[Management of postoperative complications in cases of Gorham's disease with cervical spine involvement: A case report]. / Gestion des complications postopératoires dans le cas de la maladie de Gorham de localisation cervicale : cas clinique.

Gorham's disease is a rare osteolytic bone disease, caused by pathological vascular tissue, which may spread to adjacent organs. It is a disease of unknown etiology, primarily involving the axial skeleton and whose treatment is not codified. Cervical spine involvement is unusual. Stabilization of the cervical spine is a real surgical challenge. We report the case of a young adult treated in our neurosurgery department for a cervical spine localization of Gorham's disease.

Should we fear cement leakage during kyphoplasty in percutaneous traumatic spine surgery? A single experience with 76 consecutive cases.

OBJECTIVE: Although kyphoplasty is widely used to repair osteoporotic and pathologic vertebral fractures, balloon kyphoplasty and vertebral body stenting are new treatment options in cases of traumatic spinal injury. To our knowledge, there are no literature data on the incidence of cement leakage whereas these two percutaneous techniques are commonly used to repair non-pathologic fractures. The aim of this study was to evaluate and compare the clinical characteristics and the incidence of cement leakage associated with balloon kyphoplasty and vertebral body stenting in the percutaneous treatment of traumatic spinal injury. METHODS: A series of 76 consecutive kyphoplasties (50 with vertebral body stenting and 26 balloon kyphoplasties) were retrospectively reviewed. Preoperative and postoperative computed tomography scans were analyzed in order to detect cement leakage and grade it as minor, moderate or major. RESULTS: The overall leakage rate was 50%. None of the leakages gave rise to clinical symptoms. Although balloon kyphoplasty and vertebral body stenting did not differ in terms of the leakage rate, the latter technique was associated with a lower leakage volume. The Magerl type, fracture level and use of concomitant osteosynthesis did not appear to significantly influence the leakage rate. CONCLUSION: Vertebral body stenting can reduce the amount of cement leakage due to a better cohesion of the bone fragments after kyphosis correction and maintenance.

Perfusion MRI as a neurosurgical tool for improved targeting in stereotactic tumor biopsies.

OBJECTIVE: Stereotactic biopsies are subject to sampling errors (essentially due to target selection). The presence of contrast enhancement is not a reliable marker of malignancy. The goal of the present study was to determine whether perfusion-weighted imaging can improve target selection in stereotactic biopsies. METHODS: We studied 21 consecutive stereotactic biopsies between June 2009 and March 2010. Perfusion-weighted magnetic resonance imaging (MRI) was integrated into our neuronavigator. Perfusion-weighted imaging was used as an adjunct to conventional MRI data for target determination. Conventional MRI alone was used to determine the trajectory. RESULTS: We found a linear correlation between regional cerebral blood volume (rCBV) and vessel density (number of vessels per mm(2); R = 0.64; p < 0.001). Perfusion-weighted imaging facilitated target determination in 11 cases (52.4%), all of which were histopathologically diagnosed as glial tumors. For glial tumors, which presented with contrast enhancement, perfusion-weighted imaging identified a more precisely delimited target in 9 cases, a different target in 1 case, and exactly the same target in 1 other case. In all cases, perfusion-selected sampling provided information on cellular features and tumor grading. rCBV was significantly associated with grading (p < 0.01), endothelial proliferation (p < 0.01), and vessel density (p < 0.01). For lesions with rCBV values ≤1, perfusion-weighted MRI did not help to determine the target but was useful for surgical management. CONCLUSIONS: For stereotactic biopsies, targeting based on perfusion-weighted imaging is a feasible method for reducing the sampling error and improving target selection in the histopathological diagnosis of tumors with high rCBVs.

[Brown-Sequard syndrom complicating a C6 teardrop fracture associate with an occult vertebral artery dissection: case report]. / Syndrome de Brown-Séquard compliquant une fracture teardrop de C6 associée à une dissection d'une artère vertébrale asymptomatique : à propos d'un cas.

CASE REPORT: We report the case of a 27-year-old man, presenting a C6 tear-drop fracture associated to medullar contusion with a Brown-Sequard syndrome. An asymptomatic right vertebral artery dissection in its V2 portion was also discovered by the radiologic investigations. A surgical treatment and antiplatelet therapy were performed. The patient outcome was quite satisfactory.

Correlation between tap test and CSF aqueductal stroke volume in idiopathic normal pressure hydrocephalus.

INTRODUCTION: The diagnosis and management of idiopathic normal pressure hydrocephalus (INPH) remains unclear despite the development of guidelines. In addition, the role of cerebrospinal fluid (CSF) aqueductal stroke volume (ASV) remains unspecified. OBJECTIVES: The aim of this study was to compare the results of the tap test (TT) and ASV in patients with possible INPH. MATERIALS AND METHODS: Among 21 patients investigated with both TT and phase-contrast (PC) MRI, we identified two groups, with either (1) a positive TT (PTT) or (2) a negative one (NTT), and we compared their ASV as measured by PC-MRI. ASV cutoff value was set at 70 µL/cardiac cycle (mean value +2 standard deviations in age-matched healthy subjects). RESULTS: In the PTT group (n = 9), the mean ASV was 175 ± 71 µL. Among these patients, four were shunted, and improved after surgery. In the NTT group, two patients were finally diagnosed with aqueductal stenosis and excluded. Among the remaining patients (n = 10), the mean ASV was 96 ± 93 µL (p < 0.05). However, three of these patients presented with hyperdynamic ASV, and an associated neurodegenerative disorder was diagnosed. Two patients had ventriculoperitoneal shunting despite their NTT, and improved. DISCUSSION/CONCLUSIONS: In our patient population, the noninvasive measurement of hyperdynamic ASV correlated with PTT, suggesting PC-MRI could be utilized to select those patients who would benefit from shunting. ASV may therefore be an interesting supplemental diagnosis tool.

[Subependymomas of lateral ventricle. Analysis of our series and review of literature]. / Les subépendymomes (astrocytomes subépendymaires) du ventricule latéral. Analyse de notre série et revue de la littérature.

Subependymoma is a benign lesion, slow-growing neoplasm, representing 0.2 to 0.7 % of intracranial tumors. They are often clinically silent, incidentally discovered at autopsy. These symptoms are related to big volume. They are attached to the septum pellucidum, leading to hydrocephalus by Monro foramen obstruction. Overall mean age at diagnosis is 39 years with more males than females. At CT-scan, subependymoma shows a slightly low attenuation compared to gray matter. There is no or mild enhancement following contrast injection. On MR T1-weighted imaging, subependymoma is isointense and hyperintense on MR T2-weighted imaging. Intramural calcifications and cystic components are noted in 20 to 30 % of patients. Peritumoral oedema is absent. Immunohistochemicals studies show intense positivity for S-100 and GFAP. The treatment is surgical with an excellent prognosis.

[Rare tumors of the lateral ventricle. Review of the literature]. / Les tumeurs rares du ventricule latéral. Revue de la littérature.

Metastases of lateral ventricle (LV) are attached to choroidal plexus. Primary source is cancer of kidney. Two thirds of patients are male. Oligodendrogliomas occur in young females. Signs of increased intracranial pressure are a constant feature. These tumors are found in anterior portion of the LV with severe enhancement and clumped calcifications. Treatment is surgical. Cavernomas have a preponderance of rapid growth with a bleeding revelation. Seizures are rare. Rebleeding is frequent and justifies a surgical treatment. Schwannomas are a rare entity in which the majority of patients are very young. MRI shows calcifications, cystic components and a strong enhancement. They are limited to sporadic cases, never associated with neurofibromatosis. Arachnoid cysts are located in the atrium and/or in the occipital horn. Patients are young (mean age < 40 years). MRI demonstrates an intracystic lesion with signal intensity similar to the CSF. Best treatment is an endoscopic fenestration. Epidermoid cysts occur in third decade. These pearly tumors appear isointense or a little hyperintense on T1-weighted imaging, very characteristic. They are enhanced after gadolinium injection and appear strongly hyperintense on T2-weighted imaging. An incomplete removal with a thorough long-term follow-up is necessary. Cavernomas of LV are hyperintense on T1- and T2-weighted imaging. They have a bleeding risk of 25 to 45%. Therefore, they must be operated.

[Bilateral failure of fusion between pedicles and body of C7]. / Défaut de fusion corporéo-pédiculaire bilatéral de C7.

We expose the case of a 48-year-old woman suffering of a chronic bilateral C7 radiculalgy and bilateral C7 failure of fusion between pedicles and body. According to spine embryogenesis we bring three hypothesis to explain this failure of fusion. Then we show that bilateral C6-C7 foraminal compression can arise from local cervical spine instability due to C7 and disk development abnormalities. The treatment proposed is dissectomy bone graft and anterior osteosynthesis leading to clinical and radiological good results. The patient went back to work after three months.

Non-traumatic pseudocyst of Glisson capsule complicating a ventriculoperitoneal shunt.

BACKGROUND: Cerebrospinal fluid pseudocysts in the peritoneal cavity following ventriculoperitoneal shunt are relatively uncommon. In these complications, perforation of solid organs is unusual. CASE DESCRIPTION: A case of subcapsular hepatic pseudocyst is described. A 48-year-old man treated by ventriculoperitoneal shunt presented with abdominal pain. Laboratory examinations revealed hepatic cytolysis. The CT-scan of the abdomen demonstrated a small ovoid non-enhanced cystic collection in the subcapsular area of hepatic segment V. Percutaneous hepatic fine-needle aspiration of the cyst guided by abdominal ultrasonography showed no abnormal findings. Peritoneal reimplantation at a different site was performed. The clinicopathological features of this entity are described and treatments are discussed. CONCLUSION: Reinsertion of the catheter at a different abdominal site is effective in non-infections cases. In contrast, a temporary external drainage with adequate antibiotic treatment followed by shunt reinsertion is necessary to treat a documented infection of CSF collections.

Dual, minimally invasive fixation in acute, double, thoracic spine fracture.

BACKGROUND: We report on a dual percutaneous fixation in 2 patients with a double thoracic spine fracture. The advantages and limitations of this new approach for treating traumatic spinal fractures are reviewed. CLINICAL PRESENTATION: A 67-year-old male was admitted following a fall from a height of 3 m. A neurological examination revealed sub-T11 motor and sensory paraparesis. There were a T6 vertical body and bi-articular fracture and a T11 vertebral burst fracture with > 75% posterior wall damage. A 40-year-old male was admitted after a suicide attempt. A neurological examination revealed sub-T11 paraplegia. There were a T7 vertebral body fracture with intact posterior wall and a T11 burst fracture with > 75% posterior wall damage. SURGICAL TECHNIQUE: The same technique was used in both cases. 2 minimally invasive percutaneous fixations of the 2 fractures were performed. In a third step, we performed a T10-T12 open laminectomy. This technique helped to limit blood loss and avoid an over-long fixation. Pedicle screw targeting was optimal. 16 months later, the neurological status was normal in patient 1 and there was neurological improvement in patient 2. No secondary segmental kyphotic deformities appeared.Percutaneous fixation enables the treatment of an acute thoracic spine fracture. With appropriate presurgical planning, this technique can be applied to all thoracic vertebrae. Spinal cord injuries justify the use of laminectomy together with percutaneous fixation, in order to limit erector muscle injury and blood loss.

[Odontoid process fracture in elderly patients over 70 years: morbidity, handicap, and role of surgical treatment in a retrospective series of 27 cases]. / Fracture de l'odontoïde chez le sujet de plus de 70 ans: morbidité, handicap et place du traitement chirurgical. A propos d'une série de 27 patients.

BACKGROUND AND PURPOSE: Odontoid process fractures of the axis are frequent in elderly patients. However, the impact in terms of handicap and morbidity in this particular population are unknown. The role of surgical treatment remains controversial. METHODS: We present a retrospective series of patients aged 70 years or older with odontoid fractures treated in our department between 1998 and 2006. Two cohorts were defined (surgery versus conservative) and compared. Morbidity, handicap, and radiographic fusion were analyzed. RESULTS: Twenty-seven patients were treated. The mean age was 80.67 years. Five patients died early during hospitalization. Fractures were type II in 66.7% of the cases and type III in 33.3%. Orthopedic treatment was chosen in 44.4% of the cases. A non-union at the fracture site was found in 33% of the cases and morbidity in 41.7% of the cases was found after a 1-year follow-up. Surgery was performed in 40.7% of the cases. There was 18% non-union and no morbidity after 1-year of follow-up. Morbidity was statistically lower in the surgery group (p=0.037), particularly in cases of type II fracture (p=0.0063); no statistically significant difference was found for non-union at the fracture site (p=0.64) except for type II fractures (p=0.028). CONCLUSIONS: Odontoid fractures in the elderly are a very frequent problem. Immediate mortality is still high but appears correlated to associated lesions. Today's treatments must preserve autonomy for these patients. For elderly patients, the treatment must be chosen in relation to the fracture analysis. In our opinion, surgical management is the treatment of choice for unstable fractures (type II). Conservative management is indicated for stable fractures.

[Follicular dural lymphoma. Case report]. / Lymphome folliculaire méningé. A propos d'un cas.

A case of a meningeal B-cell lymphoma is described. A 48-year-old man presented with an episode of grand mal seizure following a brain injury. An initial diagnosis of extradural hematoma was made based on the results of the cerebral computerized tomography scan. Magnetic resonance images demonstrated an enhanced mass with a dural tail attached to the meningeal layer of the temporal bone, suggesting a meningioma "en plaque". The mass was surgically excised. Tumoral removal was subcomplete (Simpson 2). Operative inspection also suggested a meningioma, but histological analysis and electron microscopy revealed a grade IV follicular B-cell lymphoma. Biological studies were normal. An extensive workup found an external iliac adenopathy with several osseous locations on PET. The patient underwent chemotherapy and radiotherapy. Three years after the first symptoms appeared, the patient is alive and free of symptoms. The clinicopathological features and treatments were discussed.

Tension pneumocephalus and rhinorrhea revealing spontaneous cerebrospinal fluid fistula of the anterior cranial base.

Spontaneous cerebrospinal fluid fistulas (CSFFs) of the anterior skull base are extremely rare. We report a case of spontaneous CSFF of the ethmoid cribriform plate presenting with rhinorrhea and tension pneumocephalus. We discuss the physiopathology, the radiological management, and the treatment of spontaneous CSF fistulas related to the anterior skull base. A 58-year-old woman was admitted to our institution for headaches with clear rhinorrhea persisting over several days. Antecedents were unremarkable. An episode of epistaxis three days before was reported. Clinical examination showed clear rhinorrhea, headaches, and anosmia. The CT scan showed voluminous epidural and subdural pneumocephalus with mass effect on both frontal and temporal lobes. A high-resolution CT scan with bone reconstruction showed a 2-mm bony defect of the cribriform plate. Surgery consisted of epidural frontal anterior skull base repair. Postsurgery follow-up was uneventful. At one year, the patient was asymptomatic apart from the persistence of anosmia. Spontaneous CSF fistulas are uncommon and can be associated with tension pneumocephalus. The physiopathology remains unclear. Their treatment by complete exclusion of the fistula is necessary because of the lethal risk of pneumococcus meningitis.

[Management of intracranial dural arteriovenous fistulas with cortical venous drainage]. / Prise en charge des fistules artérioveineuses durales intracrâniennes à drainage veineux cortical.

BACKGROUND AND PURPOSE: Intracranial dural arteriovenous fistulas (DAVF) with cortical venous drainage are vascular malformations with high hemorrhagic risk. Their treatment may be complex and requires a multidisciplinary approach. METHODS: We retrospectively report 38 observations of dural arteriovenous fistulas with cortical venous drainage from 1990 to 2001. There were 28 men and 10 women with a mean age of 57 years. Hemorrhage revealed the malformation in 24 cases (63%). The other patients had headache, neurological deficit, seizure or pulsating mass of the scalp. One patient was asymptomatic. All the patients had DAVF with cortical venous drainage and decision of treatment was in each case multidisciplinary. RESULTS: Of the 38 patients, seven had no treatment for the following reasons: spontaneous occlusion of the malformation after hemorrhage, refusal of treatment, or poor neurological status at the admission. Thirty-one patients were treated and complete exclusion of the fistula was obtained in 30 cases. Endovascular occlusion of the fistula was performed in 14 patients, surgical clipping of the origin of the draining vein in 12 and combined treatment (surgical clipping after embolization of feeding arteries) in four. One patient had an untreated fistula despite several procedures. CONCLUSION: Complete exclusion of these malformations is mandatory because of the potential risk of hemorrhagic complications. The best treatment is the occlusion of the origin of the draining vein (endovascular or surgical) and requires multidisciplinary discussion.

Phase-contrast MR imaging support for the diagnosis of aqueductal stenosis.

BACKGROUND AND PURPOSE: Patients with aqueductal stenosis (AS) present with various clinical and radiologic features. Conventional MR imaging provides useful information in AS but depends on a subjective evaluation by the neuroradiologist. The purpose of this study was to evaluate the support of the phase-contrast MR imaging (PC-MR imaging) technique (sensitive to CSF flows) for the diagnosis of AS. MATERIALS AND METHODS: We retrospectively considered 17 patients who underwent PC-MR imaging to explore hydrocephalus, with the absence of CSF flow at the aqueductal level. We analyzed their clinical and morphologic MR imaging data. RESULTS: None of the usually reported direct or indirect signs of aqueductal obstruction were seen in 7 patients in whom the clinical suggestion of AS was confirmed by PC-MR imaging results. Seven patients in this population had a third ventriculostomy, and 5 of them were among those in whom conventional MR imaging failed to reveal signs of aqueductal obstruction. All of these 7 patients had a positive postsurgical outcomes. The analysis of CSF and vascular dynamic data in this population was compared with an aged-matched population, and these data were found similar except for the fourth ventricular CSF flush flow latency. CONCLUSIONS: PC-MR imaging supports the diagnosis of CSF flow blockage at the aqueductal level in a reliable, reproducible, and rapid way, which aids in the diagnosis of AS in patients with clinical and/or radiologic suggestion of obstructive hydrocephalus. We, therefore, suggest using this technique in the current evaluation of hydrocephalus.

Dynamic contrast-enhanced T2*-weighted MR imaging: a peritumoral brain oedema study.

BACKGROUND AND PURPOSE: Glioma and meningioma are the two most common types of primary brain tumor. The aim of the present study was to analyze, using dynamic susceptibility contrast MR perfusion imaging, the effect of angiogenesis on peritumoral tissue. METHODS: In this prospective study, conducted from December 2003 to March 2005, out of 18 patients recruited, 12 were included (six with meningioma, six with glioblastoma). Using rates of maximum signal drop (MSD), we drew regions of interest (ROI) starting near the lesion, and gradually moving outwards to areas of distant edema in axial and sagittal planes at 10, 20 and 30 mm from the tumor. We also drew ROI on the contralateral brain white matter to obtain a normal baseline for comparison (relative MSD; rMSD). RESULTS: In regions of peritumoral T2 hypersignals, we observed a decrease in rMSD with distance from glioblastoma due to reduced angiogenesis, and an increase in rMSD with distance from meningioma, probably due to a reduced mass effect. CONCLUSION: In our study, dynamic susceptibility contrast MR perfusion imaging, using MSD as a parameter, revealed differences between meningioma and glioblastoma peritumoral tissue due to changes in angiogenesis.

[Giant prebulbomedullary arachnoid cyst. Case report and review of the literature]. / Kyste arachnoïdien géant prébulbomédullaire. Cas clinique et revue de la littérature.

Usual locations of arachnoid cyst are the middle cranial fossa in 50-60%, cerebellopontine angle (10%) and suprasellar area (10%). Most of these malformations are asymptomatic. Premedullar arachnoid cysts are extremely rare. All previous cases reported were operated. We report a case of an asymptomatic giant craniocervical junction arachnoid cyst with a follow up of five years. In 2002, an adolescent consulted for persistent cervical pain. Encephalic MR showed a giant ventral craniocervical junction arachnoid cyst. Neurologic examination was normal. Conservative treatment was decided with a clinical follow up and repeated MR in case of persistent cervicalgia. Craniocervical junction arachnoid cysts are anecdotic. Medical care cannot be standardized. Pathogenesis and management are discussed.

[Endoscopic anatomy of the terminal portion of the basilar artery and its distal perforating branches]. / Anatomie endoscopique de la terminaison de l'artère basilaire et de ses perforantes distales.

The aim of this study was to describe and highlight the endoscopic anatomy of the tip of the basilar artery and its perforating branches. Knowledges of the anatomy are crucial for neurosurgeons to avoid pitfalls during endoscopic third ventriculostomy.

[Primary intramedullary lymphoma. Case report]. / Lymphome primitif intramédullaire. A propos d'un cas.

A 66-year-old female presented primary intramedullary spinal cord lymphoma. This patient was referred for lower limbs weakness, which had developed six weeks earlier and right C5 radiculalgia. Physical examination revealed a medullary syndrome with Claude-Bernard-Horner syndrome. The diagnosis was established after MRI and biopsy (dorsal myelotomy). The patient was given chemotherapy and craniospinal adjuvant radiotherapy (30 Grays). The clinical, radiological and therapeutic features are discussed.

[Paraganglioma of the cavernous sinus. Case report]. / Paragangliome du sinus caverneux. A propos d'un cas.

A case of paraganglioma arising from the cavernous area is presented. A 51-year-old woman presented with a parasellar mass causing decreased visual acuity, oculomotor nerve paresis and retro-orbital headaches without endocrinological dysfunction. Diagnosis was confirmed by histological appearance and electron microscopy. The patient was treated with surgery followed by radiation therapy consisting of 45 Gy. The clinicopathological features and the possible pathogenesis are discussed.