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George T. Tindall

✓ This overview of neurosurgical practice examines patterns of case management, using several areas such as head injury, brain tumors, and the delivery of health care to illustrate the changes that have taken place over the past 40 years and the changes that might be expected in the next 40 years. The rapid pace of progress has indicated further exciting growth of this specialty into the 21st century; however, what remains constant is the dynamic character of the neurosurgeon. This view of the past and the possibilities for future innovation enables neurosurgeons of all generations to have a sense of pride in the achievements generated by their peers.

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Cerebral vasospasm following aneurysm rupture

A protocol for therapy and prophylaxis

Alan S. Fleischer and George T. Tindall

✓ A retrospective study was made of 195 patients who had ruptured intracranial aneurysms without significant intracerebral hematomas and who recovered to at least Grade III by Hunt and Hess' classification. The first 121 patients underwent aneurysm surgery 10 days to 2 weeks after subarachnoid hemorrhage (SAH) without repeat preoperative angiography and without special attention to volume replacement or avoidance of hypotension. Vasospasm resulted in cerebral ischemia in 15% of this group, more than half of these postoperatively, and was treated successfully in half the patients with a combination of aminophylline and isoproterenol. The later 74 patients were managed with aggressive maintenance of normal circulating blood volume and preoperative angiography at 2 weeks following SAH. If significant vasospasm persisted on angiography, surgery was delayed an additional week and, if spasm was still present then, aminophylline and isoproterenol were added prophylactically to aggressive volume replacement before surgery. In this second group of patients, the incidence of clinical vasospasm was essentially unchanged; however, it was almost completely limited to the preoperative period, and was more effectively treated with aminophylline and isoproterenol. Postoperative vasospasm was almost completely eliminated from the second group of patients.

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Reverse Insertion of Needle in Carotid Arteriography

A Method Recommended in Cases of Suspected Thrombosis of Internal Carotid Artery in the Neck

George T. Tindall and James R. Jackson

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Guy L. Odom, George T. Tindall, and Herbert T. Dukes

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George T. Tindall, C. Scott McLanahan, and James H. Christy

✓ The results of transsphenoidal microsurgery in treating 37 patients (30 women and seven men) with pituitary tumors associated with hyperprolactinemia are presented. Immediate (10-day) postoperative fasting prolactin levels were normal (< 25 ng/ml) in 19 of 26 patients whose preoperative prolactin level was < 200 ng/ml, and in only three of 11 patients in whom preoperative prolactin was > 200 ng/ml. Twelve of 13 patients with normal preoperative pituitary-target organ function maintained normal axes postoperatively. Thirteen other patients had preoperative deficiencies in one or more pituitary-target organ axes. Postoperatively, in these latter 13 patients, a pituitary-target organ axis that was deficient preoperatively returned to normal in six cases; there was no change in five, and there was impairment in another axis in four instances. Although gross total tumor removal was believed to be complete in 35 of 37 patients, serial postoperative prolactin determinations in four of these 35 patients indicate tumor regrowth. The authors conclude that transsphenoidal microsurgery is currently the operative procedure of choice for the majority of pituitary tumors associated with hyperprolactinemia.

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Daniel L. Barrow, Junichi Mizuno, and George T. Tindall

✓ The authors have reviewed the results of transsphenoidal microsurgical management in 69 patients with prolactin-secreting pituitary adenomas who had preoperative serum prolactin levels over 200 ng/ml. The patients were divided into three groups based on their preoperative serum prolactin levels: over 200 to 500 ng/ml (Group A); over 500 to 1000 ng/ml (Group B); and over 1000 ng/ml (Group C). The percentage of successful treatment (“control rate”) was 68%, 30%, and 14%, respectively, in these three groups of patients. Based on these results, the authors offer guidelines for the management of patients with prolactin-secreting pituitary adenomas associated with exceptionally high serum prolactin levels. The surgical control rate of 68% in Group A seems to justify surgery for these patients, while primary medical care with bromocriptine is recommended for most patients with serum prolactin levels over 500 ng/ml.

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James R. Jackson, George T. Tindall, and Blaine S. Nashold Jr.