Kinetics of circulating vasopressin uptake by choroid plexus

Uptake of circulating arginine vasopressin (AVP) by choroid plexus was studied by means of the in situ brain perfusion technique in anesthetized guinea pig and by means of single-circulation paired-tracer dilution technique in isolated perfused sheep choroid plexus. Kinetic analysis revealed saturable AVP uptake with Michaelis constant (Km) values of 32 +/- 4 and 31 +/- 5 nM and maximal saturable influx rate (Vmax) of 0.45 +/- 0.06 and 12.1 +/- 0.67 pmol.min-1.g-1 in guinea pig and sheep choroid plexus, respectively. The peptide fragments AVP-(1-8) and [pGlu4,Cyt6]AVP-(4-9), the amino acids L-phenylalanine, L-tyrosine, and 2-aminobicyclo(2,2,1)heptane-2-carboxylic acid, and the aminopeptidase inhibitors Bestatin and bacitracin did not influence hormone kinetics. However, the V1 antagonist [(1-beta-mercapto-beta,beta-cyclo-pentamethylenepropionic acid)-O-methyl-Tyr2]AVP significantly inhibited AVP uptake with inhibitor constant (Ki) values of 0.19 +/- 0.03 (guinea pig) and 0.07 +/- 0.01 microM (sheep). The V2 agonist 1-desamino-8-D-AVP and pressinoic acid produced weak inhibitions only in guinea pig choroid plexus, and Ki/Km ratios indicated 220 and 310 times lower affinities than for AVP, respectively. It is suggested that the membrane mechanism responsible for AVP uptake in choroid plexus has a binding site with properties similar to those of V1 receptor.

Management of labyrinthine fistulas caused by cholesteatoma

The surgical management of labyrinthine fistulas caused by cholesteatoma remains controversial. Forty cases (41 ears) of labyrinthine fistulas were reviewed. This represented 10% of our total series of cholesteatomas in adults and children (426 ears). Clinical presentation, extent of disease, results of fistula testing and audiometric studies, and radiographic findings were analyzed. A canal wall-down procedure was performed in all but one patient. Generally an attempt was made to completely remove the cholesteatoma, to graft the fistulous area, and to reconstruct the middle ear mechanism in one stage. The matrix was preserved in patients with large fistulas where the involved ear was the only hearing one, when the matrix was adherent to the underlying optic duct, and in selected elderly persons. Long-term followup did not reveal a significant difference in hearing, degree of vertigo, or incidence of recidivism when those patients in whom the matrix was removed were compared with those in whom the matrix was preserved. The importance of recognizing the presence of a labyrinthine fistula preoperatively is stressed, along with the need to be prepared for an unexpected fistula. Operative management is described.

Predictive value of brainstem evoked response in the diagnosis of acoustic neuroma

Predictive value positive is the probability that a positive test result represents a true positive finding. Twenty-six patients with brainstem evoked response findings characteristic of retrocochlear hearing loss were studied. Four acoustic neuromas were diagnosed in this group after radiologic workup. The predictive value in this population was 15%. Statistical considerations are presented.

Cochlear implant flap complications

In a series of 52 patients who received cochlear implants, 4 patients suffered flap complications (7.7%). The problems encountered involved the postauricular flap and were usually minor in nature. None required explantation as a direct result of these complications. Flap ischemia in a patient with Cogan's syndrome and vasculitis, two cases of suture extrusion with one having exposure of the implant, and a case of receiver unit magnet extrusion repaired with a vascularized pericranial flap based upon temporalis muscle are presented. Flap design in patients who have had postauricular incisions demands special consideration. Principles useful for avoiding complications as well as their management are discussed.

Lack of efficacy of megestrol acetate in the treatment of unresectable meningioma

The detection of hormone receptors on meningiomas raises the possibility of hormonal manipulation as a form of therapy. Since progesterone receptors are found on meningiomas more frequently and in greater amounts than estrogen receptors, manipulation of progesterone levels would be most promising. A trial of the oral progesterone agonist megestrol acetate for the treatment of unresectable meningioma was therefore performed. Megestrol acetate was administered at a dose of 40 mg four times daily which could be escalated to 80 mg four times daily. Nine patients (six meningothelial, two fibrous, and one anaplastic meningiomas) were treated for 1 to 12 months. No tumor responses were seen. However three patients required discontinuation of therapy due to deteriorating vision within 2 1/2 months. The major systemic toxicity of megestrol acetate was weight gain with a median weight gain of 14 kg for patients treated for at least 6 months. Due to the lack of efficacy and the significant toxicity noted, megestrol acetate is not recommended for the treatment of meningioma. However clinical trials of progesterone antagonists would still be of interest.

Pituitary gland metastasis from adenocarcinoma of the prostate. Case report

A case of prostatic carcinoma metastasis to the pituitary gland is reported. The presentation and rarity of such a lesion is addressed. The literature review yielded only isolated case reports of symptomatic brain metastases unassociated with bone disease from adenocarcinoma of the prostate. The management options of such a lesion are discussed.

Ultrastructure of the orbital pathway for cerebrospinal fluid drainage in rabbits

An increasing number of physiological and morphological studies indicate that cerebrospinal fluid (CSF) drains via nonarachnoidal pathways in several mammalian species. Ultrastructural tracer studies were undertaken to examine the orbital route for CSF absorption in the rabbit. At the termination of the optic nerve subarachnoid space, an area of connective tissue containing numerous small tortuous channels is present. Ferritin (molecular weight 400,000) infused into the ventricles at normal and increased intraventricular pressure was present in these channels by 15 minutes postinfusion, and subsequently reached the intraorbital connective tissue. Elevating the intraventricular pressure did not noticeably alter the morphological appearance of this region or change the gross distribution pattern of the ferritin. Ferritin did not penetrate the scleral barrier to reach the choriocapillaris, nor did it breach the arachnoid barrier layer proximal to the transitional zone at the optic subarachnoid space to reach the dura mater. These results are very similar to those described for the hamster orbital region and the rabbit cribriform region. These experiments support the concept that macromolecules exit the subarachnoid space at the termination of the optic nerve via open channels, and that no significant barrier to drainage of macromolecules in CSF is present at this location.

Computed tomography after skull base resection

We have obtained serial CT scans in the evaluation and follow-up of 80 patients with lesions of the skull base. CT scanning has been useful for assessment of recurrence in this group of patients, many of whom underwent complex ablative and reconstructive procedures.

Dysphagia in infants and children

The evaluation of dysphagia in pediatric patients involves many special considerations. A diagnostic approach to this problem is presented.

Flow cytometric analysis of pituitary tumors. Correlation of nuclear antigen p105 and DNA content with clinical behavior

Flow cytometric quantitation of the proliferation-associated nuclear antigen p105 and DNA content was performed on nuclear suspensions from 12 paraffin-embedded pituitary macroadenomas and one pituitary carcinoma and correlated with clinical outcome. Median follow-up was 41 months (range, 33 to 48 months). Three of the 13 tumors (23%) had an identifiable aneuploid peak. Of the four tumors that recurred or metastasized, only one was aneuploid. Nuclear antigen analysis of all diploid tumors showed enhanced p105 expression in G2M phase cells compared to G0G1 cells. The G2M/G0G1 fluorescence ratio for p105 was consistently higher (P less than 0.05) for the three diploid tumors that recurred (median, 1.32 arbitrary fluorescence units; range, 1.27 to 1.80) than for the seven nonrecurrent diploid tumors (median, 1.20 arbitrary fluorescent units; range 1.14 to 1.22). These findings indicate a low incidence of DNA aneuploidy among pituitary tumors and suggest that for diploid adenomas, measurement of p105 may provide information useful in predicting prognosis and directing postoperative adjuvant therapy.

Metastatic carcinoma to pituitary adenomas: a report of two cases

Two cases of carcinoma metastatic to pituitary adenomas are reported. One patient had a prostatic adenocarcinoma, giving rise to metastases in an adenoma found incidentally at autopsy; clinically and immunohistochemically, the adenoma showed lack of endocrine activity. The second patient had symptoms of cortisol excess. A corticotroph adenoma associated with a malignant neoplasm was diagnosed ante mortem; at autopsy a pancreatic endocrine neoplasm was found. Immunohistochemistry and electron microscopy were important in elucidating the primary tumor. The formation of extraportal vascular channels and altered blood flow may have importance in the pathogenesis of cancer metastases to pituitary adenomas.

May children with otitis media with effusion safely fly?

This study addresses the question of whether patients who fly with otitis media with effusion (OME) are at risk for the development of barotitis. Fourteen patients with otitis media with effusion were followed before and after air travel. No ear with OME became symptomatic, though two contralateral, previously "normal" ears did become symptomatic. An analysis of the physiology of this phenomenon is presented.

Blood-cerebrospinal fluid barrier alteration following intraventricularly administered cholera toxin

Cholera toxin (CT) has been reported to double cerebrospinal fluid (CSF) formation following its introduction into the ventricular system of cats and dogs. In our laboratory we noted that CT used in a similar fashion in rabbits and cats resulted in only a slight increase in CSF formation and was associated with a steadily rising protein content in the cisterna magna effluent. To further investigate this finding, rabbits and cats underwent ventriculo-cisternal perfusions, one group with CT introduced into the ventricles and the other without. In the rabbit only, radioiodinated serum albumin (125I-RISA) was given i.v. Other groups of rabbits had 125I-RISA or 125I-CT injected into the ventricles. The group of rabbits receiving intraventricular CT experienced a 4-10-fold elevation in the amount of both protein and 125I-RISA in the cisterna magna effluent compared with the control group. Electrophoretic pattern of the protein present in the effluent was similar to that of rabbit plasma. Autoradiography of the brains of those animals given intraventricular 125I-CT were found to have a very high uptake of 125I-CT in the choroid plexus and along all exposed ventricular surfaces, a finding not evident when 125I-RISA alone was given intraventricularly. It is concluded that CT altered the blood-CSF barriers allowing the reference marker to penetrate these barriers and plasma to leak into the CSF. These findings appear to account for most if not all of what was thought to be an increase in CSF formation in response to intraventricular CT.

Rhabdomyosarcoma in the region of the sella turcica

Intracranial extension of rhabdomyosarcoma from the face, nasopharynx or middle ear is rare. A 16-year-old boy presented with deterioration of vision and headache. CT scan revealed a soft tissue mass occupying the sphenoid and ethmoid sinuses, extending to the suprasellar fossa and impinging on the optic chiasm. The tumour, mimicking pituitary carcinoma, was removed by transsphenoidal craniotomy. Morphologic studies, including immunohistochemistry and electron microscopy, revealed that the tumour was a rhabdomyosarcoma. This case stresses the value of immunohistochemical and ultrastructural studies in the diagnosis of tumours occurring in the region of the sella turcica. The origin of this tumour was thought to be the sphenoid or ethmoid sinus. The pituitary gland appeared intact.

Correlation of meningioma hormone receptor status with hormone sensitivity in a tumor stem-cell assay

Several investigators have detected progesterone receptors in a high percentage of meningioma specimens and have noted progesterone receptors to be more common than estrogen receptors in these specimens. However, a functional significance of such hormone receptor positivity in control of meningioma growth has not been described. This paper describes a paired test of the estrogen and progesterone receptor assay as the biochemical assay and of the human tumor stem-cell clonogenic assay (HTSCCA) as the functional assay in 17 meningioma specimens. Only one (6%) of the 17 specimens was estrogen receptor-positive, while 11 (69%) of 16 specimens were progesterone receptor-positive. The HTSCCA revealed that only two (15%) of 13 specimens were sensitive to estradiol while five (31%) of 16 specimens were sensitive to progesterone. Comparison of progesterone results for the 15 specimens on which both hormone receptor assay and HTSCCA were performed revealed correlation in a majority of cases; four specimens were positive for both assays and five specimens were negative for both assays. No specimen that was negative for progesterone receptors was sensitive to progesterone by HTSCCA. These results suggest that the hormone receptor and sensitivity pattern of meningiomas may differ from that of breast cancer, and that progesterone addition or ablation may be a reasonable therapeutic approach for meningiomas.

Ultrastructural morphology of the olfactory pathway for cerebrospinal fluid drainage in the rabbit

Previous physiological studies indicate that the olfactory region serves as a major pathway for cerebrospinal fluid (CSF) drainage into the lymphatic system. The present study was undertaken to determine the ultrastructural characteristics of this egress route. New Zealand White rabbits received a single bolus injection of the tracer ferritin (MW 400,000) into both lateral ventricles in such a manner as not to raise the intraventricular pressure above the normal level. The animals were sacrificed via intracardiac perfusion of fixative between less than 12 minutes and 4 hours following injection. The cribriform region was removed en bloc, decalcified, sectioned coronally, and prepared for light and electron microscopic examination. The arachnoid, dura, and periosteum surrounding the fila olfactoria passing through the cribriform plate merge together and form the perineurium, which consists of multiple layers of loosely overlapping cells with widely separated junctions and few vesicles. The perineurium surrounding the olfactory filaments at the superficial submucosal level is only one cell thick. The subarachnoid space freely communicates with the perineural space surrounding each filament. No morphological barrier between the perineural space and the loose submucosal connective tissue was identified. Whether or not the perineurium was multi- or single-layered, ferritin was noted in abundance between the loosely overlapping perineural cells and in the submucosal connective tissue. The distribution of ferritin at 12 minutes was similar to that at 4 hours; however, the quantity of ferritin was increased at 4 hours. These results indicate that no significant barrier to CSF drainage is present at the rabbit cribriform region and that CSF reaches the submucosal region rapidly via open pathways.

Cavernous sinus invasion by pituitary adenomas

One hundred ninety-eight surgically explored pituitary adenomas were evaluated preoperatively by high-resolution computed tomography (CT). At surgery, evidence of direct cavernous sinus invasion was demonstrated in 19. CT findings in these cases included cavernous sinus expansion (17 patients) and visible encasement of the internal carotid artery (14 patients). The invasive tumor often enhanced to a lesser degree than the cavernous sinuses and ipsilateral internal carotid artery. Intracavernous cranial nerve compression, obliteration, or displacement (14 patients), invasion of the lateral wall of the cavernous sinus (seven patients), and diffuse bone destruction (seven cases) were other findings. Magnetic resonance imaging in three patients provided excellent demonstration of intracavernous internal carotid artery encasement, but displacement and obliteration of intracavernous cranial nerves was not shown as well as it was with CT. Histologically, only three patients showed anaplastic features and only one of them had distant metastases. There was no correlation between histologic features, hormone assays, and invasiveness. This experience indicates any type of pituitary adenoma, regardless of its endocrinologic activity, can invade the cavernous sinus. Cavernous sinus involvement makes complete surgical removal difficult. Preoperative recognition of invasive behavior of these tumors has prognostic value and aids in designing appropriate management. CT is the most useful technique generally available for evaluation and follow-up.

Fascicular conduction disturbances and ischemic heart disease: adverse prognosis despite coronary revascularization

In patients with ischemic heart disease, fascicular conduction disturbances are associated with increased mortality. This study reveals that increased mortality also exists for certain types of fascicular conduction disturbances after myocardial revascularization. In 227 consecutive patients undergoing bypass surgery, 24 had preoperative and an additional 52 developed at surgery a fascicular conduction disturbance. At 66 +/- 14 months of follow-up, 6 (4%) of 148 control patients without pre- or postoperative fascicular conduction disturbances had died from cardiac causes. Although right bundle branch block and left hemifascicular block were the most common form of fascicular conduction disturbance, only 1 of 55 of these patients died (p = NS). Mortality rates were much higher for patients with left bundle branch block or an intraventricular conduction defect; 8 (38%) of 21 died from cardiac causes (p less than 0.05). A high risk subgroup was identified by comparing 14 consecutive patients with left bundle branch block or an intraventricular conduction defect who survived more than 1 year postoperatively with 21 consecutive patients with these same conduction defects who died within 1 year of surgery. The following variables were significantly (p less than 0.05) different (survivors versus nonsurvivors): age (58 +/- 7 versus 65 +/- 9 years); class IV angina (2 of 14 versus 16 of 21), prior myocardial infarction (9 of 14 versus 21 of 21), left ventricular ejection fraction (53 +/- 18 versus 41 +/- 15%), three vessel disease (9 of 14 versus 20 of 21) and left ventricular aneurysm (2 of 14 versus 13 of 21).(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of cerebrospinal fluid rhinorrhea by metrizamide computed tomographic cisternography

Seven interesting and instructive cases of cerebrospinal fluid rhinorrhea evaluated by metrizamide computed tomographic cisternography are presented. The rhinorrhea was spontaneous in three patients and was related to previous head trauma or surgical procedures in four patients. The anatomical site and the extent of the fistula were demonstrated precisely by directly showing metrizamide passing through the bony defect. A combination of bone dehiscence and metrizamide within the adjacent paranasal sinuses or the nasal cavity is also useful in localization. Distortion of the interhemispheric fissure, sylvian fissure, or basal sulci indicates the probability of brain herniation through the defect.