Drug-resistant temporal lobe epilepsy is associated with postural control abnormalities

Epilepsy is responsible for falls that are not systematically associated with seizures and that therefore suggest postural impairment. There are very few studies of postural control in patients with epilepsy and none of them focus on temporal lobe epilepsy (TLE), although part of the vestibular cortex is located in the temporal cortex. The aim of this study was to evaluate the characteristics of postural control in a homogeneous population of patients with complex partial TLE. Twenty-six patients with epilepsy and 26 age-matched healthy controls underwent a sensory organization test combining six conditions, with and without sensory conflicting situations. Patients with epilepsy displayed poorer postural control, especially in situations where vestibular information is necessary to control balance. In addition to potential antiepileptic drug side effects, vestibular dysfunction could be related to the temporal pathology. Our study allows for a better understanding of the mechanism underlying falls in this population of patients.

[Cranial nerve functional neurosurgery: evaluation of surgical practice]

We report the results of an investigation carried out on the activity of functional neurosurgery of the cranial nerves in the French-speaking countries, based on the analysis of a questionnaire addressed to all the members of the SNCLF. Eighteen centers responded to this questionnaire, which showed that activities and indications varied greatly from one unit to another. The results appear homogeneous and comparable with those reported in the literature. The questionnaire sought to provide a global perspective, open to the comments and questions of all responders on the various techniques raised, with the objective of establishing a common decisional tree for these pathologies and providing if possible to a consensus for better dissemination of these therapies.

[Germ-cell tumors of the central nervous system in childhood: retrospective study of 13 patients]

BACKGROUND AND PURPOSE

Germ cell tumors (GCT) of the central nervous system are rare (2% of all brain tumors in children). Although originating from germ cells, GCT cover a spectrum of different tumors with different management and prognosis, depending on whether they secrete tumor markers or not. The aim of this study is to present a series of children with GCT and comment on overall management practices.

METHODS

We retrospectively reviewed 13 children under the age of 18 years (nine boys and four girls), treated in the same institution between 1986 and 2006 for one or more primitive GCT of the central nervous system.

RESULTS

Median age at diagnosis is 12.9 years (7-17 years). Tumor markers (alpha foetoprotein [alphaFP], human chorionic gonadotrophin [betaHCG]) were assessed 11 times in blood as well as cerebrospinal fluid (CSF). Tumors were located as follows: pineal region (10 cases), hypothalamus (eight cases), basal ganglia (one case) and corpus callosum (one case). Six were bifocal (pineal region and hypothalamus). Clinical signs were mostly dominated by diabetes insipidus and intracranial hypertension. Seven children required surgery for hydrocephalus. Tumor markers were positive in three cases and these children subsequently received chemotherapy followed by radiotherapy, except one child. Eventually, the three patients with positive markers required surgery because of a residual lesion. The eight other patients had a stereotactic biopsy for diagnosis. At the end of follow-up, treatment morbidity appears to be low and neither death nor recurrence was observed. Mean follow-up is 8.85 years (2-20 years).

CONCLUSIONS

The prognosis of cerebral GCTs in children is excellent because of their pronounced chemo- and radiosensitivity. Surgery is crucial for diagnosis in the event of negative markers, or if there is evidence of residual tumor with normalization of tumor markers at the end of chemotherapy. Tumor markers must be monitored to check the diagnosis and for follow-up. The place of tumor biopsy during endoscopic third ventriculostomy (performed if hydrocephalus is present) is still debated.

[Natural history of intramedullary cavernomas. Results of the French Multicentric Study]

INTRODUCTION

The prevalence of cerebral cavernomas is about 0.5% in the general population. In contrast, spinal cord cavernomas are considered as rare. The objective of this study was to determine the natural history of spinal cord cavernomas in a multicentric study.

METHODS

Clinical and neuroradiological findings were retrospectively collected. Diagnosis was based on pathological criteria or magnetic resonance (MR) findings.

RESULTS

Fifty-three patients were included (26 males, 27 females). Mean age at onset of symptoms was 40.2 years (range: 11-80). Initial symptoms were progressive (32) and acute myelopathy (20). One patient was asymptomatic. Clinical symptoms were related to spinal cord compression (24) and hematomyelia (19). Cavernoma location was dorsal (41) and cervical (12.). MR findings consisted of hyperintense signal on T1 and T2 sequences (19 cases), mixed hyperintense and hypointense signal (33 cases), and hypointense signal on T1 and T2 sequences in 1 case. Mean size was 16.3 mm (range: 3-54). Forty patients underwent surgical resection. Improvement was observed in 20 patients and worsening of neurological symptoms in 11. Length of follow up was 7.1 years. At the end of the study, 26 patients were autonomous, 18 handicapped and 1 bedridden.

CONCLUSION

This study provided precise data on the clinical and MR patterns of these lesions. The natural history is associated with a higher risk of hemorrhage recurrence, but is favorable in many operated patients. Microsurgery is the treatment of choice for most of these lesions.

Predicting the outcome of shunt surgery in normal pressure hydrocephalus

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

Germinoma located in the basal ganglia in an 8-year-old girl

CASE REPORT

The authors describe a unique case of an 8-year-old girl with a germinoma located in the left basal ganglia. Medical history begins 5 months before with a central diabetes insipidus, loss of weight (5 kg at admission), vomiting and asthenia. Computed tomography (CT) and cranial magnetic resonance imaging (MRI) are performed and demonstrate a left basal ganglia tumour (nucleus lentiformis). Diabetes insipidus is considered as non-visible germinoma localization on the pituitary stalk rather than as a possible consequence of peri-tumoural oedema surrounding the hypothalamus. Spinal MRI is normal. Neurological as well as general examination is normal.

DISCUSSION

The first hypothesis is low-grade glioma, but pathological examination following a stereotactic biopsy of the lesion reveals a cerebral germinoma. A few days before the biopsy, the girl experienced a mild left facial palsy, and CT scans at the time of biopsy reveals an intra-tumoural haemorrhage. Alpha fetoprotein and human chorionic gonadotrophin were negative as blood and cerebrospinal fluid markers, whereas placental alkaline phosphatase was positive on immunohistochemical profile of the tumour samples. Dedicated chemotherapy, followed by focal irradiation (40 Gy, 30 sessions, 45 days; SIOP CNS GCT 93 protocol), is performed with a complete response. The outcome is good (Glasgow Outcome Scale=I), without any cognitive impairment and the persistence of a mild facial palsy and a slight right arm dystonia on last neurological examination. There is still no evidence of tumour recurrence.

Empyèmes sous-duraux de l’enfant : stratégie thérapeutique

We report a series of five subdural empyema (SDE) in children and young adults treated in the same neurosurgical department. These five cases were reviewed retrospectively. There were four boys and one girl, aged from three months to 18 years at time of diagnosis (median age: 7 years). SDE following intracranial surgery were excluded from the study. All patients were treated surgically (burr hole evacuation or craniotomy, repeated in some cases), followed by intravenous antibiotic therapy (mean time: 52 days) adapted to the micro-organism. Only the two patients treated by large craniotomy at first had a single surgical procedure. Involved micro-organisms are as follow: Streptococcus intermedius (n=2), Streptococcus pneumoniae (n=1), Escherichia coli (n=1), absence of any identified micro-organism (n=1). The five patients are alive (median follow-up: 22 month) without any sequelae. We advocate an aggressive surgical treatment of SDE in children with a large bone flap to allow the surgeon to remove pus and membranes as much as possible, even in the interhemispheric fissure, followed by intravenous appropriate antibiotherapy and eradication of the source of infection. Even this "aggressive" treatment may sometimes not avoid re-operation. A careful follow-up is mandatory, because of the high risk of recurrence.

Les astrocytomes pilocytiques du diencéphale de l’enfant

BACKGROUND AND PURPOSE

Pilocytic astrocytoma (PA) is a WHO grade I tumor of the central nervous system mostly arising in children and young adults. Management of diencephalic PA is a difficult challenge. Surgical treatment has to cope with both the difficulties of deep location and eloquent area tumors.

MATERIALS AND METHODS

We retrospectively reviewed seven pediatric cases (female: 4, male: 3) of diencephalic PA. Opto-chiasmatic tumors were excluded from the series. Mean age at diagnosis was 108 months (9 years) (range: 4 month-18 years), median age was 111 months. Median follow-up for the series was 125 months. Tumor locations were as followed: right thalamus: 2, both thalami: 1, hypothalamus: 3, and right basal ganglia: 1. At the onset, the first symptom was mostly raised intracranial pressure. The delay in diagnosis ranged from 48 hours up to 6 years.

TREATMENT

a shunting procedure was performed in 3 patients, a direct surgical approach in 5 patients (gross total removal: 2; partial removal: 3) and one patient had only a biopsy. Three children were re-operated. Three patients were treated by radiationtherapy (RT) after surgery. Chemotherapy was delivered for 4 children.

RESULTS

The overall survival rate was 71.4 months (almost 6 years) (range: 3-184 months). Median survival rate was 42 months (3.5 years). Three children died, two by tumor progression and one death related to late side-effects of RT. Four patients have a good quality of life with GOS I (n = 3) or II (n = 1). We observed tumor regression in two patients at 1 and 17 years after the beginning of treatment. Correct diagnosis was only made for two cases at the initial pathological examination.

CONCLUSION

The course of diencephalic PA is still unpredictable. The tumor can be controlled by a partial surgical removal, and a residual tumor can sometimes decrease in size after surgery. Gross total removal of these tumors, although difficult, may be performed. With cranial navigation systems, the risk is low. Pathological diagnosis is sometimes difficult to assess.

[Methylation status of RARbeta gene promoter in low and high grade cerebral glioma. Comparison with normal tissue. Immuno-histochemical study of nuclear RARbeta expression in low and high grade cerebral glioma cells. Comparison with normal cells. 48 tumors]

Retinoic acid receptor beta (RARbeta) is a nuclear receptor often deregulated in tumors. An immunohistochemical study was conducted to examine the level of expression of this receptor in the nucleus of glial cell tumors (low and high grade glioma) as well as a study of the methylation status of the gene promoter coding this receptor on the same tumor samples. A comparison with normal tissue was done each time. 48 tumors were eligible for the study (15 glioblastomas, 20 grade III oligodendrogliomas and 13 grade II oligodendrogliomas). A constant decrease of RARbeta expression was found by comparison with normal tissue whatever the histological grade of the tumor, suggesting a deregulation of RARbeta gene expression. Methylation of RARbeta promoter gene was a rare event (12.5% of all cases), except for grade III oligodendrogliomas (20%), and is thus not a major event of this gene deregulation. Other reasons of this deregulation of RARbeta should be studied, such as loss of 3p24 heterozygoty, mRNA studies and RARbeta interactions with other retinoid receptors.

Neurosurgery and the intracranial venous system

1) Numerous of the so-called "unpredictable" post-operative complications are likely to be related to the lack of prevention or non-recognition of venous problems, especially damages to the dangerous venous structures, namely: the major dural sinuses, the deep cerebral veins and some of the dominant superficial veins like the vein of Labbé. 2) Tumors invading the major dural sinuses (superior sagittal sinus, torcular, transverse sinus)--especially meningiomas--leave the surgeon confronted with a dilemma: leave the fragment invading the sinus and have a higher risk of recurrence, or attempt at total removal with or without venous reconstruction and expose the patient to a potentially greater operative danger. Such situations have been encountered in 106 patients over the last 25 years. For decision-making, meningiomas were classified into six types according to the degree of sinus invasion. Type 1: meningioma attached to outer surface of the sinus wall; Type II: one lateral recess invaded; Type III: one lateral wall invaded; Type IV: one lateral wall and the roof of the sinus both invaded; Types V and VI: sinus totally occluded, one wall being free of tumor in type V. In brief, our surgical policy was the following: Type I: excision of outer layer and coagulation of dural attachment; Type II: removal of intraluminal fragment through the recess, then repair of the dural defect by resuturing recess. Type III: resection of sinus wall and repair with patch (fascia temporalis). Type IV: resection of both invaded walls and reconstruction of the two resected walls with patch. Type V: this type can be recognized from type VI only by direct surgical exploration of the sinus lumen. Opposite wall to the tumor side is free of tumor, it is possible to reconstruct the two resected walls with patch. Type VI: removal of involved portion of sinus and restoration with venous bypass. 3) As 20% of the patients presenting with manifestations of intracranial hypertension due to occlusion of posterior third of the superior sagittal sinus, torcular, predominant lateral sinus or internal jugular vein(s) develop severe intracranial hypertension, venous revascularisation by sino-jugular bypass--implanted proximally to the occlusion and directed to the jugular venous system (external or internal jugular vein)--can be a solution.

Bilateral subthalamic nucleus stimulation improves balance control in Parkinson's disease

BACKGROUND

Parkinson's disease (PD), the most common basal ganglia degenerative disease, affects balance control, especially when patients change balance strategy during postural tasks. Bilateral chronic stimulation of the subthalamic nucleus (STN) is therapeutically useful in advanced PD, and reduces the motor signs of patients. Nevertheless, the effects of STN stimulation on postural control are still debatable.

AIMS

To assess the impact of bilateral STN stimulation on balance control in PD and to determine how basal ganglia related sensorimotor modifications act on neurosensorial organisation of balance and motor postural programming.

METHODS

Twelve subjects aged 45-70 years underwent unified Parkinson's disease rating scale motor (part III) clinical tests, static and dynamic posturography, including sensory organisation and adaptation tests, shortly before and six months after bilateral implantation of electrodes into the STN.

RESULTS

The postoperative static test showed an improvement in postural control precision both in eyes open and eyes closed conditions. The dynamic test highlighted the decreased number of falls and the ability of the patients to develop more appropriate sensorimotor strategies when stimulated. The sensory organisation test showed an improvement of equilibrium score and, thus, a better resolution of sensorial conflicts.

CONCLUSIONS

STN stimulation allowed a reduction in rigidity and therefore an improvement in the ability to use muscular proprioception as reliable information, resulting in vestibulo-proprioceptive conflict suppression. STN stimulation has a synergistic effect with levodopa for postural control. Accordingly, non-dopaminergic pathways could be involved in postural regulation and STN stimulation may influence the functioning of these pathways.

Le xanthoastrocytome pléomorphe

BACKGROUND AND PURPOSE

We present a review of five patients who developed pleomorphic xanthoastrocytomas, presenting the clinical features, pathology findings and therapeutic approach of these rare tumours which almost always occur in children and young adults.

METHODS

This paper is a retrospective study of five patients (three males and two females), treated from 1985 to 1996.

RESULTS

Seizure was the most frequent symptom. The tumor was located in the temporal or temporo-parietal lobe in two patients, in the parietal lobe in one, the frontal in one and in hypothalamus and third ventricle in the final patient. To our knowledge, no case of pleomorphic xanthoastrocytoma located in the area of hypothalamus/third ventricle has been reported in the literature. All patients underwent surgery which was complete for two patients, subtotal for two others and partial for one. Four were given post-operative cerebral radiation therapy (two recurrences and malignant transformation and two erroneous diagnoses) (mean dose: 44.75 Gy), for two patients surgery was followed by chemotherapy. One patient was lost for follow-up. Two patients presented at least one tumor recurrence. Two died from malignant transformation. Two patients are alive without recurrence at 12 and 16 years from diagnosis with excellent quality-of-life (Glasgow Outcome Scale=I).

CONCLUSION

Surgery is the gold standard treatment. Prognosis is very good (except for malignant transformation), so that a close long-term clinical and radiological follow-up is mandatory.

[Place of the surgery in the management of brainstem cavernomas. Results of a multicentric study]

OBJECTIVE

To compare the outcome between operated and non-operated brainstem cavernomas.

METHOD

Clinical and radiological data of 30 patients harboring 35 brainstem cavernomas were retrospectively reviewed. The mean follow-up period was 47 months. Relationship between the cavernoma and the pi maer was graded. The histology of each operative case was systematically confirmed. The Karnofsky mean score was calculated at admission and at the end of the follow-up period. Patients were classified in three groups according to their outcome grade (Group I=good; Group II=unchanged; Group III=worse). We compared the outcome between operated and non-operated patients. For operated cases, we found several factors of poor outcome. Statistical tests used to compare the groups of patients were Yates modified chi(2) with calculation of the exact probability. Chosen risk was 5%.

RESULTS

Thirty-eight percent of operated patients were permanently disabled after surgery whereas the same proportion was improved. None of the patients in the control group worsened at the mean 47-month follow-up despite the occurrence of two hemorrhagic events. Statistical study showed that treatment modality affected clinical outcome in these patients. Only patients presenting with multiple deficits and progressive neurological deterioration were improved with surgery. Surgical access through the floor of the fourth ventricle was correlated with a poor outcome. Partial removal of the cavernoma increased the risk of future hemorrhage.

CONCLUSION

Surgery showed no proof of its efficiency in the management of brainstem cavernomas at the end of the follow-up period. Indications of surgical treatment must be restricted to cases with a severe and progressive neurological deterioration.

Efficacy of external fractionated radiation therapy in the treatment of meningiomas: a 20-year experience

BACKGROUND

This is a retrospective analysis of a series of meningiomas treated by radiotherapy.

MATERIALS AND METHODS

From 1978 to 1997, 45 patients with intracranial meningiomas were referred for external fractionated radiotherapy at Centre Alexis Vautrin. All patients were given 50-70Gy to the tumor bed (median: 56Gy), 1.8-2Gy per fraction.

RESULTS

Evaluation was performed in June 1999 using the Kaplan-Meyer actuarial method with a median follow-up of 30 months (range: 1-166), relapse-free survivals (RFSs) were 75% at 5 years and 67% at 8 years; overall survival (OS) was 74% at 5 and 8 years. For the 26 benign histologically documented lesions, RFSs were 95% at 5 years and 81% at 8 years; OS was 85% at 5 and 8 years. One major radiation-induced complication occurred in this series (decline of cognitive function). According to the indication of radiotherapy, we divided the series into four groups: postoperative irradiation after a first subtotal resection (11 patients), 5-year RFS was 90%; after first recurrence (+/-salvage surgery, 14 patients), 73%; after further recurrence (+/-salvage surgery, 11 patients), 67%; as exclusive treatment (nine patients), 80%. Atypical and malignant lesions (n=7) all relapsed before 24 months of follow-up, all patients but one died before 42 months. Age at the time of irradiation (> or =60 vs. <60 years) and radiotherapy dose (> or =60 vs. <60Gy) did not influence local control or OS. Atypical and malignant lesions (WHO grades II and III) meningiomas had a worse outcome than benign lesions (WHO grade I, P<0.01).

CONCLUSIONS

These results compare favorably with previously published data. External fractionated radiotherapy is well tolerated and effective. There is still a debate about the place of radiotherapy in the treatment of meningiomas: after subtotal resection, should radiotherapy be given postoperatively or at the time of progression? Should radiotherapy replace surgery when the risk of postoperative sequellae is high? Prospective randomized trials would be required to address these issues.

[Adult medulloblastoma. Review of 22 patients]

BACKGROUND AND PURPOSE

Medulloblastoma is a malignant neuro-ectodermal tumor classically considered as a pediatric tumor. Adult medulloblastoma is rare. This low incidence results in a lack of data concerning the management of treatment. We report our experience and propose a review of the literature to clarify the main therapeutic options that are nowadays suggested.

METHODS

We reviewed 22 adult patients treated for cerebellar medulloblastoma between 1979 and 1999. Actuarial relapse-free and overall survival were determined by the Kaplan-Meier method. Prognosis factors were studied by Log- Rank test.

RESULTS

The five years relapse free and overall survival rates were respectively 63.1% and 81.3%. These rates are superior to those reported in the literature. None of the studied factors (age, gender, histological subtype, total or partial surgery, presence of a CSF derivation device, radiotherapy, chemotherapy) were significantly associated to remission or survival. However our statistical results should be interpreted with caution in this small population.

CONCLUSION

Adult medulloblastoma prognosis seems to improve since chemotherapy has been introduced in the therapeutic protocols. Prospective and multicentric studies should determine the exact pattern of treatment.

[Elastic properties of a dural substitute in microvascular decompression of the trigeminal and facial nerves]

In order to decrease the microvascular compressions of the trigeminal and facial nerves, the authors report a new surgical method. The procedure consists in interposing a piece of non absorbable polyesterurethane dura substitute folded in two between the nerve and the vessel. This provides an elastic effect which keeps the vessel at a certain distance from the nerve and decreases the transmission of the vascular beats.

[Thrombosis of deep cerebral veins in form adults: clinical features and diagnostic approach]

Thrombosis of deep cerebral veins is a rare condition, and is associated with a poor prognosis. We report four new cases observed between 1994 and 1997. All four cases were women, aged less than 45 years. Initial symptoms associated alteration of consciousness, change in mental status, progressive headache and vomiting. We observed also uni or bilateral signs of long tract injury. In three cases, diagnosis initially suspected by CT scan was confirmed with encephalic MRI. For the last patient, conventional angiography was needed. Thrombosis affected straight sinus, vein of Galien and internal cerebral veins in all patients. Basilar veins were also affected in one patient, without dural sinuses extension. Lateral sinus was involved in two others cases, and superior sagittal in the last patient. Etiology remains undetermined in one patient, associated with post-partum, use of oral contraceptive pill, and familial protein S deficiency, one case each. Outcome was favorable in all four cases with anticoagulation therapy. Precocity of diagnosis is determinant and MRI is usefull in this issue. These observations show that evolution of deep veins thrombosis can be favorable, without needing fibrinolytic therapy.

[Intrasellar epidermoid cysts]

Two patients presenting with an intrasellar epidermoid cyst and operated on through a transsphenoidal approach, are reported. Problems regarding pathological controversies about the differential diagnosis (particularly craniopharyngiomas) are addressed. In order to establish the adequate preoperative diagnosis, the interest of MRI is discussed.

[Waldenström's macroglobulinemia and cerebral lymphoplasmocytic proliferation: Bing and Neel syndrome. Apropos of a new case]

Waldenström's disease is a B-cell, low grade lymphoma, secreting an immunoglobulin M, and is called immunocytoma. Neurological complications are frequent, but encephalopathies due to lymphoplasmocytoid infiltration are rare (Bing-Neel syndrome). Tumors, probably arising from confluence of infiltrative areas, are exceedingly rare. The authors report the case of a 70-year-old man, suffering from a Waldenström's immunoglobulinemia, who underwent surgery for a right sided rolandic tumor involving the vault, the dura-mater, and the cortex. On the CT scan, the tumor mimicked a meningioma. Histological study and immunohistologic stains confirmed the monoclonal nature of the tumor. Based on the review of the literature, clinical and neuroradiological features of these infiltrative and tumoral rare lesions, as well as their histopathogenesis and treatment, are discussed.

[Chordoid meningiomas. Clinical, neuroradiological and anatomopathological aspects. Apropos of a new case and review of the literature]

A 21-year old woman underwent surgery in December 1996 for the removal of a presumed tuberculum sellae meningioma. However, some radio-clinical findings were proved somewhat intriguing:the patient's age, the presence of inflammatory and febrile syndromes together with the diagnosis of aseptic meningitis associated with perilesional edema intensity (an unusual feature in such cases) made us challenge the initial neuroradiological diagnosis evoked in connection with the tumoral location and dural attachment pattern. A right sub-fronto-temporal approach allowed complete tumor resection (confirmed with a postoperative MRI) and clinical recovery of the patient. But while pathological examination suggested a chordoma, the study of immunohistochemical stains revealed a meningioma. The final diagnosis was chordoid meningioma. Our review of the literature has shown that chordoid meningiomas display several areas of physaliferous cells which give the tumor a chordoma-like aspect. However, the results of immunohistochemical studies along with the location of the tumor were not consistent with the diagnosis of chordoma. Eight cases of chordoid meningiomas are reviewed in the literature. They are described as inducing systemic symptoms, particularly anemia. They could also be linked to Castleman's syndrome according to Kepes et al. After careful evaluation, we retained the hypothesis of a cause and effect relationship between the local and generalised inflammatory syndrome and chordoid meningioma.

Stroke related to a dermoid cyst: case report

OBJECTIVE AND IMPORTANCE

We report the case of a woman presenting with sudden neurological deficit, revealing a parasellar dermoid cyst. To our knowledge, this clinicopathological finding is the first reported in the literature.

CLINICAL PRESENTATION

A neurological examination of the patient revealed a left hemiparesis, including central facial palsy, which hampered her speech. The well-documented neuroradiological work-up (including computed tomography, magnetic resonance imaging, and magnetic resonance angiography) demonstrated right frontorolandic ischemia caused by a right supra- and parasellar dermoid cyst leading to middle and anterior cerebral arterial stenoses.

INTERVENTION

Surgical intervention, using a right subfrontopterional approach, was successful. Complete dermoid cyst removal was achieved. The mechanism of the arterial stenoses is extensively discussed and is thought to result from an inflammatory reaction of the basal vessels.

CONCLUSION

The patient recovered fully. Nevertheless, postoperative magnetic resonance imaging confirmed cerebral infarction.

[Meningiomas of the sellar diaphragm. Apropos of 4 cases]

Since 1987, we have treated four patients with diaphragma sellae meningioma. Tuberculum sellae meningiomas with intrasellar extension were strictly excluded from this retrospective study. A complete tumor removal was performed in two patients. The two other patients underwent post-operative radiotherapy. According to the Kinjo's classification, the four meningiomas were classified as follows: one type A (supradiaphragmatic-prepituitary), one type B (supradiaphragmatic-retropituitary), one type C (subdiaphragmatic), one type not described in this classification characterized by sub and supradiaphragmatic extension. Based on our experience and data in the literature, the clinical and neuroradiological features of the diaphragma sellae meningiomas are reviewed. Diaphragma sellae visualization at MRI, which is not always possible, allows to localize the tumor on a supra- or infra- diaphragmatic position and to decide the optimal surgical approach. The diaphragma sellae is more visible on protonic density, or T2-weighted sequences, but can be located on T1-weighted images. Appropriate surgical approaches are the sub-fronto-pterional route for supradiaphragmatic meningiomas and the transsphenoidal approach for subdiaphragmatic meningiomas.

Endovascular occlusion of intracranial aneurysms of the posterior circulation: comparison of balloons, free coils and detachable coils in 38 patients

We treated 38 patients with 39 aneurysms of the posterior circulation by an endovascular technique using balloons, free coils or Guglielmi detachable coils (GDC) from 1986 to May 1993. The patients ranged in age from 10 to 71 years. Subarachnoid haemorrhage was the most frequent presentation (29 patients), followed by mass effect (5 patients) and epilepsy (2 patients). Treatment consisted of embolisation of the aneurysm with preservation of the parent vessel (in 29) or occlusion of the parent vessel (in 5). Multiple procedures were performed in 12 patients (32%, maximum 3 embolisations, total 17 treatments), because of incomplete initial aneurysm occlusion (in 8 cases) or re-opening of the aneurysm (in 9). Treatment could not be achieved in 5 patients. Good to excellent aneurysm occlusion was obtained in 28 patients (72%). Little or no neurological impairment occurred in 31 patients (82%). Complications related to treatment (11 patients, 29%) included 4 cases of transient cerebral ischaemia, 7 of stroke resulting in minimal neurological impairment (in 5), severe impairment (in 1) and one death. There were 6 patients who died, of rebleeding from the same aneurysm (2), basilar stroke (1) and unrelated causes (3). Comparison of the different occlusion techniques showed that the best angiographic results were obtained with balloons (good to excellent aneurysm occlusion was obtained in 17 of 22 patients treated) and the GDC (12 of 13 patients), and that less good results were given by free coils (4 of 9 patients). Complications related to treatment were fewest in patients treated with GDC (1 of 16 treatments, including multiple procedures) or free coils (2 of 12 treatments) and were more frequent with balloons (6 of 27 treatments). All five treatment failures occurred with balloon embolisation, whereas treatment was possible in all cases treated with free coils or GDC.

Aneurysm clipping after endovascular treatment with coils: a report of eight patients

Between January 1990 and December 1994, patients with subarachnoid hemorrhage related to ruptured aneurysms who were referred to our institution were treated by neurosurgical and neuroradiological teams. In each patient, the respective indications for neurosurgical or endovascular treatment were discussed, taking into consideration patients' age and the morphological and topographical aneurysm features. We report eight cases of patients with subarachnoid hemorrhage who underwent operations after primary endovascular procedures (Hunt and Hess scores III, IV, and V). The indications for surgical treatment were as follows. First, deliberate partial occlusion of the aneurysm (two aneurysms of the internal carotid artery and one aneurysm of the anterior communicating artery) was performed to obtain only partial clotting of the aneurysm sac by free coils. However, this procedure was discontinued in favor of the use of Guglielmi detachable coils. The second indication was partial occlusion after an endovascular procedure (two aneurysms of the middle cerebral artery and one internal carotid artery aneurysm). The third indication was re-expansion of the aneurysm 1 year after the endovascular treatment (one middle cerebral artery aneurysm). The final indication was secondary rupture of the aneurysm sac and false aneurysm around the migrating coil (one aneurysm of the pericallosal artery). During surgery, the aneurysm sac appeared translucent. The coils bulged out and stretched the aneurysm sac. One ruptured the membrane leading to a subarachnoid hemorrhage during the endovascular procedure. No hemorrhage occurred during the surgical clipping. Aneurysm obliteration was easily performed, especially when the packing was partial, but was very difficult when the complete aneurysm closure led to a stenosis of the parent vessel. A giant sylvian aneurysm rest, visible only with angiography, was left untreated. This series illustrates an original experience, which led us to conclude that aneurysm surgery with coils in place is not as difficult as is often thought.

[Subarachnoid hemorrhage caused by aneurysm rupture. Surgery or embolization?]

Traditionally the aneurysms of the circle of Willis have been an indication for neurosurgery. New technologies of endovascular treatment with electrically detachable coils resulted in a different therapeutical concept since four years. A series including 140 patients has been treated in our institution from 1 January 1992 to 31 December 1994, 94 of them presenting with a subarachnoid haemorrhage. Out of these 140 patients, 84 were treated with surgery, 51 with the endovascular technique, five with surgery after incomplete or unsuccessful endovascular treatment. Surgery was indicated in patients presenting early after bleeding, devoid of vasospasm, with a favourable Hunt and Hess grading and in aneurysms located in the anterior part of the circle of Willis. Endovascular treatment was indicated in patients admitted with delay, with severe vasospasm, a poor Hunt and Hess grading and in all aneurysms of the vertebrobasilar arterial network. Age was of less importance in comparison to the status of the vessels for selection of the method of treatment. Giant aneurysms are difficult to treat as surgery is faced with the size of the aneurysmal itself and endovascular technique with the width of the aneurysmal neck.

[Endovascular treatment of intracranial aneurysms]

Major improvements have been achieved in endovascular treatment of intracranial aneurysms during the last twenty years. Initial techniques of selective balloon occlusion were progressively replaced by the packing of the aneurysmal pouch with very small and soft metallic devices, named coils, with controlled detachment. In some rare cases, balloon occlusion is still used in order to occlude the parent vessel or to reverse the flow, especially in the vertebro-basilar system. Essential aims for the anaesthesiologist include: complete immobility of the patient throughout the endovascular procedure, systemic anticoagulation in order to avoid any thromboembolic complication during and after treatment, prevention and/or treatment of vasospasm, precise evaluation of fluid balance during the procedure. Our experience is based on 145 aneurysms in 135 patients, treated by endovascular route; 91 (63%) of them were revealed by a subarachnoid haemorrhage (SAH). Their main locations were: the carotid siphon (33.1%), the anterior communicating artery (19.3%), the basilar artery (17.2%) and the middle cerebral artery (17.2%). Thirty-seven of these aneurysms (25.5%) were very small in size with a diameter less than 4 mm. Total or sub-total (more than 90%) occlusion was achieved in 141 aneurysms (90.3%). Thromboembolic complications occurred in eight patients (5.9%), neurological sequelae in one. Other treatment-related complications included the migration of a coil outside the aneurysm in six cases (4.4%) without neurological deficit in one and five ruptures of the aneurysm (3.7%) during the procedure with one lethal issue due to the spontaneous bleeding of a controlateral arterio-venous malformation. Thirteen patients died (9.6%). The cause of the death was related on the initial SAH in 11 of them. The two others were both due to rupture: of a second untreated aneurysm in one case and of an associated arteriovenous malformation in the second one. At present the main indications of endovascular treatment are poor or non indications for neurosurgery. Due to the quality of results, endovascular therapy will be more and more used in case of ruptured or non ruptured aneurysms.

[Endovascular treatment of vasospasm]

Various therapeutic strategies have been recently proposed to prevent the vasospasm after subarachnoid haemorrhage, and to avoid its clinical consequences. Despite these progresses, mortality and morbidity of delayed ischaemic consequences of vasospasm remain important. Two endovascular treatments have been proposed. The successful use of transluminal angioplasty for vasospasm was first reported by Zubkov in 1984. Transluminal angioplasty is very effective with clinical improvement when the treatment is undertaken without delay after the onset of symptoms. Limitations of this technique are the inaccessibility of distal arteries and the risks (vascular rupture or occlusion). More recently, to overcome these limitations, a selective intraarterial infusion of papaverine has been proposed. These infusions are less risky and can be employed in distal vasospasm. However, clinical results seem to be less favourable and often transient. These two techniques are still used with slightly different indications. According to our experience, it seems reasonable to reserve transluminal angioplasty for symptomatic vasospasm, associated with papaverine or not, and to use papaverine alone in all other cases.

Dissection of intracranial vertebral arteries revealed by subarachnoidal haemorrhage. Report of seven cases

Between April 1986 and April 1991, seven cases of meningeal haemorrhage consecutive to dissection of the 4th segment of a vertebral artery were observed at the Neuroradiology Department of the Nancy University Hospital. Four of the 7 patients were men, and 3 were women; mean age varied from 45 to 61 years. The clinical presentation was not suggestive, except in one case where the haemorrhagic episode was associated with Wallenberg's syndrome, pointing to the aetiological diagnosis. The outcome was variable. Two patients died of early complications of the haemorrhage which occurred before treatment could be given. In 2 others patients treated with antiplatelet agents the outcome was favourable; however, at angiography the lesions regressed in one of these two patients, but they progressed in the other with formation of a false aneurysm. The remaining 3 patients were treated by endovascular occlusion of the lesion-bearing vessel: one died of complications of a haemorrhage-induced vasospasm; the other two are symptomless after a 2 to 6 months follow-up.

[Asymptomatic giant thoracic dumbbell neurinoma. Apropos of a case]

Giant thoracic dumbbell neurinomas are usually revealed by neurological or mediastinal signs. The case we are reporting was discovered accidentally and allow us to add some accuracy to the current diagnostic criteria for these tumors. MRI provides the most interesting information. The surgical exeresis of these tumors must use a double approach: first laminectomy then thoracotomy.

[Surgery for lumbar disk hernia after chemonucleolysis. Results and analysis. Apropos of 100 cases]

We studied the clinical results of 100 patients operated after failure of chemonucleolytic treatment with chemopapain for lumbosciatica caused by disk herniation. Secondary surgical procedures were performed because of persistence of sciatic pain and disk herniation visible on CT scan. Post-operative follow-up was done at a minimum of one year. Clinical results were analyzed according to the criteria of Mac-Naff. Out of 100 patients who were re-operated, there were: 14% excellent results, 38% good results, 26 mediocre results, and lastly 22% failures or worsening of the condition. Thus 52% satisfactory compared to 75-95% when surgery is done immediately; 48% of the results were unsatisfactory or worse than before. We analyzed the mechanism of action of papain and suggested a pathophysiological explanation for these results. We concluded that chemonucleolysis with chemopapain cannot be an intermediary step between systematic medical treatment and surgical treatment.

[Value of transcranial Doppler in the monitoring of aneurysmal subarachnoid hemorrhage treated with calcium inhibitors]

Fifty four patients (33 male and 21 female, mean age 47) with spontaneous aneurysmal subarachnoid hemorrhages have been tested by repeated TCD: 25 of them were systematically administered intravenous Nimodipine when admitted at hospital, the 29 others constituted a reference group. There was no statistically significant difference between the two groups of patients for age, sex, initial clinical status, importance of bleeding at CT scan, localization of aneurysm or existence of an angiospasm, whether clinically symptomatic or not. In 72% of the cases, TCD allowed to prove the existence of an angiospasm when higher flow velocity was registered in cranial basal arteries. There was no significant difference between the two groups. The final clinical status of the patients seemed to be more favourable in the treated group. Yet it did not appear to be directly linked to the existence of a spasm or not. This argued in favour of a non-univocal mechanism of action of Nimodipine.

[Effects of intracranial pressure on frontal sinus development]

Through a study of some syndromes of intra-cranial high and low pressure, the authors try to find out the relations between the intra-cranial stresses and the development of frontal sinuses. They account for the choice of frontal sinuses and the various factors determining this pneumatization. They study the morphology of the frontal sinuses in 20 cases of old and chronic hydrocephaly, in 13 cases of oxycephaly with a late diagnosis, and in 20 cases of adults suffering with infantile cerebral hemiatrophy. They show that in these syndromes, the development of frontal sinuses is an inverse ratio to the intracranial pressure. However, they point out that in standard people, the extreme differences in the morphology of their frontal pneumatization can be explained not only by various causes--a number of which is as yet not known--but also by an aleatory distribution.

[Respiratory depression after intrathecal injection of morphine: value of in situ naloxone]

A case of delayed respiratory depression following an intrathecal injection of hyperbaric morphine hydrochloride is reported. This injection was made during a lumbar myelography in a 60 year old patient suffering from metastatic epiduritis unrelieved by oral or parenteral drugs. The differences in densities between the CSF, hyperbaric opiate solution and contrast medium explain the migration of the morphine hydrochloride from the lumbar thecal space to the basal cisternae, giving a fall in the responsiveness to CO2 of the brain stem respiratory centres. Parenteral naloxone did not reverse this ventilatory depression. Only the myosis and the analgesia disappeared. After 16 h of various attempts of reversal by parenteral injections, an intrathecal injection of naloxone was tried. This small dose (0.1 mg), given intrathecally, resulted in a prompt return to normal of respiratory function.