[Intracranial hemorrhage in adults: place of antithrombotic treatment]. / Hémorragies intracrâniennes de l'adulte : implication de plus en plus importante des traitements antithrombotiques ?

BACKGROUND AND PURPOSE: Antithrombotic (anticoagulants and antiplatelets) are responsible for iatrogenic accidents, with a specific impact in neurosurgery. Bleeding complications are the most common and best-known. But the link to antiplatelet or to dual association of antithrombotic treatment with intracranial haemorrhage is not complete yet. We studied the proportion of patients under antithrombotic treatment, when an intracranial hemorrhage occurred, as well as the morbi-mortality of each group of patients (with or without antithrombotic treatment). Finally, we studied the proportion of off-label prescriptions. METHODS: We conducted a monocentric and comprehensive prospective study on a group of patients. All patients that had been admitted for intracranial hemorrhage to our hospital, in a 5-month period were included in the study. RESULTS: One hundred and sixty patients admitted for an intracranial hemorrhage were included during 70days of call. Seventy-four of these patients (46.25%) were under antithrombotic treatment: 40 under antiplatelet treatment (54%), 29 under anticoagulant treatment (39.2%), four under dual antithrombotic treatment (5.4%), and one under Arixtra(®). Half of the patients under antithrombotic treatment had poor prognosis as compared to 40% of patients without antithrombotic treatment. Off-label antithrombotic therapy was estimated at 27.3% of all prescriptions. CONCLUSIONS: The prevalence of antithrombotic therapy in patients is high when intracranial hemorrhage occurs. Some complications could be avoided by decreasing the number of off-label prescriptions and by better controlling their use (using standardized INR). Antiplatelet treatments and new antithrombotic therapies require better drug monitoring which could be part of the establishment of a specific register.

Delayed hypoglossal nerve palsy following unnoticed occipital condyle fracture.

Occipital condylar fractures (OCFs) are rare and difficult to diagnose. The routine use of computed tomography (CT) scan in traumatology has however now made their diagnosis easier, with an estimated frequency of 4 to 19% of craniospinal traumatized patients and 0.4 to 0.7% of all severe traumatized patients in emergencies. This paper describes a patient who was not diagnosed with OCF during his first hospitalization after a road accident. However, 15 days later a left sided hypoglossal nerve palsy occurred. In this case report, we underline that an examination of the cranial nerve is a quick and easy procedure to screen each head trauma patient for occipital foramen fractures. Also, careful attention must be paid to X-Rays, CT scans and magnetic resonance imaging of the craniocervical junction.

[Fractionated radiotherapy of intracranial meningiomas and neurinomas]. / Radiothérapie fractionnée des méningiomes et des neurinomes intracrâniens.

In most institutions, surgical excision remains the standard treatment of meningiomas and neurinomas; the aim of surgery is complete resection. However, total removal is not always feasible without significant morbidity and in some cases, the patient's condition contraindicates surgery. For incompletely excised tumors, recurrences will have consequences on neurological functions. There are now many reports in the literature confirming the fact that radiotherapy significantly decreases the incidence of recurrence of incompletely resected benign tumors and that it can replace surgery in some situations where an operation would involve considerable danger or permanent neurological damage: about 80 to 90% of such tumors are controlled with fractionated radiotherapy. Stereotaxic and three-dimensional treatment planning techniques increase local control and central nervous system tolerance so that the respective place of surgery and radiotherapy needs to be redefined, considering efficacy and morbidity of these two therapeutic means. In this article, we limit our remarks to fractionated radiotherapy and, after a review of the literature, we discuss the indications, volume evaluations and the techniques currently used.

[Central nervous system. Experience of the Bordeaux University Hospital Center and review of the literature]. / Les dysgerminomes du système nerveux central. Expérience du Centre Hospitalier Universitaire de Bordeaux et analyse de la littérature.

PURPOSE: Retrospective analysis of 17 patients with intracranial germ cell tumors treated in a multidisciplinary consultation at the Bordeaux University Hospital a and literature review. MATERIALS AND METHODS: Seventeen consecutive patients were treated from 1978 to 1995 for a primary intracranial germ cell tumor. Median age was 14 (range 3-29 years). There were two malignant teratoma, six proved germinoma and nine presumed germinoma (diagnostic based on biological, radiological and treatment criteria). All received radiotherapy from 30 to 60 Gy (median 40 Gy) in different volumes. Chemotherapy was administered in 15 cases, three after surgery and 12 after radiotherapy. RESULTS: All tumours were in complete remission after initial treatment. The two malignant teratomas recurred in non-irradiated area after nine and 48 months, and the patients died. None of the germinoma recurred within a follow-up period of two to 17 years (median 65 months). Five and 10 year actuarial overall survival rates were the same: 84% for all histologies and 100% for germinomas. Only two patients developed school difficulties and six presented an hypopituitarism, of which one was consecutive to radiotherapy. Chemotherapy was well tolerated. CONCLUSION: This retrospective study and literature analysis are in favor of limited dose and volume of radiation therapy associated with chemotherapy.

[Intramuscular myxoma. A case of myxoma of the spinal erector muscle]. / Myxome musculaire. Une observation de myxome des muscles érecteurs du rachis.

A case of intramuscular myxoma, extended in the lumbar erector spinae muscles, is reported. This soft tissue tumor is rare, about one hundred observations are indexed in the literature. The clinical findings are nonspecific, magnetic resonance imaging reveals few characteristics, and finally a histological examination is required, after surgical removal, to pinpoint the diagnosis. Recurrence is uncommon, but a systematic follow-up is necessary.

[Oculomotor paralysis and head trauma]. / Paralysies oculomotrices et traumatismes crâniens.

Few studies have dealt with post-trauma ocular motor palsy. We analyzed 31 personal cases and reviewed the literature, focusing on pathogenesis. We emphasize the importance of a complete radiological examination including magnetic resonance imaging when the CT-scan does not provide a satisfactory correlation between anatomic findings and clinical presentation. Systematic detection, early management and regular follow-up is mandatory.

[Temporal lobe epilepsy and ganglioglioma in children. Clinical aspects, imagery and neuropathology; nosological discussion of six cases]. / Epilepsie temporale et gangliogliome chez l'enfant. Aspects cliniques, imagerie et neuropathologie; discussion nosologique de six observations.

BACKGROUND: Gangliogliomas belong to debated nosological entity. They are classified as neuronal or neuroglial tumors. PATIENTS AND METHODS: Six children aged from 4 months to 15 years (mean age: 4 years and 6 months) were initially seen for partial seizures resistant to treatment. Tumoral resection was performed in all six. Diagnosis was made from immunohistological study of the tumor. DISCUSSION: Gangliogliomas are non-malignant, with a good prognosis, even if inaugural clinical manifestations are severe. Neuroradiological diagnosis with astrocytomas and cortical dysplasia is not easy, and pathological distinction from cortical dysplasia is difficult. CONCLUSION: The immunohistochemical confirmation of diagnosis permits a logical therapeutic attitude: complete resection of tumor is followed by an excellent outcome.

[Endocranial complications of cholesteatoma: apropos of 8 cases]. / Les complications endocrâniennes du cholestéatome: à propos de 8 cas.

The authors present a recent series of 8 cases of intracranial complications secondary to cholesteatoma. The series is made up of 3 temporal lobe abscesses, 1 parietal lobe abscess, 1 cerebellar abscess, 1 extradural abscess, one lateral sinus thrombo-phlebitis with subdural abscess and one meningitis on its own. Otological management with removal of the cholesteatoma was by open or closed technique, depending on the local anatomical conditions. It was supplemented by multiple antibiotic therapy, in turn guided by the bacteriological cultures and by any known epidemiological information. It was necessary to needle the abscess by a neurosurgical approach in two cases. The results of bacteriological samples taken for analysis from the intracranial abscesses are often negative, which limits their clinical value. In such cases, the choice of antibiotics rests on epidemiological information. The authors emphasise the progress that has been made towards the early diagnosis of intracranial complications. Appropriate combined medical and surgical treatment leads to complete cure without neurological sequelae in most cases.

Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients.

PURPOSE: To evaluate efficacy and tolerance of external fractionated radiation therapy (RT) in the treatment of intracranial meningiomas. METHODS AND MATERIALS: From January 1981 to September 1993, 91 patients with intracranial meningiomas were treated with fractionated RT. Indications were as follows: (a) incomplete surgical resection, 29 patients; (b) tumor recurrences without considering the amount of the second resection, if performed, 14 patients; (c) completely excised angioblastic, aggressive benign, and anaplastic tumors, 8 patients; (d) medically inoperable and basilar tumors where operation would involve considerable danger or permanent neurological damage, 44 patients. Most patients were irradiated with 6 to 9 MV photon beams. A three- to four-field technique with coned-down portals was used. Doses were calculated on the 95% isodose and were given 5 days a week for a median total dose of 52 Gy (1.80 Gy/fraction). RESULTS: Median follow-up from radiation therapy was 40 months. Acute tolerance was excellent, but there were six late delayed injuries. Tumor recurrences occurred in six cases. Six patients died from their tumor or RT complications, 19 from nontumoral reasons. Three, 5- and 10-year survival rates were 82, 71, and 40%, respectively. The most significant prognostic factor was age: 5-year survival rate was 86% for patients less than 65 years and 37% for patients more than 65. However, there were no differences in recurrence-free survival rates between patients younger than 65 and the oldest ones. Of 60 symptomatic patients with neurological deficits, 43 had neurological improvement (72%), beginning in some cases within 15 to 20 days after starting RT. CONCLUSION: These results reassess the role of fractionated RT in the treatment of meningiomas, and stress on its efficacy, especially on cranial nerves palsies, without severe toxicity in most cases.

Mean term follow-up of a series of post-traumatic syringomyelia patients after syringo-peritoneal shunting.

We report the follow-up of a series of post-traumatic syringomyelia patients treated by syringo-peritoneal shunting (SPS). The neurological status was determined following the international ASIA/IMSOP standards for neurological classification of spinal cord injury; this was completed by a modified Silberstein classification that identifies the ascending neurological symptoms as well as the increasing myelopathic symptoms in patients with post-traumatic syringomyelia. Magnetic resonance imaging (MRI) was systematically performed to assess the presence of a postoperative residual syrinx or of meningeal fibrosis. Eight patients were studied (five men, three women) with an age ranging from 17 to 54 years (mean of 30.7 years) at the time of the spinal cord injury. Three had a complete or nearly complete paraplegia, five were incomplete. The post-traumatic syringomyelia was diagnosed from 2 to 8 years after the spinal cord injury and was treated by syringo-peritoneal shunting. Early complications occurred in three patients: (1) displacement of the catheter, (2) obstruction of the catheter, and (3) haematomyelia, which disappeared after a new surgical procedure was performed. The postoperative follow-up ranged from 3 to 9 years (mean of 4.5 years). The neurological level decreased in every case and the ascending neurological symptoms decreased or were stabilised in seven patients. The postoperative ASIA/IMSOP scores and the increasing myelopathic symptoms improved in four patients but worsened in the four others, incomplete. The MRI showed an important decrease of the syrinxes in every patient associated with a serious meningeal fibrosis in five cases. Syringo-peritoneal shunting seems to be efficient in the treatment of the syrinx but may have a poor effect regarding the prevention of meningeal fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arachnoid cysts of the cerebellopontine angle]. / Les kystes arachnoïdiens de l'angle ponto-cérébelleux.

The authors report two cases of arachnoid cysts of the cerebello-pontine angle. The otologic symptoms were unsteadiness, hearing fall and tinnitus. In the first case, the patient who presented a cerebellar syndrome was operated. Afterwards the hearing felt and he developed a transient hydrocephalus. The symptoms disappeared in 9 months. In the second cas, the patient was not operated. She was treated medically and supervised. Then the symptoms disappeared too. The authors review the paraclinic exams especially MR, relevant to the diagnosis and discuss the opportunity of a surgical operation.

[Medulloblastoma in children. Prognostic incidence of vascular hyperplasia, coagulation necrosis and postoperative clinical state on survival]. / Le médulloblastome de l'enfant. Incidence pronostique de l'hyperplasie vasculaire de la nécrose de coagulation et de l'état clinique post-opératoire sur la survie.

Fifty consecutive children with cerebellar medulloblastoma were operated on May, 1971 to December, 1988. At 5 and 10-years, actuarial survival rates were respectively 46% & 42%. To determine prognostic factors, various clinical and histological features were analysed: multivariate analysis showed that increased vascularity, coagulative necrosis, and postoperative clinical status have a significant influence survival. When necrosis and/or increased vascularity were present (H+), the 5-year survival rate was 17%, whereas it was 70% when absent (H-) (p less than 0.0001). Postoperative clinical status was described as poor when neurological symptoms such as vigilance or vegetative disorders, akinesia, hypotonia, apragmatism, mutism and emaciation were associated; the 5-year survival rate was 10% in the presence of such deficits (C+) and 55% in their absence (C-) (p = 0.0002). From these results, 2 distinct groups were identified: Group 1: 23 patients without pejorative factors (H- and C-); 5 and 10-year survival rates were 80%. Group 2: 27 patients with one or two pejorative factors (H+ and/or C+); 5 and 10-year survival rates were respectively 18% and 12% (p. less than 0.0001). From our experience, it appears that histology and postoperative clinical status can be early predictors of patient outcome, since neurosurgical and radiation therapy techniques have been largely optimized. These factors could be the basis for developing adapted treatment protocols.

Histiocytosis X of the hypothalamus.

An unusual case of cutaneous and hypothalamic histiocytosis X (HX) is reported. The hypothalamic involvement occurred as a tumor that mimicked a chiasm glioma on computed tomography angioscanning. Magnetic resonance imaging after gadolinium injection localized the tumor within the third ventricle floor. The HX origin of the tumor was confirmed by histological examination of hypothalamic biopsies obtained by transventricular endoscopy. The results of endocrine evaluation were consistent with anterior panhypopituitarism resulting from a multiple releasing-hormone secretory defect, but there was no diabetes insipidus. This unusual endocrine aspect has not been previously described in the field of hypothalamic HX. Lastly, the tumor was insensitive to low dose megavoltage radiation therapy. This unusual case stresses the superiority of magnetic resonance imaging over computed tomography scanning in the assessment of suprasellar tumors and emphasizes the usefulness of transventricular endoscopy in these cases.

[Subdural hematoma of the posterior fossa in a full-term newborn infant]. / Hématome sous-dural de la fosse postérieure chez un nouveau-né à terme.

The authors report a case of subdural hematoma of the posterior fossa in a full-term neonate. The lack of specific symptoms is frequent. Diagnosis relies on CT scan and NMR data. In cases with neurologic involvement, good results depend on rapid neurosurgical treatment, in order to avoid sequelae.

An anatomic and dynamic study of the greater occipital nerve (n. of Arnold). Applications to the treatment of Arnold's neuralgia.

This study concerns the posterior ramus of the second cervical spinal n., or greater occipital of Arnold. By means of dissections in formalin embalmed cadavers, an attempt was made to define its winding course and to locate it in relation to clinical or radiographic landmarks, so as to provide a guide for infiltration of the nerve with local anesthetic. At the same time a dynamic study was made to elucidate the relations of the nerve to adjacent structures during the different movements of the neck. This allowed us to propose clinical tests of nerve involvement and to reveal the zones where the nerve is anatomically vulnerable.

Anatomical basis of the extended subtemporal approach to the cerebellopontine angle: its value and limitations.

The cerebellopontine angle is an anatomic region situated deeply at the anterolateral aspect of the brainstem, access to which is complicated by the presence of neurovascular bundles. The functional importance of these cranial n. (trigeminal, facial, vestibulo = cochlear, glossopharyngeal, vagus and accessory) calls for the use of special surgical routes of access in certain cases. In particular, tumors situated between the vestibulocochlear-facial bundle behind and the trigeminal n. in front are difficult to reach by the suboccipital and subtemporal transmeatal routes. The endeavor to preserve hearing in particular situations, where the side opposite the tumor is no longer functional, justifies the use of a subtemporal transmeatal route extended by opening the tentorium cerebelli. This anatomic and experimental surgical study deals with the possibilities of this route of approach.

[Intrathecal analgesia. Apropos of 50 cases]. / Analgésie par voie intrathécale. A propos de 50 cas.

Fifty patients with intractable pain, mainly of neoplastic origin, were treated by morphine through unidose drug delivery system. Criteria of selection of the patients and technical procedures are reported. Most common side effects are nausea and dysuria but can be effectively prevented. The most severe complications are leakage of cerebro spinal fluid with or without meningitis. The success rate at 20 days is 80% as well in pelvic pain as in subdiaphragmatic extra cephalic pain.