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In a 30 years period, 42 children were admitted for optic nerve and chiasm gliomas; 20 patients aged less than 5 years and 22 between 6 and 16 years. Duration of symptoms ranged from 13.15 months in children aged less than 5 years, to 10.18 months in patients aged more than 6. Onset of symptoms were characterized by visual impairment and/or proptosis in 73.8%, diencephalic disorders in 16.6% and intracranial hypertension in 9.5%. All patients underwent skull X-rays; 31 had a PEG taken and 12 a CT scan. Surgery was prompted in 27 patients, 2 of which died in postoperative course. Radiotherapy was the treatment of choice in the other 15 patients, 40 patients were followed up: the best results were obtained in the group of patients operated on and irradiated.

Intraventricular hemorrhage (IVH) is usually the result of life-threatening intracranial bleedings eventually leading to death. Early ventricular drainage is suggested as a possible means of reducing fatalities. The retrospective analysis of 80 patients with CT diagnosed IVHs has indeed shown that early drainage prolongs significantly survival before death but does not influence mortality. Clinical and CT grading still remain fundamental prognostic indexes accounting for the irreversible hemorrhagic lesion. Thus ICP monitoring and ventricular drainage may be useful only in selected patients with alterations of consciousness of intermediate severity and sluggish evolution.

Forty-one children with severe head injuries and diffuse brain lesions were selected from a consecutive series of 62 children in traumatic coma (21 focal mass lesions) and studied. According to the CT pattern, two main types of intracranial lesions were considered: diffuse axonal injury (DAI) and diffuse brain swelling (DBS). High mortality, due to secondary increases of intracranial pressure (ICP), correlated well with the patterns of severe DBS, absence of perimesencephalic cisterns, and obliteration of the ventricles. However, children with normal CTs, and/or obvious shearing injuries indicative of DAI, had favorable outcomes; there was no mortality if increased ICP was not present. We conclude that although there does not seem to be any routine indications for ICP monitoring in children with pure DAI, early ICP monitoring and aggressive management of increasing ICP should be considered in comatose children with DBS, especially when associated with subarachnoid hemorrhage and respiratory or circulatory failure.

This study deals with 390 cases of severe traumatic coma in infancy, childhood and youth, aged between 4 months and 19 years. Cases in which unconsciousness lasted less than 24-48 hours have not been considered here. 161 patients were operated upon for intracranial space-occupying lesions or for open head injury: extradural haematomas 60; extradural haematomas + brain lacerations and/or subdural haematomas 16; acute subdural haematomas 18; brain laceration 36; open head injuries 17; decompressive operations, hydromas and contusions 14. 102 patients recovered and 59 died. 229 subjects were given only to resuscitation treatment. 164 recovered and 65 died. Recovery and mortality rate are discussed in relation to the pathologicial lesions and to the clinical picture (severity, evolution and duration of coma). Overall mortality rate was 31%. Mortality was higher in operated patients (36.6%) and lower in patients in whom space-occupying lesions were not demonstrated by angiography and who underwent only resuscitation treatment (28%). The lowest rate was observed in cases of extradural haematoma (25.4%) and open head injury (23%). Highest mortality rate have been observed in cases of decerebrated coma (with or without signs of low brain stem impairment). Complete recovery can be achieved even after prolonged decerebration. 31 patients showed the typical picture of the "apallic syndrome": in 28 cases after prolonged decerebrated coma, in 3 cases after coma without decerebration. Of our 31 cases, 4 died, 4 are still in a chronic apallic state and 23 recovered. Of these, 10 patients had a remarkable recovery and 13 remained severely disabled.

Over the past 4 years 11 patients with Cushing's disease have been operated on by a transsphenoidal microsurgical technique. All patients had small intrahypophyseal adenomas found at operation. Eight of the 11 patients had a remission of the disease on the basis of clinical evaluation and hormonal studies. The endocrinological results revealed a transient state of hypocorticism in all successfully treated patients. Within 6-8 months after operation recovery of hypothalamic-pituitary-adrenal function and other tropin function took place. These findings, together with the absence of recurrence up to now, further confirm the efficacy of transsphenoidal surgery in the management of patients with Cushing's disease.

Primary intracranial rhabdomyosarcoma (RMS) is a rare tumor in infancy and childhood that is found in various locations in the central nervous system. The clinical course worsens rapidly, and the final outcome is poor, with a median survival time of 8-10 months. Invasion of the meninges, spontaneous intratumoral bleeding, spinal leptomeningeal CSF spreading of tumor cells, and early recurrence of the mass are the distinctive features of RMS. Diagnosis of RMS may be missed: immunohistochemical staining using specific markers (myoglobin, myosin, desmin, vimentin, enolase), along with ultrastructural studies, provide the basis for making the final diagnosis. Treatment of RMS includes surgical excision, craniospinal radiation therapy, and chemotherapy. We report two cases of primary RMS in the CNS located in the posterior fossa and frontotemporal area. Both children underwent total surgical removal of the mass. Early recurrence of the tumor mass was noticed in both patients 2 months after surgery. Both children died shortly thereafter.

After the transition state of decerebrate coma, at least four different kinds of the so-called apallic status can be identified: 1. Complete apallic syndrome: coma vigil, alertness without any awareness, mass movements only, impairment of sleep rhythm, absence of any emotional responses, postural abnormalities, some primitive motor responses, tetraplegia, and alteration of muscle tone. 2. Incomplete apallic syndrome: some of the features of the complete apallic syndrome are lacking, and the patient shows emotional reactions with appropriate grimacing and some appropriate motor responses. 3. False apallic syndrome: most signs of complete apallic syndrome are present, but the patient is in touch with the environment. This condition is somewhat similar to the so-called locked-in syndrome. 4. Functional apallic syndrome: full clinical picture of the complete apallic syndrome but full recovery within a few days. Long-term results in 62 patients, aged between 4 and 62, affected by a post-traumatic complete apallic syndrome are reported. Thirty two patients were operated upon and 30 were not operated upon. Out of these cases, 38 died after weeks or months; 3 patients entered a chronic apallic status; 2 patients are improving; 10 recovered with severe neurological or psychic sequels or both; 4 recovered with minimal sequels, and 5 without sequels; no patients in these two last groups were aged more than 20.

Seven patients, presenting severe neurological status (grades IV and V according to Hunt and Hess) and cerebral vasospasm following subarachnoid haemorrhage were submitted to continuous ICP recording the study of the cerebral elastic properties by PVI compliance computation. All the patients presented low ICP values (below 20 mmHg) for the whole period of monitoring. The results of PVI and compliance measurements show that the pressure-volume curves in these patients are different from the physiological P-V curve. The PVI values progressively increase with the rise in ICP. The significance of this finding is discussed.

The effects of propofol on cerebral blood flow velocity, cerebrospinal fluid pressure, cerebral perfusion pressure and mean arterial pressure were studied during induction in 25 patients scheduled for elective craniotomy. Premedication consisted of only atropine sulphate 0.007 mg/kg (im) 45 min before induction. Measurements were made or derived at time zero and 1, 2, 3, 4 and 5 min after an induction dose of propofol (2.5 mg/kg). Patients were retrospectively stratified into two groups, according to cerebrospinal pressure basal values: (i) lower than 10 mmHg (10 pts) and (ii) higher than 10 mmHg (15 pts). Cerebral blood flow velocity, measured by transcranial Doppler, fell in all the patients, but the reduction was significant at 1, 2, 3 and 4 min only in the group with high CSF pressure, while it never reached the critical value of 10 cm/s. Cerebrospinal fluid pressure and mean arterial pressure decreased in both groups of patients and the fall reached a statistical significance at 1 and 2 min in the group with higher baseline CSF pressure, only at 1 min: a parallel decrease of CPP was recorded, but it was not significant. Thus propofol decreases CSF pressure without hazardous effects on cerebral blood velocity and on cerebral perfusion pressure and seems to be a suitable anaesthetic agent in controlling high cerebrospinal fluid pressure in neuroanaesthesia.

The effect on the exercise tolerance induced by a new selective beta1-receptor antagonist, metoprolol, given by a single administration per os, has been evaluated in 16 patients with stable angina pectoris. The study was a double blind cross-over between metoprolol 100 mg and placebo. Patients were hospitalized for the time required for the performance of the study; every cardioactive drug, except for trinitrine, was stopped 72 hours prior to the study period. Exercise testing was performed two hours after the intake of the drug, in a sitting position on a bicycle ergometer; the workload was increased by 25 Watts increments every two minutes. Compared to placebo, the total workload performed and duration of exercise increased after metoprolol (P less than 0.001), heart rate decreased (P less than 0.001) both in the resting state and during exercise test, systolic blood pressure didn't change in the resting state but decreased during exercise test (P less than 0.01), pressure-rate product, an useful index of changes in myocardial oxygen consumption decreased both in the resting state (P less than 0.001) and during exercise test (P less than 0.001). It is concluded that metoprolol induces a significant increase in exercise tolerance. This is due to a marked reduction in oxygen myocardial consumption resulting by both decreased heart rate and systolic pressure.

75 children ranging in age from 3 months to 14 years, operated on for post-traumatic cerebral lacerations, within an 18-year period, have been analyzed. These represent 2.1% of 3,460 children sustaining head injury and hospitalized during this same period. Total mortality was 16%. The cases were divided into 2 groups: (A) cerebral lacerations underlying a depressed fracture (coup lesion) -- 68 cases. In 42 cases the lacerations were focal without edema and/or intracerebral hematoma. 1 child died and 41 survived. In 26 cases the laceration was diffuse and accompanied by cerebral edema and/or intracerebral hematoma. 6 children died and 20 survived. (B) Brain lacerations following a contrecoup lesion -- 7 cases, 5 of these children died and 2 survived. The follow-up of the surviving patients in the above two groups has been discussed.

A series of 185 patients operated on with extrathecal shunts for non-neoplastic aqueductal stenosis has been reviewed. The longterm results of 84 of them, followed-up for 2 to 20 years after primary surgery, are illustrated and critically analyzed. This study indicates that a normal mental development or normalization of mental and neurological conditions can be expected in a high percentage of patients after the CSF diversional procedure which nonetheless is still associated with a high percentage of even serious complications.

A new model of traumatic axonal injury has been developed by causing a single, rapid, controlled elongation (tensile strain) in the optic nerve of the albino guinea pig. Electron microscopy demonstrates axonal swelling, axolemmal blebs, and accumulation of organelles identical to those seen in human and experimental brain injury. Quantitative morphometric studies confirm that 17% of the optic nerve axons are injured without vascular disruption, and horseradish peroxidase (HRP) studies confirm alterations in rapid axoplasmic transport at the sites of injury. Since 95% to 98% of the optic nerve fibers are crossed, studies of the cell bodies and terminal fields of injured axons can be performed in this model. Glucose utilization was increased in the retina following injury, confirming electron microscopic changes of central chromatolysis in the ganglion cells and increased metabolic activity in reaction to axonal injury. Decreased activity at the superior colliculus was demonstrated by delayed HRP arrival after injury. The model is unique because it produces axonal damage that is morphologically identical to that seen in human brain injury and does so by delivering tissue strains of the same type and magnitude that cause axonal damage in the human. The model offers the possibility of improving the understanding of traumatic damage of central nervous system (CNS) axons because it creates reproducible axonal injury in a well-defined anatomical system that obviates many of the difficulties associated with studying the complex morphology of the brain.

In a series of 180 patients affected by brain stem tumors, 70 cases of children up to 16 years are analyzed. Diagnosis was made with clinical examinations, neuroradiological tests and, in 20 cases, with surgical explorations. A description is made concerning the clinical status with regard to site, extension and features of the tumor. Then the authors analyze statistically the survival of such patients in connection with clinical symptomatology, the radiological picture, medical treatment, radiation and/or surgical therapy either in the few cases of subtotal removal of the tumors, or in the more numerous cases of palliative procedures such as intra- and extra-thecal CSF shunting.

Thirty-six patients with SAH were submitted to continuous ICP monitoring: in 33 cases a continuous ventricular fluid pressure recording was performed in acute stage. According to Hunt and Hess, 2 patients were graded I, one II, one III, 13 IV and 16 V. In the remaining 3 cases who developed a normal pressure hydrocephalus 15, 20 and 40 days from bleeding an extradural miniaturized transducer was applied. B and C waves were common findings in acutely recorded patients. Typical A waves accompanied base line recordings in patients with NPH. From analysis of data the authors evidenced that elevated ICP values have been registered not only in patients graded as III, IV and V but also in those graded I and II: as 89% of patients belong to grades IV and V it was impossible to correlate clinical status with ICP. In patients with spasm it was never noted ICP values higher than 20 mmHg during recording time (from 60 hours to 10 days). In order to reduce intracranial hypertension CSF drainage was performed in 33 patients acutely registered. In patients graded I and II this procedure was followed by an ICP reduction and an improvement of the clinical status. In none of the patients graded IV and V in spite of pressure maintained at 10 mmHg, CSF drainage affected clinical evolution.

A total of 76 shunt-treated hydrocephalic children were examined at least once between two and 12-years after surgery to determine what skull changes had occurred and to assess the children's intellectual status. The high incidence of skull changes in shunt-treated, non-tumoral, hydrocephalic children was confirmed. A strict relationship existed between skull changes and low intracranial pressure. The results indicate that impairment of mental development parallels the degree of skull changes, suggesting a close relationship between impaired mental development and cerebrospinal fluid hypotension.