Superficial Temporal Artery-Middle Cerebral Artery Bypass Combined with Internal Carotid Ligation in Treating Complex Internal Carotid Aneurysms. The Willis Polygon Score is an Effective Solution for Developing Countries.

OBJECTIVE: Internal carotid complex aneurysms (ICCAs) management is challenging. Ligating the internal carotid artery (ICA) combined with Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) anastomosis is an effective treatment option. Balloon test occlusion (BTO) assessments for preoperative decision-making are unaffordable in developing countries. This article discusses the study of Willis polygon (WP) segments as an option and suggests a score for decision-making. Herein, we report the outcomes of a series of patients treated for ICCA aneurysms at a single institution. METHODS: From September 2016 to December 2020, we conducted a retrospective cohort study that analyzed data from patients with ICCAs. Among them, 9 patients received treatment involving ICA ligation combined with STA-MCA anastomosis. Partial or total carotid ligation was determined by using the WP score (WPS). RESULTS: All Patients underwent STA-MCA anastomosis, in addition to total ICA ligation in 7 patients and partial ICA ligation in 2 patients with a WPS of 7 and 5, respectively. Patients with partially ligated carotid arteries were referred to an overseas neurointerventional center 12 months after surgery. As the BTO test was negative, they underwent ICA occlusion by coiling. Postoperative clinical outcomes did not change in 8/9 patients. In 1 patient, we reported a minor parietal stroke; the patient recovered completely after 6 months. Total aneurysm exclusion by thrombosis was achieved in 7/9 patients after total ICA ligation alone and in 2/9 patients after partial ICA ligation combined with coiling. CONCLUSIONS: Limited access to endovascular assessment techniques such as BTO poses challenges in managing ICCAs. The WPS for decision-making appears to be a simple and safe option. In addition to STA-MCA bypass surgery, total or partial ICA ligation may be proposed depending on the WPS. After 12 months, patients with low WPS who underwent partial ICA ligation combined with bypass had postoperative normal BTO.

Surgical management of os odontoideum: An Algerian center experience.

Background: Os odontoideum (OO) is a craniovertebral junction malformation of unknown origin. In most times, this lesion is highly unstable demanding surgical management. We present our series of OO surgical management and we discuss clinical, radiological, and management aspects of this pathology via our experience and literature opinions. Methods: This is a retrospective study of patients operated on at our department between May 2014 and May 2021 for OO. All patients were explored with plane X-rays and computed tomography (CT). In some cases, magnetic resonance imaging (MRI) was necessary. Posterior C1-C2 or C1-C3 fixation with polyaxial screws and rod fixation was used. In postoperative, the patient is asked to put Philadelphia collar for 3 months. Hospitalization periods vary between 3 and 7 days. After discharge, all our patients are followed up regularly in consultation. Control radiographs of the occipito cervical region were performed. After 3 months postoperatively, the CT scan is performed on all our patients to assess the quality of fusion. Patient's follow-up ranges from 4 months to 6 years. Results: Fifteen patients were included in this study; nine males (60%) and six females (40%); with mean age of 32.5 years old. Ten patients (67%) presented motor weakness, three patients (20%) with neck pain, one patient (6.5%) with torticollis, and one patient (6.5%) presented vertigo. No notable cervical trauma was present in six patients (40%) and in nine patients (60%), a remote history of traumatism was noted. All cases of our series presented mobile OO. Normal thickness of the C2 pedicle was noted in nine patients (60%). In two patients (13%), there was hypoplasia of one pedicle and in four patients (27%) both pedicles. MRI showed direct signs of spinal cord aggression: simple compression, myelomalacia, strangulation, or hypotrophy. C1 lateral mass screw fixation was performed in all patients; and according to C2 morphology: nine patients underwent C1-C2 pedicular fixation, in one patient, bilateral crossing C2 laminar screws technique, in three patients, we skipped C2 to perform a C1-C3 articular fixation, and in two patients, C1-C2-C3 fixations were performed. All patients improved clinically. In one patient, we noted an infection resulting in bad wound healing this infection was successfully treated with no complications. In the patient with bilateral crossing C2 laminar screws technique, CT control objectified 4 mm exceeding of one screw; the patient was reoperated and the screw was slightly pulled back. No other complications were noted. Conclusion: Congenital origin of OO is always evoked. C1-C2 fixation according to Goel and Harms technique with grafting proved its safety, providing high fixation quality with the acceptable biodynamic outcome. Once treated, the prognostic of OO is in general good, and improvement is observed in most patients with few complications.

Traumatic cervical spine spondyloptosis: A systematic review.

Background: Spondyloptosis is a rare presentation of cervical spine traumatism where listhesis is more than 100%. Traumatic cervical spine spondyloptosis (TCS) is one of the least discussed forms of cervical spine traumatisms because of its rarity and the gravity of patient's condition, limiting good management, and the number of reported cases. Objectives: This study aimed to discuss clinical, radiological, and best management tools of the aforementioned pathology. Materials and Methods: Scopus, ScienceDirect, PubMed, and Google Scholar databases were searched for English articles about traumatic cervical spondyloptosis. Titles, abstracts, or author-specified keywords that contain the words "spondyloptosis" AND "cervical" AND "spine" were identified. There were no time limits. In sum, 542 records were identified, 63 records were screened, and 46 records were included in this review, describing 64 clinical cases of traumatic cervical spondyloptosis. The clinical cases of two patients managed at our department are also presented and included. In the end, 66 cases were included in this study. Demographics, clinics, radiology, management tools, and outcome of the reviewed cases were discussed. This study was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009. The American Spinal Injury Association Impairment Scale (AIS) score was used to evaluate the clinical presentations. Results: This review included 66 patients consisting of 46 males (70%) and 20 females (30%), with a mean age of 41 years. The accident was indicated in 62 cases; it was a road traffic accident in 29 cases (46%), a fall in 24 cases (38%), and motor vehicle accident in 15 cases (24%). The lesion was iatrogenic in four patients. Twenty-one patients were received without motor or sensitive deficit and so scored Grade E on AIS, 10 with Grade D, 11 Grade C, four Grade B, and 20 with Grade A. On imaging, spondyloptosis involved the C1-C2 segment in two cases (3%), C2-C3 in three cases (5.5%), C3-C4 in one case (1.5%), C4-C5 in six cases (9%), C5-C6 in nine cases (13%), C6-C7 in 20 cases (30%), and C7-T1 in 26 cases (38%). In all cases, there was either fracture or dislocation in posterior elements. Bilateral pedicles or facet joint fractures were noted in 53% of the 56 patients where the associated lesions were described, but it jumps to 89% when a vertebra is projected in front of another. In two cases, there was no mention of closed reduction via transcranial traction; in 13 cases (20%), it was avoided for a reason (child, patient's refusal,…). In the 51 cases where the traction was clearly applied, 17 cases (33%) were reduced totally; in 13 cases (25%) the reduction was partial; it failed in 19 cases (37%); and in the remaining cases, the result was not clear. Traction weight varied from 4 kg to 27.2 kg, applied from 6 h to 20 days. Where total reduction was achieved, an average weight of 11.9 kg with proximal average time of 6 days was needed, whereas an average of 11.5 kg was needed for partial reduction with proximal average time of 10 days. 62 patients were operated rather in one or two times. Anterior approach was used in 20 patients (32%), a posterior approach in 14 patients (23%), and combined anterior/posterior approaches in 28 patients (45%). In four patients, the outcome was not available; in the remaining 62 cases, an improvement of an initial deficit was noted in 25 patients (40%), conservation of an initial motor force integrity was noted in 19 patients (30%), and nine patients (14.5%) kept the same initial deficit. Few complications were declared: dura tears with cerebrospinal fluid leaks, meningitis, esophageal laceration, and vocal cord paralysis. There was a mortality of 11% (seven cases). Conclusion: Traumatic cervical spine spondyloptosis predominates in the lowest levels of the cervical spine, allowed in all cases by a failure in posterior elements. It is a lesion with the worst clinical presentation. Traumatic cervical spine spondyloptosis is highly instable, imposing urgent reduction followed by surgical stabilization. At the limit of the reviewed cases, outcome is in general good, but mortality is still important.

Sarcoidosis of the pineal region, dorsal mesencephalon, and periaqueductal region: Case report and systematic review.

BACKGROUND: The central nervous system is an unusual location of sarcoidosis, which commonly affects the cranial nerves, meninges, hypothalamus, and pituitary gland. Involvement of the pineal region is extremely rare. This systematic review focused on the diagnosis and management of pineal region sarcoidosis, dorsal mesencephalon, and periaqueductal region. OBJECTIVES: This study aimed to discuss diagnostic modalities and best management tools of the aforementioned pathology. METHODS: ScienceDirect, PubMed, and Google Scholar databases were searched for English or French articles about sarcoidosis of the pineal region, dorsal mesencephalon, and periaqueductal region. The clinical case of a patient managed at our department that we believe is directly relevant to this review is also presented. Patients' demographics, clinical presentations, presence of hydrocephalus, other sarcoidosis locations in the central nervous system, and medical treatment were collected. Surgical management, surgical approach, and outcomes and complications of each procedure were also obtained. This study was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: Fifteen cases were examined. The study sample consisted of nine (60%) male and six (40%) female, and the mean age was 32 years. Eight (53%) patients had hydrocephalus, and the predominant clinical presentations were signs of increasing intracranial pressure (headaches, vomiting, and papilledema). Six (40%) patients had diplopia, and convergence-retraction nystagmus was noted in three (20%) patients. Argyll Robertson sign was present in one patient and suspected in another patient (13%). Medical treatment consisted mainly of steroids (93% of cases). Open surgery on the pineal region was performed in five patients, and four of them reported to have serious complications (such as ophthalmoplegia, hemianopsia, hemiparesis, bilateral third cranial nerve paresis, and cerebellar syndrome). Endoscopic management was performed in two patients without complications. CONCLUSION: To treat hydrocephalus, brain imaging is mandatory in patients with sarcoidosis if intracranial hypertension is suspected. In pineal region sarcoidosis, management of hydrocephalus is the priority, followed by medical treatment of the lesion. Open surgery of any approach presents a high risk of complications; thus, an endoscopic approach is the preferred management, as it treats hydrocephalus and makes biopsy possible with minimal risk.

A rare case of orbital tuberculosis with cold abscess and frontal bone lesion.

Tuberculosis is a multisystem infectious disease caused by Mycobacterium tuberculosis and a leading infectious cause of morbidity and mortality worldwide. Orbital tuberculosis is a rare form of extra pulmonary tuberculosis, even in endemic areas. It may involve the soft tissue, lacrymal gland, periosteum, or bones of the orbital wall and can extend to adjacent paranasal sinuses or intracranial cavities. The delay in diagnosis can be due to the fact that the clinical signs simulate any inflammatory disease. The diagnosis is usually based on tissue examination in histopathological evidence presenting as granulomatous lesion or presence of acid fast bacilli (AFB). The long term anti tuberculosis therapy is the effective treatment. Here we present the case of orbital tuberculosis on a young man operated in our department and who had a good outcome under anti tuberculosis drugs for 12 months.

Supra- and infra-tentorial subacute extradural hematoma.

Extradural hematoma (EDH) is a rare but serious complication of brain injury. The supra- and infra-tentorial EDH is even rarer and only a few articles focusing on this topic have been published. The clinical manifestations are nonspecific but early diagnosis of supra- and infra-tentorial EDH and prompt treatment are mandatory to avoid complications. We report this case of a supra- and infra-tentorial subacute EDH on a 4 years old child.