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Irving S. Cooper and Gonzalo Bravo

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Gonzalo Bravo, Jesús Vaquero, Roberto Martínez and José Cabezudo

✓ A case of clinically unsuspected mesencephalic tuberculoma that was diagnosed at operation is presented. After intraoperative diagnosis, the surgical procedure was interrupted and specific treatment with tuberculostatic agents was started. The symptoms remitted totally in a few months. This conservative management is preferable to surgical removal when the diagnosis of brain-stem tuberculoma has been established.

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Alberto Portera-Sanchez, Gonzalo Bravo and Carlos Parera

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José García-Uría, Jose M. del Pozo and Gonzalo Bravo

✓ The authors have analyzed the results from 41 acromegalic patients who underwent transsphenoidal surgery. In 31 patients, postoperative growth hormone (GH) levels fell and remained below 10 ng/ml. This represents an endocrinological “cure” of 78%. In the remaining 10 cases, postoperative GH values have not stabilized below 10 ng/ml, although seven show some clinical improvement. The results were particularly good in those cases of localized adenomas, which allowed a selective removal while maintaining pituitary function within normal limits in 65.5% of cases. The postoperative GH level in this group fell and remained below 10 ng/ml in more than 90% of cases.

Four patients required reoperation to normalize the GH levels which had not been sufficiently modified after the first operation; only one of them remained with plasma GH levels above normal limits. There were no deaths in this series. Rhinorrhea occurred as a postsurgical complication in four cases. In three this disappeared with bed rest and lumbar drainage; in the other, surgical repair was necessary. The occurrence of surgical complications has decreased as our experience has increased, and the need for reoperation has been unusual after the first year of our study.

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Josè Garcìa-Uria, Guillermo Leunda, Rafael Carrillo and Gonzalo Bravo

✓ A retrospective study of the surgical results in 31 adult patients with syringomyelia associated with Arnold-Chiari malformation was carried out. The standard surgical procedure consisted of a posterior fossa craniectomy. The vallecula was opened in 28 patients, with plugging of the central canal in 19. In three patients, severe arachnoidal scarring was present, and dissection was not attempted. The postoperative follow-up period ranged from 5 to 10 years. More than half of the patients considered themselves improved by surgery; however, only five cases showed objective improvement. Despite the operation, six patients experienced progressive neurological deterioration.

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Roberto Martínez, Jesús Vaquero, José Cabezudo, Eduardo Areitio and Gonzalo Bravo

✓ Two cases of neurinomas of the jugular foramen in patients under 16 years of age are presented. Neurinomas of this location have not been previously reported in children.

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Empty sella and rhinorrhea

A report of eight treated cases

José García-Uría, Rafael Carrillo, Pilar Serrano and Gonzalo Bravo

✓ The association of an empty sella with rhinorrhea is an unusual finding. Of 29 cases of empty sella observed by the authors, eight underwent surgery for rhinorrhea. None of the patients showed clinical evidence of increased intracranial pressure or hydrocephalus. Seven were cases of primary empty sella, the eighth was an acromegalic patient, who had received radiotherapy 4 years before. Except for this patient, the others showed no clinical signs of a previous tumor. In the surgical treatment of these patients, the authors used both the transfrontal and transsphenoidal approaches. In spite of generally accepted good results following surgical closure of this type of fistula, four patients needed more than one operation. The fistula closed in only three of them; in the last patient rhinorrhea persisted after three operations.

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Juan J. López-Lozano, Gonzalo Bravo, Javier Abascal and the Clinica Puerta de Hierro Neural Transplantation Group

✓ The authors report results obtained in 20 severely affected patients with Parkinson's disease (Grade IV or V) who received an autotransplant of perfused adrenal medullary tissue. This study seems to indicate that these autoimplants can improve the parkinsonian symptomatology and induce amelioration in the patients' performance of routine activities. All the symptoms analyzed showed improvement, although it differed in intensity and time of onset. Moreover, this improvement was accompanied by a reduction in the daily intake of L-dopa, with discontinuance of dopamine agonists and amantadine.

A number of medical complications were encountered, including three deaths, probably related to performing abdominal surgery in seriously affected parkinsonian patients who were unable to tolerate the discontinuance of their medication. The transient psychiatric disorders observed appeared to be related to the postoperative dose of L-dopa and/or anticholinergic agents administered, and diminished or disappeared when the doses were reduced.

The reasons for improvement, which was bilateral, remain unknown, although one cause may be the surgical trauma (minicaudotomy) together with the implantation of adrenal medullary tissue, which may promote the sprouting of surviving dopaminergic fibers. Moreover, in this series, perfusion of adrenal medulla increased the capacity for revascularization of the tissue and may have reduced the damaging effects of warm ischemia on the cells. This, together with the existence of fenestrated vessels, could hypothetically have served as an access point for drugs, and if the implanted cells were viable, they might have served to store and manufacture different factors and/or transmitters. These results as well as those of other groups justify the development of a controlled international clinical trial.

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Jesús Vaquero, Rafael Carrillo, José Cabezudo, Guillermo Leunda, Francisco Villoria and Gonzalo Bravo

✓ Two cases of cavernous angiomas of the pineal region are presented. The possibility that a mass in the pineal region could be a cavernous angioma should be considered when deciding upon early surgery or a trial of radiotherapy.

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José M. Cabezudo, Carmelo Perez, Jesús Vaquero, Rafael Garcia-De-Sola and Gonzalo Bravo

✓ A case of craniopharyngioma associated with true precocious puberty is reported in a child operated on when she was 2 years and 8 months of age. Precocity was noted 10 months after operation and was fully documented 1 year later. A pneumoencephalogram showed a recurrence of tumor in the hypothalamic area. Hormonal therapy was instituted to stop sexual maturation. Reoperation was undertaken only when her visual symptoms reappeared. She received a postoperative course of radiotherapy. On last examination, she was neurologically well, and computerized tomography did not show further growth of the residual tumor. The diagnosis of precocious puberty and its etiology in this patient are discussed.