Erico R. Cardoso

Pituitary Apoplexy: A Review

&NA; The authors present a critical review of the literature on the hemorrhagic complications of pituitary adenomas, especially those leading to apoplexy. They emphasize the distinction between pituitary apoplexy, hemorrhages leading to sudden endocrine alterations, and asymptomatic hemorrhages. Moreover, they speculate upon the possible pathophysiology of pituitary apoplexy and its predisposing factors. The clinical presentation, natural history, radiological findings, and differential diagnosis are also discussed. Finally, the historical evolution of the treatment of pituitary apoplexy is reviewed, with emphasis on the surgical treatment. (Neurosurgery 14:363‐373, 1984)

Hereditary hydrocephalus in laboratory animals and humans

Cerebral ventricle dilatation secondary to disturbed flow of CSF has been observed as an inheritable trait in a variety of laboratory animals as well as in humans. In few groups, however, has the neuropathology been adequately elucidated. In most cases, defective development of the cerebral aqueduct or of the subarachnoid space has been observed. Further study is needed to understand the developmental mechanisms that fail and give rise to hydrocephalus in such models.

Pituitary Apoplexy and Vasospasm

Two cases of pituitary apoplexy complicated by cerebral vasospasm are described. They emphasize the importance of angiography in the investigation of a protracted clinical course after pituitary apoplexy. The pathophysiology of postapoplectic vasospasm is discussed.

Percutaneous tumor curettage and interstitial delivery of samarium-153 coupled with kyphoplasty for treatment of vertebral metastases.

OBJECT The object of this study was to investigate the use of a minimally invasive technique for treating metastatic tumors of the vertebral body, aimed at relieving pain, preventing further tumor growth, and minimizing the adverse effects of systemic use of samarium-153 ((153)Sm). METHODS The procedure is performed in the same fashion as a kyphoplasty, using a unilateral extrapedicular approach under local anesthesia/mild general sedation, with the patient in the lateral decubitus position. The tumor is accessed as in a standard kyphoplasty. The side is chosen according to the location of the metastasis. Prior to inflation of the balloon the tumor is debulked by percutaneous curettage. Balloon inflation is carried out as per standard kyphoplasty in an attempt to create a larger space and reduce a possible kyphotic deformity. Three mCi of (153)Sm-EDTMP (ethylenediaminetetramethylenephosphonic acid) is then mixed with bone cement (polymethylmethacrylate) and injected into the void created by the balloon tamp. RESULTS Twenty-four procedures were performed in 19 patients. There was reliable and reproducible delivery of the radiolabeled (153)Sm-EDTMP to the metastatic site, without spillage. The procedure was safe. There were no procedure-related complications. There was no hematological toxicity with the low doses of (153)Sm used. Pain improved in all patients. The long-term results related to tumor control continue to be investigated. CONCLUSIONS Combined percutaneous debulking of confined vertebral metastases and administration of local (153)Sm is feasible and safe. Furthermore, this technique leads to immediate relief of cancer-related pain and may help prevent or slow down the progression of vertebral metastatic tumors.

Quantification of abnormal intracranial pressure waves and isotope cisternography for diagnosis of occult communicating hydrocephalus.

Nineteen consecutive patients with suspected occult communicating hydrocephalus were investigated by means of clinical evaluation, neuropsychological testing, isotope cisternography, computed tomography scanning, and continuous intracranial pressure monitoring. Semi-quantitative grading systems were used in the evaluation of the clinical, neuropsychological, and cisternographic assessments. Clinical examination, neuropsychological testing, and computed tomography scanning were repeated 3 months after ventriculoperitoneal shunting. All patients showed abnormal intracranial pressure waves and all improved after shunting. There was close correlation between number, peak, and pulse pressures of B waves and the mean intracranial pressure. However, quantification of B waves by means of number, frequency, and amplitude did not help in predicting the degree of clinical improvement postshunting. The most sensitive predictor of favorable response to shunting was enlargement of the temporal horns on computed tomography scan. Furthermore, the size of temporal horns correlated with mean intracranial pressure. There was no correlation between abnormalities on isotope cisternography and clinical improvement.

Age-dependent changes of cerebral ventricular size

SummaryThe age distributions of communicating hydrocephalus (CH), pseudotumour cerebri (PC) slit-ventricle syndrome (SVS), and chronic subdural haematomas (CSH) were reviewed in the medical literature.An age-related incidence was found: CH and CSH predominated in neonates less than 2 years and adults older than 55 years, while PC and SVS occurred mainly in older children and young adults. The latter two patient groups seem to show a greater resistance to ventricular dilatation in the presence of decreased CSF absorption. This may be related to larger volume and state of maturity of the cerebrum. On the other hand, neonates and the elderly more readily develop enlarged ventricles, in association with impairment of CSF absorption, or subdural fluid collections.Factors including status of cranial sutures, cerebral atrophy, cerebral water content, degree of cerebral myelination, and glial cell composition, may contribute to the age-related incidence of the four disorders investigated. Similarly, the development of ventriculomegaly may depend upon cerebral elastic properties besides the pri mary disturbance of CSF dynamics.The authors postulate that the size of cerebral ventricles in disorders of the cerebrospinal fluid (CSF) absorption is related to the elastic properties and volume of the brain. Furthermore, cerebral volume and elastic properties may also contribute to the age distribution of chronic subdural haematomas (CSH).

Long-term multi-dimensional outcome following isolated traumatic brain injuries and traumatic brain injuries associated with multiple trauma

We retrospectively investigated long-term, multi-dimensional quality-of-life outcomes in 68 male patients who suffered pure head injuries and 63 male head-injured patients with associated multiple trauma. Results indicated that patients sustaining associated multiple trauma were significantly younger and more deeply comatose on admission. Trends were found to suggest that patients sustaining associated multiple trauma also remain in coma longer, and experience more difficulties in social interaction and overall psychosocial functioning, but less difficulties in mobility compared with pure-head-injured patients. These findings should be taken into account in the evaluation of results of treatment as well as in the planning and allocation of resources for head-injured patients.

Age-related changes of cerebral ventricular size

SummaryThirty-one hydrocephalic patients were investigated prospectively by means of computed tomographic scan performed prior to and one week after cerebrospinal fluid (CSF) shunting. Planimetric measurements of the size of the cerebral ventricles were compared before and after shunting. Children under two years of age and elderly patients showed significantly less reduction of ventricular size (8.5±6.3% and 9.7±3.5% respectively) than older children and young adults (61.2±5.2%). The degree of reduction of ventricular size did not correlate with pre-operative size of ventricles, duration of disease, or clinical improvement.These findings suggest that reduction of ventricular size following CSF shunting is related to age. We postulate that the size of cerebral ventricles in hydrocephalic patients is not exclusively related to CSF dynamics, but also depends upon the intrinsic elastic properties of the cerebral parenchyma which vary with age.

Age-dependent Changes of Cerebral Ventricular Size, Part I: Review of intracranial fluid collections

The age distributions of communicating hydrocephalus (CH), pseudotumour cerebri (PC) slit-ventricle syndrome (SVS), and chronic subdural haematomas (CSH) were reviewed in the medical literature. An age-related incidence was found: CH and CSH predominated in neonates less than 2 years and adults older than 55 years, while PC and SVS occurred mainly in older children and young adults. The latter two patient groups seem to show a greater resistance to ventricular dilatation in the presence of decreased CSF absorption. This may be related to larger volume and state of maturity of the cerebrum. On the other hand, neonates and the elderly more readily develop enlarged ventricles, in association with impairment of CSF absorption, or subdural fluid collections. Factors including status of cranial sutures, cerebral atrophy, cerebral water content, degree of cerebral myelination, and glial cell composition, may contribute to the age-related incidence of the four disorders investigated. Similarly, the development of ventriculomegaly may depend upon cerebral elastic properties besides the pri mary disturbance of CSF dynamics. The authors postulate that the size of cerebral ventricles in disorders of the cerebrospinal fluid (CSF) absorption is related to the elastic properties and volume of the brain. Furthermore, cerebral volume and elastic properties may also contribute to the age distribution of chronic subdural haematomas (CSH).

Age-Related Changes of Cerebral Ventricular Size. Part II: Normalization of ventricular size following shunting

Thirty-one hydrocephalic patients were investigated prospectively by means of computed tomographic scan performed prior to and one week after cerebrospinal fluid (CSF) shunting. Planimetric measurements of the size of the cerebral ventricles were compared before and after shunting. Children under two years of age and elderly patients showed significantly less reduction of ventricular size (8.5 +/- 6.3% and 9.7 +/- 3.5% respectively) than older children and young adults (61.2 +/- 5.2%). The degree of reduction of ventricular size did not correlate with pre-operative size of ventricles, duration of disease, or clinical improvement. These findings suggest that reduction of ventricular size following CSF shunting is related to age. We postulate that the size of cerebral ventricles in hydrocephalic patients is not exclusively related to CSF dynamics, but also depends upon the intrinsic elastic properties of the cerebral parenchyma which vary with age.