T1 Mapping for Microstructural Assessment of the Cervical Spinal Cord in the Evaluation of Patients with Degenerative Cervical Myelopathy.

BACKGROUND AND PURPOSE: Although current radiologic evaluation of degenerative cervical myelopathy by conventional MR imaging accurately demonstrates spondylosis or degenerative disc disease causing spinal cord dysfunction, conventional MR imaging still fails to provide satisfactory anatomic and clinical correlations. In this context, we assessed the potential value of quantitative cervical spinal cord T1 mapping regarding the evaluation of patients with degenerative cervical myelopathy. MATERIALS AND METHODS: Twenty patients diagnosed with mild and moderate-to-severe degenerative cervical myelopathy and 10 healthy subjects were enrolled in a multiparametric MR imaging protocol. Cervical spinal cord T1 mapping was performed with the MP2RAGE sequence procedure. Retrieved data were processed and analyzed regarding the global spinal cord and white and anterior gray matter on the basis of the clinical severity and the spinal canal stenosis grading. RESULTS: Noncompressed levels in healthy controls demonstrated significantly lower T1 values than noncompressed, mild, moderate, and severe stenotic levels in patients. Concerning the entire spinal cord T1 mapping, patients with moderate-to-severe degenerative cervical myelopathy had higher T1 values compared with healthy controls. Regarding the specific levels, patients with moderate-to-severe degenerative cervical myelopathy demonstrated a T1 value increase at C1, C7, and the level of maximal compression compared with healthy controls. Patients with mild degenerative cervical myelopathy had lower T1 values than those with moderate-to-severe degenerative cervical myelopathy at the level of maximal compression. Analyses of white and anterior gray matter confirmed similar results. Strong negative correlations between individual modified Japanese Orthopaedic Association scores and T1 values were also observed. CONCLUSIONS: In this preliminary study, 3D-MP2RAGE T1 mapping demonstrated increased T1 values in the pathology tissue samples, with diffuse medullary alterations in all patients with degenerative cervical myelopathy, especially relevant at C1 (nonstenotic level) and at the maximal compression level. Encouraging correlations observed with the modified Japanese Orthopaedic Association score make this novel approach a potential quantitative biomarker related to clinical severity in degenerative cervical myelopathy. Nevertheless, patients with mild degenerative cervical myelopathy demonstrated nonsignificant results compared with healthy controls and should now be studied in multicenter studies with larger patient populations.

The presigmoid retrolabyrinthine approach: Technical note.

BACKGROUND: The retrolabyrinthine approach is classified among the posterior petrosectomies. Its goal is to achieve an enlarged mastoidectomy while sparing the intrapetrous neurotologic structures in order to offer maximal exposure of the posterior cerebellopontine angle compound. METHODS: The stages of the procedure are subsequently the skeletonization of the sigmoid sinus, wide opening of the mastoid antrum and exposure of the semicircular canals. We present herein the technique, indications and limitations of the retrolabyrinthine approach. CONCLUSION: The retrolabyrinthine approach is a demanding technique. Nowadays the retrolabyrinthine approach is routinely combined to additional resections of the petrous bone, so-called "combined petrosectomies", to target the jugular foramen or the petroclival area.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study.

BACKGROUND: Outcomes of petroclival meningiomas (PCM) (morbidity, permanent cranial nerves deficit, tumor removal and recurrence) are inconsistent in the literature, making it a challenge to predict surgical morbidity. METHODS: A multicenter study of patients with PCMs larger than 2.5cm between 1984 and 2017 was conducted. The authors retrospectively reviewed the patients' medical records, imaging studies and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, recurrence rates and predictive factors. RESULTS: There were 154 patients. The follow-up was 76.8 months on average (range 8-380 months). Gross total resection (GTR) was achieved in 40 (26.0%) patients, subtotal resection (STR) in 101 (65.6%), and partial resection in 13 (8.3%). Six (2.6%) perioperative deaths occurred. The 5-year, 10-year and 15-year progression-free survival (PFS) of GTR and STR with radiation therapy (RT) was similar (100%, 90% and 75%). PFS of STR without adjuvant radiation was associated with progression in 71%, 51% and 31%, respectively. Anterior petrosectomy and combined petrosectomy were associated with higher postoperative CN V and CN VI deficits compared to the retrosigmoid approach. The latter had a significantly higher risk of CN VII, CN VIII and LCN deficit. Temporal lobe dysfunction (seizure and aphasia) were significantly associated with the anterior petrosectomy approach. CONCLUSIONS: Our study shows that optimal subtotal resection of PCMs associated with postoperative RT or stereotactic radiosurgery results in long-term tumor control to equivalent radical surgery. Case selection and appropriate intraoperative judgement are required to reduce the morbidity.

History of degenerative spondylolisthesis: From anatomical description to surgical management.

This review of the historical medical literature aimed at understanding the evolution of surgical management of degenerative spondylolisthesis over time. The Medic@, IndexCat and Gallica historical databases and PubMed and Embase medical databases were used, with several search-terms, exploring the years 1700-2018. Data from anatomical, biomechanical, pathophysiological and surgical studies were compiled. In total, 150 documents were obtained, dating from 1782 to 2018: 139 from PubMed, 1 from Medic@, 7 from IndexCat, and 3 from Gallica. The review thus ranges in time from (1) description of the first clinical cases by several authors in Europe (1782), (2) the identification of a distinct entity by MacNab (1963), and (3) surgical management by the emerging discipline of minimally invasive spine surgery, to its subsequent evolution up to the present day. Spondylolisthesis is a frequent condition potentially responsible for a variety of functional impairments. Understanding and surgical management have progressed since the 20th century. Historically, the first descriptions of treatments concerned only spondylolisthesis associated with spondylolysis, especially in young adults. More recently, there has been progress in the understanding of the disease in elderly people, with the recognition of degenerative spondylolisthesis. New technologies and surgical techniques, aided by advances in supportive care, now provide spine surgeons with powerful treatment tools. Better knowledge of the evolution of surgery throughout history should enable better understanding of current approaches and concepts for treating degenerative spondylolisthesis.

Chiari malformations in adults: A single center surgical experience with special emphasis on the kinetics of clinical improvement.

BACKGROUND: The Chiari malformation type I (CM-I) is the most commonly found type in adults. The efforts to further improve the treatment offered for these malformations are hampered by the existence of controversial methods and the absence of a uniform scoring system to evaluate clinical outcomes. OBJECTIVES: The goal of our study is to analyze the clinical and radiological data concerning patients operated for CM and to expose surgical techniques. PATIENTS AND TREATMENT: This is a retrospective study concerning patients of more than 16 years of age, operated on (from 2000 to 2016) in our institution. These patients underwent bony decompression of the cervico-occipital junction, with a duraplasty enlargement. Clinical and radiological follow-up was assessed sequentially. RESULTS: The mean age of patients included in this study was 39. Headaches (n=19) and sensory disturbances (n=17) were the most common presenting complaints. Furthermore, syringomyelia symptoms were present in 34.5% of the cases (n=10). Twenty-three patients displayed a Chiari malformation of type I (79.3%), and six patients were classified as Chiari malformation type I.5 (20.7%). A syringomyelia was present in 58.6% of the cases (n=17). The postoperative complications that were encountered were: one case of pseudo-meningocele, two cases of cerebrospinal fluid leakage, two cases of meningitis, and one case of delayed wound healing. The mean follow-up period was 18 months, which showed beneficial outcomes in 82.8% of the cases (20.7% cured, and 62.1% improved) and an unfavorable outcome in 17.2% of the cases (13.8% stable patients and 3.4% worsened outcomes). Syringomyelia symptoms were improved in 60% of the patients. Among the patients who presented without a syrinx, 82.3% had good outcomes; and those who presented with a syrinx, 83.4% had good outcomes. Symptoms improved for 69% of patients within 3 months. CONCLUSION: An optimal craniocervical osteo-dural decompression plus duraplasty offered early and sustainable good clinical results in symptomatic CM-I and CM-I.5 patients.

A case of brain metastasis of a thymic carcinoma with a review of the literature.

Thymic epithelial tumors (TET) are rare lesions. The brain metastases of these tumors are even rarer. We report a case of brain metastases in a known patient with a thymic carcinoma diagnosed in October 2016. She was a 73-year-old woman who presented with headache, nausea, and right hemiplegia. Brain MRI revealed five lesions (1 insular, 1 frontal and 2 left temporal, 1 right parafalcine). These lesions were initially treated using two stereotactic radiosurgery gamma knives. A macroscopically complete excision of the left frontal lesion was subsequently performed without any complications with a good evolution of the neurological symptoms postoperatively. Immunohistochemical examination was compatible with metastatic thymic carcinoma. The patient died 14 months after the initial diagnosis. A review of the literature in English has reported another 45 TET cases with brain metastases.

Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation.

Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.

Intraventricular schwannoma: Case report and review of literature.

We report here a case of intraventricular schwannoma. This location is rare. Our patient was a 68-year-old female with a large intraventricular lesion of the body of the lateral ventricle on the right side. Brain magnetic resonance imaging (MRI) revealed this lesion. After a right parietotemporal craniotomy, microsurgical excision using neuronavigation was performed to completely remove the tumor. Histological and immunohistochemical examination confirmed the diagnosis of intraventricular schwannoma devoid of atypical features. Postoperative MRI showed macroscopically complete tumor removal with no recurrence after 12 months of follow-up. A review of the literature identified 32 such cases published to date.

Extradural resection of the anterior clinoid process: How I do it.

BACKGROUND: The anterior clinoid process shares a close relationship with the optic canal, the internal carotid artery, the superior orbital fissure and the cavernous sinus. These structures may be involved in diseases whose surgical exposure requires prior clinoid process resection. METHOD: Based on operative cases we describe the different steps of this surgical technique and illustrate our surgical procedure with a video. Dividing the orbito-temporal periosteal fold is a key-step in order to optimize the elevation of the periosteal dural layer at the level of the superior orbital fissure to expose the contours of the anterior clinoid process. The clinoid tip is removed after "debulking" the bony content inside the anterior clinoid process in order to leave only a thin shell of bony contour. The bony shell is then detached from the dura, twisted and pulled out. The indications and limitations of the technique are presented. CONCLUSION: The extradural approach of the anterior clinoid process totally provides a full resection of the anterior clinoid process and safety for the paraclinoid space structures. Meticulous stepwise bony resection and optimized dura opening contribute to reduce the risk inherent to this technique.

"Giant cell reparative tumor: An exceptional differential diagnosis for a lytic lesion of the temporal bone".

BACKGROUND AND IMPORTANCE: Giant cell reparative granuloma is a very rare benign osteolytic lesion. It typically arises in the mandible and rarely involves the skull. CLINICAL PRESENTATION: A 25-year-old male was admitted in August 2002 for a painless left preauricular mass of several months duration. CT scan revealed an osteolytic extradural lesion located in the temporal bone, with extension to infratemporal fossa. We performed a surgical partial resection of the tumour via a frontotemporal approach. At 36 months after surgery, the lesion continued growth and subsequently we decided to perform a preauricular infratemporal approach. After a ten year-follow-up, the patient remained asymptomatic and a small tumour remnant was visible and stable. CONCLUSION: Giant cell reparative granulomas that originate from the temporal bone are exceptional. There are no typical radiological features of this disease. Diagnosis is confirmed by analysis of the surgical specimen. Tumor growth requires surgical resection.

Cerebellopontine angle gangliogliomas: Report of two cases.

BACKGROUND: Gangliogliomas are rare tumors of the central nervous system. We report two unusual cases of gangliogliomas located in the cerebellopontine angle (CPA). POPULATION AND METHODS: The first patient was a 57-year-old woman, who presented with dizziness and harbored a non-enhanced heterogeneous mass located in the cisternal space of the CPA. A partial microsurgical removal was performed, and the pathological examination concluded a grade I ganglioglioma according to the WHO Classification. The postoperative course was uneventful without any adjuvant treatment and the 5-year imaging follow-up indicated a stable remnant tumor. The second patient was a 35-year-old male who presented with acute vertigo and imbalance associated with recent prominent headaches; MR imaging showed a large heterogeneous and post-contrast enhanced tumor mass located in the CPA cistern with a mass effect on the brain. An optimal subtotal surgical resection was performed. The pathologists concluded a WHO grade III ganglioglioma. In spite of adjuvant radiotherapy and chemotherapy, the evolution proved unfavorable and patient died from cancer complications within a 2-year period. In both cases, the precise origin of the tumor could not be clearly identified even if the major component was present in the cisternal space. CONCLUSION: Gangliogliomas growing into the cisternal spaces are exceedingly rare particularly in the CPA. Due to its infiltrating behavior and major difficulties to identify the tumor margins, total resection is not routinely feasible. The histological grading is the most important predictor for oncological prognosis.

Ruptured posterior ethmoidal artery aneurysm and Moyamoya disease in an adult patient. Case report.

The association between Moyamoya disease and intracranial aneurysms is well described. In our case, we describe a unique aneurismal location and its management. We report the case of a 74-year-old woman affected by a Moyamoya disease who displayed a frontal lobe hematoma. The origin of the bleeding came from the rupture of a posterior ethmoidal artery aneurysm that was treated surgically with favourable outcome. This case of a ruptured posterior ethmoidal artery aneurysm in a Moyamoya patient illustrates the polymorphism of the vascular complications encountered in this disease. It stresses the need to obtain information from an angiographic investigation in order to select the best therapeutic option and to reduce procedural complications.