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Ryszard M. Pluta, Brian Iuliano, Hetty L. Devroom, Tung Nguyen and Edward H. Oldfield

. Clinical Material and Methods Patient Evaluation All patients were screened at the National Institutes of Health, under an institutional review board—approved protocol, for the presence of mutations and deletions of the VHL gene, and received the diagnosis of VHL disease. 1 To compare these patients' neurological outcomes after an anterior or posterior surgical approach had been used to treat hemangioblastomas of the ventral spinal cord, we retrospectively identified eight patients in whom tumors were located in the ventral aspect of the cord (that is, anterior

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of these tumors to occur in the pediatric age group, only two of the 10 patients whom we described were younger than 20 years of age. Thus, our series did not suggest a bias for this to occur in the pediatric age range. One interesting and unexplained aspect of pituitary tumors that arise above the diaphragma sellae is the high incidence of adrenocorticotropin-secreting tumors. We have not noted an occurrence above the diaphragma sellae of the other categories of pituitary adenomas and very few have been described by others. Finally, I have found the surgical

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P. Benjamin Kerr and Edward H. Oldfield

. Neurosurgery 60 : 46 – 59 , 2007 3 Hardy J : Transsphenoidal hypophysectomy . J Neurosurg 34 : 582 – 594 , 1971 4 Jankowski R , Auque J , Simon C , Marchal JC , Hepner H , Wayoff M : Endoscopic pituitary tumor surgery . Laryngoscope 102 : 198 – 202 , 1992 5 Jho HD , Alfieri A : Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition . Br J Neurosurg 14 : 432 – 440 , 2000 6 Liu JK , Weiss MH , Couldwell WT : Surgical approaches to pituitary tumors

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fibrous tissue. Clearly the clinical presentation of such tumors can sometimes be confusing, and there are major implications with respect to the details of surgical management when one is confronted with an endocrinologically hyperactive disorder. The concern is that an obvious tumor may be incidental to a less obvious separate lesion that actually produces the excess hormone. This paper, in which the problems and outcomes in patients with multiple adenomas are highlighted, provides a good opportunity to review certain technical aspects of the transsphenoidal surgical

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Edward H. Oldfield and Alexander O. Vortmeyer

surgical capsule of the adenoma was used to define a surgical plane that completely contains the outer margin of the adenoma, as described in the following section, indicates to us that the pseudocapsule consistently contains the entire tumor, unless the tumor invades the capsule of the anterior pituitary gland. Surgical Approach in Which the Histological Pseudocapsule is Used as a Surgical Capsule The basis of this report began with, and derives largely from, an extensive surgical experience in the detection and selective excision of microadenomas in patients with

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Joshua M. Ammerman, Russell R. Lonser and Edward H. Oldfield

T umors of the anteromedial region of the superior cerebellum are rare and technically challenging to remove because of their anatomical location. Although several surgical approaches that provide access to this area have been described, they are frequently limited by the need for significant cerebellar retraction along a narrow working corridor, the need for resection of a portion of the cerebellum to provide adequate exposure of large lesions, and the long working distances often necessary to reach the pathological entity. To overcome the limitations

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Roberto C. Heros

Ammerman and colleagues provide a very nice presentation of a well-known surgical approach—the posterior subtemporal transtentorial approach—as applied to lesions in the anteromedial superior aspect of the cerebellum. As the authors indicate, lesions in this region have primarily been approached via the suboccipital transtentorial approach or the paramedian supracerebellar infratentorial approach. I agree with the authors that the supracerebellar infratentorial approach to these lesions is less satisfactory because it presents a greater working distance, a

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Marc R. Mayberg

surgical approach will be any better at preventing late recurrence than the traditional techniques. Six patients had tumor noted in gland specimens from partial hypophysectomy; the concept of corticotroph hyperplasia in early Cushing disease has recently been raised, 5 and it is not clear if these patients are part of a spectrum of the disorder that includes both hyperplasia and discrete adenoma. Details of the radiological criteria for dural invasion were not specified. Finally, the authors' conclusion, that biochemical remission requires identification and removal of

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Editorial

Chiari malformation Type I

Mark M. Souweidane

procedure was most useful. While it is true that each patient underwent further osseous decompression, many also had simultaneous procedures aimed at reestablishing a patent subarachnoid space (that is, release of adhesions, detethering, pseudomeningocele repair, and so forth). If osseous decompression was the sole factor responsible for improvement, could one infer from the results that an extradural procedure alone would adequately address the problem? This conclusion is unlikely and the authors justifiably used a comprehensive surgical approach with admirable results

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B. Gregory Thompson, John L. Doppman and Edward H. Oldfield

. J Neurosurg 67 : 795 – 802 , 1987 Rosenblum B, Oldfield EH, Doppman JL, et al: Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVM's in 81 patients. J Neurosurg 67: 795–802, 1987 30. Sundt TM Jr , Piepgras DG : The surgical approach to arteriovenous malformations of the lateral and sigmoid dural sinuses. J Neurosurg 59 : 32 – 39 , 1983 Sundt TM Jr, Piepgras DG: The surgical approach to arteriovenous malformations of the lateral and sigmoid dural sinuses. J