[Epidural labor analgesia and parturient with type 2B von Willebrand disease]

Type 2B von Willebrand disease (vWD) is an inherited bleeding syndrome resulting from a qualitative abnormality of von Willebrand Factor with an increased affinity for the glycoprotein Ib platelet receptor. Pregnancy increases the severity of this disease by decreasing the platelet count restricting epidural anaesthesia because of adverse risk of spinal bleeding. There is a phenotypic variability of Type 2B vWD depending of the von Willebrand Factor mutation. We report here the strategy we used to administer epidural anaesthesia for a patient with Type 2B vWD resulting from the P1337L mutation of von Willebrand Factor.

[When the pupil becomes the teacher]

OBJECTIVE

To evaluate the theoretical teaching provided to ophthalmology residents in Toulouse during the 2006-2007 academic year using the PowerVote(®) system. PUPILS AND METHOD: This was a prospective study concerning all ophthalmology residents in Toulouse. Classes were given by the house doctors and senior registrars as PowerPoint presentations lasting about 45 min. Just before each lecture, the house doctors took a 5 min test comprising five multiple choice questions. There were two lectures per month on average. One month after the course of lectures ended, the course as a whole was evaluated using the PowerVote(®) tool, on objectives given to the house doctors in advance. The teaching concerned the macula.

RESULTS

Ten residents took part in the final evaluation in 2007. The residents who had given lectures obtained significantly better results, not only in the initial test but also in the final one.

DISCUSSION

Teaching can take many forms. We evaluated teaching by the students themselves. The more involved a house doctor was in teaching, the better he remembered the lesson.

CONCLUSION

Giving a theoretical lecture enables residents to reach a higher level, which is further improved if they are involved in the teaching. The use of PowerVote(®) is an interesting pedagogical tool.

[PowerVote: an evaluation tool]

OBJECTIVE

The objective was to report the experience using PowerVote software to evaluate the teaching provided to Toulouse ophthalmology residents.

SUBJECTS AND METHODS

This prospective study covers all ophthalmology residents in Toulouse during the 2006-2007 academic year. Courses were alternately given by residents and resident physicians, during a 45-minute PowerPoint presentation. At the beginning of the course, the residents answered five multiple-choice questions. A month after the end of the 12-course program, participants were tested, using PowerVote, on the content of the entire course, focusing on objectives that the residents had received at the start.

RESULTS

The level of theoretical knowledge increased significantly, from 4.0/10 to 6.8/10. (P=0.0027).

CONCLUSION

Tests using PowerVote allowed instantaneous correction of the answers to the test questions. Consequently, the teaching was easier to adapt to the students' knowledge. Descriptive statistics of the results obtained could be generated via the PowerVote software and displayed on an Excel spreadsheet. The use of PowerVote also allowed direct evaluation of student knowledge and adjustments in the teaching for the following courses. This interactive pedagogical tool has potential for development, particularly to evaluate practices in the context of on-going medical education.

Pituitary apoplexy and idiopathic thrombocytopenic purpura: a new case and review of the literature

Pituitary apoplexy can occur as a complication of idiopathic thrombocytopenic purpura. We report here a new case of such association. A male patient aged 59 years, complaining of decreased libido for one year, was referred to the emergency department for purpura and severe thrombocytopenia (4000 platelets/mm3). 24 hours after the cutaneous rash the patient presented with clinical symptoms of bilateral cavernous sinus compression comprising ptosis, bilateral ophtalmoplegia and right supraorbital hypoesthesia. Cranial CT scan showed an enlarged sella and a pituitary mass with signs of intrapituitary haemorrhage. Hormonal evaluation showed hyperprolactinemia (50 ng/mL) and hypopituitarism, and the patient needed substitution with hydrocortisone and levothyroxine. Immunoglobulins and corticosteroids were given to the patient to treat thrombocytopenia, then worsening of neurological and ophtalmological symptoms led to pituitary surgery. Histopathological examination found necrotical pituitary tissue. Immunostaining with an anti-prolactin antibody was positive in several groups of cells. Neurological symptoms subsided and thrombocytopenia was corrected by treatment. In conclusion, we report a case of pituitary apoplexy due to severe thrombocytopenia occurring as a complication of a preexisting macroprolactinoma.

Vertebral pedicle anatomy in relation to pedicle screw fixation: a cadaver study

New techniques to stabilize and correct the thoracic and lumbar spine have been developed in recent years. In view of the wide variety and complexity of fixation devices, the optimum configuration of spinal instrumentation systems needs to be defined. Linear and angular measurements of both vertebral pedicles were made in ten complete thoracic and lumbar cadaveric spines using callipers and a goniometer. The vertical interpedicular distance gradually increased along the spine up to L5. The transverse interpedicular distance was larger at both ends of the spine. Pedicular height gradually increased from T1 to L5, plateauing between T3 and T9, being widest at the thoracolumbar junction. Pedicular width was greatest at the three junctional regions of the spine. The sagittal pedicular angle decreased along the length of the spine to zero at L5. The transverse pedicular angle decreased from T1 to T12 and then increased to L5. Of the pedicular measurements only width limits the diameter of fixation screws. The vertical interpedicular distance determines the distance between the holes of plates, while the length of the transfixator is related to the transverse interpedicular distance. The pedicular angles enable triangulation of screws and determine the stability of the fixation.

A relapsing remitting lymphocytic hypophysitis

Lymphocytic Hypophysitis is a rare autoimmune disease of the pituitary presenting mainly with features of a mass lesion and loss of pituitary function. Its course is quite unpredictable and its treatment is still controversial as experience in the field remains scarce. We describe a 45 year-old woman with a history of recurrent fever and meningeal symptoms who was referred 3 years later to our department for pituitary insufficiency. Hormonal studies revealed an anterior pituitary deficiency and autoimmune thyroiditis. Pituitary hypertrophy as evidenced by magnetic resonance imaging showed complete regression upon hydrocortisone substitution therapy. Two years later, fever and meningeal symptoms recurred as well as pituitary hypertrophy. Cerebrospinal fluid analysis revealed an aseptic lymphocytic meningitis. Pituitary biopsy confirmed the diagnosis of LH. The patient was started on prednisone 70 mg per day. She improved clinically and radiologically and remained free of symptoms thereafter. At a recent follow up the MRI showed an empty sella turcica. Hereby we illustrate a yet unreported pattern of LH presenting as a recurrent aseptic meningitis. We also describe one of the long-term course of the disease which is still unpredictable.

[Cervical spine infection with Streptococcus anginosus. Case report]

A case of cervical spine infection due to Streptococcus anginosus is reported. Streptococcus milleri is encountered in the mouth, gastro-intestinal tract, vagina and nasopharynx. It is an uncommon pathogen responsible of suppurative infections such as brain liver or spleen abscesses, intra-abdominal or soft tissue abscesses and pleural empyema. In rare cases it can cause spondylodiscitis and osteomyelitis. Based on the review of eight cases of spondylodiscitis or osteomyelitis, diagnosis and treatment are discussed.

Cavernous hemangiomas of the orbit: MR imaging

PURPOSE

To describe the MR imaging findings in eight patients with cavernous hemangioma of the orbit.

METHODS

CT, MR imaging and echographic studies of eight patients with cavernous hemangioma localized in the orbit were reviewed. All patients presented with a progressive symptomatology: in seven cases with a painless proptosis, in one case with a failing of visual acuity of the concerned eye. The patients were examined with T2- and T1-weighted spin echo sequences, before and after intravenous administration of Gadolinium*, in axial, coronal and sagittal planes. In seven patients, a fat saturation prepulse was given after the Gd-enhanced study. Two patients were also examined with CT scan, with and without intravenous contrast administration. Three patients underwent a Doppler color-coded transorbital sonography. The analyzed criteria were: location, form, margins, size, signal or density. Seven patients underwent surgery with pathologically proved cavernous hemangioma. In one patient, therapy was conservative, because of the absence of significant clinical complaints.

RESULTS

In all cases, MRI showed a well-defined intraconal mass. The lesions were homogeneous, isointense to muscle on the T1-weighted sequence and hyperintense to muscle on the T2-weighted sequences. In five cases, a peripheral rim, hypointense to the mass on the T1- and T2-weighted sequences could be observed. After Gadolinium*, six lesions showed initial central patchy enhancement. On the three following T1-Gadolinium* sequences, these lesions showed total and homogeneous filling. In two patients, the lesions showed immediate homogeneous enhancement. On CT, the orbital masses were spontaneously hyperdense, with associated focus of microcalcifications. On echography, the lesions appeared hyperechogenic, heterogeneous, with individualization of small areas of very slow flow.

CONCLUSION

From the analysis of the MR appearance of an intraconal, well-defined mass, associating homogeneous signal, isointense to muscle on T1-weighted sequence, hyperintense on T2-weighted sequence, and especially progressive filling on Gd-enhanced sequences, the diagnosis of cavernous hemangioma may be highly suggestive, in a patient presenting a painless progressive proptosis.

Cavernous hemangioma of the intracranial optic pathways: CT and MRI

PURPOSE

The purpose of this work was to describe the CT and MR findings in three patients with cavernous hemangioma (CH) of the intracranial optic pathways.

METHOD

CT and MR studies of three patients with CH of the optic chiasm were reviewed. All patients underwent MRI of the chiasmal area, with coronal T2- and T1-weighted studies as well as gadolinium-enhanced coronal and sagittal T1-weighted studies.

RESULTS

The patients (mean age, 40 years) presented with chiasmal apoplexy (two cases) and progressive decrease of visual acuity (one case). In all cases, MRI showed regular enlargement of the optic chiasm, with extension to the optic nerve in one case and to the left optic tract in one case. The chiasmatic dimension was 2.5-3 cm in two cases and 1-1.5 cm in the other case. In all cases, MRI revealed an acute (isointense signal on T1-weighted and hypointense signal on T2-weighted sequences) or subacute (hyperintense signal on T1 - and T2-weighted sequences) hemorrhage with, adjacent to it, an area with signals of blood of different ages, highly suggestive of CH. CT showed, in chiasmatic CHs, a suprasellar mass spontaneously denser than adjacent brain parenchyma. In two cases, microcalcifications were associated. In two cases, CT and MRI revealed slight heterogeneous enhancement after contrast agent administration. In one case, no enhancement was observed. Two patients underwent surgery by frontopterional craniotomy. The optic chiasms were swollen with an intrinsic bluish mass. The cerebrospinal fluid was not xanthochromic. Microscope examination confirmed the diagnosis of CH. After 12 months, the operated patients had improved visual acuity and visual field but did not completely recover. The nonoperated patient (because of spontaneous rapid recovery of visual acuity) was followed clinically and on MRI over 18 months.

CONCLUSION

CH in the optic chiasm must be suspected in the presence of an acute chiasmatic syndrome. MRI is the best imaging modality, showing either an acute or a subacute chiasmatic hemorrhage or the typical pattern of CH with heterogeneous alternation of foci of blood of different ages, with a central focus of methemoglobin, a peripheral rim of hemosiderin, adjacent foci of acute or subacute hemorrhage, and slight or no enhancement after gadolinium administration.

[Hepatic portal venous gas: is it always a sign of severity and surgical emergency?]

Hepatic portal venous gas is a radiological finding due to the presence of gas in the portal vein. It was associated with a mortality rate ranging from 75% to 90% and with an indication for exploratory laparotomy. We report one case following an abdominal trauma. The portal vein gas was detected on CT Scan. The patient who was asymptomatic was not operated on and survived. The severity of this radiological symptom requiring a laparotomy has to be reassessed. CT Scan is the most efficient method to recognize portal vein gas and its larger use has allowed to diagnose more cases not detected by simple abdominal X-rays. In conclusion, surgical exploration should not be done systematically but has to be decided in relation with the clinical status of the patient.

Recurrent intracranial neurenteric cysts

Neurenteric cysts are cystic lesions lined by a columnar epithelium of endodermal derivation. They are rarely located in the central nervous system. We describe the case history of two recurrent neurenteric cysts located within the posterior fossa: one in the 4th ventricle and the second in the cerebellopontine angle. The literature is reviewed and the follow-up and recurrence of such cysts are discussed.

A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury

OBJECT

The authors prospectively studied the efficacy of tirilazad mesylate, a novel aminosteroid, in humans with head injuries.

METHODS

A cohort of 1120 head-injured patients received at least one dose of study medication (tirilazad or placebo). Eighty-five percent (957) of the patients had suffered a severe head injury (Glasgow Coma Scale [GCS] score 4-8) and 15% (163) had sustained a moderate head injury (GCS score 9-12). Six-month outcomes for the tirilazad- and placebo-treated groups for the Glasgow Outcome Scale categories of both good recovery and death showed no significant difference (good recovery in the tirilazad-treated group was 39% compared with the placebo group in which it was 42% [p=0.461]; death in the tirilazad-treated group occurred in 26% of patients compared with the placebo group, in which it occurred in 25% [p=0.750]). Subgroup analysis suggested that tirilazad mesylate may be effective in reducing mortality rates in males suffering from severe head injury with accompanying traumatic subarachnoid hemorrhage (death in the tirilazad-treated group occurred in 34% of patients; in the placebo group it occurred in 43% [p=0.026]). No significant differences in frequency or types of serious adverse events were shown between the treatment and placebo groups.

CONCLUSIONS

Striking problems with imbalance concerning basic prognostic variables were observed in spite of the large population studied. These imbalances concerned pretreatment hypotension, pretreatment hypoxia, and the incidence of epidural hematomas. In future trials of pharmacological therapy for severe head injury, serious consideration must be given to alternative randomization strategies. Given the heterogeneous nature of head injury and the identification of populations that do relatively well with standard therapy, target populations with a higher risk for mortality and morbidity may be more suitable for clinical trials of such agents.

Imaging in neurenteric cysts of the posterior cranial fossa

Neurenteric cysts are cystic masses lined by a columnar epithelium of endodermal origin. They are rare in the central nervous system. We report two neurenteric cysts in the posterior cranial fossa and describe their neuroradiological features. The lesions were of low density on CT and more accurately delineated on MRI. They gave the same signal as cerebrospinal fluid on all sequences. There was no contrast enhancement.

When is spinal fusion warranted in degenerative lumbar spinal stenosis?

This study, conducted by a group of neurosurgeons who devote a large portion of their professional time to the treatment of degenerative lumbar spine lesions, was prompted by the dramatic increase in the number of lumbar spinal fusion procedures performed over the last few years in a broad spectrum of disorders ranging from chronic incapacitating low back pain to lumbar spinal stenosis. In the authors' experience, lumbar spinal fusion is rarely warranted and often of dubious efficacy. To investigate this contradiction, the authors reviewed the medical literature on lumbar spinal fusion for the treatment of degenerative spinal stenosis. They have defined lumbar instability as objectively as possible, reviewed clinical and roentgenographic features, described spinal fusion techniques with the drawbacks of each, and evaluated outcomes of surgery for degenerative lumbar spinal stenosis with or without fusion. Findings demonstrate that spinal fusion is a technique of unproven benefit that should be used only in carefully selected patients until results of reliable, prospective, comparative clinical trials become available. In the authors' opinion lumbar spinal fusion should be used as the first-line treatment only in young patients with clinical manifestations directly related to lumbar instability as defined in this study, when decompression requires removal of both facet joints and of the disk (which is rarely the case) or when simple decompression is followed by a recurrence of symptoms ascribable to worsening vertebral slippage.

Is camptocormia a primary muscular disease?

STUDY DESIGN

This study analyzed computed tomographic scans, magnetic resonance images, and biopsies of the paravertebral muscles of patients with camptocormia and age-matched patients with lumbar interapophyseal osteoarthritis or lumbar vertebral stenosis.

OBJECTIVES

To define the muscular lesions and clarify their nature in this particular disorder.

SUMMARY OF BACKGROUND DATA

Progressive lumbar kyphosis or camptocormia, a rare disease of the elderly characterized by inability to immobilize the lumbar spine in relation to the pelvis appears to be a result of weakness of the paraspinal muscles. The features presented by these patients do not correspond to any myopathy previously described.

METHODS

Twenty-seven patients (5 men and 22 women) mean age 69 years, with camptocormia were compared to fifteen age-matched patients without camptocormia but with posterior interapophyseal osteoarthritis and to nine elderly patients operated for narrowing of lumbar canal. Computed tomographic scans, magnetic resonance images, light microscopy, histochemistry, and electron microscopy of paraspinal muscles were obtained in both groups.

RESULTS

In patients with camptocormia, computed tomographic scans and magnetic resonance imaging showed heterogeneous appearance of the spinal muscles with areas of low density. These features were distinct from those of patients with interapophyseal osteoarthritis and were similar to the features described in primary muscular dystrophies. The main microscopic change in camptocormia was the increase of fibrous tissue, frequently with a lobular pattern, not seen in osteoarthritic patients. Familial history of the disorder was frequent (20 out of the 27 patients).

CONCLUSION

Camptocormia, disappearing in the recumbent position, is thus very probably linked to muscle involvement. That there is often a family history of such disorder is in favor of a genetically transmitted condition. Magnetic resonance images and computed tomographic scan appearance seems to be in favor of primary muscular disease, restricted to the spinal muscles.

[The measurement of sensory conduction in the median nerve and its diagnostic value in the carpal canal syndrome (author's transl)]

The authors studied the rate of sensory conduction of the median nerve in three groups of subjects: a group including subjects of different ages in order to determine the variations in conduction and the evoked response as a function of age; a group of patients with the carpal canal syndrome; a group treated by median nerve infiltration in the carpal canal. It was confirmed that there is a slowing of the rate of sensory conduction and spreading of the evoked response in the elderly subjects. The electromyographic data in the carpal canal syndrome is defined, as well as the difficulty of diagnosis which sometimes necessitates specific measurement of the conduction rate between the carpal canal limits.

[Pseudo-tumoral softening of the cerebellum]

The author establish an onerall picture of cerebellar infarction with brain stem compression after reviewing 63 cases published in the literature and 4 personal observations. The frequency of this affection can be compared with that of cerebellar hematomas. Diagnosis is based on its predominance in males, the early age at which it appears, its rapid and typical onset, and the delayed signs of brain stem compression. Conventional neuroradiological procedures show an expanded cerebellar volume, and the scanner can specify the ischaemic nature of the lesion. As soon as changes in consciousness occur surgical decompression is necessary, first by external drainage of C.S.F. and later, if necessary, by direct access to the postdrior fossa.

[Long term results of electric stimulation of the conus medullaris in a case of neurogenic bladder]

The authors present long term results (19 to 45 months: Average 37 months) of electrical stimulation of the conus medullaris in neurologic bladder. In 3 cases, the result remain excellent: efficient stimulation, normal micturition, absence of residual urine. In 6 cases, after a long period of normal function, the micturition is poor with residual urine, eventhough the conus medullaris stimulation always produces a satisfactory contraction of the detrusor. In four cases the relapse is due to disease of the external sphincter region, poorly or untreated. In female patients the results are better than in male patients, with positive results in 2 of the 3 women and 1 of the 6 men. The authors find that their results can be compared with those of B. NASCHOLD, originator of the method. They emphasize the necessity of a close collaboration with the urologist to maintain excellent results.

[Percutaneous thermocoagulation of the spinal nerves for analgesia]

The authors present percutaneous technic treatment of some pain syndrom by thermocoagulation of rachidian nerves with radiofrequency generator. This method had been employed on 60 patients in various indications (cervico-occipital neuralgias, low back pain, stage syndrom, painful scar etc...). After anatomic justification one literature analysis precede personal results of this therapeutic method. This one is easy to realise and seems to deserve a good place in the actual possibility of functional neurosurgery.

[Role of transcutaneous electric stimulation in indication for implantation of an analgesic stimulator]

The author's describe: I. METHODS OF ANALGESIC CUTANEOUS STIMULATION: I) Transcutaneous analgesic stimulation: Stimulations realized by biphasic asymetrical "waves" of 0 to 80 milliamps intensity for a frequency of 10 to 100 cycles/S. -Place of the stimulation: a painful area. -Stimulation length: 15 to 20 minutes, repeated during several days.

RESULTS

appreciate patients tolerance to the tingling sensation. Test the analgesic effect, sometimes sufficient to treat the patient. 2) Analgesic percutaneous stimulation: The percutaneous electrode is applicated to the dura, without penetrating it. Same types of results as for transcuteneous stimulation but more precise. II. DEFINITION of the indication of chronic implantation of an analgesic stimulator. Studying results of repeated analgesic transcutaneous stimulations allows to distinguish between several possibilities. I) Intolerance of the sensation of stimulation: Contra-Indication or increasing of the pain. 2) Complete and lasting amelioration leads to: Chronic transcutaneous neurostimulation. 3) Partial amelioration, No amelioration leads to: Acute percutaneous stimulation either successful results after stimulation, : Chronic implantation: -of peripheral nerve -on a peripheric nerve -of dorsal column -on dorsal column, either paraesthesis without Analgesia:? III - EXPERIMENTAL APPROACH TO THE MECHANISM OF ACTION OF THE "ANALGESIANT" ELECTRIC STIMULATION. A cutaneous "analgesiant" stimulation produces, in the cat, the inhibition of evocated potential in C.M. by "nociceptive" stimulation of the sciatic nerve. The inhibition only appears after a 30 minutes latence. This let suppose different mechanisms from the "Gate Control" theory. The authors specify their personal results (Tab. 2.)