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Pituitary apoplexy is often misdiagnosed because the majority of patients have undetected pituitary adenomas, and the presentation is often mistaken for subarachnoid hemorrhage. Most cases of pituitary apoplexy occur spontaneously, although precipitating factors have been suggested. Magnetic resonance imaging is the imaging modality of choice. Treatment includes high-dose corticosteroid administration and surgery. Transsphenoidal surgery is indicated in patients with diminished levels of consciousness, hypothalamic dysfunction, and visual deterioration. Conservative management for patients with isolated cranial nerve palsies has been advocated but remains controversial.

We report twenty-four patients with cirsoid aneurysms of the scalp. For nine patients (38%), the lesions were related to trauma. Each of the patients presented with a pulsatile scalp swelling with a bruit. No focal neurological deficits were noted in any of the patients. Scalp malformations in all patients were confirmed by selective internal and external carotid angiography, with no intracerebral component revealed in any of the patients. Twenty-one patients had the lesions surgically excised, with good results. The remaining three refused surgical intervention. Meticulous surgical technique, which includes removal of the pericranial component of the malformation, was paramount.

The cases of 109 patients with a transcranial or transorbital stab wound are presented. Angiography in 74 patients revealed 26 vascular lesions: 11 aneurysms, five carotid-cavernous fistulas, three other arteriovenous fistulas, three occlusions, two transections, and two instances of severe vascular spasm. The following important points and pitfalls are stressed: the 30% incidence of vascular lesions, the delayed onset of these lesions and neurological signs from 1 week to several months after trauma, and the incidence of delayed intracranial hemorrhage in four of 11 cases with traumatic aneurysms. The basal location of the lesions is described, and the authors warn against the misleading clinical picture of a trivial scalp wound in the absence of a "slot" fracture, with life-threatening neural and vascular damage on the opposite side. Aggressive investigation and treatment of these lesions are advocated because of the associated high morbidity and mortality rates, especially in patients with aneurysms.

The patients who presented with histological features of pituitary tumor infarction alone had less severe clinical features on presentation, a longer course prior to presentation, and a better outcome than those presenting with hemorrhagic infarction or frank hemorrhage. The endocrine replacement requirements were similar in both groups.

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Five cases of pituitary apoplexy occurring in patients with pituitary tumours are described. This uncommon condition is characterized by headache, sudden loss of vision, alteration in the level of consciousness, and usually an abnormal cerebrospinal fluid. The whole picture may be complicated by endocrine dysfunction. The diagnosis is strengthened by a radiologically abnormal pituitary fossa and confirmed by the operative finding of haemorrhagic necrotic tissue. Surgical decompression under steroid cover offers the only hope of restoration of vision. Frequent postoperative follow-up is obligatory.

Sixty-one children (below 12 years) with midline dermal inclusions of the cranium and spine were operated on at the Red Cross War Memorial Children's Hospital between 1969-1990. The bregmatic area was the most common position for superficial cysts (33). Eight children had sinuses or cysts near the external occipital protuberance, 2 had isolated fourth ventricular cysts and 1 had a cyst in the quadrigeminal plate cistern. Fifteen children had spinal dermal inclusions, 13 of these were in the lumbosacral area, there was 1 sinus in the cervical spine and another in the midthoracic area attached to an intramedullary cyst. Two children had frontal sinuses, one of which was connected to an interhemispheric dermoid cyst and a lipoma of the corpus callosum. A midline swelling or sinus was the most common clinical presentation. Four out of 15 spinal inclusions and 1/11 occipital sinuses had a meningitic history. Five of 11 of the posterior fossa inclusions had raised intracranial pressure and signs suggestive of cerebellar tumor or abscess. Not one of the 33 bregmatic lesions had any connection to the central nervous system. MRI has proved useful in diagnosing both dermal sinuses and cysts, but CT scanning was our standard investigation. Plain x-ray revealed bony abnormalities in only 60% of our patients with spinal sinuses. We feel that all dermal sinuses or cysts in the midline should be surgically explored after CT or MRI scanning. Lesions mistaken for bregmatic cysts have included hemangiomas (4), hamartomas (2), an encephalocele through the anterior fontanelle (1) and lipomas (2).(ABSTRACT TRUNCATED AT 250 WORDS)