[Vascular tumors of the orbit]. / Tumeurs vasculaires de l'orbite.

Vascular tumors of the orbit include capillary hemangioma, cavernous hemangioma, hemolymphangioma, hemangiopericytoma and a few rare tumors. Capillary hemangioma and hemolymphangioma, occurring mainly in children, are covered in the chapter devoted to childhood tumors. In this chapter, cavernous hemangioma and hemangiopericytoma are discussed as well as rare vascular tumors. Although orbital varix is not a tumor, it is also considered because of the diagnostic problems and the close correlation of orbital varix with a true tumor: hemolymphangioma.

[Neurosurgical approaches to the orbit]. / Les voies d'abord neurochirurgicales de l'orbite.

Surgical approaches to the orbit differ depending on the surgical specialty. Neurosurgical approaches consider the posterior two-thirds of the orbit and can be summed up as the superior, lateral, and superolateral approaches. Orbital rim removal enlarges the exposure when necessary. Each neurosurgical approach is described in this chapter. Schematically, subfrontal approaches are used to reach the inner quadrant orbital tumors and the others to access external quadrant tumors. Nevertheless, the choice of the approach is discussed regarding to the presumed pathologic preoperative diagnosis.

[Orbital tumors. Neurosurgical activity]. / Tumeurs orbitaires. Activité neurochirurgicale.

In this chapter, we report the results of orbital tumor management in a few neurosurgical departments and compare it to a Paris neurosurgical department that has developed a close relation with an ophthalmological department. These departments' activity is quite low, treating mainly sphenoorbital meningiomas. Other tumor groups are unequally and sporadically managed.

[Pleomorphic adenoma mimicking dacryoadenitis]. / Adénome pléomorphe simulant une dacryoadénite.

A 56-year-old female patient displayed an increased volume of her left lacrimal gland with pain and inflammation. On CT scan, a hyperdense lacrimal mass was found in the left lacrimal fossa. Observation was the first course, for no steroid therapy could be applied because of evolving digestive ulcers. After 9 months of observation, the gland was surgically removed en bloc through a wide anterolateral approach. Pathological analysis of the gland showed a pleomorphic adenoma. This case illustrates the advantage of a wide surgical approach in treating lacrimal gland tumors, in order to avoid or limit the risk of recurrence.

[Unusual preseptal location of an orbital cavernous hemangioma in African patient]. / Localisation inhabituelle préseptale d'un hémangiome caverneux orbitaire chez une patiente d'origine africaine.

Cavernous hemangioma is the most common primary vascular orbital tumor in adults. Generally the benign tumor arises within the muscle cone, revealed by proptosis with choroidal folds, and more rarely develops in other orbital localizations. We report the case of a 42-year-old female African patient who had a cavernous hemangioma in an unusual anterior localization. Clinically, a small superficial tumor was palpated in the right superior nasal orbital angle. After complete surgical excision, the histopathological study established the diagnosis of cavernous hemangioma

[Residual left orbital phlebolith. An anatomic-clinical observation]. / Phlébolithe résiduelle orbitaire gauche. A propos d'une observation anatomo-clinique.

A 29-year-old female patient displayed a dense and hard left orbital mass, inferiorly, 3 years after she was treated through a neurosurgical approach for a left orbital varix. The lesion was hyperdense on CT-scan and was removed through a trans-conjunctival approach, with an excellent result. The histological diagnosis was a phlebolith.

Combined management of intracranial aneurysms by surgical and endovascular treatment. Modalities and results from a series of 395 cases.

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. We report on a series in which both techniques were applied. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysm were treated either by surgery (N = 102) or by endovascular coiling (N = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfactory results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12 and 36 months, were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfactory results were observed after surgery in 7 cases and in 25 cases after embolization. After retreatment, it remains 3 post-surgical and 2 post-endovascular cases. In the overall series, good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones; mortality was of 4.8%. In a series in which were applied both types of treatment, surgery in 25% and endovascular technique in 75%, good results in terms of aneurysm occlusion and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.

[Point of view of the neurosurgeon]. / Le point de vue des neurochirurgiens.

Stereotactic radiosurgery, a term introduced by Leksell, was born more than 40 years ago, but has made great strides for the last 15 years. There is no consensus among neurosurgeons as to the best device (gamma knife, linear accelerator), the treatment doses, and the clinical indications of stereotactic radiosurgery. Therefore, this report is the viewpoint of one neurosurgical team only. In the radiosurgery literature, there is no clear evidence of better results with the gamma-knife or the linear accelerators. With regard to clinical applications, cerebral arteriovenous malformations are the more widely accepted indications of radiosurgery, since a cerebral angiography can confirm the disappearance of the nidus of an arteriovenous malformation treated by stereotactic radiosurgery. Usually, small and deep arteriovenous malformations can be treated by stereotactic radiosurgery only. Nevertheless, the treatment of the other arteriovenous malformations more often require procedures including one or several of the following treatment methods: microneurosurgery, interventional neuradiology, stereotactic radiosurgery. Stereotactic radiosurgery in acoustic schwannomas, skull base meningiomas, especially those involving the cavernous sinus, brain metastases, and pituitary tumors seem attractive. Contrary to arteriovenous malformations, the lack of criteria for cure requires a long follow-up and carefully controlled trials to confirm the efficiency of stereotactic radiosurgery for these tumors. On the other hand, experience of stereotactic radiosurgery for astrocytomas and glioblastomas is limited, and few publications are available. Furthermore, because of the infiltrating growth, a major impact of stereotactic radiosurgery for these tumors is presumably not to be expected. Lastly, a close multidisciplinary approach seems absolutely necessary to define the best indications of stereotactic radiosurgery and to improve its clinical results.

Management of intracranial aneurysms by surgical and endovascular treatment--modalities and results from a series of 395 cases.

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysms were treated either by surgery (n = 102) or by endovascular coiling (n = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfying results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12, and 36 months were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfying results were observed after surgery in seven cases and in 25 cases after embolization. After retreatment, it remains three post-surgical and two post-endovascular cases. Good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones. Mortality is of 4.8% in the overall series. In a series in which were applied both types of treatment, surgery in 25% and endovascular techniques in 75%, good results in terms of efficiency and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.

Superolateral approach to orbital tumors.

The conventional lateral approach to the orbit (Krönlein) does not allow a satisfactory view of the superior part of the orbit and the operative field is rather narrow. Therefore, large tumors which have developed not only laterally but also superiorly are usually approached transcranially. The craniotomy and exposure of the dura may be avoided when the tumor does not extend too far posteriorly and medially, by turning a larger orbital bone flap than the Krönlein's one. This technique was described by Nakamura as "type I orbitotomy" and can be referred to as a superolateral approach. After a bicoronal skin incision, a free orbital bone flap is cut. It includes the lateral orbital rim, a large external part of the superior orbital rim, and the lateral orbital wall. From 1985 to 1990 this approach was performed on 23 patients presenting with lacrimal gland tumors in 14 cases (11 pleomorphic adenomas, 2 adenoid cystic carcinomas, 1 adenocarcinoma), schwannomas in 2 cases, dermoid cyst in 1 case, hydatic cyst in 1 case, cavernous hemangiomas in 2 cases, inflammatory pseudotumor in 1 case, and mucoceles in 2 cases. This superolateral approach provides a wider exposure to the superolateral orbit than the classical Krönlein's approach and avoids the drawbacks of a craniotomy. A direct incision through the eyebrow can be used for bald people or for patients in poor condition.

Abnormal cerebral vasodilation in aneurysmal subarachnoid hemorrhage: use of serial 133Xe cerebral blood flow measurement plus acetazolamide to assess cerebral vasospasm.

A patient with cerebral vasospasm following subarachnoid hemorrhage (SAH) was investigated by serial measurement of cerebral blood flow (CBF) using the xenon-133 emission tomography method. The CBF was measured before and after acetazolamide injection. On Day 2 after SAH, there was early local hyperperfusion in the middle cerebral artery (MCA) territory, ipsilateral to the left posterior communicating artery aneurysm. The regional CBF of this arterial territory decreased slightly after acetazolamide injection, probably because of vasoplegia and the "steal" phenomenon, and thus surgery was delayed. A right hemiplegia with aphasia and disturbed consciousness occurred 4 days later (on Day 6 after SAH) due to arterial vasospasm, despite treatment with a calcium-channel blocker. The initial hyperemia of the left MCA territory was followed by ischemia. The vasodilation induced by acetazolamide administration was significantly subnormal until Day 13, at which time CBF and vasoreactivity amplitude returned to normal and the patient's clinical condition improved. Surgery on Day 14 and outcome were without complication. It is concluded that serial CBF measurements plus acetazolamide injection are useful for monitoring the development of cerebral vasospasm to determine the most appropriate time for aneurysm surgery.

Selective endovascular treatment of 71 intracranial aneurysms with platinum coils.

Seventy-one intracranial aneurysms were treated by endovascular techniques, with the placement of minicoils inside the aneurysmal sac. Most aneurysms were manifest by hemorrhage (67 cases), and 43 of these were treated within the first 3 days after presentation. At the 1-year follow-up examination, the outcome was scored as good in 84.5% of cases, but the morbidity and mortality rates were 4.2% and 11.3%, respectively. Twenty-nine aneurysms in the anterior circulation and 42 in the posterior circulation were treated. In this series, 23 patients were classified as Hunt and Hess neurological Grade I, 27 as Grade II, 12 as Grade III, nine as Grade IV, and none as Grade V. Thirty-three aneurysms were less than 10 mm in diameter, 28 were 10 to 25 mm, and 10 were larger than 25 mm. The preliminary results from this study appear to justify the emergency treatment of aneurysms by this approach. Aneurysms in the posterior circulation are particularly well suited for this type of surgery.

[Cavernous hemangioma of the orbit]. / Hémangiome caverneux de l'orbite.

Cavernous hemangioma is one of the commonest primary orbital tumors. Painless and progressive reducible unilateral proptosis causing a variable degree of hyperopia is the usual clinical presentation. The case of a 39-year-old-female patient is reported. The clinical presentation was unilateral left axial proptosis with acquired hyperopia. Imaging studies showed a well circumscribed mass in the orbit, a superior neuro-surgical approach allowed complete resection of the tumor, and histopathology revealed the diagnosis of cavernous hemangioma.

Phase-contrast MR angiography of vascular malformations of the spinal cord at 0.5 T.

Preliminary experience with phase-contrast magnetic resonance (MR) angiography at 0.5 T applied in 12 cases of vascular malformations of the spinal cord is reported. There were six intramedullary arteriovenous malformations (AVMs), four perimedullary fistulas, and two dural arteriovenous fistulas with perimedullary drainage, all proved with x-ray angiography. The small size of the vessels and their location within a bony structure presented a technical challenge. Serpentine vascular signal patterns were identified within the spinal canal in all cases, showing good correlation with the x-ray angiographic pattern. Relative to spin-echo images, MR angiograms allowed better visualization of the venous drainage. The nidus of intramedullary AVMs was more difficult to recognize. The ability to manipulate the velocity-encoding value allows better characterization of flow speed. The results underline the two dimensions of the phase-contrast technique, which provides both anatomic images and dynamic information about vascular malformations. MR angiography does not replace selective x-ray angiography, which is indispensable for therapeutic strategy (endovascular procedure or surgery), but it can be considered a valuable alternative to x-ray angiography during follow-up.

Intra-operative monitoring of the facial nerve with an air inflated balloon. Technical note.

A simple, reliable and cheap device for intra-operative monitoring of the facial nerve during surgery for cerebellopontine angle tumours is presented. It consists of a single use tracheostomy tube with a low pressure air inflatable cuff placed in the mouth of the patient on the side of the tumour, connected by a pressure transducer to a monitoring unit. It records any pressure changes in the patient's mouth induced by muscular contractions as a result of excitation of the inferior parts of the facial nerve.

[Palpebral form of mixed tumor of the lacrimal gland. Apropos of a case]. / Forme palpébrale d'une tumeur mixte de la glande lacrymale. A propos d'une observation.

The clinico-pathological findings in a 45-year-old male patient with a lacrimal gland tumor are reported. This tumor had a spontaneous course of about nine years before it was resected. The clinical presentation was unusual as the tumor appeared as a nodular well-circumscribed swelling of the lateral part of the left superior eyelid. Imaging techniques did not reveal any involvement of the orbital part of the lacrimal gland. However a wide supero-lateral approach was chosen to achieve monobloc resection. Histopathology showed the typical features of an encapsulated pleomorphic adenoma, with no suspicious cytologic changes. Complete resection had a total curative effect for the patient. A wide lateral approach seems to be mandatory for tumors of the lacrimal gland to avoid partial resection and local recurrences.

[Cisternal cysticercosis of the cerebellopontine angle. A surgically-treated case and review of the literature]. / Cysticercose cisternale de l'angle ponto-cérébelleux. Observation d'un cas opéré et revue de la littérature.

Most neurocysticercosis (N.C.C.) cases reported occur in undeveloped countries where contaminated food by Taenia solium gives rise to human infection. People of developed countries are exposed by migrations and travels. We report a case of a 36 years old french woman living at La Reunion. Her symptomatology consisted of left unilateral hypoacusis progressing over a two years period accompagnied by intermittent headaches. CT scan showed a hypodense mass with a ring enhancement in the left cerebello pontine angle (C.P.A.). M.R.I. showed multicystic arrangement of vesicles in a racemous fashion that spread out to peduncular and carotid cisterns. Parenchymatous or ventricular involvement was not observed. A lateral suboccipital craniectomy was carried up in the sitting position. After division of a thickened arachnoid in the C.P.A., the vesicles were dissected an pulled out easily because the membranes had not any adhesions. Progressive improvement of hearing was observed in the next week. Primary cisternal involvement of N.C.C. is rare and, in literature, there is not any other reported case in the C.P.A. Different mechanisms of invasion to the C.N.S. are discussed.

[Giant intracranial aneurysm. Elective endovascular treatment using metallic coils]. / Anévrysmes géants intracrâniens. Traitement endovasculaire électif par des spires métalliques.

The authors present nine cases of giant aneurysm treated endovascularly by obliteration of the aneurysm lumen using platinum coils. Three aneurysms were located on the anterior circulation and six on the vertebrobasilar system. Presenting symptoms were mass effect in five cases and subarachnoid hemorrhage in four. Total occlusion of the aneurysms was achieved in four patients and partial occlusion in five. On follow-up (15 months), there was one repermeation and one neo-aneurysm. Both of these cases were retreated with placement of additional coils. All patients who presented with a mass effect had improvement of their symptoms (two after transient aggravation). Two patients died: one partially treated from hemorrhage, and the other from M.C.A. infarct after surgical clipping of the aneurysm. One technical complication included a lost coil which did not result in any angiographic or clinical change. One year follow-up angiographies show a permanent stable occlusion induced by coils. This technique should be considered as an option when treating giant non surgical aneurysm.

Shrinkage of a primary thyrotropin-secreting pituitary adenoma treated with the long-acting somatostatin analogue octreotide (SMS 201-995).

The long-acting somatostatin agonist octreotide can control TSH hypersecretion from most thyrotropic adenomas. Octreotide therapy has even been shown to improve chiasmal dysfunction. We report another patient in whom octreotide therapy was associated with gradual suppression of TSH hypersecretion, which escaped partially, dramatic and very rapid and sustained improvement of chiasm compression, and dramatic and sustained shrinkage of an unresectable TSH-secreting pituitary tumour. Unusual and prolonged gastrointestinal adverse reactions eventually disappeared except for steatorrhea. In conclusion, octreotide may be considered as first line treatment in patients with unresectable thyrotropic adenomas.