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A 67-year-old man with generalized fatigue and weight loss developed hyponatremia. Endocrinologic examination demonstrated panhypopituitarism. Magnetic resonance imaging showed a pituitary mass extending slightly to the suprasellar region. Transsphenoidal resection of the tumor was performed. Histological examination found exclusively granulomatous tissue with cholesterol clefts, and no epithelial component. This cholesterol granuloma may be classified as xanthogranuloma of the sellar region.

We had the opportunity to closely observe a unique case of central diabetes insipidus (DI), in which dramatic changes in both radiological findings and hypophysial functions were seen. A 63-year-old female developed central DI, and magnetic resonance imaging (MRI) revealed a mild thickening of the pituitary stalk and lack of hyperintense signal associated with normal neurohypophysis on T1-weighted images. About three months later, the stalk was found to be remarkably expanded like neoplasm; however, anterior pituitary functions were almost normal on that occasion, except for the absence of GH response to an insulin tolerance test. About nine months after the onset of DI, secondary hypoadrenalism and hypothyroidism, which required replacement therapy, developed transiently, but recovered about one year later. Results of hypophysial endocrine tests during this period showed that the dysfunction was predominantly suprapituitary in nature. As time passed, the stalk lesion began to shrink spontaneously and another MRI, obtained five years after the onset of DI, disclosed normal findings for the infundibulo-hypophysial system, except for lack of the hyperintense signal of the neurohypophysis. The patient has since been healthy, except for the DI, which has been controlled by treatment with vasopressin. We report here a unique case of central DI associated with transient pituitary stalk enlargement.

We encountered a case of traumatic basilar artery dissection presenting with "locked-in" syndrome. A 46-year-old-man fell approximately 2 meters and landed in an inverted position. He was admitted to our hospital after 4 days. He was in coma on admission, and neurological examination revealed that his pupils were 2 mm in size and reactive, the corneal reflex of both sides was absent, the pharyngeal reflex was absent, and quadriplegia was present. CT and MRI showed infarction at the ventral portion of the pons. 3D-CT and CT using a bone algorithm showed fractures of the upper clivus, the left petrous bone, and the left occipital condyle. Angiography showed a pearl and string sign at the upper basilar artery. It is suggested that the cause of the infarction of the ventral portion of the pons was the occlusion of the perforating arteries due to the basilar artery dissection, and the mechanism of the basilar artery dissection was the hyperextension or hyperflexion of the basilar artery by the movement of the brain stem caused by the traumatic impact. Repeated angiography revealed gradual improvement. Eventually he freed himself from the "locked-in" syndrome.

Eight cases of central neurocytomas were studied by immunohistochemistry and electron microscopy. Seven tumors were located in the lateral ventricles and one in the subependymal region. All but one patient had a favorable postoperative course. The tumors were composed of small uniform cells possessing amitotic round nuclei with frequent perinuclear halos, a few Homer Wright rosettes and no ganglion cells; an appearance resembling that of oligodendroglioma. Immunohistochemical studies disclosed neuron-specific enolase and Leu-7 positivity in all tumors, S-100 protein-positive cells were found in six, while glial fibrillary acidic protein--and vimentin-positive cells were confined to the blood vessels. Myelin basic protein as well as neurofilament were not detected in the tumors. Synaptophysin-positive areas were seen in one tumor. Ultrastructural examination showed distinctive neuronal tumor cells which had a cytoplasm with sparse dense-core vesicles and thin cell processes containing parallel microtubules. They were classified into three different types of tumor cells according to the extent of differentiation. The most consistent finding for histological diagnosis was the presence of typical or abortive synapses with clear and dense-core vesicles. Additionally, synaptophysin may be a specific marker for some central neurocytomas.

Two cases of germ cell tumors (GCTs) of the basal ganglia are presented and 40 previously reported cases are reviewed. The incidence of GCTs of the basal ganglia and thalamus was estimated as less than 14% of all intracranial GCTs. All patients except for two (95%) were male, aged 7-19 years. The clinical course was usually slow. The major symptoms were hemiparesis, mental deterioration such as dementia or character change, precocious puberty, diabetes insipidus, oculomotor palsy, speech disturbance, and hemianopsia. Signs of intracranial hypertension did not occur until the late stages of the disease. The plain CT finding was characterized by an irregularly defined, slightly high-density area frequently accompanied by central low-density areas without significant mass effect. The tumors showed mild to moderate and nonhomogeneous contrast enhancement. An ipsilateral cerebral hemiatrophy was often found. MR images demonstrated the corresponding findings. GCTs of the basal ganglia had a high possibility of containing components other than germinoma such as choriocarcinoma, endodermal sinus tumor, and embryonal carcinoma. Thus, tumor markers in the serum, CSF, or cyst fluid were frequently positive. With recent refinement of microsurgical techniques as well as immunohistochemical study and measurements of tumor markers of serum, CSF, and cyst fluid, major resections of tumor, accurate pretreatment histologic diagnosis, and early determination of the specific types of this tumor appear to be readily possible. This is essential for effective treatment of patients not only with radiosensitive germinoma, but also those with radioinsensitive nongerminoma variants and a combination of them located in this region.

This report describes the clinical course of pituitary apoplexy induced by a single dose of bromocriptine in a 50-year-old woman with acromegaly. The patient suddenly complained of diminished vision and headache 2 hours after the oral administration of 2.5 mg of bromocriptine. Her visual symptoms and headache persisted for several days. The basal plasma GH concentration decreased from 76.2 ng/ml to 37.2 ng/ml the day after the attack of apoplexy and to 3.0 ng/ml on the 9th day. The authors assess the changes in endocrine findings related to pituitary apoplexy and also emphasize the necessity to view with caution any symptomatic change during bromocriptine therapy.

Nine (15%) of 60 patients with repaired myelomeningocele exhibited late deterioration of neurological function with a tethered cord syndrome. Dense adhesions at the lowest laminae and at the site of previous repair were the most common findings at surgery. Postoperatively, 71% of the patients improved. Magnetic resonance (MR) imaging was performed in 29 of the 60 patients. Eight of these 29 patients exhibited a tethered cord syndrome. The MR images in all patients showed a low-lying conus fixed at the site of previous repair, irrespective of the presence or absence of a tethered cord syndrome. The MR images were classified into two groups depending upon the site of adhesions: Group A had potential sites of tethering at the ventral aspect of the last laminae and at the site of previous repair, and Group B showed the adhesion point only at the site of previous repair. Most patients with a tethered cord syndrome were found to be in Group A; conversely, most patients without the syndrome were in Group B. An enlarged low conus was seen in symptomatic patients more commonly than in those without this syndrome. It is concluded that the presence of adhesions specifically at the last laminae as well as a widened low-lying conus may be the cause of tethered cord syndrome in patients with repaired myelomeningoceles. A clear understanding of the tethering process and preoperative evaluation of potential sites of tethering, based on the MR findings, are very important for planning surgery. The release of adhesions at the lowest laminae by laminectomy appeared essential for improvement.

Specimens from operation of 211 sellar and juxta-sellar tumors were observed histopathologically, and discussed about the true form of "cholesterol granuloma reaction" in those tumors. Depending on the characteristic histological feature, "cholesterol granuloma reaction" was classified into 3 groups, each of which also represented a step of process of organization. Group I (cholesterol clefts predominates in hemorrhagic and necrotic foci), group II (foreign body giant cells, macrophages, round cell infiltrations are present other than cholesterol clefts, signifying active organization), group III (numerous cholesterol clefts predominates in fibrous scar tissue). Feature of "cholesterol granuloma reaction" were seen in 6 cases among 37 cases of craniopharyngioma with verified histology (16%), 8 among 165 in pituitary adenomas (5%) and 1 among 5 in pituitary epithelial cysts (20%). In addition, there were 4 cases in which histologic sections of the surgical specimen showed only the feature of "cholesterol granuloma reaction", in the absence of tumorous epithelial components. "Cholesterol granuloma reaction" is thought to develop as a secondary reaction to hemorrhage or tissue necrosis (pituitary adenomas), or to keratinization (craniopharyngiomas). In occasions in which surgical specimen show only a feature of "cholesterol granuloma reaction", making the final diagnosis is necessary to be careful, taking account of other lesions as well as craniopharyngiomas.

Thirty-two cases of pineal cyst diagnosed by magnetic resonance imaging (MRI) were reviewed and are described. The pineal cyst was demonstrated to be an area with slightly less intensity than the surrounding tissue and with slightly greater intensity than the CSF on T1-weighted images. On the T2-weighted images this lesion was identified as a high-intensity area with smooth margins and was homogeneous in nature. In three cases presenting with headache, compression of the vein of Galen was identified, and compression of the quadrigeminal plate was demonstrated in five cases. No patients presented with both pineal and quadrigeminal lesions. Of the cases, 63% were not detected by CT scanning alone. There were two cases in which the cyst ruptured and collapsed spontaneously during follow-up. It is emphasized that the presence of this lesion, which was more frequent than previously expected, should be kept in mind when diagnosing pineal tumors and should not be misdiagnosed. Surgery should not be undertaken unless the lesion produces symptoms due to the compression of the quadrigeminal plate, aqueduct, or the vein of Galen.

Post-shunt subdural hematoma was found in two patients with hydrocephalus due to subarachnoid hemorrhage. The first case was a 46-year-old man with two episodes of subarachnoid hemorrhage from anterior communicating aneurysm. Two weeks after neck-clipping for the aneurysm, a ventriculo-peritoneal shunt with Pudenz's system was performed since hydrocephalus with moderately increased pressure had been found. He did well for one month, then soon after mild head injury, disorientation and right hemiparesis developed. Cerebral angiogram revealed avascular space in the left parietotemporal region. After the ligation of the shunt tube, subdural hematoma was removed. The symptoms improved in two weeks. The second case was a 62-year-old man with an aneurysm at the trifurcation of the right middle cerebral artery. One month after successful clipping of the aneurysm, he received a ventriculoperitoneal shunt with Pudenz's system for normal pressur hydrocephalus. One and a half years after the operations he hit his head against the ground during his convulsive seizure. Since then, disorientation, urinary incontinence and gait disturbance appeared. After cerebral angiogram, the subdural hematoma was removed and the shunt tube was ligated. He became free of these symptoms in two weeks. The cerebrospinal fluid shunt is recommended for hydrocephalus induced by subarachnoid hemorrhage, but careful follow-up is necessary since these patients might develop post-shunt subdural hematoma, especially after head trauma as shown in our cases.

Three cases of intraspinal tumors associated with hydrocephalus were encountered and treated. This review includes 67 cases, including these 3 cases, and discusses the pitfalls associated with intraspinal tumors presenting with hydrocephalus. These tumors are not easily diagnosed, especially in cases where the chief complaint, due to hydrocephalus, is headache or dementia, and does not include back pain. Among the 67 cases reviewed, symptoms suggesting normal pressure hydrocephalus were particularly noticed in patients over 40 years old. In cases presenting with headaches or dementia, back pain corresponding to the tumor location may appear after a shunt operation or external ventricular drainage. This postoperative back pain is important in indicating the presence of an intraspinal tumor.

The squamous cell nests which appear to have developed in the base of pars tuberalis are studied electron microscopically. A fresh pituitary was obtained from a 59-year-old white woman, who underwent hypophysectomy to reduce the pain due to the breast cancer. Each squamous cell nest was completely enclosed by the basal lamina, consisted of squamous cells, and sometimes contained adenohypophyseal parenchymal cells. The squamous cells were classified into cells in the basal layer and those in the spinous layer with intercellular bridges. Most of the former cells (B cells) possessed a nuclear membrane of strong interdigitation, well-developed desmosomes and tonofibrils. Adjacent to the squamous cell nests, there were acini which consisted of adenohypophyseal parenchymal cells, a few agranulated stellate cells, follicular cells in rare cases. As no transitional types between the B cells and the adenohypophyseal parenchymal cells were observed, B cells may not be said that they have been formed through the direct metaplasia of existing adenohypophyseal parenchymal cells. In view of the morphological similarities of the earliest B cells to the stellate cells, of the close positional relationship between the squamous cell nests and the acini and between the adenohypophyseal parenchymal cells and the squamous cells, and of the past reports that squamous cell nests increase in number with aging, B cells appear to originate from the stellate cells.

Two rare cases of subdural fluid collection are reported. In these cases, the subdural space was in direct communication with the lateral ventricle through the congenital brain defects. The subdural fluid was formed by the cerebrospinal fluid which passed from the lateral ventricle through the brain defects. The difficulty to diagnose these cases from the usual subdural hygroma is emphasized.

The authors present morphological findings in the brains of rabbits, dogs, cats, rats, and mice that have been used as experimental hydrocephalic models. The methods used were as follows: (1) silicone oil injection into the cisterna magna and the neighboring basal cisterns in rabbits by the method of Wisniewski; (2) kaolin administration into the cisterna magna in rabbits and dogs (Dixon); (3) ballooning method with Foley's catheter into the 4th ventricle in rabbits (Milho-rat); (4) plug formation with small pieces of laminalia into the cisterna magna in rabbits by our method; (5) Hy-3 hereditary hydrocephalic mouse bred by Gruenberg; (6) ligation of the placental vessels of the pregnant rat at 13 days of gestation by our method, and (7) transplacental intraperitoneal administration of ethylnitrosourea in a pregnant rat at 9.5 days of gestation. The models with silicone oil, kaolin, laminalia, and ballooning methods produced obstructive hydrocephalus with various grades of ventricular dilatation. The models with the ethylnitrosourea-induced method, ligation of placental vessels, and Hy-3 mouse produced prenatal hydrocephalus. Dilatation of the ventricular system and histological abnormalities do not occur as a uniform process.

To clarify the functional characteristics of prolactin (Prl)-producing adenoma cells, the effect of TRH, prostaglandin E1 (PGE1), theophylline, dopamine and dopaminergic antagonists on Prl secretion was examined in vitro in perifused pituitary adenoma tissues obtained at surgery from 8 patients with prolactinoma. Perifusion with TRH at a concentration of 10(-6) to 10(-5) M resulted in a significant increase in effluent Prl levels in 3 of the 8 adenoma tissues. In the remaining 5 adenomas, TRH produced no effect on Prl release in vitro. On the other hand, PGE1 (10(-5) M) stimulated Prl secretion in 2 of the 4 adenomas examined. Addition of theophylline (5.5 mM) caused a marked increase of effluent Prl levels in all 8 prolactinomas regardless of the reactivity to TRH or PGE1. Dopamine (5 X 10(-7) M) suppressed Prl secretion from adenoma tissue in 5 of 7 patients tested but had no effect in the remaining two adenomas. When perifused simultaneously with dopamine, sulpiride (D2-selective dopamine receptor blocker, 5 X 10(-7) M) blocked the inhibitory effect of dopamine on Prl release in 3 of the 4 dopamine-sensitive prolactinomas. In one adenoma responsive to dopamine but resistant to sulpiride, YM-09151-2 (relatively specific D1-dopamine receptor blocker, 5 X 10(-7) M) antagonized the dopaminergic inhibition of Prl release. When perifused alone, neither sulpiride nor YM-09151-2 affected Prl release from any of the adenoma tissues tested.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of trigeminal neuralgia caused by a contralateral calcified chronic subdural hematoma is reported. Preoperative magnetic resonance imaging revealed rotational displacement of the pons caused by huge chronic subdural hematoma. The neuralgia was completely alleviated after removal of the hematoma. The clinical and radiological features are described, and the possible mechanism of the neuralgia is briefly discussed.