Acute presentation of craniopharyngioma in children and adults in a Danish national cohort

We aimed to study the occurrence of acute-onset symptoms at initial presentation in a national Danish cohort of patients with childhood- or adult-onset craniopharyngioma, and to investigate potential risk factors for acute presentation. Medical records of 189 consecutive patients (39 children, 150 adults) presenting with craniopharyngioma during the period 1985-2004 were reviewed, and data regarding initial symptoms, neuroimaging results, vision and pituitary function were systematically collected. Acute symptoms preceding hospital admission were noted. Subgroup analyses were based on age, gender and calendar year period. Potential risk factors for acute presentation were analysed through uni- and multivariate analyses. Acute symptoms were reported in 24 (13%) patients. Acute visual symptoms, headache, nausea or vomiting were most frequently reported, and acute symptoms were more frequent among children (28%) than among adults (9%) (P < 0.01). There were no differences according to sex or calendar year period. Hydrocephalus was present in half of childhood cases and one-fifth of adult patients (P < 0.001). Intra-tumour haemorrhage was seen in two cases. Acute symptoms were more frequent among patients with tumours occupying the third ventricle (P < 0.01), radiologic signs of calcification (P < 0.05) or hydrocephalus (P < 0.01). In multivariate analysis, however, only childhood onset (P < 0.05) and calcification (P < 0.05) were independent risk factors for acute presentation. Craniopharyngioma presented with acute symptoms in 13% of patients. Childhood onset and radiologic signs of calcification were independent risk factors for acute presentation. Intra-tumour haemorrhage was rare.

Experiences of duplex ultrasonography of carotid arteries performed by clinicians--correlation to angiography

One hundred and eleven carotid vessels in 56 patients were analysed by high-resolution duplex ultrasound. Vessels were graded as normal, 25, 50 or 75% stenotic and 100% occluded and the results were compared with similarly graded biplanar angiograms. There was absolute agreement in 68.5% of the vessels, agreement within one grade of severity of disease in 27.0%, while poor correlation was obtained in 4.5%. The results of ultrasound and angiography were also related to the surgical specimens obtained after thrombendarterectomy of 23 vessels in 20 patients. Good agreement was obtained between the three methods in 20/23 vessels. In one case ultrasound was better than angiography, in another case the reverse was true and in a third case both methods overdiagnosed a plaque. It is concluded that duplex ultrasound will work in the hands of a clinician and is a reliable non-invasive screening method for carotid artery disease leading to a more optimal selection of candidates for angiography.

Hypopituitarism and mortality in pituitary adenoma

BACKGROUND AND OBJECTIVE

Previous studies on hypopituitarism and mortality have concluded that insufficient pituitary function is associated with decreased survival. For several reasons the results are difficult to compare - particularly because definitions and treatment of hypopituitarism have varied and various underlying disorders have been included. The purpose was to assess the relationship between mortality and pituitary function.

PATIENTS AND DESIGN

One hundred and sixty consecutive patients (99 men and 61 women) with functionless, suprasellar pituitary adenoma. All were operated on transsphenoidally during the period 1985-1996. Additional radiotherapy was given to 29 patients. Mortality was calculated 12.4 years (median, range 8.1-19.9) after operation. Postoperative hormonal deficits were treated in most, though GH substitution was given only to a minority of patients.

RESULTS

Postoperatively 30% of the patients had normal pituitary function (normal adrenocortical, thyroid and gonadal function), 26% were panhypopituitary and 36% had partial pituitary insufficiency. Forty-one patients had died (34.7 expected) yielding a standard mortality ratio (SMR) of 1.18 (95% confidence limits (CI) 0.87-1.60). SMR was significantly increased in women (1.97, CI 1.20-3.21) but not in men (0.83, CI 0.55-1.26). SMR in patients with normal pituitary function, panhypopituitarism and partial insufficiency were not different from that in the general population. SMR in hypopituitary women was substantially higher than in men with pituitary insufficiency. Treatment with growth hormone in GH-deficient patients did not influence survival.

CONCLUSION

Pituitary surgery for nonfunctioning adenoma and subsequent pituitary insufficiency had no effect on mortality in men, but was associated with significantly increased mortality in women. Suboptimal hormonal substitution in women may play a role.

Frequent occurrence of pituitary apoplexy in patients with non-functioning pituitary adenoma

BACKGROUND AND OBJECTIVE

There is agreement in the literature that pituitary apoplexy is a rare disorder. As our experience differs from this view, we analysed the incidence in patients operated on for a nonfunctioning pituitary adenoma.

PATIENTS AND DESIGN

One hundred ninety-two consecutive patients with a suprasellar, clinically inactive adenoma operated on during the period 1985-1996 were retrospectively reviewed. A diagnosis of pituitary apoplexy was made from relevant neurological symptoms together with pertinent findings at operation.

RESULTS

Pituitary apoplexy occurred in 41 patients (21%), in 23 patients within 12 days prior to the operation. The male/female ratio was 1.9. Median follow-up time was 13.7 years (range 8.9-19.9). During this period, 12 patients had died, yielding a standard mortality ratio of 1.09 (95% CI 0.62-1.92), similar to that in the patients who had not sustained pituitary apoplexy. Postoperatively, 24% of the patients had normal pituitary function, 38% were panhypopituitary and partial pituitary insufficiency was present in 38%. Subnormal GH secretion was present in virtually all patients tested. Two patients died within 60 days of surgery and in two no or incomplete data were available, although they most likely were panhypopituitary.

CONCLUSION

Most of our findings add little to what is known about pituitary apoplexy. On one point, however, they are contrary to previously presented data. We found a much higher incidence of pituitary apoplexy despite rather rigorous criteria for the diagnosis. The outcome as regards survival and endocrine function was not different from that in patients with a nonfunctioning adenoma who did not suffer pituitary apoplexy.

Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy

PURPOSE

Follow-up of patients with severe thyroid associated ophthalmopathy treated with a transcranial two-wall orbital decompression and reconstruction.

METHODS

A two-wall transcranial orbital decompression was performed in 30 such patients (50 eyes). The patients were evaluated one month postoperatively, and long-term evaluation (median 14 months, range 2-54 months) was carried out. The main outcome measures were visual acuity, proptosis measured by Hertel ophthalmometry, soft tissue involvement, and restriction of eye motility.

RESULT

Visual acuity improved rapidly in 28 of 32 affected eyes with normalization in 19 eyes (p<0.001). Worsening was not seen. Median proptosis was reduced by 4.0 mm, range 0-10.0 (p<0.001). Double vision was present in 24 patients before operation 14 of whom achieved binocular vision (p<0.001). Three patients had unchanged complaints and the double vision worsened in one patient. Seventeen of 20 patients on preoperative corticosteroid treatment discontinued this medication in relation to surgery. Complications included one case of perioperative minor stroke and two cases of facial nerve frontal branch palsy.

CONCLUSION

The transcranial two-wall decompression is a simple, an efficient and a low-risk procedure for treatment of patients with severe thyroid associated ophthalmopathy.

In vivo secretory potential and the effect of combination therapy with octreotide and cabergoline in patients with clinically non-functioning pituitary adenomas

The secretory capacity, in vivo, of clinically non-functioning pituitary adenomas may possibly predict tumour volume reduction during intensive medical therapy. Ten patients (mean (range) 53 years (26-73)) with clinically non-functioning macroadenomas, > or = 10 mm were studied. The secretory capacity of the adenomas was examined using basal, NaCl and TRH-stimulated LH, FSH and alpha-subunit levels. The effect on tumour volume of 6 months' therapy with the combination of a somatostatin analogue, octreotide 200 microg x 3/day and a dopamine-D2-agonist, cabergoline 0.5 mg x 1/day was studied. The basal LH, FSH and alpha-subunit levels were determined before and during 6 months' therapy with octreotide and cabergoline, and MR scans were used to evaluate tumour volume before and during this period of therapy. Octopus-perimetry was used to examine the visual fields. A reduction in tumour volume (mean +/- SEM (range); 30% +/- 4% (18-46%)) during 6 months of combination therapy with octreotide and cabergoline was recorded only in patients with in vivo secretory potential. Tumour volume was not reduced in four patients: in three of these patients it remained unchanged while in one patient it was observed to have increased (by 14%). Of the six patients with pretherapy secretory capacity, one displayed a very high basal level of alpha-subunit (74 microg/l) despite unmeasurable levels of LH and TSH, and an FSH-level of 1 IU/l. The other five patients presented paradoxical LH, FSH and/or alpha-subunit responses to TRH. A reduction in basal levels of LH, FSH and/or alpha-subunit was observed in all six patients, and the maximum reduction of at least one of the hormonal levels was 66% +/- 7% (50-98%). The basal levels of LH, FSH and alpha-subunit in the 10 patients were (mean +/- SEM (range)), 3.0 IU/l +/- 1.0 (0.0-7.4), 12.7 IU/l +/- 5.0 (0.0-39.0) and 9.0 IU/l +/- 7.0 (0.2-74.0). During six months of therapy with octreotide and cabergoline, the basal levels of LH, FSH and alpha-subunit were reduced by > or = 50% in seven patients - including the six patients with in vivo secretion prior to therapy. No new visual field defects were detected during therapy and no deterioration of existing visual field defects was recorded. The medical therapy was well tolerated. The in vivo basal and TRH-stimulated secretory capacity of LH, FSH and alpha-subunit predicted tumour reduction following intensive medical therapy in all of our patients with non-functioning pituitary adenomas.

Incidence and late prognosis of cushing's syndrome: a population-based study

The main purpose was to assess the incidence and late outcome of Cushing's syndrome, particularly in Cushing's disease. Information for all patients diagnosed with Cushing's syndrome during an 11-yr period in Denmark was retrieved. The incidence was 1.2-1.7/million.yr (Cushing's disease), 0.6/million.yr (adrenal adenoma) and 0.2/million.yr (adrenal carcinoma). Other types of Cushing's syndrome were rare. In 139 patients with nonmalignant disease, 11.1% had died during follow-up (median, 8.1 yr; range, 3.1-14.0), yielding a standard mortality ratio (SMR) of 3.68 [95% confidence interval (CI), 2.34-5.33]. The SMR was partly attributable to an increased mortality within the first year after diagnosis. Eight patients died before treatment could be undertaken. The prognosis in patients with malignant disease was very poor. Patients in whom more than 5 yr had elapsed since initial surgery were studied separately, including a questionnaire on their perceived quality of health. In 45 patients with Cushing's disease who had been cured through transsphenoidal neurosurgery, only 1 had died (SMR, 0.31; CI, 0.01-1.72) compared with 6 of 20 patients with persistent hypercortisolism after initial neurosurgery (SMR, 5.06; CI, 1.86-11.0). In patients with adrenal adenoma, SMR was 3.95 (CI, 0.81-11.5). The perceived quality of health was significantly impaired only in patients with Cushing's disease and appeared independent of disease control or presence of hypopituitarism. It is concluded that 1) Cushing's syndrome is rare and is associated with increased mortality, in patients with no concurrent malignancy also; 2) the excess mortality was mainly observed during the first year of disease; and 3) the impaired quality of health in long-term survivors of Cushing's disease is not fully explained.

Cerebral microdialysis monitoring: determination of normal and ischemic cerebral metabolisms in patients with aneurysmal subarachnoid hemorrhage

OBJECT

The success of treatment for delayed cerebral ischemia is time dependent, and neuronal monitoring methods that can detect early subclinical levels of cerebral ischemia may improve overall treatment results. Cerebral microdialysis may represent such a method. The authors' goal was to characterize patterns of markers of energy metabolism (glucose, pyruvate, and lactate) and neuronal injury (glutamate and glycerol) in patients with subarachnoid hemorrhage (SAH), in whom ischemia was or was not suspected.

METHODS

By using low-flow intracerebral microdialysis monitoring, central nervous system extracellular fluid concentrations of glucose, pyruvate, lactate, glutamate, and glycerol were determined in 46 patients suffering from poor-grade SAH. The results in two subgroups were analyzed: those patients with no clinical or radiological signs of cerebral ischemia (14 patients) and those who succumbed to brain death (five patients). Significantly lower levels of energy substrates and significantly higher levels of lactate and neuronal injury markers were observed in patients with severe and complete ischemia when compared with patients without symptoms of ischemia (glucose 0 compared with 2.12+/-0.15 mmol/L; pyruvate 0 compared with 151+/-11.5 micromol; lactate 6.57+/-1.07 compared with 3.06+/-0.32 mmol/L; glycerol 639+/-91 compared with 81.6+/-12.4 micromol; and glutamate 339+/-53.4 compared with 14+/-3.33 micromol). Immediately after catheter placement, glutamate concentrations declined over the first 4 to 6 hours to reach stable values. The remaining parameters exhibited stable values after 1 to 2 hours.

CONCLUSIONS

The results confirm that intracerebral microdialysis monitoring of patients with SAH can be used to detect patterns of cerebral ischemia. The wide range from normal to severe ischemic values calls for additional studies to characterize further incomplete and possible subclinical levels of ischemia.

Simple numerical chromosome aberrations characterize pituitary adenomas

Although pituitary adenomas are among the most frequent intracranial neoplasms, only very few have been cytogenetically analyzed. We have short-term cultured and karyotyped 28 consecutive pituitary adenomas (16 clinically nonfunctioning adenomas and 12 clinically functioning adenomas), finding a normal karyotype in 22, whereas 6 had clonal chromosome aberrations (5 nonfunctioning pituitary adenomas and 1 prolactinoma). The abnormal karyotypes were relatively simple. Most anomalies were numerical, with a structural rearrangement, t(6;19), being found in only one tumor. The most common aberrations were trisomy 7 (3 adenomas), trisomy 9 (2 adenomas), trisomy 12 (2 adenomas), trisomy 20 (2 adenomas), and loss and gain in 2 separate clones of one X chromosome (2 adenomas).

Aneurysm on a persisting primitive trigeminal artery occluded with guglielmi detachable coils

SUMMARY

A persisting primitive trigeminal artery (PPTA) is present in 0.2 - 0.6% of all cerebral angiographies. 27 cases of PPTA aneurysms have been reported. We present a case with sixth cranial nerve palsy due to a non ruptured aneurysm on a persisting primitive trigeminal artery. The aneurysm was successfully occluded with Guglielmi Detachable Coils with preservation of the parent artery. The cranial nerve palsy resolved and recovery was uneventful.

Effect of 4 weeks of octreotide treatment on prolactin, thyroid stimulating hormone and thyroid hormones in acromegalic patients. A double blind placebo-controlled cross-over study

We aimed to test the hypothesis, that octreotide has a suppressive effect on unstimulated and TRH-stimulated PRL levels in both normo- and hyperprolactinaemic acromegalic patients, and besides to evaluate the effect of octreotide on unstimulated TSH and thyroid hormones. The present study is a doubleblind placebo-controlled cross-over trial; the 12 acromegalic patients were treated with octreotide or placebo (300 micrograms/d) for 4 weeks separated by a 12 weeks washout period. Before and after each 4 weeks period a TRH-test (200 micrograms iv) was performed and serum GH and PRL levels were determined. Serum TSH and thyroid hormones were determined after 0, 2, 3, and 4 weeks. In the whole group unstimulated PRL levels were 18 micrograms/l +/- 5 before and 7 micrograms/l +/- 1 during octreotide treatment (p < 0.01). The PRL lowering effect of octreotide was significantly more pronounced in hyperprolactinemic patients compared to normoprolactinaemic patients (p < 0.05). Patients with the highest pretreatment PRL levels had the most pronounced percentage suppression of unstimulated PRL levels during octreotide treatment. Eight out of 12 patients had a TRH-stimulated PRL response > or = 100%, both during placebo and octreotide treatment, but in the group as a whole maximal TRH-stimulated PRL levels were suppressed during octreotide treatment, PRL levels were 50 micrograms/l +/- 20 before and 18 micrograms/l +/- 3 during octreotide treatment (p < 0.05). Unstimulated GH levels were 48 mU/l +/- 15 before and 13 mU/l +/- 2 during octreotide treatment (p < 0.01). Serum total T3 was significantly reduced during octreotide treatment (p < 0.05); serum TSH, total T4 or free T4 index were not significantly changed during treatment. We conclude that patients with acromegaly and hyperprolactinemia will normalize PRL levels during 4 weeks of octreotide treatment and octreotide will reduce total T3 levels in acromegalic patients.

Body composition in active acromegaly during treatment with octreotide: a double-blind, placebo-controlled cross-over study

OBJECTIVE

In active acromegaly body composition is characteristically altered by an increase in lean body mass and a corresponding reduction in fat mass. These changes are induced by an excessive secretion of GH and insulin-like growth factor I (IGF-I). Growth hormone is an anabolic hormone and leads to stimulation of protein synthesis and an increased lipolysis in adipose tissue. Treatment with the somatostatin analogue, octreotide, has been shown to reduce GH levels causing reduced hormonal effects on target tissues. We have studied changes in body composition during short-term reduction in GH level by octreotide in active acromegaly.

DESIGN

Octreotide was compared to placebo in a double-blind, cross-over trial. Dual-energy X-ray absorptiometry scanning was employed to calculate body composition. Relations between body composition parameters and clinical signs of acromegaly (finger circumference and foot volume) were studied.

PATIENTS

Twelve patients with active acromegaly, confirmed by lack of GH suppression during oral glucose loading, were included. All had pituitary adenomas diagnosed by computed tomography.

MEASUREMENTS

Serum GH and IGF-I. Lean body mass, fat mass and total weight, foot volume and finger circumference.

RESULTS

Four weeks of octreotide treatment caused a 75% decrease in GH levels (n = 10), a reduction in IGF-I from 476 +/- 51.9 (mean +/- SEM) to 233 micrograms/l +/- 46.3 (P < 0.005) and a corresponding decrease in both body weight (2.51 kg +/- 0.41) (P < 0.005) and lean body mass (2.44 kg +/- 0.48) (P < 0.005). No significant changes in fat mass were observed. These findings were paralleled by significant reductions in foot volume (44.50 ml +/- 17) (P < 0.05) and finger circumference (1.3 mm +/- 0.3) (P < 0.05).

CONCLUSIONS

Short-term octreotide therapy reduces growth hormone levels leading to a significant reduction in lean body mass as assessed by dual-energy X-ray absorptiometry. Alterations in lean body mass were positively correlated with reductions in foot volume. Thus, simple clinical tests may be valuable in judging the effects of treatment in active acromegaly.

Simple numerical chromosome aberrations in two pituitary adenomas

Cytogenetic analysis of short-term cultures of one non-secreting and one prolactin-producing pituitary adenoma revealed simple clonal numerical abnormalities in both tumors. The karyotype of the non-secreting adenoma was 48,XX, +4, +9[42]/49,XX, +4, +9, +20[2]/46,XX[6]. In the prolactin-secreting adenoma, three aberrant clones were detected, giving the karyotype 45,X, -Y[20]/47,XY, +Y[6]/45,XY, -21[3]/46,XY[21]. One cell had the chromosome complement 46,X, -Y, +9; no other nonclonal aberrations were detected. The only hitherto published case of pituitary adenoma analyzed by banding techniques (Rey et al. [1986]: Cancer Genet Cytogenet 23:171-174) also had only numerical clonal changes that included extra copies of chromosome 9. We conclude that pituitary adenomas may be karyotypically characterized by numerical aberrations and that trisomy 9 seems to be the best candidate for a primary chromosomal anomaly.

Cerebral blood flow and metabolism following subarachnoid haemorrhage: cerebral oxygen uptake and global blood flow during the acute period in patients with SAH

Forty-eight patients with subarachnoid haemorrhage were studied with repeated rCBF and CMRO2 measurements. Cortical rCBF was measured using xenon-inhalation technique. CMRO2 was calculated as AVDO2 x CBF. When first studied the 29 conscious patients showed relative hyperaemia with CBF at 50 ml and reduced CMRO2 at 2.17 ml. In the following week CBF decreased to 41. CMRO2 remained reduced and constant. The 19 unconscious patients showed initially pronounced reduction in CMRO2 to 1.26, followed by gradual increase to 1.73 in 4-5 days. Simultaneously CBF increased from 18 ml to slightly above 30 ml. In the conscious patients the early reduction in CMRO2 and the concomitant luxury perfusion may be explained by global ischaemia because of very high ICP at the time of the haemorrhage. The reduced CBF in the unconscious group could be due to increased ICP, as ventricular drainage increased CBF to levels of relative hyperaemia as demonstrated in one case. As no decrease in CMRO2 was seen during the first 2 weeks, it is suggested that ischaemia at the time of aneurysm rupture is the most important single factor in reduction of global CMRO2.

Anterior sacral meningocele occurring in one family. An autosomal dominantly inherited condition

Anterior sacral meningocele is a rare congenital condition. Among 177 individuals familial occurrence was reported only seven times. In this report a family in which five members had anterior sacral meningoceles is presented and an autosomal dominant inheritance is suggested.

Patients with reversible ischemic neurological deficit (RIND) have less severe carotid artery lesions than those with transient ischemic attack (TIA) evaluated by duplex ultrasound

Fifteen patients with amaurosis fugax (AF), 37 with hemispheric TIA and 35 with reversible ischemic neurological deficit (RIND) were examined in the extracranial carotid arteries by duplex ultrasound within two months from symptoms. The most advanced atherosclerotic lesions were found among AF followed by hemispheric TIA. These two groups differed significantly from RIND which showed less advanced lesions, both on the symptomatic and asymptomatic side. Among RIND patients lesions showing 50% stenosis or more were seldom seen. Similar differences between the three groups were found after angiography of a subgroup. The hemispheric TIA group showed cholesterol, triglycerides and creatinine compared to AF and RIND. Previous atherosclerotic cardiovascular diseases were more often found among AF and hemispheric TIA than among RIND. It is suggested that TIAs, including AF, and RIND should be regarded as separate entities from a pathophysiological and clinical point of view.

Investigation of the criteria for assessing the outcome of treatment in acromegaly

The outcome of treatment in acromegaly is usually assessed by measuring plasma concentrations of growth hormone (GH)--either basal spontaneous levels or during hyperglycaemia. There is no consensus on how cure should be defined. Many studies have considered basal plasma growth hormone concentrations below 20 mU/l (10 ng/ml) as proof of cure, although some recent studies have applied lower values. At present a limit of 10 mU/l (5 ng/ml) seems to be accepted as evidence of cure. We have studied 28 acromegalic patients after transsphenoidal adenomectomy. Plasma GH concentrations (basal and during hyperglycaemia) as well as plasma somatomedin C (SMC) concentrations were measured and compared to the clinical symptoms. There was a close correlation between plasma GH and SMC concentrations (except when plasma GH levels were low) and between the clinical assessment and SMC concentrations. Very low plasma GH levels (less than 1 mU/l or 0.5 ng/ml) were associated with normal SMC values and clinical cure, high GH levels (greater than 10 mU/l or 5 ng/ml) with elevated SMC levels and persisting acromegaly. Moderately elevated plasma GH concentrations (1.9-9.6 mU/l) did not allow any conclusions on the outcome of treatment as assessed from SMC determinations and clinical evaluation. It is concluded that the usual criteria for cure in acromegaly may not be sufficiently strict.

Subarachnoid hemorrhage with normal cerebral angiography: a prospective study on sellar abnormalities and pituitary function

Ten consecutive patients with subarachnoid hemorrhage (SAH) of unknown cause were examined for sellar abnormalities and pituitary dysfunction. The diagnosis of SAH rested on a typical history and the demonstration of blood in the cerebrospinal fluid (computed tomography (CT), lumbar puncture). Initial CT and four-vessel angiography were performed in all patients, and five had repeat angiography. Endocrinological assessment was done after the initial angiography, and abnormal findings from this first study were reassessed 3 months later. The follow-up study included a high resolution CT scan of the sellar region. One patient had panhypopituitarism. Insufficient growth hormone secretion alone or combined with a low plasma concentration of estradiol or testosterone was found in another seven patients. The sella was ballooned or enlarged in three patients, and four patients had at follow-up a partly empty sella. A spontaneous development of a partly empty sella from an adenoma with suprasellar extension was observed in the patient with panhypopituitarism. This patient had experienced pituitary apoplexy with resulting SAH. Based on sellar enlargement, an empty sella, and pituitary dysfunction, this pathogenesis was suggested in another three patients. Our findings suggest that hemorrhagic necrosis in a pituitary adenoma may be an important cause of SAH with normal angiography.

Pituitary apoplexy with sterile meningitis

In 255 patients with evidence of a pituitary tumor, 7 patients presented with typical symptoms of meningitis, which all proved to be sterile. In these patients a pituitary adenoma was surgically verified in 4. In one patient the presence of acromegaly indicated a pituitary adenoma. In 2 patients an enlarged, empty sella was found, taken to reflect spontaneous disappearance of an adenoma. It is thought that the cause of the sterile meningeal reaction in the 7 patients was a spontaneous necrosis of the adenoma with expulsion of necrotic material into the suprasellar subarachnoid space. Although this sequence has been described before it has been considered to occur very rarely. Pituitary apoplexy as the underlying cause of meningitis should be suspected in patients with evidence of pituitary endocrine disturbances or lesion of structures adjacent to the fossa. The diagnosis may be established by computer tomography. Therapeutically, it may be of importance that the nature of the meningeal reaction is promptly recognized. Swift neurosurgical decompression of the sella and adequate hormonal substitution therapy may be essential.

The spontaneous course of pituitary adenomas and occurrence of an empty sella in untreated acromegaly

Twenty-three untreated patients with acromegaly for 6-46 yr who were followed for 2-13 yr were studied. High resolution computed tomographic scans in 11 patients revealed herniation of the subarachnoidal space into the pituitary fossa (empty sella) and an intrasellar cyst in 2. Suprasellar tumor extension developed during the follow-up period in only 1 patient. Eleven patients previously (in 10 patients more than 4 yr earlier) had been treated with bromocriptine; 6 of these patients at follow-up had a solid intrasellar adenoma. Six of the patients with an empty sella or intrasellar cyst had had symptoms suggesting pituitary apoplexy. The sellar volume did not increase during follow-up in any patient with an empty sella. Plasma GH levels (basal and mean concentrations during an oral glucose load) increased (greater than 50 ng/ml) in 3 and decreased in 3 patients during follow-up. Normalization of plasma GH levels was rare, and physical well-being with complete absence of acromegalic symptoms was reported by only 4 patients. These results demonstrate that GH-secreting pituitary tumors may remain stationary for extended periods of time and that complete or partial disappearance occurs frequently, probably as a result of pituitary adenoma infarction.

Cranial fasciitis of childhood

A case of the new entity cranial fasciitis of childhood is reported. It should be regarded as a special type of nodular (pseudosarcomatous) fasciitis. It is characterized by its localization to the cranial bone of young children. Knowledge of this apparently malignant, but actually completely benign lesion is equally important to both neurosurgeons and neuropathologists.

Adult hydrocephalus and the empty sella

A 51-year-old man presented with a pituitary apoplexy with symptoms and signs predominantly of meningitis. Later on, hydrocephalus and an empty sella were disclosed. It is likely that the empty sella and the hydrocephalus were both caused by the adenoma necrosis. Based on this case and cases reported in the literature, it is suggested that concomitant presence of an empty sella and hydrocephalus results from necrosis in a pre-existing pituitary adenoma.

Value of the 30 min ACTH-test in assessing hypothalamic-pituitary-adrenocortical function after pituitary surgery in Cushing's disease

Adrenocortical responses to a 30 min ACTH-test were measured before pituitary surgery and 8-12 d, 2-3 months and 6 months after, in 13 patients with Cushing's disease. The decrease in adrenocortical response to the short ACTH-test performed 8-12 d postoperatively correlated with the outcome as assessed 6 months after surgery. Adrenocortical response to ACTH became subnormal or borderline 8-12 d after surgery in patients demonstrating postoperative HPA insufficiency. These results add further support to the value of the short ACTH-test in assessing integrated HPA function in various clinical situations.

Pituitary abscess

All cases of pituitary abscesses (19 patients) reported in the literature since 1970 are reviewed. Based on the data available, it is suggested that a pituitary abscess is not a bacterial infection as commonly assumed. Probably, it represents a normal tissue reaction to an infarction of a pituitary adenoma. The frequent association with negative cultures from the abscesses, previous sterile meningitis and endocrine disturbances, and concurrent rhinorrhoea are well explained in this way.

Pituitary function in patients with evidence of spontaneous disappearance of a pituitary adenoma

Forty-four untreated patients with an enlarged sella were studied (excluding patients with acromegaly, Cushing's disease, and those with radiological evidence of suprasellar extension). In 20 patients CT revealed a completely or partially empty sella. Based on recent studies we take this finding to signify the previous presence of a pituitary adenoma which has undergone complete or partial necrosis. Ten of the 20 patients had in fact experienced symptoms typical of a pituitary apoplexy compared with only one out of the other 24 patients. Adrenal, thyroid, and growth-hormone insufficiency occurred as often in patients with an empty sella as in those with a solid pituitary tumour. In contrast, plasma prolactin levels were much lower in patients with an empty sella than in patients with a solid tumour (11 vs 166 ng/ml). It is assumed that this discrepancy reflects previous necrosis occurring in an adenoma hypersecreting prolactin. These results emphasize the importance of taking the spontaneous course of pituitary adenomas into account when assessing the effect of various treatment protocols.

Pseudotumor cerebri. A theory on etiology and pathogenesis

Ten patients with pseudotumor cerebri were studied. The diagnosis was based on bilateral papilledema and absence of intracranial masses and hydrocephalus. Based on the radiological findings, three groups of patients emerged: (A) Five patients with an empty sella. Four had an enlarged sella; (B) Two patients with a pituitary adenoma; and (C) Three patients without sellar or pituitary pathology. The onset of symptoms was acute in four patients, two from group A and one each from groups B and C. One patient from group A had a lesion of the chiasma. Two patients from group B and two from group C had symptoms and signs suggesting engagement of structures in the cavernous sinus. It is suggested that pseudotumor cerebri may be caused by bilateral compression of the cavernous sinuses because of acute necrotic swelling of a preexisting pituitary adenoma.

Pathogenesis of non-traumatic cerebrospinal fluid rhinorrhea

15 consecutive patients with non-traumatic cerebrospinal fluid rhinorrhea were studied. 13 operations were performed on 10 patients. In 8 transcranial operations, an assumed defect in the anterior fossa was plugged with muscle, but only 3 operations were successful. In 4 operations, either transcranial or transsphenoidal, the sella was packed with muscle and rhinorrhea ceased immediately. Based on radiological and operative findings, 3 groups of patients appeared (1) 9 patients had pathology related to the pituitary gland or the sella turcica: enlarged sella, empty sella, pituitary tumour, intrasellar cyst or erosion of the sellar osseous border. (2) 2 patients had rhinorrhea from extrasellar origin. (3) In 4 patients no abnormality could be found. Prior to the rhinorrhea, 6 patients (5 from group 1 and 1 from group 3) had experienced episodes of neurological symptoms, compatible with a pituitary apoplexy. It is suggested that non-traumatic cerebrospinal fluid rhinorrhea in most cases is the result of a spontaneous necrosis in a pituitary adenoma, which has caused sellar bony erosion.

The empty sella and pituitary adenomas. A theory on the causal relationship

In 44 consecutive patients with sellar volume larger than 1100 mm3, computer tomography showed that 20 had an empty or partly empty sella. None had radiological evidence of a suprasellar tumor. 10 of the 20 patients had experienced episodes with acute neurological symptoms presumably reflecting a pituitary apoplexy. It is suggested that an unknown proportion of intrasellar adenomas may disappear as a result of an infarction, which may comprise the entire adenoma or part of it--leaving an empty or partly empty sella as diagnosed by computer tomography. Air encephalography will demonstrate the empty sella only if the diaphragmatic aperture is large enough to allow cisternal herniation. The infarction may present clinically with no, slight or severe acute neurological symptoms. Late consequences of a pituitary adenoma infarction may be rhinorrhea or hydrocephalus.

Central corneal thickness and intraocular tension in patients with acromegaly

In 27 patients with pituitary adenomas the central corneal thickness and the intraocular tension were measured. Thirteen of the patients were suffering from acromegaly, and in this group the central corneal thickness was 0.561 mm +/- 0.35 (mean +/- SD). In the 14 patients with pituitary adenomas but no acromegaly the central corneal thickness was 0.526 mm +/- 0.030 (mean +/- SD). This difference is statistically significant 0.01 greater than P greater than 0.001. In the 13 patients with acromegaly the intraocular tension measured by applanation was 16.9 mmHg +/- 2.3 (mean +/- SD) and in the control group 14.7 mmHg +/- 2.4 (mean +/- SD). This difference is statistically significant (0.05 greater than P greater than 0.02). When the applanation reading is corrected for the difference in the central corneal thickness, the patients suffering from acromegaly have an intraocular tension of 14.1 mmHg, which is of the same magnitude as the tension in the patients without acromegaly.

Median and ulnar nerve transections treated with microsurgical interfascicular cable grafting with autogenous sural nerve

Interfascicular nerve grafting was used in 37 median and 26 ulnar nerves, all completely transected. In a follow-up period of 2.5 to 5 years, useful motor recovery (M3 or higher) was achieved in 84% of median nerve lesions; in ulnar nerve lesions, useful motor recovery (M2+ or higher) was achieved in 73%. Sensory recovery with some return of two-point discrimination sense was found in 63% of low median and 50% of low ulnar nerve lesions. In the median nerve group, results for patients younger than 20 years of age were significantly better than in older patients. Neurophysiological investigations gave evidence for nerve regrowth through the grafts in all but one patient, although the loss of axons was probably considerable if the amplitudes of sensory potentials were used as a parameter. Grafts of 2.5 to 5 cm in length gave better results than longer grafts, and results for the distal median nerve lesions were superior to those for the distal ulnar nerve lesions. Use of interfascicular nerve grafting techniques for nerve gaps greater than 2.5 cm is recommended.

Interfascicular transplantation in median nerve injuries

Twenty-four patients operated upon within a 3-year period for complete median nerve transection using the microsurgical interfascicular transplantation technique were examined after a minimum of 3 years' observation. Functional motoricity (M 3 or higher) was achieved by 83 per cent. With the exception of one patient, all achieved protective tactile sensibility (96 per cent). The results were best for distal lesions in children and youths. The outcome was just as satisfactory as that attained with epineurial suture carried out under ideal conditions. The method was found to be superior to epineurial end-to-end suture in cases of nerve defects longer than 2.5 cm.