Cerebral phaeohyphomycosis due to Cladophialophora bantiana in a French Guianese child.

We report a case of cerebral phaeohyphomycosis, a fungal brain infection due to a dark (dematiaceous) fungi in a 6-year-old French Guyanese boy. The child presented fever and drowsiness due to several paraventricular brain abscesses. Neurological surgeries were performed to reduce intracranial hypertension and to obtain abscess biopsies. Mycological cultures of intraoperative samples led to the diagnosis of cerebral phaeohyphomycosis due to Cladophialophora bantiana. The patient neurological status deteriorated and remained critical after several weeks of combination antifungal therapy with voriconazole 8mg/kg/day, liposomal amphotericin B 10mg/kg/day and flucytosine 200mg/kg/day. A complete surgical resection was not possible because of multiple small abscesses. A multidisciplinary ethical staff decided on home medical care with palliative ventriculoperitoneal shunt, nasogastric feeding and analgesics. One year later, the patient's neurological condition had improved and cerebral lesions had regressed, while he had not received any antifungal treatment but only traditional medicines. Cerebral phaeohyphomycosis are rare diseases affecting immunocompromised but also apparently non-immunocompromised patients, as in this case. A complete surgical resection is not always possible and mortality rates are high in spite of treatments with a combination of antifungals. The diagnosis may be difficult because of these dematiaceous fungi's slowly growing and their potential pathogenicity for laboratory staff.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns.

OBJECTIVE: Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines. METHODS: Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors. RESULTS: In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks. CONCLUSION: This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Anterior screw fixation of type IIB odontoid fractures in octogenarians.

PURPOSE: Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians. METHODS: Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability. RESULTS: There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients. CONCLUSIONS: Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.

Spontaneous regression of a symptomatic atlanto-occipital joint cyst. Case report.

Synovial cysts (SCs) are well-recognized entities occurring at various spinal sites, although atlanto-occipital joint cyst is a rare occurrence. Similarly both hypoglossal nerve palsy (as an initial clinical onset) and spontaneous cervical cyst resolution are rare. In this report, the authors describe an atlanto-occipital SC revealed by hypoglossal nerve palsy in a 75-year-old woman. Due to the paucity of neurological signs and the patient's advanced age, she was managed conservatively; 8 months later the cyst resolved completely. We discuss the potential factors involved in the pathogenesis and the therapeutic options for this uncommon cervical entity. We advise conservative treatment as a first therapeutic option for SC without signs of spinal cord compression.

Brown-Sequard syndrome revealing intradural thoracic disc herniation.

Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5-24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5-T6 and T9-T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients' condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.

[Adams-Oliver syndrome: a case with minimal expression]. / Syndrome d'Adams-Oliver : à propos d'un cas d'expression minime.

Adams-Oliver syndrome is a rare congenital anomaly characterized by aplasia cutis congenita (ACC) and variable degrees of terminal transverse limb defects. We report on a neonatal case with the sporadic form of the disease with minimal expression, illustrating the wide spectrum of clinical expression in Adams-Oliver syndrome. We also review the literature and highlight the different pathogenetic hypotheses of this syndrome.

[Subcutaneous metastasis at the operative route of an atypical meningioma of the tentorium. Case report and literature review]. / Métastase sous-cutanée au niveau de la voie d'abord d'un méningiome atypique de la tente du cervelet Cas clinique et revue de la littérature.

Metastatic spreading is a rare complication of meningioma. We report a subcutaneous metastasis from an atypical meningioma of the tentorium. A 69-year-old man presented with a meningioma of the tentorium. The tumor was totally resected. The histological diagnosis was atypical meningioma. The tumor recurred two years later and was irradiated. Despite irradiation, the tumor progressed and was resected three years later. Five months following the second surgery, an isolated subcutaneous mass developed at the skin incision and was resected. The histological examination of the subcutaneous tumor showed histological features of atypical meningioma. Surgery of atypical meningioma carries the risk of iatrogenic metastasis, despite previous irradiation.

Transtemporal-transchoroidal approach and its transamygdala extension to the posterior chiasmatic cistern and diencephalo-mesencephalic lesions.

The aim of this report is to illustrate the successful surgical management of five patients with suprasellar retrochiasmatic and diencephalo-mesencephalic tumours, using a trans-amygdala extension of the trans-temporal/trans-choroidal fissure approach. The procedure is described for five surgically treated patients with such lesions that includes three retrochiasmatic craniopharyngiomas, one hypothalamic hamartoma, and one pilocytic astrocytoma in the left crus cerebri. The management procedure included computed tomography scan (CT scan) and magnetic resonance imaging (MRI). The trans-temporal/trans-choroidal fissure approach enabled us to perform total tumour resection in four patients and a subtotal resection in one. Some technical aspects and pitfalls of the procedure are discussed. This method creates optimum conditions for a radical excision of various suprasellar retrochiasmatic and diencephalo-mesencephalic tumours without mortality and only minimum morbidity. However, no single surgical approach can provide access to the entire variety of tumours located in the suprasellar retrochiasmatic and diencephalo-mesencepalic region. Surgical approaches must be tailored to the site, type of lesion, and its extensions. This method is only another surgical option. Its successful use requires a familiarity with the anatomy of these regions and an understanding of its specificity for a radical excision of some selected tumours, as well as its limitations to access others types of lesions. Although, it seems effective, this approach needs to be evaluated by further experience, owing to the small number of patients reported in this series.

Acute presentation of hydromyelia in a child.

The authors document a rapid development, within 3 weeks, of hydromyelia in a 12 year-old boy. The boy was admitted to a local hospital because of drowsiness and persistent severe neck pain. Neurological examination disclosed a lethargic boy with no neurological deficit other than Parinaud's sign. During his transfer to our department, he presented a cardio-respiratory arrest with coma and bilateral mydriasis. External ventricular drain and craniocervical decompression achieved excellent clinical and neuroradiological outcomes. The development of hydromyelia in this case is caused by obstruction to the natural cerebrospinal fluid pathway at the craniocervical junction and the cardio-respiratory arrest is provoked by a brain stem compression against the clivus and odontoid process. This report illustrates that hydromyelia may complicate acute obstructive hydrocephalus due to acquired Chiari malformation.

Intraneural ganglion cyst of the tibial nerve.

Intraneural ganglion cyst of the tibial nerve is very rare. To date, only 5 cases of this entity in the popliteal fossa have been reported. We report a new case and review the previously reported cases. A 40-year-old man experienced a mild vague pain in the medial half of his right foot for 3 years. Magnetic resonance imaging scan demonstrated a soft-tissue mass along the right tibial nerve. At surgery, an intraneural ganglion cyst was evacuated. After 12 months, the patient was pain-free with no signs of recurrence. Trauma might be a contributing factor to the development of intraneural ganglion cysts. Application of microsurgical techniques is encouraged.

Intracranial epidural haematomas in elderly patients: observations in 14 patients.

BACKGROUND: Up to now, extra-dural haematomas (EDH) in elderly patients have been known for their poor prognosis and few studies have focused on the particularity of EDH in the elderly. Most clinical studies relating to EDH have generally focused on its occurrence in children and the middle-aged, grouping people of over 50 and 60 years together as the elderly. The purpose of this paper is to present a series of EDH cases in the elderly. METHOD: 500 EDH patients (of all ages) were admitted to our Department from January 1990 to December 2003 and this is a retrospective study of 14 of those patients who were aged 70 years and over. FINDINGS: The study consists of 8 women and 6 men with an average age of 74 years. A high incidence of disease predisposes elderly to falls, which are the most frequent cause of head trauma. The elderly are less likely to manifest signs or symptoms of increased intracranial pressure due to cerebral atrophy, and almost all haematomas occurred in the parietal area. Post-operative results were satisfactory and only one death was recorded. CONCLUSION: This study shows that the elderly, presenting EDH after a fall, have a better prognosis than is often feared.

MR imaging features of idiopathic thoracic spinal cord herniations using combined 3D-fiesta and 2D-PC Cine techniques.

Idiopathic thoracic spinal cord herniation (TISCH) is a rare cause of surgically treatable progressive myelopathy. The authors report 3 cases of TISCH diagnosed based on conventional T1- and T2-weighted Spin-Echo (SE) MR images in one case, and T1- and T2-weighted SE images combined with 3D-FIESTA (Fast Imaging Employing Steady state Acquisition) and 2D-Phase-Contrast Cine MR imaging in 2 cases. Conventional MRI findings usually provided the diagnosis. 3D-FIESTA images confirmed it, showing the herniated cord in the ventral epidural space. Moreover, in combination with 2D-Phase Contrast cine technique, it was a sensitive method to for the detection of associated pre- or postoperative cerebrospinal fluid spaces abnormalities.

[Persistent primitive trigeminal artery associated with brain cavernoma. Case report]. / Artère trigéminale associée à un cavernome cérébral.

Among cases of embryonic carotid-basilar anastomosis which may persist after birth, persistent trigeminal artery is the most common. It has been associated with a wide variety of intracranial abnormalities. We are unaware of any other reported association with cavernoma. We report a young woman who experienced seizures following spontaneous abortion. A CT scan disclosed a right frontal hematoma. MRI revealed a cavernoma associated with a persistent trigeminal artery. The cavernoma was removed through a frontal approach. The aim of the present case is to report another type of lesion fortuitously associated with a persistent trigeminal artery.

Huge colloid cyst: case report and review of unusual forms.

The authors report a case of a huge colloid cyst of the septum pellucidum with acute worsening. A 42-year-old man was admitted for unexplained lethargy. A brain CT scan disclosed a huge intra-ventricular lesion. He experienced a sudden deterioration with coma, and was managed with bilateral ventricular external shunting. Total removal was performed a few days later using a right frontal trans-ventricular approach. The discussion focuses on colloid cyst potential to mimic other intracranial lesions, rendering accurate diagnosis difficult and leading to possibly inappropriate management in similar cases.

Anterior screw fixation of odontoid fractures.

BACKGROUND: Anterior screw fixation is the best treatment for odontoid fractures when the fracture line is horizontal or oblique downward and backward, as it preserves atlantoaxial mobility, especially axial rotation. Some details regarding patient positioning and operative technique need to be stressed to obtain the best results and avoid complications. METHODS: Between 1989 and 1997, we treated 17 cases of odontoid fracture by anterior screw fixation. Only two patients presented with motor neurologic deficit. Fracture line was horizontal in 3 cases and oblique downward and backward in 14 cases. RESULTS: Adequate reduction and fixation was obtained in all cases except one, where posterior displacement of the screw occurred without neurologic complications. Functional result was satisfactory in all cases except two, where we noted significant limitation of cervical rotation. CONCLUSION: Successful anterior screw fixation gives the best anatomical and functional results for odontoid fractures. Correct installation is very important for operative success.