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Peter Dyck and Charles B. Wilson

✓ A woman presented with a mass in the left groin, which was later shown to be a sliding hernia. A bony sacral defect prompted investigation, which uncovered a massive anterior sacral meningocele. Examination, including ultrasonography and myelography, is discussed, and a surgical approach proposed.

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Esref Tel, Takao Hoshino, Marvin Barker, and Charles B. Wilson

✓ In Fischer 344 rats, 9L tumors were implanted in the left cerebral hemisphere. Compared with control animals not operated on, rats treated with an LD10 dose of BCNU 1 hour before or 1 or 12 hours after surgery on Day 16 postimplant had an increased life span of over 200% (greater than a 6 log cell kill). Minimal effect on survival was found when BCNU was administered during surgery. On the other hand, BCNU administered 12 hours before or 24 or 72 hours after surgery did not show any additive effect of surgery on BCNU treatment. These results suggest that in a clinical setting, a bolus of BCNU administered to tumor patients within 12 hours of surgery might increase substantially the total tumor cell kill compared with surgical resection alone.

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Isabelle L. Richmond, Thomas H. Newton, and Charles B. Wilson

✓ The preoperative angiograms of 100 patients subsequently undergoing transsphenoidal exploration for prolactin-secreting pituitary adenomas were reviewed in order to assess both the risk of this study and its yield of useful diagnostic information. In these patients with documented hyperprolactinemia, no vascular anomalies contraindicating a transsphenoidal approach were detected. Tumor blush was evident only in large tumors. The appearance of lateral displacement of the carotid siphon in basilar views was not a reliable predictor of lateral extension. When hyperprolactinemia can be documented, the authors' current practice is to reserve angiography for patients who have gross sellar expansion or suprasellar extension, or for those who have had prior radiotherapy.

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Philip H. Gutin, William G. Cushard Jr., and Charles B. Wilson

✓ A patient with a pituitary adenoma secreting adrenocorticotropin hormone manifested panhypopituitarism after an episode of pituitary apoplexy. The previously elevated urinary levels of 17-ketogenic steroids dropped sharply, and plasma cortisol became undetectable. The apoplexy also resulted in a partially empty sella on which the dorsum sellae collapsed. Recurrent Cushing's disease developed and was cured by transsphenoidal resection of a microadenoma.

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Charles B. Wilson, Hoi Sang U, and James Domingue

✓ In the period 1968 to 1978, 83 vascular malformations (AVM's) were treated by operation: 65 were excised and 18 were managed by interruption of afferent arteries. Three cryptic AVM's (two in the thalamus and one in the caudate nucleus) were discovered during exploration of hematomas in normotensive young women. All three of these small malformations were detected on computerized tomographic scans; none was apparent on preoperative angiograms. Two of the four deaths in this series occurred after excision of large, high-flow fistulas; the proposed cause was restoration of normal perfusion pressure in a chronically ischemic hemisphere rendered incapable of autoregulation. The addition of operative adjuncts, in particular, bipolar coagulation and operative microscopy, has extended traditional indications for operation to include favorably situated AVM's that have not bled and certain AVM's situated in critical regions of the brain.

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Victor A. Levin, Charles B. Wilson, Richard Davis, William M. Wara, Tana L. Pischer, and Lowell Irwin

✓ This Phase III clinical trial compared the effectiveness of the combination of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), radiation therapy, and hydroxyurea (BHR group) to the combination of BCNU and radiation therapy (BR group) for the treatment of malignant gliomas. In both arms of the study, BCNU was administered intravenously for 3 consecutive days before the initiation of radiation therapy, and at 8-week intervals thereafter until unequivocal tumor progression. In the BHR arm of the study, hydroxyurea was administered orally on alternate days during radiation therapy. Patients in each arm were stratified almost equally by tumor type (glioblastoma multiforme (GM) or other nonglioblastoma multiforme malignant gliomas (NGM)) and extent of surgical resection of tumor. Patients were also evaluated with the Karnofsky Performance Status (KPS) scale. Time to progression was determined by comparing the results of sequential neurological examinations and radionuclide and computerized tomographic scans.

Of the 130 patients entered into the study, 99 constitute the valid study group. Data were analyzed with Kaplan-Meier representations and the statistical methods of Gehan and Cox. The NGM patients with KPS ratings of ≥60 did better on both arms of the study, with median times to tumor progression (MTP's) of 50 and 72 weeks for BHR and BR, respectively. However, GM patients showed statistically significant differences (p = 0.03) between the two arms of the study, with MTP's of 41 and 31 weeks for BHR and BR, respectively. The GM patients with subtotal tumor resection did slightly better on BHR than on BR, with MTP's of 49 weeks (p = 0.03) and 31 weeks for the respective groups.

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William F. Hoffman, Charles B. Wilson, and Jeannette J. Townsend

✓ Over a 1-year period, a 60-year-old woman had nine episodes of transient weakness, clumsiness, and hypesthesia of the right upper extremity. Angiography revealed normal extracranial vessels and a left middle cerebral artery aneurysm. The aneurysmal sac, removed at operation, had an organized thrombus, which was believed to be the cause of the transient ischemic attacks. Postoperatively, the patient has remained free of neurological symptoms.

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William F. Hoffman, Victor A. Levin, and Charles B. Wilson

✓ The syndrome of increased focal or generalized central nervous system (CNS) dysfunction in the early postirradiation period in patients treated with radiation therapy (RT) for malignant gliomas has not been well documented. The authors have undertaken retrospective study of 51 patients with supratentorial malignant gliomas who survived longer than 26 weeks from the time of diagnosis. All patients received irradiation and chemotherapy and were evaluated at 8-week intervals. Each evaluation consisted of a neurological examination, computerized tomography (CT) and radionuclide scans, Karnofsky rating, and an evaluation of glucocorticoid levels needed to maintain neurological function. In all, 263 evaluable periods, consisting of 1290 individual evaluable tests (parameters), were analyzed. In the first 18 weeks after RT, 26 of the 51 patients studied (51%) showed deterioration in one or more tests; 14 of the 26 (53%) did not improve. These 14 patients had a median time to tumor progression (MTP) of 31 weeks. The remaining 12 patients in this group (47%) improved and had an MTP of 73 weeks. Of the 51 patients, 25 (49%) showed deterioration significant enough to presume tumor progression (two of the following three tests were unequivocally worse: neurological examination, CT scan, and radionuclide scan), seven improved with no change in therapy and had an MTP of 66 weeks, while the other 18 had an MTP of 32 weeks. Excluding the Karnofsky rating, any individual test that showed worsening during the first 18-week period had a 33% probability of significant improvement at a subsequent evaluation period. After 18 weeks the probability of the test improving was only 4%.

The authors conclude that CNS decompensation up to 18 weeks after RT, as ascertained from clinical examination, scans, or glucocorticoid dosage, does not invariably predict tumor progression, because in 28% (7/25) of such cases there will be subsequent improvement.

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James E. Boggan, Mark L. Rosenblum, and Charles B. Wilson

✓ A tumor of the trochlear nerve sheath with an unusual but diagnostic presentation is described. The rarity of reported cases may reflect failure to differentiate tumors originating from the trochlear and trigeminal nerves.

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William F. Hoffman and Charles B. Wilson

✓ A patient who presented with a subarachnoid hemorrhage was found to have a saccular aneurysm arising from the proximal basilar artery. The aneurysm was bilobed, directed anteriorly and inferiorly, and associated with a proximal fenestrated segment of the basilar artery.