[Clinical and imaging features of diffuse cerebral vasoconstriction]. / Aspects radio cliniques de l'angiopathie cérébrale aiguë réversible.

PURPOSE: To report clinical and imaging features of diffuse cerebral vasoconstriction and to discuss the role of non-invasive imaging modalities for the diagnosis and the follow-up. PATIENTS AND METHODS: Retrospective study including 13 consecutive patients with a diffuse cerebral vasoconstriction. Evaluation of the sensitivity of Doppler US and magnetic resonance angiography for the diagnosis. RESULTS: The diagnosis is based on the association of a thunderclap headache, declenching factors found in 50% of cases and of stenosis involving middle and small cerebra arteries. In some cases cerebral hemorrhage may be present. DISCUSSION: Diffuse cerebral vasoconstriction is a rare cause of thunder clap headhache, which needs to exclude other causes such as subarchnoid hemorrhage from aneurysm rupture. Non contrast CT of the head, frequently normal, may be falsely reassuring. It is therefore necessary to further assess the cerebral arteries to exclude an aneurysm but also to detect the presence of stenoses that would suggest the diagnosis. Non-invasive imaging modalities (MRA and Doppler US) are favored for detection and follow-up of proximal lesions.

[Cerebral cavernomas, epilepsy and seizures. Natural history and therapeutic strategy]. / Cavernomes intracrâniens, épilepsie et crises d'épilepsie. Histoire naturelle et modalités thérapeutiques.

PURPOSE: To review, from a retrospective series of 48 patients presenting with seizures associated with one or more supratentorial cavernoma(s), the natural history of the seizures and outcome according to medical and surgical treatment. METHODS: Patients were divided into two groups: group A included patients presenting with a single seizure or rare seizures (n=21), and group B patients having intractable epilepsy (n=27). All received antiepileptic drugs and 35 were operated on (12 in the group A and 23 in the group B). Stereo-EEG was performed in 8 patients in group B. Surgery included lesionectomy alone (n=16), resection of the cavernoma and perilesional tissue (n=7) or tailored corticectomy including the cavernoma (n=12). RESULTS: The natural history of seizures was different in the two groups: mean age at seizure onset was 25 years in group B and 33 years in group A (p<0.05), seizures were partial in all patients in group B and 8 patients in group A (p<0.05). Seizure frequency and periodicity also varied. Prolonged seizure-free periods were observed. The cavernoma was temporal in 17 patients in group B and 4 patients in group A (p<0.01). In group A, seizure outcome was favorable following surgery or with antiepileptic medication only (7 patients out of 12 operated were seizure-free, as were 5 out of 7 non-operated). In group B, seizure outcome was better after surgery than with medication only (17 patients out of 23 operated were in Engel's Class I, while 3 patients of 4 non-operated patients had persisting seizures despite antiepileptic polytherapy). CONCLUSION: Variations in seizure severity in patients harboring cavernomas suggest different therapeutic approaches. In case of unique or rare seizures, surgical resection of the cavernoma is appropriate, but benefits of surgery over antiepileptic medication in terms of seizure control remains unclear. Intractable epilepsy associated with cavernomas is better controlled after surgery rather than with medication only. In these patients, a detailed preoperative work-up is necessary and should be followed by wide resection associated or not with corticectomy, especially in the temporal lobe. Evaluation of outcome after surgery should consider the surgical strategy, antiepileptic medications and the patient's seizure history.

[Cerebral cavernomas followed by epileptic seizures: clinical picture, diagnosis, and treatment]. / Kavernomy golovnogo mozga, protekaiushchie s épilepticheskimi pripadkami: klinika, diagnostika, lechenie.

The clinical features of epilepsy associated with cerebral cavernomas and the results of different types of its surgical treatment: cavernonectomy, extended cavernomectomy, and epileptic focus resection were analyzed. The clinical, radiological, and electrophysiological data were studied in 48 patients with epileptic seizures associated with cerebral cavernomas who had been admitted to the Unit of Neurosurgery, Saint Anna Hospital (Paris, France) in 1982-2001. According to the severity of epileptic manifestations, the patients were divided into 2 groups: 1) 21 patients with single and rare seizures and 2) 27 patients with drug-resistant epilepsy. All the patients received medical antiepileptic therapy. Twelve patients from Group 1 underwent cavernomectomy or "extended" cavernomectomy. In Group 2, 23 patients were operated on and 3 types of operations (cavernomectomy, "extended" cavernomectomy, and corticoectomy) were performed. Statistically significant differences were found in anatomic, clinical, and electrophysiological parameters. Criteria associated with the development of drug-resistant epilepsy were established. These included: the early onset of seizures, temporal cavernoma, and a combination of partial and generalized seizures in one patient. The paper shows it necessary to choose a surgical intervention in relation to the duration of seizures, their frequency, and a response to medical antiepileptic therapy. The advantages of surgical treatment over medical one were not found in single and rare seizures (Group 1), while in drug-resistant epilepsy, surgical treatment yielded much better epileptological results than did medical treatment. The volume of a surgical intervention depends on the sizes of an epileptic focus detected by an in-depth preoperative study and on the site of a cavernoma.

[Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]. / Conservation gastrique dans les lésions caustiques sévères du tube digestif: est-elle légitime?

OBJECTIVE: To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries. METHODS: Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation. RESULTS: Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality. CONCLUSION: Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

[The role of surgery in the treatment of prolactinomas]. / Le point sur la place de la chirurgie dans le traitement des prolactinomes.

TECHNIQUE: Almost all prolactinomas are operated through a transsphenoidal route, even in case of significant suprasellar extension or intracavernous invasion. Since 1996, we use the only endonasal route which is easier, quicker, less haemorrhagic and less aggressive than the sublabial one. If the removal of a large macroadenoma cannot be completed (50-70% of cases), a second procedure, usually transsphenoidal, is performed a few weeks later. INDICATIONS: Microprolactinomas: usually surgery is proposed as soon as medical treatment is not well tolerated or if the patient wishes to be pregnant. Macroprolactinomas: bromocriptine or quinagolide are sometimes prescribed in a first stage. Surgery beeing indicated in case of inefficacy or intolerance of the medical treatment, or in emergency due to an acute visual pathways compression (tumoral necrosis). Giant adenomas (= 30-40 mm): usually dopaminergic agonists allow a tumoral volume reduction and assure a limitation of visual risks due to rapid decompression of visual pathways. Exceptionally, medical treatment leads to a complete regression of the adenoma. RESULTS: Morbidity of transsphenoidal procedures: insipidus diabetes: transient 5-15%, definitive: 1-2%; septal perforation: 3-5%; rhinorrhea: 5%; visual aggravation: 2%. The most frequent complaint for patients operated through sublabial route is gum and dental pain, non-existent with endonasal procedures. Operative mortality: 0-1.7% (0% in our series). In men, normalization of prolactinemia is linked to the tumoral volume: 90-100% in case of microprolactinoma, 30-35% for enclosed macroprolactinomas, 0-5% for invasive macroprolactinomas. Conventional, conformational or stereotactic radiotherapy can be useful in case of contraindication to surgery and failure of medical treatment.

Prolongation of cardiac allograft survival by selective injection of donor liver leukocytes in non-immunosuppressed rats.

Liver grafts are spontaneously accepted in several animal combinations and are able to induce acceptance of another organ originating from the same donor, which would be rejected when transplanted alone. However, the exact mechanism of this unique tolerance induction capability remains unclear. The aim of our study was to investigate the ability of nonparenchymal liver cells to induce tolerance when they were separated from their parenchymal environment. In the murine combination we used (BN --> LEW), heart transplants were constantly tolerated after combined liver plus heart grafting, but rejected when transplanted alone. Nonparenchymal liver cells were isolated from BN rat livers by enzymatic digestion and injected, at different times, to LEW rats, which were recipients of BN heart transplants. The average number of mononuclear cells obtained after isolation was 20 x 10(6)/5 g of rat liver. Immediate trypan-blue exclusion test showed more than 95% of viable cells. Phenotypic studies showed a predominant (47%) lymphocyte population, 7% were monocytes and 46% were cellular debris. Among the lymphocyte population, the majority of cells were bearing the NKR-P1 receptor and about 30% CD3 receptors. Inoculation of nonparenchymal liver cells 7 and 30 days prior to heart transplantation significantly prolonged graft survival compared to controls (14.6 and 12.7 vs. 8.1 days; p = 0.0008 and 0.0059, respectively), whereas simultaneous injection (day 0) had no effect. Injection of donor splenocytes or nonparenchymal liver cells from a third party, at any time, had no effect on rejection. These results provide some more evidence about the specific role of liver lymphocytes in allogenic unresponsiveness. They also suggest that the hepatic parenchymal environment is necessary for the optimal development of this phenomenon.

Mixed ductal-endocrine carcinoma of the pancreas: a possible pathogenic mechanism for arrhythmogenic right ventricular cardiomyopathy.

We describe herein a case of a mixed ductal-endocrine pancreatic carcinoma. Rare cases of mixed pancreatic tumors have been described, with endocrine and exocrine components each making up a significant proportion of the neoplasm; to our knowledge, only one case has been reported with a mixed liver metastasis. In our case, ductal and endocrine cells were intimately admixed in the primary tumor and in a peripancreatic lymph node metastasis, diagnosed by standard light microscopy and double immunostaining for cytokeratin 19 and synaptophysin. The endocrine component was immunoreactive for somatostatin. Tumors with admixed endocrine and exocrine components support the hypothesis of a common endodermal histogenesis for the ductal and endocrine cells in the human pancreas.

[Gastrointestinal hemorrhage caused by rupture of an aneurysm of visceral arteries. Presentation of 4 cases]. / Hémorragie digestive par rupture d'un anévrisme des artères viscérales. Présentation de quatre observations.

STUDY AIM: Gastrointestinal bleeding by rupture of splanchnic artery aneurysms is very rare. The aim of this study is to report four cases observed between 1990 and 1996. MATERIALS AND METHODS: In the first case, the celiac trunk aneurysm was revealed by hematemesis due to erosion of the posterior wall of the stomach. Excision of the aneurysm associated with splenopancreatectomy was followed by revascularization of the common hepatic artery with a bypass implanted in the aorta. The second case concerned a splenic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding which was treated by excision and splenopancreatectomy. In the third case, the common hepatic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding was treated by obstructive endoaneurysmorrhaphy. The fourth case concerned a superior mesenteric aneurysm revealed by duodenal erosion causing gastric and intestinal bleeding, which was treated by obstructive endoaneurysmorrhaphy and revascularization of the mesenteric artery by a spleno-mesenteric bypass. RESULTS: Surgical treatment was successful in all four patients. In the first case, an acute acalculous cholecystitis required a cholecystectomy after 3 weeks. In the fourth case, a splenic infarction disappeared spontaneously. CONCLUSION: Such observations are rare. The site of the bleeding was located by endoscopy. The aneurysm was recognized by contrast-enhanced computerized tomography (CT) scan and/or celiac and mesenteric arteriography which was performed in all cases and was very useful for the management of such aneurysms. After excision (n = 2) or obliterative endoaneurysmorrhaphy (n = 2), revascularization had to be done in two cases for celiac and mesenteric aneurysms.

[Intracavernous invagination of pituitary macro-adenomas]. / L'invagination intra-caverneuse des macro-adénomes hypophysaires.

Depending on authors, intra-cavernous invasion by a pituitary adenoma is found in 9% to 40% of cases. In the light of our own experience, we think that such an invasion is probably much less frequent than usually evoked on CT-scan and MRI. In our study, it was confirmed in only one case over 125 (0.80%), though radiological data suspected an intra-cavernous invasion 17 times. An anatomical study on 20 cadavers showed that 30% of normal pituitary glands present with a lateral expansion into one or both cavernous sinuses (CS). These natural invaginations were already evoked by Harris and Rhoton in 1976. They can resemble an intra-cavernous extension or invasion on MRI views, moreover when an adenoma increases the volume of this expansion, and in the absence of any rupture of the medial wall of the CS. The medial wall of the CS is, in fact, constituted by a dural pouch which close-fits the pituitary gland and its expansions; it invaginates more or less in the CS, depending on the importance of the pituitary lateral expansion. In case of a large adenoma, the finger-glove lateral distension of the pouch disappears progressively during the tumoral removal. Finally the dura returns to its normal place back, at the end of the procedure. This concept of invagination of the CS medial wall, as opposed to that of invasion and therefore of rupture of the dural plane, explains the wide range of figures concerning the frequency of intracavernous invasion by pituitary adenomas, in the literature. These figures are all the more variable as there is no absolute criteria of intra-cavernous invasion on CT-scan nor MRI views. In the same way, no clinical criteria can be retained to assume the existence of such an invasion. So, an ophthalmoplegia seems to be usually linked to a compression of occulomotors nerves; it recovers in a large majority of cases, after the adenoma is removed. In conclusion we emphasize the necessity of interpreting with great care radiological imaging when it evokes' a possible intra-cavernous invasion of a pituitary adenoma. The indication of an eventual radiotherapy should be retained with as much care as possible, since complete removal of an adenoma and its lateral expansion(s) is almost always feasible through a trans-sphenoidal route.