion was continued for incremental periods of 30 seconds to 10 minutes, increasing the time of infusion by 30 seconds after each subsequent trial. At 10 seconds after the cessation of nitroprusside administration, intravenous dopamine was infused to raise the systemic arterial pressure to a mean of 100 mm Hg, and the subsequent response in intracranial pressure was recorded in each instance. In no animal was a loss of cerebral autoregulation noted when the nitroprusside infusion was maintained for 3 minute or less. When the infusion was maintained for 4 minutes or longer, cerebral autoregulation was lost in each animal, and the length of time to return of cerebral autoregulation correlated with the duration of nitroprusside infusion. Sodium nitroprusside disturbs the integrity of cerebral pressure autoregulation, and the onset and extent of this disturbance is a dose-dependent phenomenon.

Transoral exposure of the atlantoaxial region

A broad spectrum of disease entities affects the atlantoaxial-clival region. This area is readily accessible through a transoral approach, which offers capabilities for canal decompression and fusion. A case is reported that required transoral odontoidectomy with concurrent excision of an osteophyte from the base of an ununited odontoid fracture. Operative preparation, technique, and postoperative management are described in detail. The advantage and applications of the procedure are discussed.

Modulation of CSF production by alterations in cerebral perfusion pressure

The rate of CSF production in cats was studied in relation to changes in intracranial pressure (ICP), systemic arterial pressure (SAP), and the resultant alterations in cerebral perfusion pressure (CPP). When ICP is raised to the point where CPP falls below 55 mm Hg, CSF production will diminish. Elevation of ICP does not appear to influence CSF production rate if CPP is maintained above 70 mm Hg.

Acute fractures of the odontoid process. An analysis of 45 cases

✓ Between 1969 and 1974, 45 cases of acute odontoid fracture were diagnosed and treated at this institution. The group consisted of 35 men and 10 women; 24 were between 19 and 40 years of age, and 21 were over 40 years old. Detectable myelopathy was appreciated in eight cases (18%). Diagnosis was established within 72 hours of the traumatic event. Initial evaluation disclosed displacement of the fracture in 17 cases (38%). Following reduction, the initial treatment was posterior fusion in three cases, and external immobilization in 42 cases. Excluding two deaths within the first week of treatment, 40 cases were available for follow-up analysis. Bone union failed to occur following periods of immobilization ranging from 4 to 6 months in 13 cases (33%). Fibrous union with no evidence of instability was apparent in two cases. Nonunion in displaced fractures was seen in 60%, with a rate of 88% in those displaced more than 4 mm. The rate of nonunion in undisplaced fractures was 16%. The rates of incidence of displacement (53% vs 26%) and nonunion (78% vs 33%) in those displaced were higher in individuals over 40 years of age than in those under 40 years. The incidence of nonunion in individuals aged under 40 with nondisplaced fractures was 12%; it was 25% for individuals over 40 years old. A total of 13 patients underwent posterior fusion. All eventually manifested stability at the C1–2 level. However, 69% failed to show bone union at the fracture site in a 6- to 18-month follow-up period.

This review indicates that in consideration of the fracture, external immobilization is the initial treatment of choice in all nondisplaced fractures. Displaced fractures occurring in patients over 40 years old, and those displaced more than 4 mm are candidates for internal stabilization and fusion as a primary mode of treatment.

Experiences with sterilization of the operating microscope

Experiments were conducted to assess the feasibility of both paraformaldehyde and ethylene oxide gas sterilization of the operating microscope. From these experiments and practical experience, it is concluded that ethylene oxide sterilization of the operating microscope is a feasible and desirable alternative to cumbersome draping technique.

Epidural spinal metastases: factors related to selection of cases for decompressive laminectomy

We have treated a selected series of patients with spinal epidural metastatic tumors by dorsal decompression according to principles we presumed would produce the most favorable therapeutic results. There was no operative mortality, and morbidity was minor. In the first postoperative week, improvement in motor function was apparent in 44% of cases. By 3 months postoperatively, 40% of the patients were independently ambulatory and an additional 28% were ambulatory with minimal assistance. This 68% composite compares favorably to the 30 to 40% results in several series of unselected cases. On the basis of this data, it is concluded that consideration of the tumor's histological type, biological history, the host's response, the extent of neurological deficit, the progression of neurological deficit, and dissemination of disease will aid in the definition of those cases with epidural metastases which may be expected to benefit from surgical decompression.

Failure of selective pituitary adenomectomy to cure acromegaly

Complete selective pituitary adenomectomy for acromegaly may fail to cure the underlying endocrinopathy. A 40-year-old man who had acromegaly of ten-years duration was initially treated with pituitary irradiation eight years prior to surgery. Three years after irradiation his mean GH concentration decreased from 53 to 9.0 ng/ml, then subsequently increased, and was associated with development of severe hyperglycemia. A transsphenoidal microdissection was performed, and a discrete pituitary adenoma was visualized and totally removed at surgery. GH concentrations decreased from 46 to 5.0 ng/ml one week after surgery and to 3.0 ng/ml 10 months after surgery. Despite improvement postoperatively, the patient still demonstrated abnormal GH dynamics and responses to the GTT, abnormal nocturnal and random GH sampling, and abnormal responses to the L-dopa, apomorphine, and TRH stimulation tests. Acromegaly could be caused by either hypothalamic hyperfunction, an autonomous pituitary tumor, or both; but the latter would not explain the results obtained in this patient. This suggests that reduction of GH to normal concentrations following selective pituitary adenomectomy is not synonomous with curing acromegaly.

The influence of myoneural blockers on intracranial dynamics

A series of animals was studied to evaluate the effect of commonly used myoneural blockers (curare, succinylcholine, gallamine, and pancuronium) on intracranial physical dynamics. Of this group, only curare alters intracranial pressure. Histamine release secondary to curare administration results in bronchoconstriction with subsequent major alterations in pulmonary ventilation. Resultant hypercarbia along with a decreased cerebral vascular resistance affects intracranial dynamics by alterations in cerebral blood flow; changes in CSF flow patterns passively reflect the alterations in intracranial pressure. These changes can be blocked by prior treatment with antihistamines.

Neurosurgical endoscopy using the side-viewing telescope

✓ The authors report their application of the Hopkins telescope to various neurosurgical procedures, and describe the technique and advantages of its employment.

Acquired spontaneous, nontraumatic normal-pressure cerebrospinal fluid fistulas originating from the middle fossa

Five cases of spontaneous cerebrospinal fluid (CSF) fistulas originating from the middle fossa are described, including one patient with an "empty" sella. It is suggested that acquired meningocele and meningoencephalocele progress to become CSF fistulas. The normal anatomical and physiological factors which give rise to acquired bone/dural/arachnoid dehiscences are discussed and illustrated.

Malignant glial neoplasms: definition of a humoral host response to tumor-associated antigen(s)

There is increasing evidence that human tumors possess tumor-associated neo-antigens. The host mounts an immunological response to these antigens, as evidenced by the detection of circulating humoral antibodies in a variety of human neoplasia.An indirect immunofluorescent antibody technique was employed to detect antibodies to tumor-associated antigens in the sera of patients with malignant gliomas. Viable single cell suspensions were used to demonstrate antibodies to surface contents of tumor cells and cell preparations were snap-frozen at -160° C to demonstrate antibodies to cytoplasmic components of tumor cells. After incubation with serum, the preparations were treated with polyvalent sheep antihuman globulin conjugated to isomer-1-fluorescein isothiocyanate, washed, and examined with a Leitz incident fluorescent microscope.Of the 17 sera from histologically proven malignant glial neoplasm patients, 2 (11%) were positive for an autologous surface antibody reaction. Five (23%) of 21 were positive for an autologus cytoplasmic antibody, however, 10 (47%) of 21 of the sera gave a positive reaction for cross-reacting cytoplasmic antibodies when tested with a battery of tumor cells obtained from different patients with malignant glial tumors.No reaction was observed with normal brain tissue. Absorption studies indicated the presence of a tumor-associated antigen.This study demonstrated that certain patients with malignant gliomas possess circulating antibodies to cytoplasmic components of their own tumor cells. The fact that a number of sera cross-reacted with tumor cells obtained from different patients suggests that antigenic cross-reactivity exists between malignant glioma cells from different patients. It is suggested that with further refinement, immunofluorescent detection of antibodies could evolve as a useful diagnostic adjunct in malignant glioma.

Pituitary apoplexy, therapeutic assessment

The management of pituitary apoplexy with reference to both diagnosis and operative sequelae remains a major challenge. Acute onset of retro-orbital headache in association with visual loss and ophthalmoplegia are the cardinal symptoms; however, obtundation and signs of subarachnoid hemorrhage also may be present. Good quality plain skull radiographs and complete angiography prove sufficient for preoperative radiographic studies. Preoperative endocrine preparation focuses on supplemental glucocorticoids since these patients must be presumed deficient in cortisol reserve. Residual visual deficit appears to be more a function of the extent of damage at the time of ictus rather than rapidity of decompression. Our experience indicates that transsphenoidal decompression in appropriate cases offers an ideal opportunity to minimize mortality and morbidity. The acute onset of severe retro-orbital headache in association with stupor and ocular palsies would alert most physicians to the potential diagnosis of spontaneous subarachnoid hemorrhage. The association of complex ophthalmoplegias and visual defects in this constellation of symptoms should, in addition, alert one to the possibility of an acute intrasellar or parassellar expansile process. During the past two years, we have had the opportunity to care for 8 such patients with confirmed diagnoses of acute hemorrhagic infarction of the pituitary enabling us to formulate diagnostic and therapeutic schemata with reference to management of this problem.

Anatomico-physiological considerations in exploration of the fourth ventricle

The advancement of surgical techniques has enabled the neurosurgeon to undertake a continually more aggressive approach toward lesions within the fourth ventricle. Laboratory and clinical observations have enabled us to conclude that (1) exploration of the fourth ventricle is feasible without anatomical disruption of the vermis, (2) controlled ventilation during such explorations is physiologically most desirable, and (3) irrigation of neural structures must consider acid-base and ionic parameters in order to maintain physiologic stability.

Management of cervical spinal cord trauma in Southern California

Acute cervical spinal cord injuries were reviewed in 356 patients treated by the neurosurgical community in Southern California. Neurological recovery was compared in operated and nonoperated patients with complete and incomplete cervical myelopathies. The complications of nonsurgical and surgical therapy are identified. No neurological improvement was noted in any patient with a complete lesion who underwent early surgical decompression. In those with incomplete sensorimotor paralysis, it was difficult to document any effect of surgical decompression on neurological recovery. Patients with some degree of sensory preservation had a similar incidence of motor recovery in both surgical and nonsurgical groups. With complete sensorimotor paralysis, anterior cervical fusion within the first week of injury was associated with increased pulmonary morbidity.

Collagen sponge for surface brain protection. Technical note

The authors discuss the properties, use, and advantages of collagen sponge as a microneurosurgical adjunct. Experience with the material in over 300 operative cases has demonstrated its value for protecting the surface of the brain during exposure and retraction in neurosurgical procedures.

Anterior decompression of the thoracic and thoraco-lumbar spine

The authors report their experience with six cases of acute spinal cord compression due to tumor, trauma, and infection in which the thoraco-lumbar spine and cord were most satisfactorily decompressed using an anterior transthoracic approach. Consideration is given to the appropriate pre-operative diagnostic procedures utilized to define those cases that are most amenable to an anterior approach. In addition, a consideration of paravertebral anatomy in the thoraco-lumbar area provides a basis for variance in approaching the ventral aspect of the thoraco-lumbar spine in order to minimize potential vascular complications.

Alterations in ventricular fluid pressure during ketamine anesthesia in hydrocephalic children

We studies ventricular fluid pressure changes in 26 hydrocephalic children following administration of ketamine. The increase in VFP previously found with intravenously administered ketamine was compared with changes after ketamine given intramuscularly, and the possible alteration of this increase with sedative premedicants was studies. Changing the route of administration did not change the time to peak VFP changes or the duration of pressure elevation. There was no demonstrable alteration of the increase in VFP by premedication with secobarbital, dorperidol, or diazepam in clinical dosage. We feel that acute rises of VFP may affect areas of marginal cerebral blood flow and may increase the risk of herniation of brain tissue.

Penetrating gunshot wounds of the cervical spine in civilians. Review of 38 cases

The authors present a series of 38 civilian patients with cervical gunshot injuries, and compare neurological recovery in patients with complete lesions and patients with incomplete lesions according to whether therapy was surgical or nonsurgical. In patients with incomplete injury, ultimate recovery was a function of the initial injury more than surgical or nonsurgical therapy; nor did patients with complete lesions show significant change in outcome with either mode of therapy. Cord pathology at laminectomy rarely provided a clue about neurological recovery, and fural decompression did not alter neurological outcome. The authors conclude that the sole indication for routine surgical intervention appears to be progressive neurological deficit.

Ventricular perfusion for ventriculitis

A system of ventricular perfusion of appropriate antibiotic solutions in the management of neonatal ventriculitis is described. The technique of perfusion as well as considerations in the appropriate selection of antibiotics and perfusates is detailed. The procedure was successfully utilized in a consecutive series of nine children refractory to conventional modes of therapy.