Is non-contrast MRI sufficient to detect meningioma residue after surgery?

BACKGROUND

Contrast-enhanced magnetic resonance imaging (MRI) is the imaging modality routinely used to follow up patients who have undergone surgical resection of brain meningiomas. There are growing concerns about the massive use of gadolinium-based contrast agents (GBCA). Our aim was to evaluate the performance of a new imaging protocol, performed without GBCA injection, in the detection of tumoral residue or local recurrence after surgery of parafalcine and convexity meningiomas.

MATERIALS AND METHODS

Only adult patients with a documented resected parafalcine or convexity meningioma were included. We performed a dedicated MRI protocol that included non-contrast and post-contrast sequences. The presence or absence of residue on the unenhanced sequences was independently recorded by three observers: first blindly, then in comparison with a baseline enhanced MRI examination.

RESULTS

A total of 51 patients were included. 37 of them featured a tumor residue on the reference enhanced sequence. Overall, an average of 32 of 37 (87%) residues were identified on the unenhanced sequences that were blindly reviewed; and more than 34 of 37 (93%) were identified with the help of the comparative baseline enhanced examination, with a high sensitivity. The missed cases were related to small residues.

CONCLUSION

Unenhanced MRI sequences are highly sensitive and specific in identifying a tumor residue or a local recurrence in the post operative follow up of brain meningiomas. Sensitivity is even higher with the help of a comparative baseline enhanced MRI examination, whatever the strength of magnetic field.

Changes in the characteristics of patients treated for brain metastases with repeat stereotactic radiotherapy (SRT): a retrospective study of 184 patients

PURPOSE

Brain metastases (BMs) are the leading cause of intracranial malignant neoplasms in adults. WHO, Karnofsky performance status (KPS), age, number of BMs, extracerebral progression (ECP), recursive partitioning analysis (RPA), diagnosis-specific graded prognostic assessment (Ds-GPA) are validated prognostic tools to help clinicians decide on treatment. No consensus exists for repeat stereotactic radiotherapy (SRT) for BMs. The aim of this study was to review the changes in patient characteristics treated with repeated SRTs.

METHODS AND MATERIALS

The data of patients treated between 2010 and 2020 with at least two courses of SRT without previous whole brain radiotherapy (WBRT) were reviewed. Age, WHO, KPS, ECP, type of systemic treatment, number of BMs were recorded. RPA, Ds-GPA and brain metastasis velocity (BMV) were calculated.

RESULTS

184 patients were treated for 915 BMs and received two to six SRTs for local or distant brain recurrence. The median number of BMs treated per SRT was 1 (range: 1-6), for a median of 4 BMs treated during all sessions (range: 2-19). WHO, Ds-GPA and RPA were stable between each session of SRT, whereas KPS was significantly better in SRT1 than in the following SRT. The number of BMs was not significantly different between each SRT, but there was a tendency for more BM at SRT1 (p = 0.06). At SRT1, patients had largest BM and undergo more surgery than during the following SRT (p < 0.001). 6.5%, 37.5% and 56% of patients were classified as high, intermediate, and low BMV, respectively, at the last SRT session. There was almost perfect concordance between the BMV-grade calculated at the last SRT session and at SRT2 (r = 0.89; p < 0.001).

CONCLUSION

Repeated SRT doesn't lead to a marked alteration in the general condition, KPS was maintained at over 70% for more than 95% of patients during all SRTs. Long survival can be expected, especially in low-grade BMV patients. WBRT shouldn't be aborted, especially for patients developing more than twelve BMs annually.

Acute toxicities and cumulative dose to the brain of repeated sessions of stereotactic radiotherapy (SRT) for brain metastases: a retrospective study of 184 patients

BACKGROUND

Stereotactic radiation therapy (SRT) is a focal treatment for brain metastases (BMs); thus, 20 to 40% of patients will require salvage treatment after an initial SRT session, either because of local or distant failure. SRT is not exempt from acute toxicity, and the acute toxicities of repeated SRT are not well known. The objective of this study was to analyze the acute toxicities of repeated courses of SRT and to determine whether repeated SRT could lead to cumulative brain doses equivalent to those of whole-brain radiotherapy (WBRT).

MATERIAL AND METHODS

Between 2010 and 2020, data from 184 patients treated for 915 BMs via two to six SRT sessions for local or distant BM recurrence without previous or intercurrent WBRT were retrospectively reviewed. Patients were seen via consultations during SRT, and the delivered dose, the use of corticosteroid therapy and neurological symptoms were recorded and rated according to the CTCAEv4. The dosimetric characteristics of 79% of BMs were collected, and summation plans of 76.6% of BMs were created.

RESULTS

36% of patients developed acute toxicity during at least one session. No grade three or four toxicity was registered, and grade one or two cephalalgy was the most frequently reported symptom. There was no significant difference in the occurrence of acute toxicity between consecutive SRT sessions. In the multivariate analysis, acute toxicity was associated with the use of corticosteroid therapy before irradiation (OR = 2.6; p = 0.01), BMV grade (high vs. low grade OR = 5.17; p = 0.02), and number of SRT sessions (3 SRT vs. 2 SRT: OR = 2.64; p = 0.01). The median volume equivalent to the WBRT dose (V_WBRT) was 47.9 ml. In the multivariate analysis, the V_WBRT was significantly associated with the total GTV (p < 0.001) and number of BMs (p < 0.001). Even for patients treated for more than ten cumulated BMs, the median BED to the brain was very low compared to the dose delivered during WBRT.

CONCLUSION

Repeated SRT for local or distant recurrent BM is well tolerated, without grade three or four toxicity, and does not cause more acute neurological toxicity with repeated SRT sessions. Moreover, even for patients treated for more than ten BMs, the V_WBRT is low.

Radionecrosis after repeated courses of radiotherapy under stereotactic conditions for brain metastases: Analysis of clinical and dosimetric data from a retrospective cohort of 184 patients

PURPOSE

Between 10 and 40% of patients with cancer will develop one or more brain metastases (BMs). Stereotactic radiotherapy (SRT) is part of the therapeutic arsenal for the treatment of de novo or recurrent BM. Its main interest is to delay whole brain radiation therapy (WBRT), which may cause cognitive toxicity. However, SRT is not exempt from long-term toxicity, and the most widely known SRT is radionecrosis (RN). The objective of this study was to analyze the occurrence of RN per BM and per patient.

MATERIAL AND METHODS

Between 2010 and 2020, data from 184 patients treated for 915 BMs by two to six SRT sessions for local or distant brain recurrence without previous or intercurrent WBRT were retrospectively reviewed. RN was examined on trimestral follow-up MRI and potentially confirmed by surgery or nuclear medicine. For each BM and SRT session plan, summation V_12Gy, V_14Gy, V_21Gy and V_23Gy isodoses were collected. Volumes of intersections were created between the 12Gy isodose at the first SRT and the 18Gy isodose of the following SRT (V_18-12Gy).

RESULTS

At the end of follow-up, 23.0% of patients presented RN, and 6.3% of BM presented RN. Median follow-up of BM was 13.3 months (95%CI 18.3-20.8). The median interval between BM irradiation and RN was 8.7 months (95% CI 9.2-14.7). Six-, 12- and 24-month RN-free survival rates per BM were 75%, 54% and 29%, respectively. The median RN-free survival per patient was 15.3 months (95% CI 13.6-18.1). In multivariate analysis, the occurrence of RN per BM was statistically associated with local reirradiation (P<0.001) and the number of SRTs (P<0.001). In univariate analysis, the occurrence of RN per patient was statistically associated with the sum of all V_18-12Gy (P=0.02). No statistical association was found in multivariate analysis. A sum of all V_18-12Gy of less than 1.5ml was associated with a 14.6% risk of RN, compared with 35.6% when the sum of all V_18-12Gy was superior to 1.5ml. The sum of all V_18-12Gy larger than 1.5ml was associated with a 74% specificity and 53% sensitivity of RN (P<0.001).

CONCLUSION

Based on these results, a small number of BMs show RN during repeated SRT for local or distant recurrent BMs. Local reirradiation was the most predictive factor of brain RN. A V_18-12Gy larger than 7.6ml in the case of local reirradiation or larger than 1.5ml in proximity reirradiation were prognostic factors of RN. The more BM patients need radiation therapy, and the longer they survive after irradiation, the higher their individual risk of developing RN.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND

Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma.

METHODS

A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS).

RESULTS

The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30].

CONCLUSION

iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS.

TRIAL REGISTRATION NUMBER

No. IRB00011687 retrospectively registred on July 7th 2021.

Surgical management of persistent post-traumatic trans-tentorial brain hernia

INTRODUCTION

Temporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome.

MATERIALS AND METHODS

This was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6months' follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E).

RESULTS

At postoperative evaluation 48h after DTLD, we observed a significant improvement in GCS score (initial 6±3, preoperative 7±3, postoperative 14±1; P=0.02), midline shift (initial 16±3mm, preoperative 13±5mm, postoperative 9±2mm; P=0.049) and ONP (P=0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P=0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded.

CONCLUSIONS

In traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.

Is physical activity a trigger factor for subarachnoid hemorrhage?

INTRODUCTION

Subarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature.

METHOD

A systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency.

RESULTS

Physical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity.

CONCLUSION

Physical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.

Investigating the real impact of COVID-19 pandemic on the daily neurosurgical practice?

OBJECTIVE

The objective of this study was to relate the neurosurgical activity during a time of sanitary crisis such as experienced during the SARS-CoV-2 pandemic.

METHODS

A monocentric retrospective analysis was made based on a prospectively gathered cohort of all patients requiring neurosurgical care between March 15th and May 12th, 2020. Local impact of SARS-CoV-2 was analysed regarding number of patients admitted in ICU.

RESULTS

One hundred and sixty patients could benefit from neurosurgical care with a wide-ranging profile of clinical and surgical activities performed during the study that seemed similar to last year profile activity. Surgical indications were restricted to non-deferrable surgeries, leading to a drop in operative volume of 50%. Only 1.3% of patients required transfer to other units due to the impossibility of providing gold standard neurosurgical care in our centre.

CONCLUSION

Despite the challenges represented by the SARS-CoV-2 pandemic, it was proven possible to ensure the routine neurosurgical continuity and provide high standards of neurosurgical care without compromising patients' access to the required treatments.

The Cryo-immunologic effect: A therapeutic advance in the treatment of glioblastomas?

The immunotherapy of cerebral glioblastoma has become a hot topic. Immune checkpoint blockade antibodies have progressively acquired a role in the management of malignant tumors. A multimodal approach using surgery, radiotherapy, chemotherapy in combination with immunotherapy represent a potent weapon against glioblastomas. In parallel, clinical applications of cryotherapy-freezing tumors based on repetition of rapid freeze-slow thaw cycle-for various cancers such as skin, lung, breast, esophagus, hepatic, kidney, prostate and bone tumors were developed. The future immunomodulatory approaches might be combined with brain tumors cryoablation to increase the cryoimmune response. The objective of this study was to analyze from the literature the relationship between cerebral cryosurgery and immunomodulation using PRISMA method. The animals' studies demonstrate the dendritic cells maturation and activation with the enhancement of antigen-presenting function after cryotherapy suggesting the potential usefulness of the association of cryotherapy and immunomodulator in the management of gliomas.

[Choice optimisation of radiation therapy technique for central neurocytomas from literature data]

Neurocytomas represent 0,25 to 0,5 of brain tumours. These tumours have neuronal differentiation. It's a young adult disease. The main treatment is neurosurgery. The place of other therapies is still unclear, noticeably with regards to radiotherapy. This review aim is to determine the place and the modalities of radiotherapy in the management of neurocytomas. A literature search using PubMed allowed to select the most relevant studies. Finally, 22 studies were selected according to pre-established criteria to answer the problem. All studies were retrospective studies except one. The analysis conclusion defined radiotherapy as a treatment of choice in selected patients, when surgical resection was incomplete or when tumour was atypical.

A combined single-stage procedure to treat brain AVM

Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BACKGROUND

Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment.

METHODS

This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge.

RESULTS

The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi² test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment.

CONCLUSION

Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Benefits of using the "Micro-Clock" to evaluate the acquisition and maintenance of microsurgery skills

This study was done using an educational tool called the "Micro-Clock", which was inspired by Chan's "round-the-clock" training model. The Micro-Clock consisted of a surgical sponge on which 12 sewing needles were configured in the shape of a clock. The subjects were asked to thread a small suture through the eyelets as quickly as possible. Steadiness and instrument manipulation were evaluated during each trial and graded from 1 to 3. The execution time was measured in seconds. Fifteen instructors did the Micro-Clock test once in order to validate this tool's ability to assess the skills of qualified microsurgeons. Next, nine students, who were enrolled in a microsurgery diploma program, did the test nine times during the program to measure their progression and to evaluate their mastery and execution speed. There was no significant differences among the three instructor sub-groups (residents, assistants and senior surgeons) in their steadiness, instrument manipulation and execution time. When the students performed the Micro-Clock test, there was a significant improvement in movement fluidity as well as the execution time between the first and ninth test. Nevertheless, the execution time did not improve further after the fourth test. The Micro-Clock is a useful and reliable tool for teaching microsurgery skills and testing the maintenance of skills in qualified microsurgeons.

Diagnostic value of fusion of metabolic and structural images for stereotactic biopsy of brain tumors without enhancement after contrast medium injection

BACKGROUND

The heterogeneous nature of glioma makes it difficult to select a target for stereotactic biopsy that will be representative of grade severity on non-contrast-enhanced lesion imaging. The objective of this study was to evaluate the benefit of fusion of metabolic images (PET 18F-DOPA) with magnetic resonance imaging (MRI) morphological images for cerebral biopsy under stereotactic conditions of glioma without contrast enhancement.

PATIENTS AND METHODS

This single-center prospective observational study conducted between January 2016 and April 2018 included 20 consecutive patients (mean age: 45±19.5 years; range, 9-80 years) who underwent cerebral biopsy for a tumor without MRI enhancement but with hypermetabolism on ¹⁸F-FDOPA PET (positron emission tomography). Standard ¹⁸F-FDOPA uptake value (SUV_max) was determined for diagnosis of high-grade glioma, with comparison to histomolecular results.

RESULTS

Histological diagnosis was made in all patients (100%). Samples from hypermetabolism areas revealed high-grade glial tumor in 16 patients (80%). For a SUV_max threshold of 1.75, sensitivity was 81.2%, specificity 50%, PPV 86.7% and VPN 40% for diagnosis of high-grade glioma. No significant association between SUV_max and histomolecular mutation was found.

CONCLUSION

¹⁸F-FDOPA metabolic imaging is an aid in choosing the target to be biopsied under stereotactic conditions in tumors without MR enhancement. Nevertheless, despite good sensitivity, ¹⁸F-FDOPA PET is insufficient for definitive diagnosis of high-grade tumor.

[Base of the skull meningioma: Efficacy, clinical tolerance and radiological evaluation after radiotherapy]

Skull base meningioma leads to functional disturbances, which can significantly alter the quality of life. The optimal management of these lesions, whose goals are neurological preservation and tumour local control, is not yet clearly established. It is widely recognized that the goal of a radical excision should be abandoned despite the advances in the field of microsurgery of skull base lesions. Although less morbid, partial tumour excision would be associated with increased risk of local tumour recurrence. Although discussed both exclusive and adjuvant have proven to be highly successful in terms of clinical improvement and local control. Various radiation techniques have demonstrated their efficacy in the management of this pathology. However, high rates of clinical improvement are in contrast with low rates of radiological improvement. The notion of clinical and radiological dissociation appeared. However, in most of these studies, the analysis of the radiological response could be subject of legitimate criticism. This work proposes to review the local control, the efficacy and the clinical tolerance and the radiological response of the various radiation techniques for the meningioma of the base of the skull and to demonstrate the interest of quantitative volumetric analyses in the follow-up of meningioma after radiotherapy.

Multimodal management of severe herpes simplex virus encephalitis: A case report and literature review

BACKGROUND

Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature.

CASE DESCRIPTION

The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1.

CONCLUSION

Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.

The Grisel's syndrome: A non-traumatic subluxation of the atlantoaxial joint

INTRODUCTION

Grisel's syndrome consists in rotational subluxation of C1-C2 following ENT infection or surgery. There is no consensus on management. We present 2 cases requiring surgical treatment in our center.

CASE REPORTS

Two 10-year-old patients presented torticollis with cervical pain resistant to medical treatment, with onset a few months after tonsillectomy. In both cases, radiological assessment, comprising CT scan and MRI, showed Fielding-Hawkins type-3 C1-C2 rotational subluxation, without ligament lesion. After failure of conservative treatment, posterior reaming, realignment, C1-C2 arthrodesis using lateral masses and pars interarticularis screws and bone graft achieved good fusion and immediate spinal stability in all planes of the atlantoaxial complex.

DISCUSSION

Grisel's syndrome consists in non-traumatic subluxation of the atlantoaxial joint with intact atlantoaxial ligaments. Initial pharyngeal inflammation spreads to the prevertebral fascia via direct connections between the periodontoidal venous plexus and pharyngovertebral veins, inducing fasciitis that leads to abnormal relaxation of the atlantoaxial ligaments and reactional muscle contraction with ankylosis. This phenomenon, appearing gradually and insidiously over a period of a few weeks, creates a frozen joint with ankylosis. Medical treatment with NSAIDs, muscle relaxants, and immobilization is usually sufficient; cervical traction may be needed. Surgical treatment by C1-C2 arthrodesis is indicated in case of failure of medical management or onset of neurologic signs.

CONCLUSION

Close collaboration between pediatricians, ENT surgeons and neurosurgeons is essential for early diagnosis and management, which is the main prognostic factor for successful medical treatment, avoiding surgery.

Multidisciplinary management of an intra-sellar cavernous hemangioma: Case report and review of the literature

Extra-axial cavernous hemangiomas (ECH) are rare vascular lesions with a tendency to grow within the medial structures of the middle cranial fossa. This pathological entity lacks specific symptoms, and falls into the category of differential diagnosis of space occupying lesions in the cavernous sinus (CS) with or without sellar involvement, including those of tumoral, vascular and inflammatory nature. Of note, ECH can also be indolent, and is at times discovered incidentally during autopsy investigations. On radiological studies, ECH with sellar extension are frequently mistaken at first for pituitary adenomas. Total removal of intrasellar-CS ECH is technically demanding and burdened by remarkable morbidity and mortality rates, mostly related to the complex neuroanatomy of the CS-sellar region (i.e., peri and postoperative bleeding, and transitory or permanent nerve palsies, hormonal deficits). Consequently, only a few cases of successful total removal have been reported so far in the literature. Surgical debulking with cranial nerve decompression followed by stereotactic radiosurgery is currently considered the best alternative to total removal when the latter carries excessive perioperative risks. We present a rare case of a mainly located intrasellar ECH extending to the left CS discussing its clinical features and focusing on the most relevant aspects of the surgical management along with a review of the pertinent literature.

Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament - Concerning one case

BACKGROUND

An isolated rupture of the alar ligament is a rare occurrence with only a few cases reported in the literature.

CASE REPORT

The objective was to report the case of a young man with a unilateral rupture of the alar ligament that we closely monitored, clinically and radiologically, in order to describe the evolution of the alar ligament lesions.

CONCLUSION

Radiological diagnosis using cervical MRI and duration of the conservative treatment remain debated and we proposed a close radiological follow-up in order to best understand the nature of these ligament lesions and their evolution following specific treatment.

Thalamic rosette-forming a glioneuronal tumor in an elderly patient: Case report and literature review

The rosette-forming glioneuronal tumor (RGNT) is a novel type of brain tumor recently listed in the WHO 2007 classification of central nervous system (CNS) tumors. We report the case of a 75-year-old woman harboring a thalamic RGNT with third ventricle dissemination. Age and location make the present case exceptional and which has never previously been reported. A review of the clinical, pathological and radiological features is presented along with the relevant literature.

Familial intracranial aneurysm, the relationship of the aortic diameter

OBJECTIVES

Familial predisposition appears as an identified risk factor for cerebrovascular disease. The primary objective of our study was to assess intracranial aneurysm (IA) recurrence rate in a population of familial IA. Secondary objectives were first to analyse the inheritance categorisation/pattern of these families and second to assess the correlation between the aortic diameter on MRI and the aneurysmal characteristics.

PATIENTS AND METHODS

Over a period of 20 years (1990-2010), 26 patients from 23 families, identified from a regional register, accepted to participate in this prospective trial in order to determine, the inheritance pattern, the screening of de novo aneurysms by CT angioscan, and the aortic mensuration by MRI. The transmission pattern was categorised into autosomal dominant inheritance, autosomal recessive and autosomal dominance with incomplete penetrance. The aortic diameter was measured: anatomic coverage in the caudo-cranial direction from the iliac arteries to the ventriculo-aortic junction.

RESULTS

All 26 patients [from 55.4 ± 11.2 years, sex ratio female/male: 1.36] were reviewed after a mean follow-up of 7.9 ± 6.6 years after the diagnosis of a cerebral aneurysm. The characteristics of this population were the diagnostic circumstances such as a subarachnoid hemorrhage (SAH) in 14 (53.8%), the multiple locations in 10 (38.5%) and a giant aneurysm in 4 (15.4%). Four de novo aneurysms were diagnosed in 3 patients (11.5%) after a mean follow-up of 22.3 ± 4 years, which corresponds to an annual incidence of 1.9 (95% CI 1.4-2.6%). The transmission pattern was autosomal dominant in 16 (61.5%), recessive in 3 (11.5%) and not defined in 7 (26.9%). As regards the aortic diameter, a significant decrease in the aortic diameter was observed in patients with an aneurysmal diameter superior to 10mm.

CONCLUSION

The rate of de novo aneurysm justifies prolonged monitoring by imaging of these patients with familial intracranial aneurysm. The narrowing of the terminal part of the aorta could be a hemodynamic factor involved into the IA development.

[Orbital neurenteric cyst. A case report and review of the literature]

INTRODUCTION

Neurenteric cysts defined as a cyst lined by endodermal-type epithelium are extremely rare. We report a rare case of an orbital neurenteric cyst.

CASE REPORT

A 19-year-old female presented with an orbital cyst tumor that had cosmetic consequences. The signal of the cyst was not enhanced after administration of gadolinium on MRI examination. The patient underwent surgery due to the increase in size of the tumor. A complete cyst removal including the cyst wall through the inferior palpebral fold was performed. The histological examination confirmed the diagnostic of neurenteric cyst. The patient was discharged home in excellent condition.

CONCLUSION

This report discusses the clinical presentation, neuroradiological aspect, pathological findings and therapeutic consideration of the neurenteric cyst. We described a rare case of orbital neurenteric cyst. Due to the local recurrence rate observed after partial resection, the goal of the surgery should be a total resection of the cyst with the cyst wall.

[Endoscopic approaches to the orbit]

During the last decade, the use of endoscopic endonasal approaches to the pituitary has increased considerably. The endoscopic endonasal and transantral approaches offer a minimally invasive alternative to the classic transcranial or transconjunctival approaches to the medial aspect of the orbit. The medial wall of the orbit, the orbital apex, and the optic canal can be exposed through a middle meatal antrostomy, an anterior and posterior ethmoidectomy, and a sphenoidotomy. The inferomedial wall of the orbit can be also perfectly visualized through a sublabial antrostomy or an inferior meatal antrostomy. Several reports have described the use of an endoscopic approach for the resection or the biopsy of lesions located on the medial extraconal aspect of the orbit and orbital apex. However, the resection of intraconal lesions is still limited by inadequate instrumentation. Other indications for the endoscopic approach to the orbit are the decompression of the orbit for Graves' ophthalmopathy and traumatic optic neuropathy. However, the optimal management of traumatic optic neuropathy remains very controversial. Endoscopic endonasal decompression of the optic nerve in case of tumor compression could be a more valid indication in combination with radiation therapy. Finally, the endoscopic transantral treatment of blowout fracture of the floor of the orbit is an interesting option that avoids the eyelid or conjunctive incision of traditional approaches. The collaboration between the neurosurgeon and the ENT surgeon is mandatory and reduces the morbidity of the approach. Progress in instrumentation and optical devices will certainly make this approach promising for intraconal tumor of the orbit.