[Adult supratentorial oligodendrogliomas. Surgical treatment: indications and techniques]. / Oligodendrogliomes supratentoriels de l'adulte. Traitement chirurgical: indications et techniques.

Surgical resection is the first step in the treatment of adult supratentorial oligodendrogliomas (OLG). However, the role of resection on prognosis, the most appropriate time for surgery along the natural history of those tumors, and the best operative strategy remain debated. Survival curves after resection vary greatly among reported series, in particular as a result of a persisting confusion in identification and classification of cerebral OLG. Surgical or stereotactic biopsy is the first surgical procedure which enables confirmation of the diagnosis suggested on imaging, assessment of extension of tumor cell infiltration beyond abnormalities limit described an imaging, and currently available molecular biology studies. Biopsies may be the only surgical procedure in patients having a deep-seated tumor with minimal mass effect, or prior to a surgical resection or a "wait and watch" strategy. Surgical resection is indicated for the other patients. However, it has not been demonstrated that time for resection has an influence on survival, excepted in patients with rapidly growing tumors, with mass effect causing increased intracranial pressure. A wait and watch strategy is therefore warranted in patients with a tumor aspect suggestive of a grade A OLG; surgical resection may be indicated later. There is a current trend for maximal safe resection, preserving functional cerebral areas, since truly complete resection of the tumor including infiltration is exceptional. However, from the contradictory results reported to date, one cannot ascertain whether large or complete resection based on imaging is associated with significantly longer survival. Neuronavigation guidance, intraoperative imaging, and cortical stimulation techniques are helpful neurosurgical techniques enabling maximal safe resection with preservation of functional areas.

[Results of the Sainte-Anne - Lyons series of 318 oligodendroglioma in adults]. / Résultats de la série Sainte-Anne - Lyon de 318 oligodendrogliomes intracrâniens de l'adulte.

INTRODUCTION: Incidence of cerebral oligodendrogliomas is increasing because of better recognition made possible by improved classifications. We studied a homogeneous series using the Sainte-Anne grading scale in order to better understanding the history of these tumors with or without treatment and to assess prognosis and associated factors. PATIENTS AND METHODS: A retrospective series of 318 adult patients with oligodendroglioma (OLG) treated at Hôpital Sainte-Anne, Paris (SA) and Hôpital Neurologique, Lyons (L) between 1984 and 2003 was analyzed: 182 grade A OLG (SA + L), 136 grade B among which a homogenous series of 98 (SA) were included. For grade A: age at diagnosis ranged from 21 to 70 (mean: 41), sex ratio was 1.28. For grade B: age at diagnosis ranged from 12 to 75 (mean: 45.5), sex-ratio was 1.58. The main first symptoms were: epilepsy (A: 91.5%; B: 76%), intracranial hypertension (A: 7.9%; B: 14.6%), neurological deficit (A: 5.1%; B: 17.7%). The most frequent locations were: frontal, insular and central for both A and B. Mean size was 55 mm for grade A, 62 mm for B. Calcifications were found in 20% of A, 48.5% of B. No tumor was enhanced on imaging (CT/MRI) in grade A, all but 7 in grade B. All patients underwent surgery either for biopsy (A: 47.2%; B: 53%), or removal which was partial (A: 26.4% vs B: 19.4%) or extended (A: 36.3% vs B: 37.8%). Fifty-six patients underwent 2 procedures and 12 three procedures. Radiotherapy was performed in 76.9% of grade A, and 91% of B patients, in the immediate postoperative period for 71% A and 82.7% B. Chemotherapy was delivered for 36% of grade A (in the event of transformation to grade B or failure of radiotherapy) and 67.5% of B patients. Among grade A tumors, 38% transformed into grade B within a mean delay of 51 months with a mean follow-up of 78 months. RESULTS: Median survival was 136 months for grade A and 52 for grade B. Survival at 5, 10 and 15 was 75.5%, 51% and 22.4% for grade A vs 45.2%, 31.3% and 0% for grade B respectively. In univariate and multivariate analysis, grade A survival was associated with age at diagnosis, tumor size, large removal and response to radiotherapy. Grade B survival was associated with age at diagnosis, wide removal and sharply defined limits of the tumor on imaging. CONCLUSIONS: Analysis of both published data and this series underlines many prognostic parameters. It shows that OLG are heterogeneous tumors even in each grade (A and B). Treatment should consequently progress towards more targeted procedures for patients mainly with postoperative radiotherapy and chemotherapy.

Tentorial meningiomas. Report on twenty-seven cases.

OBJECTIVE: Report our experience with 27 tentorial meningiomas (TM) surgically treated between 1985 and 1998. METHODS: The records of 27 patients with TMs were retrospectively reviewed for clinical presentation, neuroradiological evaluation, surgical treatment and long-term outcome. The extent of tumor resection was scored according to the Simpson's grading for tumor removal. Long-term results were evaluated according to the Glasgow Outcome Score (GOS). RESULTS: The average age was 53 years. Female predominance was 74%. The most common complaints at presentation were headaches (51%), gait ataxia (33%), memory disturbances (30%) and hypoacousia (30%). A classification of TMs into 5 subgroups according to tumor site is proposed on the basis of imaging studies. A cerebrospinal fluid shunt was established prior to direct approach in 7 patients and as the sole procedure in one inoperable patient. Twenty-seven direct approaches were undertaken in 26 patients, including 17 infratentorial and 10 supratentorial approaches. Total tumor removal was achieved in 20 patients (77%) and subtotal removal in 6 (23%). Fifteen patients (55%) experienced 22 postoperative complications. One patient died three months after a subtotal resection (mortality = 3.7%). With a mean follow-up of 54 months, all 26 survivors are currently alive with 23 having resumed their normal activities and 3 needing assistance. Five of 6 patients with subtotal resection survived and were followed for a period ranging from 72 to 132 months: none showed residual tumor progression and no re-operation was considered. An additional patient experienced a () recurrence 6 years after total removal, with no tumor progression 2 years after his recurrence was recognized. DISCUSSION: The best surgical approach to TMs is still a controversial matter. The advantages and drawbacks of conventional versus transbasal approaches are reviewed. Our experience suggests that subtotal removal can be associated with long recurrence-free intervals and preserved quality of life. TMs located at the tentorial edge carried a definitely worse prognosis than peripheral forms.

Is reoperation for recurrence of glioblastoma justified?

The purpose of the present study was to determine the effect of surgery on the time length and quality of survival in patients with recurrent glioblastoma multiforme. Two groups were compared; the first included 18 patients who underwent surgery at the time of tumour recurrence. The second group included 36 patients who did not undergo surgery at the time of tumour recurrence. Both groups were matched according to the following criteria: gender, age, Karnofsky Performance Scale (KPS) score, at the time of initial surgery and of tumour recurrence, extent of initial surgery, interval between initial surgery and tumour reccurence. Both groups received conventional treatment after initial surgery. There are no statistically significant differences between the two groups as regards to the previously mentioned criteria. After tumour recurrence, the median survival time was 5 months in the group of patients undergoing a second resection and 2 months in the group of patients not undergoing repeat surgery. The difference was statistically significant on univariate analysis. Moreover, the median length of time spent in an acceptable condition (KPS >/=60) from the time of tumour recurrence was found to be significantly longer in patient who underwent a second resection (4 months) compared with patients who did not undergo repeat surgery (1 month). Even in a relatively favorable subgroup of reoperated patients, the survival benefit although significant was only 3 months. It was impossible to completely match the two groups of patients suggesting that the difference might have been even less. Although symptomatic improvement is modestly achieved by repeat surgery, its transient nature necessitates clear discussion with patient and family on an individual basis.

[Clinical experience with the Sp[hy adjustable valve in the treatment of adult hydrocephalus. A series of 147 cases]. / Expérience clinique de la valve réglable Sophy dans le traitement de l'hydrocéphalie de l'adulte. Une série de 147 cas.

OBJECTIVE: Evaluate the advantages, results and drawbacks of the Sophy adjustable valve (SV) in the treatment of hydrocephalus in the adult. MATERIAL AND METHODS: One-hundred and forty-seven adult hydrocephalic patients (mean age = 64.5 years) shunted with a SV between 1990 and 1997 were retrospectively reviewed. Etiologies of hydrocephalus were: "normal pressure" chronic hydrocephalus (NPH) in 124 and tumoral hydrocephalus with intracranial hypertension in 23 patients. One-hundred fifty shunts were established in 147 patients: 14 ventriculoatrial and 136 ventriculoperitoneal shunts. The initial pressure settings of the SV were: high pressure: 12 times (8%), medium pressure: 136 times (90.6%) and low pressure: 2 times (1.3%). RESULTS: Sixteen patients were lost to follow-up. Two patients died within hours following the procedure. So, the results were analyzed in the 129 remaining patients, with a follow-up of 16.7 months (+/- 17.8). Three patients died from shunted-related causes (2.3%). Eighty-four patients had good results (65%), 25 had fair results (19.5%) and 20 failed to improve or deteriorated (15.5%) after shunting. Fifty-three reoperations were performed in 44 patients (34%), including 37 procedures for mechanical obstruction and 6 for septic complications. Subdural effusions (SDE) occurred in 16 patients (12.5%): 10 surgical evacuations were required in 7 patients; 8 patients were successfully treated using uprating of the SV pressure alone; one was managed conservatively. Fifty-eight pressure readjustments were performed in 47 patients. The pressure settings were uprated 28 times in patients showing clinical or computerized tomographic (CT) features suggesting overdrainage; 20 of those proved to be successful (71.5%). The pressure settings were lowered 30 times in patients showing a lack of improvement after shunting, attributed to underdrainage; only 12 of those proved to be successful (40%). Spontaneous changes of the pressure settings were observed in 14 patients (10.8%). After a MRI exposure, SV pressure changes were observed in 64% of patients. DISCUSSION: The technological refinements that have been proposed to eliminate the overdrainage which occurs in most usual cerebrospinal fluid shunts are reviewed. The SV valve has allowed non-invasive adjustments of its opening pressure in patients showing complications ascribed to inappropriate drainage. The need for additional surgery was eliminated in 20% to 25% of patients of the present series. Because of frequent spontaneous and magnetic resonance-induced pressure changes, the need for repeated controls of valve pressure is to be reemphasized. CONCLUSION: This experience suggests that the SV represents a substantial improvement over standard fixed-pressure valves.

Diffuse brain stem tumor in an adolescent with multiple enchondromatosis (Ollier's disease).

Among patients with enchondromatosis, those with Ollier's disease are usually considered to be at a lower risk for extra-osseous malignancy than those with Maffucci's disease. However, several reports suggest that Ollier's disease may also be associated with gliomas. We report here the youngest patient in the literature (16 years) to be detected with a brain tumor and Ollier's disease. This is also the first case with diffuse brain stem involvement. Thus, counselling of patients with Ollier's disease may become more difficult than initially thought.

[Thoracic spinal cord compression by a gouty tophus. Case report. Review of the literature]. / Compression médullaire thoracique par tophus goutteux intra-rachidien extra-DURAL.

An unusual case of thoracic spinal cord compression caused by extradural tophaceous deposits is reported in a 59-year-old female with a long-standing history of gout involving the metatarsophalangeal joints. T1 and T2 magnetic resonance images of the spine illustrated an extradural hyperintense signal extending from T2 to T9. A decompressive laminectomy disclosed a white caseum-like material in the extradural space, together with a small organized hematoma. Histologic examination showed areas of amorphous substance containing urate crystals surrounded by inflammatory cells, which was diagnosed as a gouty tophus. The patient made an uneventful recovery after surgery. Fifteen similar cases of the literature are reviewed. Although spinal involvement by gout seems relatively common, a compression of the spinal cord or of the cauda equina in gout patients seems exceptional. The diagnosis should be considered in patients showing a relevant history of gout, but spinal cord compromise may also represent the initial manifestation of the disease.

Syringomyelia associated with type I Chiari malformation. A 21-year retrospective study on 75 cases treated by foramen magnum decompression with a special emphasis on the value of tonsils resection.

The purpose of the present study is to evaluate retrospectively the effects of several intra-operative manipulations on the results of foramen magnum decompression (FMD) in patients having syringomyelia associated with type I Chiari malformation. Seventy-five patients having syringomyelia associated with Chiari I malformation were operated on between 1975 and 1996. This population was grouped into 4 subgroups according to the surgical protocol: group I = 42 patients with FMD alone; group II = 16 patients with FMD and third ventricle shunting; group III = 9 patients with FMD and syringosubarachnoid shunting (SSS); group IV = 8 patients with FMD and cerebellar tonsils resection. Pre- and postsurgical magnetic resonance imaging (MRI) studies were analyzed (and compared). Nine patients were lost to follow-up. The results were evaluated in the 66 remaining patients (mean follow-up: 52 months), using the Bidzinski's outcome scale (ref). Two patients (3%) died postoperatively, 31 (47%) had very good results (after additional surgery in 7), 16 (24.2%) had good results (after additional surgery in 7) and 17 (25.7%) had poor results despite further surgery in 9. A total of 27 reoperations were undertaken after primary FMD in 23 patients (35%). Thirty-nine patients (59%) had both pre- and postsurgical MRI evaluation. In 28 (72%) the syrinx had markedly decreased whereas it had remained stable in 11 (28%). Clinical results were not significantly different between the patients of groups I, II and III. Very good or good results were obtained in 24 patients (64.8%) of group I (after additional surgery in 10), in 8 (61.5%) of group II (after additional surgery in 1) and in 7 (87.5%) of group III (after additional surgery in 3). Results in group IV were as follows: 7 patients (87%) had very good results and one had a good result. With a mean follow-up of 28 months, no patient required additional surgery. Postsurgical MRI syrinx reduction was observed in all 8 patients either in the early postoperative course or on delayed followup. It is suggested that tonsils resection might enhance the results of FMD in individuals having Chiari I-related syringomyelia.

[Tethered cord syndrome in adults]. / Syndrome de moelle attachée de l'adulte. Une série de 25 patients.

A series of 25 adult patients surgically treated for a tethred cord syndrome is reported. Preoperatively 19 patients presented with a sensorimotor deficit in their lower limbs, 17 with sphincter disturbances, 12 with pain and/or neuroorthopedic symptoms and 9 with cutaneous lumbar anomalies. At surgery, an isolated anomaly (lipoma, anomalous or adherent filum terminale) was disclosed in 18 patients. In the remaining 7, a more complex form of dysraphism was disclosed. Follow-up ranges from 3 months to 20 years (mean: 6.5 years). Ten patients improved, 6 were stabilized and 9 showed continuous worsening. The best results were obtained in patients in whom the cord tethering resulted from an anomalous filum terminale. Results were significantly worse in patients suffering long standing symptomatology and showing either radiologically or surgically mixed mechanisms of cord tethering. Early surgical correction should be idealy undertaken in patients suffering from minor neurological deficits and in whom magnetic resonance imaging illustrates a low conus medullaris attached by a short thickened filum terminale.

[Intramedullary subependymoma of the cervical spinal cord. Review of the literature a propos of a case]. / Sub-épendymome médullaire cervical. Revue de la littérature à propos d'une observation.

A case of intramedullary subependymoma (SE) of the cervical spinal cord is reported. A 35 year-old female patient developed paresthesiae in her right upper and lower limbs for approximately two years. Magnetic resonance imaging (MRI) of the cervical spinal cord disclosed an intrisic medullary tumor at the C2-C3 levels, predominantly involving the right hemicord. At surgery, a subpial ependymoma was totally removed using the ultrasonic surgical aspirator with no resulting anomalies of the intraoperative somatosensory evoked responses. The patient made a good recovery. At one-year follow-up, she had resumed her previous occupation and complained only from minor sequelae. Twenty-nine spinal cord SE of the literature are detailed. It is likely that they account for less than two per cent of all spinal cord tumors. A majority of cases involved the cervical cord or the cervicothoracic junction. Signs and symptoms are similar to those of other spinal intramedullary tumors. In 17 cases explored by MRI, no specific pattern could distinguish SE from astrocytomas or ependymomas, except perhaps for a more marked tendency for SE to grow excentrically within the cord or to show an exophytic component. Spinal cord SE show pathological features grossly comparable to those described in intracranial SE with clusters of small glial cells scattered among densely packed fibers. Histogenesis of SE has been a matter of debate over years, whereas it is currently admitted that they may represent a variant of ependymomas. In conclusion, most clinical and imaging features of spinal cord SE are similar to those of other pathological varieties. Radical removal is the most appropriate treatment modality, despite inherent risk of postoperative deterioration and significant sequelae on long term follow-up.