Management of benign nerve sheath tumors of the brachial plexus: relevant diagnostic and surgical features. About a series of 17 patients (19 tumors) and review of the literature.

Brachial plexus (BP) tumors are rare, potentially difficult-to-manage lesions. The method is retrospective chart analysis. Among the 17 patients, four had neurofibromatosis and one schwannomatosis (NF +). The latter has bilateral BP tumors that remain stable on MRI at a 6.5 year follow-up. Another NF + patient has bilateral non-operable BP plexiform neurofibromas. The complaints of the 15 operated patients were radiated pain, a mass, local pain, paresthesia, a neurological deficit (n = 15, 12, 7, 10, 7). On MRI, the tumors appeared as nodular or ovoid large masses. Four operated tumors were proximal, reaching the foramen. The FDG-PET scan (n = 4) always showed tumor hypermetabolism. A preoperative percutaneous biopsy was done in three patients before neurosurgical consultation; one of them developed neurogenic pain and a sensory deficit following two percutaneous biopsies for a misinterpreted cervical lymphadenopathy. Surgery was performed using a supra-, infra-, supra- + infra-clavicular or posterior subscapular approach (n = 8, 3, 3, 1). Intraoperative electrophysiology was used in all patients. Complete or gross total resection was achieved in 14 patients. Two patients had fascicle reconstruction with grafts. Pathology revealed 13 schwannomas and two neurofibromas. Neurogenic pain transiently developed or worsened after surgery in five patients. At last follow-up, a mild deficit remained in four patients (preexisting in three). No recurrence had occurred. We conclude that a thorough examination of any patient with a cervical or axillary mass is crucial to avoid misinterpretation as a lymphadenopathy. MRI is the best imaging modality. Most BP benign tumors can be completely and safely resected through the use of microsurgical techniques and intraoperative electrophysiology.

Iatrogenic nerve injuries: a potentially serious medical and medicolegal problem. About a series of 42 patients and review of the literature.

OBJECTIVE: To analyze the management of iatrogenic nerve injuries (iNI) in 42 patients. METHODS: Retrospective analysis of the charts. RESULTS: The iNI occurred mostly during a surgical procedure (n = 39), either on a nerve or plexus (n = 13), on bone, joint, vessel or soft tissue (n = 24) or because of malpositioning (n = 2). The most commonly injured nerves were the brachial plexus, radial, sciatic, femoral, or peroneal nerves. 42.9% of the patients were referred later than 6 months. A neurological deficit was present in 37 patients and neuropathic pain in 17. Two patients were lost to follow-up. Conservative treatment was applied in 23 patients because of good spontaneous recovery or compensation or because of expected bad prognosis whatever the treatment. Surgical treatment was performed in 17 patients because of known nerve section (n = 2), persistent neurological deficit (n = 12) or invalidating neuropathic pain (n = 3); nerve reconstruction with grafts (n = 8) and neurolysis (n = 8) were the most common procedures. Outcome was satisfactory in 50%. Potential reasons of poor outcome were a very proximal injury, placement of very long grafts, delayed referral and predominance of neuropathic pain. According to the literature delayed referral of iNI for treatment is frequent. We provide an illustrative case of a young girl operated on at 6.5 months for femoral nerve reconstruction with grafts while nerve section was obvious from the operative note and pathological tissue analysis. Litigation claims (n = 10) resulted in malpractice (n = 2) or therapeutic alea (n = 5) (3 unavailable conclusions). i CONCLUSIONS: NI can result in considerable disability, pain and litigation. Optimal management is required.

A case of aphasia due to temporobasal edema: Contemporary models of language anatomy are clinically relevant.

BACKGROUND: Understanding the anatomy of language in the human brain is crucial for neurosurgical decision making and complication avoidance. The traditional anatomical models of human language, relying on relatively simple and rigid concepts of brain connectivity, cannot explain all clinical observations. The clinical case reported here illustrates the relevance of more recent concepts of language networks involving white matter tracts and their connections. CASE DESCRIPTION: Postoperative edema of the ventral occipitotemporal cortex, where modern network models locate a crucial language hub, resulted in transient severe aphasia after a subtemporal approach. Both verbal comprehension and expression were lost. The resolution of edema was associated with complete recovery from phonetic and semantic dysfunction. CONCLUSION: Complete aphasia due to a functional disturbance remote from the areas of Broca and Wernicke could be explained by contemporary neuroanatomical concepts of white matter connectivity. Knowledge of network-based models is relevant in brain surgery complication avoidance.