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Pineal region: Surgical management of tumours and vascular malformations
Pineal R ion: Sur#cal M nagement of Turnouts and Vascular Mmlfo ations Enriqu¢ C G. Vem~¢e~*~, MAX, ER.C.SACL FoA,C.S.
From August, 1977, to April, I980, 11 patients were ape=ted on for lesions in and aroand the pineal ~olon. The ~adndogy consisted o~ 8 yamaha, 1 giant arteHovenous maiformati~ of ~ ¢ vein of Galen, I #.ant anenrysm of the ~sterlor cerebral a~e~', and 1 VenOUS malformation of the vein of Galen. A different tactical approach ~ s used, depending o~)n the t~atlon and the type of l~ion, The ~ s e n t series d~umcets the f~ibili~, of the direct sur#cal attack on vascular and tumoural lesions of the pineal region with low morta|it~ and no morbidity. Tactical and technical aspects a ~ discussed. Neu~) 16:~7-.~. 198)
TF~, s~ar~k:a)m a n a ~ ¢ n t o( i~ions ifi the envim~ of tile pineal gland re~ins c o r , ~ v ~ i a l "ut,A has challe)~ged nE?arosurgmns for generatio~.s 11-34]. In I910, Sit Vicu)r Hor~ley lnade one of the first attem~t~ to approach the pineal regiert ti~rough the posterior fos~ [ 12]. His re~alts in two c ~ s convinced him tha~ his appre~ch was nor the best and that in the ~ture he w ~ l d Frya supratentoriai approach. Ever since Hordey'~ pioneering ex~ri. encc& there ha~ ~ n an ongoing COntroversy concerning the ~ t modalitv of ~eatment for turnouts arising ~om the pineal ~x~JyI2, 5, 6, ~ 1 I , 13, 15, 19~ 21, 22, 25-28, 31, 33). ~ m e ~J£~o~ have ~owed a prefierence itrr the direct suwical attack. Whereas e.Chershave advocated a ce~'ebrospihal fluid shunting pr,~edute followed by radiotherapy, reserving the direct su~ical approach for r~ose turnouts or lesior~ that appear r~9~ radioresistant [ 11.13, 15, ]~8, 19, 22, 23, 2 % ~ L The ~ird position is by t))ose
From ~h*: D~v}s)on t~t Nt:u~'~JJrgea', ChiIdren'~ He~pilat e~: ~ t c m
On.
advt~ating the value at a stereorac,ic biopsy which is fob )ov~.{ by radiation d)e~apy
Pm'*'een August, 1977. and April, 1980. a total of 11 patients wc~e oDeratoJ uFon for lesions in the pineal region. Table I zes infotraat{on about them patients. Tl~Ere were 7 m~fcs and 4 |creoles; ages mng~d from 6 munths to 31 yea,s, w(r]x a mean age t.ff 10.5 VEa~, Eight patients had tumot~r~ and 3 patients had va~:ular malformations, in 8 patient, there we~ simms and symptoms of i ~ r ~ . t inlaCmrltaI p.-~sure ~a¢ondary to ok~activc hydroceN'~du~. Limiation of coniugaa upward gaze was obvious in 7 patients. [n 2 patients diabetes imipidus was lhe iniriM complaint. Interestin~b'. the~ was no incidence of prec~Jous p~g~cr~yfmmd in ~his series. There were inC Ievels of at#a-re n in the serum a ~ curehal fluid (CaSF) d Parien~ 2 in keeping with O~e mixed histo~o#cal characteristics of hi~ pineaJ ttimour. Ro~Jtine roentgenog~mz of the &uIt were done in every patient, and in 5 pa0ents, the diagnosis of a pineal lesk~n was Confirrr-~d. ()~mputeri~d aDhy {f.~) of Ib~e brain was al~ peK~t~,~3 in eve~ g~tient, con~rming the diagrams in m~t ~ (Figs, !, 2L In a&litk~ ~o the roentgenograms of the skull and the ~ scan, carotid and vertebral angiograms were made in every patient in order m PJle Oat a vascular matformaoon or to asse~sthe va~ularity d the PJmOIIr. T ~ of the vascular malformatinn~ were well demomtmted, bt~r cerebral anti y failed to demonstrate the wscular nature of the l~ion in Patient 9 [30]. In the rest of the patients, cerebral angiography was not particularly co~ributo~' :n the diagnmis or in the decision/'or tl~e ~r~cal , lri addition to the above*~ntioned neumradiologicai investigations, 4 patienr~ had air studies after decompre~ion of the ven~cdar system with a ventricutoperitoneal shunt or extem~t ventricular drainage. The air s~adies did not contribute Fard~er to dia~c~is ar~A m
erxL
l~ p t . ~ e ~ v e svadi~.a, elevated leveIs of ~r~m arm ~ F A&&~ t~fint reque~ato ~ . E G G. Vmrure}ga.~tikaren', Hc~pt~al alpha-fetoprotein we~ found in Patient 2, and the elevated d~ ~tarlo, 40t Sm}.thPM..Ott~z KIH 8Lt, CMtafio,~ M a , levels of this bio-maker showed fluctuation wi~ the in, Key~ : pinealregion;pinealn!motw,¢w~eiptt~itran~entoriMapproach; c~: ... ~ie,al cistern; ~ant ~,~oalmtmifivrmatiommcxiaiitie~~ t~a¢- stiWtton of cobak ~erapy and chemotherapy and with the cheat. rec of the namour{ t 71. The inal fluid ex•390-301918t1070077.05501.Z5 @ 19S0 by Litd,, Bro~aaand :~rapany (inca 77
ARe (~+)
i6+M
9,V
+4+M
3I,M
5
6
+I
8
6,F
I +M
9
|O
%*m2iJL~*t Lea++~
~p+~ +v+t ii+++~+)
~,M
4
Vein eft Galen,
++'~:ir~~ Chief)
PineobL~.+tom+)
I++ne+~++.+~m+~++
A+tmcFtom +
T+:mlom++
I ++J~.{
+~
Mi+ted l~11~inom~ :rod en&xletmal +itms t~+t~+t+t O+mlr~+m+
~++++o++ +*;+ +. +++;+
12+M
+L~J ~x
2
~t[etr~ N(), :
~m,Jrcm¢
hr+i+, he, it
" | |CP,
~ iC+P
p~dnn+M++ +re+Prone, + I{+P P+trin~m|'s +)mdmmc+ I ICP
| I~P, a*+,~++ P;+|I)+~++J'+ +++mlmme+ h+r++ip;tlesi+ p ICY, +~t+xi.a
~+~l~rt)me +
l++,++~+mJ'.,+
|+~I+tm i~++pb]+m
P+ttitl;lu~J'+* ~yrt+jrtm~¢+t+ ICP
(++~l)~+t P++++el)t;+t+ort --+~++,+..
Ye~
Yc~
Y*'~
Ye+
Y++
Ye+
Ye+
Ye+
Y'cs
Yes
Ye~
Ye.~
Ye+
Ye~
Yes
+Yes
Y+~+ Ye+
+++~ (++
(."T
N~)
Ye,+
Nt~
No
N<)
N+
Y++~
Ye+
Ye++
AEG
Table I, S))r~ical Man++++mnem of Tm+..mrm +rod Va.~ct)i~)r L<:sion~ of the Pme;)I l~c#i.)+
Yes
Ye.~
y~
Ye++
Ye;+
No
~e+
N.
Yes (EVD!
VP ~htmP (+r EVt)
P+e~+~)i~e
L~c~p~ta+
Sttpoceee~p~l+|r
L~cipi)+l mm+~e++)o+i++l
~+P;II~IImPIpI,PP+;II
Oec+F+t+l
Oc¢ip+t+~I +#+~n+tcnttv)++]
++'++++p~+z+dh+~J
lr;m,~tq~|~)<++i:)[
).~¢+p+~I rams+e++++#++++ ( ~-¢ipi)++]
O¢¢iplt;)[ trmlstc0mtia!
Ap+)r+++++~h
+a++v+++t
¢+3i~+i~,
+Fhr~,mN;seJ
ToPer e+++L+i+m, (X)+++
(+~)<+)
Sbt. exc+si+)n,
++P+t+~++7+Z~i~p
T~t+d ~.xci+.iol~, ( ~)¢,, +fee+
+%L exd++,m
SIt. e~ck.,tm, CO~+~+ chimtqhe+++p+ 7++mI ex¢im+m+ (X~ T~)ta] ex,+~+i(+t+
MoJ+ttks+ ++{T+e++tmeflt
No
N,,
N~
No
No
Ye+
Ye.
N.+
"+~o
Ye~
F,~tx-tllrencp
A++++e Grin+ "+'dl
Alive ,.xl well
Ahw rex! ++~t!
L))e +i<,)~k
+)~T
] roD;roved+,+4"p~ l~te demh
AIi++e m)J ,.ell
¥ m
"¢t;.llnlfeyp3: Pw.:+;l| Tullu,~,~ 79
c,~ra4am, quite wall w+d~ die kvel .|hh~- ~nlor~al +ncimm~.
Wc~u~e and du: C~ ~can confrontal ~hc prc~-i~c~ o{ o~m~ctive hydr,~ce~iah~-, a vvnlrici+lopemone;i} slmn+ ~.a~ il~c~Cd app~ox~malciy itv,+ wCek~ bef;o~c lhc dc({nit~" ven~rietm ~:he par<.¢aI wa~::dh,~.a~ ar,r¢~ad~ wa~ u.-e& ~,~')
f:ig. L C T ~.c~tu~d~+:+ml+~stc++}umec+ne+++~+++m+~a P+m+~'1~m+'bP`i'+
+~++~a,'a+
~vh~J+..+~+,+l+i. P++,+ Z
Fig. 2+ C T ~'+ ~:+d~¢'+ma+:
t ~,u+ a &+~
c>'+++q+~he filmed +egi,m + Pmi:+++5+ amhmtion m Patient 3 demo~trated a |ymp'_~xyti¢ plec~y~is of 250 celia per mma+ S~¢al ent + a m~tld wa~ u N + }ng t a ~ n d;_~ baatirm and the napare o f the tes~n+ I~ t ~ present ~ries, every ~atient+ ~nderwen~ a ~ ~ a n prior to surgiga| in+ terventiort+ N n e e die quadtiNminat ¢ t s t + is readily-
q,aadrigt+,minal cistern and ~ulping ml,~ the p+~-lerh,r lhlrd echoic|e, the {xcipilaI transicnroviat approilch u~+x ,i..ed+ The gian~ vascuk,r maltbrmalkms (Patients 10+ 11)re+ qui~d a bilateral supnRentodaf ¢xp¢~ule carried out in either one or two stapes 129, ~2}, in ,lit the pmier, rs, magmificatioa and ilh,minnti~m o{ d~c deep surgical i~c}d were ol~rained ~x+ith ~ e t+pc++ating miCrOScope+ a+~d mici+*+ +cchniqm: +~++ u~d in every pa+ienl° A+ n-~+ca+ed in TaNe I+ ? pati.cm~+ rt-quireJ a ceeebm>iq+mt Bi+idshtiming wemedure ~ , r e the d¢Iilr+ile +i+rg}ca| +lea+merit. I~ all g+tier.a:vma)m+~ol 2@};, {I gm r,:+ klk)~ram +d ~,|V weighO asuJ dexameethamn¢ (0.5 mg pep kg) v,+ere giv¢n "in~avem+uslg du+h;g induction t~+ lhe g~me+aI a+~a<+~lm+li¢ and h~afiarc d~e }~me +lap wa.. r+i~t+ ~1~e:~+ mca~+re++ m c¢+mt~in+~ticm wida ++mtml+ed hyper.~+r+t/|a+i+m+ imluoved the +ur+~at ex;m+surz m+d theref++m c~mtfihuted coas~dera+ bly it+ Ihe a++~+~ance +ff &mtp+ieatR++++ +~+++li:+pmkm~ed r~-+ ~a¢+km +if the bra/+ patench++m+ ~ m tx¢ipRa} trar~qcl-a.otiat ar~+ach war d~e m,+% ¢¢~m++lt+n ~urgicaI rout~: ux~3 ill thi~ series, t+a+iet+t )0 ++c+ q~tired a Nlatcra| exposure ¢a~ied trot in {me smI~e 132t. Different mt:~jMilies ~ff surgical treatmet~t were applied; 6 lesions were rurally exeg~-J, 4 +tJbtutatly exei.v..d, and I wa,~ thmmbo~d in situ, Parient.s harboudng ]',istologically mMig~ant tt,mo~rs received r~)sto~rative cobalt radta~ion m the emniospinal axis. In thi~ ~ m e group ~ffl,atienrs+ IN+ tien+ 2 received chemod~erap}, in addition to the el+gab radix+urn+ ~ e surgical o_n~}plieativffl~enco~teped in this ~'~s are ~mmari~.¢d m %~ble Z. ~ e e~I7 ~atk, e ~a+h wa, in Patient lO after the clipping and e×¢is++ d the g+a~+t e~e+gen+aus malfom+atim+ o f the vci~ of Galen+ Pose+ + r a t i v e mo+b~di+ w + negligible, ,i~c~ 3 pa~ienms sho+e-J transient ~,~rsening of their rative ][Ndnaud>s s)~> &ome that t ~ l v e d wid~in o~e we&+ One patient d~. transient tire ataxia lasting for approxi+ rim{ely aN days; onI), one patieaa d e v e l o p ~ a trar~_~ic-nt h~iimrtopia which ~ t e d for ~ h ~ s ; ar~l one ~ t i c ~ t de+ ve generalized m:~.~te+ +hat ~a+ere well cuntrolled by antie~wulsants. The~e w~s no g~$topenitiv¢ incidence of h~ipaeesis or irffeetion+
80 +%.++:i+++++INe~ ~vd+,m+'++A4i6 N+~++ +h++h + >+81
D~RrcT
laX~RAV~pal+RICDt~R
,~vE~..;r~IKLILAR
--
71~e rumour in Patient 2, M~ich wa~ initially sul';mtally excised, recurred t~n nmn~h~ after this first sul+gical trearm
-
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voe S H ~ r
A~ £hown in Table 1 there was eme postoperative death after lhe dipping and excision of a gianv areeriovenous nmlformation of the vein of Galen. tn this patient, death wa~ re|atmd to post<-gmu~tive intraventrietdar ~age [ 321. ~ l e other I0 patients have ~'en folk~'ed from 7 m 38 monrh.~., wid+~ an avera+~e perie~ of obser+,ation +~ I8
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( ~ , ~ ~Pt'~ AL "~R A'r'~:T[NTCR | A k
Pineal ~m+ours are ra~ and represent O. 5% of all in~aeraniaI ~mo,Jr~ found in adults; d~ey are more common during d~fldhood, with a~ h~cidenee of 2.5%, V~seular maifi-,rmations of ~he pineal region am m~ on|y extr~m~ely m~e b~t they am spot{ocular' m appearance, and dangerous; however, they are potcnria~ly curable iesi,ms I L }6, 29, .>3~ 32, 341. Rceen~ t+:-.dm~Io~,i¢~l advances in neumsurgery have allowed neuros*argeons m ~Ix,mte in the pineal r ~ i o n with a g e m den! ~ ~gc~y {t 5, 19, 22, 27, 3tl. One of the major steps in dealing wi~h Ibis vitat a e a of ~he nee¢ous system is planning the surgical approach [6, 12, 13, 15, 18, 19. 2t.-23, 271. I found useful the rationale de~ribed under surgical man0gemem ~rd illuserared in Fi~are t. Mieromrglen{ ~e~hnique "+~+¢khcareJul exp~+~are and presence:ion
TaMe Z. St+rgic+RGampltcations i,~ i ~ P,~tien~ ,*Rh Pineal L~sim~.~ Morbidity ~:sim~
M~atie4
P~:ri~aud*,,i S~dmme
~mta~pia
Araxla
~i~ure~
T~mour
0
~
|4
p
l
I
I~
0
0
O
I ( < t0%)
3 ( < 33%) °
! (0%p
1 ( < 10%)~
~ ( < t ~ ) '~
(8 patient-) Va~ulat
3 r~tiez~r~) Tom!
~La+~mgI ~ tha~ one ~
C
~m~u~~~ ~¢~f'~i~ ~*~ ~ e ~ c ~
¢~-~e
~,~. ~¢ ~¢qi~
C
D
die s~!rg~xm¢o detach tile tt~mg-~tarfrom the ga[e!!ic veI~ous sy:rcm, A:5 mcmieme3 berlin-, special atre~ltJon slmuld lhc paid ~o the zmrm~l v;:scutar sm~cmre.~, and ]ig~adon or coa~d~ion of these viral structures sh~.~uld b~.-avoided if p~ssible., ~ m e ~mmirs in ~his region cm~ be db~sected ~ee
care ,~terc, o~ctic biopsies of ma~,~ ]¢skm,* in the pineal re-
giom I Mve tbu~K] ¢h¢ ~cipita] tr:ms~e~toriat i~ppmach a sat~st~cwr~- route for exposiag the pineal region in or&r Io deal vi'ith tile various I~Aons i t 3, I5, 21, 22, }~1 (see T~I~e 1), After n3"ing the d i f f ~ c to the pineal rettir~+ and pmvee p}.~cen,~ai ~:,xcisio~. 0,~ owe oc~s~om, w e av~ gio~ w~Ctithe pav;~a i~ ch~ ~lxmg, otherwiae uns~ls~cved va~oa~a ~mdformaoon ~.,,H:& w:as r,o~irioo;, we ¢o~ider the prone ~ i t i o ~ p~bablF the best not dem~*~stm~.d b? ce.,-~%rat/mgmgraph~/130L ~ g ~ o when usit,#~ the ~,:clpitaI trar,~tentodal route, since the usual finding should se~'e as a warning to fl~ose who adw~, whnte exp,~urc can be made with minimal recractioa of the
Ve~l,tJteV,~+: I>inea[ Tumor+- 8~
<+¢ipirai l~>P++As s d by ReM and a..+,~mte+ ~22i+ we have immfiably used a % ~ a p e d dum+omy wid+ a r+an+,+vme ~ . n m g cf only 4+5 m 5 ca+ The du++otom~ Vh~ald k.++.+ide em~@~ m Mk+w the me~¢~,n c,f g}e N a & +ff a N~++ 5 Mac+ ~en:+c I~ain t+e~rac~+o+at~aci+ed {+~ a ++e~g~¢~imng +++~,t~'m+ A h e r splitting the +o+torivm and openir~g (++e a~chnoid+ ~t }~+ov~sbece~m~t,+'+if s c ~ e of the lesions ale tw++ h~smbo~ka|t~' ~nign+ a t o ~ l excisi..m i+ u ~ | | y f ~ i b ~ e ( ~ ¢ Ng+ 5L Tak/ng into consideration the technolo++w r,e~ently available, which allt+a~ a aafe pineal exploradcm+ we s~+g.e~>t@+at a|I pir~aI was++ |¢sica+~ ~ exph~ared and ~+ri6ed h/~+]kgically ~ f o r e coE~It ~ e m p y is it~{k=ted+ ¢N+r ex+ periencg; clearly irtdiC~tes thaw the rides from +%|ind++ md/od+era~, am £+r +~ea+er Ihan L ~ from m+,ca) intervent|on+ ~ e p a n i m l a details ing t h e c|miea| p r ~ n t a t , o n and statical mann o f ++he vascular trial. formations i ~ d . d e d in thi~ .series have l-~een the m~hject o f p~¢vmus ~ab~icatiorls ~Zg~ 30~ 32i+
~c|usion
+w+~ ++t|+aak I~ ~+|~t !~a++++-~+vd+a+~++%v~+m++NYt++m++~gg~++f+++ +}w i++~m~++~t+,g~+f~hm pa;~:++~ ~+ |.me.+betra+++R+.+¢+~++~t+e~t + +++m+m+++ v+ct++F:++B+ G+ ~r~+i++ HeM +~+)+he |)+v++oa+++},~e+~++++g*r~++ ,b+" (~t+m\+ (:P¢i+ ~+t,+t+~ ¢~+ ~4W+~ ++a+~;',~pgta+l+++++++}+ +~++t+#++-",*~aJ-+¢+
~.~+ of ~+++m++ mudt;+,al},+++m~@m+md+*~m +++.d+ +.+¢m +h+ ~++~ +Le +:aff++f~}+e+Med+c+i+|+m+s::ra+:+m+~+F+~+++¢++++++>|+}W(+++++¢¢~++,}+~+~,~+ [3++ +++"F.4+~,:m G~++tC+i~Cit{~P } +~+ p+P+t~<+++++'+~++~ +}+ +{|+~+tra,',++++++a t~+bl++~
+m|+&,,i +n ++h++++++i++++-a~+t+++ ++~ }'~+n+ A+++-+m,;6+ i~+ mm+~ +++++++ {
¢~e maP++~++R+~+ ~(erenees
IV7++ 4, (~,h lI Timmur~ m ~h~.~.,. ~,t d~ pm~,aI C1m ~3~d ~Z:ItO11~, la?l
Thtmmttd Vera+e+J( ~ + wnJ+ ~++CJ+~~+~++t+yh++amm+:Thee¢++~+ ++m~¢M+ IL; T~++~+. ++JZ+p 0 Da++&¢+0~+E:Aa ¢+~Patmmf~+rthe Pemmw++o+ pw+~++d++inc.++ ~++~ Ely.yawlOb+,m+ ))+tt++ I I+. IV21 7+ I)andv ~.~: +.gr~-~a+q+.eexpc~er~c+em a +a~e +• pme++ +-m*+++A+~ch ~+I NY Acaat M+J ++:537+++Z I+t~? 9+ I~:J+ms}~;U+ HH (~mux~?alh~a~+~++~Mso+dF++l$3u+m;~,;d t|u. +~+mt~e~mm,, J N,:tm+¢,m++m+9~4%+++~.+IW+ i+~ H(+man |{J H¢o+J+&EB: P<+~+m~ths++ ++:+~+vcI¢+:++++++;;|m+++~ ~+ p+~m:ntm+m+++dalp +hf m+++~+eP,++++ (~det~ J~ {¢+JL{ ~ e + +++ t%+Ulgs+d+t~o:e~i++,~+ ~k+e++th Gi+~cal C, m6++++¢++~+~+~Or++ mare(~+ce+ T++amu.m+M i4~e+++
~+~r+r+em
a
+.e+ (d 22 c;~es.A+d+ N¢.ml P,'v&m+w~ 227-24L 19SO +a 14,,=+4.vV+ D+xc.~ia+~~ff pal++ b¢ CMg }{~+~i| ~m ~u;no~ d dw ~ra+ hx++ P+~+Z S~+¢+++ka3:+7+ 1910 t)+ JP++~+v-+mKG; E×+.++~++t++ +~maI +mm~+++J N+mx+t+~ }Sa+}O +5}. +9++ 14. La T~n+¢E+ D*-.IiPMaA, ~tan~ V }4em+mm~+~(t ~ q~dr+mm~ i%U~. j N~ur++su~4qd0tO~M1+ tq,?~ I$+ I~'-~rML Clark K: D+~+ct,u+~mal ~++r+a;~e+m~ffr~m+++e+is+(l~* ~+a+@+¢~,+I2 |>21+ +++74 16+ T_,,n¢:DM+ S+t~&+m~L+Gh+mgM. Fwmeh|~; Gm+¢ ae~r~++~,'+m+m mai|.naat,on++ of infancy at~ childhood, J N+ur+m~ 40;104+++12+ I974 I L J'.+eu++,d~F+% M+ +;m+~+¢dG C~+k WK: +Mal+~m++.~al +~.i+m +++a+u>+a d+~+e+++~ad++~m~++~++ J Ne~m~++*+:++;592+ 62L ~9+9
g/¢M arrack u ~ m mmnurs and v a ~ u ~ r malf0rmaticm~ of low mot+mlity and no motb|diry+ ~erefore+ wc believe that an a ~ r e x q v e and }udi¢ious su~gicat ~ n d u e t wiII p+t~'{de a &6nit,.++ diaD<~sis i~ most cas¢~ ar+,d in ~ m e a definite trea~ent+ Further+ mote. o p e ~ t i o n s in d~¢ pineal Fegioax can be carried out s~eiV and fly p m v i & ~ that ~ e ++eF~and pte~l++ vions d + c r i l + ~ above are taken into ¢ongdevacioa in planning a n d c ~ ' i n g o u t m R i c a l in+;ervent/on,
pmeai a~+ N+e+~Pe++~e~+I:)6-~0+ 197~ 20. Pc&el J+ ~+w~n JM+Va|+ee,B+g~+£+ J+M:TPemmea~me+am++
Ad~endam
2L P + ~
flxe pineal ~gion ass~iated w i ~
Si++ce+dt+pap¢C+ s~bmi+++% I have h+~ e ~ n e n ¢ +
tmr_*mr* of +he pineM ~R~,4-, Ac~aNe,+r+m|t+r{Wi¢+} MI++- 171.
t+++~++~8+ t+T9 +~.++ }L+M+,ino R Jr: ~mabm+ m+~d+++++++.if+l+i+e+~+ + +
wRh 3 addi+
vaguqa+ m+ ++ms)+ Two ~ +he rm~+cn+~+h + ram+a+ ( m e ~gliogtiom+ of the: medial ~ c i V t a l |6be a ~ 'o~e a midbavair+ Ac~ +Noa~hi~ {Wi~} 34:I$3+I57+ 1976 a grade lI1). "]++heva+~ol~t malfcg~++fon was supplies] by 24+ .qam~K; Pmealoma ~ children+C h i ~ Bt~nZ:67~72, 1976 ~+mche, of ~ e Hghr ar~crr aetd ~ i I a ~ bifurca+ 2~. ~t+mi&k HH: Mat+~t ~ Pie,ca| geg*~ T~or~+ lion+
84 S~:rl:ic~]Ne~eoiotD'Vol 16 N',, ] JuI~' P,%I
~i~. J Nc~tm~,r~35o19;~~02, t92I
2~:5~%57I t%5
~9~8 3L Wa~dA, ~ l i ~
RG ~ e ¢cm~'a~iee i~e~m~v.~ofd~ td ~cmdd¢
¢~. $ ~ Nemd I|a22S-22& 19g~
Book Reviews Information to Authors 1980-I981 compged by Hamer R, Me,ss and Doris A, Jaeger of r& Mount S*r,ai ~ho~d of of d,.e Cit:¢ U..it~siry # N e w gm(~.~P ~ u n ' e a ~ Mun~'~ Lg~n a ~ Sch t980 665 pp. $26, ~3
Advances in Epi|epsy. Xtih Epilepsy
[nter~afi~l Sym~slt~m e&te~ b~' Pc~ffea:~ C r i e r , F~anco A~l~len, aM ]. Y4ffin 510 p~., $~.00
by Pard C ~ug% M D~ ~ w v Thi, is another edition of this bc~k~ It is comg~osed c~fa The ~po~ of ~hi~ ~ymlx~,~mmheld from Septem~r 30 ~o compilation of the edi~oriaI ~ e l i n e ~ from 266 medical ~, ~1979,~n ~lo~enc¢~ I~ly, contains many p~i"~ers by m~n~"~J~hors. it ran~:s widely ove~ ~ t of d~e lucid J papers and ro their,editotia| ~i~r~nt~, A eop~"Of ~i~ b~K epilef~y. Mo~ of the art|ties are ,el~ive|y h~ief~ h ~ fhan sh~ld be i~ ecer~ medicat |ibrary. exhaustive The ~ea cov¢,ed i~Mde~ the anatomi~L bio|ogica~, and i~l ~r-xe~ations; CT ~m~n~i PET sea,ruing; n c u ~ t t ~ M ~ e m e n e anM i~ resu~; drug the~pyl nettro~tho|ogv; e|ectir~.~ermephalogta#y;a ~ e×* perimen~al ~itev~y. Everyone int'erest~ in e#|e~'f, whether it ~ from the tberabx~tk Or etiologic ~.andg~oint, s'_n~|d ~ d this bcmk. It wiB be & intc¢e~t to t',¢uroi,~giszs, ~o~tos~geons, ~n8 ne/lrophysioiogisls. It shouM he in the pnvat~ libraries of all ffto~ w ~ epilepsy al~d i~ a|| medical Iibmdes.
From August, 1977, to April, I980, 11 patients were ape=ted on for lesions in and aroand the pineal ~olon. The ~adndogy consisted o~ 8 yamaha, 1 giant arteHovenous maiformati~ of ~ ¢ vein of Galen, I #.ant anenrysm of the ~sterlor cerebral a~e~', and 1 VenOUS malformation of the vein of Galen. A different tactical approach ~ s used, depending o~)n the t~atlon and the type of l~ion, The ~ s e n t series d~umcets the f~ibili~, of the direct sur#cal attack on vascular and tumoural lesions of the pineal region with low morta|it~ and no morbidity. Tactical and technical aspects a ~ discussed. Neu~) 16:~7-.~. 198)
TF~, s~ar~k:a)m a n a ~ ¢ n t o( i~ions ifi the envim~ of tile pineal gland re~ins c o r , ~ v ~ i a l "ut,A has challe)~ged nE?arosurgmns for generatio~.s 11-34]. In I910, Sit Vicu)r Hor~ley lnade one of the first attem~t~ to approach the pineal regiert ti~rough the posterior fos~ [ 12]. His re~alts in two c ~ s convinced him tha~ his appre~ch was nor the best and that in the ~ture he w ~ l d Frya supratentoriai approach. Ever since Hordey'~ pioneering ex~ri. encc& there ha~ ~ n an ongoing COntroversy concerning the ~ t modalitv of ~eatment for turnouts arising ~om the pineal ~x~JyI2, 5, 6, ~ 1 I , 13, 15, 19~ 21, 22, 25-28, 31, 33). ~ m e ~J£~o~ have ~owed a prefierence itrr the direct suwical attack. Whereas e.Chershave advocated a ce~'ebrospihal fluid shunting pr,~edute followed by radiotherapy, reserving the direct su~ical approach for r~ose turnouts or lesior~ that appear r~9~ radioresistant [ 11.13, 15, ]~8, 19, 22, 23, 2 % ~ L The ~ird position is by t))ose
From ~h*: D~v}s)on t~t Nt:u~'~JJrgea', ChiIdren'~ He~pilat e~: ~ t c m
On.
advt~ating the value at a stereorac,ic biopsy which is fob )ov~.{ by radiation d)e~apy
Pm'*'een August, 1977. and April, 1980. a total of 11 patients wc~e oDeratoJ uFon for lesions in the pineal region. Table I zes infotraat{on about them patients. Tl~Ere were 7 m~fcs and 4 |creoles; ages mng~d from 6 munths to 31 yea,s, w(r]x a mean age t.ff 10.5 VEa~, Eight patients had tumot~r~ and 3 patients had va~:ular malformations, in 8 patient, there we~ simms and symptoms of i ~ r ~ . t inlaCmrltaI p.-~sure ~a¢ondary to ok~activc hydroceN'~du~. Limiation of coniugaa upward gaze was obvious in 7 patients. [n 2 patients diabetes imipidus was lhe iniriM complaint. Interestin~b'. the~ was no incidence of prec~Jous p~g~cr~yfmmd in ~his series. There were inC Ievels of at#a-re n in the serum a ~ curehal fluid (CaSF) d Parien~ 2 in keeping with O~e mixed histo~o#cal characteristics of hi~ pineaJ ttimour. Ro~Jtine roentgenog~mz of the &uIt were done in every patient, and in 5 pa0ents, the diagnosis of a pineal lesk~n was Confirrr-~d. ()~mputeri~d aDhy {f.~) of Ib~e brain was al~ peK~t~,~3 in eve~ g~tient, con~rming the diagrams in m~t ~ (Figs, !, 2L In a&litk~ ~o the roentgenograms of the skull and the ~ scan, carotid and vertebral angiograms were made in every patient in order m PJle Oat a vascular matformaoon or to asse~sthe va~ularity d the PJmOIIr. T ~ of the vascular malformatinn~ were well demomtmted, bt~r cerebral anti y failed to demonstrate the wscular nature of the l~ion in Patient 9 [30]. In the rest of the patients, cerebral angiography was not particularly co~ributo~' :n the diagnmis or in the decision/'or tl~e ~r~cal , lri addition to the above*~ntioned neumradiologicai investigations, 4 patienr~ had air studies after decompre~ion of the ven~cdar system with a ventricutoperitoneal shunt or extem~t ventricular drainage. The air s~adies did not contribute Fard~er to dia~c~is ar~A m
erxL
l~ p t . ~ e ~ v e svadi~.a, elevated leveIs of ~r~m arm ~ F A&&~ t~fint reque~ato ~ . E G G. Vmrure}ga.~tikaren', Hc~pt~al alpha-fetoprotein we~ found in Patient 2, and the elevated d~ ~tarlo, 40t Sm}.thPM..Ott~z KIH 8Lt, CMtafio,~ M a , levels of this bio-maker showed fluctuation wi~ the in, Key~ : pinealregion;pinealn!motw,¢w~eiptt~itran~entoriMapproach; c~: ... ~ie,al cistern; ~ant ~,~oalmtmifivrmatiommcxiaiitie~~ t~a¢- stiWtton of cobak ~erapy and chemotherapy and with the cheat. rec of the namour{ t 71. The inal fluid ex•390-301918t1070077.05501.Z5 @ 19S0 by Litd,, Bro~aaand :~rapany (inca 77
ARe (~+)
i6+M
9,V
+4+M
3I,M
5
6
+I
8
6,F
I +M
9
|O
%*m2iJL~*t Lea++~
~p+~ +v+t ii+++~+)
~,M
4
Vein eft Galen,
++'~:ir~~ Chief)
PineobL~.+tom+)
I++ne+~++.+~m+~++
A+tmcFtom +
T+:mlom++
I ++J~.{
+~
Mi+ted l~11~inom~ :rod en&xletmal +itms t~+t~+t+t O+mlr~+m+
~++++o++ +*;+ +. +++;+
12+M
+L~J ~x
2
~t[etr~ N(), :
~m,Jrcm¢
hr+i+, he, it
" | |CP,
~ iC+P
p~dnn+M++ +re+Prone, + I{+P P+trin~m|'s +)mdmmc+ I ICP
| I~P, a*+,~++ P;+|I)+~++J'+ +++mlmme+ h+r++ip;tlesi+ p ICY, +~t+xi.a
~+~l~rt)me +
l++,++~+mJ'.,+
|+~I+tm i~++pb]+m
P+ttitl;lu~J'+* ~yrt+jrtm~¢+t+ ICP
(++~l)~+t P++++el)t;+t+ort --+~++,+..
Ye~
Yc~
Y*'~
Ye+
Y++
Ye+
Ye+
Ye+
Y'cs
Yes
Ye~
Ye.~
Ye+
Ye~
Yes
+Yes
Y+~+ Ye+
+++~ (++
(."T
N~)
Ye,+
Nt~
No
N<)
N+
Y++~
Ye+
Ye++
AEG
Table I, S))r~ical Man++++mnem of Tm+..mrm +rod Va.~ct)i~)r L<:sion~ of the Pme;)I l~c#i.)+
Yes
Ye.~
y~
Ye++
Ye;+
No
~e+
N.
Yes (EVD!
VP ~htmP (+r EVt)
P+e~+~)i~e
L~c~p~ta+
Sttpoceee~p~l+|r
L~cipi)+l mm+~e++)o+i++l
~+P;II~IImPIpI,PP+;II
Oec+F+t+l
Oc¢ip+t+~I +#+~n+tcnttv)++]
++'++++p~+z+dh+~J
lr;m,~tq~|~)<++i:)[
).~¢+p+~I rams+e++++#++++ ( ~-¢ipi)++]
O¢¢iplt;)[ trmlstc0mtia!
Ap+)r+++++~h
+a++v+++t
¢+3i~+i~,
+Fhr~,mN;seJ
ToPer e+++L+i+m, (X)+++
(+~)<+)
Sbt. exc+si+)n,
++P+t+~++7+Z~i~p
T~t+d ~.xci+.iol~, ( ~)¢,, +fee+
+%L exd++,m
SIt. e~ck.,tm, CO~+~+ chimtqhe+++p+ 7++mI ex¢im+m+ (X~ T~)ta] ex,+~+i(+t+
MoJ+ttks+ ++{T+e++tmeflt
No
N,,
N~
No
No
Ye+
Ye.
N.+
"+~o
Ye~
F,~tx-tllrencp
A++++e Grin+ "+'dl
Alive ,.xl well
Ahw rex! ++~t!
L))e +i<,)~k
+)~T
] roD;roved+,+4"p~ l~te demh
AIi++e m)J ,.ell
¥ m
"¢t;.llnlfeyp3: Pw.:+;l| Tullu,~,~ 79
c,~ra4am, quite wall w+d~ die kvel .|hh~- ~nlor~al +ncimm~.
Wc~u~e and du: C~ ~can confrontal ~hc prc~-i~c~ o{ o~m~ctive hydr,~ce~iah~-, a vvnlrici+lopemone;i} slmn+ ~.a~ il~c~Cd app~ox~malciy itv,+ wCek~ bef;o~c lhc dc({nit~" ven~rietm ~:he par<.¢aI wa~::dh,~.a~ ar,r¢~ad~ wa~ u.-e& ~,~')
f:ig. L C T ~.c~tu~d~+:+ml+~stc++}umec+ne+++~+++m+~a P+m+~'1~m+'bP`i'+
+~++~a,'a+
~vh~J+..+~+,+l+i. P++,+ Z
Fig. 2+ C T ~'+ ~:+d~¢'+ma+:
t ~,u+ a &+~
c>'+++q+~he filmed +egi,m + Pmi:+++5+ amhmtion m Patient 3 demo~trated a |ymp'_~xyti¢ plec~y~is of 250 celia per mma+ S~¢al ent + a m~tld wa~ u N + }ng t a ~ n d;_~ baatirm and the napare o f the tes~n+ I~ t ~ present ~ries, every ~atient+ ~nderwen~ a ~ ~ a n prior to surgiga| in+ terventiort+ N n e e die quadtiNminat ¢ t s t + is readily-
q,aadrigt+,minal cistern and ~ulping ml,~ the p+~-lerh,r lhlrd echoic|e, the {xcipilaI transicnroviat approilch u~+x ,i..ed+ The gian~ vascuk,r maltbrmalkms (Patients 10+ 11)re+ qui~d a bilateral supnRentodaf ¢xp¢~ule carried out in either one or two stapes 129, ~2}, in ,lit the pmier, rs, magmificatioa and ilh,minnti~m o{ d~c deep surgical i~c}d were ol~rained ~x+ith ~ e t+pc++ating miCrOScope+ a+~d mici+*+ +cchniqm: +~++ u~d in every pa+ienl° A+ n-~+ca+ed in TaNe I+ ? pati.cm~+ rt-quireJ a ceeebm>iq+mt Bi+idshtiming wemedure ~ , r e the d¢Iilr+ile +i+rg}ca| +lea+merit. I~ all g+tier.a:vma)m+~ol 2@};, {I gm r,:+ klk)~ram +d ~,|V weighO asuJ dexameethamn¢ (0.5 mg pep kg) v,+ere giv¢n "in~avem+uslg du+h;g induction t~+ lhe g~me+aI a+~a<+~lm+li¢ and h~afiarc d~e }~me +lap wa.. r+i~t+ ~1~e:~+ mca~+re++ m c¢+mt~in+~ticm wida ++mtml+ed hyper.~+r+t/|a+i+m+ imluoved the +ur+~at ex;m+surz m+d theref++m c~mtfihuted coas~dera+ bly it+ Ihe a++~+~ance +ff &mtp+ieatR++++ +~+++li:+pmkm~ed r~-+ ~a¢+km +if the bra/+ patench++m+ ~ m tx¢ipRa} trar~qcl-a.otiat ar~+ach war d~e m,+% ¢¢~m++lt+n ~urgicaI rout~: ux~3 ill thi~ series, t+a+iet+t )0 ++c+ q~tired a Nlatcra| exposure ¢a~ied trot in {me smI~e 132t. Different mt:~jMilies ~ff surgical treatmet~t were applied; 6 lesions were rurally exeg~-J, 4 +tJbtutatly exei.v..d, and I wa,~ thmmbo~d in situ, Parient.s harboudng ]',istologically mMig~ant tt,mo~rs received r~)sto~rative cobalt radta~ion m the emniospinal axis. In thi~ ~ m e group ~ffl,atienrs+ IN+ tien+ 2 received chemod~erap}, in addition to the el+gab radix+urn+ ~ e surgical o_n~}plieativffl~enco~teped in this ~'~s are ~mmari~.¢d m %~ble Z. ~ e e~I7 ~atk, e ~a+h wa, in Patient lO after the clipping and e×¢is++ d the g+a~+t e~e+gen+aus malfom+atim+ o f the vci~ of Galen+ Pose+ + r a t i v e mo+b~di+ w + negligible, ,i~c~ 3 pa~ienms sho+e-J transient ~,~rsening of their rative ][Ndnaud>s s)~> &ome that t ~ l v e d wid~in o~e we&+ One patient d~. transient tire ataxia lasting for approxi+ rim{ely aN days; onI), one patieaa d e v e l o p ~ a trar~_~ic-nt h~iimrtopia which ~ t e d for ~ h ~ s ; ar~l one ~ t i c ~ t de+ ve generalized m:~.~te+ +hat ~a+ere well cuntrolled by antie~wulsants. The~e w~s no g~$topenitiv¢ incidence of h~ipaeesis or irffeetion+
80 +%.++:i+++++INe~ ~vd+,m+'++A4i6 N+~++ +h++h + >+81
D~RrcT
laX~RAV~pal+RICDt~R
,~vE~..;r~IKLILAR
--
71~e rumour in Patient 2, M~ich wa~ initially sul';mtally excised, recurred t~n nmn~h~ after this first sul+gical trearm
-
I ....
voe S H ~ r
A~ £hown in Table 1 there was eme postoperative death after lhe dipping and excision of a gianv areeriovenous nmlformation of the vein of Galen. tn this patient, death wa~ re|atmd to post<-gmu~tive intraventrietdar ~age [ 321. ~ l e other I0 patients have ~'en folk~'ed from 7 m 38 monrh.~., wid+~ an avera+~e perie~ of obser+,ation +~ I8
•
= J m ~
. . . . .
-
-
t
°*¢+
°W
g/N"~g ~-,,Cf RENt kLAN | N ~ A1 ~,¢,,;TClR I:A L
( ~ , ~ ~Pt'~ AL "~R A'r'~:T[NTCR | A k
Pineal ~m+ours are ra~ and represent O. 5% of all in~aeraniaI ~mo,Jr~ found in adults; d~ey are more common during d~fldhood, with a~ h~cidenee of 2.5%, V~seular maifi-,rmations of ~he pineal region am m~ on|y extr~m~ely m~e b~t they am spot{ocular' m appearance, and dangerous; however, they are potcnria~ly curable iesi,ms I L }6, 29, .>3~ 32, 341. Rceen~ t+:-.dm~Io~,i¢~l advances in neumsurgery have allowed neuros*argeons m ~Ix,mte in the pineal r ~ i o n with a g e m den! ~ ~gc~y {t 5, 19, 22, 27, 3tl. One of the major steps in dealing wi~h Ibis vitat a e a of ~he nee¢ous system is planning the surgical approach [6, 12, 13, 15, 18, 19. 2t.-23, 271. I found useful the rationale de~ribed under surgical man0gemem ~rd illuserared in Fi~are t. Mieromrglen{ ~e~hnique "+~+¢khcareJul exp~+~are and presence:ion
TaMe Z. St+rgic+RGampltcations i,~ i ~ P,~tien~ ,*Rh Pineal L~sim~.~ Morbidity ~:sim~
M~atie4
P~:ri~aud*,,i S~dmme
~mta~pia
Araxla
~i~ure~
T~mour
0
~
|4
p
l
I
I~
0
0
O
I ( < t0%)
3 ( < 33%) °
! (0%p
1 ( < 10%)~
~ ( < t ~ ) '~
(8 patient-) Va~ulat
3 r~tiez~r~) Tom!
~La+~mgI ~ tha~ one ~
C
~m~u~~~ ~¢~f'~i~ ~*~ ~ e ~ c ~
¢~-~e
~,~. ~¢ ~¢qi~
C
D
die s~!rg~xm¢o detach tile tt~mg-~tarfrom the ga[e!!ic veI~ous sy:rcm, A:5 mcmieme3 berlin-, special atre~ltJon slmuld lhc paid ~o the zmrm~l v;:scutar sm~cmre.~, and ]ig~adon or coa~d~ion of these viral structures sh~.~uld b~.-avoided if p~ssible., ~ m e ~mmirs in ~his region cm~ be db~sected ~ee
care ,~terc, o~ctic biopsies of ma~,~ ]¢skm,* in the pineal re-
giom I Mve tbu~K] ¢h¢ ~cipita] tr:ms~e~toriat i~ppmach a sat~st~cwr~- route for exposiag the pineal region in or&r Io deal vi'ith tile various I~Aons i t 3, I5, 21, 22, }~1 (see T~I~e 1), After n3"ing the d i f f ~ c to the pineal rettir~+ and pmvee p}.~cen,~ai ~:,xcisio~. 0,~ owe oc~s~om, w e av~ gio~ w~Ctithe pav;~a i~ ch~ ~lxmg, otherwiae uns~ls~cved va~oa~a ~mdformaoon ~.,,H:& w:as r,o~irioo;, we ¢o~ider the prone ~ i t i o ~ p~bablF the best not dem~*~stm~.d b? ce.,-~%rat/mgmgraph~/130L ~ g ~ o when usit,#~ the ~,:clpitaI trar,~tentodal route, since the usual finding should se~'e as a warning to fl~ose who adw~, whnte exp,~urc can be made with minimal recractioa of the
Ve~l,tJteV,~+: I>inea[ Tumor+- 8~
<+¢ipirai l~>P++As s d by ReM and a..+,~mte+ ~22i+ we have immfiably used a % ~ a p e d dum+omy wid+ a r+an+,+vme ~ . n m g cf only 4+5 m 5 ca+ The du++otom~ Vh~ald k.++.+ide em~@~ m Mk+w the me~¢~,n c,f g}e N a & +ff a N~++ 5 Mac+ ~en:+c I~ain t+e~rac~+o+at~aci+ed {+~ a ++e~g~¢~imng +++~,t~'m+ A h e r splitting the +o+torivm and openir~g (++e a~chnoid+ ~t }~+ov~sbece~m
~c|usion
+w+~ ++t|+aak I~ ~+|~t !~a++++-~+vd+a+~++%v~+m++NYt++m++~gg~++f+++ +}w i++~m~++~t+,g~+f~hm pa;~:++~ ~+ |.me.+betra+++R+.+¢+~++~t+e~t + +++m+m+++ v+ct++F:++B+ G+ ~r~+i++ HeM +~+)+he |)+v++oa+++},~e+~++++g*r~++ ,b+" (~t+m\+ (:P¢i+ ~+t,+t+~ ¢~+ ~4W+~ ++a+~;',~pgta+l+++++++}+ +~++t+#++-",*~aJ-+¢+
~.~+ of ~+++m++ mudt;+,al},+++m~@m+md+*~m +++.d+ +.+¢m +h+ ~++~ +Le +:aff++f~}+e+Med+c+i+|+m+s::ra+:+m+~+F+~+++¢++++++>|+}W(+++++¢¢~++,}+~+~,~+ [3++ +++"F.4+~,:m G~++tC+i~Cit{~P } +~+ p+P+t~<+++++'+~++~ +}+ +{|+~+tra,',++++++a t~+bl++~
+m|+&,,i +n ++h++++++i++++-a~+t+++ ++~ }'~+n+ A+++-+m,;6+ i~+ mm+~ +++++++ {
¢~e maP++~++R+~+ ~(erenees
IV7++ 4, (~,h lI Timmur~ m ~h~.~.,. ~,t d~ pm~,aI C1m ~3~d ~Z:ItO11~, la?l
Thtmmttd Vera+e+J( ~ + wnJ+ ~++CJ+~~+~++t+yh++amm+:Thee¢++~+ ++m~¢M+ IL; T~++~+. ++JZ+p 0 Da++&¢+0~+E:Aa ¢+~Patmmf~+rthe Pemmw++o+ pw+~++d++inc.++ ~++~ Ely.yawlOb+,m+ ))+tt++ I I+. IV21 7+ I)andv ~.~: +.gr~-~a+q+.eexpc~er~c+em a +a~e +• pme++ +-m*+++A+~ch ~+I NY Acaat M+J ++:537+++Z I+t~? 9+ I~:J+ms}~;U+ HH (~mux~?alh~a~+~++~Mso+dF++l$3u+m;~,;d t|u. +~+mt~e~mm,, J N,:tm+¢,m++m+9~4%+++~.+IW+ i+~ H(+man |{J H¢o+J+&EB: P<+~+m~ths++ ++:+~+vcI¢+:++++++;;|m+++~ ~+ p+~m:ntm+m+++dalp +hf m+++~+eP,++++ (~det~ J~ {¢+JL{ ~ e + +++ t%+Ulgs+d+t~o:e~i++,~+ ~k+e++th Gi+~cal C, m6++++¢++~+~+~Or++ mare(~+ce+ T++amu.m+M i4~e+++
~+~r+r+em
a
+.e+ (d 22 c;~es.A+d+ N¢.ml P,'v&m+w~ 227-24L 19SO +a 14,,=+4.vV+ D+xc.~ia+~~ff pal++ b¢ CMg }{~+~i| ~m ~u;no~ d dw ~ra+ hx++ P+~+Z S~+¢+++ka3:+7+ 1910 t)+ JP++~+v-+mKG; E×+.++~++t++ +~maI +mm~+++J N+mx+t+~ }Sa+}O +5}. +9++ 14. La T~n+¢E+ D*-.IiPMaA, ~tan~ V }4em+mm~+~(t ~ q~dr+mm~ i%U~. j N~ur++su~4qd0tO~M1+ tq,?~ I$+ I~'-~rML Clark K: D+~+ct,u+~mal ~++r+a;~e+m~ffr~m+++e+is+(l~* ~+a+
g/¢M arrack u ~ m mmnurs and v a ~ u ~ r malf0rmaticm~ of low mot+mlity and no motb|diry+ ~erefore+ wc believe that an a ~ r e x q v e and }udi¢ious su~gicat ~ n d u e t wiII p+t~'{de a &6nit,.++ diaD<~sis i~ most cas¢~ ar+,d in ~ m e a definite trea~ent+ Further+ mote. o p e ~ t i o n s in d~¢ pineal Fegioax can be carried out s~eiV and fly p m v i & ~ that ~ e ++eF~and pte~l++ vions d + c r i l + ~ above are taken into ¢ongdevacioa in planning a n d c ~ ' i n g o u t m R i c a l in+;ervent/on,
pmeai a~+ N+e+~Pe++~e~+I:)6-~0+ 197~ 20. Pc&el J+ ~+w~n JM+Va|+ee,B+g~+£+ J+M:TPemmea~me+am++
Ad~endam
2L P + ~
flxe pineal ~gion ass~iated w i ~
Si++ce+dt+pap¢C+ s~bmi+++% I have h+~ e ~ n e n ¢ +
tmr_*mr* of +he pineM ~R~,4-, Ac~aNe,+r+m|t+r{Wi¢+} MI++- 171.
t+++~++~8+ t+T9 +~.++ }L+M+,ino R Jr: ~mabm+ m+~d+++++++.if+l+i+e+~+ + +
wRh 3 addi+
vaguqa+ m+ ++ms)+ Two ~ +he rm~+cn+~+h + ram+a+ ( m e ~gliogtiom+ of the: medial ~ c i V t a l |6be a ~ 'o~e a midbavair+ Ac~ +Noa~hi~ {Wi~} 34:I$3+I57+ 1976 a grade lI1). "]++heva+~ol~t malfcg~++fon was supplies] by 24+ .qam~K; Pmealoma ~ children+C h i ~ Bt~nZ:67~72, 1976 ~+mche, of ~ e Hghr ar~crr aetd ~ i I a ~ bifurca+ 2~. ~t+mi&k HH: Mat+~t ~ Pie,ca| geg*~ T~or~+ lion+
84 S~:rl:ic~]Ne~eoiotD'Vol 16 N',, ] JuI~' P,%I
~i~. J Nc~tm~,r~35o19;~~02, t92I
2~:5~%57I t%5
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RG ~ e ¢cm~'a~iee i~e~m~v.~ofd~ td ~cmdd¢
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Book Reviews Information to Authors 1980-I981 compged by Hamer R, Me,ss and Doris A, Jaeger of r& Mount S*r,ai ~ho~d of of d,.e Cit:¢ U..it~siry # N e w gm(~.~P ~ u n ' e a ~ Mun~'~ Lg~n a ~ Sch t980 665 pp. $26, ~3
Advances in Epi|epsy. Xtih Epilepsy
[nter~afi~l Sym~slt~m e&te~ b~' Pc~ffea:~ C r i e r , F~anco A~l~len, aM ]. Y4ffin 510 p~., $~.00
by Pard C ~ug% M D~ ~ w v Thi, is another edition of this bc~k~ It is comg~osed c~fa The ~po~ of ~hi~ ~ymlx~,~mmheld from Septem~r 30 ~o compilation of the edi~oriaI ~ e l i n e ~ from 266 medical ~, ~1979,~n ~lo~enc¢~ I~ly, contains many p~i"~ers by m~n~"~J~hors. it ran~:s widely ove~ ~ t of d~e lucid J papers and ro their,editotia| ~i~r~nt~, A eop~"Of ~i~ b~K epilef~y. Mo~ of the art|ties are ,el~ive|y h~ief~ h ~ fhan sh~ld be i~ ecer~ medicat |ibrary. exhaustive The ~ea cov¢,ed i~Mde~ the anatomi~L bio|ogica~, and i~l ~r-xe~ations; CT ~m~n~i PET sea,ruing; n c u ~ t t ~ M ~ e m e n e anM i~ resu~; drug the~pyl nettro~tho|ogv; e|ectir~.~ermephalogta#y;a ~ e×* perimen~al ~itev~y. Everyone int'erest~ in e#|e~'f, whether it ~ from the tberabx~tk Or etiologic ~.andg~oint, s'_n~|d ~ d this bcmk. It wiB be & intc¢e~t to t',¢uroi,~giszs, ~o~tos~geons, ~n8 ne/lrophysioiogisls. It shouM he in the pnvat~ libraries of all ffto~ w ~ epilepsy al~d i~ a|| medical Iibmdes.