[Benefit of a prolonged adjuvant treatment with temozolomide for the management of patients with glioblastoma]. / Intérêt d'un traitement d'entretien prolongé par témozolomide dans la prise en charge des patients atteints d'un glioblastome.

PURPOSE: Temozolomide has significantly improved the outcome of patients with glioblastoma. However, the optimal duration of continuation treatment after chemoradiation remains uncertain. This retrospective analysis aims at assessing the feasibility, the tolerance, and the potential benefit of prolonging adjuvant temozolomide more than six months, which is the reference protocol. PATIENTS AND METHODS: Forty-six patients were included in the analysis. Median age at diagnosis was 61 years old (range 40 to 77). Forty-five patients received a conformal external beam radiation with concurrent temozolomide-based chemotherapy. Then, 37 patients received adjuvant chemotherapy with temozolomide. The treatment was continued until progression or toxicity. RESULTS: During the adjuvant phase, no treatment discontinuation for toxicity was necessary. Eight patients required dose adaptation because of toxicity. Thirty-two patients presented tumor progression during the adjuvant phase. Overall median survival was 12.3 months (range 11-13.2 months) and progression-free survival (PFS) was 7.6 months (range 5.6-9.6 months). CONCLUSION: These results suggest feasibility of delivering temozolomide beyond the six months of the standard protocol, with mild toxicity and survival data at least comparable to those from literature. Prospective assessments are ongoing.

[Evaluation of the clinical and radiological results of cervical longitudinal median somatotomy without graft]. / Evaluation des résultats cliniques et morphologiques de la somatotomie cervicale médiane longitudinale sans greffe.

OBJECTIVES: To evaluate the clinical and radiological results of cervical longitudinal median somatotomy without graft, used for the treatment of cervical myelopathy and radiculopathy, and compare it to techniques with graft and to laminectomies. MATERIAL AND METHOD: Thirty-four patients (25 males and nine females), with a mean age over 60 years, were included in a study comparing pre- and postoperative clinical status on the Japanese Orthopaedic Association (JOA) functional scale and radiological status with evaluation of the cervical curve on plain films and dynamic tests in flexion and extension. RESULTS: No significant difference was found with the clinical and anatomical results published in the literature concerning median somatotomies performed with graft and/or osteosynthesis and laminectomies and their variants. CONCLUSIONS: The cervical longitudinal median somatotomy without graft is an easy and reliable technique that can be proposed as first-line treatment for cervical spondylotic myelopathy related to anterior compression. It decreases the cost and the duration of the surgical procedure, it protects the patient from the complications and sequelae related to graft harvesting and the use of implants. It should be limited to patients without preoperative kyphosis who are over 50 years old.

[Multiple actinomycosis brain abscesses]. / Abcès cérébraux multiples à Actinomyces.

BACKGROUND: Actinomycosis is a subacute or chronic bacterial infection, which can affect immunocompetent or immunodeficient subjects. It most often occurs in cervico-facial or thoracic-abdominal locations. Central nervous system infection is rare but of severe prognosis. CASE REPORT: A 56 year-old woman with no history of immunodepression was admitted with unexplained fever, inappropriate behaviour, and spatial and temporal disorientation. The progressive worsening of the neurological signs let to coma and mechanical ventilation was required. Brain imaging showed multilocation cerebral abscesses. Stereotaxial biopsy permitted diagnosis of actinomycosis. Patient's outcome was favourable following appropriate dual antibiotherapy without surgical exeresis. DISCUSSION: When lacking bacteriologic identification, diagnosis of cerebral actinomycosis is performed by pathologic findings. Dual antibiotherapy allows full recover, even in the case of multilocation cerebral abscesses.

[Non traumatic spinal epidural hematomas. Report of twenty cases. Review of the literature and outcome aspects]. / Hématomes épiduraux non traumatiques du rachis. Présentation de 20 cas. Revue de la littérature et étude des aspects évolutifs.

BACKGROUND AND PURPOSE: We report a personal series of 20 non traumatic spinal epidural hematomas and study outcome aspects with a review of data in the literature. METHOD: Clinical presentation of non-traumatic spinal epidural hematomas observed between January 1980 and December 1998 was acute in 17 cases (85%) and chronic in 3 (15%). Symptoms were spinal and/or radicular pain, sensorimotor and sphincter dysfunction. Radiological evaluation consisted in myelography (n=6), myelography-CT scan (n=5), CT scan (n=1) and MRI (n=9). Patients underwent surgery in 15 cases, between 8 hours and 2 months after the first symptoms. All our patients were clinically reevaluated between 2 and 4 months after either surgery or admission for cases of spontaneous resolution. RESULTS: Good results (complete neurological resolution or moderate sequelae) were observed in 14 patients (70%). A partial recovery with major persistent neurological impairment was observed in 1 patient (5%), an initial persistent neurological impairment in 1 (5%). Three patients (15%) died and 1 (5%) was lost to follow-up. Complete spontaneous resolution were observed in four patients. CONCLUSION: Postsurgical outcome is mainly related to the preoperative neurological impairment, the duration of spinal cord compression and the time interval between the onset of symptoms and maximal deficit. A prompt laminectomy is necessary except in the cases where a spontaneous resolution can be expected from the early neurological course.

Phase II study of a radiotherapy/etoposide combination for patients with newly malignant gliomas.

PURPOSE: Etoposide, a semisynthetic derivative of podophyllotoxine, is a topoisomerase II inhibitor. This drug is currently used in several types of human cancer. The aim of this study was to evaluate the efficacity and tolerance of a near-concurrent association of radiotherapy and etoposide for newly malignant gliomas. METHODS: From May 1995 to December 1996, 30 malignant glioma patients were included in this phase II study; 16 patients underwent surgical tumor resection, and a stereotactic biopsy was performed in 14 patients. Standard cranial irradiation and six courses of etoposide (100 mg/m2, x days 1-3) were administered. The first course of etoposide was administered on days 1-3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks. RESULTS: Only 26 patients could be evaluated for the purpose of our study. The median age was 60.1 years, and the median Karnofsky performance score (KPS) was 80.2. The rate of objective response for evaluable patients was 34.6%, and four complete responses (CR) and five partial responses (PR) were noted. The median survival (MST) was 12 months, and the average overall survival was 12.5 months. Hematological toxicity was mild, and grade 3 or 4 neutropenia (white blood cell count < 1500/ml) was noted in three patients, without any sepsis or bleeding. CONCLUSIONS: The results obtained in this study are comparable to the best reported results on the combination of radiotherapy and nitrosoureas. The near-concurrent combination of radiotherapy and etoposide seems to be effective and well tolerated in the treatment of newly malignant gliomas.

99mTc-MIBI uptake in a primitive leptomeningeal melanoma.

Primitive leptomeningeal melanoma is a rare and aggressive condition. The authors report on a case of primitive leptomeningeal melanoma imaged with 99mTc-Sestamibi (MIBI). There was an intense accumulation of the radiotracer in the frontal and parietal leptomeningeal regions and even after injections of gadolinium the MRI continued to reveal a cystic image of the brain. In view of the diagnosis, MRI demonstrated only limited usefulness. On the other hand, this case highlights the important role of MIBI for the imaging of malignant tumors.

[Complications of lumboperitoneal shunts. A retrospective study of a series of 195 patients (214 procedures)]. / Complications des dérivations lombo-péritonéales. Etude rétrospective d'une série de 195 patients (214 interventions).

BACKGROUND AND PURPOSE: We report our experience with the lumboperitoneal shunt (LPS) in 195 patients. The aim of this retrospective study was to assess and compare the rate of complications and to discuss 4 indications. MATERIAL AND METHOD: Between January 1983 and July 1994, 195 patients including 14 pediatric cases were treated with a LPS. Sex ratio was 1.24. The mean age at insertion was 59.5 years (from 6 months to 88 years) and the follow-up in this series was from 6 months to 12.5 years. The indications for a LPS were: chronic idiopathic hydrocephalus (115 cases), post-hemorrhagic hydrocephalus (37 cases), cerebrospinal fluid fistula (11 cases), post-traumatic hydrocephalus (9 cases), post-surgical hydrocephalus (8 cases), hydrocephalus of the child (6 cases), post-meningitis hydrocephalus (4 cases), benign intracranial hypertension (4 cases), post-radiotherapy hydrocephalus (1). Forty patients (20.5%) presented with at least one complication. A total of 47 complications were observed: chronic subdural effusion (8 cases), meningitis (10 cases), mechanical failures (28 cases), acquired Chiari abnormality (1 case). Mechanical complications varied with the type of shunt. CONCLUSION: Complications of LPS in adults are less frequent than is usually reported after ventricular atrial or peritoneal shunting. In adults, LPS can be used as the first valuable treatment in case of chronic communicating hydrocephalus. LPS is also valuable in the treatment of benign intracranial hypertension or recurrent CSF fistulae. Conversely, in the pediatric cases general and specific complications are frequent, so an indication for LPS must be strictly discussed.

[Anterior and anterolateral surgery of the lower cervical spine (25 years after H. Verbiest). I: Technical bases]. / Chirurgie antérieure et antéro-latérale du rachis cervical inférieur. (Vingt-cinq ans après H. Verbiest). Première partie: les bases techniques.

The anterior approach to the cervical spine is currently a worldwide traditional surgical technique used by neurosurgeons or orthopedists in the treatment of traumatic, degenerative or tumoral cervical spinal lesions. Many original rules of these techniques were raised by pioneers as R. Cloward and H. Verbiest, and are still valid. Advances in the surgical armentarium and in bio-materials markedly improved the original technique and subsequently improved the clinical results. The present course was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was helded during the winter meeting in December 1995. The aim of this course is to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points are strengthened by the author's personal experience and comments. Part I presents the different anterior or antero-lateral approaches which any surgeon involved in cervical spine surgery actually needs to know. Secondly, the materials and technical basis needed to achieve an interbody graft or fusion or fixation are described. Lastly, some practical applications are detailed as a microdiscectomy, a medial or lateral cervical spine decompression, and the use of acrylic plastic or prothesis for a cervical vertebral replacement.

[Anterior and antero-lateral surgery of the lower cervical spine (25 years after H. Verbiest). 2: Indications, results, complications)]. / Chirurgie antérieure et antéro-latérale du rachis cervical inférieur. (Vingt-cinq ans après H. Verbiest).Deuxième partie: Indicaions, rèsultats, complications.

The present course on the anterior and antero-lateral surgical approach of the lower cervical spine was organized for the neurosurgery trainees by the French Speaking Neurosurgical Society, and was held during the winter meeting in December 1995. The aim of this course was to recall the basic technical principles of the microsurgical anterior cervical approach, and to discuss the main indications of this surgical treatment. Many theoretical points were strengthened by the author's personal experience and comments. In Part I, the technical bases of the different anterior or antero-lateral approaches were presented (1996, 42 : 105-122). In the present Part II, the main indications of the anterior surgical approach to the cervical disk or the vertebral body are detailed, and the requirement of a bone graft and/or an osteosynthesis are discussed with their consequences on the final results. Secondly, variants of the surgical technics in use in case of cervical spinal instability are commented. Then various approaches to the cervical spinal tumors and to the vertebral artery are detailed and commented. Lastly, general and specific complications of the anterior cervical approach are listed with their rate of occurrence, and their prevention and management are discussed.

Cervical root compression by a loop of the vertebral artery: case report.

A case of an abnormal loop of the extracranial vertebral artery enlarging the intervertebral foramen at C5-C6 and the transverse foramen at C5 is reported. This occurrence is rare and was associated with cervicobrachial neuralgia caused by neurovascular compression of the C6 root. The patient was cured by microvascular decompression.

[Anterior osteosynthesis of the cervical spine by phusiline bioresorbable screws and plates. Initial results apropos of 5 cases]. / Ostéosynthèse antérieure du rachis cervical par vis et plaques biorésorbables en Phusilines. Résultats préliminaires à propos de cinq cas.

The authors have designed a biocompatible and bioresorbable plate (1) in Phusilines* for anterior cervical interbody stabilization. Phusilines* are polymer of alpha hydroxyacid (poly lactic acid), and their in vivo degradation (in lactic acid and via the Krebs circle, in water and carbon dioxide), is complete within 18 months. Screws are available in the same material. Phusilines* are radiotransparent and do not interfere with MRI. The size and shape of the plate have been determined with three dimensional computed tomography, their thickness and their molecular weight and chemical structure have been determined to obtain the best compromise in mechanical properties and time of resorption. Biomechanical studies have been performed in cadaver, and have showed a good quality of the osteosynthesis. Five patients with anterior cervical disco-ligamental instability were operated on according the french law of bioethic (Huriet Law). In these five cases the operation was performed via antero lateral approach, and it consisted in a interbody xenograft with Surgibone (2) and interbody osteosynthesis with a plate and four screws of 16 mm of length and 4 mm of diameter. Clinical and radiological examinations were realised during 18 months. In all cases, clinical results in rachialgia and neurological signs were excellent, in four case the tolerance was excellent, in a case inflammatory phenomens were observed the 8th and the 14th month successfully treated with non steroid anti-inflammatories. Anatomical results were excellent in two cases, good in two cases and incomplete in one case. Reasons of these incomplete results are discussed. These preliminary results are sufficient to continue these implantations.

[Familial aneurysms, multiple aneurysms and "de novo" aneurysms. Apropos of 2 cases]. / Anévrysmes familiaux, anévrysmes multiples et anévrysmes "de novo". A propos de deux observations.

The authors report the case of two sisters: each suffered from two intracranial hemorrhages caused by aneurysmal rupture at an interval of respectively 8 and 5 years. In the first case, the first subarachnoid hemorrhage (SAH) was related to a left middle cerebral artery aneurysm and the second, 8 years later, to the rupture of one of three right aneurysms (anterior communicating, supraclinoid internal carotid and middle cerebral arteries). But the "de novo" character of the right aneurysms could not be established. In the second case, the first SAH was related to an aneurysm of the right middle cerebral artery, with the left one appearing normal on the initial angiography. The second SAH, 5 years later, was related to a "de novo" left aneurysm. These two observations of familial, multiple and "de novo" intracranial aneurysms suggest a genetic basis for the pathogenesis of the arterial dysplasia. As in the literature, these hypothetical congenital factors could not be identified in both cases, but their probability justifies further investigations. If this factor exists, can we hope for a total recovery of the aneurysmal disease?

[Treatment of chronic hydrocephalus in adults by lumboperitoneal shunt. Results and indications apropos of 82 cases]. / Traitement de l'hydrocéphalie chronique de l'adulte par dérivation lombo-péritonéale. Résultats et indications à propos de 82 observations.

Patients with chronic hydrocephalus are most often aged people and in bad general condition. It seems that treatment may be more simplest possible and the less iatrogenic. Furthermore, the diagnosis of chronic hydrocephalus is not often certain, and can be generally assert after the good result of the CSF shunting. Since 1985, when hydrocephalus appears communicant, a lumboperitoneal shunt was systematically implanted in the aim to decrease the number of complications due to ventricular shunts. The operation can be performed on neuroloptanalgesia and/or local anesthesia. Post-operative orthostatic intracranial hypotension can be prevented by using valves with opening pressure varying with the position or valves with a flow depending of the opening pressure. Our clinical series includes 82 patients (51 males and 31 females), aged from 27 to 88 years (average 55 years). In 47 cases, hydrocephalus was idiopathic and in 35 cases hydrocephalus was secondary to an identified aetiology: subarachnoid or intracranial hemorrhage (20 cases), post-traumatic (11 cases), post meningitic (1 case) and post anoxic (1 case). In this last case, physiopathological mechanism was unclear. The middle delay between the first symptom and the operation was greater than 6 months for the majority of observations, but in few cases, precoce shunting was performed (between 1 to 3 months) in post S.A.H. and post traumatic hydrocephalus when C.T. Scan shows increasing ventricular size. Clinical results are evaluated after 2 months and at long term, and complications analysed. The lumbo-peritoneal shunt gives same results on the clinical symptoms, and less iatrogenic complications than ventricular shunts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spontaneous rhinorrhea disclosing intranasal meningoencephalocele and ependymoma of the 4th ventricle]. / Rhinorrhée spontanée révélatrice d'une méningoencéphalocèle intranasale et d'un épendymome du IVe ventricule.

The authors report a case of a spontaneous rhinorrhea due to an intranasal meningoencephalocele associated with a benign, perhaps congenital, ependymoma of the floor of the fourth ventricle. The tumour was initially unknown, because clinical symptoms suggested a congenital aqueductal stenosis (macrocrania, no neurological signs, association with a congenital defect of the cranial base). This observation, which belongs to "hypertensive spontaneous rhinorrhea" suggests that the C.S.F. fistula is possible only when hydrocephalus coexists with a congenital abnormality of the cranial base. Therapeutic problems are discussed: the direct approach of the fistula alone is most often insufficient, the treatment of the hydrocephalus alone is possible, but may induce a tension pneumocephalus, the best attitude is the treatment in the same stage, of the fistula and the hydrocephalus. But, in case of chronic non communicant hydrocephalus, aqueductal tubing or ventriculocisternostomy can be insufficient and permanent internal C.F.S. derivation may be performed.

[Anterior sacral meningocele. Apropos of 11 cases]. / Méningocèle sacrée antérieure. A propos de onze cas.

The authors report 11 cases of anterior sacral meningocele, cystic mass connected with lumbar sac through a sacral bony defect: 2 children and 9 adults. Clinic presentations are analysed. Examination including, X ray, ultrasonography, scanner is discussed. The authors believe that these lesions must be treated surgically because a risk of rupture in the rectum with important meningitis exists. There is also a septic risk if an error of diagnosis ends at a puncture. The transacral approach is easy and it gives the best results.