Advanced Insights into Human Uterine Innervation: Implications for Endometriosis and Pelvic Pain.

(1) Background: Understanding uterine innervation, an essential aspect of female reproductive biology, has often been overlooked. Nevertheless, the complex architecture of uterine innervation plays a significant role in conditions such as endometriosis. Recently, advances in histological techniques have provided unprecedented details about uterine innervation, highlighting its intricate structure, distribution, and density. The intricate nature of uterine innervation and its influence on pathologies such as endometriosis has garnered increasing attention. (2) Objectives: This review aims to compile, analyze, and summarize the existing research on uterine innervation, and investigate its implications for the pathogenesis of endometriosis and associated pain. (3) Methods: A systematic review was conducted in line with PRISMA guidelines. Using the PubMed database, we searched relevant keywords such as "uterine innervation", "endometriosis", and "pain association". (4) Results: The initial literature search yielded a total of 3300 potential studies. Of these, 45 studies met our inclusion criteria and were included in the final review. The analyzed studies consistently demonstrated that the majority of studies focused on macroscopic dissection of uterine innervation for surgical purposes. Fewer studies focused on micro-innervation for uterine innervation. For endometriosis, few studies focused on neural pain pathways whereas many studies underlined an increase in nerve fiber density within ectopic endometrial tissue. This heightened innervation is suggested as a key contributor to the chronic pain experienced by endometriosis patients. (5) Conclusions: The understanding of uterine innervation, and its alterations in endometriosis, offer promising avenues for research and potential treatment.

A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery.

PURPOSE: Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV. METHODS: We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table. RESULTS: The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway. CONCLUSION: A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial.

OBJECTIVE: The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS: Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS: From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%-22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%-28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%-25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%-21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%-37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%-20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%-40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%-21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%-35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%-29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%-33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%-34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%-26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%-34%). CONCLUSIONS: Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations.

BACKGROUND: The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients. METHODS: The first randomized clinical trial (RCT-1) offers 1:1 randomized allocation of intervention versus conservative management for patients with arteriovenous malformation (AVM). The second randomized clinical trial (RCT-2) allocates 1:1 pre-embolization or no pre-embolization to surgery or radiosurgery patients judged treatable with or without embolization. Characteristics of RCT patients are reported and compared to registry patients. RESULTS: From June 2014 to May 2021, 1010 patients with AVM were recruited; 498 patients were observed and 373 were included in the treatment registries. Randomized allocation in RCT-1 was applied to 139 (26%) of the 512 patients (including 127 of 222 [57%] with unruptured AVMs) considered for curative treatment. RCT-1 AVM patients differed (in rupture status, Spetzler-Martin grade and baseline modified Rankin Score) from those in the observation or treatment registries (P < 0.001). Most patients had small (<3 cm; 71%) low-grade (Spetzler-Martin I-II; 64%) unruptured (91%) AVMs. The allocated management was conservative (n = 71) or curative (n = 68), using surgery (n = 39), embolization (n = 16), or stereotactic radiosurgery (n = 13). Pre-embolization was considered for 179/309 (58%) patients allocated/assigned to surgery or stereotactic radiosurgery; 87/179 (49%) were included in RCT-2. RCT-2 patient AVMs differed in size, eloquence and grade from patients of the pre-embolization registry (P < 0.01). Most had small (<3 cm in 82%) low-grade (83%) AVMs in non-eloquent brain (64%). CONCLUSIONS: Patients included in the RCTs differ significantly from registry patients. Meaningful results can be obtained if multiple centers actively participate in the TOBAS RCTs.

Behavioural disinhibition in frontotemporal dementia investigated within an ecological framework.

Disinhibition is a core symptom in behavioural variant frontotemporal dementia (bvFTD) particularly affecting the daily lives of both patients and caregivers. Yet, characterisation of inhibition disorders is still unclear and management options of these disorders are limited. Questionnaires currently used to investigate behavioural disinhibition do not differentiate between several subtypes of disinhibition, encompass observation biases and lack of ecological validity. In the present work, we explored disinhibition in an original semi-ecological situation, by distinguishing three categories of disinhibition: compulsivity, impulsivity and social disinhibition. First, we measured prevalence and frequency of these disorders in 23 bvFTD patients and 24 healthy controls (HC) in order to identify the phenotypical heterogeneity of disinhibition. Then, we examined the relationships between these metrics, the neuropsychological scores and the behavioural states to propose a more comprehensive view of these neuropsychiatric manifestations. Finally, we studied the context of occurrence of these disorders by investigating environmental factors potentially promoting or reducing them. As expected, we found that patients were more compulsive, impulsive and socially disinhibited than HC. We found that 48% of patients presented compulsivity (e.g., repetitive actions), 48% impulsivity (e.g., oral production) and 100% of the patients group showed social disinhibition (e.g., disregards for rules or investigator). Compulsivity was negatively related with emotions recognition. BvFTD patients were less active if not encouraged in an activity, and their social disinhibition decreased as activity increased. Finally, impulsivity and social disinhibition decreased when patients were asked to focus on a task. Summarising, this study underlines the importance to differentiate subtypes of disinhibition as well as the setting in which they are exhibited, and points to stimulating area for non-pharmacological management.

Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial.

OBJECTIVE: The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS: TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS: From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS: The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).

"Stand-up straight!": human pose estimation to evaluate postural skills during orthopedic surgery simulations.

PURPOSE: Surgery simulators can be used to learn technical and non-technical skills and, to analyse posture. Ergonomic skill can be automatically detected with a Human Pose Estimation algorithm to help improve the surgeon's work quality. The objective of this study was to analyse the postural behaviour of surgeons and identify expertise-dependent movements. Our hypothesis was that hesitation and the occurrence of surgical instruments interfering with movement (defined as interfering movements) decrease with expertise. MATERIAL AND METHODS: Sixty surgeons with three expertise levels (novice, intermediate, and expert) were recruited. During a training session using an arthroscopic simulator, each participant's movements were video-recorded with an RGB camera. A modified OpenPose algorithm was used to detect the surgeon's joints. The detection frequency of each joint in a specific area was visualized with a heatmap-like approach and used to calculate a mobility score. RESULTS: This analysis allowed quantifying surgical movements. Overall, the mean mobility score was 0.823, 0.816, and 0.820 for novice, intermediate and expert surgeons, respectively. The mobility score alone was not enough to identify postural behaviour differences. A visual analysis of each participants' movements highlighted expertise-dependent interfering movements. CONCLUSION: Video-recording and analysis of surgeon's movements are a non-invasive approach to obtain quantitative and qualitative ergonomic information in order to provide feedback during training. Our findings suggest that the interfering movements do not decrease with expertise but differ in function of the surgeon's level.

What surgical approach for left-sided eloquent glioblastoma: biopsy, resection under general anesthesia or awake craniotomy?

PURPOSE: Neurosurgeons use three main surgical approaches for left-sided glioblastoma (GB) in eloquent areas: biopsy, tumor resection under general anesthesia (GA), and awake craniotomy (AC) with brain mapping for maximal safe resection. We performed a retrospective study of functional and survival outcomes for left-sided eloquent GB, comparing these surgical approaches. METHODS: We included 87 patients with primary left-sided eloquent GB from two centers, one performing AC and the other biopsy or resection under GA. We assessed Karnofsky performance score (KPS), language and motor deficits one month after surgery, progression-free survival (PFS) and overall survival (OS). RESULTS: The 87 patients had a median PFS of 8.6 months [95% CI: 7.3-11.6] and a median OS of 20.2 months [17-3-24.4], with no significant differences between the three surgical approaches. One month after surgery, functional outcomes for language were similar for all approaches, but motor function was poorer in the biopsy group than in other patients. The proportion of patients with a KPS score > 80 was higher in the resection with AC group than in the other patients at this timepoint. CONCLUSION: We detected no real benefit of a resection with AC over resection under GA for left-sided eloquent GB in terms of survival or functional outcomes for language. However, given the poorer motor function of biopsy patients, resection with AC should be proposed, when possible, to patients ineligible for surgical resection under GA, to improve functional outcomes and patient autonomy.

An ecological approach to identify distinct neural correlates of disinhibition in frontotemporal dementia.

Disinhibition is a core symptom of many neurodegenerative diseases, particularly frontotemporal dementia, and is a major cause of stress for caregivers. While a distinction between behavioural and cognitive disinhibition is common, an operational definition of behavioural disinhibition is still missing. Furthermore, conventional assessment of behavioural disinhibition, based on questionnaires completed by the caregivers, often lacks ecological validity. Therefore, their neuroanatomical correlates are non-univocal. In the present work, we used an original behavioural approach in a semi-ecological situation to assess two specific dimensions of behavioural disinhibition: compulsivity and social disinhibition. First, we investigated disinhibition profile in patients compared to controls. Then, to validate our approach, compulsivity and social disinhibition scores were correlated with classic cognitive tests measuring disinhibition (Hayling Test) and social cognition (mini-Social cognition & Emotional Assessment). Finally, we disentangled the anatomical networks underlying these two subtypes of behavioural disinhibition, taking in account the grey (voxel-based morphometry) and white matter (diffusion tensor imaging tractography). We included 17 behavioural variant frontotemporal dementia patients and 18 healthy controls. We identified patients as more compulsive and socially disinhibited than controls. We found that behavioural metrics in the semi-ecological task were related to cognitive performance: compulsivity correlated with the Hayling test and both compulsivity and social disinhibition were associated with the emotion recognition test. Based on voxel-based morphometry and tractography, compulsivity correlated with atrophy in the bilateral orbitofrontal cortex, the right temporal region and subcortical structures, as well as with alterations of the bilateral cingulum and uncinate fasciculus, the right inferior longitudinal fasciculus and the right arcuate fasciculus. Thus, the network of regions related to compulsivity matched the "semantic appraisal" network. Social disinhibition was associated with bilateral frontal atrophy and impairments in the forceps minor, the bilateral cingulum and the left uncinate fasciculus, regions corresponding to the frontal component of the "salience" network. Summarizing, this study validates our semi-ecological approach, through the identification of two subtypes of behavioural disinhibition, and highlights different neural networks underlying compulsivity and social disinhibition. Taken together, these findings are promising for clinical practice by providing a better characterisation of inhibition disorders, promoting their detection and consequently a more adapted management of patients.

Relationships between pelvic nerves and levator ani muscle for posterior sacrocolpopexy: an anatomic study.

BACKGROUND: The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle. OBJECTIVES: The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle. STUDY DESIGN: Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus. RESULTS: Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1-3.5) cm. CONCLUSIONS: The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.

Case report: Dyspareunia as a symptom of a pelvic schwannoma.

Schwannomas are benign nerve tumors arising mainly in the intracranial, cervical, or lumbar regions. We describe the case of a presacral schwannoma in a 42-year-old woman. This atypical localization is most often discovered by symptoms related to compression of nervous structures. Our patient presented only with deep dyspareunia. The schwannoma was diagnosed on MRI which revealed a presacral hyperintense mass with an antero-posterior diameter of 47 mm opposite the S3 sacral orifice. After 6 years of follow-up, the mass was resected because of worsening dyspareunia and sudden lesion growth. The resection was performed through an open abdominal anterior approach and resulted in alleviation of the symptoms without postoperative complications. To our knowledge, this is the first case of pelvic schwannoma expressing a gynecological symptom such as dyspareunia.

Anatomic and functional mapping of human uterine innervation.

OBJECTIVE: To better understand the physiology of pain in pelvic pain pathological conditions, such as endometriosis, in which alterations of uterine innervation have been highlighted, we performed an anatomic and functional mapping of the macro- and microinnervation of the human uterus. Our aim was to provide a 3-dimensional reconstruction model of uterine innervation. DESIGN: This was an experimental study. We dissected the pelvises of 4 human female fetuses into serial sections, and treated them with hematoxylin and eosin staining before immunostaining. SETTING: Academic Research Unit. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Detection of nerves (S100 +) and characterization of the types of nerves. The slices obtained were aligned to construct a 3-dimensional model. RESULTS: A 3-dimensional model of uterine innervation was constructed. The nerve fibers appeared to have a centripetal path from the uterine serosa to the endometrium. Within the myometrium, innervation was dense. Endometrial innervation was sparse but present in the functional layer of the endometrium. Overall innervation was richest in the supravaginal cervix and rarer in the body of the uterus. Innervation was rich particularly laterally to the cervix next to the parametrium and paracervix. Four types of nerve fibers were identified: autonomic sympathetic (TH+), parasympathetic (VIP+), and sensitive (NPY+, CGRP1+ and VIP+). They were found in the 3 portions and the 3 layers of the uterus. CONCLUSIONS: We constructed a 3-dimensional model of the human uterine innervation. This model could provide a solid base for studying uterine innervation in pathologic situations, in order to find new therapeutic approaches.

Relationship between uterine veins, ureter, and hypogastric nerve for uterine transplantation: An anatomic study.

Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon. Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extra fascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods. An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table. We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement.

Long-term surgical oncological and functional outcome of large petroclival and cerebellopontine angle epidermoid cysts: a multicenter study.

Cranial nerve (CN) disorders are the foremost symptoms in cerebellopontine angle (CPA) and petroclival area (PCA) epidermoid cysts (EC).The aim of this work was to  assess the long-term surgical results on CN function and tumor control in these patients. We performed a retrospective cohort study about 56 consecutive patients operated on for a CPA or PCA EC between January 2001 and July 2019 in six participating French cranial base referral centers. Sixteen patients (29%) presented a PCA EC and 40 a CPA EC (71%). The median clinical and radiological follow-up was 46 months (range 0-409). Preoperative CN disorders were present in 84% of patients (n = 47), 72% of them experienced CN deficits improvement at the last follow-up consultation (n = 34): 60% of cochlear and vestibular deficits (n = 9/15 in both groups), 67% of trigeminal neuralgia (n = 10/15), 53% of trigeminal hypoesthesia (n = 8/15), 44% of lower cranial nerve disorders (n = 4/9), 38% of facial nerve deficits (n = 5/8) and 43% of oculomotor deficits (n = 3/7) improved or were cured after surgery. New postoperative CN deficits occurred in 48% of patients (n = 27). Most of them resolved at the last follow-up, except for cochlear deficits which improved in only 14% of cases (n = 1/7). Twenty-six patients (46%) showed evidence of tumor progression after a median duration of 63 months (range 7-210). The extent of resection, tumor location, and tumor size was not associated with the occurrence of new postoperative CN deficit or tumor progression. A functional nerve-sparing resection of posterior fossa EC is an effective strategy to optimize the results on preexisting CN deficits and reduce the risk of permanent de novo deficits.

Frontotemporal dementia subtypes based on behavioral inhibition deficits.

INTRODUCTION: We aimed to investigate phenotypic heterogeneity in the behavioral variant of frontotemporal dementia (bvFTD) through assessment of inhibition deficits. METHODS: We assessed occurrences of 16 behavioral inhibition deficits from video recordings of 15 bvFTD patients (early stage) and 15 healthy controls (HC) in an ecological setting. We extracted dimensions of inhibition deficit and analyzed their correlations with cognitive and clinical measures. Using these dimensions, we isolated patient clusters whose atrophy patterns were explored. RESULTS: After identifying two patterns of inhibition deficit (compulsive automatic behaviors and socially unconventional behaviors), we isolated three behavioral clusters with distinct atrophy patterns. BvFTD-G0 (N = 3), an outlier group, showed severe behavioral disturbances and more severe ventromedial prefrontal cortex/orbitofrontal cortex atrophy. Compared to bvFTD-G1 (N = 6), bvFTD-G2 (N = 6) presented higher anxiety and depression along with less diffuse atrophy especially in midline regions. DISCUSSION: Identifying clinico-anatomical profiles through behavior observation could help to stratify bvFTD patients for adapted treatments.

Functional sparing surgery policy for giant vestibular schwannomas.

OBJECTIVE: The objective of this study was to compare the tumour control and facial nerve outcome according to the therapeutic strategy, that is extent of resection and post-operative radiotherapy. DESIGN: Retrospective study of patients with a giant vestibular schwannoma surgically treated from 4 academic skull base centres. SETTING: Extent of resection, neurological complications, facial nerve function, MRI follow-up and occurrence of complementary treatment were reviewed. PARTICIPANTS: Sixty patients were included from 2000 to 2018. MAIN OUTCOME MEASURES: Primary end points were comparison the tumour control rate and the post-operative House-Brackmann grade at last follow-up according to the extent of tumour removal (ie total or subtotal removal). Secondary end points were assessment risk factors of poor facial nerve function and comparison complication rate according to extent of tumour removal. RESULTS: Sixty patients had initial surgery at diagnosis. A total resection was realised in 21 cases and a subtotal resection in 39 cases. Thirteen patients needed further treatment. One patient had a recurrence and needed a second surgery 108 months after the initial total resection surgery. Twelve patients underwent post-operative radiotherapy, for an evolutive residual tumour. Tumour control was more successful in the total resection group (log-rank test, P = .015). There was no tumour recurrence after post-operative radiotherapy. The facial nerve outcome was significantly better in the subtotal resection group (Mean House-Brackmann grade at last follow-up: 2.2 ± 1.9) than in the total resection group (House-Brackmann grade: 3.5 ± 2.2) (P = .033). Vestibular schwannoma with a cystic component had better facial nerve outcome (P = .0082). Other than facial paralysis, neurological complications were observed in six patients (10% of patients): lower cranial nerves dysfunction in five cases and hemiparesis in one case. CONCLUSIONS: Subtotal resection of giant vestibular schwannomas leads to favourable tumour control and facial nerve function and therefore seems to be a valuable strategy.

Ruptured intracranial arachnoid cysts in the subdural space: evaluation of subduro-peritoneal shunts in a pediatric population.

PURPOSE: Rupture of arachnoid cysts (AC) in the subdural space after trauma may cause a subacute/chronic subdural hematoma or a hygroma. Treatment of this complication still remains controversial, and no consensual strategy is to date clearly proposed. In this study, the authors evaluated the clinical and radiological evolution of patients treated by a subduro-peritoneal shunt for symptomatic subdural collections complicating ruptured AC. METHODS: Medical records of the 10 patients treated at our institution between January 2005 and December 2018 for a subdural collection associated with an intracranial AC were reviewed. Subduro-peritoneal shunts consisted of low-pressure valves from 2005 to 2012 (6 cases) and medium-pressure valves after 2012 (4 cases). RESULTS: A benign head trauma was retrospectively found in the history of 8 patients. The mean time to diagnosis ranged from 15 days to 5 months. Symptoms resulted mainly from intracranial hypertension. Six patients had an ipsilateral hygroma to the AC, 2 patients had a bilateral hygroma predominantly to the AC side, and 2 patients presented an ipsilateral chronic subdural hematoma. Arachnoid cysts were classified as Galassi I in 5 cases and Galassi II in 5 cases. Patients with chronic subdural hematoma were given a medium-pressure valve. Patients with subdural hygroma received a low-pressure valve in 6 cases and a medium-pressure valve in 2 cases. There were no complications during surgical procedures. All patients were rapidly free of symptoms after surgery and were discharged from hospital 1 to 4 days postoperatively. The subdural collection completely disappeared in all cases. In the long term, only 2 patients with low-pressure valves underwent shunt removal without any consequences, while a second surgical procedure was necessary to treat recurrence of intracranial hypertension in the 4 remaining cases. All the medium-pressure valves were removed without problems. The size of the AC was reduced in 3 cases, remained stable in 4 cases, and increased in 3 cases. No patients experienced recurrence of subdural collection during follow-up. CONCLUSIONS: Medium-pressure subduro-peritoneal shunts should be considered as part of the arsenal of surgical strategy in symptomatic ruptured AC in the subdural space. The procedure is simple with a very low morbidity, and it allows rapid improvement of symptoms. Although the shunt is located in the subdural space, we strongly recommend avoiding devices which may create an overdrainage and expose the patient to shunt dependency such as low-pressure shunts.

Interruptions in Surgery: A Comprehensive Review.

BACKGROUND: Recent literature showed that analysis of interruptions can contribute to evaluating the care process in the operating room, and thus, understanding potential errors that may occur during surgical procedures. The aim of this comprehensive review was to summarize current knowledge on the description and impact of interruptions in surgery. MATERIAL AND METHODS: A literature search was conducted according to a set of criteria in the databases MEDLINE, BASE, Cochrane's Library, and PsycINFO. RESULTS: 41 articles were included. Two main methodological approaches were found, observational in the OR, or controlled in an experimental simulated environment. Interruptions in the OR were manifold, and several classifications were used. The severity of interruptions differed according to the category of the interruptions. Interruptions were influenced by team familiarity and the expertise of the surgical team; high team familiarity and a high level of expertise decreased the frequency of interruptions. However, our literature search lacked controlled studies carried out in the OR. Interruptions seemed to increase the workload and stress of the surgical team and impair nontechnical skills, but no clear evidence of this was advanced. CONCLUSIONS: Interruptions are probably risk factors for errors in the operating room. However, there is as yet no clear evidence of the association of interruption frequency with errors in the operating room. There is a need to define and target interruptions, which should be reduced by putting safeguards in place, thereby allowing those which could be beneficial and neglecting those with no potential consequences.

Selective neurotomy of the sciatic nerve branches to the hamstring muscles: An anatomical study.

BACKGROUND: Hamstring spasticity can bring about a flexion deformity of the knee, liable to cause disability. Surgical treatment by selective neurotomies of the sciatic nerve branches leading to the hamstring muscles may then be indicated. Few studies have investigated the precise origin of these branches on the sciatic nerve, describing the innervation pattern of the hamstring muscles. Further anatomical data are needed to enhance surgical techniques in neurotomies of the sciatic nerve branches, to define the best incision and surgical approach and what section and length of the SN need to be exposed. Therefore, we performed an anatomical study to: (1) define a surgical approach to perform selective neurotomies of the sciatic nerve branches for hamstring spasticity?(2) whether the anatomical variants of the hamstring innervation have been identified? HYPOTHESIS: Our anatomical data could lead to the definition of an approach to the sciatic nerve for the purpose of selective neurotomy. MATERIAL AND METHODS: Twenty posterior compartments of the thigh were dissected. We counted each branch of the sciatic nerve leading to the hamstring and described their arising point using the centre of the lateral surface of the great trochanter and the lower edge of the gluteus maximus muscle as main anatomical landmarks. We also described the presence of branch divisions and their muscular penetrating points. RESULTS: The mean distances between the center of the lateral surface of the great trochanter and the emergence of branches from the SN were: 2.2±3.6cm (-5 to 9cm) for the long head of the biceps femoris muscle, 2.3±3cm (-4 to 10cm) for the semitendinosus muscle, and 2.2±3cm (-5 to 8cm) for the semimembranosus muscle. No branches originated from the sciatic nerve below the lower edge of the gluteus maximus muscle. In summary the branches innervating the hamstrings originated from the SN within an interval of 15cm (5cm above and 10cm below the centre of the lateral surface of great trochanter). The average number of sciatic nerve branches for the hamstring muscles was 4.7 (minimum: 3; maximum: 6) with 1.8 branches for the long head of the biceps [1 in 7/20 (35%), 2 in 10/20 (50%), and 3 in 3/20 (15%)], 1.5 branches for the semitendinosus [1 in 11/20 (55%) and 2 in 9/20 (45%)], 1.4 branches for the semimembranosus [1 in 12/20 (60%) and 2 in 8/20 (40%)]. No branches had a common origin with cutaneous nerves. DISCUSSION: This anatomical study enabled us to propose an approach to exposing the sciatic nerve in order to perform a selective neurotomy: horizontal cutaneous incision on the gluteal fold, incision of the lower edge of the gluteus maximus, exposure of the sciatic nerve to a distance of 10cm below the great trochanter, and visualization of the nerve branches to the hamstring muscles. Exposure of the nerve above the great trochanter is not necessary because the branches which emerge from the SN above the great trochanter are still contiguous with the SN. LEVEL OF EVIDENCE: IV: prospective study without control.