✓ The authors review 37 cases of primary aneurysms of the vein of Galen reported in the literature and present five new ones. The magnitude of the shunt from arterial feeders to the primary aneurysm indicates the age at which the patient's symptoms first appeared as well as the nature and severity of those symptoms. Newborn infants have intractable heart failure, older infants have hydrocephalus, and adolescents have headache and syncope. Four clinical categories, based on the time of onset of symptoms, are described, and the diagnostic studies and surgical techniques discussed. Four-vessel angiography and ligation of the feeding vessels at the point of entry into the vein of Galen are recommended.

This paper summarizes the clinical presentation, location, surgical management, and results in 32 patients with cerebral aneurysms. Surgical mortality has been 21.9% for aneurysms (all grades). For good risk aneurysms (Botterell 1 and 2), the surgical death rate was 8.0% (2/25). Clinical presentations and techniques of treatment are summarized.

In an attempt to derive a consensus for rational therapy of craniopharyngioma, pertinent recent literature has been reviewed. By seeking answers to specific questions, I have tried to remove personal bias from the conclusions. A consensus is suggested.

The influence of intracranial pressure (ICP), systemic arterial pressure (SAP), and cerebral perfusion pressure (CPP) upon the development of vasogenic cerebral edema is largely unknown. To study their relationship, the authors have produced an osmotic disruption of the blood-brain barrier unilaterally in rabbits by injecting 1 cc/kg of 2M NaCl into the left internal carotid artery. The amount of vasogenic edema produced was assessed by quantitation of the extravasation of Evans blue dye into the area of maximum blood-brain barrier breakdown by means of optical densitometry following formamide extraction. The ICP was measured using a cisterna magna catheter into which mock cerebrospinal fluid could be infused at a predetermined pressure. The SAP was controlled by exsanguination from a femoral artery catheter. In 18 animals in which blood pressure was not controlled, no significant relationship between the ICP and the degree of Evans blue dye extravasation was noted. In these animals, however, a direct relationship between CPP (defined as mean arterial pressure minus mean ICP) and extravasation of Evans blue dye was found (correlation coefficient 0.630; p less than 0.001). When ICP was held constant at 0 to 5 mm Hg in another group of 16 animals and different levels of blood pressure were produced by exsanguination, a significant direct relationship between extravasation of Evans blue dye and the SAP was found (correlation coefficient 0.786; p less than 0.001). In a third group of 20 animals, the blood pressure was held constant at 90 to 100 mm Hg and the ICP was varied between 0 and 75 mm Hg. There was a highly significant result indicating increasing Evans blue dye extravasation with lower levels of ICP (p less than 0.001). Cerebral blood flow determinations by the hydrogen clearance method indicated loss of autoregulation in all animals in the areas of brain injured by intracarotid hypertonic saline. These results indicate that high SAP and low ICP (that is, a large CPP) promote Evans blue dye extravasation in this model of blood-brain barrier disruption. This finding has implications for the management of patients with vasogenic edema.

✓ Four patients with hydrocephalus due to membranous obstruction of the fourth ventricle are presented. This rare entity produced radiographic and clinical findings suggestive of posterior fossa tumor. Operative findings included normal cerebellar development and a translucent membrane just above the foramen of Magendie. Etiological possibilities are discussed.