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✓ Ventricular fluid pressure (VFP) and volume-pressure response were measured during nitroglycerin (NTG) infusion in nine patients anesthetized with N2O and fentanyl. The patients' ventilation was controlled, and PaCO2 was kept at 32 ± 4 mm Hg. When an infusion of 0.01% NTG was given intravenously to decrease the mean blood pressure to 95.1%, 84.7%, and 78.2% of control, the VFP increased from control levels of 9.94 ± 2.14 mm Hg to 12.89 ± 2.25, 15.6 ± 2.85, and 14.43 ± 3.45 mm Hg, respectively. The volume-pressure response showed a significant increase when blood pressure decreased to 84.7% and 78.2% of control. These results suggest that intravenous NTG caused an increase in the intracranial pressure and a decrease in the intracranial compliance.

✓ Seven cases of giant posterior hemisphere arteriovenous malformations are described. The significance of meningeal feeding vessels from the external carotid artery in addition to the primary cerebral supply through the internal carotid and vertebral arteries to these malformations is discussed. The necessity of bilateral selective external carotid arteriography is stressed, and the value of preoperative embolization is questioned.

✓ Musculocutaneous (skin-muscle) flaps have been used predominantly by plastic surgeons for a variety of reconstructive purposes. With the advent of microvascular techniques, the area to be reconstructed is no longer limited to the arc of rotation of the vascular pedicle of the muscle. Instead, the muscle and overlying skin that is best suited for the reconstructive procedure may be dissected out as a free flap, with microvascular anastomosis of an arterial supply and venous drainage to locally existing vessels. This report demonstrates the usefulness of musculocutaneous free flaps in the repair of large defects of the scalp, cranium, and dura after trauma or resection of invasive neoplasms. The authors describe the use of a latissimus dorsi free musculocutaneous flap in eight patients who would have required multiple operations to provide coverage by other techniques. There have been no major complications, and adequate repair has been accomplished, even in cases involving exposed brain.

✓ Previous studies have demonstrated that cerebrospinal fluid (CSF) from the lateral ventricle of patients without disturbance of sensorium or intracranial pressure, contains 15 to 30 nM 3′,5′ cyclic adenosine monophosphate (cAMP). The concentration of this cyclic nucleotide was measured by radioimmunoassay in 133 samples of CSF from the lateral ventricle of 26 patients who were comatose following acute head trauma for periods up to 40 days. Concentration of CSF cAMP in diminishing coma Grades V, IV, III, II, and I was 1.5 ± 0.1 nM; 1.24 ± 0.34 nM; 3.14 ± 0.7 nM; 10.06 ± 3.47 nM; and 13.36 ± 1.38 nM, respectively. After the sensorium cleared (coma Grade 0), cAMP was 22.0 ± 1.7 nM. The correlation between the grade of coma and cAMP concentration was −0.80 (p > 0.01). These results imply that alteration in the level of consciousness following head trauma is associated with a disturbance of cAMP metabolism within the central nervous system. Possible mechanisms explaining this observation as well as therapeutic implications are discussed.

Prolonged coma after head trauma is associated with a depletion of 3′,5′ cyclic adenosine monophosphate (cAMP) in the cerebrospinal fluid (CSF). Because cAMP has been implicated in neuroendocrine secretion, we have examined pituitary-hypothalamic function in 7 adult male patients with traumatic coma lasting longer than 2 weeks. Within 1–3 days after trauma, a ventricular catheter connected to a subcutaneous Rickham reservoir was placed in the lateral ventricle to treat intracranial hypertension. Via the reservoir, CSF cAMP was measured at 2–4 day intervals for 10–25 days. Simultaneously, plasma hormone concentrations were also determined. CSF cAMP and plasma levels of TSH, T4, free T4, T3, LH, FSH, and testosterone became subnormal in all 7 cases. In 5 patients whose level of consciousness fluctuated, the reductions in plasma T4 and testosterone were proportional to both severity of coma (r > 0.89, P 0.81, P < .05). In 3 patients who remained deeply comatose for 17–25...

✓ A case of primary carcinoma of the pituitary with metastasis to the brain stem is presented. Although both tumors had the microscopic appearance of benign adenomas, the infiltrative characteristics necessitated the diagnosis of carcinoma.

Two cases of acute obstructive hydrocephalus from intraventricular hemorrhage following head injury are presented. Each patient was involved in a motor vehicle accident and sustained closed-head trauma. Computed tomography scans revealed a fourth ventricular hematoma with obstructive hydrocephalus in each case, and both cases required emergency ventricular drainage to manage acute cerebrospinal fluid hypertension. Ventriculostomy resulted in complete recovery in the first case; however, the second patient eventually underwent ventriculoperitoneal shunting. One patient manifested an eight-hour lucid interval prior to neurologic deterioration.

✓ As carotid-cavernous sinus fistulas (CCSF) are not life-threatening, therapeutic attempts should carry a very low morbidity and mortality. The authors believe that utilization of detachable balloons is the treatment of choice for CCSF, although this procedure is not without risk. Seven patients have been treated for high-flow traumatic intracranial fistulas over the past 2 years with detachable balloons using a coaxial catheter system. This paper presents several complications that have been encountered during this experience, and advances suggestions regarding treatment and avoidance of potential complications.

A previous study showed that cerebrospinal fluid from the lateral ventricle of patients without disturbance of sensorium or intracranial pressure contains 15 to 30 nm 3', 5' cyclic adenosine monophosphate. We measured the concentration of this cyclic nucleotide by radioimmunoassay in cerebrospinal fluid from the lateral ventricle of six patients with prolonged coma (20 days or longer) after head trauma (four), or spontaneous intracranial hemorrhage (two). Coma was graded IV to I in order of decreasing severity. Fluid was removed at intervals of six to 72 hours from a Rickham reservoir placed in the lateral ventricle. Concentration of the cyclic nucleotide (mean +/- S.E.M.) in coma of Grades IV, III, II and I was 2.1 +/- 0.3, 4.6 +/- 0.5, 6.3 +/- 1.4 and 12.5 +/- 2.4 nM respectively. After sensorium became normal, cAMP was 21.0 +/- 1.4 nM. Correlation between grade of coma and concentration was -0.89 (P less than 0.01). Thus, prolonged coma appears to be associated with a disturbance of cyclic AMP metabolism within the central nervous system.

A flexible ventriculofiberscope was used to diagnose intraventricular pathological conditions in eight adult hydrocephalic patients. In each case the entire procedure was recorded on videotape for documentation, review, and teaching. Four representative cases are presented to illustrate the use and value of this technique.