[Optic nerve sheath decompression in optic neuropathy complicating idiopathic intracranial hypertension: a new focus]. / Décompression intra-orbitaire du nerf optique par ouverture des méninges péri-optiques lors de neuropathies optiques compliquant une hypertension intracrânienne idiopathique.

Optic nerve sheath decompression is a surgical procedure only used in optic neuropathy complicating idiopathic intracranial hypertension. We describe this technique and compare it with the classic technique of cerebrospinal liquid derivation. Several points contrast optic nerve sheath decompression and cerebrospinal fluid derivation: there is no biomaterial, it is limited to the orbital area, and intracranial pressure remains unchanged. The complications are different, yet analysis of the literature shows the same efficacy in terms of visual function. We recommend a practical management of optic neuropathy complicating idiopathic intracranial hypertension, depending on the functional severity and the therapeutic efficacy. The surgical indication should only concern serious optic neuropathy not responding to medical therapy, with the choice of the surgical technique belonging to the surgeon.

[Intra-orbital decompression of the optic nerve by opening the peri-optic meninges in the treatment of severe optic neuropathies complicating benign intracranial hypertension]. / Décompression intra-orbitaire du nerf optique par ouverture des méninges péri-optiques dans le traitement des neuropathies optiques sévères compliquant une hypertension intracrânienne bénigne.

Papilledema from benign intracranial hypertension can cause severe loss of visual acuity and visual field, with an optic neuropathy. We report a study of 5 patients with benign intracranial hypertension, and severe visual loss (visual field loss and visual acuity reduced to 1/10 or less) not improved by medical therapy (acetazolamide). We performed unilateral orbital decompression of the optic nerve sheath. No major operative complication was noted. Follow-up ranged from 11 months to 23 months, with an average of sixteen months. Visual function improvement was noted within 3 months after operation in 4 patients (for 2 eyes on the surgical side improvement of 2/10 and 5/10, for 3 eyes on the opposite surgical side average improvement of 4.6/10). The other patient showed improvement, but no significant. Optic nerve sheath decompression in benign intracranial hypertension seems to be a safe procedure and a therapeutic option in the management of raised intracranial pressure complicated by optic neuropathy with severe visual loss.

Anatomic basis for the treatment of aneurysms of the upper cervical segment of the internal carotid artery by extra-intracranial cervico-petrous bypass with inverted "in situ" saphenous vein graft.

In the surgical treatment of aneurysms of the upper cervical portion of the internal carotid a., exclusion of the affected vascular segment combined with an extra-anatomic cervico-petrous bypass using a vein graft (great saphenous v.) may be considered. One of the problems specific to these extra-anatomic bypasses is associated with the sub-cutaneous positioning of the vein graft, exposing it to risks of angulation, torsion or extrinsic compression that may lead to early venous thrombosis. We suggest an alternative technique using the principle of telescoping and consisting of positioning the vein graft within the cervical portion of the artery ("in situ" bypass). The cervical portion of the ICA may be used as a tunnel for the vein graft since there are no collateral arterial branches at this level. The technical features of such a bypass are defined by means of an anatomo-surgical study in the cadaver: exposure of the petrous portion of the internal carotid a. in its horizontal segment by subtemporal access, exposure of the ICA in the neck, transverse arteriotomies of the ICA, angioplasty with a Fogarty balloon, intracarotid telescoping of a saphenous vein graft from the cervical to the petrous region, distal end-to-end anastomosis between the vein graft and the petrous portion of the ICA, and proximal end-to-end anastomosis between the vein graft and the cervical portion of the ICA.

Cervical-to-petrous internal carotid artery saphenous vein in situ bypass for the treatment of a high cervical dissecting aneurysm: technical case report.

OBJECTIVE AND IMPORTANCE: We describe a novel cervical-to-petrous internal carotid artery (ICA) saphenous vein in situ bypass for the treatment of a high cervical dissecting aneurysm. The cervical ICA has no major collateral branches and can be used as a tunnel for the vein graft. CLINICAL PRESENTATIONS: A 25-year-old man was involved in a car accident. A cerebral angiogram revealed a right ICA dissection with aneurysm formation at the C1-C2 level. The patient recovered fully and was anticoagulated. Six months after the initial angiogram, a second angiogram disclosed ICA stenosis (80%) and persistence of the traumatic dissecting aneurysm. Definitive surgical bypass was considered the most appropriate course of action. TECHNIQUE: The horizontal portion of the petrous ICA was exposed by an extradural subtemporal approach. The cervical arteries were exposed by a separate surgical incision. After dividing the petrous ICA and the cervical ICA, the cervical ICA was dilated using a Fogarty balloon embolectomy catheter. A saphenous vein graft was inserted inside the lumen of the cervical ICA and was anastomosed to the ICA end-to-end both proximally and distally (cervical-to-petrous ICA in situ bypass). The graft was patent on the follow-up angiogram. CONCLUSION: We describe a new technique that could be considered an alternative to the classical extra-anatomic cervical-to-petrous ICA bypass procedures.

[Sub-temporal supra-petrous approach to the horizontal portion of the sub-petrous internal carotid artery. Technique, indications, incidents and accidents]. / Exposition par voie sous-temporale sus-pétreuse de l'artère carotide interne intra-pétreuse dans sa portion horizontale. Technique, indications, incidents et accidents.

Cavernous sinus exploration, anterior middle fossa transpetrous approach, and saphenous vein graft bypass require proximal control of the horizontal segment of the petrous internal carotid artery. Exposing the petrous portion of the internal carotid artery is not without the potential for serious complications (cochlea, facial nerve, auditory tube, musculus tensor tympani). With guidance from the classicaly landmarks within Glasscock's triangle, the bony petrous carotid canal can be unroofed. The authors describe an alternative method for obtaining direct vascular control under the trigeminal ganglion, safety unroofing of the carotid canal and control of the posterior face of the carotid bend. The indications, advantages, and disadvantages of this approach are described in details, along with its use in seven patients.

Early restructuration of consciousness after traumatic coma.

Recovery of consciousness after acute brain injury is a remarkable phenomenon, yet, not completely understood. We describe the early clinical stages of recovery of consciousness in 48 selected patients by means of different items of the Glasgow Coma and Liege Coma Scales. Arousal, expressed by the stimulated opening of the eyes (E2) was correlated with the appearance of the localizing pain response (M5), with the capacity to obey commands (M6), with the opening of the eyes (E4) and with the blink reflex (R5). This study confirms the classical clinical sequence of arousal and recovery of consciousness characterized by the consecutive appearance of E2, R5, E4, M5 and M6. When the appearance of E2 and R5 are considered separately, we noticed a significant difference, suggesting different structural and functional brain recovery processes.

Clinical recovery of consciousness after traumatic coma.

OBJECTIVE: To describe early clinical stages in the recovery of consciousness, using selected items from the Glasgow Coma Scale and the Liège Coma Scale. DESIGN: Validation cohort study, conducted in a tertiary care center. SETTING: Neurosurgical intensive therapy unit in a university teaching hospital. PATIENTS: Patients (n = 137) with traumatic coma who were selected according to the following criteria: a) coma due to blunt head trauma with an initial Glasgow Coma Score of < or = 7; b) admission to the neurosurgical intensive therapy unit within the first 24 hrs after trauma; c) patients > 14 yrs of age; requiring endotracheal intubation, mechanical ventilation, and the administration of drugs; and d) survival period allowing analysis of the recovery of consciousness. MEASUREMENTS AND MAIN RESULTS: Arousal, as expressed by stimulated opening of the eyes and recorded as a delay in days, was correlated with the appearance of the localized pain response, capacity to obey commands, blink reflex, and the cessation of drugs in three groups of patients. These groups were defined according to the time in which there was an appearance of the stimulated opening of the eyes: < 8 days (group 1); between 8 and 15 days (group 2); and after 15 days (group 3). When the three groups of patients were compared, significant differences existed between the mean delays of appearance of stimulated eye opening and the appearance of the blink reflex. Extubation coincided with the appearance of spontaneous eye opening, with a mean delay of 13.5 days. CONCLUSIONS: This study confirms the classical clinical sequence of arousal and recovery of consciousness, with the appearance of stimulated eye opening and the blink reflex first, followed by spontaneous eye opening, and the capacity to obey commands in intubated, traumatized, coma patients. A direct correlation existed between the delay of arousal and the complete recovery of consciousness. When groups of patients with various mean delays for the appearance of stimulated eye opening are considered, reappearance of the blink reflex did not always coincide with stimulated eye opening, suggesting differing structural and functional brain recovery processes.

Disco-computed tomography in extraforaminal and foraminal lumbar disc herniation: influence on surgical approaches.

Between January 1990 and February 1992, a total of 301 patients underwent discectomy for lumbar disc herniation; 29 had an extreme lateral herniation, i.e., foraminal or extraforaminal. The intervertebral foramen is a three-dimensional area demarcated primarily by the pedicles; we call it the lateral interpedicular compartment. The extraforaminal zone is the space outside the lateral border of the pedicles. All patients were evaluated by computed tomography (CT), water soluble myelography, postmyelographic CT scanning, or magnetic resonance imaging. Fifteen patients consecutively underwent disco-enhanced CT to adjust a correct diagnosis and to distinguish extraforaminal from foraminal herniation. In 10 cases of extraforaminal herniation, a selective radicular decompression with good-to-excellent clinical results was achieved by an extra-axial lateral decompression of the interpedicular compartment, with preservation of the facet joint. The operative target was the lateral aspect of the pars interarticularis and not the intertransverse space, as previously described. In two cases of both foraminal and extraforaminal herniation, the same technique was used. Fourteen patients with foraminal disc herniation and three patients with both foraminal and extraforaminal herniation underwent a standard intervertebral foraminotomy. An accurate preoperative diagnosis established by disco-CT is crucial in order to select the most suitable surgical approach.

[Bacterial abscesses of the spinal cord. Review of the literature (73 cases)]. / Abcès bactériens de la moelle épinière. Revue de la littérature (73 cas).

Intramedullary spinal cord abscesses are an uncommon entity with 73 cases reported in the literature; the first case was reported in 1830. Sixty-seven percent of abscesses occur in the first 4 decades of life. Staphylococcus and Streptococcus are the most common organisms; 25% of patients have negative intraoperative cultures. The primary source of the infection could be found, in only 45% of patients. Most of these infections are secondary to metastatic spread from infections of the lung, endocarditis, genitourinary tract; 10 reports have described an intramedullary abscess secondary to a dermal sinus. The signs and symptoms depend on the location of the lesion; the thoracic spine is the most commonly area involved. Patients are usually divided into three clinical groups; acute onset (symptoms less than 1 wk), subacute onset (symptoms up to 6 wk), and chronic course (symptoms more than 6 wk). Patients with the acute form are more likely to have a fever and an elevated white blood cell count and may show either a partial or complete transverse myelitis picture. The patients with chronic abscesses are less likely to have fever and leukocytosis, and their symptoms often mimic those of an intramedullary spinal tumour. The erythrocyte sedimentation rate tends to be elevated in all patients regardless of their clinical findings. CSF cultures are usually sterile. Plain x-rays of the spine are often normal. A myelogram in conjunction with a computed tomographic scan may show the intramedullary lesion. MRI studies usually demonstrate intramedullary lesions with exceptional clarity; the use of gadolinium with T1-weighted MRI studies enhances the abscess wall.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indentation sign in the sylvian sulcus and the arterial origin of an acute subdural hematoma. Contribution of computerized tomography]. / Le signe de l'indentation dans la vallée sylvienne et l'origine artérielle d'un hématome sous-dural aigu. Apport du diagnostic tomodensitométrique.

Thirty-two traumatic subdural haematomas were operated between 1984 and 1990. In 16 cases (50%), we encountered, after removal of the heamorrhage, a bleeding from a cortical artery at the lateral sulcus (middle cerebral artery). Four mechanisms of arterial bleeding have been reported: a) rupture of a cortico-dural bridging artery, b) "fire-hose" rupture, c) rupture at the level of an arachnoid attachment and d) rupture at the level of a dural adhesion. The characteristic finding of such haematomas on computerized tomography (CT-scan) was an indentation towards the lateral sulcus. This was called the "double brackets sign". In seventy-nine percent of subdural haematomas of arterial origin, the "double brackets sign" was demonstrated on CT-scan on at least two slices (9 mm). In 9% of subdural haematomas of non-arterial origin, this sign was absent or present in only one CT image. The characteristic "double brackets sign", when present on 3 or 4 CT-scan images, seems to have a very high specificity for an arterial origin of the haematoma.

[Tetraparesis caused by ossification of the posterior longitudinal ligament of the spine]. / Tétraparésie secondaire a une ossification du ligament commun vertébral postérieur.

A case of pure motor tetraparesis with a slowly progressive course was due to an ossification of the posterior longitudinal ligament. The role of retinol in the pathogenesis of this case is discussed.