IDH mutation is paradoxically associated with higher 18F-FDOPA PET uptake in diffuse grade II and grade III gliomas.

PURPOSE: The World Health Organization Classification of Tumors of the Central Nervous System has recently been updated by the integration of diagnostic and prognostic molecular parameters, giving pivotal attention to IDH mutation as a favourable factor. Amino acid PET is increasingly used in the management of gliomas, but its prognostic value is a matter of debate. The aim of this study was to assess the relationship between IDH mutation and 18F-FDOPA uptake on PET in newly diagnosed gliomas. METHODS: A total of 43 patients, presenting with diffuse astrocytic and oligodendroglial grade II and III gliomas, reclassified according to the 2016 WHO classification of tumours of the CNS, were retrospectively included. They had all undergone 18F-FDOPA PET at an initial stage before surgery and histological diagnosis. 18F-FDOPA uptake values were compared between patients with and without IDH mutation in terms of maximum standardized uptake value (SUVmax) ratios between tumour and normal contralateral brain (T/N), and between tumour and striatum (T/S). RESULTS: Patients with IDH mutation showed higher 18F-FDOPA T/N SUVmax ratios (1.6 vs. 1.2) and T/S SUVmax ratios (0.9 vs. 0.6) than patients without IDH mutation (p < 0.05). CONCLUSION: This study showed paradoxically higher 18F-FDOPA uptake in diffuse grade II and III gliomas with IDH mutation. Despite evident interest in the management of gliomas, and especially in relation to posttherapy evaluation, our findings raise the question of the prognostic value of 18F-FDOPA uptake on PET uptake in this group of patients. This may be related to differences in amino acid integration, metabolism, or cell differentiation.

[Operative treatment of complex lombosacral fracture dislocation: L5 chance fracture with trans S1-S2 dislocation]. / Traitement chirurgical d'une fracture complexe de la charnière lombo-sacrée: luxation S1-S2 et fracture de type chance de L5.

Sacral fractures are uncommon injuries that are often diagnosed late, the transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture has never been reported. The purpose of this report is to describe operative treatment of transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture. A 17-year-old woman sustained multiple injuries in a road accident and presented with hypovolumic shock. Radiological assessment demonstrated transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance-fracture. Neurologic examination demonstrated L5 root deficit and perineal hypoesthesia. Operative treatment was undertaken. The procedure consisted of laminectomy of L5, S1, and S2 and osteosynthesis of L3-L4 - S3-S4 (in sacral alae). Attempts to reduce dislocation failed. Postoperative recovery was uneventful. One year after operative treatment the patient presented no neurologic deficit and had resumed normal activity. Follow-up radiological imaging demonstrated consolidation of fracture zones. Management for uncommon lumbrosacral junction injuries must take into account various parameters including hemodynamic condition, neurologic status, and stability of the spinal lesions. Decompression of neural impingement and stabilization of fractures by osteosynthesis appear to be a useful alternative that allows patients to stand again and begin rehabilitation quickly.

[Idiopathic acute obstructive hydrocephalus. Case report]. / Hydrocephalie aigue obstructive idiopathique. à propos d'un cas.

Acute hydrocephalus is rarely encountered in adults without venticuloperitoneal or venticuloatrial shunts. The purpose of this report is to describe a case of acute hydrocephalus due to no identifiable cause. A 40-year-old man developed a typical clinical picture of intracranial hypertension within a 24-hours period. On the morning of hospitalization, the patient consulted his physician for severe headache followed quickly by nausea and vomiting. After cerebral CT-scan, the patient was referred to our department. His condition rapidly worsened, with confusion, then drowsiness. Magnetic resonance imaging (MRI) demonstrated quadri-ventricular hydrocephalus with a Chiari I malformation. In view of his rapidly deteriorating clinical condition, emergency endoscopic third ventriculostormy was performed. The patient recovered rapidly and was discharged 8 days after the procedure. Diagnostic work-up included lumbar puncture showing normal cerebrospinal fluid (thereby eliminating multiple sclerosis, low-grade intracranial hemorrhage, and meningitis (bacterial, viral, fungal)), spinal MRI depicting no medullary lesions, and brain angiography revealing no vascular abnormalities. Follow-up brain MRI carried out at six months after hospitalization demonstrated normal ventricles and complete disappearance of the Chiari I malformation. No conclusion can be drawn as to whether the Chiari I malformation was the consequence or cause of hydrocephalus. The explanation of this acute hydrocephalus is the acute decompensation without identifiable cause of idiopathic stenosis of the foramen of Magendie and Luschka. Treatment with endoscopic third ventriculostomy is effective.

[The value of dynamic cervical MRI in management of selected patients presenting traumatic cervical cord injury]. / Intérêt de l'IRM cervicale dynamique dans la prise en charge de certains patients victimes de traumatismes vertébraux médullaires.

OBJECTIVE: The purpose of this report is to describe our experience with dynamic cervical MRI for detection of cervical spinal cord instability in patients presenting spinal cord trauma without fracture or dislocation of the spinal column. MATERIAL AND METHODS: Since January 2000 a total of 95 patients presenting spinal cord trauma have been treated in our department. All patients underwent MRI for diagnostic work-up. Dynamic MRI was performed if spinal cord instability was suspected. Whenever possible, high-quality plain radiography dynamic views were obtained (coma, severe deficit, study of the cervicothoracic junction). RESULTS: Dynamic MRI allowed diagnosis of spinal cord instability in 6 patients with a mean age of 65 years (range, 45 to 75). Instability occurred during extension in 4 patients and during flexion and extension in one case. In the remaining case instability was associated with herniation of a cervical disc due to a severe cervical sprain. All 6 patients underwent early surgical stabilization that allowed improvement in-hospital patient care and quick transfer to rehabilitation centers. CONCLUSION: Dynamic MRI can be a useful tool to detect unstable spinal cord instability in some patients presenting noncompressive spinal cord injuries.

[Endovascular treatment of benign intracranial hypertension by stent placement in the transverse sinus. Therapeutic and pathophysiological considerations illustrated by a case report]. / Traitement endovasculaire d'un syndrome d'hypertension intracrânienne bénigne par mise en place d'un stent dans le sinus lateral. Considerations thérapeutiques et physiopathologiques à propos d'un cas.

We report a case of benign intracranial hypertension in a 31-year-old man treated by endovascular stent placement in the right transverse sinus. The patient presented with a typical benign intracranial hypertension syndrome. Ophthalmologic findings showed bilateral papilledema with a 7/10 loss visual acuity loss in the right eye and 2/10 in the left eye. At lumbar puncture, cerebrospinal fluid (CSF) pressure was 40 mmHg. Magnetic resonance imaging (MRI) showed slit ventricles and dilatation of optic nerve sheaths. optiques. After failure of medical treatment, the patient was referred to our neurosurgical department for therapeutic decision. Direct retrograde cerebral venography showed predominant cerebral venous drainage via the right transverse sinus which exhibited stenosis in its proximal third. Mamometry revealed a 25 mmHg pressure gradient across the point of stenosis. Due to possible venogenic benign intracranial hypertension, endovascular stent placement was proposed and accepted by the patient. At 3 months follow-up, the patient was symptoms free, papilledema had disappeared and visual acuity was 10/10 on both eyes. CSF pressure on lumbar puncture was 11 mmHg. The pathophysiological aspects and therapeutic management of this pathology illustrated by this are discussed along with a careful and exhaustive review of the literature.

[Endoscopic treatment of a voluminous benign symptomatic cyst of the pineal region responsible for an obstructive hydrocephalus]. / Traitement endoscopique d'un volumineux kyste bénin symptomatique de la région pinéale responsable d'une hydrocéphalie obstructive.

Asymptomatic non neoplastic cysts of the pineal region are common incidental findings in adults. On the contrary, voluminous and symptomatic cysts of the pineal region are rare and their management are not well defined. We present the case of a 32-year-old woman suffering who suffered from mild intracranial hypertension, gait disturbance and vertigo for one year. The neuroradiological workup showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. An endoscopic etiological treatment was decided. The operation consisted in a marsupialization of the cyst in the third ventricle with a stereotactic guidance system. A frozen section of the cyst wall failed to show tumoral cells. Immediate postoperative course was uneventful. Intracranial hypertension symptoms resolved in 24 hours. Clinical examination and neuropsychological testing were normal at two years postoperatively. The two years follow-up cerebral MRI demonstrated a remnant cystic cavity without mass effect and the patency of the aqueduct of Sylvius. Endoscopic treatment of symptomatic pineal cysts constitutes an interesting therapeutic alternative in the management of this pathology.

[Transsacral approach to lumbosacral extraforaminal disc herniations]. / Traitement chirurgical des hernies discales extraforaminales L5/S1 par voie trans-sacrée.

INTRODUCTION: The lateral approach is classically used for surgical treatment of extraforminal disc herniations (EDH). However, its use at the level of the L5-S1 space can require more or less extensive resection of the facet joint. This study reports our experience in the treatment of L5-S1 EDH using the transsacral approach described by Muller and Reulen in 1998. MATERIAL AND METHODS: From February 2002 to October 2004, 12 patients presenting EDH at the L5-S1 level underwent treatment using the transsacral approach. There were 8 men and 4 women. Mean age was 55 years (range: 36 to 75 years). All patients presented lumbalgia and L5radiculalgia. Only one patient had dysesthesia. Five patients presented motor deficits and 3 presented sensory deficits. Surgical treatment was proposed after failure of medical treatment and two L5 corticoids infiltrations. RESULTS: All patients were re-examined two months after the procedure. Mean follow-up was 15 months. Complete resolution of radiculalgia with no paresthesia was achieved in all patients. Patients presenting preoperative motor deficit recovered fully after treatment. All patients resumed normal activity. CONCLUSION: The transsacral approach is a valid alternative to the lateral approach for treatment of L5-S1 EDH. The amount of operative exposure achieved using this technique is sufficient to avoid joint injury that can result in chronic postoperative lumbalgia. Another advantage is that excision of the protruding disc fragment can be achieved without mobilization of the nerve root or dorsal root ganglion, thus avoiding postoperative dysesthesia.

[Hydroxyurea treatment for unresectable meningioma]. / Traitement des méningiomes par hydroxyurée.

BACKGROUND: Management of unresectable progressive meningioma remains controversial and constitutes a major challenge since therapeutic options including chemotherapy and hormone modulation are limited. Recent data have suggested that hydroxyurea treatment may have an antitumoral effect. The purpose of this prospective phase II study was to evaluate the efficacy of hydroxyurea treatment for unresectable progressive meningioma. METHODS: From 1997 to 1999, consecutive patients presenting unresectable meningioma with clinically and/or neuroradiologically documented progression were considered for entry into this protocol. Previous radiotherapy was not a mandatory inclusion criteria. Treatment consisted of continuous oral administration of hydroxyurea at a dose of 20 mg/kg per day. Follow-up assessment included physical examination, computed tomography (CT), and magnetic resonance imaging (MRI) performed every three months, as well as regular blood testing. The primary endpoint was documentation of objective response by MRI or CT. RESULTS: The intent-to-treat population was 43 patients with at least 18 months follow-up. Median age was 60.4 years. Twenty-eight patients had undergone surgery following initial diagnosis. The meningioma was located in the skull base in 67% of patients. Histology was benign in 18 and atypical in 10. The eligible population included 36 patients with documented progressive disease at the time of inclusion; with progression documented clinically in 29 (67.5%) and/or radiologically in 20 (46%). In 7 patients, clinical or radiological progression could not be confirmed. The intent-to-treat analysis at median 26 months follow-up revealed objective response to hydroxyurea in only 3 patients (7%) including one on the basis of improvement in visual symptoms and two on MRI analysis. Progressive disease was observed clinically or radiologically in 26 patients (60.5%). Of the eligible population (n=36), 2 achieved an objective response and 13 (36%) exhibited stabilization under hydroxyurea therapy, while 21 (58%) progressed under treatment. Overall tolerance was good but anemia (grade I-II) and asthenia (grade I-II) were observed in 28% and 23.5% respectively. Treatment was discontinued in 3 patients because of chronic skin toxicity in one and anemia and asthenia in two. CONCLUSION: Hydroxyurea treatment is of marginal efficacy for meningioma and must not be considered as an alternative if radiotherapy or surgery is feasible. New efficient medical treatments are still required for progressive meningiomas.

[Traumatic spondylolisthesis of the axis: arguments in favor of surgical management after analysis of 8 patients]. / Spondylolisthesis traumatique de C2. Indications chirurgicales après analyse de 8 cas opérés par voie antérieure.

BACKGROUND AND PURPOSE: The purpose of this report is to assess the efficacy of primary surgical stabilization in the management of traumatic C2 spondylolisthesis. MATERIAL AND METHODS: Eight patients including 5 men and 3 women (mean age, 44 years) were treated surgically for traumatic spondylolisthesis of the axis. Three patients presented permanent neurological deficit. The indication for operative treatment included fracture instability and association with either neurological deficit or multiple trauma. External immobilization was attempted and failed in two patients. In all cases the procedure was performed by the anterior route and consisted of surgical fixation with C2/C3 discectomy, intersomatic graft placement, and bone fusion. RESULTS: Using the Effendi and Levine classification, fractures were classified as type I in 2 cases, type II in 3, type IIa in 2, and type III in 1. The two patients with severe tetraparesis presented spinal cord contusion at the C2/C3 disk level. Postoperative radiography demonstrated C2/C3 fusion in all patients. No surgical complications were observed. The average hospital stay was 4.5 days. CONCLUSION: Surgical stabilization by C2-C3 fusion via the anterior route is effective for management of all types of traumatic C2 spondylolisthesis. It achieves immediate stability. We recommend its use as a primary intervention not only for unstable lesions but also for lesions associated with neurological deficits or multiple trauma. A major benefit is to facilitate nursing care and patient rehabilitation.

[Intracranial aneurysm revealed by panhypopituitarism. Considerations on therapeutic management based on a case report and review of the literature]. / Anévrysme intra-crânien révélé par un panhypopituitarisme. Considérations sur la prise en charge thérapeutique à propos d'un cas et revue de la littératue.

We report a case of an unruptured intracranial aneurysm in paraclinoidal location which was a unmasked by severe panhypopituitarism. An ipsilateral internal carotid artery (ICA) clamp test was performed in the pretreatment stage. The test was well tolerated and the aneurysm could be embolized with GDC (Guglielmi detachable coils) without necessitating an occlusion of the ICA. The postoperative course was uneventful and the patient was discharged after 48 hours. At one year, cerebral angiograms confirmed complete obliteration of the aneurysm. Therapeutic management of this rare entity is discussed along with a careful and exhaustive review of the literature.

[Metastatic meningioma to the first thoracic vertebral body. A case report and review of the literature]. / Métastase rachidienne de T1 d'un méningiome. Cas clinique et revue de la littérature.

This report describes a case of metastatic meningioma involving the first thoracic vertebral body in a 63-year-old woman. The patient was treated surgically 10 years earlier for a benign meningioma of the right parietal vault. Local recurrence was diagnosed in 1992. Despite the gamma-knife radiosurgery, recurrence required surgical treatment in 1999. Histological findings were compatible with atypical meningioma (grade II WHO). One year later, the patient presented left C8 cervicobrachial neuralgia. Investigation led to discovery of a D1 tumor that was a metastasis of the atypical intracranial meningioma. A resection of the vertebral T1 body with C7-T2 osteosynthesis was performed with an excellent recovery and no postoperative complication.

[Endoscopic third ventriculostomy for management of obstructive hydrocephalus secondary to supratentorial intraventricular hematoma. Case report]. / Apport de l'endoscopie dans la prise en charge des hématomes intra-ventriculaires supratentoriels compliqués d'hydrocéphalie. A propos de deux cas.

We report two cases of intraventricular hematoma with obstructive hydrocephalus. We perform endoscopic treatment of the hydrocephalus: aspiration of the hematoma associated with a third ventriculostomy. Both patients respectively aged 59 and 74 years had an obstructive hydrocephalus due to intraventricular hemorrage. The patient neurological status worsen at day 6 for patient No. 1 and at day 4 for patient No. 2. Endoscopic ventriculoscopy was performed respectively at day 6 and at day 5. Operatively, immediate vision was poor but was progressively improved by repetitive irrigation with Ringer-lactate (RL). Obstruction of the right Monro foramen by clot was observed. Introduction of the neuroendoscope into the third ventricle was possible after suction of the hematoma. Perforation of the floor of the third ventricle was performed after identification of the mammillary bodies and the infundibulum. Neurological status recovered within 10 days after surgery and the patients were referred to a medical unit. The patients were independent at home. The one-year MRI follow-up study showed a functional acqueduc in case 1 and a non-functional acqueduc in case 2 indicating in this case that the ventriculocisternotomy was useful. Intraventricular hematoma is not a contraindication for endoscopic third ventriculostomy. If possible, waiting for 6 or 5 days to allow the structuring of the blood clot and using large irrigation RL may facilitate the endoscopic procedure. This indication for endoscopic third ventriculostomy constitutes an alternative to external ventricular drainage which is significatively associated with complication (infection and obstruction). We cannot affirm that the removal of the clots and ventriculocisternostomy versus temporary external drainage avoids secondary hydrocephalus.