Pilot study of 6 weeks of chemoradiotherapy with 5 FU and hydroxyurea in malignant gliomas.

In an attempt to improve the primary treatment of malignant gliomas we used a concomitant 6-week course of chemoradiotherapy with 5 fluorouracil (5 FU) and hydroxyurea (HU) in 24 adults with anaplastic astrocytoma (AA) (7 cases) or glioblastomas (GLB) (17 cases). This patient population was characterised by a poor prognostic profile; 50% of cases had biopsic or subtotal surgery and 70% had GLB. Patients received 2 Gy/day 18 MV photons with 300 mg/m2 of 5 FU in continuous infusion and 500 mg x 4/day per os of HU, five days per week during 6 weeks. Treatment was poorly tolerated in terms of toxicity and implied heavy logistics (hospitalization, central venous access) worsening the quality of life which is already bad in malignant gliomas. Unfortunately we did not improve median survival which does not exceed 26 weeks with 7 long survivors (> 49 weeks). This pilot study does not offer any benefits over current standard approaches. Aggressive locoregional approaches such as this should perhaps be attempted in patients with a better profile.

[Intracranial localization of Hodgkin's disease. Apropos of 2 cases]. / Localisations intracrâniennes de la maladie de Hodgkin. A propos de deux cas.

Intracranial localizations of Hodgkin's disease (HD) are uncommon. We report on 2 patients with HD who presented with an intracranial relapse. We discuss 1) the pathogenesis of those rare recurrences; 2) the therapeutic strategy.

[Stereotaxic ventriculocisternostomy in the treatment of triventricular obstructive hydrocephalus. Apropos of 23 cases]. / La ventriculocisternostomie stéréotaxique dans le traitement de l'hydrocéphalie obstructive triventriculaire. A propos de 23 cas.

UNLABELLED: During the period January 1975-October 1987, we performed stereotactic ventriculocisternostomy (V.C.S.) on 23 patients (13 M., 10 F.; age: 11-73 years, m: 33). Sometimes used as an isolated therapeutic procedure, V.C.S. may also follow stereotactic biopsies using Talairach's methodology. Serial stereotactic biopsies were performed in 15 out of 23 patients showing 11 tumoral lesion, two arachnoïdal cysts and two cryptic vascular malformations. Eight patients presented with an isolated aqueductal stenosis. Among the 12 non tumoral patients, seven had very large triventricular hydrocephalus (6 with a retroclival dilatation of the third ventricle) and 5 showed significant dilatation. Of the 11 tumoral patients, 7 had significant ventricular dilatation (1 with a protrusion of the floor of the third ventricle) and 4 with modest dilation. V.C.S. is done by creating an opening (diameter: 5-6 mm) in the floor of third ventricle with a fine forceps introduced through a tubular guide (diameter: 2.45 mm). The percutaneous double oblique transfrontal trajectory (drill-hole: 2.5 mm of diameter) passing through the foramina of Monro, avoids superficial and deep vessels visualised on the previous Stereoscopic Tele-Angiographic and Ventriculographic study. A systematic verification of the V.C.S. patency is made intraoperatively by injection of iodine contrast medium into the third ventricle. RESULTS: (non tumoral patients: 12) (m follow-up: 4 years): two patients needed a ventricular shunt after 3 and 1 months respectively, the first one because of an associated communicant hydrocephalus, the second because of a post-operative meningeal infection. Long-term clinical and CT-Scan follow-up showed that complete resolution (7 cases) or partial (2 cases) improvement of symptoms and signs was not accompanied by normalization of ventricular size, even though the dilatation was significantly reduced in 8 cases and to a lesser extent in 2. RESULTS: (tumoral patients: 11) (m follow-up: 3 years). Hydrocephalus was reduced in 6 cases and remained unchanged in 5. Two patients needed a ventricular shunt 2 years after the V.C.S.: 1 patient, because of a tumoral recurrence involving the region of the fenestration, the second patient because of adhesive arachnoiditis following reoperation for suspicion of recurrence, though this was found to be granulomatous inflammation. Two patients died as a result of their tumors at 2 and 6 years. CONCLUSION: Stereotactic V.C.S. is the treatment of choice for triventricular obstructive hydrocephalus even when there is no retroclival dilatation of the floor of the third ventricle.

Symptomatic Rathke's cleft cysts; clinical and therapeutic data.

The authors report on a case of symptomatic Rathke's Cleft Cyst (RCC). The only clinical feature was headache. The cystic fluid was aspirated through a trans-sphenoidal approach. The postoperative course was uneventful. The rarity of symptomatic RCC (70 cases described in the literature; 30 operated patients) makes necessary the comparison of all data quoted in the different publications so as to define an appropriate attitude to treatment. It thus seems that the surgical procedure should be limited to an aspiration of the cyst contents through a trans-sphenoidal approach; such a procedure is more reliable than a craniotomy to avoid leakage of the cystic fluid into the subarachnoid space and possible postoperative aseptic meningitis. Some authors discussed the possibility of postoperative radiotherapy although only six patients developed recurrence of their clinical features several years after operation and also the efficacy of such a procedure has not been proved.

Arachnoid cyst of the quadrigeminal cistern.

Arachnoid cysts of the quadrigeminal region are rare. We report two new cases. The first is a 29-year-old woman, who had a recurrence five years after sub-total removal of the cyst wall. Initially it was communicating and was treated by a ventriculo-atrial shunt; later it became noncommunicating and direct drainage of the cyst cavity was required. The second was a 25-year-old female, successfully treated by wide removal of the cyst wall thus creating a large communication with the subarachnoid space. Diagnosis of these lesions, as regards either morphological or functional features, nowadays rests largely on CT. Choices about treatment are extremely difficult. The most radical one, namely, complete removal of the capsule, is not without risks and disadvantages. More prudent methods, such as partial removal of the capsule and/or drainage of the cyst and the ventricles, seem on the whole to be preferable, but careful pre- and post-operative evaluation of CSF dynamics are essential for a satisfactory and long-lasting outcome.

Posterior fossa hemangioblastomas.

The authors report 40 personal cases of infratentorial hemangioblastomas and review 36 series from the literature for a total number of 1023 patients. The clinical, pathological, and surgical features of these tumors are discussed, with particular consideration of localizations outside the nervous system, multicentric tumors, recurrences, and long-term results. Although hemangioblastomas are benign tumors, their high growth potential makes their long-term development unpredictable in some cases.

[Real-time ultrasonography in neurosurgery. Puncture of an intracranial hypoechogenic cavity]. / Ultra-sonographie en temps réel en neurochirurgie. Ponction d'une cavité hypo-échogène intracrânienne.

The authors have been using real time echography in neurosurgical procedures since 1981: either for detection of a small sub-cortical tumor during a surgical operation, either for biopsy-guidance, or for puncturing a cavity (abscess, cyst or hematoma). The imaging is performed with a CGR SONEL 100 apparatus and two different frequency transducer elements: 3.5 MHz and 5 MHz. 56 patients underwent this technique; 22 times the lesion was hypoechoic: abscess give homogeneous, round hypoechoic image, often surrounded by a fine hyperechoic line; intracerebral hematoma produces an hypoechoic image after a 10 to 15 days evolution: compared to an abscess it then has a more hyperechoic irregular wave-like limit; tumoral-cyst echogenicity is very low; it can even be anechoic. If a stereotaxic structure exists, indication of real time echography must be limited to such stereotaxy contraindications: threatening intracranial hypertension, suppurated lesion, fragile patient. The technique has its limit: that is the small volume of the target-lesion (inferior to 10 mm); advantages must be emphasized: light procedure, satisfying confidence when considering the probe progression, sometimes better information than that of a CT-Scan examination especially for tumoral and cystic lesions.

Results of radiation treatment of medulloblastoma in adults.

From 1961 to 1982, 20 adults (greater than 16 years of age) were treated with radiation therapy following surgery for medulloblastoma. All patients received neuro-axis irradiation. Five patients received adjuvant chemotherapy. A 5- and 10-year survival rate of 78 and 55%, respectively, were achieved. Treatment failures were mainly a result of local recurrences, but also of metastases. One patient died of acute myeloid leukemia. One patient developed paraplegia. The survival rate was better in males (2 deaths out of 14) than in females (5 deaths out of 6). All the survivors are free of deficit or sequelae, except the patient with paraplegia.

Sites of primary malignancies in patients presenting with cerebral metastases. A review of 120 cases.

A retrospective study is reported of 120 consecutive cases of patients presenting with brain metastases as the primary sign of their malignancy. Primary site was found in 62 patients (53 while alive and 9 at postmortem examination) and remained unknown in 58. Lung was the most frequent primary site (45% of known sites), and digestive malignancies were surprisingly the second most frequent primary site (19% of known sites), whereas breast was found in less than 5%. When primary site was disclosed, in 85% it was after history, clinical exam, chest x-ray, and pathologic findings. Survival was almost identical in both known and unknown primary sites: 54% versus 44% at 6 months, 20% versus 16% at 1 year, and 6% versus 5% at 2 years. It was concluded that extensive evaluations to identify primary sites do not appear to be rational in patients presenting with brain metastases.

Giant intradiploic epidermoid cysts of the skull. Report of two cases.

The authors describe two cases of giant intradiploic epidermoid cysts of the cranial vault in which there was massive intracranial extension causing signs of neurological involvement. The very slow growth and the benign histological nature of these tumors explain their long preoperative evolution and the mild neurological signs in some cases. Roentgenographic and computerized tomography findings permit a correct diagnosis. Complete removal of these cysts and their capsules can be easily accomplished, despite their large size. Total removal of these cysts is associated with a very good long-term prognosis.

Intracranial haemostasis with a neurosurgical CO2-laser unit.

The authors have been using CO2-laser radiation routinely for more than 2 years. After having recalled the basic thermal properties of this beam, they present their experience. The goal of this work is to point out the particular benefit of CO2-laser cautery to perform tumoral haemostasis. The technical data of this CO2-laser haemostasis are detailed for 3 main indications: In cases of a precise origin of the haemorrhage, the coagulation of small intratumoural vessel necessitates a low output power: 2-4 watts in continued emission; 10-15 watts in the pulsed mode. The beam must be defocussed so as to be as large as the aimed vessel. A micro-manipulatotor is necessary for deeply located tumours. Basal meningiomas, neurinomas, giant adenomas are the best indications. If a diffuse bleeding is encountered in the operative cavity the output must be a little higher: 3-8 watts in continuous mode or 15-30 watts in the pulsed mode; first the cavity is swept with a defocussed CO2-laser ray; then the few larger vessels which have not been cauterized are coagulated one by one either by laser or by bipolar coagulation. The insertion zone of a meningioma can be efficiently coagulated by CO2-laser: a 150-200 watts output in the pulsed mode is necessary if the attachment is dural, a 300-400 watts pulsed output in the case of bony infiltration.

[Physical and technical bases of tumor hemostasis with a CO2 laser in neurosurgery]. / Bases physiques et techniques de l'hémostase tumorale avec un laser CO2 en neurochirurgie.

The particular thermal properties of CO2 laser make it an useful instrument for neurological surgery. Necrosis and carbonization zones, as well as its thermal diffusion in the nervous tissue are dramatically less important with a CO2-laser unit than with other lasers (Nd-Yag or Argon) and moreover with the electrical mono--or bipolar coagulator. That is why the authors chosed this instrumentation for achieving a good hemostasis. It was particularly useful during removal of intracranial tumors situated close to the functional structures of the basis of the brain and the brainstem. The authors present their experience with the french CO2-laser unit Ercelas 80 (Robert et Carrière Biomedical) that they have been using routinely since 1983 in 60 neurosurgical procedures. They present the technical standards necessary to perform such an hemostasis either with the hand-piece or using the micromanipulator. In all cases the output power must be much lower for hemostasis than for tumoral cutting or vaporization. Depending on the type of tumor, radiation power should vary from 2 to 10 watts if a linear emission is used, and from 10 to 30 watts in case of pulsed emission. On the other hand, CO2-laser beam must be unfocussed so as to avoid cutting the vessels less than 0.5 mm in diameter before coagulating them properly.

[Contribution of iodinated cisternography to craniocerebral computed tomography]. / Apport de la cisternographie iodée à la tomodensitométrie cranio-cérébrale.

Computerized tomography is usually adequate to explore supratentorial lesions of the skull and brain. However, it is often inadequate for a detailed analysis of lesions of the base of the skull and their anatomical rapports. Opacification of the subarachnoid spaces by means of a contrast medium (computerized cisternography) has proved extremely useful in such cases. The contrast media utilized are tri-iodized, water-soluble compounds which are well tolerated. The technique and anatomical data of the method are described, and its applications in different fields of tumoral and non-tumoral pathology are discussed.

[Frontal osteoma with orbital extension. Apropos of a case]. / Ostéome frontal à extension orbitaire. A propos d'un cas.

Fronto ethmoidal osteoma are rare slow growth benign tumors. Exceptional ophthalmological and neurological complications can occur. The authors report a case of 32 years old man with eye compression by a giant frontal sinus osteoma. This lesion was responsible for a vertical diplopia and moderate proptosis. Plain skull X-Ray show a well defined opacity filling the whole left frontal sinus and C.T. scan delimited precisely orbital extension. Neurosurgical exposure enabled a complete extraction of the tumor and satisfying recovery. The authors have compared this case to those described in literature and insist on the importance of the pre-operative C.T. scan.

[Value and limitations of the use of CO2 laser in neurosurgery. Reflexions from a French experience]. / Intérêt et limites de l'utilisation du laser CO2 en neurochirurgie. Réflexions tirées d'une expérience francaise.

The authors have been using routinely since February 1983 a french 80W. CO2 Laser unit. They discuss the advantages and limits of this technic in the light of the first 26 intracranial and intraspinal operations carried on with it. The main and wellknown qualities of CO2 Laser are: the easiness of the hemostasis of the tumor and of the surgical cavity; and the absence of traction on the same tissue. The coupling of CO2 Laser with the operating microscope appeared very useful and made safer deep tumor excision, particularly that of the posterior fossa such as neurinomas and meningiomas. It was also quite efficient for intra-orbital tumors. The maniability of the hand piece was increased by the use of oblique mirror (45 degrees and 60 degrees) fixed at its extremity. The incision of skin, subcutaneous and muscular layers was not simplified by CO2 Laser; indeed this apparatus increased the operatory duration and was responsible of a healing time extension.

Spinal metastases with neurological manifestations. Review of 600 cases.

The authors have studied 600 cases of spinal metastasis causing a neurological syndrome. The most significant statistical data are reviewed. The cases are examined according to clinical characteristics, type of primary tumor, site of lesion, and survival. Each of these factors influenced the choice and results of treatment. As a general rule, combined treatment (surgery and radiotherapy) was used. Preliminary surgery was performed as an emergency, designed to halt progression of the neurological syndrome and to prevent its more serious manifestations. The technique and usefulness of surgery are discussed for different situations and the short-term results of treatment are related to the various factors involved.