Pyogenic parenchymatous and nidus infection after embolization of an arteriovenous malformation. An unusual complication. Case report.

Infectious complications of cerebral angiography and of therapeutic angiographic procedures are very seldom reported. The case of an infected embolized arteriovenous malformation (AVM) by staphylococcus aureus is reported. Abscess formation became manifest seven months after the endovascular procedures. Antibiotherapy was initially started after puncturing the abscess, but finally the cure of the lesion could only be obtained by radical excision of the infected and embolized AVM, as if the persisting embolization material was promoting the infection. The modalities of infection after cerebral endovascular procedures are discussed.

Diffusion of cefpirome into the cerebrospinal fluid of patients with purulent meningitis.

We evaluated the diffusion of cefpirome into the cerebrospinal fluid (CSF) of 25 patients with bacterial meningitis or ventriculitis who were receiving conventional antibiotic treatment. A single cefpirome dose of 2 g was infused at day 2-3 after the onset of therapy. Concentrations of cefpirome in serum and CSF obtained at 2, 4, 8 or 12 h after the infusion were determined by high-performance liquid chromatography. The mean (+/- S.E.M.) concentrations of cefpirome in CSF ranged from 2.26 +/- 1.16 to 4.17 +/- 0.83 mg/L. These concentrations were higher than the MBCs for the pathogens usually responsible for bacterial meningitis.

[Evaluation of cerebral blood flow in severe brain injuries by SVO2 measurement in the internal jugular vein]. / Evaluation du débit sanguin cérébral des traumatisés crâniens graves à partir de la mesure de la SVO2 dans le golfe de la jugulaire interne.

The purpose of the present study was to assess the value of jugular oxyhemoglobin saturation percent (SvO2) in predicting cerebral blood flow (CBF). SvO2 and CBF were measured in 25 adults with acute brain trauma (Glasgow Coma Scale < 8). From the data a classification of CBS and SvO2 was developed: in the first group of patients the presence of cerebral ischemia could be identified in the presence of low CBF (< 40 ml/min/100g) and a low SvO2. In the second group he CBF is closely coupled to and regulated by the cerebral metabolic rate of oxygen (CMRO2) and values of SvO2 are intermediate. In the third group hyperaemia was defined as both an increase of SvO2 and CBF (> 60ml/min/100g) and a decrease of CMRO2. The SvO2 was measured in 18 of these 25 patients following 1) intravenous infusion of mannitol (1 g.kg-1) and hyperventilation (PCO2 = 3.4 kPa). The data suggest that there is no correlation between SvO2 and CBF, but a reliable estimates of CBF may be made from SvO2 measurement after mannitol and hyperventilation.

[Hemodynamic and metabolic effects of thiopental in patients with severe head injuries]. / Effets hémodynamiques et métaboliques du thiopental chez le traumatisé cranien grave.

The effect of pentobarbital was evaluated in 12 comatose brain injured patients (Glasgow coma scale < 7 at admission). Mean hemispheric cerebral blood flow (CBF) was studied following intravenous administration of 133Xenon. The results indicated a decrease in CBF, mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral metabolic rate of oxygen (CMRO2). The increase in cerebral perfusion pressure (PP) was found only in patients with diffuse brain injury. The results supports the hypothesis that barbiturate therapy is more effective at reducing ICP while preserving CPP when the cause is a diffuse lesion.

Reversible hearing loss in a patient with cryptococcosis.

A 16-year-old girl had hearing loss, paroxysmal tremor, gait disorders, and psychiatric disturbances as the initial manifestations of a cryptococcal meningoencephalitis. Imaging demonstrated an obstructive hydrocephalus, and neuro-otological explorations showed a retrocochlear deafness and diffuse brainstem involvement. Emphasis is on the deafness, which rarely occurs as a presenting symptom in this condition, and on its dramatic improvement following antimycotic therapy.

Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note.

In surgery, better access to the anterior part of the foramen magnum with less risk to the lower brainstem can be obtained by lateral enlargement of the usual posterior opening. This requires exposure and control of the vertebral artery (VA) and the sigmoid sinus (SS) and, for further enlargement, medial transposition of the VA and section of the SS with inferior petrosal resection. This technique has been applied fully or partially in 14 cases of anteriorly located tumors of the foramen magnum. It widens exposure on the anterior aspect of the neural axis and allows work in a nearly frontal plane.

[Value of the measurement of cerebral blood flow in choosing the operative time of ruptured intracranial aneurysm]. / Intérêt de la mesure du débit sanguin cérébral dans le choix de la date opératoire des anévrysmes intracrâniens rompus.

The authors report a series of 135 patients treated between 1984 and 1987, for a ruptured intracranial saccular aneurysm in the Department of Neurosurgery at the Lariboisiere Hospital. The value of C.T. scan and cerebral blood flow measurements (C.B.F.) in predicting the development of vasospasm was studied on 99 cases. The analysis confirmed that the C.T. Scan findings are closely related to vasospasm. A low C.B.F. between the fourth and the eight day following the bleeding was significantly associated with the development of delayed cerebral ischaemia. On the contrary, no relation was found between vasospasm and the C.B.F. measured during the three days following the bleeding. The authors propose to operate without delay on clinical grounds on patients referred during the first three days after the hemorrhage and to decide, on clinical and C.B.F. data, the timing of the intervention for patients admitted after this data, i.e. 35% of their patients.

[Intracranial arterial aneurysm. Differences in origin and prognosis in men and women]. / L'anévrysme artériel intra-crânien. Une origine et un pronostic différents chez l'homme et chez la femme.

A statistical model was defined from a series of 144 patients referred for a subarachnoid hemorrhage due to intracranial aneurysm rupture, occurred less than 3 days before admission. This model was then prospectively applied on a second series of 70 patients and allowed to find out four datas predicting the final functional result: age (p = 0.02), clinical status (p = 0.001), angiographic evidence of spasm (p = 0.01) and sex (p = 0.001). Concerning sex, functional result appears worse in women than in man. This more severe prognosis of aneurysmal rupture in woman is explained by the higher frequency of spasm (p less than 0.0005). This fact and the predominance of multiple aneurysms and localizations on the supraclinoid internal carotid artery (38.3% in females and 17.7% in males) suggest a different origin of intracranial aneurysms according to sex. Fibromuscular dysplasia might correspond to the datas here observed, and is currently explored.

[Arguments for early intervention in intracranial aneurysms. From a series of 33 aneurysms with hematoma]. / Arguments pour une intervention précoce dans les anévrysmes intra-craniens. A partir d'une série de 33 anévrysmes avec hématome.

33 cases of intra-cerebral hematomas after rupture of intra-cranial aneurysm are reported: 12 were operated on emergency (before 24 hours); surgery was delayed in 13 cases, and 8 died before surgery. Mortality in operated cases is not as high as usually considered (28%). Results of patients with late surgery (day 3 to day 30) are similar to those patients with early surgery in spite of better neurological state. These poor results are related to worsening because of spasm development during time elapsed before surgery. Early surgery may prevent spasm development by release of blood clots out of basal cisterns. This attitude can be extended in cases with large amount of blood clots in subarachnoid spaces. Out of 23 cases with unoperated aneurysm, 8 cases had an hematoma and 6 died, and 11 cases had an important subarachnoid haemorrhage and 9 died. Except in one case, death was related to spasm development.

[Analysis of infectious sequelae of 1000 neurosurgical operations. Effects of prophylactic antibiotherapy]. / Analyse des suites infectieuses de 1 000 interventions neurochirurgicales. Incidence de l'antibiothérapie prophylactique.

Postoperative infections: cellulitis at the site of skin incision and/or meningitis, were reported in 5.1 p. cent of 1 000 cases treated by neurosurgery in Pr R. Houdart's department between december 1980 and march 1982. Statistically significant factors predisposing to infection were: emergency surgery, opening of the sinus, presence of a foreign body, and operation lasting more than 5 hours. The age of the patient, diabetes, or previous corticoid therapy did not significantly alter the risk of infection. Prophylactic antibiotic therapy had been administered to 37 p. cent of patients, but this had not affected the incidence of general infection, a statistically significant effect being observed only after operations lasting for more than 5 hours. The risk of infection was high after craniotomies and major after external ventricular shunts (valves). For the latter type of operation it was not possible to determine factors favorable for infection: neither duration of surgery, nor age of patient, nor absence of antibiotic therapy. The risk of postoperative infection was low (less than 1 p. cent) in the absence of factors favorable for its development, but its frequency increased considerably in patients presenting one or more other intercurrent infections. It is therefore possible to recognize surgical and general factors influencing infection, but prophylactic antibiotic therapy has only a weak effect on morbidity modification.

[Topographical distribution of EEG activity induced by anesthetic agents]. / Remarques sur la répartition topographique des activités E.E.G. induites par les produits anesthésiques.

Having noticed in a wide series of subjects submitted to prolonged anaesthesia that the EEG activities induced by anaesthetic products exhibited transverse topographic distributions (preferentially medial or preferentially lateral) which varied in relation to the product utilised, the authors have verified, in a more limited series of 25 subjects, that benzodiazepines, the targets of which are situated within the axial structures of the CNS, are responsible for EEG modifications which show a maximal amplitude on the parasagittal medial area of the scalp, while propanidide, which mainly affects the cortex of the convexity (i.e. the superior level of the lateral structures of the CNS), induces activities which show a maximal amplitude on the lateral areas of the scalp. The EEG modifications induced by thiopental and fentanyl are also lateralized but more diffuse. These data must be verified by a more precise study of a larger series, taking into account the dose and the speed of injection of the anaesthetic agent.