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Russell R. Lonser, John D. Heiss and Edward H. Oldfield

devascularization could be accomplished by injecting ETOH directly into tumors during surgery, reducing bleeding and facilitating resection. We report our initial experience in four patients who underwent intratumoral injection of ETOH during resection of neoplasms affecting the central nervous system. Of the four patients, three had spinal epidural and one had a cerebellar neoplasm requiring resection ( Table 1 ). One patient underwent partial intraarterial embolization of the tumor vasculature before surgery. TABLE 1 Intraoperative injection of ETOH for tumor

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Editorial

Transnasal endoscopic surgery for craniopharyngiomas

Edward H. Oldfield

Dr. Campbell and colleagues 1 report on a series of 14 adults who underwent transnasal endoscopic surgery for craniopharyngiomas, in which one of the goals was to preserve the pituitary stalk while removing as much tumor as could be safely removed without causing new neurological or endocrinological deficits. In 4 patients (29%) a gross-total resection of the tumor was performed, while in 10 (71%) tumor removal was incomplete. In 5 of these 10 patients at least 95% tumor removal (near-total resection) was achieved, and in the other 5 subtotal resection was

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Editorial

Unresolved issues: radiosurgery versus radiation therapy; medical suppression of growth hormone production during radiosurgery; and endoscopic surgery versus microscopic surgery

Edward H. Oldfield

This issue of Neurosurgical Focus contains important reviews of several aspects of acromegaly. Three themes are emphasized in at least 3 contributions: the attributes of radiosurgery compared with conventional fractionated radiation therapy for patients with residual tumor after surgery; the use of medical therapy to suppress tumor production of growth hormone (GH) during radiosurgery; and the “pure” endoscopic approach for surgery. The authors of these reports already emphasize much of what I have to say here. However, certain arguments, arguments that

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Edward H. Oldfield

Today the most common type of spinal vascular abnormality, the dural arteriovenous fistula (DAVF), can always be eliminated with successful treatment, although whether that should best be done initially with surgery or with embolic occlusion is still controversial, as is evident by the differing views in several of the papers in this issue of Neurosurgical Focus. Despite the fact that DAVFs can be successfully obliterated, many patients are left with neurological deficits or chronic pain, both of which can be avoided in many cases if the diagnosis is

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Rob D. Dickerman and Edward H. Oldfield

T ranssphenoidal pituitary surgery is the primary treatment for most types of pituitary adenomas. Despite advanced pituitary imaging and enhanced techniques for tumor localization and removal, however, many pituitary tumors are not cured by surgery. 8, 19, 34 Surgical failure rates range from 20 to 80% and recurrence rates for pituitary adenomas range from 7 to 35%, depending on the length of follow up, tumor size, adenoma subtype, and the particular surgeon. 2–5, 8, 10, 17, 18, 30, 31, 33, 35 Pituitary adenomas that do so usually recur within the first 5

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Gautam U. Mehta and Edward H. Oldfield

P ersistent cerebrospinal fluid leakage is the leading cause of morbidity following transsphenoidal surgery for pituitary adenomas. 2 Persistent CSF rhinorrhea can lead to headache and meningitis. A national survey of complications following transsphenoidal surgery defined the incidence of a postoperative CSF leak as 3.9%. 4 Studies have aimed to define the factors that contribute to persistent CSF leakage. Surgery for macroadenomas, particularly those with suprasellar extension, has been correlated with an increased rate of postoperative CSF leakage

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Beatriz R. Olson, Julie Gumowski, Domenica Rubino and Edward H. Oldfield

R ecently we 18 and others 12, 20, 22 reported that hyponatremia is a delayed, frequent, and occasionally serious complication of transsphenoidal pituitary surgery. Lack of appropriate suppression of arginine vasopressin (AVP) secretion in a few hyponatremic hypoosmolar patients 6, 14, 18, 20 and prevention of the development of hyponatremia by complete removal of the posterior pituitary in dogs 10 suggest that hyponatremia in this setting is caused by inappropriate antidiuretic hormone release 6, 10, 14, 18, 20, 23 from damaged posterior pituitary

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Jay Jagannathan, Russell R. Lonser, Rene Smith, Hetty L. DeVroom and Edward H. Oldfield

Material and Methods Patient Population Consecutive patients with VHL disease who underwent resection of cerebellar hemangioblastomas at the NIH between January 1987 and December 2006 were included. Eighty patients (44 female and 36 male patients) underwent a total of 126 operations for resection of 164 cerebellar hemangioblastomas at the NIH during the study period. The patients' mean age at the initial visit was 33.4 ± 11.3 years (range 11–61 years). The mean age at initial NIH surgery was 37.8 ± 10.3 years (range 11–62 years). All patients had germline mutations

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Gautam U. Mehta, Russell R. Lonser and Edward H. Oldfield

with Cushing syndrome underlies the significant morbidity and significantly shortened life span in untreated patients. In most patients, Cushing syndrome arises from ACTH-secreting basophilic pituitary adenomas (CD), which are frequently less than 1 centimeter in diameter. While the current treatment of choice for these lesions is selective adenomectomy by transsphenoidal pituitary surgery, the widespread use and acceptance of pituitary surgery for CD was delayed until the latter half of the 20th century for a variety of reasons. Surgery of the pituitary gland and

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Gautam U. Mehta, Kamran D. Bakhtian and Edward H. Oldfield

and eliminate any arachnoid herniation, ESS is more likely to present with microadenomas and hormonesecreting tumors. To date, treatment outcomes for pituitary tumors in the setting of primary ESS remain undefined, described only in case reports and small series. 1 , 2 , 4 , 7 , 12 , 15 , 19 , 20 , 26 , 27 Pituitary surgery, which is first-line therapy for adrenocorticotropin (ACTH)- and growth hormone (GH)-secreting tumors, is particularly challenging in the setting of ESS due to diminished pituitary gland volume, as well as the frequent presence of an arachnoid