An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.

The results of transsphenoidal adenomectomy for growth hormone (GH)-secreting pituitary adenomas in acromegaly performed over a 17-year period were analyzed retrospectively to determine which preoperative factors significantly influenced the long-term surgical outcome. These variables were then used to develop a logistic regression model to determine the probability of surgical failure. The series consisted of 103 patients. Long-term follow-up study (mean duration 102 +/- 64 months) was performed to derive outcome analysis and determinants of failure. Surgical control was defined as a long-term postoperative serum basal GH level of less than 5 micrograms/liter, a long-term postoperative serum somatomedin C (SM-C) level of less than 2.2 U/ml, and a favorable clinical response. Eighteen (17.5%) patients did not meet these criteria. The overall control rate by the GH criteria was 81.3% and by the SM-C criteria 76.2%. By multivariate logistic regression analysis, tumor stage was the strongest predictor of outcome (p < 0.05). The preoperative GH level, tumor grade, and preoperative SM-C level were significant univariate predictors (p < 0.05). There were statistically significant differences in mean preoperative GH and SM-C levels (p < 0.05, t-test) and tumor stage (p < 0.05, chi-squared test) between patients whose acromegaly was controlled by surgery and those whose acromegaly was not. Furthermore, estimates were derived of the probability of surgical failure based on preoperative GH level, preoperative SM-C level, and tumor grade and stage. The authors believe these findings will enhance clinical decision-making for neurosurgeons considering transsphenoidal microsurgery in patients with acromegaly.

SUMMARY Measurements of cerebral spinal fluid pressure, arterial pressure, and internal carotid artery blood flow were obtained in a series of patients during a Valsalva maneuver. During straining (phase II), an 11% reduction in mean arterial pressure was associated with a 21 % decrease in internal carotid flow from control values; and following release (phase IV), the 19% increase in mean arterial pressure produced a 22% increase in internal carotid artery flow. Perfusion pressure computed as the mean arterial pressure minus cerebral spinal fluid pressure and internal carotid artery blood flow were used to calculate an index of cerebral vascular resistance. The data indicate that a modest but significant decrease in vascular resistance occurred during phases II and III followed by return to control levels during phase IV. These changes in vascular resistance were not rapid enough or of sufficient magnitude to maintain constant cerebral perfusion during the Valsalva maneuver. Stroke Vol 15, No I, 1984 THE PRECISION with which cerebral vascular blood flow can be maintained at a constant value during rapid changes in perfusion pressure has not been defined in man primarily due to the methodologic limitations encountered in measuring phasic cerebral blood flow. Quantitative measurements of phasic internal carotid artery flow have been obtained in man with an electromagnetic flowmeter and can be used as an index of cerebral flow.2 -3 The Valsalva maneuver is associated with marked changes in arterial pressure and thus, can be used to study the effects of rapid changes in arterial pressure on cerebral blood flow. 9 The purpose of this study was to measure the internal carotid artery blood flow and to compute for the first time the changes in cerebral vascular resistance which occur accompanying a brief Valsalva maneuver in a series of nine patients. MethodsNine male patients were studied who had been hospitalized on the Neurosurgical Section of the Veterans Administration Hospital, Durham, North Carolina. In each patient subtotal resection of a supratentorial malignant brain tumor had been carried out from 10 to 20 days previously. The data described in this report were obtained during exposure of the carotid vessels so that an antitumor agent (S-l 12, a chlorethylthioacetamide, Sfxg/kg) could be infused directly into the internal carotid artery. This drug was given immediately after the completion of the studies described. The informed consent of each patient was obtained.* At the time of study, the patients were alert and showed no major neurological deficits. The cerebrospinal fluid (CSF) pressure was less than 250 mm H 2 O. *This investigation was carried out under the procedures currently applicable for human investigation. Before the surgical procedure the patients were premedicated with 50 mg of meperidine and 25 mg of promethazine. Local anesthesia was accomplished with injections of lidocaine. The common carotid artery and proximal portions of both the internal and external carotid arteries were exposed, ...

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