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Dennis Becker, David Norman and Charles B. Wilson

✓ Meningiomas have been reported to have associated areas of surrounding low density on computerized tomography (CT). These low-density areas may represent edema, widened subarachnoid spaces, loculated cerebrospinal fluid, demyelination, or adjacent tumor. Two cases are presented in which this adjacent area of low density represented a tumor cyst. Recognition is important as the CT appearance of these lesions may simulate a metastatic tumor.

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Letters to the editor

Epidural Bleeding in Anterior Discectomy

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David C. Crafts, Victor A. Levin, Michael S. Edwards, Tana L. Pischer and Charles B. Wilson

✓ Seventeen patients with recurrent medulloblastoma were treated with a combination of three drugs: procarbazine, CCNU, and vincristine (PCV). Tumor recurrence was documented at varying periods following surgery and radiotherapy. Among 16 evaluable patients, ten showed a response to PCV on the basis of subjective neurological improvement and a decrease in tumor size by radiological criteria. Five patients were designated as having stable disease on the basis of no change in neurological status and tumor size. One patient showed uninterrupted progression of disease. The median time to progression for all patients was 45 weeks.

Significant myelotoxicity, exacerbated by prior spinal irradiation, compromised therapy. After an initial response, it was often necessary to reduce the higher doses of CCNU and procarbazine that caused concomitant bone-marrow toxicity; as a consequence of the lowered doses, tumor progression was then frequently observed. The authors conclude that PCV is an effective form of palliative therapy for recurrent medulloblastoma.

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Michael D. Walker, Eben Alexander Jr., William E. Hunt, Collin S. MacCarty, M. Stephen Mahaley Jr., John Mealey Jr., Horace A. Norrell, Guy Owens, Joseph Ransohoff, Charles B. Wilson, Edmund A. Gehan and Thomas A. Strike

✓ A controlled, prospective, randomized study evaluated the use of 1,3-bis(2-chloroethyl)-l-nitrosourea (BCNU) and/or radiotherapy in the treatment of patients who were operated on and had histological confirmation of anaplastic glioma. A total of 303 patients were randomized into this study, of whom 222 (73%) were within the Valid Study Group (VSG), having met the protocol criteria of neuropathology, corticosteroid control, and therapeutic approach. Patients were divided into four random groups, and received BCNU (80 mg/sq m/day on 3 successive days every 6 to 8 weeks), and/or radiotherapy (5000 to 6000 rads to the whole brain through bilateral opposing ports), or best conventional care but no chemotherapy or radiotherapy. Analysis was performed on all patients who received any amount of therapy (VSG) and on the Adequately Treated Group (ATG), who had received 5000 or more rads radiotherapy, two or more courses of chemotherapy, and had a minimum survival of 8 or more weeks (the interval that would have been required to have received either the radiotherapy or chemotherapy). Median survival of patients in the VSG was, best conventional care: 14 weeks (ATG: 17.0 weeks); BCNU: 18.5 weeks (ATG: 25.0 weeks); radiotherapy: 35 weeks (ATG: 37.5 weeks); and BCNU plus radiotherapy: 34.5 weeks (ATG: 40.5 weeks). All therapeutic modalities showed some statistical superiority compared to best conventional care. There was no significant difference between the four groups in relation to age distribution, sex, location of tumor, diagnosis, tumor characteristics, signs or symptoms, or the amount of corticosteroid used. An analysis of prognostic factors indicates that the initial performance status (Karnofsky rating), age, the use of only a surgical biopsy, parietal location, the presence of seizures, or the involvement of cranial nerves II, III, IV, and VI are all of significance. Toxicity included acceptable, reversible thrombocytopenia and leukopenia.

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Robert F. Spetzler and Charles B. Wilson

✓ The authors review 39 patients with cerebrospinal fluid (CSF) leaks originating from the middle or posterior fossa. They evaluate the usefulness of preoperative investigative procedures, including cisternal radionuclide scanning and the deliberate increase of intracranial pressure. The results in this series emphasize the important role that abnormal CSF dynamics play in the recurrence of problematic cases of rhinorrhea or otorrhea. The following guidelines are recommended by the authors on the basis of their recent experience: 1) if hydrocephalus is present, if the cisternogram is abnormal, or if the CSF leak is intermittent and slight, the initial treatment should be insertion of a lumboperitoneal shunt; 2) if the leak is localized in the sellar or parasellar area, a transsphenoidal approach to obliterate the leak is advised; 3) if the CSF leak originates through a dural opening into the middle ear, an intracranial repair is indicated.

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Isabelle L. Richmond and Charles B. Wilson

✓ This report describes a group of 25 children and adolescents with biopsy-proven pituitary adenomas. They were found in 33% of patients encountered in our recent study of 74 parasellar tumors detected in patients under 20 years old. Earlier detection accounts for this apparent increase in frequency. This interpretation is supported by the rarity of signs of intracranial hypertension at presentation, as well as decreased incidence and severity of visual failure. More than 70% of patients have evidence of pituitary hypersecretion at presentation. Increased awareness of these endocrinological signs as well as improved hormonal assays facilitate both diagnosis and management. Hypopituitarism is rare; the important exception is suppression of gonadotrophic function that is known to occur early in the natural history of intrasellar pituitary adenomas.

The low incidence of suprasellar and extrasellar extension is documented by both radiographic and operative findings. Transsphenoidal resection was employed in 92% of patients, with an estimated total resection in 73% of cases. Follow-up studies show a high quality of survival; no patient has severe neurological deficit and less than half of them require replacement therapy. The recurrence rate is 8%. Our findings do not support a previous report that pituitary adenomas in this age group are frequently extrasellar and invasive.

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U Hoi Sang and Charles B. Wilson

✓ In three cases, anterior cervical discectomy was complicated by acute postoperative paraplegia secondary to epidural hematomas at the operative sites. Prompt evacuation of the hematomas was followed by recovery in each instance. The source of bleeding was an arterial arcade that may be encountered during the course of removing the posterior longitudinal ligament. As a result of this experience, the authors suggest steps to be taken to avoid this uncommon complication.

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Takao Hoshino, Kazuhiro Nomura, Charles B. Wilson, Kathy D. Knebel and Joe W. Gray

✓ Flow cytometry (FCM) is a technique that measures the quantity of DNA contained in individual nuclei and records a frequency distribution of the DNA content per nucleus in the sampled cell population. Nuclei from a variety of human brain-tumor types were isolated by means of tissue grinding, purified by centrifugation through 40% sucrose (15 minutes at 4000 rpm), fixed with 10% formalin, stained with acriflavin-Feulgen, and analyzed by FCM. Profiles of DNA distribution in histologically benign tumors, such as meningiomas, pituitary adenomas, neuroblastomas, and low-grade astrocytomas, revealed a large diploid population (2C) with a few nuclei in DNA synthesis, as well as a small premitotic population (G2 cells) that contains a 4C DNA complement. In contrast, malignant gliomas, including glioblastomas, consist of more cells in DNA synthesis; these tumor cells show a highly variable distribution of ploidy consisting not only of diploid, and/or aneuploid, but also of triploid, tetraploid, and possibly octaploid populations. Also, a large variability between different regions of each tumor was always observed. In contrast, metastatic brain tumors, despite the fact that they contain a considerable number of cells undergoing DNA synthesis, demonstrate little variability within each individual tumor. The ability to rapidly characterize the cell populations of human brain tumors with FCM may enhance the effectiveness of their clinical management.