Solitary fibrous tumours and haemangiopericytoma of the meninges. A retrospective study for outcome and prognostic factor assessment.

BACKGROUND: To report on the outcome of patients diagnosed with central nervous system haemangiopericytoma (HPC) or solitary fibrous tumours (SFT) and identify factors that may influence recurrence and survival. MATERIAL AND METHODS: Between January 1977 and December 2016, a retrospective search identified 22 HPCs/SFTs. The patients underwent a total of 40 surgical resections and 63.6% received radiotherapy. Median follow-up was 7.8 years. RESULTS: Six patients (27.3%) were re-operated for tumour recurrence. At the end of the study, 15 patients (68.2%) had no residual tumour on the last imaging. Surgical recurrence-free survival at 5 years was 77.4%, [95% CI: 60.1-99.8]. None of the investigated variables was associated with recurrence. At the end of the study, 5 patients were deceased (22.7%) and only 10 patients (45.5%) had no residual tumour on the last imaging and were alive. Overall survival at 5 years was 95%, [95% CI: 85.9-100]. None of the investigated variables was associated with overall survival. Patients who received radiotherapy demonstrated neither a reduced risk of surgical recurrence (P=0.378) nor a longer overall survival (P=0.405). CONCLUSION: SFTs/HPCs are associated with a significant risk of recurrence that may reduce the survival. Even if we could not demonstrate their benefit in this limited series, we believe that tailored maximal tumour resection on initial surgery is beneficial and that adjuvant RT is useful for tumours displaying grade II or III, even in case of complete removal.

Non-invasive diagnosis of intracranial aneurysms.

Patients need to be examined for intracranial aneurysms if they have had a subarachnoid hemorrhage. The preferred technique in this situation is CT angiography. Screening can be done for familial forms or for elastic tissue disorders, for which the first line investigation is magnetic resonance angiography. These non-invasive methods have now taken over from conventional angiography that was reserved for the pretreatment phase. A good technical knowledge of these imaging methods, their artifacts and misleading images enables reliable detection of intracranial aneurysms and for an accurate report to be returned to clinicians.

Advanced technologies applied to physiopathological analysis of central nervous system aneurysms and vascular malformations.

While depiction and definition of morphological and architectural characteristics of CNS vascular disorders remains the first step of an MR analysis, emerging imaging techniques offer new functional information that might help to characterize rupture risk of CNS vascular disorders. Two main orientations are suggested by recent studies: inflammation of the vessel wall and analysis of physical constraints of blood flow using 4D flow imaging (shear parietal). This paper will focus on radiological application of 4D flow imaging and inflammation imaging, in the characterization of potential prognostic markers of CNS vascular disorders. We will review the basic technical considerations of 4D flow MRA, inflammation imaging and discuss their applications in CNS vascular disorders: aneurysms, arteriovenous malformation, dural arteriovenous fistulas. We will illustrate their potential in the development of individual rupture risk criteria in brain vascular disorders.

[Stereotactic intracranial radiotherapy: dose prescription]. / Radiothérapie stéréotaxique intracrânienne : prescription de la dose.

The aim of this article was the study of the successive steps permitting the prescription of dose in stereotactic intracranial radiotherapy, which includes radiosurgery and fractionated stereotactic radiotherapy. The successive steps studied are: the choice of stereotactic intracranial radiotherapy among the therapeutic options, based on curative or palliative treatment intent, then the selection of lesions according to size/volume, pathological type and their number permitting the choice between radiosurgery or fractionated stereotactic radiotherapy, which have the same methodological basis. Clinical experience has determined the level of dose to treat the lesions and limit the irradiation of healthy adjacent tissues and organs at risk structures. The last step is the optimization of the different parameters to obtain a safe compromise between the lesion dose and healthy adjacent structures. Study of dose-volume histograms, coverage indices and 3D imaging permit the optimization of irradiation. For lesions close to or included in a critical area, the prescribed dose is planned using the inverse planification method. Implementation of the successively described steps is mandatory to insure the prescription of an optimized dose. The whole procedure is based on the delineation of the lesion and adjacent healthy tissues. There are sometimes difficulties to assess the delineation and the volume of the target, however improvement of local control rates and reduction of secondary effects are the proof that the totality of the successive procedures are progressively improved. In practice, stereotactic intracranial radiotherapy is a continually improved treatment method, which constantly benefits from improvements in the choice of indications, imaging, techniques of irradiation, planification/optimization methodology and irradiation technique and from data collected from prolonged follow-up.

[Hypofractionated stereotactic radiotherapy for brain metastases]. / Place de l'irradiation stéréotaxique hypofractionnée dans le traitement des métastases cérébrales.

PURPOSE: A survey of the literature has been performed to find arguments in order to help the choice between radiosurgery and hypofractionated stereotactic radiotherapy in the treatment of brain metastases. PATIENTS AND METHODS: A comparison of two groups of brain metastases treated with hypofractionated stereotactic radiotherapy or radiosurgery, with or without WBRT was performed. Hypofractionated stereotactic radiotherapy: there were eight series including 448 patients published from 2000 to 2009; treated with 5-6 MV X-Rays, non invasive head immobilization, a margin 2 to 10mm; 24 to 40Gy in three to five fractions; a 5 to 8 days duration in six series and 15-16 days in two other series. WBRT (30%) ; radiosurgery: there were 12 series (1994 to 2005) including 2157 patients; an invasive head immobilization, no margin; doses from 10 to 25 Gy; six series over 12 had Gamma Knife radiosurgery and six had Linacs X-Rays. WBRT (30 Gy/10 F/12 days) associated to radiosurgery in several series. The following parameters were compared: median GTV, median survival, 1-year survival rate, local control rate, necrosis and WBRT rates. RESULTS: Hypofractionated stereotactic radiotherapy series: the parameters were respectively: 0,52-4,47 cm(3) (median 2,8 cm(3)); 5-16 months (median 8,7 months); 68,2-93% (median 82,5%); necrosis rate 3,1%; associated WBRT 30%. Radiosurgery series: the parameters were respectively: 1,3 to 5,5 cm(3) (median 2 cm(3)); 5,5 to 22 months (median 11 months); 71 to 95% (median 85%); 0,5 to 6% (median 2,4%); associated WBRT 58%. Results seem similar in the two groups: Hypofractionated stereotactic radiotherapy with non invasive immobilization could theoretically treat all brain metastases sizes except lesions<10 mm (500 mm(3)). In large volumes,>4200 mm(3) GTV, the toxicity of hypofractionated stereotactic radiotherapy was not reported, thus it was difficult to compare its results with the published reports of radiosurgery toxicity. WBRT was a confusing parameter. Obviously, this initial survey has important limitations, specifically its methodology. CONCLUSION: Radiosurgery and hypofractionated stereotactic radiotherapy could be used to treat brain metastases with GTV>500 mm(3) and < or = 4200 mm(3) (Ø 20mm); for GTV<500 mm(3) (Ø 10mm) an invasive procedure with radiosurgery is necessary. For GTV>4200 mm(3) (Ø 20mm), hypofractionated stereotactic radiotherapy could be proposed, provided further studies, using 4 to 6 Gy fractions, a duration less or equal to 10-12 days and a margin of 2mm will be performed.

Endovascular coil transfixing a cranial nerve five years after embolisation.

After endovascular coiling, several authors have reported refilling of the aneurysm, appearance of a mass effect, coils protruding into the parent artery, migration of coils into parent artery or through aneurysm wall, and compression of the parent artery by coil impaction. This is the first report of an endovascular coil transfixing a cranial nerve. We present a 59 year old man who presented with a symptomatic bilobulated aneurysm of the right internal carotid artery. The aneurysm was embolised by endovascular coiling. Angiographic follow up showed occlusion of the aneurysm. Five years later, the patient complained of progressive diplopia with ptosis. Follow-up angiography showed renewed filling of the aneurysm at its neck. The aneurysm was clipped surgically. At operation, a coil mass effect was noted and one coil penetrated the fibres of the right oculomotor nerve.

[Surgical resections in functional areas: report of 89 cases]. / Résections en région fonctionnelle: étude d'une série de 89 cas.

Surgical resections for intractable epilepsy are generally associated with a high risk of permanent neurological deficit and a poor rate of seizure control. We present a series of 89 patients operated on from 1992 through 2007 for drug-resistant partial epilepsy, in whom surgery was performed in a functional area of the brain: the central (sensorimotor and supplementary motor areas) region in 48 cases, posterior regions (parietal and occipital) in 27, the insula in eight, and the language areas in six. Epilepsy was cryptogenic in 12 patients, and lesion-related in 77: malformation of cortical development in 43, tumor in 17, perinatal cicatrix in 13, vascular lesion in three, and another prenatal lesion in one. Seventy patients underwent stereoelectroencephalographic (SEEG) exploration. The surgical procedure was resective (lesionectomy or SEEG-guided corticectomy) in 83 patients and multiple stereotactic thermocoagulations in six. Ten patients were reoperated because of early seizure recurrence. A postoperative complication was observed in 12 patients. Postoperative deficits were observed in 54 patients (61%) and resolved completely in 29. In 25, a permanent deficit persisted, minor in 19 and moderate to severe in six, which did not correlate with localization or etiology. With a one-year follow-up in 74 patients (mean, 3.6 years), 53 (72%) were in Engel's class I, including 38 (51%) in class IA. Seizure outcome was significantly associated with etiology: 93% of Taylor-type focal cortical dysplasia, whereas only 40% of cryptogenic epilepsies were in class I (p<0.05). This suggests that resective or disconnective surgery for intractable partial epilepsy in functional areas of the brain may be followed by excellent results on seizures and a moderate risk of permanent neurological sequelae.

[Brainstem cavernomas: surgical experience at the CH Sainte-Anne general hospital]. / Cavernomes du tronc cérébral: l'expérience chirurgicale du centre hospitalier Sainte-Anne.

BACKGROUND AND PURPOSE: No standard treatment for brainstem cavernoma has been established because of the lack of sufficient data about the natural history of these lesions in a highly functional location with potential difficult surgical accessibility. METHODS: We present a series of 82 brainstem cavernomas managed at the Sainte-Anne Hospital. Surgery was undertaken for 25 with stereotactic biopsy for 9 and direct surgery for 19 (3 after biopsy). RESULTS: Surgical outcome was good or fair for 17 patients. Two patients worsened and one died. Biopsy results were disappointing with high morbidity (4 patients with 2 permanent deficits). Histological diagnostic was possible for all biopsies. CONCLUSION: In light of these results, an active surgical attitude could be proposed for cavernomas in an accessible locations which have produced at least one previous hemorrhage. Stereotactic biopsies for suspect brainstem cavernoma must be avoided.

Dystonic posturing in seizures of mesial temporal origin: electroclinical and metabolic patterns.

OBJECTIVE: To test the hypothesis that extratemporal neuronal networks are involved in dystonic posturing (DP) observed in mesial temporal epilepsy (MTLE). METHODS: The authors analyzed electroclinical findings in 36 patients with MTLE with or without DP. Three DP types were defined (types I, II, III) corresponding to a gradual increase in duration and complexity. Interictal [18F]fluorodeoxyglucose-PET in different groups and subgroups was compared with control subjects using statistical parametric mapping software (SPM99). RESULTS: DP was found in 20 patients (55%), contralateral to the epileptogenic focus in 95%. Patients with DP had longer seizure duration, higher frequency of head deviation, salivation, motor manifestations, secondary generalization, severe clouding of consciousness, and prolonged postictal confusion when compared with patients without DP. Ictal discharge patterns during DP consisted of fast rhythmic activity spreading to frontal or suprasylvian areas, whereas slow rhythmic activity restricted to the temporal areas occurred in the absence of DP. In patients with DP, widespread temporal and extratemporal hypometabolism including the putamen was found. Hypometabolism was restricted to the anteromesial part of the temporal lobe and anterior insula in patients without DP. Putaminal hypometabolism was found in all DP types, but different extratemporal cortical involvements were found in DP subgroups: insula and inferior frontal gyrus in type I, inferior and superior frontal gyri and anterior cingulate gyrus in type II, and parietal areas in type III. CONCLUSION: Dystonic posturing may result from involvement of both putaminal and extratemporal cortical areas. Moreover, different frontal or parietal networks may be involved according to the duration or complexity of dystonic posturing.

[Oligodendrogliomas: historical background of classifications]. / Oligodendrogliomes: historique des classifications.

The story of the classifications for gliomas is related to the development of the techniques used for cytological and histological examination of brain parenchyma. After a review of these techniques and the progressive discovery of the central nervous system cell types, the main classifications are presented. The first classification is due to Bailey and Cushing in 1926. It was based on histoembryogenetic theory. Then Kernohan introduced, in 1938, the concept of anaplasia. The WHO classification was published in 1979, then revised in 1993 and 2000. It took into account some data from both previous systems and introduced gradually the notion of histological criteria of malignancy. More recently; molecular genetics data and clinical evolution were retained. The Sainte-Anne classification for oligodendrogliomas is based on both histological and imaging data. It includes the notion of spatial histological structure of oligodendrogliomas. Contrast enhancement is closely related to endotheliocapillary hyperplasia. Gliomas classifications are changing and confusions can be made because of lack of reproductibility and misinterpretations of samples.

[Reappraisal of the Sainte-Anne Hospital classification of oligodendrogliomas in view of retrospective studies]. / Classification des oligodendrogliomes de l'hôpital Sainte-Anne. Mise au point à l'usage des études rétrospectives.

PURPOSE: Definition of homogeneous tumor groups of oligodendrogliomas or oligo-astrocytomas is a basic condition for an adequate evaluation and comparison of the results of treatments in patients from various institutions. However, increasing discordances are observed in the histological diagnosis of these tumors. The main goal of this study is to assess whether, for retrospective studies, MRI data may serve as a common basis for encompassing asymmetry in diagnosis established according to the WHO or Ste-Anne (SA) classification. PATIENTS AND METHODS: This study included 251 adult patients in whom a SA grade A or B oligodendroglioma or oligo-astrocytoma was newly diagnosed at our institution from 1984 to 2003. Routine histological preparations and post-contrast preoperative MRI/CT-scan were simultaneously reviewed in order to assess the impact on survival of the following features: presence or absence of a polymorphous or gemistocytic astrocytic component, of necrosis and of contrast enhancement (CH); endothelial hyperplasia (EH) assessed as absent, present minor (HE+) or (HE++) when conform to the threshold of HE defined in the SA grading system of oligodendrogliomas. The tumors were graded A: no CH and no EH; in B: CH and /or HE++, and A/B: EH + but no CE. RESULTS: 70.1% of the tumors were classified as "pure" oligodendroglioma, 19.5% as "polymorphous oligo-astroastrocytoma" and 10.3% as "gemistocytic oligo-astrocytoma". In grade A, or B tumors, the presence of a polymorphous or a gemistocytic component had no significant influence on survival; however respectively 53% and 65% of these tumours versus 32% of "pure" oligodendrogliomas were grade B at the time of diagnosis. In either histological subtypes, survival was not significantly different when HE was absent or minor (HE+). After regrouping of the histological subtypes and of the tumors with HE+ or absent, the series included 153 oligodendrogliomas grade A and 98 grade B. Survival in patients with grade A versus grade B tumors was respectively 142 versus 52 months (p<0.0001). In grade B tumors, necrosis had no significant influence on survival. Ring-shaped contrast enhancement surrounding large foci of necrosis was observed in only 4 cases. In tumors with or without CE, patient survival was respectively 148 versus 40 months (p<0.0001). On post contrast MRI done in 235 patients, only 7 tumors (3%) were grade A/B (EH++ but no CH). CONCLUSIONS: From these results and our previous observation that, according to the SA classification of gliomas, only oligodendrogliomas or oligo-astrocytomas may not show CE, we propose that for retrospective studies: 1) tumors diagnosed according to the Ste-Anne classification as oligodendroglioma or oligo-astrocytoma be regrouped in a unique category, 2) independent of their histological type and grade according to the WHO, gliomas that do not show CE be regrouped with SA oligodendrogliomas grade A, 3) concerning gliomas that show CE on MRI: oligodendrogliomas or oligo-astrocytomas WHO grade II or III, as well as WHO secondary glioblastomas or glioblastomas with an oligodendroglial component, be regrouped with SA oligodendrogliomas grade B; however tumors that show ring-like CE surrounding large foci of necrosis and finger-like "peritumoral" edema should be excluded or analysed separately.

[Spatial delimitation of low grade oligodendrogliomas]. / Délimitation spatiale des oligodendrogliomes de bas grade.

Image-guided surgery is the central element of therapeutic management of low grade gliomas and consequently, a precise preoperative definition of their spatial extension is necessary. The question of the present work is: do the imaging abnormalities delineate the real spatial development of low grade oligodendrogliomas? A review of the literature showed that MRI on T2-weighted and FLAIR sequences are used to delineate the spatial developement of these tumours and that spectroscopic magnetic resonance imaging is more sensible to appreciate it. Moreover, mathematical models and histological studies suggest that MRI does not indicate the actual spatial extension of low grade oligodendrogliomas. This study focused on histological analysis of biopsy samples performed outside MRI imaging abnormalities in patients who harboured a low grade oligodendroglioma. It showed that isolated tumour cells were identified beyond imaging abnormalities in all of the 17 patients studied. In 15 of those 17 patients, isolated tumour cells were identified in the most distant biopsy samples taken outside imaging abnormalities. Thus, conventional imaging findings, including MRI on T2-weighted and FLAIR sequences, are not able to provide the real spatial development and boundaries of low grade oligodendrogliomas.

[Adult supratentorial oligodendrogliomas. Surgical treatment: indications and techniques]. / Oligodendrogliomes supratentoriels de l'adulte. Traitement chirurgical: indications et techniques.

Surgical resection is the first step in the treatment of adult supratentorial oligodendrogliomas (OLG). However, the role of resection on prognosis, the most appropriate time for surgery along the natural history of those tumors, and the best operative strategy remain debated. Survival curves after resection vary greatly among reported series, in particular as a result of a persisting confusion in identification and classification of cerebral OLG. Surgical or stereotactic biopsy is the first surgical procedure which enables confirmation of the diagnosis suggested on imaging, assessment of extension of tumor cell infiltration beyond abnormalities limit described an imaging, and currently available molecular biology studies. Biopsies may be the only surgical procedure in patients having a deep-seated tumor with minimal mass effect, or prior to a surgical resection or a "wait and watch" strategy. Surgical resection is indicated for the other patients. However, it has not been demonstrated that time for resection has an influence on survival, excepted in patients with rapidly growing tumors, with mass effect causing increased intracranial pressure. A wait and watch strategy is therefore warranted in patients with a tumor aspect suggestive of a grade A OLG; surgical resection may be indicated later. There is a current trend for maximal safe resection, preserving functional cerebral areas, since truly complete resection of the tumor including infiltration is exceptional. However, from the contradictory results reported to date, one cannot ascertain whether large or complete resection based on imaging is associated with significantly longer survival. Neuronavigation guidance, intraoperative imaging, and cortical stimulation techniques are helpful neurosurgical techniques enabling maximal safe resection with preservation of functional areas.

[Results of the Sainte-Anne - Lyons series of 318 oligodendroglioma in adults]. / Résultats de la série Sainte-Anne - Lyon de 318 oligodendrogliomes intracrâniens de l'adulte.

INTRODUCTION: Incidence of cerebral oligodendrogliomas is increasing because of better recognition made possible by improved classifications. We studied a homogeneous series using the Sainte-Anne grading scale in order to better understanding the history of these tumors with or without treatment and to assess prognosis and associated factors. PATIENTS AND METHODS: A retrospective series of 318 adult patients with oligodendroglioma (OLG) treated at Hôpital Sainte-Anne, Paris (SA) and Hôpital Neurologique, Lyons (L) between 1984 and 2003 was analyzed: 182 grade A OLG (SA + L), 136 grade B among which a homogenous series of 98 (SA) were included. For grade A: age at diagnosis ranged from 21 to 70 (mean: 41), sex ratio was 1.28. For grade B: age at diagnosis ranged from 12 to 75 (mean: 45.5), sex-ratio was 1.58. The main first symptoms were: epilepsy (A: 91.5%; B: 76%), intracranial hypertension (A: 7.9%; B: 14.6%), neurological deficit (A: 5.1%; B: 17.7%). The most frequent locations were: frontal, insular and central for both A and B. Mean size was 55 mm for grade A, 62 mm for B. Calcifications were found in 20% of A, 48.5% of B. No tumor was enhanced on imaging (CT/MRI) in grade A, all but 7 in grade B. All patients underwent surgery either for biopsy (A: 47.2%; B: 53%), or removal which was partial (A: 26.4% vs B: 19.4%) or extended (A: 36.3% vs B: 37.8%). Fifty-six patients underwent 2 procedures and 12 three procedures. Radiotherapy was performed in 76.9% of grade A, and 91% of B patients, in the immediate postoperative period for 71% A and 82.7% B. Chemotherapy was delivered for 36% of grade A (in the event of transformation to grade B or failure of radiotherapy) and 67.5% of B patients. Among grade A tumors, 38% transformed into grade B within a mean delay of 51 months with a mean follow-up of 78 months. RESULTS: Median survival was 136 months for grade A and 52 for grade B. Survival at 5, 10 and 15 was 75.5%, 51% and 22.4% for grade A vs 45.2%, 31.3% and 0% for grade B respectively. In univariate and multivariate analysis, grade A survival was associated with age at diagnosis, tumor size, large removal and response to radiotherapy. Grade B survival was associated with age at diagnosis, wide removal and sharply defined limits of the tumor on imaging. CONCLUSIONS: Analysis of both published data and this series underlines many prognostic parameters. It shows that OLG are heterogeneous tumors even in each grade (A and B). Treatment should consequently progress towards more targeted procedures for patients mainly with postoperative radiotherapy and chemotherapy.

Cerebral oligodendrogliomas in adults and children. Current data and perspectives.

Cerebral oligodendrogliomas represent more than 30% of glial tumors in adults. Mean age at diagnosis is 41 for grade A and 45(1/2) for grade B, epilepsy being the main revealing symptom (91.5% of A, 76% of B). Survival at 5, 10 and 15 years is respectively 75.5%, 51% and 22.4% for grade A (median: 136 months), and 45.2%, 31.3% and 0% for grade B (median: 52 months). It is influenced by age at diagnosis: median, before 40 years of age, is 12 years for A and 8(1/2) for B; between 40 and 60, is 12 years for A and 4(1/2) for B; over 60, is 4 years for A and 1(1/2) for B. In children, they represent less than 2.5% of cerebral tumors and include 23% grade A and 77% grade B (48.5% WHO grade II and 51.5% WHO grade III). Mean age at surgical removal is 9.5 +/- 5 years. One third are hemispheric, 2/3 are revealed by epilepsy. A complete surgical removal is performed in 60%. Mean survival is 13 years (154 +/- 20 months), with a mortality at 5 and 10 years of 60% +/- 9%, and a risk of recurrence of 54% +/- 9% at 5 years and 46.5% +/- 10.5% at 5 years. The main differential diagnosis of grade A oligo is dysembryoplastic neuroepithelial tumors (DNT). Inversely, thalamic locations, most often grade B, generally present with a motor deficit; complete removal can be achieved in only 15%. The only efficient treatment is chemotherapy, requiring search for chemosensitivity (1p19q deletion, expression of MGMT gene, analysis by MR-spectroscopy and TEP). Logically, surgical debulking should be as wide as possible, but with preservation of neurological and cognitive functions with the help of modern imaging progresses (fMRI, diffusion and perfusion MRI, tractography, PET) and operative techniques (navigation, cortical stimulation, and even opertaive MRI). Tumors presenting clinical and radiological progression should be removed. Operative mortality varies from 0 to 6%, transient morbidity from 20 to 25%, definit morbidity from 5 to 10%. Radiotherapy does not significantly modify survival whatever the delivered dose. The important point is the patient's radiosensitivity: survival is 148 months for radiosensitive patients versus 12 months for non responsive patients. Studies and development of pretherapeutic assays of tumoral radiosensitivity will be a fundamental research axis (PET, sample studies).

Intraventricular haemorrhage from a renal cell carcinoma pituitary metastasis.

Symptomatic pituitary metastasis and intraventricular haemorrhage from a cerebral metastasis are exceptional events in the natural history of a renal cell carcinoma. We report the first case of a metastatic renal cell carcinoma to the pituitary gland presenting with intraventricular haemorrhage. The origin of intraventricular haemorrhage and its association with renal cell carcinoma pituitary metastasis are discussed.

[Dynamic MRA in the evaluation of intracranial vascular diseases]. / Applications de l'ARM dynamique dans la pathologie vasculaire du systeme nerveux central.

Conventional catheter angiography (CCA) remains the gold standard for the evaluation of most intracranial vascular malformations. MRA techniques such as Time of Flight, Phase Contrast or 3D contrast-enhanced MRA, provide anatomic evaluation but without hemodynamic information. Recently developed, dynamic MRA is based on dynamic acquisition of images and image subtraction; these two principal characteristics produce images comparable to those obtained by CCA. The purpose of this review is to explain the principles, advantages and drawbacks of this technique in the evaluation of arteriovenous malformations, arteriovenous fistulas, aneurysms and venous thrombosis.

[Cerebral cavernomas followed by epileptic seizures: clinical picture, diagnosis, and treatment]. / Kavernomy golovnogo mozga, protekaiushchie s épilepticheskimi pripadkami: klinika, diagnostika, lechenie.

The clinical features of epilepsy associated with cerebral cavernomas and the results of different types of its surgical treatment: cavernonectomy, extended cavernomectomy, and epileptic focus resection were analyzed. The clinical, radiological, and electrophysiological data were studied in 48 patients with epileptic seizures associated with cerebral cavernomas who had been admitted to the Unit of Neurosurgery, Saint Anna Hospital (Paris, France) in 1982-2001. According to the severity of epileptic manifestations, the patients were divided into 2 groups: 1) 21 patients with single and rare seizures and 2) 27 patients with drug-resistant epilepsy. All the patients received medical antiepileptic therapy. Twelve patients from Group 1 underwent cavernomectomy or "extended" cavernomectomy. In Group 2, 23 patients were operated on and 3 types of operations (cavernomectomy, "extended" cavernomectomy, and corticoectomy) were performed. Statistically significant differences were found in anatomic, clinical, and electrophysiological parameters. Criteria associated with the development of drug-resistant epilepsy were established. These included: the early onset of seizures, temporal cavernoma, and a combination of partial and generalized seizures in one patient. The paper shows it necessary to choose a surgical intervention in relation to the duration of seizures, their frequency, and a response to medical antiepileptic therapy. The advantages of surgical treatment over medical one were not found in single and rare seizures (Group 1), while in drug-resistant epilepsy, surgical treatment yielded much better epileptological results than did medical treatment. The volume of a surgical intervention depends on the sizes of an epileptic focus detected by an in-depth preoperative study and on the site of a cavernoma.

[The endonasal approach to pituitary adenomas: experience in 105 procedures]. / Intérêt de la voie d'abord endonasale pour l'exérèse des adénomes hypophysaires.

OBJECTIVE: The endonasal approach to the sella turcica is supposed to simplify surgical techniques and reduce the risk and sequelae linked to removal of pituitary adenomas. We report our experience with 105 procedures using this approach. METHOD: The series included 45 men and 60 women, aged 17 to 83 years. Their intrasellar lesions were: 43 non-functional adnomas, 37 prolactinomas, 7 GH- adenomas, 9 corticotrop adenomas, 9 miscellaneous lesions (abscess, Rathke cleft cysts, empty sella). Mean duration of the procedures was 50 minutes. Mean hospital stay was 4 days. RESULTS: There were no deaths. Morbidity included: 1 (0.95%) rhinorrhea associated with meningitis which cured without sequelae, 11 (10.5%) transient diabetes insipidus lasting no longer than 48 hours, 2 cases of permanent diabetes insipidus (1 non-functional macroadenoma, 1 pituitary abscess), 1 transient hyposmia (3 months), 2 transient nasal obstructions. There were no cases of septal perforation, nasal deformation, partial or complete mucosal anesthesia, nasal pain, dental pain, or epistaxis. CONCLUSION: This surgical approach is easier to perform and causes less rhinological sequelae than the sublabial transsphenoidal approach. It allows an as effective tumor removal than the latter. Hospitalization stay is significantly shortened.