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✓ The authors have analyzed their experience with intracranial pressure (ICP) monitoring in 207 patients over a 4-year period. Patients with either high-density or low-density lesions on computerized tomography (CT) at admission had a high incidence (53% to 63%) of intracranial hypertension (ICP persistently over 20 mm Hg). In contrast, patients with normal CT scans at admission had a relatively low incidence of ICP elevation (13%). Among these patients, three features were found to be strongly associated with the development of intracranial hypertension: 1) age over 40 years; 2) systolic blood pressure under 90 mm Hg; and 3) motor posturing — unilateral or bilateral. When two or more of these features were noted at admission, the incidence of intracranial hypertension was 60%, as compared to 4% when only one, or none, of these features were present. Thus, the patients at high risk for developing intracranial hypertension after severe head injury are those with abnormal CT scans at admission, and those with normal CT scans who demonstrate two or more of the above-mentioned adverse features. Based on these criteria, only 16% of this series of patients with normal CT scans would have qualified for monitoring. In addition to the three clinical features noted above, multimodality evoked potential (MEP) studies were also found to be strong predictors of ICP elevation in the normal CT scan group, with a 75% incidence of intracranial hypertension in patients with disseminated deficits. There was no statistically significant correlation between the Glasgow Coma Scale score, eye movements, pupillary reaction, hypoxia, or anemia at admission and subsequent ICP elevation in the group with normal CT scans. In this series, an intraventricular catheter was used as the sole monitoring device in 91% of the cases. In the remaining 9%, subarachnoid screws were employed, either alone, or upon failure of the ventriculostomy. While no mortality was directly ascribed to the monitoring process, there was a 7.7% complication rate (infection 6.3% + hemorrhage 1.4%). Eighty-five percent of the infections occurred in patients who had been monitored for 5 days or more, while no infections were noted in those monitored for less than 3 days. Used judiciously, this technique can be valuable in the monitoring and treatment of the brain-injured patient.

The recently described "spindle cell oncocytoma of the adenohypophysis" is a very rare and often misdiagnosed entity. A benign biologic behavior has been suggested based on the absence of recurrences with a median follow-up of 3 years. Herein, we present 2 cases of recurrent spindle cell oncocytomas. One patient is a 71-year-old woman (case no. 1) and the other a 76-year-old man (case no. 2). Recently, both underwent transsphenoidal reexploration for recurrent "pituitary adenoma." Patient no. 1 had initial surgery 11 years ago with a recurrence after 3 years that was initially stable. Ultimately, a partial resection was performed after compression of optic pathways by the tumor, and approximately 1 year later, re-resection was carried out. Patient no. 2 had initial surgery 10 years ago with recurrence and resection after 3 years. He recently presented with a large mass that involved the pituitary fossa and base of the skull, with extension into the nasopharynx and nasal cavity. The primary and recurrent lesions of both cases showed similar architecture with interlacing fascicles of spindle cells that alternated with areas of epithelioid-like cells that exhibited eosinophilic, granular cytoplasm. Neoplastic cells were positive for vimentin, S-100 protein, and epithelial membrane antigen, and negative for glial fibrillary acidic protein, chromogranin, and pituitary hormones. Increased mitotic activity was noted in 1 lesion (case no. 2), although both cases had high Ki-67 indices (18% and 20%, respectively). The ultrastructural features of both cases were characteristic with intracytoplasmic accumulations of large mitochondria. The histopathologic features of these lesions are consistent with spindle cell oncocytoma of the adenohypophysis. In summary, we are reporting 2 cases of recurrent spindle cell oncocytoma of adenohypophysis with longer follow-up than previously published cases, suggesting the possibility of a more aggressive behavior than has been initially considered.

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Sinus histiocytosis with massive lymphadenopathy (SHML) is an uncommon disorder that typically manifests as systemic symptoms and lymphadenopathy. Extranodal, intracranial disease is uncommon. The authors report on a 15-year-old adolescent girl who had a suprasellar mass at magnetic resonance imaging. Biopsy results demonstrated lymphophagocytosis consistent with a diagnosis of SHML. The clinical, radiologic, and histologic aspects of the disease are discussed.