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Clinical and radiographic features of 63 patients with a vascular malformation of the brain stem are described. On radiological grounds they were divided into two groups: one with angiographically visible lesions (AVAVMs), the other with lesions not seen angiographically, that is, occult (AOVMs). In the first group the initial clinical manifestation was due to haemorrhage in 20 of the 33 cases and consisted of a progressive neurological deficit in 12. In the second group 29 of the 30 initially presented with a brain stem haemorrhage. The latter was often characterised by development of symptoms over two days or more (16 cases), absence of headache (48 cases) and tendency to recurrence (20 cases). Clinical diagnosis was difficult in many cases especially in the AOVM group. Several of the patients were misdiagnosed as having multiple sclerosis. Clinical data in conjunction with magnetic resonance imaging were helpful in determining the nature of these lesions. [ABSTRACT FROM AUTHOR]

A case of angiographically occult brainstem vascular malformation presenting solely with pathological laughing and crying is reported. Although this emotional syndrome has been seen in association with several different pathological entities, review of the literature failed to identify its occurrence as the only clinical expression of angiographically occult brainstem vascular malformation, or as a solitary symptom in any disease. Our data suggest that pathological laughing and crying can occur without any other manifestation of pseudobulbar palsy. An attempt is made to correlate this patient's clinical and radiological findings. This case was treated by stereotactic Bragg-peak proton beam therapy. [ABSTRACT FROM AUTHOR]

Congenital arteriovenous malformation (AVM) of the brain represents a defect in capillary development resulting in a high flow fistula between arterial and venous systems. In this study, AVM hemodynamics were related with clinical findings. Volume flow was calculated based on transcranial Doppler (TCD) and angiographic data. Forty patients admitted to the Massachusetts General Hospital for proton beam therapy (33 +/- 10 yr old; mean +/- SD) were studied. Four symptoms were considered: intracranial bleeding, progressive neurological deficit, seizures, and headache. Fourteen control subjects aged 30 +/- 7 years (mean +/- SD) were normal volunteers. Angiography with calibrated markers permitting magnification correction was available for all patients. Lateral and medial depth limits of the intracranial basal arteries in relation to the TCD temporal window were determined by TCD and angiogram with excellent correlation. Selected depth for data acquisition was determined independently in the angiogram and by TCD. The difference between the two techniques was less than 4 mm. Mean flow velocity, pulsatility index, and vessel diameter were studied. Flow volume was calculated from these data. Mean flow velocity, pulsatility index, vessel diameter, and flow volume were significantly different among AVM feeders, non-feeders, and control arteries. The non-feeding middle cerebral artery, anterior cerebral artery, and posterior cerebral artery flows were 254 +/- 13, 136 +/- 14, and 79 +/- 8 ml/min, respectively. Accordingly, the estimated cerebral flow volume was 938 ml/min. The feeding middle cerebral artery, anterior cerebral artery, and posterior cerebral artery flows were 552 +/- 47, 369 +/- 70, and 484 +/- 67 ml/min, respectively (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

We studied two patients with angiographically documented cerebellar venous angioma (malformation) and angiographically occult vascular malformation of the brain stem. One patient had recurrent hemorrhage in the pontine tegmentum. The second patient had recurrent hemorrhage in the midbrain. None had hemorrhage originating from the abnormal cerebellar venous channels. The more benign nature of angiographic venous malformations is supported by the cases we are presenting, as well as from a review of the literature, which includes an autopsy study of similar cases. The management of multiple vascular brain lesions is contingent on the verification of symptomatic pathological blood vessels. It is emphasized that angiographically occult vascular malformation could possibly exist in the vicinity of angiographic venous malformation when the patient with intracerebral hemorrhage, especially in the posterior fossa, was diagnosed as having venous malformation.

A technique to apply reconstructed X-ray computed tomography (CT) and magnetic resonance imaging (MRI) for target determination in stereotactic Bragg peak proton beam therapy of intracranial lesions was developed. Twenty-one benign intracranial tumors and vascular abnormalities were managed using this technique. Clinical features of these lesions, as well as targeting problems associated with the MRI and CT image interpretation, are presented.

The need for improved specificity in the diagnosis of "occult" vascular malformations led to the use of MR in suspected cases in order to determine MR's potential for improved diagnostic accuracy. Six patients with six lesions histologically diagnosed as vascular malformation after partial (1) or complete (5) microsurgical excision were studied by CT, MR, and selective magnification subtraction angiography. In all cases, the cerebral lesions were apparently solitary and were visible as focal lesions on both CT and MR. Since angiography failed to reveal the pathologic blood vessels of the lesions, and no arteriovenous shunting was evident, these lesions were termed vascular malformations occult to angiography (VMOTA). Angiography revealed a mass effect in only two cases. MR did not reveal additional vascular malformations missed by CT. In each case, MR, which was performed in an attempt to support the diagnosis suggested by CT, did in fact do so by revealing signal abnormalities indicative of nonacute hemorrhage within the lesion on T1- and T2-weighted pulse sequences. Although, as on CT, MR features of these lesions were found to be nonspecific, the MR criteria reinforced the probable diagnosis of VMOTA in an additional 30 cases that had shown similar nonspecific CT features. In this second group, excluded from this study, in which histologic verification was not obtained because of perceived hazards of surgery, the increased assurance regarding the diagnosis led to proton-beam therapy without histologic verification in 18 cases. It is concluded that MR can provide significant improvement in the accuracy of diagnosing VMOTA beyond that obtainable just by plain and contrast-enhanced CT.

A study was undertaken to determine the length of time that human pituitary tumours are capable of releasing anterior pituitary polypeptide hormones in vitro under basal conditions and to study the spectrum of hormone release by functioning and "non-functioning" pituitary neoplasms. Fragments from the pituitary tumours of 10 patients in the following categories: 1 Cushing's disease, 2 with amenorrhoea-galactorrhoea, 3 with acromegaly, and 4 with "non-functioning" pituitary tumours and from 2 normal human anterior pituitary glands were placed in primary culture immediately after surgery. The in vitro release of human growth hormone (hGH), prolactin (Prl), thyrotrophin (TSH), adrenocorticotrophin (ACTH), luteinizing hormone (LH), and follicle stimulating hormone (FSH) was measured by specific radioimmunoassays at the end of each week in culture. Hormone release was surveyed from 6 weeks to 6 months depending upon the survival of the culture. Hormone release patterns were compared with clinical and pathological data. In the initial week of the study, all 6 anterior pituitary polypeptides were detected in the media from the 2 control pituitaries and from 4 of the tumours (1 amenorrhoea-galactorrhoea and 3 acromegaly) in concentrations up to 100 ng/ml of medium while 5 of the 6 hormones were readily detectable in the media from 2 additional tumour samples (Cushing's disease and 1 "non-functioning" pituitary tumour). The media of the remaining 4 tumours contained at least 3 of the 6 hormones (1 amenorrhoea-galactorrhoea and 3 "non-functioning" pituitary tumours). After 6 months in culture, the 6 hormones were readily detectable in at least 1 of the 5 surviving cultures and hGH (up to 800 ng/ml) and LH were each detectable in the media from 2 cultures. Although most of the hormone concentrations in the media decreased with length of time in culture, there were 2 exceptions. First in the media from 5 of the 12 cultures from both controls and tumours, Prl concentrations increased after 50 to 80 days culture. This increase usually lasted for several weeks before Prl levels again began to decline. The second unusual finding occurred in a tumour from a patient with acromegaly in the media of which hGH levels rose from 60 ng/ml to 800 ng/ml between days 125 and 174. These findings of prolonged hormone release in vitro give promise of future usefulness of tissue culture methods for study of polypeptide hormone releasing mechanisms and long-term production of human anterior pituitary hormones for use in research and possible therapy.

Administration of estrogens to acromegalic patients has been shown to reduce the serum concentrations of bioassayable somatomedin and to cause improvement in clinical status. These effects appear not to result from an effect on the secretion of growth hormone since growth hormone concentrations are not consistently reduced. Using a sensitive radioimmunoassay for somatomedin-C, we have assessed the relationship between the estrogen-induced reduction of somatomedin-C and changes in several indices of disease activity in five acromegalic patients. Statistically significant reductions in serum somatomedin-C (p < 0.02), urinary hydroxyproline (p < 0.05) and the phosphate clearance ratio (p < 0.01) occurred within three days of the institution of treatment with 1 mg ethynyl estradiol daily. Unlike the consistent reduction in serum somatomedin-C erratic changes in growth hormone were observed. The decline in serum somatomedin-C was not due to an estrogen-induced increase in somatomedin-binding proteins since total serum somatomedin-C concentrations measured after treatment of serum with acid also were reduced by estrogen therapy, and the magnitude of this reduction was equivalent to that observed in untreated serum. The study indicates that the reduction of immunoreactive somatomedin-C correlates with estrogen-induced improvement in the metabolic activity of acromegalic patients and suggests that measurement of somatomedin-C may be useful in monitoring the effects of other drugs on this disease.

The authors measured blood pressure changes non-invasively in 56 conscious, unpremedicated patients with cerebral arteriovenous malformations (AVMs) during preparation for proton beam therapy. The procedure requires six injections of local anesthetic and application of a stereotactic frame by fixation into the outer table of the skull, and has been used during the past 20 yr to treat over 1,000 patients with cerebral AVMs. No effort was made to control blood pressure. Blood pressure increased during administration of the local anesthetic and application of the frame. Maximum systolic and mean arterial pressures averaged 160 +/- 17 and 118 +/- 7 mmHg (mean +/- SD), respectively. This represented an average increase of 44 mmHg (38%) in systolic pressure and 32 mmHg (37%) in mean blood pressure at some point during the procedure (P less than 0.01 compared with pretreatment control pressures). Systolic pressure increased more than 60 mmHg in 21% of patients. Nevertheless, none of these 56 patients nor any of the more than 1,000 patients treated in similar fashion suffered a clinically evident AVM hemorrhage during the procedure. Since the treatment protocol has not changed materially during the past 20 yr, the authors assume that most patients treated in this fashion developed a similar degree of hypertension and conclude from this large clinical experience that moderate arterial hypertension does not precipitate spontaneous hemorrhage of intracranial AVMs.

Although a probable initial diagnosis may be suggested by computed cranial tomography, the diagnostic accuracy is often increased by the complementary use of other neuroradiologic studies. The use of CT scanning is conjunction with other more invasive neuroradiological studies results in improved diagnosis and patient management in almost the entire spectrum of neurosurgical diseases-- subarachnoid hemorrhage due to aneurysm, stroke, trauma, normal pressure hydrocephalus, and especially neoplasms.

We measured serum concentrations of somatomedin-C by radioimmunoassay in 57 acromegalic patients and compared them with various indicators of disease activity. The mean fasting somatomedin-C concentration was 6.8 U per milliliter (range, 2.6 to 21.7) for the acromegalics and 0.67 U per milliliter (range, 0.31 to 1.4) for 48 normal, fasting adults. The somatomedin-C concentration correlated significantly with: heel-pad thickness (r = 0.73), fasting glucose (r = 0.74), and one-hour postprandial glucose (r = 0.77). In contrast, "glucose-suppressed" growth hormone correlated weakly (r = 0.34, 0.36, 0.34) with these clinical indexes of severity. Fasting growth hormone levels showed no correlation (r = 0.14). Five active acromegalics had "normal" growth hormone levels after glucose suppression, but they had elevated somatomedin-C. In 15 patients studied one year after treatment, changes in somatomedin-C concentrations paralleled the degree of clinical improvement. Measurement of somatomedin-C appears to provide a reliable means for confirming the diagnosis of acromegaly and of clinical disease activity than measurement of growth hormone concentrations.

A case of subdural tension pneumocephalus is presented. Computerized cranial tomography permitted rapid diagnosis including localization of the air, thus facilitating prompt treatment. Tension pneumocephalus should be considered in a patient with a cerebrospinal fluid drainage device who deteriorates after craniotomy.

A total of 30 patients with pituitary adenoma was studied by sagittal polytomography en route to coronal and axial computed tomography (CT) cisternography after a low FDA-approved dose of 6 ml of 170 mg I/ml metrizamide via lumbar injection. The requirement for defining the relation of the optic nerves and chiasm to the intrasellar contents or suprasellar mass before proton beam irradiation or certain surgical approaches was satisfied. Pneumoencephalography as a supplemental procedure to CT and CT cisternography was replaced. The concomitant elimination of conventional sellar polytomography and pneumoencephalography results in decreased total radiation exposure and a more comfortable, expeditious workup.

A series of 709 patients with inaccessible AVMs treated with the proton beam is reported. There is a follow-up time of over 2 years for 92% of the patients. AVMs have slightly lower thresholds for proton injury than does normal brain tissue. Proton beam therapy involves very low risk. However, the risks of treatment failure grow with inadequate therapeutic doses.

With tomography and encephalography of 78 cases with primary Cushing's disease, changes in the appearance of the pituitary gland and fossa have been demonstrated in greater numbers than previously reported. One or more direct or indirect signs of enlargement of the pituitary gland either by hyperplasia, microadenoma, or adenoma occurred in 60 per cent. Most of these cases were unproved as to cell type because they were given proton beam therapy. There were more cases of pituitary enlargement in those with adrenalectomy in comparison to non-adrenalectomy cases and in those with pigmentation in comparison to non-pigmented cases. The high incidence of pituitary gland enlargement in the different phases of this disease supports the importance of this gland in the pathogenesis of primary Cushing's disease. Limitation in correlation of the pituitary fossa to size of the pituitary gland when the latter enlarges only slightly has been discussed.