Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

[Intramedullary tumors. Results of a national investigation in private neurosurgery]. / Les tumeurs intramédullaires. Résultat d'une enquête nationale en neurochirurgie libérale.

UNLABELLED: The frequency of intramedullary tumors is 0.5 cases per year for 100,000 inhabitants. The study reported herein was a retrospective study conducted from January 1985 to September 2007. MATERIAL: Seventy-nine cases were distributed in the following manner: ependymomas, 38; astrocytomas, 22; oligodendrogliomas, four; gangliogliomas, two; hemangioblastomas, 10 (nine sporadic cases and one case of Von Hippel-Lindau disease); primitive melanoma, one; and intramedullary neurinomas, two. Three patients were lost to follow-up and 10 patients died. METHOD: All patients were explored using MRI and were operated using a microsurgical technique. Tumor removal was complete in the cases of ependymoma and hemangioblastoma and subtotal in the cases of astrocytoma. RESULTS: Ependymoma: 38 cases with three cases of ependymoblastoma. Mean age: 47 years (range, 17-74 years); 17 males and 21 females. Diagnostic delay: less than one year, 11; one year, 15 cases; two years, nine cases; three years, three cases. Seven recurrences with one 35 years after a prior removal. Localizations: cervical and cervicodorsal, 19; dorsal, ten; dorsolumbar, seven; holomedullary, one. Number of levels concerned: 5-12 (with the cysts associated). Mean follow-up was 10 years (range, two months to 35 years). Patients stabilized, 19; worse, six; improved, nine. Patients deceased: four, one by suicide, three cases of ependymoblastoma (survival, seven months). Astrocytomas: 22 cases, with 14 cases of astrocytoma, two pilocytic astrocytoma, four malignant astrocytoma, and two glioblastoma. Mean age: 44 years (range, 22-73 years); 14 males and eight females. Diagnostic delay: malignant tumors, one to nine months; low grades; three to six years (range, eight months to 25 years). Number of levels concerned: two to eight. Mean follow-up: seven years (range, six months to 10 years). Stabilized patients: 13; worse, five; deaths, four. Oligodendroglioma: four cases. Mean age: 58 years; two males and two females. Diagnostic delay: 10months. Localization: cervical, three; dorsal, one. Oligodendroglioma A, two; B, two. Results: two cases stabilized, one case with recurrence, and one patient deceased. Ganglioglioma: two. Both cases were associated with scoliosis. Recurrence in the eighth month and two years for the second case. One patient died. Hemangioblastoma: 10 cases, nine sporadic and one case of Von Hippel-Lindau disease. Nine cervical localizations, one on the medulla cone. Mean age: 45 years (range, 11-54 years); eight males and two females. Total removal in nine cases. One case of recurrence seven years after a prior surgery and operated a second time with no recurrence after 10 years of follow-up. Intramedullary neurinomas: two cases with a total removal and 15 years of follow-up. Primitive melanoma: one case with mediothoracic location. Treatment with surgery plus radiotherapy. Follow-up, seven years without recurrence. CONCLUSION: Total removal of the intramedullary tumors is a challenge. In cases of removal, the risk of worsening status is 18-19.5%. Subtotal or incomplete removal 27-40% risk of recurrence.

[Management of malignant gliomas diagnosed during pregnancy]. / Prise en charge des gliomes malins découverts au cours d'une grossesse.

INTRODUCTION: Glioma is seldom diagnosed during pregnancy. In this situation management presents difficult problems for both neuro-oncologists and obstetricians. We report four cases and discuss the management of this unusual situation. CASE REPORT: The first patient was admitted to hospital at 29 weeks' gestation because of a generalized seizure and a right hemiparesis. MRI showed a left fronto-insular lesion. A stereotactic biopsy was obtained and revealed an anaplastic oligodendroglioma. With corticosteroids the patient remained stable until cesarean delivery at 36 weeks. In post-partum additional treatment with chemotherapy was started. The second patient was hospitalized at 26 weeks' gestation because of cranial hypertension, right hemiparesis and aphasia. MRI showed an important left fronto-parietal lesion. Partial resection was performed at 28 weeks. Histology revealed a glioblastoma multiforme. With corticosteroids the patient remained stable until cesarean delivery at 33 weeks. In post-partum additional treatment with radiotherapy and chemotherapy was started. The third patient was admitted to the hospital at 12 weeks' gestation because of cranial hypertension. MRI showed a left frontal lesion. A subtotal resection was done at 13 weeks. Histology revealed a glioblastoma multiforme. Two weeks after surgery the patient's neurological condition worsened and in agreement with the patient a therapeutic abortion was decided. Afterwards additional treatment with radiotherapy and chemotherapy was started. The last patient received combined treatment with radiotherapy and chemotherapy for local recurrence of a mesencephalic high-grade glioma. A posteriori it was discovered that the patient was at 4 months' gestation during this treatment. Cesarean delivery was done at 36 weeks. The child was normal at birth and is still in good health 5 years later. CONCLUSION: The management of gliomas diagnosed during pregnancy should not be different from the standard management of gliomas in young non-pregnant adults. Pregnant women because of their young age can have a long survival. Their pregnancy should not prevent them from receiving the best treatment for their glioma. Treatment will depend upon clinico-radiological presentation, histology, gestational age and the patient's desires. Generally speaking, surgical resection of high-grade gliomas should not be delayed during pregnancy. Progress in anesthesia and neurosurgery have greatly reduced the risks for the foetus. After delivery, if the delay between surgery and delivery is too long it is possible to begin cerebral radiotherapy during pregnancy. After the first trimester of gestation this treatment can be given without any important risks for the child.

[Intracranial cavernoma. Surgical results of 47 cases]. / Cavernomes intracrâniens. Résultats chirurgicaux de 47 cas opérés.

We report the surgical results in a series of 47 patients with cerebral cavernous malformation who had undergone surgery between 1973 and 1994, with a follow up ranging from 12 months to 24 years (mean: 4 years). They were divided in there groups according to their initial clinical presentation: epilepsy (31 cases), hemorrhage (11 cases) and neurological deficit (5 cases). Surgery consisted of cavernoma resection only (11 cases) or its extension to surrounding gliotic tissue (36 cases). Results are satisfactory: no surgical mortality, low morbidity (4 cases), no recurrent hemorrhage, seizures disappearance with anticonvulsant therapy stop (4 cases) or alleviation (20 cases). Only one patient died far from surgery (6 months) consequently to his initial bleeding, while all the others lead a normal active life. The therapeutic management, compared to the literature, pleads in favour of intentionally surgical attitude and gliotic tissue removal as often as reasonably possible.

[Epidermoid cyst of the lateral ventricles]. / Kyste épidermoïde des ventricules latéraux.

A case of epidermoid cyst of the lateral ventricles is reported. The patient presented with a weakness of the left lower limb and neuropsychological disorders. The diagnosis was assessed by CT scan and MRI, and confirmed at the operation. The lesion has been largely removed through a transcallosal approach though incompletely. However the long term follow-up was uneventful. Twenty-nine cases of the literature have been reviewed.

Ventral transdural herniation of the thoracic spinal cord: surgical treatment in four cases and review of literature.

BACKGROUND: A specific cause of progressive Brown-Sequard syndrome has been identified: a ventral herniation of the thoracic spinal cord through the dural sleeve on one side. METHOD: Four female patients who were affected by a progressive Brown Sequard syndrome related to a transdural spinal cord herniation have been investigated and were submitted to surgery and postoperative evaluation. FINDINGS: The MRI scan showed atrophy and forward displacement of the spinal cord on one side and adhesion of the spinal cord to the dura mater. CT myelography demonstrated the disappearance of the premedullar rim at the level of the herniation and the shadow of the extradural herniation. Surgical treatment consisted in the excision of the arachnoid cyst when there was one, section of the dentate ligament, release of the adhesions, detachment of the spinal cord from the hernial orifice, and lastly suture of the dural tear or placement by a patch. Follow-up examination showed motor improvement with persistent sensory deficit in two cases and stabilisation in two cases. INTERPRETATION: The cause of the dural tear, either traumatic or congenital could not be confirmed in the four cases. Symptoms probably occur when herniation fills the orifice and strangulation happens which explains the late appearance and progressive evolution of this myelopathy. Mobilisation of the herniated spinal cord back into the intradural space can be achieved by surgery and may stop the evolution of the symptoms and signs.