[Etiologic spectrum of intracerebral hemorrhage in young patients]. / Hématome intracérébral spontané du sujet jeune. Etiologies et rapports avec l'hypertension artérielle

INTRODUCTION: Hemorrhagic stroke is uncommon in young patients. The etiologic spectrum is very wide in the literature. The purpose of this study was to determine the range of etiology in a group of patients completely investigated and to study the relation with a history of high blood pressure. PATIENTS AND METHODS: We reviewed study database, clinical and diagnostic records of 130 patients identified in a population based study, aged 18 to 55 years presenting with hemorrhagic stroke. There were divided into two groups: 67 patients treated at Hotel-Dieu Hospital in Beirut, Lebanon, and 63 patients reviewed at Yale New Haven Hospital, Connecticut, USA. Patients presenting with selective subarachnoidal or intraventricular hemorrhage were excluded. Diagnostic evaluation was assessed for completeness (based on prospectively articulated evidence based criteria) and for identifiable etiology of hemorrhagic stroke and its relation to high blood pressure. RESULTS: There were 84 cases (64%) with complete diagnostic workup. The most common cause of incomplete investigations in remaining cases was death, poor neurological condition and incomplete follow up. Hematoma was superficially located (lobar) in 59.2%, deep seated (thalamo-capsulo-lenticular) in 26%, within the brain stem in 8.7% and cerebellar in 6.1%. An etiology was established in 70.4% of cases (pial AVM 16.7%, aneurysms 15.5%, hematological disorders 13%, cavernous malformations 10.7%, tumors 4.8%, bleeding within ischemic area 3.8%, vasculitis 2.3%, venous thrombosis 1.2% and venous angioma 1.2%. 29.6% of patients remained with undetermined etiology despite complete investigations. In a subgroup of 45 patients, a history of high blood pressure was found in 46.7%. In this cohort, an underlying etiology was established in 71% of cases. CONCLUSION: Complete investigation can establish an etiology in 70% of young patients who survived hemorrhagic stroke, independently from the presence of a history of high blood pressure.

Spontaneous disappearance of vein of galen malformation and posterior fossa venous pouch.

Cerebrovascular anomalies remain an issue of controversy regarding diagnosis, classification, and treatment. We report the first case of total and asymptomatic regression and disappearance of a vein of Galen malformation associated with a posterior fossa venous pouch. Different aspects of the vein of Galen are discussed together with emphasis on the underlying mechanisms of spontaneous thrombosis and regression.A 4-month-old boy presented with macrocrania and signs of intracranial hypertension. Computerized tomography disclosed two masses, the first was a giant aneurysmal dilatation in the posterior fossa, and the second was a gigantic pouch at the level of the vein of Galen. Hydrocephalus was treated by ventriculo-peritoneal shunting. Two months later, the shunt was revised, and posterior fossa was explored without active treatment. Both abnormalities regressed spontaneously. No recurrence occurred, and the child remained neurologically intact. Total disappearance of the masses as well as normal brain and cerebrovascular anatomy were confirmed by angiography, MRI, and MRA. Over a follow-up period of 17 years, the patient did not develop complications. He had perfect clinical tolerance and resumed a normal life.

[Temporary occlusion in surgical management of intracranial aneurysm. Report of 54 cases]. / Le clampage temporaire réglé dans la chirurgie anévrismale intracrânienne. A propos de 54 cas.

Temporary arterial occlusion (TAO) is commonly used in the surgery of intracranial giant aneurysms. Its usefulness and safety in the surgical management of all cases of aneurysms remains to be proved. We report a series of 54 patients operated on for an intracranial aneurysm with the use of TAO. Among the 27 patients, admitted before the 4th day following post subarachnoid hemorrhage with I or II on WFNS score clinically, 24 had early aneurysm surgery. The size of the aneurysm was small in 16 cases, medium in 22, large in 13 and giant in 3 cases. The protocol proposed by Batjer in 1988 for large and giant aneurysms (etomidate, normotention and hypervolemia) was used without any electrophysiological monitoring. All patients underwent a post-operative cerebral CT scan to evaluate the incidence of a cerebral ischemia. Serial transcranial doppler was used to evaluate the severity of vasospasm. Clinical results were assessed using the GOS. TAO was elective in 51 patients and done after peroperative aneurysm rupture in 3 patients. The duration of TAO was less than 5 mn in 25 patients, between 5 and 10 min in 12, between 10 and 15 in 11, between 15 and 20 in 5 and more than 20 min in one patient. The last one developed a reversible neurological deficit secondary to ischemia attribuated to TAO. Intracranial aneurysm peroperative rupture was noted in 3 patients, clinical vasospam in 13 patients. These results allow us to recommend the routine use of TAO in the surgery of intracranial aneurysm. When application time is limited and cerebral protection used, TAO is safe. It decreases the risk of intraoperative rupture from a 18% rate in literature to 4.2% in our present experience and the risk of symptomatic vasospasm is not increased.

[Extrapontine myelinolysis: treatment with TRH]. / Myélinolyse extra-pontine: traitement par T.R.H.

Central pontine and extra-pontine myelinolysis are a well known complication of hyponatremia. Other causes may be present. We report a case of head injury in a 13 year-old girl, who recovered well after surgery for extra-dural hematoma, but presented endocrinological disorders with hyperglycemia followed by a severe hyponatremia. Despite the correction of these metabolic disorders, the patient became comatose, and MRI, on T2 weighted image, showed hyperintense signals in the basal ganglia consistent with extra-pontine myelinolysis. The patient's state remained unchanged for six weeks. Since S. Konno and H. Wakui published cases of myelinolysis who dramatically improved after TRH treatment, the patient was given 0.6 mg i.v daily of TRH for six weeks. Improvement began within a few days, and continued until complete recovery.

[Intracranial arterial aneurysm: from diagnosis to treatment. A retrospective study of 46 surgically treated cases]. / L'anévrisme artériel intracrânien: du diagnostic au traitement. Etude rétrospective de 46 cas opérés.

The authors report a series of 46 patients operated for an intracranial aneurysm from January 92 to January 96 in Hôtel-Dieu de France. There were 28 males and 18 females ranging from 22 to 69 years. Forty-four patients presented a typical clinical pattern of subarachnoid haemorrhage. In 20 cases (45%), correct diagnosis was not made at the time of bleeding but at another outpatient visit or at a bleeding recurrence. Cerebral angiography was performed in all our patients. The most frequent aneurysmal location was at the anterior communicating artery (n = 20). Surgical total exclusion of the aneurysm was possible in 45 patients. Forty-one patients had a favourable outcome but three presented important neurological sequelae. We encountered 2 postoperative deaths due to irreversible arterial vasospasm. These results suggest that the preoperative neurological state and the occurrence of an arterial vasospasm are the main prognostic factors of the intracranial aneurysm. Early diagnosis and treatment allow to avoid rebleeding, mostly responsible of the poor neurological status, and to better manage the arterial vasospasm in order to improve the outcome.

["Mirror" intracavernous aneurysms. Therapeutic dilemma apropos of a case with review of the literature]. / Anévrismes intra-caverneux "en miroir". Dilemme thérapeutique à propos d'un cas avec revue de la littérature.

"Mirror" cavernous aneurysms are exceptional; only 66 such cases having been published until mid-1996. We report on a 68-year-old woman who presented for left exophthalmos, diplopia and neuralgia. MR and angiography demonstrated a giant symptomatic aneurysm on the left side and an incidental small one on the right side. The patient was treated in two sessions: first, she had selective embolization of her right aneurysm; two weeks later, her left carotid artery was sacrificed with detachable balloons, after a well-tolerated occlusion test. This original and successful approach permitted to achieve a reasonable goal when considering the patient's age, operative morbidity, risk of future complications and final result. A review of the pathophysiology, clinical manifestations and therapeutic indications is presented and discussed.

[Cerebral metastasis disclosing osteosarcoma. Apropos of a case]. / Métastase cérébrale révélatrice d'un ostéosarcome. A propos d'un cas.

Brain metastasis from osteosarcoma is a rare entity. Almost 20 cases have been reported in the literature. We report an illustrative case of a 15 years old boy presenting with isolated brain metastase revealing a fibular osteosarcoma. Diagnostic methods and treatment modalities are discussed.

[Thermocoagulation in the treatment of facial neuralgia. Preliminary results in 22 cases]. / La thermocoagulation dans le traitement de la névralgie faciale. Résultats préliminaires de 22 cas.

Twenty-two patients suffering from trigeminal neuralgia were treated by thermocoagulation from June 92 to June 94 at Hôtel-Dieu de France Hospital. Epidemiological, clinical, para-clinical elements and the therapeutic approach were studied. The results after a median follow-up of one year were satisfactory in twenty patients (90.9%) who became asymptomatic. No major complication was noticed. Two recurrences occurred however, one responded to another thermolesion. We propose and discuss this technic for the treatment of the trigeminal neuralgia.

[Critical study of 200 surgically treated lumbar disk hernias]. / Etude critique de 200 hernies discales lombaires opérées.

The authors reviewed 200 cases of operated lumbar disk hernias. Hernias of the L4-L5 disk were twice as frequent as those of the L5-S1 disk. When clinical examination revealed simultaneous involvement of the L5 and S1 nerve roots, the L4-L5 disk was more frequently responsible (75%). Clinical examination alone was not sufficient to localize the level of the disk hernia and CT scan used for this purpose had a sensitivity of 93.2%. In 20% of cases, the CT scan demonstrated a second asymptomatic lesion. The results of surgical treatment were assessed as 83% good and very good results and 50% complete cures. The authors propose the following recommendations: Look for involvement of the L5 and S1 nerve roots which is suggestive of an L4-L5 hernia; only operate after radiological demonstration of the level of the herniated disk; do not operate on asymptomatic lesions detected by CT scan.

[Ossification of the posterior longitudinal ligament of the lumbar spine]. / A propos de l'ossification du ligament longitudinal postérieur du rachis lombaire.

The authors present five cases (4 men, 1 women) of ossification of the posterior lumbar longitudinal ligament. The mean age is 61 years. They emphasize the extreme rarity of this location, its association with ankylosing spinal hyperostosis and diabetes in three patients; they also give a reminder of the characteristics of this radiological symptom. They discuss the etiology on the basis of three hypotheses (disc deterioration, hyperostosis, disease described by Japanese authors).

[Compression of the common peroneal nerve by a synovial cyst]. / Compression du nerf sciatique poplité externe par un kyste synovial.

The authors report a successfully treated case of compression of the peroneal nerve by a simple (extraneural) ganglion. A brief review of the pathogenesis of intraneural and extraneural ganglions is exposed. The authors emphasize on considering this diagnosis in every patient who is complaining of pain or paralysis in the territory of the peroneal nerve. The treatment is always surgical. Prognosis depends on early diagnosis, non mutilating surgery for the nerve and ligation of an eventual stalk joining the ganglion to the articulation.

[Hypophyseal tuberculosis. A case report]. / Tuberculose hypophysaire. A propos d'un cas.

The authors present a case of hypophyseal tuberculosis. It is the case of a patient with abnormal sella turcica, erosion of sella and hypopituitarism. At intervention, they ascertain a lesion of sphenoïdal sinus with the lesion of hypophysis. The authors made the review of literature and ascertain the singularity of the both lesion. Generally, the tuberculosis of adenohypophysis is associated with tuberculosis meningitis. They think that it is an extension of sinusal lesion.