Cranial reconstruction after a post-craniotomy empyema.

This article presents a case report of a cranioplasty performed after a post-craniotomy empyema with osteitis. The skull reconstruction was performed using a bioceramic implant and a combined muscular free flap of latissimus dorsi and serratus anterior. This procedure not only provided coverage of a wide skull defect but also allowed the filling of the intracranial dead space. Clinically, we observed an improvement of the patient's preoperative neurological status with a near-complete correction of her right hemiparaesis and phasic disorders. Eight months after the cranioplasty, (1) no recurrence of infection was noticed; (2) no distortion of the skull was noticeable and (3) the patient again experienced a normal social life. Using computed tomography (CT) scan images, we observed a re-expansion of the left cerebral hemisphere without any dead space or extradural collection. The only observable sequelae were a temporoparietal alopecia (10 cm x 4 cm) and a winging of the scapula, induced by the skin graft and the removal of the lower-third of the serratus anterior muscle, respectively. The use of a muscular free flap associated with a customised biomaterial allows a single-stage reconstruction of extensive skull defect (120 cm(2)) in a previously infected area.

[Epidural intracranial hematomas: practical issues revealed by management of 100 recent cases]. / Hématomes intra-crâniens extra-duraux: à propos de 100 cas récents. Notre expérience et considérations pratiques.

We present a retrospective study on the management of 100 patients who presented epidural hematoma over a four-year period. Our goal was to provide an update on management of this injury. Computed tomography was performed because of the clinical presentation. Results provided information on the type of injury and appropriate treatment. A three-phase clinical progression was observed in only 6% of the patients. Despite state-of-the-art management, mortality remained high in these brain-injured patients (21%). No progress appears to have been achieved in the last ten years. This paradoxical fact probably results from the enhanced severity observed in our patients, who often suffered from associated intracranial injuries as well as multiple trauma (thoracic, abdominal trauma). Analysis study of the results confirms an improvement in mortality among patients with isolated epidural hematoma (6.6%), but great concern remains about the high mortality among patients with associated intracranial lesions (33.3%) or multiple trauma (32%).

[Subperiosteal hematoma of the orbit. Three cases]. / Hématome sub-périosté de l'orbite.

Orbital subdural hematoma should be considered in victims of head and face trauma with signs of exophthalmia. Early diagnosis and treatment, consisting of decompression, is mandatory to avoid long-term functional complications.

[Extradural hematoma of the posterior fossa]. / Hématome extradural de la fosse postérieure.

Extradural hematoma of the posterior fossa (EDHPF) is considered to be a rare complication of head injuries. In early reports, diagnosis was made only at the time of autopsy. Today, CT scanning prompts early diagnosis leading to better outcome. We report 20 consecutive patients observed over the last ten years who underwent surgery for EDHPF. This localization was found in 14,3% of all trauma patients operated for extradural hematoma. In our experience, EDHPF occurs in young adults with a clear male predominance. Vehicle accidents are the most frequent mechanism of injury. The main clinical presentation is subacute onset of signs (50% of our cases). Postoperative outcome was favorable in 19 of our patients (95%). We propose mandatory CT scanning that may have to be repeated as needed, to prevent delay in diagnosis and decision for surgery. Surgical removal of the EDHPF must be carried out as soon as possible as this is the only way to reduce morbidity and mortality.

[Tuberculous abscess of the cerebellum. Apropos of a case]. / Abcès tuberculeux du cervelet. A propos d'un cas.

A 22-year-old Asian man developed intracranial hypertension with a 38 degrees C fever. Two months earlier, he had undergone surgery and medical treatment for tuberculous otomastoiditis and pulmonary tuberculosis. The CT scan revealed multiple tuberculous abscesses of the cerebellum. Histological, microbiological and biological proof of diagnosis was obtained. We advocate surgical treatment of intracranial tuberculous abscesses associated with antituberculosis chemotherapy for 18 months. The earlier the treatment, the better the prognosis. This pathology must be kept in mind when treating patients from countries with a high endemic rate of tuberculosis and suffering from immunodeficiency syndrome.

[Unusual extra-axial infra-tentorial localization of a cavernoma in the cisterna magna]. / Localisation infra-tentorielle inhabituelle extra-axiale d'un cavernome au niveau de la cisterna magna.

A case of an extra-axial cavernous angioma of the cisterna magna is described. The clinical presentation, radiographic features, treatment of that unusual location in the posterior fossa are discussed. The patient is a 31 years old man admitted for the sudden onset of occipital headache and instability. A CT scan demonstrated a slightly calcified lesion, minimally enhanced after intravenous injection of a contrast agent, located within the posterior fossa. A T2-weighted MR image showed a well circumscribed mass, located between medulla oblongata and left cerebellar tonsil, of mixed signal intensity surrounded by a rim of decreased signal intensity related to the presence of hemosiderin. Cerebral arteriography was normal. A medial suboccipital craniectomy was performed, with the patient in the ventral position, in which a 1.5 x 1 cm solid dark-red mass was encountered arising from the cisterna magna and was easily removed "en bloc". The operative extra-axial aspect of that lesion was evident excluding a medulla oblongata tumor protruding into the cisterna magna. Histologically, the lesion was a cavernous angioma consisting of numerous vascular channels with collagen fibrous walls filled with fibrin thrombi and hemosiderin. Few elastic fibers were found in vascular walls. The patient's post-operative course was unremarkable.

[Distal aneurysm of the postero-inferior cerebellar artery. Anatomical and surgical considerations]. / Anévrysme distal de l'artère cérébelleuse postéro-inférieure. Considérations anatomiques et chirurgicales.

A patient with a rare peripheral aneurysm of the posterior inferior cerebellar artery (P.I.C.A.) was treated by microsurgery. Anatomical features and surgical procedures are discussed. The aneurysm was located in the retromedullary, tonsillomedullary segment of the right P.I.C.A. and formed a caudal or infratonsillar loop in the cisterna magna close to the inferior part of the tonsil. The operation was performed with the patient in the sitting position using a median suboccipital approach through a cervical 1 (C1) laminectomy. The widened neck of the aneurysm was clipped successfully and the post-operative course was completely asymptomatic. A vertebral angiogram control showed the P.I.C.A. to be patent. The surgical approach should be related to the site of the aneurysm. Those affecting the telovelotonsillar segment of a P.I.C.A., forming cranial or supratonsillar loops, and those involving its cortical segment can be effectively operated using the same median suboccipital approach. Aneurysms arising from the anterior or lateral medullary segment of a P.I.C.A. should be approached through a unilateral suboccipital craniectomy extending down to the foramen magnum. Although clipping the neck of the aneurysm is preferable, trapping is possible for lesions arising from or distal to the telovelotonsillar segment, this preserving the small arteries arising from the lateral and posterior medullary segments.

[Spontaneous cerebellar hematoma in adults. 44 cases]. / Hématomes intracérébelleux spontanés de l'adulte. 44 cas.

Spontaneous cerebellar hematomas account for 10 p. 100 of all spontaneous intra-cranial hemorrhages. In this series of 44 cases, 3 clinico-pathological groups are described on the basis of clinical and pathological data (small, middle and massive hematomas). The mortality rate was high (50 p. 100). Nevertheless, early and direct draining of the hematomas provides the best chances of survival.

[Aneurysm of the internal carotid artery bifurcation. Technical reflections apropos of a series of 10 cases]. / Anévrysmes de la bifurcation de la carotide interne. Réflexions techniques à propos d'une série de 10 cas.

Cerebral aneurysms at the bifurcation of the internal carotid artery are uncommon and represent less than 10% of intracranial aneurysms. A recent series of 10 cases (out of a total of 221 aneurysms over a period of five years, from 1983 to 1988, i.e. 4.5%) treated via a microsurgical approach is presented. Anatomical and operative aspects are discussed. These malformations are located at the point of union of the carotid artery, sylvian and lamina terminalis cisterns. They are close to perforating vessels which usually lie on their deep aspect. Surgery is performed via the standard pterional approach and, as Yasargil points out, two specific dissecting times are required for the opening of the sylvian and lamina terminalis cisterns, in order to avoid dangerous traction on the brain. In our experience, deep hypotension was used in the four cases of large malformations, and there was no need for a temporary dip. All aneurysms were clipped at the neck and the sac then punctured or removed. Post-operative evolution was completely asymptomatic in 9 cases (grade I-II--Hess and Hunt), one patient (grade IV) died from an apparent vascular spasm, confirmed by CT scan.

[Radiation-induced meningioma. 3 cases]. / Méningiomes radio-induits. 3 observations.

During the same year (1984), we have seen 3 cases of meningiomas following radiation therapy of the brain for previously diagnosed tumors. A causal relationship between irradiation and meningioma has been postulated. Nevertheless, the coincidental occurrence in same patient of two different histological lesions is possible. The neoplasms developed after irradiation are of mesenchymal origin; they are fibrosarcomas, osteogenic sarcomas and meningiomas.

Haemangioblastoma of the brain. Computed tomography and angiographic studies in 17 patients.

Between 1975 and 1983, 17 patients who underwent surgery for haemangioblastomas of the brain (16 lesions occurring in the posterior fossa) were studied with CT scans (17 cases) and vertebral angiograms (15 cases). The CT scans were superior for demonstrating a cystic tumour, its topography in the posterior fossa, its relationship to the fourth ventricle, and the presence and degree of an obstructive hydrocephalus. The vertebral angiographies were more sensitive and specific than CT for revealing the vascular nature, and were imperative in order to establish the supply and drainage of the tumours. It is clear that CT and angiography each make an important contribution toward defining these tumours. Their association is necessary.

[Evaluation of 138 fractures of the cervical spine during a recent 5-year period (1979 to 1983). Therapeutic approaches]. / Bilan de 138 fractures du rachis cervical sur une période récente de 5 ans (1979 à 1983). Attitudes thérapeutiques.

138 cervical spine fractures are reviewed during a recent period of 5 years (1979-1983). Their frequency stay high. The serial concern 67% of men and 33% of women. We observe a peak age between 20 and 30 (23%). 65% of lesions are caused by a traffic injury, 27% by a falling down, 10% by a diving. 45% of cases interest the upper cervical spine (C1-C2) with a high proportion of odontoid process fractures (60%) and Hangman's fractures (30%); 54% of cases concern the lower cervical spine (C3-C7) with an important part of fracture-luxation (72%), specially C5-C6 (35%). Clinically, we note almost a same part of fractures without neurological disturbances (54%) and with neurological abnormalities (46%). In this situation, the sensitive and motor loss are often severe (78%). In 40%, the injuries are polytraumatism and association spine lesion, cranio-cerebral lesion is the most frequent (61%). In upper cervical spine fractures, after Crutchfield or Gardner traction, posterior fixation was performed (62%). The treatment was conservative in 30%. In lower cervical spine lesions, a secondary surgical approach by an antero-lateral way was made (53%). The treatment was initially surgical in 13% and conservative in 28%. The mortality rate of this pathology is important (22%; i.e. 30 deaths on 138 cases).

[Meningeal fibrosarcomas]. / Fibrosarcomes méningés.

The authors present 4 operated cases of primary fibro sarcomas of the dura mater. Only, a few number of cases had been described in the literature. In Zulch's classification (1957) of 6000 brain tumors, there were 162 cases of sarcoma (i.e. 2,7%) and among sarcoma, 30 cases of fibrosarcoma of the dura mater. In according with the WHO classification of brain tumors (Zulch, 1979), the primary fibrosarcoma of the dura mater takes place in the group of meningeal sarcomas with the polymorphic cell sarcoma and the primary meningeal sarcomatosis. The pre-operative diagnosis is difficult, because neither clinical data, neither neuroradiological findings are characteristics. The prognosis of the patients with this tumor is poor, however some examples are known to have had a long post-operative survival. The association: complete surgical extirpation--post-operative radiation appears like to best treatment. Pathological examination showed in our four tumours, the features of fibroblastic sarcomas with haemorrhagic zones and foci of osteoid metaplasia. The ultra-structural study in 2 cases, confirmed the specificity of tumoral cells which did not display any histological similarity to the arachnoïdal cells. In one case, a myofibroblastic differentiation was evident, and thus, confirmed the plasticity of tumoral fibroblastic cells. The immuno-histochemical reaction of GFAP revealed reactive astrocytic areas in one case inside the immuno-histochemical sarcomatous tissue.

[Post-traumatic intracerebral hematomas. Apropos of a series of 38 cases]. / Les Hématomes intracérébraux post-traumatiques. A propos d'une série de 38 cas.

Our study is based on the analysis of traumatic I.C.H. 38 cases observed since we have had a C.T. Scan at our disposal (1975). Those cases (recorded in the departments of Paillas, Vigouroux, Sedan, Combalbert) represent 2,3% of the brain traumas, 6,5% of the traumatic intra-parenchymatous lesions and 9,5% of the traumatic intra-cranial hematomas. Most of the cases reported deal with male patients, with on average age of 46, who are often victims of traffic accidents. In half the cases of skull fractures, the hematoma is located in the opposite side of the fracture. In almost all cases, initial loss of consciousness is observed, followed by consciousness alterations, with few free intervals and with neurological focal signs depending on the site of the lesion. The C.T. Scan data of the those traumatic hematoma have been studied.

[Fracture dislocation of the sacral spine with cauda equina lesion. Report of two cases (author's transl)]. / Fractures transverses du sacrum avec lésions de la queue de cheval. Considérations à propos de 2 cas.

Transverse sacral fractures with cauda equina lesion appear only sporadically in the world literature. In our medical center 667 spine fractures were admitted during a twelve year period and we report only 2 cases of sacral fractures with neurological lesions (0,20%). The neurological abnormalities that occur are a perianal sensory loss with bladder and anal sphincters disturbance. Sphincters electromyographic studies and cystometric examination show a lower motor neuron lesion. In one of our cases, the nervous lesion was more spread with an unilateral sensory loss S1-S2 and a motor loss L4-L5 S1 in the same side. The high level of sacral lesion (S1-S2), the association with other pelvic fractures and fractures of the lower lumbar transverse processes, suggests the mechanism of injury (sudden flexion). Radiological studies show that sacral fractures are often difficult to detect (necessity of lateral view). Lumbar metrizamide exploration seems not very interesting. Sacral laminectomy which permits the decompression of sacral roots appears like the best treatment. The post-operative course, studied by clinical findings, electromyographic and cystometric examinations, shows the habitual resolution of neurological deficit (incomplete nevertheless in our 2 patients).

[Clinical pathological study of two cases of gliosarcoma (author's transl)]. / Gliosarcomes cérébraux. Etude anatomo-clinique de deux observations.

The authors report 2 cases of frontal tumors in adult men with neuroradiological signs of malignant glial tumor. Histological study allowed to diagnose a mixed gliosarcomatosis tumor. Scannographical, histological and ultrastructural signs are specifically studied.

[Arterio-veinous malformations located within the occipito-cerebello-mesencephalic dihedral (author's transl)]. / A propos des malformations artério-veineuses du diedre occipito-cérébello-mésencéphalique.

About 4 cases of arterio-veinous malformations located within the occipito-cerebello-mesencephalic dihedral (which is this region of the brain including the cistern of Galen and the surrounding formations : the quadrigeminal bodies forwards, the splenium of the corpus callosum upwards, the upper face of the cerebellum and the pedonculus cerebellaris superior below) the authors related their own experience. These 4 cases are detailed from a clinical point of view. Them, a synthetic study is undertaken in which a comparison is done between the literature and the clinical features encountered : headache, sub-archnoid hemorrhage, impairment of consciousness, clinical features such as cranial nerve impairment, nystagmus motor impairment, cerebellar deficit, hydrocephaly. The value of angiography, ventriculography and CAT is discussed. All these patients have been operated upon as far as the authors think that a better chance can thus be offered to them. The choice of the technique is discussed. For one patient, the sub-temporal route was performed ; but it seems worth using the posterior inter-occipital route : this allows a better view on the lesion and an easier treatment of the malformation. These 4 patients suffered post operatively of a visual defect. The control angiography revealed no more arterio-venious malformation in two patients, a mild one in two others.