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Improvements have been made concerning circulation on the road. At the same time there has been a reduction of head trauma.

Large supratentorial arteriovenous malformations (AVMs) of the carotid system are vascularized by the ipsilateral internal carotid artery (ICA) and often, in addition, by the contralateral ICA via the anterior communicating artery (ACoA). In these AVMs we have previously advocated (1981) multiple staged operations with the progressive reduction of the blood stream passing through the AVM. In twenty-two cases, starting in 1983, the reduction of the blood stream into the shunt has been performed as a first operation by placing a clip on the middle of the ACoA through a pterional approach on the opposite side of the AVM before radical open surgery. Results were excellent when considering the control angiogram and the measurement of the blood velocity in the ICA opposite to the AVM side. There were no neurological complications and no mortality.

Between 1972 and 1989, 131 unruptured intracranial saccular aneurysms were clipped in the Neurosurgical Department of La Pitié Hospital, Paris. Only 89 of these are considered here, the remaining 42 aneurysms having been discovered and clipped during surgery for a ruptured aneurysm. All isolated unruptured aneurysms were detected by angiography, computerized tomography or magnetic resonance imaging. Twenty out of the 89 aneurysms were asymptomatic ("incidental") while 69 were accompanied by clinical symptoms indicating radiological examination. It is generally accepted that in ruptured aneurysms the mortality rate during 3 days following the rupture is about 50 percent, and for this reason many neurosurgeons are in favour of unruptured aneurysms being treated either by open surgery with clipping of the aneurysmal neck or by inserting a balloon into the aneurysmal sac. The results obtained in 377 published cases, including ours, justify this approach: no recurrent bleeding was observed after open surgery and the mortality rate was nil when the contra-indications of surgery were respected. There was a permanent morbidity of less than 2 per cent directly related to the surgeon's experience.

Dandy was the first to describe the successful removal of a colloid cyst in 192110. Initially a variety of open surgical approaches were described mainly through the frontal horn of the lateral ventricle or through the corpus callosum and although these were attended by considerable mortality and morbidity in the past12, 13, 23,24, 34, modern microsurgery has revolutionized the management of these conditions1, 27. The two series reported here by classical neurosurgical techniques, from Zurich and London, indicate that complete excision of these tumours may now be achieved with low mortality and morbidity. Since 1975, an increasing number of reports have described aspiration techniques avoiding craniotomy5, 11, 15, 17,29,30,31 and a series from Homburg/Saar is described using these techniques. The ventriculoscope has been employed stereotactically or freehand29 (Calliauw) and a brief description of the modern ventriculoscope is appended from Brussels.

Using a Doppler Mark 500 of ATL we measured the systolic and diastolic velocity of the red cells into the main arteries of the neck (diastolic rate cm/sec) thus approaching the flow in two cases of upper brain stem AVM with a unique drainage into the superior longitudinal sinus through an enlarged vein of Galen and a falcine sinus. Because of the desperate clinical condition of the children it was decided to stop the high blood flow by closing the aspiration coming from the low pressure of the venous system above and below the site of union between the malformation and the superior longitudinal sinus. An intra-operative and post-operative measurement of the diastolic rate showed a radical effect of the closure of the superior longitudinal sinus. The demonstration of this aspirative factor has allowed us to classify an AVM as a haemodynamic push-pull malformation.

This paper concerns the historical developments and technical properties of haemostatic devices used in neurosurgery with the exception of coagulation. Therefore there are described haemostatic clips designed for the scalp, clips used on arteries and veins, a clamp for the reduction of the carotid diameter in the neck, and a clamp for closing the venous dural sinuses. Special reference will be made regarding non ferro magnetic Phynox clips by Aesculap.

The rupture of a saccular aneurysm during a direct attack can led to a disastrous result unless deep hypotension has been induced before the dissection. If the mean pressure recorded through a microcatheter introduced into the radial artery is at 30 mm Hg level or below the rupture remains circumscribed and the operative field can be dried easily with adjustable suction wherever the situation of the rupture may be. This technique was used in 52 cases with the operative microscope which enables, a clear vision of the lesion and of its vicinity. The mortality was 2, or 3.8%, in spite of 34 operative ruptures.

After reviewing the literature with respect to hemodynamic factors in AVM the authors describe their experience monitoring the blood volume under induced arterial hypotension. They have been able to select cases which presented disorders of the vascular autoregulation of the brain and represent, for this reason, a challenge to a radical excision; in such cases they advise to remove the AVM in several programmed stages. In addition it was possible to predict the efficiency of the hypotension on AVM vessels pressure during operation enabling the surgeon in case of positive effect of the hypotension to realize more securely the haemostasis. Moreover, the authors present the first data regarding the mean circulatory time the knowledge of which seems very promising. The last 33 cases of a series of 179 radical removals have been monitored before and in some cases after operation; the knowledge of these hemodynamic factors allowed the surgical team of La Pitié to extend the surgical indications for radical removal to AVM recently considered as inoperable.

SUMMARY Eighteen acromegalic patients were studied 8 months to 5 years after transsphenoidal selective adenomectomy in order to evaluate the most reliable criteria for assessing the efficacy of treatment. Dynamic growth hormone (GH) studies were performed after administration of oral glucose (OGTT), thyrotro-phin-releasing-hormone (TRH) or l-dopa, and after insulin-induced hypogly-caemia. Insulin-like growth factor (IGF) was measured by means of a competitive protein-binding assay which detects all somatomedins, particularly those which are GH-dependent. Of the 18 subjects reported in our study, five showed clinical symptoms of persistent acromegaly. After oral glucose, seven patients had minimum plasma GH levels above 5 ng/ml, five had GH levels between 5 and 2 ng/ml (three of whom maintained a positive GH response to TRH), and six had minimum plasma GH values below 2 ng/ml. Only the latter six patients had normal IGF levels; however, one was still responsive to TRH and three did not increase their GH plasma levels after insulin or l-dopa administration. Thus, our data suggest that the criteria used to assess the cure of acromegaly should be more rigorous than those generally applied. When plasma GH levels remain above 2 ng/ml after OGTT, it is doubtful that the cure is complete. A positive GH response to TRH after neurosurgery indicates incomplete removal of the adenoma. The lack of a GH response following insulin-induced hypoglycaemia and l-dopa administration suggests that the initial somatotroph dysfunction persists. Finally, high plasma IGF levels point to residual GH overproduction. The definition of cure in acromegaly should involve stricter biochemical criteria than those currently in use.

When the ventricular fluid pressure has reached a level of 120 to 150 mm H2O, there is a risk of rapid internal herniation. The effects of corticoids and hyperosmolar drugs on this are not as striking as they are on brain oedema. The only efficient therapy is the establishment of an external ventricular drainage system proposed for the first time in 1941 by Ingraham and Campbell and regulated with a valve system by Whiteet al. 1967. From our experience of 202 cases we review the technique, the indications, and the complications of ED.

The senior author's experience has been reviewed in 353 operated meningiomas; so called “malignant meningiomasch” have been discarded. The whole series has been split into two groups: the first (A) includes 273 cases operated before the CT era, the second (B) consists of 80 cases the operability of which was based mainly on the CT. In addition, during the time elapsed to constitute the second series surgery has been refused to 15 patients which were considered for CT and clinical reasons as surgically incurable when one wants to reduce the risk of mortality and morbidity. Therefore, we have reviewed in series B indisputable, questionable and incurable cases with respect to operability in the present condition of our technical possibilities including arterial hypotension, the operative microscope and the CUSA. Considering localization, we have made technical observations with respect to the principles on which operations have been based since 1958 when general anaesthesia became available in La Pitie. Among the patients of the whole series, 14 were admitted for a recurrence. The time interval between surgery and readmission has been given as well as the primary location of the meningiomas. The mortality rate has been 26 out of 353 (7%), and the main causes have been reviewed especially in series B. With regard to series B, we have been able to get in touch with 53 patients out of 80; 90% of them returned to work or family without sequelae. Intracranial meningiomas remain the most curable tumours, nevertheless some of them must be considered incurable like in meningiomatosis or when the dural attachment is extensive. For those cases surgery is not the final answer and we must accept the fact that in the future other kinds of treatment will develop.

In the course of hydrocephalus treated by ventriculoatrial shunt revision operations are often necessary mostly for elongation of the catheter. After several revisions it may became difficult or even impossible to introduce the catheter into the auricle through the jugular vein. The authors report on 19 direct cardiac implantations using a medial sternotomy. Operative technique, complications and results are described. This approach proved to be very safe and useful and seems to be superior to the thoracotomy already recommended by other neurosurgical teams. But it is not recommended for children under the age of 3 years.

In many patients with cerebral lesions, the degree of natraemia was normal, but it was nevertheless possible to establish the existence of an antidiuretic hypersecretion by means of free water clearance measurement or the determination of the Na + ser K + rbc ratio. These conditions might often be improved by a combined treatment of ACTH and weak doses of posterior pituitary extract.

The concept of the use of arterial hypotension as an adjuvant in neuro-surgery was first proposed by Cushing in 1917: he observed that in the locally anaesthetized patient haemorrhage during operation was followed by arterial vasoconstriction and subsequently a dry operating field. This observation was radically different from that of Bayliss (1902) who had noticed that arterial hypotension in animals under general anaesthesia was followed by dilatation of the arteries of the brain.

The authors have searched for oestrogene (RE) and progesterone (RP) receptors in 22 cases of meningiomas. Hormone receptors were determined on the cytosol and nuclear fractions of tumor tissues, using synthetic oestrogen R 2858 and progestin R 5020 in conditions where exchange was nearly achieved. The receptors were considered as present for values equal or higher than 100 femtomoles per gram of tumour tissue (fmol/gT). For the 22 studied cases the RE were present in 13 cases (59 p. 100) with values between 100 and 500 fmol/gT in 9 cases and higher than 500 fmol/gT in 4 cases. The RP were present in all cases (100 p. 100), with values between 100 and 500 fmol/gT in one case, between 500 et 5 000 fmol/gT in 13 cases and higher than 5 000 fmol/gT in 8 cases. The results were compared with neuropathologic data obtained by light microscopy. The clinical and biological significance of results are discussed.

The authors advocate to operate grades I, II and III patients on the 6th or 7th day following the onset of SAH, that is to say between the "oedema" period and the rebleeding period. They study all investigations and therapy which are necessary previously to the operation and advocate to perform a CT scan as the first investigation as well as to control the intraventricular pressure. Their opinion is based on the study of 316 cases admitted over a period of 5 years 218 have been operated upon by a team of 7 neurosurgeons with an overall mortality of 18.3 p. 100. The mortality in grade I and II patients has been 13.3 p. 100. This percentage includes all fatalities occuring in the six months following surgery. The senior author assumes that a good audio-visual teaching of the trainees can improve the results.

This chapter contains a review of the present status of the management of non-traumatic intracerebral haematoma in Europe. The questionnaire was addressed to the Editorial Board of Advances and Technical Standards and the views expressed represent a consensus of major interests throughout Europe.

The paper is based on the experiences which have been collected and analyzed from a total of 237 cases in the Neurosurgical Departments at the University Clinics La Pitie, Paris, and Homburg/Saar. The senior authors are the Heads of these Departments. Both Departments have different traditions according to the different history of French and German neurosurgery. As might be expected the senior authors did not agree on all points. The divergencies of opinions and policies have not been concealed but considered important and openly discussed in our paper in order to give an as large a view as possible. In the end we feel that with regard to rhinorrhea the old proverb remains true, more than one road leads to Rome.

The 250 patients of this series, whatsoever was the location of the aneurysm, were operated radically on the 6th and 7th day following the rupture. That is to say at the end of the brain swelling period and before the rebleeding period. During these 5 or 6 days the blood pressure was stabilized by a daily intake of diazepam (15 to 30 millig); 10% only of the patients were resistant; in these cases clonidine was used. During this period antifibrinolitic agents were not given as well as antioedematous therapy. No case of rebleeding was observed in this series under this therapy.

A series of 162 arteriovenous malformations (A.V.M.) surgically removed is reported. All patients had a post operative control angiogram showing that the lesion had been totally excised. Supra and infra tentorial A.V.M. are included in the series as well as conscious and comatous patients. The overall mortality has been 11.1% and the mortality in conscious patients has been 6.9%. Mortality is higher when the volume of A.V.M. is over 60 cm3 and when a rupture has occurred. The influence of the operation on epileptic seizures, motor, speech or visual fields deficits has been reviewed in 109 patients who answered to the survey. Morbidity has been higher in patients with a cerebral heamorrhage, therefore the authors advise to operate these patients before the rupture when, for instance, seizures represents the only clinical picture. C.A.T. scan in these epileptic patients is a remarkable investigation to track down A.V.M.

The findings in 107 pathological studies of meningeal hemorrhages due to rupture of arterial saccular aneurysms are reported. There were 62 women (58 p. 100) and 45 men (42 p. 100). Mean age was 56, lower in men (53) than in women (58). 45 aneurysms of the Anterior Communicating Artery, 26 of the Middle Cerebral Artery, 15 of the Internal Carotid Artery, 10 of the Anterior Cerebral Artery, 1 of the Anterior Choroidal Artery and 10 of the Posterior System were studied. These ruptured aneurysms were compared to 31 non ruptured ones. Mean size of the ruptured aneurysms was 10, 62 mm, not statistically different from that of non ruptured aneurysms (9, 05 mm). Multiple aneurysms represent 10 p. 100 of the whole ruptured aneurysms population. They affected mostly the Middle Cerebral Artery. High blood pressure had been present in 56/107 cases of ruptured aneurysms (52 p. 100). The prevalence of high blood pressure in patients with ruptured aneurysms (men: 60 p. 100 between 35 and 49, 63 p. 100 between 50 and 64; women: 31 p. 100 between 35 and 49, 54 p. 100 between 50 and 64) was statistically higher than in the same age and sex ranges of the general French population. The other causes of bleeding were rare: 4 liver cirrhosis (2 of the patients were also hypertensive) and 5 anticoagulant therapies (2 of which were also associated with high blood pressure). Intracerebral hematomas were found in 43 cases (40 p. 100): 39 lobar, more frequent in the frontal (26) than in the temporal (13) lobes, due mainly to Anterior Communicating Artery and Anterior Cerebral Artery aneurysms; very few were in the basal ganglia (3) or brainstem (I). Intraventricular hemorrhage was found in 39 cases (36 p. 100). Forty (37 p. 100) cerebral infarcts had occurred. They were located in the territory of the same artery in 20 cases (19 p. 100), in a different territory in 11 cases (10 p. 100), in both in 9 cases (8. p. 100).

One thousand extemporaneous examinations performed in the neurosurgical department over a nine years period have been reviewed. The purpose of these examinations was to deal with the following points: - presence or absence of a tumor, - primary or secondary nature of this tumor, - appreciation of the malignancy degree. It seems possible to draw the following conclusions: The frequency of false diagnoses was not significantly different from the one observed in out precedent series. On the other hand, with experience, the number of "approximate diagnoses" was strongly reduced. Some special diagnosis problems were discussed. The importance of the clinical data in establishing a correct diagnosis was emphasized.