[Value of retrolabyrinthine approach for surgical resection of meningiomas inserted around the lateral sinus between the transverse and sigmoid parts]. / Avantages de l'abord rétro-labyrinthique pour l'exérèse des méningiomes insérés au pourtour du coude du sinus latéral.

PURPOSE: To describe the retrolabyrinthine approach for the resection of 9 meningiomas inserted around the lateral sinus between the transverse and sigmoid parts, to discuss the value of this approach compared to the retrosigmoid approach for resection of meningioma in this localization and to review the literature. METHODS: Retrospective study. Between 1988 and 2002, 9 patients (8 female, mean age 50 years) underwent surgery via the retrolabyrinthine approach for resection of meningiomas inserted around the lateral sinus between the transverse and sigmoid parts. RESULTS: Resection was total (8 Simpson I and 1 Simpson II) in all patients. In the early postoperative course, one patient was treated for meningitidis with an LCR leak and one patient present a temporary paresis of the vagus nerve. Mean follow-up was 5 years (6 months-10 years). All patients continued their pre-treatment occupation after surgery. No recurrence was observed. CONCLUSION: Two approaches can be used for resection of meningiomas in this localization. The retrosigmoid approach is a common neurosurgical approach exposure of the cerobellopontine angle. It is practised by most neurosurgeons. Via this approach, the cerebellar lobe must be pushed back so the arteries feeding the tumor are in the operative field at the end of the procedure. For numerous authors the operative field is too narrow. On the other hand, the retrolabyrinthine approach described in 1972 by Hitselberger and Pulec allows exposure of feeding arteries during the first steps of operation, an easier resection of meningioma insertion and better control of the lateral sinus. This approach can be enlarged to the retrosigmoid or the subtemporal anatomic region.

[What sedation for prevention and treatment secondary brain insult?]. / Quelle sédation pour la prévention et le traitement de l'agression cérébrale secondaire ?

The aim of sedation and analgesia is to prevent secondary brain insult. The goals of sedation are the prevention and treatment of intracranial hypertension and systemic disorders. In such situation, the use of sedative and analgesic therapy should respect the rate of cerebral blood flow/cerebral oxygen consumption coupling while preserving cerebral perfusion pressure and decreasing the intracranial pressure. This treatment should have an analgesic and myorelaxing action with short and predictable time of action. The optimal agent with all these characteristics does not exist, but the combination of several pharmacological compounds may reach this goal. Benzodiazepines are the most frequently agents used. In most of cases they are associated with analgesics like opioids or ketamine. Opioids are the basis of analgesia because they do not produce brain haemodynamic alterations if arterial pressure is maintained. Ketamine, which use in this indication is matter of debate, has the advantage to maintain haemodynamics. Ketamine has no side effects on brain haemodynamics when used in combination with propofol or midazolam. Because of their side effects on haemodynamics and immune response, barbituric are no longer used as long term sedative agents. However, they are still recommended in cases of refractory intracranial hypertension. Propofol remains the optimal sedative agent because of its short duration action although its use is restricted because it is an expensive drug. Its use is recommended for short time sedation with or without opioids. The use of neuromuscular blockers should be focused on the patients with an intracranial hypertension refractory to standard treatment. The presence of brain damage in patients makes difficult to assess the level of sedation. One should avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation.

[Epidural intracranial hematomas: practical issues revealed by management of 100 recent cases]. / Hématomes intra-crâniens extra-duraux: à propos de 100 cas récents. Notre expérience et considérations pratiques.

We present a retrospective study on the management of 100 patients who presented epidural hematoma over a four-year period. Our goal was to provide an update on management of this injury. Computed tomography was performed because of the clinical presentation. Results provided information on the type of injury and appropriate treatment. A three-phase clinical progression was observed in only 6% of the patients. Despite state-of-the-art management, mortality remained high in these brain-injured patients (21%). No progress appears to have been achieved in the last ten years. This paradoxical fact probably results from the enhanced severity observed in our patients, who often suffered from associated intracranial injuries as well as multiple trauma (thoracic, abdominal trauma). Analysis study of the results confirms an improvement in mortality among patients with isolated epidural hematoma (6.6%), but great concern remains about the high mortality among patients with associated intracranial lesions (33.3%) or multiple trauma (32%).

[Subperiosteal hematoma of the orbit. Three cases]. / Hématome sub-périosté de l'orbite.

Orbital subdural hematoma should be considered in victims of head and face trauma with signs of exophthalmia. Early diagnosis and treatment, consisting of decompression, is mandatory to avoid long-term functional complications.

[Extradural hematoma of the posterior fossa]. / Hématome extradural de la fosse postérieure.

Extradural hematoma of the posterior fossa (EDHPF) is considered to be a rare complication of head injuries. In early reports, diagnosis was made only at the time of autopsy. Today, CT scanning prompts early diagnosis leading to better outcome. We report 20 consecutive patients observed over the last ten years who underwent surgery for EDHPF. This localization was found in 14,3% of all trauma patients operated for extradural hematoma. In our experience, EDHPF occurs in young adults with a clear male predominance. Vehicle accidents are the most frequent mechanism of injury. The main clinical presentation is subacute onset of signs (50% of our cases). Postoperative outcome was favorable in 19 of our patients (95%). We propose mandatory CT scanning that may have to be repeated as needed, to prevent delay in diagnosis and decision for surgery. Surgical removal of the EDHPF must be carried out as soon as possible as this is the only way to reduce morbidity and mortality.

[Tuberculous abscess of the cerebellum. Apropos of a case]. / Abcès tuberculeux du cervelet. A propos d'un cas.

A 22-year-old Asian man developed intracranial hypertension with a 38 degrees C fever. Two months earlier, he had undergone surgery and medical treatment for tuberculous otomastoiditis and pulmonary tuberculosis. The CT scan revealed multiple tuberculous abscesses of the cerebellum. Histological, microbiological and biological proof of diagnosis was obtained. We advocate surgical treatment of intracranial tuberculous abscesses associated with antituberculosis chemotherapy for 18 months. The earlier the treatment, the better the prognosis. This pathology must be kept in mind when treating patients from countries with a high endemic rate of tuberculosis and suffering from immunodeficiency syndrome.

Central neurocytoma: 2 case reports and review of the literature.

Central neurocytoma is a rare benign tumor of the central nervous system occuring in young adults and typically located in the ventricles. The tumor is composed of small round cells with neuronal differentiation and has a favourable prognosis. We report two cases of giant central neurocytomas with a triventricular extension in two young women. The first case concerned a 26 years old righthanded woman in whom an intraventricular mass was discovered, after a car accident with head trauma. Skull radiography showed an enlargment of the sella turcica. A CT scan performed in order to examine the pituitary gland revealed a voluminous and heterogenous intraventricular tumor with calcification. The second case concerned a 26 years old righthanded woman, presenting with a 4 Glasgow Coma Scale Score preceded by an acute onset of headache with projectile vomiting. A CT scan performed in emergency revealed a voluminous intraventricular mass with significant hydrocephalus. We review the different pathological and topographical patterns of previously published neurocytomas and discuss surgical management, effectiveness of radiation therapy and biological behavior.

[A psychopathologic conflict in the 18th century in the East Indies Squadron]. / "Un conflit psycho-pathologique au XVIII siècle au sommet de l'escadre des Indes."

The authors first give a psychological evocation of the Bailli de Suffren, a great captain who vastly contributed to improve the image of the French Navy after the appalling seven years war, but whose character showed, nevertheless, originality, authoritarism, violence, sometimes vindictiveness and often negligence. The quarrels he had with most of his subordinates culminated as he was in command of the East Indies Squadron, applying sometimes exaggerated punishments. Chevalier de Tromelin was hierarchically just under him; this Chevalier had a character as chilly and stiff as the Bailli was the opposite; both were ambitious and deserving officers, the Chevalier being as much conformist as his "adversary" was fiery and bold. The shouts and rancours of the Bailli, when confronted to the rigidity and cold technicity of the Chevalier, marked their relationship. More than objective reasons arising from their duties, the fundamental incompatibility of their characters, explain their conflicts. Suffren played a double-game with his immediate subordinate; not lacking verbal smoothness, he nevertheless abused him in such a way in his reports to the authorities, that when Chevalier de Tromelin, being ill, asked to return to France, he learned that he had been dismissed of the Navy without having ever been heard or able to attempt to defend himself. He then spent his time trying to claim for a hearing without ever obtaining it, writing justificatory reports. He was "rehabilitated" in 1793 and died in half-exile in 1815. The authors were struck by the fact that for 200 years, no historian of the Fast Indies has ever taken into account the Squadron's distinctive features and the personality of Suffren. Thanks to their research in family documents, in the National and especially Navy Archives, they are able to show the importance of this psychological, not to say the psychopathological, aspect. One can only be struck by the silence of the various historians who worked on the subject, misjudging this "conditioning" which explains excessive punishments and long-harboured grudges. It is possible that Tromelin was the most affected because he was hierarchically the nearest. As the various documents or testimonies show, no fault or error could ever be retained against him that he could non justify. A detailed study of the handwritings of the two protagonists is presented in the text. Such conflicts are rather common within the Administration, but they seldom are of such duration.(ABSTRACT TRUNCATED AT 400 WORDS)

[Acedia or the depressed between sin and illness]. / L'acédie ou le déprimé entre le péché et la maladie.

Acedia is a term of the classical greek vocabulary that a christian author of the IVth century, Evagre the Pontic, uses in a special sense, to describe a mental state characterized among other things, by disgust and dejection, and which, according to him, falls into what became the first list of deadly sins. The word was conveyed to us by another monk of the egyptian deserts, Jean Cassien, with a change of meaning which made it very difficult to distinguish from sadness: his audience being very different from his predecessor's, as he wrote for Latins, little inclined to anachoretic life but among which developed the first great coenobitic institutions of the Occident. One century later, Pope Gregory the great removes acedia from the list of deadly sins, either because he does not distinguish it from sadness (and laziness) or because he considers it a morbid state and, as such, depending on medical care. The word has nevertheless survived until Thomas Aquinas and later, and its study provides valuable data on the mental states prefiguring our modern depressions.

[Aid to patients with mental disorders in Provence in the 18th century]. / L'assistance aux malades mentaux en Provence au XVIIIe siècle.

The provençal attitude towards the "insane" presents during the studied period several leading characteristics; they separate it clearly from the other part of the Kingdom, but, on the other hand, integrate it into a more specific latino-mediterranean behaviour. These characteristics are chiefly: a comparatively kind demeanor towards the mentally ill; an already very medical sight of madness, compared with that of North Europe; the foundation of specialized institutions for insane earlier than in other parts of Western World. The investigations of the leading "provençal" mental hospitals, public and private, confirms this statement. The authors have studied for that purpose: the three "lunatic asylums" of Avignon (1681, the most conclusive), Aix (1691) and Marseille (1699); several private foundations at Saint Remy, Salon de Provence, Manosque. The study of the attendance on mental patients in Provence during the Classic Era shows the danger to speculate perilously as Michel Foucault in his book "La Folie à l'Age Classique much greater than. The investigations on the institutions, that only begins, proves it was very diversified, and the patients were took charge medically long before Pinel.

[Bilateral tumors of the acoustic nerve and Recklinghausen's disease observed in several generations. Considerations on heriditary acoustic nerve tumors]. / Tumeurs bilatérales de l'acoustique et maladie de recklinghausen observées dans plusieurs générations. Considérations sur les tumeurs de l'acoustique héréditaires

Since 1933, four families have been found in Marseilles with bilateral tumours of the acoustic nerve spread over three generations in three families. The fourth only showing a cutaneous neuro-fibromatosis in the second generation. The authors recall briefly the clinical characteristics and compare their cases with similar ones found in the literature. Bilateral and familial neurinomas of the VIIIth cranial verbes were found in 21 families, making a total of 111 cases, unilateral neurinoma being used as a term of comparison. Among the groups of cases published, the family observed by Gardner and Frazier is the most remarkable (43 cases over 6 generations). From the hereditary point of view, the phenomenon of antiposition is not always constant. From the evolutionary point of view, bilateral neurinomas manifest themselves earlier clinically than unilateral ones. As far as associations are concerned, cutaneous manifestations of neuro-fibromatosis are the most frequent if the neurinomas are bilateral and non familia. Among tumors of the nervous system, meningiomas and gliomas have been found, other dysembryoplastic or degenerative tumoral associations being rare. The incidence of cutaneous symptoms is very low when the neurioma is unilateral. The association of cutaneous symptoms with bilateral and familial neurinomas does not worsen the prognosis, but the presence of such cutaneous signs is significantly more serious if the neurinoma is isolated. These considerations do no more than touch the fringes of the problems raised by these sporadic or hereditary tumours of the VIII the cranial nerves, developing within the framework of phacomatosis. Great caution is necessary in assessing the correlations observed in view of the narrow range of statistics available.