Nasal visual field loss with intracranial lesions of the optic nerve pathways.

Five patients developed nasal visual field defects as a result of involvement of the intracranial portion of the optic nerves. The cause in each patient, respectively, was as follows: (1) dolichoectatic carotid arteries, (2) optochiasmatic arachnoiditis, (3) meningioma of the olfactory groove, (4) pituitary apoplexy, and (5) pituitary chromophobe adenoma. The common factor in these cases was probably impaired circulation in the prechiasmal arterial anastomotic network. The nasal visual field loss present in these cases was characterized by a pattern similar to that seen in glaucoma but with impairment of visual acuity. The superior nasal visual field was usually normal and the lower temporal visual field often defective.

Spinal subdural hematoma associated with anticoagulant therapy in a patient with spinal meningioma.

A case of spontaneous subdural hematoma in the cervicothoracic region associated with a small meningioma in a patient on anticoagulant therapy is presented. The neurological complications of anticoagulant therapy are discussed briefly. Progressive neurological deterioration in a patient on anticoagulant therapy should prompt the performance of an emergency myelogram and a possible laminectomy in spite of the potential risks of these procedures. Intraspinal bleeding occurs more frequently in the form of an epidural hematoma, but the clinical presentation may not allow differentiation from a subdural hematoma. The possible causal relation between the asymptomatic spinal meningioma, the anticoagulant therapy, and the formation of the subdural hematoma is discussed.

Technical note: the removal of free peritoneal catheters in the revision of ventriculoperitoneal shunts.

The widespread usage of ventriculoperitoneal shunts has been followed by a plethora of complications. One of these complications, the separation and migration of the distal tubing to be free intraperitoneally, has been relatively disregarded in the literature both as a phenomenon and as to treatment. We present our experience with nine such cases, four involving two peritoneal catheters. Unless contraindicated, we think that such tubing should be removed during shunt revision by single digit blind palpation of the tubing. No complications arose from this procedure, and the postoperative course was uneventful. The indications for this procedure are discussed in relation to the relevant literature.

Regional cerebral blood flow in the acute stage of experimentally induced subarachnoid hemorrhage.

Subarachnoid hemorrhage (SAH) was induced in 13 adult mongrel cats by a slow injection of fresh autogenous blood into the cisterna magna. Serial determinations of regional cerebral blood flow (rCBF) in the cortex and deep-seated areas (internal capsule, thalamus, and caudate nucleus) were made during the following 2 hours, while intracranial pressure (ICP) was maintained at normal values. A decrease in rCBF was observed in all the areas examined. This reduction followed a characteristic triphasic pattern with an initial steep decline immediately after the SAH. The clinical implications of these findings are discussed.

Intracranial pressure monitoring after elective intracranial surgery. A retrospective study of 514 consecutive patients.

A retrospective study of 514 consecutive patients whose intracranial pressure (ICP) was monitored after elective supratentorial or infratentorial surgery is reported. Of the 412 patients operated on in the supratentorial region, 76 (18.4%) had a postoperative sustained ICP elevation exceeding 20 torr. Abnormally high ICP occurred after 13 (12.7%) of the 102 infratentorial operations. Risk factors for postoperative ICP elevation were: resection of glioblastoma in 27.2% of cases, repeat surgery in 42.9% of cases, and protracted surgery (greater than 6 hours) in 41.7% of cases. Of the 89 patients with elevated ICP, 47 (52.8%) had an associated clinical deterioration. In 19 of these, the rise in ICP occurred before this deterioration was noticed, leading as a rule to quick diagnostic and management response. In eight patients clinical deterioration was noticed before the rise in ICP, and in 20 it happened simultaneously. The higher the level of ICP elevation, the greater were the chances of associated deterioration. The most common findings on computerized tomography scanning in 35 of 89 patients with elevated ICP were brain edema (19 cases) and bleeding in the tumor bed (15 cases). Mannitol, thiopental, additional hyperventilation, and reintubation (in patients who were previously extubated) were used to reduce ICP, in addition to surgical decompression whenever indicated. Thirteen patients with raised ICP and clinical deterioration underwent reoperation. The postoperative infection rate was 1.2% (six cases). In only one patient could infection be attributed to ICP monitoring. It was concluded that ICP monitoring is advantageous in the immediate postoperative management after elective intracranial surgery and is almost risk-free. It should therefore be used liberally, especially when risk factors for ICP elevation can be identified prior to the end of surgery.

Radiation-induced cerebral meningioma: a recognizable entity.

The authors retrospectively analyzed the clinical and histopathological findings in 201 patients with intracranial meningiomas operated on in the period 1978 to 1982. Forty-three of the patients (21.4%) had at some previous time received radiation treatment to their scalp, the majority for tinea capitis. The findings in these 43 irradiated patients were compared with those in the 158 non-irradiated patients. Several distinctive clinical and histological features were identified in the irradiated group, which suggest that radiation-induced meningiomas can be defined as a separate nosological subgroup. The use of irradiation in large numbers of children with tinea capitis in the era prior to the availability of griseofulvin may be responsible for a significantly increased incidence of intracranial meningiomas.

Conus ganglioglioma in a 2 1/2-year-old boy. Case report.

Gangliogliomas are rare tumors, primarily seen in patients under the age of 30 years. They occur least commonly in the spinal cord. This report presents a 2 1/2-year-old boy who harbored an intramedullary conus tumor with the light microscopic appearance of a ganglioglioma. The neurobiological behavior of this tumor is yet to be determined.

Anomalous anterior inferior cerebellar artery simulating intracanalicular acoustic nerve tumor.

A case is described of tinnitus and hearing loss associated with widening of the left internal meatal canal. Surgical exploration revealed a vascular loop adherent to the VIIIth nerve. Release of the adhesions was followed by cessation of the tinnitus and improvement in hearing.

Neurosurgical management of the elderly patient.

The records of 59 patients above the age of 65 operated on for diverse neurosurgical problems between January 1975 and September 1976 were reviewed. It was found that in only about half of the cases was the referral diagnosis correct. Most of the referred patients diagnosed as cerebrovascular accident or senile dementia were found to be suffering from intracranial space-occupying lesions or normal pressure hydrocephalus. Post-operatively there was a significant improvement in 48% of this group of geriatric patients, with no change in 23% and a poor result in 29%. when the data on patients with benign lesions were considered separately, it was found that in this group there was a significant improvement in 60%, with no change in 23% and a poor result in only 17%.

Extraosseous extradural tuberculous granuloma of the cervical spine: a case report and review of intraspinal granulomatous infections.

A 70-year-old woman presented with a 5-month history of tetraparesis. Her cerebrospinal fluid and roentgenographic examination of the cervical spine were both normal. Myelography showed an extradural type of spinal cord compression at the C7 level. At operation, an extraosseous extradural mass of granulation tissue was removed, which proved on histological and bacteriological examination to be a tuberculous granuloma.

Intra-operative computerized axial tomography.

A case is presented in which the entire surgical procedure for a recurrent brain glioma was carried out on the computerized axial tomography (CAT) table. Repeated intra-operative CAT scans provided vital information as to the extent of the tumor. Using this method there was no remnant of tumor tissue detectable on the CAT scan at the end of the operation.

Neurosurgical management of single brain metastasis.

A series of 74 consecutive cases undergoing craniotomy for single brain metastasis in the Beilinson Medical Center between October 1975 and October 1981 were reviewed. All patients underwent radiation therapy after craniotomy. The most common metastasis was that of unknown origin (35%), followed by lung (24%) and breast (16%). Overall median survival after craniotomy was 6.6 months. Overall 1- and 2-year survival rates were 30 and 15%, respectively. Operative mortality (30 days) was 15%. For the patients with metastases to the lung, median survival was 7.5 months and 1-year survival rate was 33%. It appears from this report that two dominant factors affect the prognosis of these patients. The first is the long latent interval (time between diagnosis of primary tumor and detection of metastasis). The second is the location of the metastasis; those with lesions in the cerebral hemispheres had a far better outcome than those with cerebellar lesions (p less than 0.0001).

[Transsphenoidal approach to pituitary tumors].

Over the past 2 years 44 patients with pituitary tumors underwent transsphenoidal resection. A specialized team performed the procedure so as to optimize the results. 20 patients had nonsecreting macroadenomas and 24 suffered from hormone-secreting adenomas. All who presented with visual deterioration had improved vision after operation. Only 3 developed new endocrine deficits following surgery, while in 4 with invasive prolactinoma vision improved following surgery but hyperprolactinemia persisted. 8 of 11 patients with acromegaly were cured, while in the other 3, who had invasive tumors, growth hormone decreased significantly. 8 of 9 patients with Cushing's disease were cured. In only 1 case did a permanent complication, diabetes insipidus, occur; there was no mortality. These results demonstrate the efficacy of the procedure and the advantages of a dedicated team.