Malignant pheochromocytoma with cerebral and skull metastasis is a very rare disease. Combining our case with 16 previously reported cases identified from a PubMed search, an analysis of 17 cases of malignant cerebral pheochromocytoma was conducted. This literature review aimed to provide information on clinical manifestations, radiographic and histopathological features, and treatment strategies of this condition.

A 60-year-old man was admitted with a progressive headache and enlarging scalp mass lasting for 3 mo. Radiographic images revealed a left temporal biconvex-shaped epidural mass and multiple lytic lesions. The patient underwent a left temporal craniotomy for resection of the temporal tumor. Histopathological analysis led to identification of the mass as malignant pheochromocytoma. The patient's symptoms were alleviated at the postoperative 3-mo clinical follow-up. However, metastatic pheochromocytoma lesions were found on the right 6th rib and the 6th to 9th thoracic vertebrae on a 1-year clinical follow-up computed tomography scan.

Magnetic resonance spectroscopy and histopathological examination are necessary to make an accurate differential diagnosis between malignant cerebral pheochromocytoma and meningioma. Surgery is regarded as the first choice of treatment.

Control of blood pressure can be a problem for intracranial procedures. To investigate the relationship between hemodynamic variables and endogenous vasoactive substances, we studied patients undergoing resection of arteriovenous malformations (AVMs).

This was a nonrandomized, prospective study of six patients who had resection of an intracranial AVM and six patients who had clipping of an intracranial aneurysm (ICA) that had not bled. Operative and postoperative blood pressure was controlled with sodium nitroprusside. Heart rate (HR), mean arterial pressure, pulmonary capillary wedge pressure, and cardiac index (CI) were measured after induction of anesthesia; before, during, and after hypotensive anesthesia; immediately postoperatively; and at 12, 24, and 36 hours postoperatively. Blood samples were drawn simultaneously in the AVM group to measure levels of norepinephrine, epinephrine, renin, aldosterone, vasopressin, angiotensin I, and angiotensin II and correlated with significant hemodynamic changes.

HR and CI increased significantly among patients with AVMs compared with patients with ICAs (p<0.001 and p=0.05, respectively). HR was significantly correlated with renin (r=0.60), norepinephrine (r=1.00), and vasopressin (r=0.66). CI was significantly correlated with epinephrine (r=1.00), renin (r=0.77), angiotensin II (r=0.71), and vasopressin (r=0.82). Patients with AVMs had a hyperdynamic state characterized by increases in HR and CI. These increases were accompanied by increased renin, norepinephrine, vasopressin, epinephrine, and angiotensin II serum concentrates.

There were no significant differences in blood pressure changes between patients who had resection for AVM and those who had clipping of ICA, probably due to the use of sodium nitroprusside in the AVM group. Patients with AVMs had a hyperdynamic state with increases in epinephrine, norepinephrine, angiotensin II, plasma renin activity, and vasopressin. Whether this hyperdynamic state is caused by the resection of the AVM or the use of sodium nitroprusside (SNP) cannot be concluded. Blockage of these mediators preoperatively may help control blood pressure without sodium nitroprusside.

Autonomic hyperreflexia occurs in up to 85 percent of individuals with spinal cord injuries above the major splanchnic sympathetic outflow. In such cases, paroxysmal reflex sympathetic activity develops in response to noxious stimuli below the level of the neurologic lesion. The clinical features of autonomic hyperreflexia are due largely to reflex sympathetic adrenergic and cholinergic discharges with dysfunctional supraspinal regulatory control. Cephalgia, diaphoresis, flushing, tachycardia or bradycardia, and paroxysmal hypertension are most commonly observed. Although a variety of stimuli can provoke autonomic responses of variable magnitudes, bladder and bowel distention continue to account for most episodes. Removal of the offending stimulus is important to restoring the autonomic nervous system to its baseline activity. Current understanding of the pathophysiology, clinical features, and medical management of this fascinating but potentially serious complication of spinal cord injury are reviewed.

The clinical, laboratory and operative findings from three cases of extra-adrenal phaeochromocytoma are reviewed. Some of the difficulties encountered in localizing such a neoplasm are highlighted. Data from intraoperative catecholamine monitoring on the three patients are also presented. Adequate alpha and beta blockade produced stable cardiovascular parameters during surgery in all three individuals.

Meningiomas involving the temporal bone are very rare. Until 1964, only 39 cases had been reported in the world literature. Most series reported are very small and a physician is unable, based on his own experience, to acquire a sufficient knowledge about this entity and may raise serious doubts regarding the diagnosis and management of these tumors. In the past nine years the author has encountered five cases of meningiomas involving the temporal bone. This became a stimulus for a thorough research of the world literature of meningiomas in general, with emphasis on temporal bone involvement. Nine more cases were collected from cooperative physicians with whom the author has been associated. These 14 cases are the clinical material analysed in this study. This thesis is divided into three sections: 1. Exhaustive review of the world literature on meningiomas with emphasis on involvement of the temporal bone. 2. A detailed presentation and discussion of the clinical material stressing the importance of the newer diagnostic methods available and the most modern microsurgical techniques used in otological and neurological surgery procedures, applied to the treatment of those lesions. A light microscopic histopathological study of all cases reported is presented. Electronmicroscopy demonstrates the true intracellular nature of an atypical, recurrent meningioma occurring in a child. 3. A critical evaluation of the cases presented and the value of the diagnostic and therapeutic methods applied in this series of patients are here analysed. Conclusions are then drawn based on the experience and knowledge accumulated in this study. The histopathological diagnosis of meningiomas sometimes is difficult. Probably those tumors involve the temporal bone more commonly than has been reported in the literature. Some of these lesions probably are being misdiagnosed as chemodectomas or other neoplasias. Computerized axial tomography, particularly applied to the diagnosis of brain lesions, is the major break-through of recent modern medicine. A noninvasive technique, when used with contrast enhancement, offers great diagnostic possibilities. Early diagnosis of meningiomas and their complete surgical excision are the key factors necessary for a successful result with a good prognosis and a low recurrence rate. Although these tumors are classically considered radioresistant, radiotherapy may play a role in the treatment of incompletely excised lesions or in patients of a poor surgical risk. Further experiences and time will probably lead to more definite conclusions regarding the role of radiation therapy or the combined surgical and postoperative radiation treatment. Of all brain tumors, meningiomas offer the best prognosis.

Five children are described who developed hypertension in relation to acute neurological disease. Possible pathophysiological mechanisms for the hypertension are considered. It is thought that the hypertension may have been related to interruption of the ascending tracts in the brain stem, leading to failure of integration between, or independent action of, the baroreceptors and osmoreceptor system. Management and treatment are discussed. Diazoxide (5 mg/kg bodyweight, given intravenously) appears to be the most effective drug for use in the acute episodes.

A case is reported of a patient with a cerebral aneurysm in whom it was difficult to induce hypotension. The hyperadrenergic state mimicked, in some respects, that seen in patients with neural crest lesions. Possible mechanisms are discussed and the anaesthetic management described.