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The authors report on an infant with a bifrontal encephalocele that was associated with multisuture craniosynostosis, spasticity, and a progressively severe epilepsy. They describe the initial presentation, genetic screening results, staged multidisciplinary operative plans, clinical course, complications, and long-term surgical and developmental follow-up. To their knowledge, the comprehensive surgical management of this type of complicated congenital cranial anomaly has not been previously described.

Surgical management was staged and multidisciplinary and required careful attention to all 3 components of the condition: 1) hydrocephalus, 2) frontal meningoencephalocele, and 3) epilepsy.

✓ An acute necrotizing encephalitis due to herpes simplex virus may complicate craniotomy and cause death. Two such cases are reported and the subject reviewed. Early diagnosis is essential so that idoxuridine can be given and external surgical decompression contemplated.

✓ The case of an infant with a peculiar tumorous malformation of the cerebellum is described. The tumor apparently developed as an exophytic, hypertrophic sprout of the inferior vermis. It had a monstrous appearance resembling a crab, with a metameric body and multiple pairs of limbs attached to the folia of both cerebellar hemispheres. Histologically, the lesion was formed by poorly differentiated neuroepithelial cells without any evidence of organization into nuclei, cortex, or fascicles. Clinically, the tumor behaved in an indolent manner and did not regrow after subtotal surgical resection. Because of its gross appearance and its biological behavior, this unusual hamartoblastomatous growth is readily distinguished from medulloblastoma. The morphology of the cerebellum in Lhermitte—Duclos disease is reviewed, and a new interpretation of its basic structure is proposed. This and other known types of cerebellar hypertrophy are different from the malformation in the present case.

✓ Intraoperative digital subtraction angiography using commercially available equipment was employed to confirm the precision of the surgical result in 105 procedures for intracranial aneurysms or arteriovenous malformations (AVM's). Transfemoral selective arterial catheterization was performed in most of these cases. A radiolucent operating table was used in all cases, and a radiolucent head-holder in most. In five of the 57 aneurysm procedures, clip repositioning was required after intraoperative angiography demonstrated an inadequate result. In five of the 48 AVM procedures, intraoperative angiography demonstrated residual AVM nidus which was then located and resected. In two cases intraoperative angiography failed to identify residual filling of an aneurysm which was seen later on postoperative angiography, and in one case the intraoperative study failed to demonstrate a tiny residual fragment of AVM which was seen on conventional postoperative angiography. Two complications resulted from intraoperative angiography: one patient developed aphasia from cerebral embolization and one patient developed leg ischemia from femoral artery thrombosis. This technique appears to be of particular value in the treatment of complex intracranial aneurysms and vascular malformations.

✓ Interventional neurovascular techniques have advanced to a level where treatment of intracranial aneurysms by intravascular detachable balloon embolization therapy is now possible. A patient is presented who had a spontaneous subarachnoid hemorrhage from a large aneurysm of the distal basilar artery. The aneurysm arose at the bifurcation of the posterior cerebral arteries and measured 15 × 9 × 9 mm. With the patient fully awake, a detachable silicone balloon was passed into the basilar artery by a transfemoral arterial approach. Stenosis (> 60%) of the mid-section of the basilar artery, secondary to arterial vasospasm from the recent hemorrhage, was present. The stenosis was treated by transluminal angioplasty, after which the balloon was passed into the aneurysm and detached. A follow-up angiogram 3 months later demonstrated complete occlusion of the aneurysm and a widely patent basilar artery at the angioplasty site.

✓ This study explores the effects of infusion of nerve growth factor (NGF) on behavioral outcome and cell death in the septal region using the clinically relevant model of fluid-percussion brain injury in the rat. Animals were subjected to fluid-percussion brain injury and 24 hours later a miniosmotic pump was implanted to infuse NGF (12 animals) or vehicle (12 animals) directly into the region of maximum injury for 2 weeks. Four weeks postinjury the animals were tested for cognitive function using a Morris Water Maze paradigm. Neurological motor function was evaluated over a 4-week postinjury period. The rats receiving NGF infusions had significantly higher memory scores than vehicle-treated animals. Examination of the cholinergic neurons in the medial septal region using choline acetyltransferase immunohistochemistry demonstrated significant cell loss after injury. Infusion of NGF significantly attenuated loss of these cholinergic neurons.

A second group of animals was subjected to fluid-percussion brain injury alone (23 rats) or injury followed by NGF infusion (18 rats). These animals were killed between 24 hours and 2 weeks postinjury and the septal region was examined for the presence of apoptotic cells using the terminal deoxynucleotidyl transferase—mediated biotinylated-deoxyuridinetriphosphate nick-end labeling technique. Apoptotic cells were identified as early as 24 hours postinjury; their numbers peaked at 4 and 7 days, and then declined by 14 days. The NGF-treated animals had some apoptotic cells; however, even at 7 days there were significantly fewer of these cells. No significant motor differences were observed between the NGF- and vehicle-treated groups.

These data indicate that NGF administration beginning 24 hours after fluid-percussion brain injury has a beneficial effect on cognition and results in sparing of cholinergic septal neurons. These improvements persist after cessation of NGF administration. The beneficial effects of NGF may be related to its ability to attenuate traumatically induced apoptotic cell death.