[Study of the middle ear. Value of multiplanar reconstructions in spiral tomodensitometry]. / Etude de l'oreille moyenne. Intérêt des reconstructions multiplanaires en tomodensitométrie spiralée.

We point out the interest of computed tomographic reconstructions from spiral acquisition--particularly sagittal reconstructions--in the study of middle ear anatomy and adjacent structures: the facial canal and the chorda tympani. The reference reconstructions are axial and coronal reconstructions. So, we demonstrate the superiority of sagittal reconstructions for the visualization of the lateral process of the malleus, the body and long process of the incus, the third portion of the facial canal, and the chorda tympani. For the other structures of the middle ear and the other parts of the facial canal, these sagittal reconstructions are complementary. Besides, the best type of reconstruction to visualize the stapes and the vestibular window is the axial plane parallel to the stapes axis.

Percutaneous sclerotherapy for venous malformation of the lips: a retrospective study of 23 patients.

Labial venous malformations are relatively common. Depending on their size, they are responsible for functional and cosmetic handicap. When treatment is indicated, it will be based on percutaneous sclerotherapy, using Ethibloc or Aetoxysclerol, with surgery in some patients. Our purpose was to review 23 patients with soft-tissue venous malformations of the lips. Follow-up ranged from 6 months to 4 years. Sclerotherapy alone or with surgical resection achieved good results in 18 patients. In six patients mild improvement was obtained. No worsening of the initial clinical situation occurred, and no persistent complication was observed. We discuss the indications for treatment and the different types of sclerosing agent. Percutaneous sclerotherapy is safe and is effective for small and medium-size labial malformations. For larger lesions the treatment is more complex and combined long term sclerotherapy and surgery procedures may be required over several years.

[Arteriovenous malformations: a study of 200 cases]. / Malformations artérioveineuses: étude de 200 cas.

OBJECTIVE: The aim of this study was to analyze the natural history of arteriovenous malformations by reviewing 200 consecutive cases observed in all localizations between 1992 and 1996 in a multidisciplinary angioma clinic. PATIENTS AND METHODS: Files concerning 200 arteriovenous malformations were reviewed with a standardized observation sheet applying the severity criteria defined by the International Society for the Study of Vascular Anomalies. We used the Schobinger staging system which includes 4 grades of severity: grade I=dormancy, grade II=expansion, grade III=destruction, grade IV=cardiac decompensation. RESULTS: There was no predominance by gender. Cephalic localizations were the most common. The malformation was present at birth as indicated by history taking in 40 p. 100 of the cases. Progression during childhood (grade II) was observed in 84 p. 100. At the first consultation, the patients generally were more often in grade II than in grade I or III. Bone destruction was observed in 3 cases, signs of cardiac decompensation in 5. Arteriovenous malformations were part of a more complex syndrome in 9 cases. We noted a flare-up in the prepuberty or puberty period in 75 p. 100 of the cases and the possible role of puberty (64 cases), trauma (39 cases) and pregnancy (25 p. 100 of the adult women). Explorations were generally completed (Doppler, arteriography) by grade II, expressing the need for a map of expanding lesions. Finally it was difficult to assess posteriorly the beneficial or deleterious effect of the often multiple treatments prescribed for these patients. DISCUSSION: The review of these 200 cases pointed out the "pediatric" nature of the problem of arteriovenous malformations in the large majority of the cases and the often misleading presentation of these vascular anomalies, particularly grade I malformations. A false aspect of capillary malformation could raise the risk of inappropriate treatment. This review also confirmed known factors of exacerbation (puberty, pregnancy, trauma) and demonstrated the severity of these vascular anomalies which can progress with loco-regional expansion and invasion without a cellular proliferation component. The analysis of treatments used showed that embolization alone cannot definitively and totally control a superficial arteriovenous malformation and that no one treatment, even combined embolization and large excision, can be a guarantee to provide total cure.

Superficial hemangiomas: associations and management.

The vast majority of hemangiomas, the most common skin tumor of infancy, are small lesions, easily recognized by their clinical features, and left to involute spontaneously. Hemangiomas also grow in a number of visceral locations, although rarely. In addition, associated malformations are reported. We analyzed 175 cases of severe superficial hemangiomas that represented approximately 10% of all hemangiomas evaluated from 1980 to 1995. In this particular group of severe hemangiomas, with marked female preponderance (6.6:1), symptomatic visceral hemangiomas were present in 20 of 175 patients (11.4%) and associated malformations were present in 12 patients (6.9%), with both present in 4 patients. We describe these associations and discuss which hemangiomas required active treatment and which therapeutic modalities can be used. Progress has been made in the management of problem hemangiomas.

Changes in the execution of a complex manual task after ipsilateral ischemic cerebral hemispheric stroke.

OBJECTIVE: To analyze behavioral adaptation of hemiplegic patients performing a complex manual task without time constraint. It was postulated that ipsilateral motor disturbance could not be observed after a hemispheric stroke. DESIGN: Two manual tasks were used: (1) a new one, "Pig-Tail," required the patients to run a 3-cm-diameter copper ring in a wooden handle along a wavy copper wire without any time constraint; (2) the second task was the Nine-Hole Peg Test (NHPT). SETTING: A hospital department of rehabilitation. PATIENTS: A consecutive sample of 36 patients, who had all suffered an ischemic stroke in the middle cerebral artery territory, 18 with left hemisphere damage (LHD) and 18 with right (RHD), and who had similar ages (mean 54 +/- 13), stroke severity, time since stroke (mean 60 days), and functional independence according to the FIM. MAIN OUTCOME MEASURE: Main data were number of faults, time in seconds, and difference of time for two trials. Analysis compared the results with the same hand for patients and 86 healthy subjects. RESULTS: Patients scores for NHPT were worse than controls, whatever the side of the lesion (p < .05). For Pig-Tail, the number of faults by patients was greater than by controls (p < .05); time was higher for LHD, but not significantly, and was similar to controls for RHD. All patients and controls speeded up between the two trials. Although the RHD were clumsy, they were always faster than LHD patients. CONCLUSION: There are ipsilateral motor disturbances in a complex manual task after hemispheric stoke, even without a speed constraint, and regardless of the hemisphere damaged. Further studies are needed to examine speed control that seemed impaired by right hemisphere damage and could explain clumsiness in these patients.

Cerebral developmental venous anomalies associated with head and neck venous malformations.

PURPOSE: To study cerebral developmental venous anomalies in patients with extensive venous malformations of the head and neck. METHODS: All patients had undergone carotid angiography 10 to 15 years previously. Four-vessel cerebral angiography was carried out in 40 patients with venous malformations. All patients had a physical examination, 16 had CT, and 22 were examined with MR imaging. One patient had MR angiography. RESULTS: Eighteen developmental venous anomalies were noted in 8 (20%) of 40 patients. Four patients had multiple anomalies, and these were bilateral in 1 patient. Developmental venous anomalies seen in association with cervicofacial, cutaneous, and mucosal venous malformations were remarkable in their absence of neurologic events and associated cavernoma; significance of ectatic venous convergence, extension, and preponderance of deep drainage routes; and frequency with which they multiple in occurrence. CONCLUSION: Developmental venous anomalies have a remarkable prevalence of 20% in patients with extensive superficial venous malformations. Therefore, it is important to search for a cerebral developmental venous anomaly when confronted with a cervicofacial venous malformation.

[Cervicofacial superficial venous malformations and developmental abnormalities of the cerebral venous system]. / Malformations veineuses superficielles cervicofaciales et anomalies de développement du système veineux cérébral.

INTRODUCTION: Cerebral developmental venous anomalies (DVA) are uncommon trajectories of the brain venous drainage. They must be differentiated from cavernomas. Patients with head-and-neck venous malformations can have DVA in their brain, a finding much more frequent than in general population. OBSERVATIONS: Three patients had DVA in their brain; this was an incidental discovery when investigating their facial or cervical superficial venous anomalies using arteriography, CT, MRI and MRA. COMMENT: DVA are uncommon variations of the brain venous system. In a vast majority of patients, this anatomical variant appears to be tolerated well, in contrast to cerebral cavernoma that can cause intracranial hemorrhage and neurologic symptoms. We want to stress the fact that the frequency of DVA occurring in patients with cervicofacial VM is much higher than in general population. This pattern is often a fortuitous finding in the work-up of these patients and it must be known in order to stop confusing it with true cerebral venous "angioma": the carvernoma.

[Hypophyseal adenomas: functional and tumor evaluation and therapeutic approaches]. / Adénomes hypophysaires: bilan tumoral et fonctionnel et abords thérapeutiques. therapeutic approaches]

Patients with pituitary adenomas present with hypersecretion syndrome(s), and/or pituitary failure(s), and/or signs of mass effect, or incidentally. Pituitary function evaluation, visual acuity and field check-up, and MRI or at least CAT are compulsory for diagnosis, and for therapeutic approach; surgery for Cushing's disease, dopamine agonists for prolactinomas, somatostatin analogs or surgery for thyrotroph adenomas, surgery and/or somatostatin analogs and/or radiotherapy in acromegaly, surgery with additional irradiation in most adenomas of other types, or even expectation in some instances.

The current management of cervico-cephalic venous malformations.

Venous malformations are often detected at birth and progressively increase in size if not treated. They can have severe aesthetic and functional consequences. Our purpose is to evaluate therapeutic results with Ethibloc. From 1982 to 1994, we have been using Ethibloc injections under fluoroscopic control in a group of 421 patients with malformations in cervicofacial veins. The diagnosis was made on the basis of clinical examinations as well as by using CT and MRI. In addition, 40 patients had a diagnostic angiogram. The therapeutic procedure consisted of direct puncture and opacification of venous the basis of lakes before injection of Ethibloc. Two hundred patients have been analyzed. In 139 patients treated with Ethibloc alone, the venous malformations were reduced significantly in size in 64%, while we obtained good results in 67% of the 61 patients treated with a combined procedure (Ethibloc followed by surgical excision). In those, Ethibloc effectively prevented extensive blood loss during surgery and delineated the malformations. Minor complications occurred such as fever or aseptic superficial abscesses. Ethibloc is safe, has no neurotoxicity, is efficient can be repeated many times and facilitates surgery. It must be used as the therapy of choice in venous malformations.

Spinal epidural haematoma: report of 11 cases and review of the literature.

Spinal epidural haematomas (SEH) are rare; most are caused by trauma, anticoagulant therapy, vascular anomalies, hypertension, blood dyscrasias, epidural anaesthesia or, rarely, spinal surgery. We report 11 cases and review the literature (16 cases). The clinical picture is that of acute spinal cord compression. MRI characteristics are quite specific. On sagittal sections, the SEH appears as a biconvex mass, dorsal to the thecal sac, clearly outlined and with tapering superior and inferior margins. The dura mater is seen as curvilinear low signal separating the haematoma from the cord. Within 24 h of onset, the haematoma is isointense with the cord on T1-weighted images and heterogeneous on T2-weighted images. Later, it gives high signal on both T1- and T2-weighted images. Differential diagnosis must include subdural haematoma, epidural neoplasm and abscess. Complete neurological recovery rapidly follows laminectomy and removal of the clot. In three of our cases, the haematoma resolved spontaneously. MRI is the best examination for diagnostic and follow-up.

Intraforaminal neurinoma in the lumbosacral region.

A series of 12 patients with intraforaminal neurinomas in the lumbosacral space was reviewed. Our classification according to tumor extension relative to the affected root into intradural intra-arachnoid, intraforaminal extra-arachnoid, and extraforaminal types was useful in determining the best surgical approach to achieve root preservation and minimal postoperative deficits. Where sacrifice of roots was unavoidable, surprisingly few neurological deficits occurred.

Phase contrast magnetic resonance of the spinal cord preliminary results in spinal cord arterio-venous malformations.

In spite of the recent advances in neuroradiology including the CT scan and the spin-echo-magnetic resonance (MR), accurate diagnosis of arteriovenous malformations (AVMs) involving the spinal cord is still based on selective angiography. This last procedure is invasive and needs to be repeated during the follow up. Phase contrast angio MR was performed with a 0.5 Tesla unit on 12 patients with an AVM involving the spinal cord (7 intramedullary AVMs, 4 perimedullary fistulas, and 1 dural fistula with perimedullary venous drainage); 4 of these were investigated before and after treatment. Angio MR showed abnormal vascular patterns within the spinal canal in all cases, without distinguishing between arteries and veins; the nidus of the intramedullary AVMs was displayed in all cases. Angio MR provided images of the whole AVMs comparable to the angiographic pictures, in contrast to the spin-echo MR, which provided only discontinued images of the vessels. The efficient range of velocity providing images varied, according to the type of the malformation (slow for dural fistulas, rapid for intra-medullary AVMs). In the 4 patients investigated after treatment, comparison of the images obtained before and after treatment permitted assessment of the degree of occlusion of the malformation. Finally, angio MR as a complement of spin-echo MR can now be used as a reliable tool for detection of spinal cord AVMs, assessing the indication for angiography, and, furthermore, it can probably replace most of the post-operative control angiographies.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

[French language Society of Neurosurgery. 44th Annual Congress. Brussels, 8-12 June 1993. Tumors of the foramen magnum]. / Société de neurochirurgie de langue française. 44e congrès annuel. Bruxelles, 8-12 juin 1993. Pathologie tumorale du foramen magnum.

Since what seems to be the first reported case of foramen magnum (F.M.) tumor by Hallopeau in 1874, literature on tumoral pathology of this region is rather scarce; beside reports of single cases or short series, there are very few large series and most of them are not recent (Meyer et coll., Yasuoka et coll., Guidetti and Spallone). The present report includes 230 cases of extramedullary tumors collected from 21 french departments over the last ten years (series of the French Speaking Society of Neurosurgery = S.N.C.L.F. series). Delimitation of what is called the F.M. region is rarely given in the literature. In this report, the inferior limit is put at the C2 level and the superior one at the ponto-medullary junction and the lower third of the clivus. To belong to the F.M. region, tumor must have its main part or its insertion within these limits even if it extends beyond them. On the contrary, if the gross development is out of these limits but with some extension into the F.M. region, the case is rejected. A chapter of this report deals with the anatomy of the F.M. with emphasis on the points useful for the management of the tumors. Some details are given on the dimensions of the different parts of the F.M. as given by anatomical studies and also by measurements on C.T. scanner and M.R.I. including during flexion and extension of the head. The S.N.C.L.F. series is then analyzed as a whole. It includes 106 meningiomas (M), 49 neurinomas (N), 28 chordomas (Ch), 32 osseous tumors (T.Os) (19 primary and 13 metastasis) and 15 cases considered as uncommon tumors. (T. Part.) (4 melanomas, 3 hemangioblastomas, 3 dermoid or epidermoid cysts, 2 ependymomas, 1 cavernoma, 1 angiomyolipoma and 1 cholesterin cyst). Mean age is 47 years, with a sex ratio F/M of 1.5/1. Duration of symptoms before diagnosis is of 27 months. Topography is classified into 3 groups anterior (70 cases), lateral (142 cases) and posterior (24 cases). A particular definition is given to these localizations, essentially referring to surgical difficulties and specially for meningiomas. The localization of a tumor is defined by the point of attachment to any structure (dura, spinal root, spinal cord); anterior tumors are attached to the F.M. on both sides of the midline; lateral tumors between the midline and the dentate ligament and posterior ones behind the dentate ligament. According to this way of classification, N are always lateral even if they present anterior or posterior extensions.(ABSTRACT TRUNCATED AT 400 WORDS)

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.

MR imaging of head and neck vascular malformations.

Between 1980 and 1990, 150 patients with cervicofacial vascular malformations were studied at the authors' institution with computed tomography, plain radiography, and angiography. Since 1989, 34 of these patients have also undergone magnetic resonance (MR) imaging. Capillary-venous hemangiomas seem to be the best indication for the adjunctive use of MR imaging. The venous pouches, characteristic of this type of lesion, cause elevated signal intensity, well seen on the T2-weighted images. Excellent fat and muscle differentiation with MR imaging allows appreciation of the depth of extension of these lesions and their delimitation from normal tissue. Arteriovenous malformations (AVMs) are characterized by serpentine signal voids, indicative of the high flow rate of these lesions. Delimitation of the AVM nidus in the midst of the afferent and efferent dilated vessels is often difficult. Study of immature angiomas with MR imaging should be restricted to lesions in specific locations (eg, orbital, laryngeal). Lymphatic malformations showed either tissular or cystic signal intensity changes. MR imaging does not replace other studies but represents an important complementary study for the delineation and diagnosis of deep extensions of vascular malformations, allowing better planning of therapy.

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.

MRI in spontaneous dissection of vertebral and carotid arteries. 15 cases studied at 0.5 tesla.

Fifteen patients were observed between 1987 and 1990: there were six with angiographically confirmed vertebral artery dissection, and 9 with carotid artery dissection. Results showed concordance of MRI and angiographic findings, in all cases but one. The dissected portion consistently showed a semilunar hyperintensity narrowing the residual eccentric signal void of the lumen when the artery was not completely occluded. In one angiographically occluded vessel, MR detected a small signal void within the hyperintensity, indicating that the artery was not completely occluded. The length of the dissected portion was clearly demonstrated by MR. Follow up MR and angiographic studies confirmed the regression of the dissection, and also allowed examination of the cerebral parenchyma.

MRI in multiple vascular lesions: identification of the ruptured malformation.

4 patients were recently admitted for subarachnoid haemorrhage with multiple vascular lesions. 3 of them presented with multiple aneurysms, and one with an aneurysm associated with an arteriovenous malformation. In these 4 cases identification of the ruptured lesion was difficult in spite of clinical examination, CT scan, and complete panangiography; on magnetic resonance imaging (MRI) was found a signal hyperintensity, mainly on T2 weighted views, corresponding to blood clots around the ruptured aneurysm. This signal hyperintensity was completely absent in the vicinity of the associated vascular lesion, which appeared only as a signal void corresponding to the blood flow inside the unruptured lesion. Therefore MRI can be used in such cases to identify the ruptured lesion, so permitting the choice of the best approach and strategy of treatment.

[Intraforaminal lumbosacral neurinoma]. / Neurinomes lombo-sacrés intra-foraminaux.

Twelve cases of intra-foraminal localization of lumbosacral neurinoma are reported including 9 schwannomas, 2 neurifibromas and 1 melanotic schannoma. According to their extension, they are classified in type II strictly intra-foraminal and extra-arachnoïdal: N = 6, type I-II, extending into the subarachnoïdal space; N = 5, type II-III, extending out of the spine. There were 7 men and 5 women with mean age of 49.5 years and a 5.2 years delay before diagnosis. The most common, though not permanent, symptom was radiculalgia; a generally weak sensorimotor deficit was noticed in 4 cases and hypoesthesia in two cases. Diagnosis was sometimes doubtful using myelography for the oldest cases, but is now made easily with CT scan and M.R.I. Microsurgery allows to dissect out the tumor inside the perineural sheath and to preserve the nervous root in most cases even in extra-arachnoïdal forms (N = 8). However, in cases of neurofibromas and of large tumors, the root had to be divided (N = 4) with rather surprisingly no new post-operative deficits. Intra-foraminal localization of lombo-sacral neurinomas is rare but now easily identified; it should be cured surgically with the goal, often reached, of maximum preservation of the nervous root.