Frameless stereotaxy for transsphenoidal surgery.

Objective: To evaluate the utility of performing transsphenoidal surgery with computer-assisted image guidance.

Methods: Thirty-seven patients underwent transsphenoidal surgery in which a frameless stereotactic system was used to confirm the trajectory to the sella and to locate the anatomic midline. This technique was compared with our standard method of using an image intensifier to confirm the approach (n = 43).

Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing's disease.

Object: Transsphenoidal surgery is the usual treatment of choice for adrenocorticotropic hormone-secreting pituitary adenomas associated with Cushing's disease. In this paper the authors investigate the complications of transsphenoidal surgery in the treatment of a contemporary series of patients with Cushing's disease.

Methods: Between January 1992 and December 1997, 105 patients with Cushing's disease underwent transsphenoidal surgery at the University of Virginia Health Sciences Center.

Optimizing accuracy in magnetic resonance imaging-guided stereotaxis: a technique with validation based on the anterior commissure-posterior commissure line.

Object: Some of the earliest successful frame-based stereotactic interventions directed toward the thalamus and basal ganglia depended on identifying the anterior commissure (AC) and posterior commissure (PC) in a sagittal ventriculogram and defining the intercommissural line that connects them in the midsagittal plane. The AC-PC line became the essential landmark for the localization of neuroanatomical targets in the basal ganglia and diencephalon and for relating them to stereotactic atlases. Stereotactic/functional neurosurgery has come to rely increasingly on magnetic resonance (MR) imaging guidance, and methods for accurately determining the AC-PC line on MR imaging are being developed.

Pituitary surgery.

Surgical management of pituitary adenomas continues to be a safe and effective method for treating many patients with these lesions. The goal of overall management should be to provide the patient with the most effective means of long-term control of this benign but potentially disabling disease. Currently, surgery has a significant role.

Radiosurgery for pituitary tumors and craniopharyngiomas.

Standard techniques of conventional radiation therapy have been used for many years to treat pituitary adenomas and craniopharyngiomas. These techniques are not always effective and carry with them morbidity in the form of damage to the normal pituitary gland, damage to the hypothalamus, the potential of damage to the visual system and to intellectual functions of the brain and a small but real risk of the development of secondary malignancies. In an effort to avoid these complications and to provide more effective adjunctive radiation therapy, techniques of stereotactic delivery of high-dose radiation to the pituitary region have been developed, known as radiosurgery.

Third ventricular lesion masquerading as suprasellar disease.

We discuss the case of a patient who presented with a bitemporal visual field disturbance thought to arise from chiasmatic compression secondary to a suprasellar mass. The patient was ultimately diagnosed with medulloblastoma with diffuse intraventricular disease. Careful review of magnetic resonance (MR) findings in this case demonstrate the apparent suprasellar mass to be within the suprachiasmatic recess of the third ventricle.

Small cell lung carcinoma causing epidural hematoma: case report.

Background: Epidural hematoma usually stems from trauma, yet it may occur from other etiologies, including neoplasms. We present a case of small cell lung carcinoma with focal hemorrhagic central nervous system metastasis producing an epidural hematoma, and review the associated literature.

Clinical Presentation: A 67-year-old man was undergoing chemotherapy for small cell carcinoma of the lung.

Brain tumor survival: results from the National Cancer Data Base.

Hospital-based data reported to the National Cancer Data Base (NCDB) were available for over 60,000 patients with a primary brain tumor diagnosed from 1985-1988 and 1990-1992. The most common histologies were glioblastomas, astrocytomas and meningiomas. Five-year survival rates for these tumors were 2%, 30% and 70% respectively.

A phase I-II trial of lovastatin for anaplastic astrocytoma and glioblastoma multiforme.

Malignant gliomas are thought to be highly dependent on the mevalonate pathway for cell growth. Lovastatin, a cholesterol-lowering drug, inhibits not only the rate-limiting step in the mevalonate pathway (hepatic hydroxymethyl glutaryl coenzyme A reductase), but also the prenylation of several key regulatory proteins including ras and the small guanosine triphosphate binding proteins. Therefore, from August 1994 through March 1996, 18 patients with either anaplastic glioma or glioblastoma multiforme were entered into a trial testing the safety of high-dose lovastatin with or without radiation.

Growth hormone secretagogue receptor expression in human pituitary tumors.

The GH secretagogue (GHS) receptor (GHS-R) has been characterized and cloned. It is a member of a family of seven transmembrane receptors and is closely related to the neurotensin and TRH receptors. To determine the expression of this receptor in normal anterior pituitary and in 24 human pituitary adenomas, we analyzed GHS-R messenger ribonucleic acid (mRNA) using a RT-PCR assay.

Central nervous system tumors: what have we learned and where are we heading?

Molecular biology, laboratory and human studies, and clinical trials have furthered knowledge about the pathogenesis, behavior, and treatment of brain tumors. Technical advances such as functional imaging, computer-guided stereotactic surgical devices, and radiosurgery have improved treatment. The future promises continued progress, with the exploration of areas such as new chemotherapy delivery systems, gene therapy, boron capture therapy, and photodynamic therapy.

A neurosurgical way of life. The 1998 presidential address.

The author provides a review of the relationship between Harvey Cushing and William Osler. Dr. Osler's influence on Cushing's role as a leader in neurosurgery is examined.

Selective expression of estrogen receptor alpha and beta isoforms in human pituitary tumors.

The physiological effects of estrogen on the pituitary, including cellular proliferation and regulation of hormone synthesis, are mediated by the nuclear estrogen receptor (ER). The ER acts as a dimer to modulate gene transcription and contains specific functional domains encoded in different exons. Two separate, but related, forms of the receptor (ERalpha and ERbeta) exist, with distinct tissue and cell patterns of expression.

Pallidotomy improves motor responses and widens the levodopa therapeutic window in Parkinson's disease.

Stereotactic posteroventral pallidotomy (PVP) as a treatment for Parkinson's disease (PD) symptoms has been increasingly used in moderate-advanced disease. We examined the pharmacodynamic responses of PD patients to single oral levodopa doses and intravenous levodopa infusions before and after PVP surgery. Nine subjects with advanced PD received a single oral dose and ramped intravenous levodopa infusions before and 3-5 weeks after unilateral PVP.

Sutureless repair of major intracranial vessels with the Sundt clip-graft: technical note.

Major intracranial vessels can be damaged during tumor resection. With the availability of refined microvascular techniques, direct repair or by-pass of the damaged segment is possible. These methods, however, often require temporary occlusion of the offending vessel, can result in a less than optimal angiographic result, and are difficult to perform in a deep field.

Sulfonylurea receptor mRNA expression in pituitary macroadenomas.

ATP-sensitive K+ (KATP) channels modulated by sulfonylurea compounds have been previously identified in the anterior pituitary of the rat and have been demonstrated to influence GH release. Recently, a sulfonylurea receptor (SUR) has been cloned from an islet cell tumor and identified as a member of the ATP binding cassette superfamily capable to coupling with inwardly rectifying potassium channels. To determine if the same receptor is expressed in pituitary tumors, SUR mRNA levels were measured in 28 human macroadenoma specimens using an RNase protection assay.

Primary fibrosarcoma of the sella unrelated to previous radiation therapy.

Fibrosarcomas involving the sella turcica are rare lesions and, when encountered, have been associated with previous radiation of a pituitary adenoma. Although primary intracranial fibrosarcomas are well recognized, no case of primary fibrosarcoma of the sella turcica has been reported to date. We describe here a patient who presented with a 2-month history of headache, visual disturbances, and diabetes insipidus.

Symptomatic pituitary metastases.

Object: The diagnosis and treatment of metastasis to the pituitary gland can be difficult to determine. The goal of this study was to analyze the clinical presentation, treatment, and prognosis of patients who presented with symptomatic pituitary metastasis.

Methods: The cases of 36 patients with symptomatic pituitary metastases were reviewed.

The role of preoperative adjuvant treatment in the management of esthesioneuroblastoma: the University of Virginia experience.

Objective: Multidisciplinary management of esthesioneuroblastoma has effected markedly increased survival during the past 20 years. The potential for radical craniofacial surgery for complete en bloc resection, the availability of advanced neuroimaging modalities, and the incorporation of neoadjuvant therapy into treatment strategies for tumor remission have all contributed to this accomplishment. However, a standard protocol for the management of these lesions has not been accepted; preoperative radiation and chemotherapy have been advocated, but neither radiographic nor clinical response has been quantified.

Factors associated with survival in patients with meningioma.

Object: To explore factors affecting the survival rate in patients with meningiomas, the authors used the National Cancer Data Base (NCDB), which includes tumors from approximately 1000 hospitals participating in the American College of Surgeons tumor registry program.

Methods: Analysis included over 9000 cases diagnosed from 1985 to 1988 and 1990 to 1992. Survival estimates were computed and prognostic factors were identified using a proportional hazards model.

Glioma occurrence after sellar irradiation: case report and review.

Objective: Tumor neogenesis is an uncommon but known consequence after therapeutic irradiation of the central nervous system. Causative agents for glioma induction remain unknown, but laboratory and clinical data suggest a possible role for radiation as a promotor. In the treatment of both pituitary adenomas and craniopharyngiomas, adjunctive conventional radiation therapy has long played a role.

Pitfalls and successes of peer review in neurosurgery.

As the first editor of the Journal of Neurosurgery, Louise Eisenhardt, acting with the advice of the editorial board, was responsible for making decisions on the acceptance or rejection of submitted manuscripts. Her log, covering the first 14 years of editorial decisions, is a record of neurosurgical progress and of the forces--scientific, technical and other--that shaped the field of neurosurgery. Any peer-review process is subject to pitfalls that become evident in retrospect, but an effective peer-review process is one of the basic ingredients of scientific progress.

Lumbar disc surgery in a fixed compensation population: a model for influence of secondary gain on surgical outcome.

Background: Reported outcomes in patients undergoing surgical procedures for lumbar disc herniation are poorer in patients eligible for workers' compensation or with pending litigation. In the civilian community, the amount of compensation for one's disability is variable and thus its influence on surgical outcome is difficult to quantify. In the military, all members are covered by a standardized workers' compensation system, and have generally standardized work requirements, a standard pay scale, and third party evaluation of disability based on the Veterans Affairs rating system.

Antiproliferative effect of the somatostatin analogue octreotide on growth hormone-producing pituitary tumors: results of a multicenter randomized trial.

Objective: To determine and quantify the in vivo effects of octreotide on the cell cycle kinetics of growth hormone-producing pituitary adenomas.

Design: A multicenter randomized trial had been conducted to assess the clinical efficacy of octreotide, and we studied tissue specimens from pituitary macroadenomas in 32 patients with acromegaly from that trial-16 of whom had received 4 months of octreotide therapy before surgical resection and 16 of whom had undergone surgical resection only.

Material And Methods: All tumors had been fully characterized on the basis of their immunophenotypic profile and their ultrastructural morphologic features.