We describe a patient who experienced focal cerebral and brainstem ischemia in the setting of postpartum eclampsia. Cerebral angiography showed spasm of large-and medium-caliber arteries. This case provides rare documentation that vasospasm may account for cerebral ischemia in eclamptic women with focal signs. This observation suggests that in such patients cerebral angiography may be informative and useful. (Stroke 1988; 19:326-329) T he neurologic manifestations of preeclampsiaeclampsia include headache, visual disturbances including cortical blindness, generalized seizures, depressed alertness, and coma.12 Focal neurologic abnormalities are rare and, in the absence of parenchymal hemorrhage, their mechanism is uncertain. 3 We describe a patient with focal deficits in the context of eclampsia in whom we documented spasm of large-and medium-caliber cerebral vessels. This angiographic finding provides rare documentation that in such eclamptic patients vasospasm may be a mechanism of ischemic injury.Case Report A 27-year-old woman, gravida one (Gl), para zero (PO) in the 42nd week of gestation by dates, was admitted shortly after the onset of irregular contractions. Her blood pressure on admission was 120/70 mm Hg. She had 2 + pitting edema, mild hyperrefiexia, and 2 + proteinuria and was without complaint of headache, visual disturbance, or epigastric pain. Pitocin was administered because of minimal progress of labor. She had a normal spontaneous vaginal delivery 12 hours after admission. Fifteen minutes postpartum, she complained of headache, nausea, and epigastric pain. Blood pressure was 172/88 mm Hg. Magnesium sulfate was begun promptly with a loading dose of 4 mg i.v. followed by an infusion of 1.5 mg/hr, which was later increased to 2 mg/hr. Blood pressure initially rose to 190/102 mm Hg and then remained in the range of 160-170/85-90 mm Hg. The following morning, she was found stuporous. Blood pressure was 140/80 mm Hg; respirations were regular. She made no response to verbal stimuli but had purposeful spontaneous movements. No papilledema was evident. The pupils were 2 mm bilaterally and reacted to light. Left lateral gaze paralysis was noted with the oculocephalic (doll's head) maneuver and persisted after ice water calorics. Muscle stretch reflexes were slightly brisk and symmetric. The plantar responses were flexor. Magnesium sulfate was discontinued. A magnesium level was 5 (therapeutic range 3-6) meq/1. A cranial computedFrom the

Thirty-one patients operated upon for supratentorial glioblastomas or anaplastic astrocytomas were studied to evaluate the effect of the extent of surgical resection on the length and quality of survival. The median age was 50 years and the median preoperative Karnofsky rate was 80. Twenty-one patients (68%) had glioblastoma multiforme, and 10 patients (32%) had anaplastic astrocytoma. Early postoperative enhanced computed tomography was used to determine the extent of tumor resection. Gross total tumor resection was accomplished in 19 patients (61%), and subtotal resection was performed in 12 patients (39%). The two groups were comparable regarding age, sex, pathological condition, preoperative Karnofsky rating, tumor location, postoperative radiation therapy, and postoperative chemotherapy (P greater than 0.05). The gross total resection group lived longer than the subtotal resection group by life table analysis (P less than 0.001; median survival of 90 and 43 weeks, respectively). Postoperatively, the mean functional ability measured by the Karnofsky rating was significantly increased in the gross total resection group (P = 0.006), but not in the subtotal resection group (P greater than 0.05). The difference in degree of change between preoperative and postoperative Karnofsky rating in the two groups was statistically significant (P = 0.002). The gross total resection group spent significantly more time after the operation in an independent status (Karnofsky rating greater than or equal to 80) compared to the subtotal resection group (P = 0.007; median time of 185 and 12.5 weeks, respectively). Gross total resection of supratentorial glioblastomas and anaplastic astrocytomas is feasible and is directly associated with longer and better survival when compared to subtotal resection.

The authors have reported on 108 patients with pituitary macroadenomas (measuring 2 cm in at least one diameter) who underwent 117 transsphenoidal operations and five craniotomies, and were followed for periods ranging from 6 months to 14 years. Vision improved in 90% of the patients. Gross total tumor removal with no evidence of residual tumor tissue demonstrable on the postoperative computerized tomography scan was accomplished in 41% of cases. However, gross total tumor removal is not synonymous with complete tumor removal. Endocrine cure was possible in 25% of prolactin-secreting and 20% of growth hormone-secreting adenomas. The incidence of recurrence was 12%, with the majority occurring from 4 to 8 years postoperatively. Both the tumors with suprasellar extension of more than 2 cm and the hard fibrotic tumors had a higher recurrence rate. Postoperative administration of radiation therapy has been associated with a significantly lower recurrence rate than when this therapy was withheld. Transsphenoidal surgery of pituitary macroadenomas confined to the extra-arachnoid space is associated with a relatively small number of complications. The operative technique used in this series is described.