Basilar artery aneurysm simulating pheochromocytoma.

Stimulation of sympathetic vasomotor centers by lesions in the posterior fossa has been described in humans and animals. We describe a patient with a pheochromocytoma-like syndrome and a basilar artery aneurysm. Repair of the aneurysm was followed by disappearance of hypertensive episodes. Posterior fossa lesions must be considered in patients with hypertensive crises when diagnostic procedures do not indicate an adrenal or extra-adrenal pheochromocytoma.

Pseudogrowth in skull fractures of childhood.

We report two cases in which linear fractures of the parietal bone in infants healed spontaneously after initial enlargement suggested growth of the fracture line. We suggest the term "pseudogrowing skull fracture" to indicate this phenomenon. Growing skull fractures are best managed by early surgical correction. It is, therefore, important to recognize that some fractures may heal after an initial period of growth.

Intra-operative evoked potential studies of newborn infants with myelomeningocele.

Somatosensory evoked potentials were studied in seven infants during surgery for repair of thoraco-lumbar myelomeningocele. All were operated on during the first 24 hours of life. Because anaesthetics were known to suppress somatosensory evoked potentials, narcotics and muscle relaxants were used for anesthesia. Before surgical dissection, stimulation of median nerves evoked cortical responses in five of the seven patients. After dissection, evoked potentials could be retrieved from the neural plaque with peroneal nerve stimulation in five of the seven infants. Stimulation of the neural plaque produced cortical responses in five of the seven but cortical responses with long latencies could be obtained from peroneal nerve stimulation in only two of the seven patients. In two patients lumbar-root stimulation distal to the plaque produced low-amplitude and delayed-latency cortical responses. These findings indicate that the distal nerves and neural plaque may have intact afferent connections with the cortex: therefore at surgical repair the neural plaque has been meticulously preserved.

Arteriovenous malformations of the spinal cord in children.

Spinal arterivenous malformations occur in the pediatric age range more commonly than previously acknowledged. An analysis of 64 cases with onset under 18 years of age demonstrates pain to be the most common first symptom. A long delay to diagnosis permits development of significant paresis or plegia in the majority. Correctly performed myelography (with supine views) provided the diagnosis in 60%. A radical microsurgical excision appears to offer the best long-term results.

External drainage for ventricular infection following cerebrospinal fluid shunts.

57 children with shunt-related ventricular infection were treated with external ventricular drainage and a combination of systemic and intraventricular antibiotics. For persistent infection or inadequate drainage volume the external ventricular drain was promptly changed. Cerebrospinal fluid cultures of 54 (95%) of the children became sterile within an average of 5.1 days. As soon as three consecutive 48-hour cultures of the cerebrospinal fluid were negative, the external ventricular drainage was removed and a new ventriculoperitoneal shunt was inserted. Provided that three consecutive 48-hour cultures of the cerebrospinal fluid were negative at the time of reinstitution of ventriculoperitoneal shunting, low cerebrospinal fluid glucose readings were not associated with any greater risk of recurrent infection than following primary ventriculoperitoneal shunting.

Biopsy of pediatric brain stem tumors.

26 patients, average age of 7.3 years, has biopsies of a brain stem tumor. 62% of the patients presented with hydrocephalus, and ventriculoperitoneal shunts were placed 7-10 days prior to biopsy. The midbrain was biopsied 13 times, the pons 3 and the medulla 12 times. Tissue for histopathologic examination was obtained at each operation and demonstrated astrocytoma in 13 patients, glioblastoma in 6, 'no tumor seen' in 5 and ependymoma in 2. Astrocytomas were usually located in the upper brain stem, and all of the glioblastomas were located in the medulla. The operative mortality was zero, and the morbidity was largely related to increased cranial nerve deficit. All the astrocytoma patients were treated with radiation only; whereas, 4 patients with glioblastoma were treated with vincristine, CCNU and methylprednisone in addition to radiation as described by the Children's Cancer Study Group (CCG-944). 3 patients with 'no tumor' were not treated and are alive and well 15-41 months following operation. 2 patients with no tumor were treated, one as a glioblastoma multiforme, subsequently verified at postmortem examination, and one as a midbrain astrocytoma. 1 patient with astrocytoma died 3 months following operation, all the remainder are living and well 4-51 months following operation. Irrespective of the treatment, all 7 patients with glioblastoma expired within 9 months of diagnosis. The prognosis for survival for patients with brain stem astrocytoma is superior to those with glioblastoma multiforme. Specific histopathologic correlation with clinical management may lead to improved and prolonged survival for patients with brain stem glioma.

Calcified intramedullary aneurysm in spinal angioma.

A case of a calcified intramedlllary aneurysm in a spinal angioma is presented. The value of preoperative angiography in the evaluation of intraspinal calcifications is discussed.

Dermatomal somatosensory evoked potentials in children with myelomeningocele.

Evoked responses were obtained from electrical stimulation of dermatomes representing individual lumbar and sacral roots. Normal ranges of latency have been established for adults, but have not been extended to children at this time. DSSEPs can be utilized, however, to sequentially follow lumbo-sacral cord function in individual children at risk of progressive myelopathy.

Myelography in patients with medulloblastoma.

Unsuspected metastatic medulloblastoma involving the spinal cord was detected by myelography in 2 of 3 patients with newly diagnosed medulloblastoma. Myelography revealed unsuspected spinal cord metastases in an additional patient with recurrent medulloblastoma in the posterior fossa. The authors suggest that myelography be performed prior to radiotherapy in all patients with either primary medulloblastoma or recurrence in the posterior fossa.

Tethered spinal cord following meningomyelocele repair.

Of 16 consecutive patients with tethered spinal cord studied, most had undergone repair of a meningomyelocele. All were evaluated using somatosensory evoked potentials at 6 to 12-month intervals. Other possibilities include tethered filum terminale, lipomeningocele, membrana reuniens, and miscellaneous conditions (diastematomyelia, neurenteric cysts, etc.). Metrizamide myelography with polytomography was superior to gas myelography in showing a low-lying cord, obtuse nerve root angles, and a thin subarachnoid space between the cord and the dorsal meninges cephalad to the tether. Surgery is generally helpful in these patients.