Tuberculous meningo-encephalitis complicated by hydrocephalus in HIV patient

Hydrocephalus is a serious complication of tuberculous meningoencephalitis in HIV patients. The disease can affect vital and functional prognosis of patients. A 20 years-old woman was admitted for deterioration of her consciousness. She has a history of HIV infection since 3 months. Cerebral imagery showed signs of tuberculous meningoencephalitis. The paient was treated by antituberculous therapy with a good evolution. At the third months of treatment the patient presented roughly alteration of her consciousness and intracranial hypertension. Cerebral scan showed active ventricle hydrocephalous. The patient had ventricle extern derivation and then ventricle peritoneal derivation. Antituberculous and antiretroviral therapies were maintained. The outcome was favourable [follow up of one year]. central nervous system involvement in HIV patient can be observed at any stage of the disease with a consequent mortality and morbidity. central nervous system tuberculosis is observed in 10% of patients who presented an association of HIV-tuberculosis and only in 2% to 5% of tuberculous immunocompetent patients. Hydrocephalous is observed in 32% to 51% of HIV patients associated with tuberculosis meningoencephalitis. Hydrocephalous is a common complication of tuberculous meningoencephalitis witch can worsened the neurological statue of HIV infected patient. An early surgical and medical management was associated with a good prognosis

[Primary central nervous system lymphoma in an immunocompetent patient]

Primary cerebral lymphoma is a rare tumour usually seen in immunodepressed patients. The clinical manifestations depend on its localization. Imaging using both magnetic resonance imaging and CT scan leads to the diagnosis that is confirmed bythe histolopathologic exam. Several therapeutic strategies are adopted in this type of tumour associsating neurosurgery, chemotherapy and radiotherapy. A 29 -year- old immunocompetent patient presented to our service with a 2-month history of headaches, vomiting and decrease in the visual acuity. Clinical examination and radiological findings revealed the presence of a cerebral lymphoma localized in the thalamus. Primary cerebral lymphoma is a rare tumour but whatever is the therapeutic strategy used, the evolution is normally rapid and positive

[Spinal metastases: About 70 cases]

From 70 cases of vertebral metastasis of various origins, the authors discusss the indications of the surgical treatment. The mean age of patients is 48 years old. The mole sex predominates [64.5%]. The primitive cancer is dominated by the bronchogenic carcinoma and the breast cancer. 70% patients were admitted for neurological deficiency. This reflects the delay in diagnosis and consequently in the management of this affection. The dorsal spine is the first area of localisation, with 52.6% of cases, and the lumbar spine the second one. Surgical decompression is effective in relieving neurological symptoms of spinal metastasis [44 cases]

Cushing's disease: results of Ibn Sina neurosurgical department and review of the literature

Cushing's disease in an excessive secretion of adrenocorticotrophic hormone [ACTH] by a pituitary corticotroph tumour, which is responsible for two-thirds of all cases of Cushing's syndrome. We attempt in this paper to present our results, and to review the literature for a better understanding of this pathology that poses many problems in diagnosis and treatment. The authors report 15 cases of Cushing's disease from a series of 174 pituitary adenomas admitted in Neurosurgical department of Ibn Sina hospital, between January 1987 and December 1999. These 15 corticotroph adenomas, only 13 of which have sufficient data and follow-up are retained in our survey. We noted a female preponderance [11/2], with a mean age of 33 years. In our series and by reason of selection methods, surgical treatment was indicated according to focal lesions on magnetic resonance imaging and not on clinical and biological findings alone. All of these patients underwent trans-sphenoidal approach as a primary choice. Five [5] patients developed recurrence of high level cortisol in blood: * 2 refused subsequent operations * 2 underwent irradiation * 1 underwent removal of tumour by successful sub-frontal approach. There was no mortality in this series and the only case of morbidity consisted of one rhinoliquorrhea that improved after surgical treatment

Spontaneous hemorrhages of cerebral arteries

The authors report here 6 cases of protuberantial hematomas with a dramatic course in 5 patients. The arterial hypertension represents the greater cause, it was found to be present in 4 patients. The begining mode was sudden in all cases and the clinical picture was clearly marked by coma. The cerebral C.T. scan allowed the diagnosis, whereas the arteriography that was carred out in 2 cases was normal. No surgical management was expected. The course was marked by a mortality rate of 83%

Lesfistules carotido-caverneuses: [a propos de 16 cas]

The authors report here their own experience about 16 carotido-cavernous fistula cases, managed from 1976 to 1990. The mean age of patients is 30 years with equal distribution in the two sexes. The traumatisme notion is found to be present in 15 case In all cases, exophtalmos constitues the most constant symptom. The carotid arteriography. Was too useful to confirm the clinical diagnosis. The therapeutical management has led to immediat disappearance of all functional signs. As For exophtalmos, the total regression was noted in 10 patients. The mortality rate was 19%

Une complicatlion inhabituelle de la derivation ventriculo-peritoneale

The authors report herein a case of [externalization] spontaneous externalization of the peritoneal catheter by anus in a girl, carrier of a ventriculo-peritoneal shunt. Withdrawal of this catheter did not appear, nor by peritonitis, nor by meningitis

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