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We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.

The authors analysed the serial computerized tomography (CT) findings in a large series of severely head injured patients in order to assess the variability in gross intracranial pathology through the acute posttraumatic period and determine the most common patterns of CT change. A second aim was to compare the prognostic significance of the different CT diagnostic categories used in the study (Traumatic Coma Data Bank CT pathological classification) when gleaned either from the initial (postadmission) or the control CT scans, and determine the extent to which having a second CT scan provides more prognostic information than only one scan. 92 patients (13.3% of the total population) died soon after injury. Of the 587 who survived long enough to have at least one control CT scan 23.6% developed new diffuse brain swelling, and 20.9% new focal mass lesions most of which had to be evacuated. The relative risk for requiring a delayed operation as related to the diagnostic category established by using the initial CT scans was by decreasing order: diffuse injury IV (30.7%), diffuse injury III (30.5%), non evacuated mass (20%), evacuated mass (20.2%), diffuse injury II (12.1%), and diffuse injury I (8.6%). Overall, 51.2% of the patients developed significant CT changes (for worse or better) occurring either spontaneously or following surgery, and their final outcomes were more closely related to the control than to the initial CT diagnoses. In fact, the final outcome was more accurately predicted by using the control CT scans (81.2% of the cases) than by using the initial CT scans (71.5% of the cases only). Since the majority of relevant CT changes developed within 48 hours after injury a pathological categorization made by using an early control CT scan seems to be most useful for prognostic purposes. Prognosis associated with the CT pathological categories used in the study was similar independently of the moment of the acute posttraumatic period at which diagnoses were made.

The case of a 21-year-old woman without previous cervical pathology in whom irreversible tetraplegia developed after operation for tracheal stenosis is reported. After tracheal resection the neck was kept in extreme flexion and after extubation she was moved to a sitting position. The different causal agents that could produce the neurologic damage remain unclear, although we think that the combination of relative arterial hypotension secondary to the sitting position and disturbed autorregulation, caused by extreme neck flexion, could result in ischemic spinal cord injury.

Percutaneous compression of the trigeminal ganglion, which is currently being used for the control of trigeminal neuralgia, induces marked intraoperative elevations of the systemic blood pressure and heart rate changes, which may increase the risk of cardiovascular complications. We have analyzed the characteristics of the arterial hypertensive response and the cardiac rhythm changes induced by percutaneous compression of the trigeminal ganglion in 42 consecutive, unselected patients undergoing operations for essential trigeminal neuralgia under three different regimens of anesthesia. The first 22 patients (Group 1) underwent operations under brief general anesthesia without endotracheal intubation. The following 10 patients (Group 2) had general anesthesia with intubation and mechanical ventilation and received larger doses of hypnotic and analgesic agents. Finally, 10 more patients (Group 3), who had general anesthesia with intubation, underwent local anesthetic blockade of Meckel's cave (injection of 1 ml of 1% lidocaine) before ganglion compression. Foramen ovale puncture elicited bradycardia in the majority of the patients of Groups 2 and 3, but only four patients (18%) of Group 1 showed bradycardia. Ganglion compression caused marked tachycardia in all patients of Groups 1 and 2; about one-third of the patients also had extrasystoles. By contrast, patients of Group 3, who had local anesthetic blockade of Meckel's cave before ganglion compression, did not develop tachycardia or extrasystoles. Foramen ovale puncture elicited marked elevations of the systemic blood pressure in all patients. Ganglion compression further increased blood pressure, except in patients of Group 3, who had local anesthetic blockade of Meckel's cave.(ABSTRACT TRUNCATED AT 250 WORDS)

✓ Of 838 patients with severe head injuries admitted since the introduction of computerized tomography, 211 (25.1%) talked at some time between trauma and subsequent deterioration into coma. Of these 211 patients, 89 (42.2%) had brain contusion/hematoma, 46 (21.8%) an epidural hematoma, 35 (16.6%) a subdural hematoma, and 41 (19.4%) did not show focal mass lesions. Thus, four of every five patients who deteriorated into coma after suffering an apparently nonsevere head injury had a mass lesion potentially requiring surgery; the mass was intracerebral in 52.3% of the cases and extracerebral in 47.6%. Patients aged 20 years or less had a 39% chance of having a nonfocal mass lesion (diffuse brain damage), a 29% chance of having an epidural hematoma, and a 32% chance of having an intradural mass lesion; patients over 40 years had only a 3% chance of having a nonfocal mass lesion, an 18% chance of having an epidural hematoma, and a 79% chance of having a intradural mass lesion. Sixty-eight (32.2%) patients died and 143 (67.8%) survived. The following were independent outcome predictors (in order of significance): Glasgow Coma Scale score following deterioration into coma, the highest intracranial pressure during the patient's course, the degree of midline shift, the type of intracranial lesion, and the age of the patient. In contrast, the mechanism of injury, the verbal Glasgow Coma Scale score during the lucid interval, and the length of time until deterioration or until operative intervention did not influence the final result.

A sixty-®ve year old hypertensive man complaining of lumbar pain radiating down the right leg was admitted for L4±L5 discectomy. He was on verapamil and aspirin. MRI showed a lumbar disc herniation at L4±L5 which was removed by L4±L5 hemilaminectomy. On the ®rst postoperative day he gradually lost strength for the dorsiexion of the right foot until he developed a drop-foot accompanied by L5 radicular pain. Control MRI showed a huge haematoma at the operative site (Fig. 1). At re-operation a large haematoma compressing the dural sac was evacuated. Over the following days radicular pain disappeared completely though he still had L5 hypo-aesthesia and 4/5 paresis for dorsiexion of the right foot. Six months after the ®rst operation strength was completely recovered but L5 hypo-aesthesia persisted unmodi®ed.

Introduccion. Los tumores talamicos bilaterales son neoplasias muy raras y recientemente se han identificado como un subgrupo de neoplasias talamicas debido a su caracteristica forma de presentacion, con trastornos de la memoria y la conducta y sin afectacion sensitiva ni motora. Describimos el caso de una enferma que se consulto por cambios en el caracter y conducta debido a una masa bitalamica; revisamos la literatura acerca de estas raras neoplasias y las bases anatomicas de esta caracteristica forma de presentacion. Caso clinico. Una mujer de 67 anos de edad acudio a nuestro servicio por cambios en la conducta y el caracter, y olvidos frecuentes. La exploracion neurologica era normal, excepto un deficit en el recuerdo de series de numeros y palabras. La resonancia magnetica craneal mostro la existencia de una masa talamica bilateral que era isointensa en T1, hiperintensa en T2 y densidad protonica y que no captaba contraste. El tumor se diagnostico como astrocitoma mediante una biopsia estereotactica. La enferma continuo deteriorandose y un ano despues del diagnostico estaba encamada y con una demencia grave. Conclusiones. Los tumores bitalamicos, al igual que otras lesiones que afectan al talamo bilateralmente, se presentan especificamente con cambios en el caracter y comportamiento y trastornos de la memoria.

The authors compared the clinical presentations of angiographically apparent arteriovenous malformations (AVMs) and angiographically occult vascular malformations (AOVMs) of the brain in 188 consecutive patients treated when computed tomography and magnetic resonance were available. There were 133 patients (70.7%) with AVMs and 55 patients (29.2%) with AOVMs. AOVMs tended to occur more frequently in male patients and in the posterior fossa and to present earlier clinically than AVMs, but differences were not significant. One distinctive feature was the greater size of AVMs, as compared with AOVMs. Presentation by hemorrhage occurred in 64.3% of the patients with AVMs and in 61.8% of those with AOVMs. Malformations of both types located in the posterior fossa presented with hemorrhage more frequently (84.2% of AVMs and 78.5% of AOVMs) than similar lesions lying above the tentorium (60.8% of AVMs and 56% of AOVMs). Bleeding was more severe in patients with AVMs than in those with AOVMs, as indicated by the higher mortality associated with hemorrhage (7.5 vs. 3.6% of the cases) and the more frequent and marked decrease in the level of consciousness observed at admission (34 vs. 16.2% of drowsy or comatose patients). Brain hematomas caused by AVMs were on average bigger than those caused by AOVMs (58.8 and 20% of large hematomas, respectively), and intraventricular and subarachnoid hemorrhages were also more common and profuse in patients with AVMs. However, AOVMs bled subsequently more times than AVMs (61.7 vs. 15.6%), before they were diagnosed and treated, leading to a higher nonoperative morbidity (16.3 vs. 13.6%).(ABSTRACT TRUNCATED AT 250 WORDS)

✓ The cases of 11 patients with hydrocephalus secondary to cerebral cysticercosis are analyzed. Most of the patients had suffered from epilepsy before they developed hydrocephalic symptoms, and computerized tomography showed that infestation of the parenchyma coexisted with ventricular or cisternal colonization. In four cases, the parasitic vesicles compromised cerebrospinal fluid (CSF) flow in the ventricular system, resulting in internal hydrocephalus. Communicating hydrocephalus, caused by the presence of Cysticercus larvae in the basal cisterns (Cysticercus racemosus), or by the occurrence of a chronic basal meningitis, or both, developed in seven more patients. Changes in CSF pressure were related to the number and location of the cysts and to the leptomeningeal inflammatory reactions evoked by them. The majority of patients presented with a chronic and relatively normotensive hydrocephalus. All patients except one had identifiable ventricular or cisternal Cysticercus larvae; these patients were treated with open removal of the cysts, and did well. However, most of them had impairment of CSF flow through the basal cisterns and required permanent CSF shunting. Communicating hydrocephalus due to leptomeningeal scarring was also successfully managed with extracranial shunting. Epilepsy was controlled with anticonvulsant therapy. Although good lasting results may be obtained with aggressive treatment of neurocysticercosis, patients are liable to relapse because surgery is only palliative in most instances.

✓ The influence of the type of intracranial lesion on the final outcome in a consecutive series of 277 severely head-injured patients was analyzed. Patients were studied with computerized tomograpy (CT) and underwent continuous measurement of intracranial pressure. They received identical treatment according to a standardized protocol. Outcome of patients with either epidural hematoma (38 cases), subdural hematoma (56 cases), brain contusion (87 cases), or diffuse brain damage (96 cases) was rather heterogeneous, and serial CT scanning allowed the authors to outline eight consistent anatomical patterns in the whole series which have stronger prognostic significance than the four major lesion categories mentioned above. Patients with pure extracerebral hematoma (19 cases), single brain contusion (45 cases), general brain swelling (41 cases), and normal CT scans (28 cases) had a significantly better outcome than patients developing acute hemispheric swelling after operation for a large extracerebral hematoma (27 cases), patients with multiple brain contusion, either unilateral or bilateral (74 cases), and patients with diffuse axonal injury (43 cases). These anatomical patterns are interesting because, in addition to having clinical and physiopathological significance, they provide useful prognostic information and facilitate improved therapeutic decision-making in severely head-injured patients.

✓ Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.

✓ The authors have analyzed the clinical course and intracranial pressure (ICP) changes in 55 severely headinjured patients presenting with bulk enlargement of one cerebral hemisphere within a few hours after trauma. These patients represent 10.5% of a series of 520 patients with severe head injury studied with computerized tomography (CT). Cerebral hemispheric swelling has the highest mortality rate and the shortest survival period after trauma in all series of severe head injury. In this series, it was associated with an ipsilateral subdural hematoma of variable size in 47 patients (85%) or with a large epidural hematoma in five patients (9%); in three patients (5.4%) it occurred as an isolated lesion. Evacuation of an associated extracerebral hematoma, which was performed within 4 hours after injury in only 20% of cases, scarcely changed the patients' preoperative neurological status. The high incidence of arterial hypotension and/or hypoxemia at admission (47% of cases) and the severity of the clinical presentation (82% of patients scored 5 points or less on the Glasgow Coma Scale, 74% had unilateral or bilateral mydriasis, and 80% had an initial ICP above normal) correlated with a very poor final outcome (87% mortality). Only one of the 11 patients with normal initial ICP continued to have normal pressure throughout the course. High-dose thiopental failed to control severe intracranial hypertension in 24 patients (51%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 15 patients (31.4%) and definitive control in eight patients (17%), among whom were the seven survivors in this series. In the authors' experience, once ICP is controlled, barbiturate administration should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

✓ A consecutive, unselected series of 82 patients with epidural hematoma treated between 1973 and 1980 is presented. Forty-one patients were managed before the advent of computerized tomography (CT) and the other 41 after this neuroradiological method was available. Mortality and disability rates which were 29.2% and 31.7% during the pre-CT period decreased to 12.1% and 19.5%, respectively, with the aid of CT scanning. This technique allowed a more rapid and accurate diagnosis of the hematomas than angiography, and defined better the presence and the evolutional changes of the associated cerebral lesions. As a consequence, surgery has been more effectively planned and executed during the CT era.

Among patients categorized as suffering from severe head injury there is a great heterogeneity in both the clinical course and the type of intracranial lesion (Becker et al. 1977, Clifton et al. 1980, Gennarelli et al. 1982, Jennett et al. 1979, Miller et al. 1981) and it is necessary to separate they into meaningful subgroups in order better to analyse the factors influencing outcome. Segregation of cases may be achieved by different criteria and a pathological classification based on the computed tomography (CT) findings, seems to be rational and appropriate (Clifton et al. 1980, Gennarelli et al. 1982). Although post-traumatic intracranial lesions are not always mutually exclusive, by defining a principal lesion in cases with multiple intracranial pathology a practical, simplified subdivision may be built.

The clinical and computed tomographic (CT) findings in a series of 161 consecutive patients operated upon for postraumatic extradural hematoma are analyzed. Thirteen (8%) patients had delayed epidural hematoma formation. The overall mortality for the series was 12%, significantly lower than that observed during the prior "angiographic" period at the same unit (30%). Because all but 1 of the deaths occurred among the 66 patients unconscious at the time of operation (27% mortality in this subgroup), the authors sought differential factors between comatose and noncomatose patients at operation. There were no significant differences between these groups in age, sex, mechanism of injury, preoperative course of consciousness (lucid interval or not), or epidural hematoma location and shape. In contrast, significant differences were seen between the two subgroups in trauma-to-operation interval, hematoma volume, CT hematoma density (mixed low-high CT density vs. homogeneous hyperdensity), midline displacement, severity of associated intracranial lesions, and postoperative intracranial pressure (ICP). Patients comatose at operation usually evidenced a more rapid clinical deterioration (a shorter trauma-to-operation interval) and tended to have a large hematoma volume, a higher incidence of mixed CT density clot (hyperacute bleeding), more marked shift of midline structures, more severe associated lesions, and higher postoperative ICP levels.

The experience with the administration of intraventricular morphine for the control of malignant pain in 197 patients is analyzed. Small doses of morphine injected via a ventricular reservoir provided satisfactory control of otherwise intractable pain in terminal cancer-patients. Complete analgesia together with a favourable behavioral response was obtained without noticeable neurological changes or side-effects annoying or severe enough for the patients to discontinue therapy. Tolerance was much less marked than with parenteral opiates. Chronic intraventricular therapy can be safely performed on an outpatient basis by injecting the opiate once or twice a day. The method may be improved by using refillable continuous-infusion devices and new drugs, able to retain the analgesic effects of morphine while eliminating the unwanted ones.

Intracranial pressure (ICP) continuous monitoring after severe craniocerebral trauma seems to be a valuable technique in order to improve the therapeutic management of the patients5, 7, 10. Nevertheless its value in predicting the ultimate outcome of the individual patient remains controversial. Some authors have found a good correlation between ICP levels and outcome1, 7, 10, 11 while others deny this correlation2, 5, 6, 9. These discrepances may be explained in part by the heterogeneous clinicopathological groups of patients included in some series.

The clinical course and the intracranial pressure (ICP) changes in 66 severe head injury patients presenting bulk enlargement of one cerebral hemisphere within a few hours of trauma have been analyzed. These patients represent 11% of a series of 589 severe head injury cases studied with computerized tomography (CT). Cerebral hemisphere swelling, which was associated with an ipsilateral subdural haematoma of variable extent in 58 patients (88%), or a large epidural haematoma in 5 patients (7%), and occurred as an isolated lesion in 3 patients (4%), carried the highest incidence of uncontrollable intracranial hypertension, the highest mortality rate and the shortest survival period after trauma in the authors' severe head injury series. The high incidence of arterial hypotension and/or hypoxaemia at admission (48% of cases), and the severity of clinical presentation (82%) of patients scored 5 patients or less in the Glasgow Coma Scale, 77% had uni- or bilateral mydriasis and 82% initial ICP above normal limits) correlated with the very poor final outcome (85% mortality). Only one of the 12 patients with normal initial ICP continued to have low pressure throughout the course. High dose thiopental failed to control severe intracranial hypertension in 29 patients (44%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 17 patients (26%) and a definitive control in 12 patients (18%), among them the 10 survivors in this series. In the authors experience once ICP is controlled, and unless haemodynamic instability compells action to the contrary, barbiturate should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

There are not systematic studies of the CSF hydrodynamics in adult patients suffering non-neopI astic obstruction of the aqueduct. In this work we analyze intraventricular pressure (IVP) and CSF Pressure/Volume relationships in 17 juvenile and adult patients affected by non-tumor aqueductal stenosis. The degree of hydrocephalus and the site of the aqueductal stricture was demonstrated in all these cases by means of pneumoventricuIography. Some patients had CT scans.

The authors describe four cases of subependymoma studied with computed tomography (CT) and review 18 previously reported cases in an attempt to define the most characteristic CT presentation of this rare, benign tumor. Subependymoma usually appears as an isodense, or even hypodense, intraventricular tumor on plain CT scan and shows minimal or no enhancement in postcontrast studies. Differential diagnosis between subependymoma and the more malignant true ependymoma is difficult, particularly when the tumor occurs in the posterior fossa. Recognition of subependymoma should prompt the surgeon to attempt radical tumor removal because it can be achieved without sacrificing contiguous tissue and carries a good prognosis.

Two hundred twenty five patients with intracranial lesions underwent diagnostic and therapeutic stereotactic surgery during the period 1978–1985. In the first 98 cases target coordinates were determined by transferring the information from the CT images to the standard stereotactic films. In the remainder, a simple, CT adapted stereotactic system has been used. Operations were as a rule performed under local anaesthesia. Positive histological diagnosis using paraffin embedding was achieved in 96% of the patients (biopsy success rate). Therapeutic procedures included abscess and cyst aspiration, cyst shunting, interstitial (Ir 192) or intracavitary (Y 90) irradiation and ventriculocisternostomy. Stereotactic surgery implied a refinement of the eventual therapeutic management in 90% of the cases. Transient neurological deficit occurred in 5.7% of the patients and there were three deaths (mortality rate 1.3%). Infection or other complications were not seen. The rationale and indications for non-functional stereotaxis are discussed.

Eighteen children with severe head injuries and diffuse brain swelling were studied. They were separated into two groups based on the computed tomography (CT) findings. Seven patients had small ventricles in the normal location and small or absent cisterns. Eleven had these signs plus small deep-seated intraparenchymal hemorrhagic foci and/or intraventricular hemorrhage. Patients in the first group were in relatively good neurological condition; their intracranial pressure was easily controlled and all had a favourable outcome. On contrast, children in the second group had a more severe clinical presentation, frequently had uncontrollable intracranial hypertension, and more than 50% died.

✓ Two cases of intermittent exophthalmos are reported. In both instances, cerebral angiography and orbital venography failed to outline the lesion, which was clearly demonstrated with the aid of computerized tomography. An orbital varix was seen to be the cause of proptosis in one surgically verified case, whereas in the other this same diagnosis was suspected on the basis of the clinicoradiological findings. The etiology, clinical manifestations, and management of orbital varix are briefly discussed.

Most often pseudotumor cerebri occurs as a self-limiting disease but in many cases it follows a chronic course threatening the patient’s visual function (Boddie et al. 1974, Gucer and Viernstein 1978, Johnston and Paterson 1978). Since the occurrence of both remissions and relapses in cases of pseudotumor cerebri is usually established on clinical grounds without determining the changes in CSF pressure the outcome of this entity and the effectiveness of the current methods of treatment are not well known at the present time.

Favorable results have been reported with the use of barbiturate induced coma in patients suffering from intracranial hypertension of various origins (Rockoff et al. 1979). However it is still doubtful whether high dose barbiturates greatly influence the outcome of head injury patients presenting severe intracranial hypertension (SIH), (Miller 1979). Because of the difficulties and the high risks of this type of treatment we limited its use to patients in a very poor neurological State in whom raised ICP could not be controlled by conventional means.

A group of 78 severe head injury patients showing computerized tomography (CT) findings of the so-called “diffuse axonal injury” is analyzed. These patients represent 20% of the authors' series of severe head injury. Twenty-three patients showed small intraparenchymal haemorrhages in the CT scan study, 15 intraventricular haemorrhage and 40 patients had both intraparenchymal and intraventricular haemorrhages. Signs of brainstem haemorrhagic contusion were seen in 29 (38%) patients. Generalized brain swelling superimposed on the above findings was present in 75% of the cases. Raised intracranial pressure, which was found in 50% of the patients, correlated with the presence of ventriculocisternal collapse in the CT scan and an unfavourable outcome. Only 4 patients in this series made a good recovery, 13 developed a moderate disability, 11 a severe disability, 12 became vegetative and 38 (49%) died. The prognosis with this post-traumatic lesion is the worst in the authors' severe head injury series after excluding cases with subdural haematoma.

✓ The clinical, radiological, and histopathological features of 21 cases of angiographically occult intracranial vascular malformations (AOIVM's) are analyzed, and a review of 241 additional appropriately documented, histologically verified cases collected from the literature is presented. In all, there were 115 (43.8%) arteriovenous malformations, 82 (31.2%) cavernous angiomas, 26 (9.9%) venous angiomas, 10 (3.8%) cases of capillary telangiectasis, and 29 (11%) mixed or unclassified angiomas. The result of the analysis shows that there are no essential differences in the patterns of clinical presentation, the computerized tomography (CT) appearance, or the surgical prognosis among these pathological types of vascular malformations. Certain histological features common to all AOIVM's (such as the small caliber, the more or less complete thrombosis of the malformed vessels, and the changes induced in the surrounding brain tissue by repeated microhemorrhages) seem to determine the biological behavior of the anomaly rather than the predominant type of vessel involved. Thus, subdivision of AOIVM's into the four classical pathological types has little practical value. Most AOIVM's are visualized by the CT scan and show a rather typical appearance. Surgical removal, which prevents rebleeding and ameliorates or suppresses seizure activity, is usually easy to perform and represents the treatment of choice for patients with clinically symptomatic AOIVM's.

Since Computed Tomography (CT) has been available in common neurosurgical practice, the term diffuse brain injury has been used to define a lesion which excludes both gross contusive lesions and intra- or extracerebral hematomas (Becker et al. 1977, Snoek et al. 1979, Papo et al. 1980, Gennarelli et al. 1982). The clinical findings, the intracranial pressure (ICP) and the CT images have been weltdocumented in patients with diffuse cerebral swelling (Sweet et al. 1978, Bruce et al. 1981). A good correlation has been demonstrated between CT examinations and gross autopsy findings in the so-called diffuse shearing injury of the white matter (Zimmermann et al. 1978).

The authors review the literature on subarachnoid haemorrhage of unknown aetiology (SAHUE) and analyze a personal series of 212 patients diagnosed as SAHUE. These patients represent 30% of all cases of primary SAH admitted over a 14.5 year period. The age, sex, antecedents and initial clinical presentation of patients with SAHUE were indistinguishable from those of patients with subarachnoid haemorrhage due to ruptured aneurysm (SAHRA). However, the present series of SAHUE compare favourably with both a personal and a previously reported series of SAHRA insofar as clinical grade on admission (94% of patients in grades I-II of Botterell), presence of blood on CT (51%), vasospasm (5%), ischaemic deficits (3.3%), persistent hydrocephalus (3.5%), rebleeding (6%) and fatal result (3.9%) are concerned. The amount of blood on CT scan in our patients with SAHUE was associated with a significantly higher incidence of brain ischaemia and hydrocephalus but did not correlate with the Botterell grade on admission or final outcome, which were good in the majority of cases regardless of the presence or not of visible cisternal haemorrhage. The results of the present series confirm that the final prognosis of patients with primary SAH showing normal four-vessel cerebral angiography is essentially favourable.

✓ Satisfactory control of intractable pain has been achieved in 17 terminal cancer patients by injecting small doses of morphine into the lateral cerebral ventricle via an Ommaya reservoir. Pain relief together with a favorable behavioral response was obtained without interference with other sensory modalities, noticeable physical changes, or side effects annoying or severe enough for the patient to discontinue therapy. Eleven patients developed tolerance, but this phenomenon does not require withdrawal of treatment. Chronic intraventricular morphine administration can be safely performed on an outpatient basis, and results in control of midline, bilateral, and diffuse pain associated with orofacial and disseminated cancer. However, this experience is preliminary and further clinical trials are needed to determine the place of this method of therapy in the management of chronic pain.