Massive non-aneurysmal subarachnoid hemorrhage after cervical carotid angioplasty and stenting: A case report and review of the literature.

INTRODUCTION: Carotid angioplasty and stenting (CAS) of the cervical segment is a safe and effective procedure for the treatment of carotid artery disease. In rare cases, this procedure causes intracranial hemorrhage (ICH), which is described most often as an ipsilateral intra-parenchymal hematoma. This ICH is the result of a cerebral hyperperfusion syndrome (CHS). Isolated subarachnoid hemorrhage may occur exceptionally, with only 9 cases that have been reported in the literature. OBSERVATION: We reported a case of a 71-year-old man who presented a massive non-aneurysmal subarachnoid hemorrhage one hour after angioplasty and stenting of the cervical segment of the left internal carotid artery. Medical and surgical management included external ventricular drain placement. Rebleeding occurred two days later, worsening the patient's clinical condition. Finally, the patient died 2 weeks later. COMMENTS: This rare presentation of ICH following CAS allows us to discuss the risk factors, complications and management of CHS.

Tumor-to-tumor metastases: Latent renal cell carcinoma discovered after elective surgical resection of a convexity meningioma.

BACKGROUND: Tumor-to-tumor metastases are extremely rarely reported lesions, which usually involve an indolent lesion hosting a more aggressive neoplasm. We present an unusual initial manifestation of a previously unknown clear cell renal cell carcinoma as a tumor-to-tumor metastasis in a typical meningothelial meningioma. CASE REPORT: A 73-year old patient with transient left slight monoparesis was addressed to our Neurosurgical Department after being evaluated by his general practitioner and passing a cerebral MRI which revealed a right frontotemporal mass attached to the meninge. At presentation, no deficits were identified; therefore an elective surgery was proposed. Histological analysis revealed a typical meningothelial meningioma containing a metastatic clear cell renal cell carcinoma. Additional thoraco-abdominal computer tomography identified a 6cm diameter lesion within the right kidney with radiological features highly suggestive of a primary clear cell renal cell carcinoma. CONCLUSION: Our case highlights the need for a specialized neuropathological approach to clinical and imagistic indolent meningiomas, as they may require important differential diagnosis that can highly impact the treatment and follow-up of brain tumor patients.

Sudden paraplegia due to spontaneous bleeding in a thoracic epidural angiolipoma and literature review.

BACKGROUND: Spinal angiolipomas are rare epidural tumours that are usually revealed by chronic symptoms of medullar irritation. We report a case of acute paraplegia caused by spontaneous bleeding revealing a thoracic angiolipoma. CASE DESCRIPTION: A 17-year-old male patient with no previous medical history was admitted for acute onset of paraplegia with bladder retention and loss of sensation in the lower limbs, preceded by dorsal pain during the three previous days. MRI showed an enhanced T1-weighted image of a T7-T12 epidural lesion. The T1-weighted isosignal and the T2-weighted hyposignal suggested haemorrhagic complications. Due to a mass effect on the spinal cord, an emergency laminectomy was performed. Histopathological examination of the lesion revealed an angiolipoma with spontaneous bleeding. Clinical outcome was favourable after two months. CONCLUSION: This case is one of the first to be reported, although the clinical presentation is similar to that of other rare reported cases of paraplegia due to spinal compression by tumoural bleeding.

Untreated unruptured aneurysm: Natural history at long-term.

BACKGROUND AND OBJECTIVES: Although the diagnosis of unruptured intracranial aneurysm (IA) has become more frequent, its natural history and management still remain controversial. A better comprehension of its evolution could optimize our therapeutic strategies. The aim of our study was to evaluate, in a cohort of patients with untreated unruptured IA based on the proposition of multidisciplinary staff meetings, the proportion of bleeding, death and cardiovascular events during a long-term prospective follow-up. PATIENTS AND METHODS: This longitudinal study concerned a series of patients with unruptured IA collected over a period of 8 years (2006-2014) identified from a prospectively collected database including all patients with unruptured IA discussed during multidisciplinary staff meetings in the neurosurgery department at Rouen University Hospital. Clinical endpoints were the rupture rate, incidence of death or occurrence of noticeable pathological event defined by any event leading to death, admission to the intensive care unit or challenging the vital prognosis. RESULTS: After a mean follow-up delay of 46.9±18.7 months, the IA remained stable in 73 patients (98.6%) out of 74. The rate of rupture per aneurysm year of follow-up was 0.3%, the rate of cardiovascular events was 2.1% and the death rate was 2.8% per year of follow-up. DISCUSSION: In this study, we emphasize the important incidence of adverse events in these patients, which has to be taken into account before proposing a prophylactic IA exclusion. The low incidence of IA rupture confirmed the decision of conservative treatment made during a multidisciplinary staff meeting.

Management and outcome of cerebral venous thrombosis after head trauma: A case series.

Cerebral venous thrombosis (CVT) is an underdiagnosed complication of head trauma. To date, initiation of anticoagulation is still a matter of debate because of the risk of worsening traumatic hemorrhage. This report describes a case series of five patients admitted for head injury complicated by CVT. The main associated radiological signs were skull fractures crossing the venous sinus and adjacent traumatic hematoma. In four patients, anticoagulation was introduced within 48-72h of CVT diagnosis, with no subsequent hemorrhagic complications. The present report and data from the literature raise the question of systematic additional venoscans when confronted by associated radiological features of post-traumatic CVT. The safety of anticoagulation in selected patients is also discussed.

Effects of melatonin in the treatment of asthenia in aneurysmal subarachnoid hemorrhage.

BACKGROUND AND OBJECTIVES: Survivors of aneurysmal subarachnoid hemorrhage (aSAH) commonly experience sleep disorders resulting in asthenia. The objective of this prospective study was to determine, in a cohort of patients with treated ruptured intracranial aneurysm (IA), the proportion of asthenia at 2months, in a cohort of patients treated with melatonin and in a control cohort. PATIENTS AND METHODS: Twenty consecutive patients admitted for the treatment of ruptured IA and able to answer a standardized questionnaire were included in the study. After evaluation for fatigue at discharge, we divided our population into 2 cohorts of 10 patients: the first cohort was treated with melatonin for a period of 2months; the second cohort had no specific treatment for fatigue. The primary endpoint was the proportion of asthenia at 2months in both groups. Confounding factors, such as depression, autonomy and apathy were evaluated at the same time. RESULTS: At discharge, there was no significant difference observed between both groups in terms of mean age and initial clinical status (WFNS, Rankin Scale and Fatigue Severity Scale). At 2months, the mean FSS score in the control group was of 4.7±1.0 versus 3.8±0.9 in the melatonin group (P=0.03). The mean MADRS score in the control group was of 1.1±1.45 versus 2.7±2.5 in the melatonin group (P=0.10). The mean LARS score in the control group was of -32.5±1.7 versus -31.7±1.9 in the melatonin group (P=0.24). DISCUSSION: In a prospective evaluation of post-aSAH fatigue, we suggest that melatonin could decrease fatigue. There is no significant impact on depression and apathy. Further studies would be necessary to improve our comprehension of fatigue physiopathology in a context of aSAH.

Giant intracranial aneurysms in the paediatric population: Suggested management and a review of the literature.

OBJECTIVES: Intracranial aneurysms are rare in children although giant aneurysms more commonly occur in adolescence. The aims of our study were to perform an extensive review of the literature over the past two decades and assess intracranial aneurysm management. METHODS: Based on a Pubmed search, we carried out a review of the literature from 1990 to 2012 regarding giant intracranial aneurysms diagnosed in the paediatric population. This descriptive study concerned clinical presentation, cerebral aneurysm characteristics, therapeutic management procedures and outcome. RESULTS: Forty-six cases were reported in 31 papers. The male/female sex ratio was 1.15, the clinical presentation was a tumour mass syndrome in 56.6%, followed by rupture in 30.4%. The aneurysm location was the posterior circulation in 41.3%, and microsurgical treatment (52.2%) predominated over endovascular coiling (28.3%). CONCLUSION: To date, no evidence-based medicine recommendation has been accepted for the management of rare intracranial aneurysms. Each reported patient was the object of a multidisciplinary clinical decision. Management of this challenging pathology should be performed on a case-to-case basis.

Cervical spine fractures in patients with ankylosing spondylitis: Importance of early management.

INTRODUCTION: Ankylosing spondylitis (AS) affects 0.5% of the population. Alteration of the biomechanical properties of the spine related to AS explains the high prevalence of traumatic vertebral fractures and risk of instability. At admission, 65% of patients present neurological signs. There are no reported studies regarding secondary neurological deterioration. The aim of this study was to evaluate the rate of secondary neurological deterioration before surgical treatment of spine fracture in a context of AS. METHODS: This retrospective cases series consisted of patients admitted for traumatic cervical spine fractures or luxation in a context of AS between June 2007 and December 2012. Clinical status was evaluated using Frankel classification at time of trauma, at admission to the neurosurgery ward, as well as before and after surgery. Delay between trauma and admission, and between admission and surgery was recorded. Causes of morbidity, mortality and surgical management were discussed. RESULTS: During the study period, seven patients were admitted for traumatic cervical spine fracture or luxation. All patients were autonomous before trauma. Between trauma and transfer to neurosurgery ward, the status of four patients worsened. Mean delay between trauma and admission was 12.9 days (range 1 to 60 days). Between admission to neurosurgery ward and surgical treatment, two more patients worsened and only two patients remained autonomous. Mean delay between admission and surgery was 15.7h (range 2 to 24h). Neurological deterioration was due to both deterioration during transfer despite immobilization with a rigid cervical collar and failure of X-ray to reveal any fractures, in two and three cases respectively. After surgery, clinical status remained unchanged in two patients, four patients improved, and one patient worsened. Two patients died from respiratory failure a few days after surgery due to neurological deterioration. Five patients had a delayed diagnosis (>24h). CONCLUSION: Cervical spine fracture in AS is a serious condition with high instability. Our series emphasizes the necessity of early surgical treatment because of risk of secondary neurological deterioration in cases of delayed treatment. CT scan must be the gold standard for exploration of these patients.

Coincidental vascular anomalies at the foramen magnum: dural arteriovenous fistula and high flow aneurysm on perimedullary fistula.

We report the case of a 59-year-old woman admitted for a sudden headache due to a subarachnoid haemorrhage. On CT scan, the clots predominated into the posterior fossa without high-density in the sylvian or interhemispheric fissures. The vertebral angiography revealed a dural arteriovenous fistula at the foramen magnum associated to an aneurysm of the cervical anterior spinal artery. Due to the high rebleeding risk of a dural shunt, we proposed curative treatment using microsurgical interruption of the intradural draining vein. On the postoperative angiography at 15-day follow-up, the 2 malformations were corrected and the outcome at 6 months was excellent. Based on the literature, we assess this exceptional association and suggest its possible management.

Distal middle cerebral artery aneurysm: A proposition of microsurgical management.

OBJECTIVES: Based on a cohort of patients treated on distal middle cerebral artery (MCA) aneurysm by microsurgical approach, the objectives were to assess the following: the postoperative functional outcome, study the causes of early neurological deterioration and to determine the predictive factors of favourable outcome. PATIENTS AND METHODS: From a neurovascular prospective database, this retrospective longitudinal study included all the patients treated for cerebral aneurysm located on the distal segment of the MCA over two decades (January 1990-December 2011). The patients were all treated by microsurgical clipping exclusion. Any aneurysm was associated to infectious angiopathy. Data were retrieved from the patient's medical charts. The outcome was analysed twice: during the immediate postoperative period and at 6 months according to the modified Rankin scale. The relative risk was estimated for each variable and the prognostic factors were assessed using a multivariate logistic regression model (P<0.05). RESULTS: Twenty-eight patients, mean age 40±13.3 years (median: 43 years; range 6-70 years) were divided into the ruptured group (n=20) and unruptured group (n=8). In the ruptured group, the initial clinical status was good (WFNS I-III) in 12 patients (60%) and poor in eight (40%) with an intracerebral haematoma (ICH) in 11 (55%). For both groups, the aneurysm location on the distal MCA decreased at a rate from 64.8% of the insular segment to 25% of the opercular then 10.7% to the cortical. During the hospital stay, neurological deterioration occurred in 16 patients (57.2%). The diagnosed causes were cerebral ischaemia in 10 (35.6%), initial ICH in three (10.7%), hydrocephalus in two (7.1%) and epilepsy in one (7.1%). At 6 months, a favourable outcome (mRS 0-2) was observed in 19 patients (68.1%), a definitive morbidity in seven (24.9%) and death in two (7.2%). Based on the prognostic factors, only the absence of immediate postoperative neurological deterioration was identified as significant for a favourable outcome. CONCLUSION: These rare cerebral aneurysms resulted in a high proportion of poor initial status related to a frequent ICH. Cerebral ischaemia was a major cause of the immediate neurological deterioration and the absence of immediate neurological deterioration was the single identified prognostic factor.

Elderly patients with aneurysmal subarachnoid hemorrhage: Coils but also clips.

The ageing of the population in good health or without severe morbidity expose them to the occurrence of a subarachnoid hemorrhage (SAH) and requires effective management. Currently, the pertinence of cerebral aneurysm treatment by clipping or coiling is accepted for patients in the 8th or 9th decade of life, and the risk of postoperative morbidity induced by our therapeutic alternative must be carefully assessed. In these decades, the female/male sex ratio for aneurysmal SAH was greater in female who had a 1.6 times higher ratio than in male. The initial clinical status did not appear worse with age despite the frequent severity of bleeding observed on CT scan probably due to the large subarachnoid space. The aneurysm distribution and size were similar to those classically reported in the global population. The endovascular (EV) coiling appears as the first option with a favorable outcome rate estimated at 48% to 63%. Nevertheless, the benefit of EV coiling compared to microsurgical clipping for treatment of ruptured aneurysm in the elderly has not been demonstrated in a large randomized study. This is the reason why the vascular section of the French Society of Neurosurgery developed a prospective and randomized study of the aneurysmal SAH (PHRC 2007-042/HP) on the elderly patients.