Phlebogmphy of the Cavernous and Intercavernous Sinuses Et+~P+~) de DMIii+, M+ |)+ ++ Renat() SFt:iante+ M, D++*

+ Vitmri+) laccath+o, MAt+++ Lm+c+o ~: celia+ M+D++ + at++ l+t~igi Gentwe++ b.LD+ +

The +tt+dy ~+| pitui|ar}" di+ea-~+~ i+ de,~¢ri|+,.xt+ with vi+uaikation of the ¢avernou~ a+~d inte~we~nou~ ~ime, e~ a¢¢~+mpli~h~d through D:+eulanem+s+ tr,m+i++mora| +athctcri:atio~+ ++i+g +~+iM meth+ ~+ m et++u¢+ |ix ¢diabilR++ The m~+,i tharatte+i+li+ normal and path+kg4G+| findin~ a¢~ + diverted+ The vaI~,: Of lhi~ m¢lhi~ a~3 +he iodication, f~+¢ its +~c in di+tg,~++i+~ are dbcu+~i++ The p.~++~i+ hilitg of ¢omhlning mo+holo+:ica| im++ti~,:adOn+ with n:~:kmal ~+netbnal ++udle. ~+f pituitary; |mcP+um¢+ b+ ~+cl+ecli+ ¢ M~+~Y ~+m+ plin+ i.~ +ugg~.+t++d+ Th+ Ieeh+~ica| dev¢l++m+nt open> +set pro,+ p~+¢+s +*w the |ira+re a+d |urihe+ |+t++ade+++ +he i+dk+a~i+m+ h+r ++e o| + thi+~ pu+c+edu+;++

CeltiC+ b+:ct+mv a h+Ht++++ i+W+,',t+~J++Otl +~+r p i t + t i t ; i t +~|++-c+t~ +

i4L ++h|u,+<h +ice ca,+, +m,h~'J m+ ia+ a+ ++++ +he data ~,b+ +a~+~+,i ace t+l >~+ch ~rm++ il~t¢++:+t t+~at + e ~++ie+¢ it+d> +tvtho,| :.h~mt3 |... mud+ m o t +~ddy +t+d+

A+~at~+mka| Aspe¢ts The hvD+ph~al +~+~.a +- +~+mwd chic+iv ~++ the ++.vH ~ +urcica +t ++ do+.cd +~q+~++++~++tv h~ t |+ d+aphm~ma +llae~ whict+ , ,++¢h+ K+t+~ce|~ +he mterc+/a~.d Ii+m+¢+++++ +m,+ tlw L++eml |+,+~++++ia++e. ;+tr h++tlu++J by the +avv+~o~|+ +++it+++,>+

Nart+m+ ++atl.verw ve++~t++ >inlet+tip}+ with the chata++ +cr++tk> ,+t cerv|mt| vcn++t+ ~+rm~e++ rim wi+|+m die di+m/ m+l+er of the ~eiIat +~+r m d ptovh|¢ at~+tom++¢s b¢0xcvI+ the cavvmo,+ smut+e+ tFiV+ +L Wlwrc ate ti,tlally three of lhvse anas~,+m~,~e~ wh+ch are term~+d the +interior+ int~,rior~ +||~I++| tX+~t+fh+t II~teIi%tV~++rllOt|+ +i|~||+t'+

The interior mlercavcmoa~ ~m~+.~ flu + Liggett and the mint ++eq++cm|+ |,+ew+n +++ +he it+re ~4+ 8i ff+~:+ ~+)+ m.+ m tl~e ai+++t++u|~++i~+ pat+ uf th~ + +tic+ t~++<<a+ mmmediatelg ~:+ ++~eati~ t i c +~+~¢+'~d~im ,,ciL~v+ T i e mt~:++~+r m+c+cavem~+~+. +-i~+++ i+ m~a||++ a~d is f++tmd m d + m~xha~ pat+ ~++ dw +h~++ of t l+ +alia +~+t+:ic+++ +mr iwh++ +he p++mti,+tv ~Lmd iF+m+ 2bL

F++m+ ++. I+++i++++ Net++.. }a +++re+c,+ a+++l +L+'+++m+ d+ R+d~4 ++:+.+ 2+~ f.+.++++++ +++ .Me+|+~ i+++++ ,e t h++'~+~+++o ~ +++++++++++ +|+ N++I~+I{+ Na+p+¢++ +t++~++

+~+++++{'++ ¢p¢++++ +++|++~+~t~ |t+ t++l ~e++*+~++ ~p+~+L+++I++% ~ | ~ m a Ne~m~h++++++ ~++.a+ 2++J L+,~4+a d+ M~+dm+m~ e ++ ~+++++++ V++ P+m*m+ N+ ~+ ~++ ++ NaSa++ bah K+.+ m++A+ |4+b~+++ +h++ ++~+~+~ ++m+.+ m+eP;a+~q++ ,+m++++,+ w||+++ +cg+++++ p++~++~+.+¢+ ++&+++++m+L .+vk+v++~¢ +++'++++. ~a~+p|+~G

!t i> a|m++>t always prc~++nt; hmvev+r+ mmetimes+ instead of bcmg a +ramie d m t m d , it i+ made up of a fine+ rich plexus ttmt +cove+ t+u+t of the &ira mater of t:he fltulr o f the rim+ itaty l~>+a {4+ 8j {Fig+ 3)+ The ~utmior i~temavemous +mus i the ++am+west md ti~e tin+st variably Rmnd | i4+ I6L ~+~+ing ~i~+a+cd along d+e ~+pl~+r cd~v of the &+r~mn ~2Ilae+ }++>r |++~ th the D++vP+~+¢ di+oids (Fig+ X+)+ Px+th the D++ + retie| and interior ieteteavet+um+ +imue+~ have a +light an+ { e ~ r Concavity+

|chic to their I~ati~m their ch~:.e proximity t~+ the hVF~+ph+:.+++ and their mi+demt+ mtema| pr~:+tim+ +he+-+ three re+all +im++~+++ ~wcia | iy +he at~&+i++r and it:dcrkm are pa+rti¢+t+a+iy m++ceplib+e +++ ¢ap|y |no+am+ +ff +premium within +he pit{++lag (~+>+~a+ Eve++ wheI~ tile p+++++t+tc ¢t+aagm's are minimal ;rod |+~a|i:~+d+ thg,~,v effect+ era+ |++++ +,:vn wall ~41~+e there ace m+ alte+ti+m+ it+ the mitt|mR+row old++ + h m + v+f t|~e ~d|a ~u+¢~c~ ~4L Thi~ is the p+in¢ipa| team+a whx/ phtvh+~taphv ++ ~+! +~+h ~+vat i~ter~,,,,t+

M;m:+hl and Mvdu+d h~ ~l~ • pa~+ tadi~r~ph+c visuah:amm ~+f ff~e cav,:mtm~

a pm~+tary adtmmm+ The two mel|u~t~ ¢+~:d wv¢¢ inje~:dtm ~a a ff+m+;d veto and c~¢m+et¢~+r+e~t injection via the ~mdar vcm 12 17L

The medical ~ . . s e i+~ din+ interested by l'~'lver+ ;rod a,~.u~. cia~e~ 14[. in ~hich sck~;tiv¢ catheleti:atitm of the inferior F~.m~sal ~inus (~++m:+ll} the tight sin,s) is done b~ ,+ the ~r+ c++fa+~eous+ tran;femoral to~+te+ This gives a go~.t picture of

A 7 ~+r" 8F cad~vler u+ith prcfom~cd three i~ inm~t~ed via d~e tight tbm~md veto ~km~ d~c i,~i~i~r vena cava i ~ o the +i~hl at+im+u I+~+m lhele it ++ pushed along the s~+~rior ve~m c+va t~+ the ~+I'+:+k++ b+db of +l~e ti~ht mtema| jt+++k:ir veim With the aid o+ t+~mtaI and lateral flmm>+opi¢ image++ one aIwmpb t~+ ente+ the mfedor +++etromd +inu+ i+ a~ an+ teromediaL +++D:rio+ di+eeti+m+ The tip ~+f the cad~eter mu+ ally eaters d+e +ira+++ b++t i+ d++s not pt~Ke~'.+ ~+r mote tha~ a +bw mill|mete+, l++)~ce co+eel ~+itkming of the catheter bats N + n obta i~ l+ the t~di0gm+phi¢ in-tin|ignition g carded +t+

Vatlo~+ pc+vice+it+n+ (stlch + the h¢eml ~+t high h{mm|} ea~ Pro+ t++cd+ |:+t+t fi+r dream+silt g+++e+ Hitt=+s axia| prt+eetion ++ bv far +he k-++ I4L ~+ia l vie++++ a w taken rapidly (one radial |am f+¢ mecond to+ 8 +o I0 moon&)+ and an auto+

~ &+*©+ +~I ++ SI ;040~+07~I 2~ :~ +~0 b~ ̧ L+~tle+ I~+wn +rod ~ +++m~my (In¢+)

de |)ivitiis c~ ~t|; |$~|el-~g¢~phy ~t IntetGtvernou~ Sinuse~ 307

A B

m~tic inj~.:tor delivers 20 ml of ~ r l ~ t m~ium (we prefer ~X~ megM~ine di~tri:oate |Ur~,¢~fi~L ~ince we ~he~,e it Dyes ~he ~s t #|e~gra#~ic pict/~te) with a flow M 5 ~o 7 ml per ~:c~nd~ In ~xia| views d~e ~llar ~gion is ps~j¢~t¢~ onto the relatively t tent image of the sphen~-~M~d sinus and the three intercaverno~s sinuses can ~: ck-arl~ identified bec~lu~e they are not obscured by other str~cr~res, sltch as the bnsihr venous plex~s (the rich|~" ana~tomotic #exus connecting the two inf,.riot ~:trosal sinuses~ which~ esp~:c:iai|~ • in ~ n t a i "¢iews~ ~c~mes sl~F~dm~ed ot~ the inferior and ~sterior in~e~cavemo~s sin~s)~ The ~s~ltin~ #|ebt~g,~m is clear e to be interfere& ~ it i~ ~s r ro ~d~rm im;~ge s~btraction in order to ~void e~ors c~u~d b~. the si¢~rimrosition of vat(oils bony smtctiires (Figs. 3, 4L

Adt~t~ate injection provides complete filling of the right caverno~S sin~s~ the d ~ incercavemous sinuses, the let~ cap.moils 8inus~ the orbital veins~ t|~e inferior ~:trosa| sin~ses~ the basi|ar venott4 plext~s~ :rod the intem;~l j@idar veins. Teehnica|iy the investigat~r~ is ~ceptable whcr~ ~here is g ~ d filling of ~he su~riot orbital vein on the side op~site to that i n j ~ t ~ i4]. |n:~llfficient q~nti ty or t/ow of c~m~rast m~xiitm~ iml:~-r~%ct catheteri:ation tff d~e inferior I-,etr~al sirtt~s~ or preferential| flow via the ~si |ar ve~t~s piex~s ma,i call fc, t either simadta~eous percute.,~e~us t~ns~ femoral catheteri:ation of the coati, lateral inferior l~t t~a | sin.s (Fig. 2) or compte~,km of the interns| jug~l;Ir vein in the neck.

~ 5 2 6 0

Under norma| conditions (Fig, 2) the cavemo~s sinu~s f o ~ ~x~ br~ad ~ n & at ~he lateral a ~ c t s of the pit~itap~" f ~ . ~ e i r ¢eguk~r media| e~dge is straight l~r siightIy c~m- Fi~ 3 N , ~ L ~ h ~ ' ~ i ~ m ~', =~t~'~Bxs~ T&. iaJCn~ m ~ cave, The radiot~r'M~cent image of the internal car~tid c , ~ ~u~ t,. ,~t~. ~ ~.~fa fi,¢. rich ~xu~ ~a~o~ ck~t ¢ ~ ~ePi is seen within ~he cavernous slm~s. The~e is a |~aVs 8 . l ~ l ~,f |he d~¢.l ~. l¢¢~ ,4 ~ , ~b ~,~" ¢,i (go ¢~t~d~.,~ ~ )¢;~s~a

+:+v 4 3.++++,~dph+,+b++++mm++va++++++~+,+++.+ O++,+u+&+c+~dp+gm++ The: +,h~+<m~p++ ++++++<+,+ +~ +++ to+?, ++d ++m~+e. ++m! ~,++++ +&++ +~+e + ++++ ewd+~+~++ ~gh+++ ++ Oh+ ~v++++++~ +~++~cgu+c.+ Fhc +++~++,'++ mt~+c+++mcm+ ++++ +mu+ + ++++ ++p:~m+++: +++ ++~¢+ ++ +, p~+~4++m ++me h++L+,+~ ~ :he ++q++++mp~+d k++y +g++++:e++++'<+ ++++ +~ +~+ mum++ + p++b~ ++ ++++:++I +++ ~+~ 3+ ~ + + h + + + + + ~ + ~ + mr+k++++++, + + + l ~

+|tip of c~mtra,+ medium b~etween the in~ema| ca+otid a++e~ + a~d the media+ ma+a:+r+ +ff ~he +ira+s°

T h e three i~+ercavemo~++ sim++4s +orm ha+row tmmve~+ ban&+ T h e a~te+ioP is stmigh++ a~d the ~++her two am +h~htlv c~mcave a+teHodv+ The infeti++~ i+te+cavemm,s smt++~ i ~+~+a~|v ch++~ t~+ ~he D+~s~etio~ i~tercave~m~u simms+ Whe~ in+e@+tin~ phlebagmms+ ho~++ver+ it i+ imp~++tant to+ {u:+a+ i~ mind that anattm~icM varkmt+ ~+f vent+u+ stout+ +m+~++£ ale nm++ ~|~com+++{+~

Phk%+~pk+e A+'m+++mm+h+~,.+:+

Pm+ita~ + disea+,+ + ¢at~+t.s ahemti tms +of +he ph| phic +indiag+ d+sctib~+d ahwe+ Eve~ minimal cha~ge+ o f pressure wi~hir+ the pit~+im~ + + ~ + can cause comp~e~ion o~ dis+ placement of the+e delicate venous strocmte++ The m~+&a| ma+em of the ¢avemo++ sire++ ~come+ d e f o ~ e d and the ~ n d oleo+intrust medmm medml to the internal cau+t+d ½+

+ ? +

+ , ++

+> + + + ? + +

{ +

G: • , + + .... + + + + + + ; + +, | . . . . . . +? +

tee 5+ Ph¢:b-+m+m +++ ax+at pr-~',++++m+ T~+ ~O+d ++a++~,+ ++j'<~ ++Jq am+~++++ ,mu+ ++ +++m+ve~.M i+~ i+ ~m~+~ g+a++ { |ar++~ a+ow)+ ~ h

~+m+ i+ +~+++pum++~+ t+hin am+we)+ The ++q~++ +n+~++++,+a++~+++ +~m +

-+++,++q+,:.i++e. ++Pro + ~+m~+ +++++no+ >,++ +4~h+ p+~+++a+ ¢;,+m+

+mu+ +~ ++u++.+e,+e.1 +n +~ &+to ~+~i +bemv~m +he +u,, am+~+ T+e ge+i+m ++~u +m ++mop+curacy m++~g++~.m+ +,.~+upy+g ~+ +¢[+ ~+,f+hegt++~+ The +n~5¢+h+ mgcw++v+~+m, ainu+ t+,+ ~+m~emm+~. +~+<++++

comes p ivelv na~ower or even d i ~ a p ~ a ~ |4 , 13] (Fig. 5L

~ h e amcr~or and inferior in~e~avemous +inure+ which a~v mo~+ c h ~ b + m ¢~mtac+ with the pitu~ta~++ ~ ¢ o m e fl~t+ ten+] ca+{+ o+ a + amputat+J {Fig. 6}. | may e a u ~ ~ h ~ v*o s i m ~ s m ~ ap~m wi~h a ma~ked inerea+e of ~he concavity o f the inferior intetca simms {Fig 5}+ A |esion deve|oping anterkMy ma}' o M i ~ m t e the anterior inte~averr~+us ~inus~ p~xJ~ ing a cb~re+'is. ~ie O++ha~'~ image on the ph m [41 {Fig. 7 ) m

d~. |++~+++~+ ~'t M: Ph}c+~+++:+++++|+v ++++ h+lcr~:++++cm+m++ ~+++i++c+ 309

+++y++a++ l+ ~++t+ +~+ ++p+++~+ti+m O++n++~+d t~ C~+t ++++if+h+ ++++ c++~:a+m # t~,+ ++++m+

i~ ~nammic~} B,sition, the B~t¢~}o~ }me,cavernous ~imL-, dc~ not ,a~a|ly invo|ved ~nti| th~ te~on ~d~ p~.,+ duces ~|terat~orts of the ¢ntitc +¢iI~ t~tt¢~ca, mchMin~ the do.urn s¢ilae

Enlarging lesions progressively cause the di~appe~wance of the infi2rior and nnterior intercavemous sinuses, while the pc~sterior one may b,:come hy~.rm~phic a~: fi~t ~tbrc +t to~+ disappear:s (Fig. 8L The cavernous sinu~:s beck+me stcgm#~" concave media|ly+ displi~:ed laterally I6L and of d e c r e e d thickness [ 13I* ~met/mcs VC~; targc Ies~ons bk~k the m+ ~ercavemous sirm~'s comp|eteiy ~md thus prevent tmih,teral injection from filling h~tt~ cavemou~ sim~ses a~ the a me time (FIR. 9L lnfihmtion of ~he cavemot+s sitars by a ne,+- plastic leskm ¢m,~e~. a filling: decec~ with i~e~ld;+r, jacked edges (F~g+ 10)

~he l~cet of the ph|cF~¢mm of gteate.q mter~'~ i-. d~at minor c h a n ~ , such as ~ a l l tmih~te~l cdte~ations ~+f the mMia| ~ l i of ~ cavemc~s +im~ o~ d~,~hcemmt o, ilmtxm++ tion of an intetcavemous sinus+ can h+ seen F~,-6~tc ~mv ahemtions of the ~:|la t~r¢ica become app;ircnt or when thes~ alte~tions are minimal |41.

Indications Pit~ita~ micm~denoma+ ptovid~ the mo~t interesting ;rod the most im~+~tant indi¢a~io~ for phlebugmphv of the in.

t

310 S~fgical NeumkNy Vol ~5 No 4 Aptd P)+|

P~+~+ +~ +++~k'~+++++ m a~+a+ H,W,:~+++~+ The ~+++P+++&+++m+++:+l fi+m ;,,b.++ tb~t+ +he ~m++++ ++~+ ++#+:n~++ i+++++<~ucm+m+ +tomes ~,c am/m~l+++d +~ e+'~" ~m+++m+++ +in+v+ a + 1++++,+~+ +mare++ T¢+c m+:&d .++g+. +4 +b: ~I+ +dI¢++IOa+P+ +++1|~+ ++ + + ~ % + J ~+~d +~'~,r~+~r+ ++++ +~ +++teSt P+++++&~++++ ++++~++|+ +++ +he c~m++d +++mrs:sam +:is++ iv +,b+,c~t,d. The ~++w+a~+m +~+~+aG+ a ++a+++++lu++y,g++++mt ++ifihmm+g Jw gel+ +++a+cm+ms +++++,~+

tercavemou+ s/hums { t81. Lesions only }mm in diameter cause marked phieb,~gmphic t+hanges lind; this is a great improvement over findings obtained from computeri:ed tomo~tmphlc (C~) scans, which can only detect lesions of 7 mm or larger [ l 51 12L Phle t h ~ provides the earlWst diagram*is of an lntmeellar Ieskm ~+erefom+ we feel that it i+ an e+~e~tia/investigation liar all patients susg~cvcd of having a pituitary adenoma+ even when no ~ellar ehange~ are present (~rade OL In this sitiiatio~ it is the investigation of choice. The concardance o+ phleN~gmphic and clinical findmgs alh+ws ~me m p¢,~eed with an ~ m t i ~ m withmlt the nc*ed R+r further diagnostic pr~,ed++~es |4+ 18/+

With larger sdlar lesions that can ~ diagno~-d by other radio|ogicat methc, als. ph|eb~gmp|wy comp|ements these methods and p+ovides preoperative infi+rmation as to (I) the hteral expansum o+ the ~llar minor {91 13|; (2) the sit~ of the carotid sip|runs and of the cavernous and inter+ cavemnus sinuses; ++nd (3) the involvement of the cavern+ ous stresses 119+ 201+ This is esN~cialty mefut when the transsphenoidal muu~ is to be reed [ 161; for instance, when the ~sirion and the nature ~ff the +nfierior intercavemous sinus are knt~wm one can av~+id troublesome b|eeding at o~mtion [4, ISL Similady~ preo~mtive evidence that a neop|asdc lesion is infiltrating the cavemnus sinus leads to the Correct choice lff treatment I2+ I1 I+

In our opinion+ #le~+gmphy is al~+ t+seful in studying the empty sella when one suspects that there is an a s c i i ated l~ion such as an adenoma, ~ e pr~ence d phle~+ ~-'.aphic si~.~az D~cal of" an adenoma is ~lid confi,natkm

this di;~m'~is and justifies surgical action+ The ph|eN++ gr.ff~ic picture d ~ i m ~ {Miot~thic) empw ~lla either is almost completely normal or, in more advanced l~rms+ is characterized b) + an increasing of the distances ~tween the cavernous sinum+s and between the inrercavemot+s sim+~s {namely tile amerior and die infer|up ones)+ ~:cat+++ at + the enlargement i~t + the ~A|a t~+Nica+ However+ ones &~s not .~ee thn+: signs t+f asymmetrieN and circunua:ri~d pressure+ either on the cavernous or on the intemavemous sinuses+ that aw characteristic of an adenoma (as de~crii~d al:~ve). The pre~nce of such signs unmistakably evokes the exis+ tence of an expansive k.skm (adennma)

Complications No majt~r ¢omNieations have ~ e n i;bserved either in ~ r ca~s or in tho~ rep~+rted in the literature {181. In expert hands the investigation is easy m ~ffonn+ rakes le~ than one lu~ur &,es not requiie a general anesthetic or heavy scdatMn+ is well m|emted+ and can t:~a ~ffomled on an out- patient basg. As a precaution the patient sh(mld be given heparin+ We have not observed extmva~don d contrast medium or pJptured ve~|s+ even in Ixltients with increased v ~ a l a r f~gi|it~" (Cushing*s disea~eL Even if tb~zse prob- lems were m c~:ur+ we &a r~t ~|ieve that they wouM represent ..~6ous complications+

Future Prospects T~e method of rcrcmaneous~ tmnsfemom} catheteri~dnn that ~'e use R~r phlebogmphy of the intercavemous sinuses aim gives us the chance to measure the level of the pitu~ icag" harm|mrs in vadmls parts of the ~d}" Currendy we take bkx~d rumples from the common iliac vein. the left renal vein ( inn which the le+~ adrenal vein usually dminsL the hepatic veins, the tight atrium. R~th in~ernal jugular veins, and the inferior ~ m ~ l sinus. Thus all the main pituitary bare, ones can be measured (F@+ l IL

Stmh >:lecdve sampling iS U~fu| ~eau~e it facilitates a detailed stndy nfpituita~ activity (R~ example+ sampling at the infi±tit~r ~ t m m | sin~, which drains the pituit:ay arc~+ measurt~ blc~d levels ~fore dilution c~cur~ with ble,~ from other p~=s of {he h~,dr): this methc-] also allmv~ the determination of any ~topicalty produced substances with hormonal activity, which can cause a clinical syndrome that resembles pituitary dimrder.~+ This problem ~mca~ e++ l, ecially in mine ty~s of Cushlng's syndrome {3+ 101+ when it may ~ difficult to i:e or exclude primary pituitae¢ di~mJe~; such tesions may ~ extmpttuita~*+ in which case a pituimD" o~vmtiun ~a~ould ~ completely unsuccessful

+rhg is on|y a preliminart reign=+ since we do not yet have +~fficiem data m show statistical significance. How+ ever. we have already ~ e a a i n e d that prolactin levels ate higher centml|y than peripherally+ | h a this ~ d i e n t markedly incnaa~d in patients with h ~ m l a c t i n e m i a due

de D+vm+,, e+ a|+ Phic}~+e++aphv +~++I |r++,+:g+,:av,ct++++++++ Stow, c+ $I I

Fig '+ 1%~+s++us ++++:,, l+++ +h +,+ u+k'+:+hv m~++Ve++< +qH++++++.+,, +++++~+++y+ {a+ C+sm'mm +k+~c ,+++g.+ {~} L+:{~: +,c+,+,a~ re+i,++++ {c+ H+++ +~v++ ~d) R+Kht ,~++:+++am {<) h~t++++'++++ +++&+ ~++'++++ ({} I++~+ q+++++ lm 1+md ++++I++

h+ a micmadeaoma+ amd ~ha~ ia d~e~: padems ~hcw are dis~inc{ dfffi:~c~cc,~ ~t~+,'*+:'e~ the levels ~r+ ti~e Iwo imemal B=gular vei~+ gikewi+~e, m pa~{ent, with C~4~in~'s disease, ad~cm,¢or~ic~m~pic h~m~onc {ACTIt) concc~{¢ad{m m d~c iaferiot p~m~al +im+~+ c~}mpated with A C g H coacen+ ~mtu, m +r~ a p+a~ipi+,,+++~al vein. is hi+.d~cr hy a /~ca~ ~g +wo o~r mr:,,++ A larger m+mk++ ~+f cam:+ is n~vx,.+a+ l~+r these r,:s.hs +~} Pro" |~+liy eva|uated+ b+++ them a+ a+~.ad+ similar +er~}+fs i++ d'+c Ihcmmrc {++ lO+ 18I+

Phle~<~gva~w of 1he ime~cave~u+ ,m*a:~+ is a~ m~stiga+ don that is ea,++y m l+'+g++~+m+++ is well ill+Dinted+ and has n,++ mr++ ¢omplica+kms+ Ti+e a~awmieal aad f.~c+hmaI characteristics of the delicate vcn~+> sin+crates ar~umd +he pimimef f{~+~ allow eady r e c ~ i t i o a o{ even mimma| at+ tem¢ioa+ of its ¢(mtcnr+

Fo~ lemon+ +mall,+++.+ thaa 7 mm i+ ,Jkm*¢I¢~, ~,~'hich ate m~,t ~++.atly ++It d ¢ + n ~ with C + mam~i+, we ~+~lmv+ +hat phD ph+¢ i+ the iavcstigation of ch{+ke la cx~n+t

m~{s am/+0r d~e pa.~pc~a~h'c sin&+:++ of~+thc~ +ypes oI ~,cllar

Whc~l o~c tries tO dote(* d~c smaHcsi iIllta~,|hr ~g evcl~ iIl{r~piluRaPf lc:,~m as car|if as ~+,s,b~e+ a+~d whe~ dia}m~+~, ~i¢ exploralioi~ of d~e pitmtaW {os,,a at limes ~ccm~ h~ bc jus{ihcd | ?l+ we mamhd+] that p|~Db,}~traphy ~cpw,ct]t~ m+c pr{~.~,+ The mdka+um., ~+~ i+s ~++,< arc f.~d+cr br~+adcncd |T d ~ ~Be},~|i~y ~{ pace, ceding d~m~g d+c ~am¢ hwc~va , Ibm from +m+~eue~<icai ~+ fim<Ii~ma| m~d{c~+ by ~akmg ~+.'19:tivc bh~+d >amplc.~ ++h}m whd+ h+ mcas+++c +c~i+m;d l+vel+ ++f hor+m,r+c<

Rdm,.~es

M2 Sl~rga'al Nt.~m4ogv ',A4 ~5 N++ 4 Apri| i981

+5 Rh+m+'q'i AL+ } lardy IKL CharoN+i++ SM M~¢+o+,,,+++gt++d +m+++~m,+++ + +++r,+~i +(h+e+t++m ,,if +i+e .rhm.d hm¢+ ¢awm, m:+. ~+++++ aM +dis+ +e~+~*++ S++~ Nvuvr,+ 12:0,+- lO4+ Io7,+

It, Rh,,+++,+~ AL+ Ham~ +'S Rem~ WH M+¢m~utgicid atom+my of die .',++:ila+¢ +v~++m a;~d +: +~em+.m,+ >m~+++ C[+n Neu+,++v~+e 24:+4+8++ ++77

! 7+ T.,veta~ JM. W~+~ El+: ['m+m+t++ mm+~.++~li,+4~m+, ed 2+ B++hmu+r+:++ gdham> & \'++qik{+~+ 1+~6+ 12GI pp

l& ~4m~ J [N,gea~li¢ dte~ adcm~m~ mme.elk,re~ p~r phleb*~taphie de~ ~im~ mlereav~meux+ in P~gmhng.~ of the ~4¢.o~,d gur~.a~, W.~Gh ,r o~ tStmtary Aden.ms++, I3ns+ .%:~emN¢ 20-22. PaN

pa Walkc+JR+ ffat~12D: P+t~m~+~'a+J,:mt+mapt++:v.*ntinga~n:i'+,tmngpait,. +++I +++phthah+r, ple¢++++ St+in Netm4 8: + 1% ~2+. 1+77

20+ W+!mm (g+ I\+mp,,e+ ~C: Tr;m+phcn+,'++L+[ +met.inimical +em<+al +if 2++0 rm+++;+tv ;+¢.,+.++x. ] +'+~e.l+++mme 4s:l }-22, I978

Book Review

E~ot Cnm~unds and Brain Function: Ncun~:ndocrine and Neuropsychiatric Aspects (in Advance~ in Biochemical Psycho#armacokNy, VoL 23) edited b:, +',£,.& G,,N:,tein, D.mdd B+ Cab,c+ Atm&~m Lieb~'r~mm. and Mi&a¢t ()+ TMmcr+ N,ew Y+uk+

* t Rca¢, P+¢~. 1980 43I Ira+

R~.aewed ~b Gc.+Ve J+/),k-reran, M,D. Ph.D. ,od Hden L M.m+~m, M+ D++ Chic,<.+ I~in+m

This hardRmnd nob+me contains a .~enes ~f pape~ pre+ s~med ~ a ~vmposium+ Er~:ot A&ak~id. m Neumkgic+ Nei+mp.+~°chiamc and Ne~m~vn&vrine DiumJe~+ hem it} New Y~+rk in ~9D. It is publi+.hcd a> the twenty.third nob rune of A&~mce~ m Bi~chcrmc, d P+~yd@b.mm~c.b~ag* The 39 papers are divid+xt into the lb~lowing ections: bic~hem+ i~t ~" and pharm~mdoey+ neuroe~&~dnology+ parkinumim~+ gcrmmc dim)triers+ :rod dvskin,:sia.

O~ interest ~o rh~se in the dingaI a~d basic netm,~+v ences is a review of tt~¢ c~rrent kn~+wledee ~g ere~.~+ corn+ p.mnds+ Ergut actions at catechoiamine receptor.., errant eL k.cts {m co~eical and striata] doF<+minendic and serot.net~ic ~eceptt~rs, and tl~e interactions ~tween ergot derNat~ves and rbe cvchc nuc|eotide system are di~guss~+ Some e m phasis is given m the neurophatmacd~+;~¢ of synthetic ergot detivaives in man aM the pharmacokinetica of bmmo+ criptine m man.

The section dinting with neur<mn&+crim4ov~" is proR~bly the stronRe~t, and of srvate++++ .t interest to nei~rosur~eons and neuu4ogi+.t+-. A brief review is given of ergot drugs in the treatment d en&vrine dimrdee< Mechanisms of h}~er- prolacrinemm are diveu~sed, as are ct~rrenr concepts of management including medical therapy with bromocrip+ tine+ Much empha.is is given m various tMrapeutic uses of

bromncdp0ne; the medical management of acmmegaty with bmm~)criptine and the treatment of the amenorrhea+ ~dacu~hea syndrome in women with suspected pituitary micmaden.mas are Ix+th addrc~+d as well

Phammcothempy of parkinmmism is covered in a brief review+ A R4k+w.up of ,p m five yea~ is giv~en in >Ain- ~onism patient.~ treate~ with bmmocdptine+ A compari~m of bmmc<dptine and levt~Jopa in the treatment of the pa+ ~ient with g~rkinmnism is made This b~gd~ pre~z+mation of data concerning the potential fix serious p+ychommb tactic efft~rs in the older padent with preexisting abnormal- ities in the elecm~ncephalogn~m is very clinically de~np+ rive+

A review of die effectiveness of H++de¢ine in the geriat+ ric patient with cognkive and t~.havioml change.~ attempts m conchide that the & g is somewhat efficacious. ~ e all. rhor~ do >rare that their review is of*+mughly comparable ..urines" and recommend furfl~er re,,~arch+ ~ e difficulty with the review is clarified in the ch;kpter comparing rating scales mea>uring mlt~mm of tm~tmen~ in the geriaric >> tient Gmfounding ratit~oas, lack of meaurement of emo- tional £tctors, and the limitation of single ~ales applied m th& complex +x~pulation do not permit adequate assessment of outcome+

The Iack of impm~ment of dyskinetic padems or of the mntor and c¢Nnkive dist,~tmncm in schimphreni¢ patients t+ea{ed w~th etgo~ dop~dne a~mgts is well presented al- thtm+ah the mdng ~<ale fi+~ otttcome is nu~ defined.

Overall this book is a rueful addition to the h~her un+ dersranding of ergo+ compounds and brain fimction because it compiles trader one cover papers of numem~s inves+ ti~ators workin~ m this field, ~~e l:~ov/k is recnmmendd m medical libraries and to those in the neum+ciences with a specific interest in the neumen&~rine and neumpsychiat- tic atriums of ergot eompmmds+