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Pituitary abscesses

Report of seven cases and review of the literature

James N. Domingue and Charles B. Wilson

✓ Seven cases of pituitary abscess are presented and the relevant world literature is reviewed. An enlarged sella co-existing with bacterial meningitis, or bacterial meningitis coinciding with a known or suspected pituitary tumor should suggest the diagnosis of pituitary abscess. Visual field defects should evoke similar suspicion when present in a patient with meningitis. This reasoning enabled us to make the first reported preoperative diagnosis of pituitary abscess. Therefore, in the management of purulent meningitis, we recommend the following: first, skull films are mandatory; second, if the sella turcica is abnormal, the correct presumptive diagnosis is pituitary abscess; and third, if prompt improvement does not follow appropriate antibiotic therapy, the suspected abscess should be explored and drained via the transsphenoidal approach.

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Intracranial Aneurysms

Results of Surgical Treatment

James L. Poppen and Charles A. Fager

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James L. Poppen and Charles A. Fager

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Conducted somatosensory evoked potentials during spinal surgery

Part 1: Control conduction velocity measurements

James B. Macon and Charles E. Poletti

✓ Intraoperative recordings of conducted bipolar epidural somatosensory evoked potentials (SEP's) generated by unilateral common peroneal nerve stimulation have been obtained in 27 patients. The SEP's were multiphasic, 0.3 to 1.5 µV in amplitude, and recorded in 100% of patients with normal cords or in patients with spinal lesions, at a site caudal to the lesions. Control spinal conduction velocities (CV's), measured in the midthoracic to lower cervical regions, were in the range of 65 to 85 m/sec. Control lumbar and lower thoracic CV's were in the range of 30 to 45 m/sec. The CV values were obtained periodically throughout the course of surgery and were plotted as a function of time. In control patients with extradural lesions and neuroleptic anesthesia, the CV's remained constant (± 3%). The consistency, sensitivity, and safety of SEP recordings obtained by this technique make precise monitoring readily available during spinal operations.

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Cerebral vasodilation and prostacyclin

The effects of aspirin and meclofenamate in vitro

Charles E. Chapleau, Richard P. White and James T. Robertson

✓ The effects of aspirin and meclofenamic acid on the diphasic responses produced by prostacyclin in isolated canine basilar arteries were compared. Meclofenamate enhanced the relaxant action of prostacyclin in low concentrations (10−8M to 10−6M) and also significantly inhibited the contractions caused by the highest concentration (10−6M) of this prostaglandin. Aspirin had no such effects. The results indicate that some drugs classified as prostaglandin synthetase inhibitors can directly enhance the vasodilator action of prostacyclin on cerebral arteries, and suggest that this enhancement could be of value in the clinical applications of prostacyclin.

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James E. Boggan, J. Blake Tyrrell and Charles B. Wilson

✓ The development of transsphenoidal microsurgery and the refinement of endocrinological and radiological diagnostic procedures have afforded therapeutic options appropriate to the individual case in patients with hypercortisolism. The present series of 100 cases is derived from 104 patients with the diagnosis of Cushing's disease who underwent transsphenoidal pituitary exploration between 1974 and 1981. Excluding four patients in whom the pituitary gland was not exposed because of intraoperative technical difficulties, an overall cure rate of 78% was achieved. Among 71 patients with tumors confined to the sella turcica, 87% had correction of their hypercortisolism, 11% represented therapeutic failures, and one patient had tumor recurrence. In contrast, among 25 patients with extrasellar extension, correction of hypercortisolism was achieved in only 48%, 40% failed to respond, and 12% of the patients had recurrence. Four patients who failed to respond to total hypophysectomy have ectopic sources of adenocorticotropic hormone.

The results indicate that transsphenoidal microsurgical exploration for a basophilic adenoma is the procedure of choice in adults and children with Cushing's disease. The diagnostic and surgical approach to these tumors, as well as pitfalls in the transsphenoidal treatment of Cushing's disease, are discussed.

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James C. White, Robinson LeR. Bidwell and Charles S. Kubik

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David S. Baskin, James E. Boggan and Charles B. Wilson

✓ A series of 137 patients with growth hormone (GH)-secreting pituitary adenomas were treated by transsphenoidal surgery during a 10-year period. Group A comprised patients for whom this surgery was the first therapeutic intervention, and Group B included those who underwent the surgery after previous therapeutic intervention. The results were analyzed considering preoperative and postoperative endocrinological, neurological, ophthalmological, and neuroradiological data. Remission was defined as clinical response and a normal postoperative GH level, and partial remission as clinical response and postoperative reduction of the GH level by more than 50%. Any other result was considered failure. The mean follow-up period was 37.1 months; follow-up review was achieved in all the patients.

Among the 102 patients in Group A, remission was achieved in 80 (78%) patients with transsphenoidal surgery alone, and in an additional 16 (16%) after postoperative irradiation (combined response rate, 94%). All failures and patients with partial remission had preoperative GH levels of more than 50 ng/ml and suprasellar extension of the tumor. There were no deaths; 8% of patients had minor surgical morbidity; 5% had new hypopituitarism postoperatively. Of patients subsequently irradiated, 71% developed hypopituitarism.

Among the 35 patients in Group B, remission was achieved in 26 (74%), partial remission was obtained in two (6%), and seven (20%) were considered treatment failures. There were no deaths, and the morbidity rate was 14%; 66% of patients had hypopituitarism postoperatively. Of the eight patients who had received prior irradiation only, seven (88%) went into remission. All failures and partial responders had preoperative GH levels greater than 40 ng/ml; 56% had suprasellar extension. These results confirm the efficacy of the transsphenoidal approach for the treatment of GH-secreting pituitary adenomas.

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David L. LaMasters, James E. Boggan and Charles B. Wilson

✓ A presumed developmental variant of the dorsum sellae was found in a patient undergoing evaluation for a suspected pituitary adenoma. An initial computerized tomography (CT) scan suggested a suprasellar mass; however, high-resolution CT with reformations clearly revealed the mass to be the pituitary gland, which was deformed and displaced upward by an osseous spine projecting from the dorsum sellae. The radiographic appearance and etiology of this anomaly are discussed. Neurosurgeons and neuroradiologists should be aware of this anomaly when evaluating a patient for pituitary adenoma.

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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.