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Pathophysiology of Spinal Cord Injury

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Neurilemmoma of the fourth cranial nerve

Case report

James E. Boggan, Mark L. Rosenblum, and Charles B. Wilson

✓ A tumor of the trochlear nerve sheath with an unusual but diagnostic presentation is described. The rarity of reported cases may reflect failure to differentiate tumors originating from the trochlear and trigeminal nerves.

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Ventriculoperitoneal shunt infection with Mycobacterium fortuitum: a rare offending organism

Case report

Gilbert Cadena, Jean Wiedeman, and James E. Boggan

Postsurgical infection is one of the greatest potential morbidities of ventriculoperitoneal shunt surgery. The majority of infections can be linked to contamination with skin flora at the time of surgery, a phenomenon that has been well described. However, there is a paucity of literature regarding infection with nontuberculous mycobacteria. The authors report a case of postoperative ventriculoperitoneal shunt infection with Mycobacterium fortuitum and review the available neurosurgical literature and treatment strategies.

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Effect of hematoporphyrin derivative photoradiation therapy on survival in the rat 9L gliosarcoma brain-tumor model

James E. Boggan, Catherine Bolger, and Michael S. B. Edwards

✓ Intracerebral tumors were produced in 99 rats by stereotaxic implantation of 9L gliosarcoma brain-tumor cells. Hematoporphyrin derivative (HPD), 10 or 20 mg/kg, was administered as an intravenous bolus 24 or 48 hours before irradiation of the tumor region with light from an argon pumped-dye laser (632 nm). Laser light, at a dose of 30, 60, or 200 joules/sq cm, was delivered through a craniectomy 10 or 13 days after tumor implantation. Survival times were significantly prolonged in rats exposed to laser light at a dose of 200 joules/sq cm 24 hours after administration of HPD, 20 mg/kg.

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Transsphenoidal microsurgical removal of growth hormone-secreting pituitary adenomas

A review of 137 cases

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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Intrasellar epidermoid cyst

Case report

James E. Boggan, Richard L. Davis, Greg Zorman, and Charles B. Wilson

✓ The authors report the uncomplicated removal of an intrasellar epidermoid cyst that on presentation mimicked a pituitary adenoma. Current controversies regarding the differentiation of this cyst from other cystic lesions of the sellar region are reviewed.

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Computerized tomography of a sellar spine

Case report

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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Lasers in Neurological Surgery

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Transsphenoidal microsurgical management of Cushing's disease

Report of 100 cases

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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The laser in neurological surgery

Michael S. B. Edwards, James E. Boggan, and Terry A. Fuller

✓ The use of lasers in neurosurgical procedures has received a great deal of attention recently. Surgical use of lasers has been viewed with suspicion and skepticism, probably because of (justified) apprehensions about the misuse of lasers in early work and about the ways in which laser light affects tissues, and a lack of understanding of the basic physics and practical operation of lasers. The authors review the physics, biophysics, experimental findings, and operative use of lasers in current neurosurgical practice, and discuss briefly their experience gained in over 150 neurosurgical procedures using the carbon dioxide and argon surgical lasers.