Thirty seven adult patients which chronic subdural haematoma were randomized into two groups. Eighteen patients served as controls and underwent evacuation of the haematoma via burr holes and a gravity dependent closed-system drainage. Nineteen patients comprised the study group. These patients had a continuous irrigation-drainage system installed in an attempt to facilitate the removal of fibrinolytic substances present in the haematoma fluid and to try to reduce the rate of rebleeding from the haematoma membranes. No differences were found between the pre- and post-operative clinical status, haematoma volumes and the degree of CT changes between the two groups. The complication rate was similar in the two groups. One patient in the study group and three patients in the control group required an extended period of drainage (24-48 hours) prior to the removal of the drains. All patients improved following the procedures. Within 30 days post the initial evacuation of the chronic subdural haematoma, re-operation was required in only one patient in the study group as opposed to four of the controls. This difference was not however statistically significant. When the need for re-operation was combined with the need for extended drainage period, a significant difference was shown in favour of the study group. These results indicate that drainage combined with continuous irrigation of the subdural space does not affect the clinical outcome of the patients, but significantly reduces the frequency of inadequate drainage of the haematoma and prevents longer drainage periods and repeated operations.

Twenty-five children, most of them with high risk medulloblastoma, were treated at the Chaim Sheba Medical Center between 1982-1992. All patients had surgical resection and craniospinal irradiation followed by adjuvant chemotherapy. Nine of them were treated with the CCSG protocol and 16 with the ''eight in one'' protocol. The two- and five-years actuarial survival rate of the 25 patients was 63 % and 45 %, respectively. There was no statistical difference between the two chemotherapy regimens (p = 0.05). The role of adjuvant chemotherapy in the multimodal approach to medulloblastoma patients is discussed.

A child is described in whom intraventricular tension pneumocephalus developed 10 days after removal of a cerebellar medulloblastoma and 1 day after suture removal. The tension pneumocephalus was associated with hydrocephalus and CSF leakage from the suture line. The symptoms of the pneumocephalus were rapidly progressing loss of consciousness and hemiplegia which were promptly reversed upon aspiration of the intracranial air. A large amount of intraventricular air present in the immediate postoperative period was, however, clinically silent. The characteristics of this unusual presentation, its relation to asymptomatic pneumocephalus. hydrocephalus and the preventive and therapeutic measures required to deal with such conditions are discussed.

Between January 1982 and January 1990,120 newly diagnosed pediatric patients were treated at The Chaim Sheba Medical Center. Sixty three (52.5%) tumors arose in the posterior fossa and 57 (47.5%) appeared supratentorially. A wide variety of histologic subtypes was seen, each requiring tumor-specific treatment. The modern imaging techniques - CT and MRI - offered better planning of operation, treatment and follow up. All children with highly malignant tumors were treated with combination chemotherapy besides the ‘conventional radiotherapy’. Since 1987 the “eight in one day” protocol has been used extensively pre- and post-irradiation. Five-year survival, varied significantly according to tumor type, location and stage. The average delay from presentation of symptoms to diagnosis was 6 months. A multidisciplinary approach has been used in the treatment, rehabilitation and follow-up of these children. In this study, the results of treatment are presented and the role of chemotherapy is discussed.

We induced experimental delayed cerebral vasospasm by the intracisternal injection of greater than 0.5 ml blood in 30 rats. Seventy-two hours later the basilar artery was exposed via the transclival approach and photographed at high-power magnification through an operating microscope. We then evaluated the effect of topical (n = 30) and intravenous (n = 20) magnesium sulfate on the spastic artery by computerized image analysis. A greater than 50% reduction in baseline diameter of the basilar artery was observed in the rats subjected to subarachnoid hemorrhage compared with the 10 controls (p less than 0.0001). Intravenous magnesium sulfate dilated the spastic artery to approximately 75% of the baseline diameter in control rats (p less than 0.0001). Topical magnesium sulfate caused dramatic dilation of the basilar artery in both the control and the subarachnoid hemorrhage groups to near 150% of the baseline diameter in the controls (p less than 0.001). All rats receiving intravenous magnesium sulfate reached therapeutic plasma levels of the ion. Hemodynamic effects were mild and immediately reversible upon cessation of magnesium sulfate administration. We suggest that magnesium has a role in the treatment of subarachnoid hemorrhage-induced vasospasm in humans.

Epidural empyema is a rare complication of elective spinal surgery. Four such cases are described. The clinical features of this postoperative complication were surprisingly vague and misleading. Fever was uncommon. Local inflammatory signs or rapid neurologic deterioration were absent. Computerized tomography proved useful in diagnosis and follow-up. Unlike spontaneous spinal epidural abscess, postoperative spinal epidural empyema had a benign course. Causative bacteria were miscellaneous. Surgical evacuation of the purulent collection and appropriate antibiotic therapy resulted in cure in all cases.

Although the pathophysiology of chronic cerebral vasospasm following subarachnoid haemorrhage (SAH) is still unclear, it is certain that the amount of subarachnoid blood is predictive of the severity of cerebral vasospasm. Accordingly, massive subarachnoid haemorrhage (>0.5 ml) was induced in adult rats via direct injection into the cisterna magna. Compared to other previously published models of experimental SAH in rats a much larger amount of blood was injected.

RAM, ZVI MD*; FINDLER, GIDEON MD*; TADMOR, RINA MD†; SAHAR, ABRAHAM MD*; SHACKED, ITZHACK MD* Author Information

Twenty-one patients with various types of pituitary macroadenomas underwent hypophysectomy at the Chaim Sheba Medical Centre between 1985 to 1987. Intraoperative fine needle aspiration of the tumoural content was attempted prior to tumour excision. Although none of the patients had a history compatible with pituitary apoplexy, intratumoural fluid suggestive of a cyst within the tumour was found in 57% of the patients. Analysis of the hormones in the aspirated fluid revealed variable elevations in hormone levels, some reaching 3,000 times the equivalent plasma levels. Concomitant elevated levels of other pituitary hormones found in the cyst fluid support the concept of mixed secretory potential of pituitary adenomas, including the apparently non-functioning tumours. Six out of seven patients (86%) who received preoperative treatment with bromocriptine had an intratumoural cyst while only seven out of fourteen patients (50%) who were not treated with this drug prior to surgery had a cyst within the tumour. The implications of these observations on current theories concerning the pathophysiology of pituitary adenomas are discussed.

Twenty-eight patients with high-grade cerebral gliomas (16 biopsy-proven and 12 diagnosed clinically and by computed tomography scan) were treated with altered fraction radiation and concomitant cisplatin (C-DDP). Twenty cases (Groups IA and IB) whose Karnofsky performance status (KPS) was 60% or less received hypofractionation and C-DDP. All these patients had received high-dose Decadron (Merck Sharp & Dohme, West Point, PA), and their conditions were not improving or progressively deteriorating. The first 11 patients (Group IA) received from 600 cGy twice weekly to 3600 cGy over 3 weeks combined with C-DDP IV at 40 mg/M2 every 2 weeks for two courses. The nine subsequent patients (Group IB) received from 600 cGy weekly to 3600 cGy over 5 to 6 weeks with C-DDP IV at 40 mg/M2 every 1 to 2 weeks for four courses. The target volume in all cases was confined to the tumor as defined on computed tomography (CT) scan with a 2 cm to 3 cm margin. The C-DDP at 40 mg/M2 was administered immediately (within 5 minutes after radiation). Eight cases (Group II) with a KPS of more than 60% were treated with hyperfractionation, i.e., from 200 cGy twice daily to 4800 cGy in just under 3 weeks. The C-DDP was administered every 2 weeks for a total of two courses, as for Group IA. In Group I, 15 of 20 (75%) patients experienced rapid improvement in their performance status, which usually becoming evident within 1 to 2 weeks from the initiation of treatment, and progressed over time. Four patients with a KPS of 10% improved their KPS to over 60%. This regimen was both well tolerated and logistically very convenient both for the patients and attending staff. Follow-up CT scans in three of 16 evaluable patients in the hypofractionated group showed complete tumor resolution. Median survival for Group IA was 7 months, for Group IB was 12 months, and overall was eight months. The Group II median survival was 9 months. This experience suggests that hypofractionated radiation in combination with C-DDP may offer rapid palliation with improvement in functional status in severely compromised patients with malignant glioma.

Spinal cord involvement in leukemia is rare and has been described only once in association with acute monocytic leukemia. A patient whose presenting symptom of acute monocytic leukemia was the syndrome of cauda equina compression due to an epidural and retroperitoneal leukemic mass is reported. Peripheral blood smears were normal throughout the evolution of the disease. The radiological, surgical, and pathological findings are presented, and the therapeutic, along with the prognostic implications of spinal cord involvement by leukemia are discussed.

Visual hallucinations were the presenting symptom in three patients with pituitary adenoma. One patient reported only simple unformed hallucinations, which are a well-documented phenomenon occurring in lesions compressing the optic nerves and chiasm. The other two patients, however, experienced complex formed visual hallucinations believed to be of the release type. No evidence of seizure activity responsible for the hallucinations was found; the mechanism producing them is discussed with correlation to operative findings and electrophysiological studies.

A case of spontaneous intermittent priapism in a patient with spinal canal stenosis is presented. Erection, as well as intermittent neurogenic claudication and urinary incontinence were provoked by physical exertion, mainly walking. The symptoms completely resolved after decompressive lumbar laminectomy.

Intracranial hemorrhage (ICH) is a life-threatening complication of hemophilia. Seven of the 288 hemophiliacs living in Israel suffered eight episodes of ICH during the years 1972 to 1982. All episodes occurred in hemophilia A patients, with a higher incidence among patients with factor VIII inhibitor. Diagnosis was confirmed by computed tomographic scan in seven of the eight episodes. Four of the 7 patients died despite adequate factor replacement and supportive therapy, probably due to a conservative and hesitant neurosurgical approach. The correction of factor VIII to hemostatic level alone is inadequate in the majority of cases, and there is sudden deterioration in the patient's condition and death. Operation is strongly recommended when no improvement is noted within a few hours. (Neurosurgery 18:538-541, 1986)

The authors report three patients with symptomatic postlaminectomy pseudomeningocele. At operation a loop of a nerve root was found to be trapped within the dural defect. All three patients exhibited a delayed onset of radicular symptoms and signs after disc surgery. The pseudomeningocele was demonstrated computed tomography and myelography, but the entrapped root could be identified only at operation.

A case of a cystic meningioma recurring in its cystic form, two years after the initial removal, is presented. Regarded as a true cystic meningioma, the possible aetiology of the cyst formation is suggested. As the cyst wall itself may give rise to tumour cells, it is recommended that the initial operation should be directed at total removal of the tumour mass and cyst wall, thus reducing the possibility of a tumour recurrence. A CT finding of a hypodense lesion in a patient, operated on previously for a cystic meningioma suggests a recurrence of the tumour. However, other non-neoplastic changes should be considered.

Manifest or occult spinal dysraphism in the absence of neurological symptoms is likely to remain undetected. Therefore, accurate and early diagnosis of such underlying anomalies is of prime importance for early surgical intervention in order to avoid late irreparable damage. During a period of just over 1 year, 17 such cases of spinal congenital anomalies were diagnosed by myelography with metrizamide and computed tomography-myelography. There were 16 cases of tethered cord, six with myelomeningocele, two with diastematomyelia, two with a split spinal cord, three with a lipoma, and the remaining three with vertebral anomalies. Scoliosis was present in 60%, weakness of both legs in 45%, and asymmetry of the feet in 25%. Some of these patients were initially brought to the orthopedic department for corrective surgery before undergoing a complete neurological evaluation; thus the radiologist was acting as the link between patient and neurosurgeon. Clinical experience has shown that surgical treatment can be successful and can thereby obviate further progression of neurological symptoms.

In a 2-year-old girl with signs and symptoms of a posterior fossa tumor, the computed tomographic scan showed what appeared to be a brain stem glioma. However, magnetic resonance imaging (MRI) demonstrated the lesion to be extrinsic to the brain stem. Posterior fossa exploration disclosed a medulloblastoma filling the 4th ventricle. This discrepancy in imaging techniques points out the usefulness of MRI in the evaluation and treatment of posterior fossa lesions. (Neurosurgery 17:487-489, 1985)