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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.

A 16-year-old girl with systemic lupus erythematosus and diabetes mellitus who was receiving prednisone, azathioprine, and insulin developed headaches, fever, irritability, and seizures. Studies revealed a large proximal basilar artery aneurysm with subarachnoid hemorrhage. Despite intubation and a ventriculopleural shunt, she became decerebrate and died. Postmortem studies revealed that this patient had an intracranial mycotic aneurysm due to Candida albicans.

✓ A retrospective study was made of 195 patients who had ruptured intracranial aneurysms without significant intracerebral hematomas and who recovered to at least Grade III by Hunt and Hess' classification. The first 121 patients underwent aneurysm surgery 10 days to 2 weeks after subarachnoid hemorrhage (SAH) without repeat preoperative angiography and without special attention to volume replacement or avoidance of hypotension. Vasospasm resulted in cerebral ischemia in 15% of this group, more than half of these postoperatively, and was treated successfully in half the patients with a combination of aminophylline and isoproterenol. The later 74 patients were managed with aggressive maintenance of normal circulating blood volume and preoperative angiography at 2 weeks following SAH. If significant vasospasm persisted on angiography, surgery was delayed an additional week and, if spasm was still present then, aminophylline and isoproterenol were added prophylactically to aggressive volume replacement before surgery. In this second group of patients, the incidence of clinical vasospasm was essentially unchanged; however, it was almost completely limited to the preoperative period, and was more effectively treated with aminophylline and isoproterenol. Postoperative vasospasm was almost completely eliminated from the second group of patients.

✓ 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.

Four photosensitive patients with EPP showed markedly elevated RBC protoporphyrin levels. In vitro exposure of. a monolayer of their RBC in buffered saline to 3 x 10(6) ergs/mm2 of 4000 A irradiation (= 45 minutes under a bank of fluorescent black lights) produced complete hemolysis within 24 hours; normal RBC showed negligible hemolysis after similar exposure. All of the cellular potassium was released from the patients' cells before the onset of significant hemolysis. Hemolysis was largely prevented by suspending the patients' cells in a 1:1 mixture of isotonic buffered NaCl and isotonic sucrose. These findings suggest that the initial photochemical lesion is of a "small hole" nature, creating channels through which small ions (but not sucrose) can diffuse. Since the effect of the intracellular colloid is offset by addition of sucrose to the external medium, the lesions appear to be less than 10 A in diameter.

✓ A case of a cerebral arteriovenous malformation treated by embolization with Silastic pellets is described, and the postmortem findings presented.

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.

A 52-year-old patient who underwent a superficial temporal-middle cerebral artery anastomosis subsequently developed an unusual squamous cell carcinoma in the skin overlying the anastomosis. The pathological picture and course of events suggest that this tumor was implanted into deeper tissues at the time of operation. Systematic microscopically controlled operation (Mohs' chemosurgical technique) was required to preserve the anastomosis while completely extirpating the tumor.

A patient who developed transtentorial herniation postoperatively was successfully treated by needle aspiration of the subdural space with removal of gas under pressure. This case demonstrates the diagnosis by CT scan and the successful management of expanding pneumocephalus due to the diffusion of nitrous oxide anesthetic into an intracranial air cavity.

A successfully managed case of posterior fossa subdural hematoma occurring in a hemophiliac is reported, and the rarity of this lesion is mentioned. The management of the hemophiliac who is a victim of craniocerebral trauma is discussed, with emphasis on the use of computerized tomographic scanning to obtain rapid diagnosis. The importance of prophylactic Factor VIII replacement is emphasized, and appropriate methods of Factor VIII administration are outlined.

✓ 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.

✓ The authors report the cases of two shunt-dependent children with recurring ventricular catheter obstruction treated by subtemporal craniectomy with excellent results. It is suggested that the procedure permits some dilatation of the ipsilateral ventricle which in turn makes future catheter obstruction less likely.

Cyclic AMP [(cAMP) cyclic adenosine 3′,5′-monophosphate] was initially discovered by Sutherland and Rall31 in 1958. Further investigations have led to the concept that cAMP may be involved as the intracellular mediator of the actions of other hormones and of various putative synaptic transmitters. According to this concept, first messengers, the hormones or transmitters themselves, move from their cells of origin and induce the synthesis of cAMP in their target cells. Thereby, cAMP, by activating an appropriate sequence of enzymes, can evoke the specific response of a target cell to the hormone.33 During the course of research on cAMP, a second cyclic nucleotide, cyclic guanosine 3′,5′-monophosphate (cGMP), was discovered1 and is now thought to act as a second messenger for the actions of various neurotransmitters, including acetylcholine.

✓The authors describe four of their own cases of primary rhabdomyosarcoma (RMS) of the head and neck and summarize an additional 25 cases collected from the world literature, each manifesting neurological involvement. The need for early diagnosis and radical surgery is stressed.

The advent of computerized axial tomography (CAT scan) has augmented the neurologic diagnostic armamentarium dramatically. The ability of the CAT scan to differentiate and accurately locate various intracranial densities in a noninvasive manner makes it a very valuable method of investigating craniopharyngiomas. Because they are often composed of cystic, solid, and calcified portions, craniopharyngiomas are very well demonstrated, with the same CAT scan revealing ventricular size as well. A recent and representative case is reported demonstrating the correlation between the CAT scan and the operative findings.

Erythropoietic protoporphyria is a relatively rare metabolic anomaly occurring in childhood and characterized by various types of cutaneous lesions on light-exposed areas. The lesions are a photosensitive response to an excess of protoporphyrin. Diagnosis can be established by demonstrating a quantitative increase in erythrocyte protoporphyrin levels. A patient with this abnormality clinically presented the cutaneous changes of hydroa aestivale. Lesions were induced under controlled conditions by exposure of the patient's skin to natural sunlight. The patient's red blood cells in vitro showed a markedly abnormal photohemolytic pattern to radiation in the long ultraviolet (about 4,000 Angstroms [A]) range.

Infusions of 5% albumin and/or dextran 40 in nine patients with acute ischemic neurological deficits reduced mean hematocrit values from 41% to 32%, raised mean central venous pressure from 4 to 12 cm H 2 O, and reduced mean arterial BP from 101 to 94 mm Hg. Six alert patients had ischemic structural damage on cranial computed tomography. All six alert patients with upper arm paresis objectively improved and two others with only dysphasia also improved within 24 hours after infusion initiation. Although the improvement in two patients seemed to be temporarily dependent on the continuing of the infusion, all eight alert patients were eventually weaned without loss of regained function. This report of neurological improvement during hypervolemic hemodilution suggests that augmentation of collateral perfusion secondary to reduced blood viscosity may rapidly relieve cerebral ischemia, impede infarction, and allow time for compensatory mechanisms to maintain blood flow above ischemic thresholds. ( JAMA 1982;248:2999-3004)