Intracranial meningiomas in elderly patients. Postoperative morbidity and mortality. Factors predictive of outcome.

We studied retrospectively a series of 96 patients (36 men, 60 women), older than 65 years of age (mean age: 70 +/- 4 years, range 65-82), operated upon for an intracranial meningioma from October 1978 to December 1988. Fifty-two patients (54%) were under 70, 32 between 71 and 75 and 12 over 75 (46%). The tumours were diagnosed for all the patients by CT scan. Thirty-four (35%) were located over the convexity, 24 (25%) in the falx/parasagittal region, 38 (40%) in the base, tentorium and posterior fossa. Neurological and physical conditions were assessed preoperatively and at the closing date in June 1989. Operative mortality was 16% (15/96). Patients were divided into two groups: poor outcome, defined by the death or a post-operative Karnofsky index less than or equal to 70 (n = 36), and good outcome defined by a Karnofsky index of 80 or more (n = 60). The two groups did not differ regarding age, sex ratio, tumour size and peritumoural oedema. The only predictors of poor outcome were poor preoperative general health condition (stage III of the American Society of Anesthesiology classification), (p less than 0.01), poor preoperative neurological condition (Karnofsky's index) (p less than 0.001), and location of the tumour on the base or in posterior fossa (p = 0.02).

[Psychic life and awakening from coma in neurosurgical intensive care]. / Vie psychique et réveils de coma en réanimation neurochirurgicale.

What is knowable concerning the lived experience and the psychopathology of patients during the border state between coma and waking? The waking up period appears divided in two parts: "apparent incommunicability" and "waking in strangeness". A pluridisciplinary follow-up seems necessary for patients beginning with the neurosurgical reanimation process.

Prevention of vasospasm in subarachnoid haemorrhage. A controlled study with nimodipine.

A prospective randomized double blind study was conducted in 70 patients suffering from subarachnoid haemorrhage, due to aneurysm rupture, to determine if the use of nimodipine reduces the severity of ischaemic deficits secondary to vasospasm. At the end of the study, two patients had severe deficit or died in the treated group, while 10 had a bad outcome in the placebo group. Angiographic vasospasm was not significantly different in its frequency or its severity between the two groups. However, the association of extensive and diffuse vasospasm was less frequent in the nimodipine group. This study confirms the effectiveness of Nimodipine in reducing the occurrence of neurological deficit due to vasospasm, even if this action is not observed in all cases.

Use of nitroglycerine to produce controlled decreases in mean arterial pressure to less than 50 mm Hg.

The cardiovascular effects of nitroglycerine (TNG) were studied in 30 patients requiring controlled hypotension for intracranial aneurysm surgery. In patients "resistant" to TNG (n = 9), sodium nitroprusside (SNP) was used to supplement the TNG. With TNG alone at a total dose of 31 mg and a mean hypotension duration of 28 min, mean arterial pressure (MAP) decreased by 43%, from 78.3 to 44.4 mm Hg as a result of decreases in cardiac index (Cl) (18%) and systemic vascular resistances (SVR) (21%). Simultaneously, a moderate increase in (Cao2 - Cvo2) (21%), and a significant increase in plasma renin activity (90%) were observed. In patients "sensitive" to TNG, the MAP decreased by 54%, Cl by 27% and SVR by 35%; HR remained stable. In patients "resistant" to TNG, the decreases in Cl and SVR were less marked: 2% and 22% respectively; the observed increase in HR was 12%. When non-toxic doses of SNP were used (less than 2 micrograms kg-1 min-1), hypotension was caused by decreased SVR (31%) and increased Cl (8%). TNG alone can be used to produce controlled decreases in MAP to around 50 mm Hg, and in patients "resistant" to TNG, SNP can be added to increase the hypotensive effect.

Prediction of cerebral vasospasm value of fibrinogen degradation products (FDP) in the cerebro-spinal fluid (CSF) for prediction of vasospasm following subarachnoid haemorrhage due to a ruptured aneurysm.

In a new treatment regimen with antifibrinolytic drugs in patients with aneurysmal subarachnoid haemorrhages, we have systematically controlled the level of fibrinogen degradation products (FDP) in the cerebrospinal fluid (CSF). The frequency of severe vasospasm with clinical ischaemia has been compared with the patient's initial level of FDP. Fifty patients have been included in this study. (All in Hunt and Hess's grades I or II on their arrival.) Patients with a secondary deterioration unrelated to vasospasm were excluded. The FDP levels were measured in the first three days following the bleeding and we were informed of them at the end of the study. The diagnosis of severe vasospasm was confirmed by arteriography and computed tomography (CT) and it was named "severe" when accompanied with signs of clinical ischaemia. Twenty patients developed a severe vasospasm with clinical ischaemia. In these patients, the mean value of the initial FDP level was between 80 and 320 mcg/ml compared with 20 to 80 mcg/ml for those who had not developed clinical ischaemia (p = 0.0009). Furthermore, two different groups may be discriminated by their initial FDP level: FDP greater than 80 mcg/ml; n = 23, 65% severe vasospasm; FDP less than 80 mcg/ml; n = 27.8% no severe vasospasm (p less than 0.001). These results do not imply a direct role of FDP in pathophysiological mechanisms of vasospasm, but they suggest a relationship between the clot lysis and the appearance of vasospasm with clinical ischaemia. To our knowledge this is the first time that such a predictive role can be attributed to the initial FDP level in the prognosis of vasospasm.

[Prognostic value of cerebrospinal fluid fibrinolytic activity in meningeal hemorrhages as a result of aneurysm rupture]. / Intérêt pronostique de l'activité fibrinolytique du l.c.r. dans les hémorragies méningées par rupture anévrysmale.

26 patients with subarachnoid hemorrhage from ruptured cerebral aneurysms have been reviewed. Fibrinolytic activity of the C.S.F. has been evaluated by the dosage of Fibrin/Fibrinogen degradation products (F.D.P.). When patients have developed clinical signs of ischemia, F.D.P. levels were significantly higher than in those without neurological deficit. Even, if the detection of F.D.P. seems directly correlated to the presence of blood in the C.S.F., there is no direct relation between their level and the importance of S.A.H. as shown by C.T. scan. However when F.D.P. levels are greater than 80 mcg/ml, there is a high risk of vasospasm with clinical signs.

[The use of electrical transcutaneous nerve stimulations in chronic pain. Method and preliminary results in 28 cases (author's transl)]. / Utilisation des stimulations nerveuses transcutanées dans le traitement des syndromes douloureux chroniques. Méthode et résultats préliminaires obtenus dans 28 cas.

The analgesic effect of conventional transcutaneous nerve stimulation has been studied in 29 patients, all having a chronic pain caused by peripheral neurological disease. As already reported in the literature half of patients were improved on a short-term basis. Long-term improvement was observed mainly in patients with traumatic nerve lesions; such cases, thus appear to be the best indication for this method. It should be emphasized that whatever the etiology, the delay between the onset of pain and the beginning of transcutaneous stimulations was a critical factor. Nine out of ten patients suffering for less than one year were satisfactorily improved. This suggests that transcutaneous stimulations should be used as early as possible after the onset of neurological pain.

[Total removal through the ventricle in 2 cases of pallidocaudal arteriovenous abnormalities under deep hypotension]. / Exérèse totale par voie ventriculaire de deux malformations aftério-veineuses pallido-caudées sous hypotension profonde

Two cases of A.V.M. situated in the pallido-caudal area and directly nourrished by the anterior perforated space arteries have been investigated using three angiographic techniques: selective internal carotid angiography, angiotomography including pneumoencephalography and angiography under deep hypotension at 30 mm Hg (mean pressure) induced by sodium nitroprusside. These investigations led to the conclusion that the A.V.M. could be removed through the lateral ventricle. Both were radically removed using the retrograde technique under deep hypotension and the operative microscope. Both patients are alive without additional neurological deficit.