Can acromegaly be cured? A twenty year review

A retrospective review was performed on 41 patients under going transphenoidal surgery for treatment of acromegaly between 1977 and 1997. The mean age was 16.9 years (range 8-67). There were 28 (68.3 percent) male subjects. The mean follow-up was 4.4 years (range 0-17 years). 14 (34.1 percent) patients underwent postoperative adjuvant treatment with radiotherapy, bromocriptine or both. Three (7.3 percent) patients required a second transphenoidal procedure for persistent disease. Postoperatively 27 (65.9 percent) patients (3 had unknown postoperative growth hormone levels) had normalisation of growth hormone (GH) levels (<5 ng/ml). Of these, 5(20.8 percent) of 24 patients (excluding 3 who were lost to follow-up) had biochemical recurrence of disease. This yields surgical cure in 22 (57.9 percent) of 38 patients (excluding the three who were lost to follow-up). Of the fourteen patients who underwent adjuvant treatment 6 (42.3 percent) attained GH levels <5 ng/ml. Considering all treatments combined, 26 (74.3 percent) of 35 patients (6 lost to follow-up) achieved biochemical cure. These results compare favourably with previously reported cure rates in the literature. Transphenoidal surgery is the initial treatment of choice for acromegaly. An overview of the management of this fascinating neuroendocrine disorder will be presented.(AU)

Occult vascular malformations of the brain - abstract

Intracranial vascular malformations have been classically divided into four groups: arterio-venous malformations (AVMs), cavernous angiomas, venous angiomas and capillary telangiectasias. The AVMs are the best documented of these lesions and are readily characterized with cerebral angiography. The other malformations have previously been rarely diagnosed during life as they are usually not seen on cerebral angiograms. Recently, however, with the use of advanced neuro-imaging techniques these lesions have been increasingly recognized in association with intracranial haemorrhage and epilepsy. Cavernous angiomas, in particular, have a characteristic appearance on MRI scans. This paper will define these "occult" vascular malformations of the brain, their incidence, clinical presentation, natural history and issues related to management. The experience of the Department of Neurosurgery and the Division of Neuro-Radiology at the Victoria General Hospital in Halifax during 1990 will be summarized. Of over 1,200 consecutive cranial MRI scans, 18 cases of cavernous angiomas were encountered. Some of these caused intracerebral haemorrhage and others were seen in patients with complex countered. Some of these caused intracerebral haemorrhage and others were seen in patients with complex partial seizures. A surprising number were multiple and familial in occurrence. These lesions can present in the brain stem or spinal cord thus mimicking multiple sclerosis. The majority of them are asymptomatic and are incidental findings. Venous angiomas are, in fact, hamartomas and rarely lead to symptoms; because they drain normal neural tissue they cannot be sacrificed without risk of significant neurological sequelae. The emerging literature on angiographically occult vascular malformations of the brain will be reviewed (AU)

A comparison of early versus delayed surgery for ruptured intracranial aneurysms - abstract

The timing of surgical clipping for ruptured intracranial aneurysms has been a subject of debate for many years. Initial attempts at early surgery (within 24-72 hours) had disastrous results and led to the standard practice of delaying surgery for 7-10 days. The use of antifibrinolytic agents during this waiting period was shown to decrease the incidence of rebleeding but also seemed to cause increased frequency of ischaemic deficits and hydrocephalus. With the refinement of microneurosurgical techniques, early surgery for intracranial aneurysms underwent a rebirth in many centres over the last few years. This paper presents the experiences with aneurysm surgery at the Neurosurgical Unit Halifax, Nova Scotia over the four-year period 1984-1987. Ruptured aneurysms lead to subarachnoid haemorrhage in over 50 percent of the cases, arteriovenous malformations comprised 10 percent, and subarachnoid haemorrhage with normal angiography 25 percent of the total cases. During the period under review 25 patients presented with ruptured vertebrobasilar aneurysms and 211 patients presented with ruptured supratentorial aneurysms. The latter group form the basis for comparing results of early vs. delayed clipping for ruptured aneurysms. Despite the fact that the series comprised a consecutive, unmatched group of patients without any attempt at randomization, there were striking similarities in the mean ages, sex distribution and distribution of aneurysms at the various sites in the two groups being compared. Sixty-nine patients presented in good clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades I and II). Twenty-nine patients (mean age 44.5 years) underwent early surgery and 40 (mean age 45 years) had delayed surgery. Despite the higher rebleed rate in the delayed group (12.5 percent vs. 0 percent) there was no statistically significant difference in the eventual outcome between the two groups (mortality rate and the quality of survival). Eighty-five of the patients had excellent outcomes. However, the length of hospital stay was significantly shorter in the patients operated on early (17 days vs. 30 days). Symptomatic vasospasm (40 percent) and hydrocephalus (10 percent) occurred with similar frequencies in both groups. Fifty-two patients presented in poor clinical condition after aneurysmal subarachnoid haemorrhage (Hunt & Hess Grades III and IV). Twenty-three patients (mean age 49.5 years) had early surgery and 29 patients (mean age 53 years) had delayed surgery. The mortality rate (approximately 25 percent) was similar in both groups. Rebleeding was the culprit in the delayed group (24 percent) whereas the surgical mortality was 26 percent in the early group. There was an equally high incidence of symptomatic vasospasm and hydrocephalus in both groups. The quality of survival was better in the early group but achieved statistical significance only in the number of patients making "excellent" recoveries (43 percent vs. 17 percent). The numbers of patients however were small. Aggressive treatment of acute hydrocephalus by ventricular drainage played a large part in improving the clinical status prior to surgery in the early group. As with previous studies (including a large co-operative series), we have been unable to show a really convincing advantage of early aneurysm surgery over delayed surgery if mortality rate and quality of survival are used as the basis of comparison. Clearly, a large scale randomized trial would have to be launched to answer this question conclusively. To answer the criticisms of ardent proponents of delayed surgery, however, we have confirmed that early surgery provides at least as good results. We have not found early surgery technically more difficult. It allows removal of large collections of subarachnoid blood and aggressive treatment of cerebral vasospasm and hydrocephalus and at the same time prevents rebleeding from the aneurysm. We feel early surgery will become more frequently used as newer methods of preventing cerebral vasospasm are discovered. The implications of our experiences to the situations that obtain in the Caribbean will be discussed (AU)

The incidence and pathology of breast cancer in Jamaica - abstract

Figures accumulated in the Jamaica Cancer Registry for the period 1958-1968 show that this cancer ranks second among all malignancies in females. The incidence is higher than that in Africa and in other underprivileged communities. The histological sub-division of these cancers will also be presented. Further work in Jamaica - and possibly other West Indian territories - should be undertaken to study possible explanations for the high incidence observed (AU)