Treatment of large vestibular schwannomas: towards a compromise between recurrence and facial function preservation

Ideal treatment of large vestibular schwannomas [VS] is complete removal without significant morbidity. The aim of this study is to assess the long-term outcome of surgery, focusing on factors influencing facial function and recurrence. Large VS were removed from 76 consecutive patients, through the retrosigmoid approach, from 1990-2004. Prognostic factors evaluated were age, size hydrocephalus, IX[th] and X[th] nerve signs, extent of surgical removal, and tumours's consistency. Statistics were taken by assessment of Chi-square, Fisher, student t-test. The mean age was 40 +/- 14 years, and the mean diameter was 45 +/- 9 mm. Preoperatively, 93% had significant hearing loss, 74% had cerebellar ataxia, 77% had high intracranial pressure and 40% had IX[th] and X[th] nerve signs. The perioperative mortality dramatically decreased from 17.6% in the earlier period [1990-1996] to 4.5% in the latter period [1997-2004]. At long-term follow-up, 84% of the patients had a Karnofsky score superior to 80%. Mean facial function was better for solid tumours [mean House-Brackmann [HB] standard deviation [SD], 3.7 [1.7] vs. 4.5 [1.7], p = 0.035]. Facial anatomical continuity was preserved in 76% of the cases [n = 58] and was correlated with a better facial function [mean HB [sd], 3.1 [0.7] vs. 5.8 [1.3], p < 0.001]. Excluding patients with a preoperative facial palsy, good facial function was achieved in 58% of the patients, without statistical difference between gross total and subtotal resection [mean HB [SD], 4.3 [1.4] vs. 4.8 [1.9], p=0.229]. The method resulted in improved outcome. Subtotal resection is a good strategy with high likelihood of preserving facial nerve function, without significantly increasing the risk of recurrence. New strategies associating subtotal resection and radiosurgery must be evaluated

Intraventricular cavernoma

Intraventricular cavernoma is rare; only 45 cases have been reported in the literature. Magnetic resonance imaging has wildly contributed in the diagnosis and the surgical approach. Case file: We report a 45-year-old man presenting with syndrome of intracranial hypertesion and retrograde amnesia for one year. CT scan and MRI revealed an intraventricular tumour, which was responsible for active hydrocephalus. A ventriculo-peritoneal shunt was performed and a stereotactic biopsy allowed the diagnosis of cavernoma. Post operative follow-up was uneventful, the patient rests asymptomatic. Ventricular cavernoma is rare and should be suspected in atypical localisations in order to chosse the best surgical approach. The author attack the attention to that rare localisation of cavernoma and for its hemorrhagic risles

Exophthalmos as a presenting sign of extradural haematoma

A conscious 14-year old boy admitted to hospital with progressive right exophthalmos, decreased visual acuity and headache 9 days after head trauma, with neurological deficit. Computerized tomography [CT] scan demonstrated intracranial and intraorbital cystic mass. At craniotomy, a subacute extradural haematoma was found which communicated with an orbital subperiosteal haematoma through an orbital roof fracture. Postoperative outcome was marked by complete recovery of exophthalmos and visual acuity. This case demonstrated the rare diagnosis of epidural and subperiosteal orbital haematoma. The literature is reviewed and surgical management is discussed

Observation d'un teratome mature du cervelet

A twenty nine female presented with Occipital headaches,and profound visual acuity impairment. CT scan and MRI were consistant with a teratoma of cerebellum. The patient underwent surgery with total removal of the tumor.Histological study confirmed the diagnosis of teratoma with no immature component. Post operative course was uneventiful but no visual improvement occurred post operatively neither one year later at control. The authors discuss the epidemologic, clinic, MRI, and therapeutic features of this rare affection. The literature review revealed only 13 similar previously published cases

Lestumeurs de la fosse cereabrale posterieuea [FCP]: [a propos de 150 cas]

The authors have reported the experiment of the neurosurgical department at the "Specialised Hospital" about the tumoral pathology of the posterior cranial fossa concerning 150 cases encountered between 1983 and 1990. In about 56% cases, the patients were young, less than 20. Their clinical aspect was dominated by intracranial hypertension [I.C.H.] syndrome [78%]. Due to the patients delay in consulting, there is blindess in most of the cases [16%]. The CT. scan, carried out systematically in all our patients has amliowed us to distinguish the tumor and to find out an associate hydrocephaly in 62% cases. The main anatomo-pathological types encountered in our series are medulloblastoma in 34 cases, astrocytomas in 30 cases, and neurinoma in 23 cases. The dreadful prognosis of this affection is death in 25% of the cases in the pen-operating period. It is reduced gradually year after year thanks to an early management of the patients, to the progress we have achieved, and to a better multidisciplinary collaboration

Role du developpement et du modelage du polygone arteriel de willis chez l'homme dans la pathogenie des anevrysmes arteriels cerebraux et leur incidence dans les pays du Maghreb

Several works have been devoted to the anatomic description of the circle of Willis and its role in the cerebral vascularisation. We have carried out a post-mortem examination of 250 brains [100 adults, 100 children, and 50 foetus] using the techniques of intra-arterial injections of coloring resin, followed by dissection of the arterial circle of Willis with a morphological study of its different segments and the afferent segments [intra-cranial part of the vertebral and carotids arteries]. We have shown that while growing older, there is a progression in the growth of each segment of this circle as well as the appearance of segmentary hypoplasia or agenesia, and the most changing segments are represented by the posterior cerebral and communicating arteries; Thus, we have described 15 morphological types of the circle of Willis in adults, 8 in children and 8 in foetuses with a decreasing rate of frequency of the ideal arterial circle [that is circle where all the segments are permeated without agenesia or hypoplasia] from the foetus [60%] to the adult [18%] through the child [53%]. Age and acquired factors control the modelling of the circle of Willis. Our findings and the- study of the literature have allowed us to find out that aneurysms are more frequent on the circle of Willis with segmentary anomalies, and the hemodynamic disturbances caused by the morphotype of the circle of Willis entail some modifications of the arterial wall with some defects of the media, a fragmentation of the internal elastic lamina, and thickening of the intima. These modifications which are maximal at the level of arterial bifurcations result in the formation of pre-aneurysmal lesions that lead to aneurysms; the study of the experimental aneurysms in animals and that of serial sections on cerebral arteries in man allow us to observe these changes and to show that, in addition to the physical mechanisme due to hemodynamic stress, there are a biochemical mechanism and varied systemic factors which result in the growth of aneuryms, and lead to the rupture of some of them. In our systematic research on aneurysms in our post-mortem series, we have encountered one only case in adults, i.e. a rate of recurrence of 0,4%. A survey carried out in the departments of neurosurgery in the Maghreb countries [14 departments of neurosurgery have taken part in the survey], has shown a frequency of about 0,004 per 100 000 inhabitants [20 to 25 aneurysms new cases per year in a population of 55 millions inhabitants], and in cerebral and subarachnoidal haemorrhage, the aneurysmal etiology varies from 34,6% in Rabat, to 24% and 27% in Algeria, and 9,4% in Tunisia. In spite of the difficulties encountered in managing patients, and the medical infrastructure inadequency in some areas, these figures let us think that the cerebral arterial aneurysms are less frequent in Morocco and the Maghreb than in Europe and North America. We believe that this is due to the rareness of risk factors, and the young age of the population. [People over 40 represent 19% of the population in Morocco, on the other hand, there are 40,8% in France, 41,8% in Japan, and 40% in the U.S.A

Traitement neurochirurgical des douleurs chroniques

A neurosurgical treatment must be considered whenever there is a permanent pain which is rebellions to important antalgics. At the moment, a wide range of techniques is available. Some of them are destructive, aiming at cutting the tracts taken by the painful message. Among them, the most used are posterior radicotomy, dorsal root entry zone lesion [DREZ-tomie] and commissural myelotomy. The two last ones are used only when the pain has cancerous origin. The other techniques are conservative, aiming at strenghtening the mecanism of checking pain. We point out: electric neurostimulation used when the sort of pain is a sensitive deafferenta tion [peripheral nerve trauma, amputation stamp pain]. Intrathecal morphine are conservative technique of the present used more for diffuse cancerous pain with a weak life expectancy. The choice of an adequate takes into account the type of pain and its mechanism as well as it site. We do our best to choose the most conservative technique and the least impairing

Compression modullaire par hernie discale dorsale

We report a case of acute medullary compression by thoracic disc-herniation. This uncommon entity require surgical decompression without delay. The discussion concerns the important information provides by the TDM and RMN and they concerns too, the different surgical approaches

Hypertension intra-cranienne benigne

Benign intracranial hypertension [BICH]. We have accepted 3 criteries to define the BICH - Existence of an ICH clinical syndrome.- Existence of a high I.C.P. - Absence of clinical ICH etiologies that would wate known physiopthological mechanisms such as a neovolume, brain oedema or hydrocephalus. A study of 35 observations meeting this definition has allowed us to conclude that the BICH hes become more and more frequent in neurosurgical practice [6% of the total ICH in general and 7% of secondary ICH with an expansive intracranial development]. It is a disease that is to be found more frequently within young and obese women [4 women for 3 men, 22 years old, 71 kg for 1 m 61 in average for women]. Reasons for this disease are multiple and variable. They can be divided in 2 groups: * A group of patients with antecedents of which the cause-effect relationship seems to be arguable Among these: * 17 patients of our study, had in their antecedents a cranio-facial pathology with 6 quiet important head injuries, 8 O.R.L. diseases with 2 M.C.O.; 2 ophtalmological fits and a meningitis going back to childhood. * 4 patients had obstetrical and endocrinal antecedents, a thyroidal goitre, a dysmenorrhoea, a repeating gravidic toximia and recurring abortions. - Within 27 patients of our study we have noticed antecedents due to use of drugs, among them solycil [4 times], cyclines [Twin], penicillin [5 times], corticoids [6 times], contraceptive pills [twin] and A vitamin [once] without nevertheless being able to incriminate one of these factors in the BICH genesis. * 11 patients of our study have directly accused some decompensating factors which were immediately followed by the appearance of BICH symptoms that is how we have noticed amomg the triggering causes, 5 BEHCET diseases, 4 pregnancies, a head injury, tonsilitis treated with G penicillin, and a salpingitis treated with the Bactrim. The BICH symptomatology is one of an ICH without any localization signs associating a visual symptomatology of which the papilledema is one of the constant elements. Subjective visual troubles have been reported by the majority of our patients in the form of a decline in the visual acuity, a diplopia [11 cases], unsharp vision episodes [9 cases], transitory amaurosis [3 times]; and photophobia [3 times]. Four patients have reported having ear-humming and 8 others troubles in standing up and walking. The ophthalmological attack is the most important element in the objective symptomatology. This needs a particular attention as it determines the pronosis. The drop in the visual acuity from the very first test has been detected 24 times out of 33; 12 patients were unfortunately blind, seven had a very altered visual acuity [1/10 to 4/10], 5 an altered visual acuity [5/10 to 7/10] and only 9 had a normal visual acuity on their admission; out of the 14 indicating a carried out visual fields; 9 had campimetric defects extending from the simple expansion of the blind sport [6 times], to the global contraction of the isopters [1 case], to a systematized amputation evoking a bitemporal hemianopsia [1 case] or even a reduction of the visual field to a simple islet of central vision. The C.S.F. study appears mostly normal. Albumin rate was superior to 0,60 g/l in 6 cases but has never exceeded 1 g/l, Cytology has been in all cases inferior to 10 BE/mm3. Always systematically carried out and analysed, simple brain X-rays have shown ICH signs in 10 cases [28%] such as sutures disjunctions [7 times], finger-like impressions [5 times] and small modifications of the sella turcica [3 times]. The angiography have been carried out 32 times out of 35. The phlebographical times have clearly indicated a pathology of the intracranial veinous sinuses within 12 patients. It was either a size reduction, or a bad visualization, or an absence of injection of one or several of the sinuses. The pneumencephalography, ventriculography and the T.A.C. have been carried out in 31 cases. To measure the ventricular volume we have used the EVANS ratio whose normal volumes are in between 0,25 and 0,34 [24 cases]. 3 patients have shown a slight increase of the ventricular size and in 4 others, ventricles were inferior to the normal. In two cases, we have noticed the aspect of an empty sella on the T.A.C. The continuous recording of the ICP has allowed us to confirm the ICH in all cases. The average pressure in our study varied from 15 to 61 cm H20. 23 patients had an average ICP between 25 and 50 cm H20. We have had recourse to 3 symptomatic and therapeutic methods: - The brain anti-edema treatment [used in 27 cases] with in order of frequency in the use of corticoides [in 77%], the osmotherapy [17%] and the diuretics [14%]. - The repeated substractions of the C.S.F. have been carried out in all cases with an average number of 4 substractions per patient. - The external derivations of C.S.F. have been carried out with 14 patients of our study among which 2 have become complicated by a thrombosis of the superior vena cava on atrial catheter, in two cases, it was ICH on BEHCET diseases. The total follow up of the B.I.C.H. usually happens towards the clinical and manometric stabilisation in a delay going from 1 month to two years and a half after one or several attacks, The fonctional signs disappear first, after a general 4 months evolution, that is about 1 month before the normalization of the ICP [average time of evolution = 5 months]. The ophtalmological signs are the last to disapear 6 months and a half in general after the manometric remission. However few observations are to be stated as far as the stabilization of the BICH is concerned. 1 - From the manometric point of view, 4 patients in our study have remained with a quite high I.C.P. [20 cm H20] in spite of the clinical and ophthalmological remissin. These 4 patients are in fact still in danger of falling into hypertensive fits on the smallest triggering factor. 2 - 6 patients of our study [18%] have had a relapse from their BICH and this in a delay of evolution which didn't exceed one year. 3 - If the majority of our patients have positively followed up, in particular on the ophthalmological level, thanks to an adequate and timely treatment; this has not unfortunately prevented an after - effect atrophy within 11 patients among whom 7 [20%] have kept their initial blindness. This leads.us to wonder about the qualificative " benign " associated with this type of ICH specially that 2 other patients of our study have been hospitalized and treated in emergency in a pre-engagement state. In the last chapter we have reported 4 physiopathogenic hypothesis classicaly accepted: a trouble in the resorption of the C.S.F., increase of the blood brain volume, cerebral edema, increase in the secretion of C.S.F. It seems that these 4 factors have an inter relationship with each other to give birth to the B.I.C.H. but the trouble in the resorption of C.S.F. appears to be the most important factor. A better knowledge of the physiopathogenic phenomena in the genesis of this disease should allow for a better knowledge of this disease and thus to foresee a better codified therapeutic approach

abces encephaliques [Etude d'une serie de 50 cas]

From a total of 70 cases of brain abscess operated in 15 years, the authors have studied 50 cases and tell us their experience. These brain abscess are mainly found within young males and are often secondary to either head injuries or O.R.L. infections. After a brief study on the anatomical evolution of brain abscess, the authors discuss the diagnosis methods which have been recently improved through the C.A.T. The treatment of brain abscess is based on associated and adapted antibiotherapy with a total surgical excision. This is the only efficient method to improve the prognosis which still now a days remains very serious with death rate between 30 and 50% in most statistics [42% in our cases]

kyste hydatique de la fosse cerebrale posterieure [Revue de la litterature a propos de 5 cas]

The hydatid cyst is rarely localized in the posterior fossa. In literature review, we could only find 37 published cases, among them only 13 were described. We have had the opportunity to gather 5 personal cases [2 found during autopsy], the rough 45 cases of cerebral hydatid cyst operated in 15 years. The authors give a general commentary on their own observations and those of literature