A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

Radiography of scoliosis: Comparative dose levels and image quality between a dynamic flat-panel detector and a slot-scanning device (EOS system).

PURPOSE: To compare radiation dose and image quality between a slot-scanning system (SSS) and a dynamic flat-panel detector (DFD) in assessing scoliosis in children. METHODS: An experimental study was first performed with a phantom to assess the quality of each device. The clinical part included a prospective observational dosimetric and qualitative comparative study with acquisition of whole-spine X-ray: SSS (31 children), DFD (26 children). Institutional review board approval and informed consent were obtained. Dosimetric statistical analysis was performed from dose area product (DAP) and entrance skin dose measured by thermo-luminescent dosimeters localized in the cervical, thoracic and sacral areas. Assessment of the diagnostic quality (phantom and clinical) was realized by independent evaluation by 3 observers, using statistical analysis of quality score and inter-observer reproducibility. RESULTS: DAP was equivalent with the 2 systems. Entrance skin dose was significantly higher with DFD in thoracic and pelvic regions (P<0.05). Image quality scores of the SSS were significantly better than DFD for a majority of criteria, in both phantom and clinical evaluations. CONCLUSION: For scoliosis evaluation, the SSS, compared to the DFD system, offers enhanced image quality while reducing the entrance skin dose in the most radiosensitive areas.

[Gradenigo syndrome and petrositis in a child]. / Syndrome de Gradenigo au cours d'une apicite chez un enfant.

Gradenigo syndrome is caused by petrous inflammation, also called petrositis. It includes acute otitis media, diplopia, and homolateral retroorbital pain due to trigeminal and abducens nerve injury. We describe a child with petrositis secondary to acute otitis media. The lack of otoscopic abnormality and the presence of bilateral headache made the diagnostic difficult. After complementary investigations searching for an intracranial process, the diagnosis was made based on brain and skull base dimensional computed tomography.

[Dural carotid-cavernous fistulas: progression in therapeutic management from 1989 to 2004. A report of ten cases]. / Fistules carotido-caverneuses indirectes (durales): évolution de la prise en charge thérapeutique de 1989 à 2004. A propos de 10 cas.

INTRODUCTION: Dural carotid-cavernous fistulas are rare and require multidisciplinary management. Today there is no consensus on treatment, even though embolization is currently the first-line treatment. We present the cases of ten patients with a dural carotid-cavernous fistula diagnosed between 1989 and 2004 in order to compare the therapeutic choices used to treat dural carotid-cavernous fistulas in the late 1980s and mid-1990s to the therapeutic strategy currently favored. PATIENTS AND METHODS: The ten patients, with a mean age of 65.9 years, were seven women and three men. They had an ophthalmologic examination and the diagnosis was angiographically confirmed. Treatments were either noninvasive (such as decoagulation and/or carotid-jugular or ocular compression) or embolization. A combination of these different treatment modalities was provided for several patients. RESULTS: The main symptoms were arterialized conjunctival veins, proptosis, diminished visual acuity, chemosis, elevated intraocular pressure, and diplopia. Of the seven patients who only had noninvasive treatment (embolization not possible), three remained stable, three showed partial improvement, and the last one was clinically cured. As for the three patients treated with embolization (prior or not), this treatment led to a dramatic clinical improvement for one patient, a clinical cure for the second, and a complete cure in the remaining patient. CONCLUSION: Prior embolization when possible appears to be an effective and safe treatment for dural carotid-cavernous fistulas. Nonetheless, noninvasive treatment options, particularly compressions, remain an important therapeutic alternative.

How helical CT helps the surgeon in oculo-orbital trauma.

Whether isolated or associated with craniofacial lesions, traumatic oculo-orbital injuries occur frequently. Radiological evaluation is often necessary to appropriately manage the trauma-related vision loss and oculomotor disturbance. In the emergency setting and after clinical examination, helical CT scanning is the optimal imaging technique for displaying injuries of the orbit and its contents, for determining their severity and for helping the surgeon to choose the best course of treatment. MRI is indicated if the cause of the loss of vision or ocular mobility remain unexplained on CT after ferromagnetic foreign body has been ruled out. Drawing from numerous clinical cases, the purpose of this pictorial review is to demonstrate the wide variety of traumatic lesions of the orbit and eyeball as revealed by helical CT, as well as the limitations of the technique, to provide relevant information for patient care. Helical CT scans remain, in cases of emergency, the optimal imaging technique for the evaluation of oculo-orbital trauma.

[MR and CT perfusion imaging of the brain: principles and clinical applications]. / Imagerie de perfusion: principes et applications cliniques.

MR and CT imaging techniques provide both morphological data and functional data. MR and recently CT perfusion have substantially modified the treatment of acute stroke. CT perfusion offers new opportunities to improve the management strategy in vasospasm after subarachnoid hemorrhage. Both are also helpful for the diagnosis of brain tumors and the assessment of treatment effects.

Specificity of the monocular crescents of the visual field in postural control.

Postural reactions elicited by monocular visual stimulation in the temporal crescent of the visual field were studied in adult subjects in dynamic balance on a rocking platform. Circular translation of a visual scene was induced in the temporal crescent by the rotation of membrane prisms placed laterally to the stimulated eye. In anteroposterior balance, postural reactions are identical whichever eyes is stimulated: ventral extension of the body when the visual scene moves upwards and dorsal extension when it moves downwards. In lateral balance, postural reactions vary with the stimulated eye: extension of the right side of the body when the right eye is stimulated by an upward displacement of the visual scene, extension of the left side when the left eye is stimulated. This difference, which contrasts with the similarity of reactions elicited by the stimulation of either para-foveal fields, suggests that the most peripheral part of the nasal retina has a specific role in head and body stabilisation.

A persistent pharyngohyostapedial artery: embryologic implications.

A 3-year-old child was examined because of otorrhagia. CT scans showed an unusual vessel, confirmed by angiography, related to a persistent pharyngohyostapedial artery. This embryonic persistent artery associated with the normal internal carotid artery would explain the "duplication" aspect of the internal carotid artery.

Anteroposterior dynamic balance reactions to circular movement of the visual field without ocular pursuit.

It has been hypothesised that during natural vision, retinal image motion and eye motion information exert antagonistic effects on balance that cancel each other out. In a previous study, we found that pursuit movements of the eye unaccompanied by background slip on the retina induced strong, stereotyped anteroposterior sway in dynamic balance. In the present work, we investigated the influence of background retinal image slip alone on anteroposterior dynamic balance. We expected that retinal slip without ocular pursuit would induce large anteroposterior sway. Circular slip without rotation of the whole visual field image on the retina was obtained using a rotating prism. In this study, carried out on monocular vision, eye movement was prevented by fixating a stationary target seen through a small aperture in the prism. Anteroposterior dynamic balance conditions were elicited by a rocking platform. Strong, stereotyped anteroposterior sway accompanied by a visual illusion of target motion was observed. The induced sway was synchronised to the stimulus and led to a significant disturbance of balance. The similarity in magnitude of the effects of both retinal image motion studied here and eye motion information obtained previously, and their opposing phases, strongly support the initial hypothesis that the antagonistic effects of the two sources of information provided by normal ocular pursuit could interact in an additive algebraic mode.

Lateral dynamic balance reactions to circular translation of the visual field.

Lateral sway of subjects in spontaneous dynamic balance conditions on a seesaw platform was measured during a visual stimulation monocularly produced by a rotating glass covered with a prism membrane. Prism rotation induced the perception of a circular translation of the whole visual field and an ocular pursuit movement. Therefore, the retinal slip that occurs in normal pursuit was cancelled. Strong stereotyped postural reactions were observed in a direction that depended upon both the vertical visual field deviation and the eye stimulated: upper position of the right visual field induced a leftward sway resulting from an extension of the right hemibody; symmetrical reactions occurred for the left stimulation. The results suggest that the postural reactions recorded depend on the isolated oculomotor activity and, in addition, on retinal afferences corresponding to the temporal crescent of the stimulated side, which orientates the postural reaction on the homolateral lower limb muscles.

[Benign vertebral osteoblastoma. Report of 6 cases]. / L'ostéoblastome bénin vertébral. A propos de 6 observations.

We present six cases of benign spinal osteoblastoma. This localization of this uncommon benign bone tumor occurring in young subjects is rare. The patients were explored with radiotomography, computed tomography, myelography and medullo-spinal angiography. These benign tumors may appear radiographically as pure bone lysis mimicking malignancy. The size of these tumors often leads to widening search for extension, particularly in recurrent, aggressive, multifocal forms which require wide resection, and sometimes total vertebrectomy. Medullo-spinal angiography can confirm the vascular involvement of the tumor nidus and is require to identify arteries supplying the spinal canal which would modify operative strategy.

Direct emergence of the dorsospinal artery from the aorta supplying the anterior spinal artery: report of two cases.

We report two cases of an isolated dorsospinal artery that emerged directly from the aorta to supply the anterior spinal artery, which in one case had another blood supply on the opposite side, in a lower position. It is important to identify this anatomic variant, otherwise spinal angiography might be incomplete, especially when the isolated dorsospinal artery supplies the anterior spinal artery.

Unusual vestibular and visual input in human dynamic balance as a motion sickness susceptibility test.

BACKGROUND: Motion sickness (MS) is commonly thought to arise from a sensory conflict. However, few quantitative methods based on this theory are available to detect MS susceptibility. HYPOTHESIS: It was asked whether the standardized unusual stimulation of a single sensory channel under quantified dynamic balance conditions in man could elicit a sensory conflict and therefore trigger motion sickness (MS) METHODS: Vestibular and visual channels were stimulated by galvanic current and rotating prismatic glasses, respectively. The moving platform used to create the requirements for dynamic balance conditions was chosen not only to worsen the malaise but also to obtain an objective measurement of the balance consequences of the stimulations. RESULTS: Both vestibular and visual stimulation, applied separately, elicited MS-like symptoms (in 56% and 73% of subjects, respectively) and stereotyped balance reactions. A relationship was found between subjective MS-like symptoms and objective measurements of dynamic balance performance. Subjects sensitive to unusual vestibular messages differed from the others by a greater increase in the parameters indicating a difficulty of balance whereas subjects sensitive to unusual visual messages were recognized by the strategy they used to balance themselves. CONCLUSIONS: These results demonstrated that a sensory conflict can trigger MS-like symptoms. We conclude that the measured parameters of a global somatomotor activity, such as the dynamic balance task proposed here, could be useful for objectively detecting subjects predisposed to MS, for training them and testing the efficiency of anti-MS drugs.

Anteroposterior dynamic balance reactions induced by circular translation of the visual field.

The anteroposterior sway of subjects under conditions of spontaneous dynamic balance on a wobbly platform was measured during visual stimulation by a visual target executing a circular trajectory in the frontal plane. The target was either a component of the whole moving visual scene or moving on a stationary background. With the former stimulation, obtained through the use of rotating prismatic glasses, every point of the visual field appeared to describe a circular trajectory around its real position so that the whole visual field appeared to be circularly translated, undistorted, inducing a binocular pursuit movement. Under these conditions, stereotyped anteroposterior dynamic balance reactions synchronous with the position of the stimulus were elicited. The latter stimulation consisted of pursuing a luminous target describing a trajectory similar to that of the fixation point seen through the rotating prisms on the same, this time stable, visual background. Although pursuit eye movements were comparable, as demonstrated by electro-oculographic recordings, no stereotyped equilibration reaction was induced. It is concluded that the translatory motion of the background image on the retina in the latter experiments contributed to the body's stability as well as to the perception of a stable environment.

[Role of hormonal exploration in avoiding of the failures of anterior pituitary gland surgery in Cushing disease]. / Rôle de l'exploration hormonale dans l'esquive des échecs de la chirurgie anté-hypophysaire de la maladie de Cushing.

Patients with Cushing's disease are not cured by transsphenoidal microsurgery in about 30% of the cases. Beside the problem of invasive macroadenomas, these failures are due either to diagnostic errors, or to very small microadenomas that could no be found. Positive diagnosis of hypercortisolism is quite straightforward and the problem is sensitivity rather than specificity. Primary adrenocortical hypercortisolism should not be mistaken. Depression-related hypercortisolism can be difficult to distinguish from Cushing disease: most cases are recognized after clinical story and CRF stimulation test. Ectopic ACTH secretion by a carcinoid tumor represents at least 8% of ACTH-dependant hypercortisolism. It cannot be reliably distinguished from corticotroph microadenoma by either classical dynamic tests or anterior pituitary imaging. However measurements of ACTH in the inferior petrosal sinus under basal condition and CRF stimulation allow the diagnosis of central or peripheral ACTH secretion with a quasi 100% sensitivity and specificity. In contrast this technique is of poor help for the diagnosis of lateralization of corticotroph microadenomas, for which it gives erroneous results in 25 to 50% of the cases. Rapid intraoperative measurement of ACTH in peripituitary blood seems a more reliable approach. In our series it gave correct results in 11 out of 12 cases. In 1995 hormonal exploration of Cushing disease should limit the failures of anterior pituitary surgery to the cases of invasive macroadenomas that cannot be completely removed.

Step-length biofeedback device for walk rehabilitation.

A biofeedback gait training system for step length is proposed, adapted to the correction of spatial walking asymmetries by means of a simple, quick and reliable method for daily clinical use. The system is composed of a walkway and a gait analysis device (locometer) measuring the main temporal and distance factors of gait. The step length is imposed on the subject by lighted targets appearing on the walkway, alternately on the right and left side; the subject is asked to place a swinging foot on the lighted target. Feedback to the subject is supplied by direct visual information (the subject looking at the movement and the position of the foot with respect to the lighted target) and an acoustic signal delivered in real time when the length step error is greater than an allowed value. The method is validated on a population of hemiparetic patients who have suffered from a stroke and who have been reeducated with traditional rehabilitation methods. The patients were divided into two groups; one group following a gait training with biofeedback (BFB group) and one group following a gait training without biofeedback (reference group). Preliminary results are presented, showing a significant beneficial effect of the biofeedback method in increasing the step length of paretic limbs and in correcting step-length asymmetry.

Spectral frequency analysis of dynamic balance in healthy and injured athletes.

Different neurophysiological circuits underlie the various frequencies of the body sway for the regulation of human upright posture. Servo-controlled platforms allowed experimental studies about latency responses after a sudden external disturbance but power frequency repartition during spontaneous dynamic equilibrium has rarely been examined. The purpose of the present study was to examine the zone of sway frequency assigned to proprioceptive afferences from muscular, articular and tendinous receptors in healthy and injured subjects standing on an unstable and minimal area. Dynamic balance conditions were realized by asking athletes to stand up on a seesaw (stabilometer). The recordings (stabilograms) were monitored by means of an accelerometer. Their power spectra were obtained by a fast Fourier transform process. A first study was conducted in order to specify the contribution of articular receptors of the ankle in the regulation of spontaneous dynamic equilibrium of five soccer players with unilateral injured ankle (IA). The balance parameters in lateral sways were measured in monopodal stance on the healthy ankle (HA) comparatively to IA. The stabilogram was longer (P < 0.05), the total energy of 2-20 Hz band (P < 0.01) higher in the IA (1074 +/- 111 mm and 53 +/- 8 V2) than in the HA (836 +/- 150 mm and 36 +/- 8 V2). A second study analyzed the contribution of knee articular receptors involved in the reflexes of antigravity extension. We assessed during bipodal stance the anteroposterior sways of five basketball players with injured knee (IK) and 3 with healthy knee (HK) in eyes-open and eyes-closed situations.(ABSTRACT TRUNCATED AT 250 WORDS)