[Capillary hemangioma of the spinal cord. A new case]. / Hémangiome capillaire médullaire. Un nouveau cas.

A 49-year-old man presented with a 8-month history of gait and sphincter disturbances. Examination revealed a spastic paraplegia predominant on the left limb, associated with decreased tactile sensitivity below T10. MRI showed a right posterolateral intramedullary lesion with an isosignal on T1-weighted images and a mild hypersignal on T2-weighted images, with an intense contrast enhancement; the spinal cord presented with an hypersignal on T2-weighted images. At operation, a vascular tumor presented at the spinal cord surface, was well demarcated from the parenchyma and was easily removed. Microscopic examination showed a capillary hemangioma. Three months later the patient exhibited a motor improvement with a right spasticity, deficits in proprioception, without sphincter abnormalities. A new MRI showed the disappearance of the hemangioma and of the preoperative spinal cord hypersignal. Capillary hemangiomas are unusual on nerves or roots. Cases found in the spinal cord are extremely rare: to our knowledge, 5 cases have been reported. On MRI, they are easily distinguished from cavernous hemangiomas, but microscopic examination is necessary to distinguish them from hemangioreticulomas. The postoperative prognosis is generally good. However, a report of a multiple location case, on roots and spinal cord, suggests the need for long follow-up.

[Spinal cord histoplasmoma. A case report]. / Histoplasmome médullaire. A propos d'un cas.

Over a period of 2 months, a 60-year-old man, a chicken breeder, experienced low back pain, lower limb weakness predominant on the right side, and urinary difficulties, leading progressively to a flaccid paraplegia with sphincter impairment. Concomitant poor cognitive performances were noted. MRI showed enlargement of the conus terminalis, with a low-intensity signal on T1-weighted images, high-intensity signal on T2-weighted images, and areas of intramedullar contrast enhancement. A biopsy of the lesion showed macrophages containing yeast cells, with PAS and Grocott staining aspects compatible with the presence of Histoplasma capsulatum (Hc). A brain MRI showed multiple localizations in the brain stem and in both hemispheres with associated edema. Disseminated histoplasmosis was confirmed by a biopsy of a sub-maxillary ganglion demonstrating a necrotic tuberculoid lymphadenitis containing yeast cells resembling Hc. Immune tests disclosed the presence of HTLV1 anti-bodies without immunodeficiency nor HIV co-infection. An anti-micotic treatment was started 2 weeks after surgery, with intra-venous amphotericin B, for 21 days, followed by itraconazole, orally for 90 days. Cognitive functions improved significantly in 5 weeks while paraplegia and sphincter impairment remained unchanged. Seven months later, cerebral MR aspects dramatically improved while the conus medullaris lesion diminished, and the edematous component disappeared in all areas. Even though histoplasmosis is endemic in our region, CNS localization is rare, generally in disseminated forms associated with immunodeficiency. Brain granulomas are well-known, but spinal cord histoplasmomas are exceptional: only four cases have been evaluated by MRI. Unlike our case, spinal cord forms generally improve, due to surgery associated with antifungus medication, or sometimes due to specific medical treatment alone but with sufficient dosage.

[Vermian epidermal cyst developing in the fourth ventricle. A case report]. / Kyste épidermoïde vermien développé dans le ive ventricule. Une observation.

A 34-year-old man presented with recent severe headache. Neurological examination found gait disturbance and a static cerebellar syndrome. The CT scan showed a tumor located in the fourth ventricle and which presented with a density close to that of the cerebellar parenchyma, without contrast enhancement, associated with an enlargement of the third and the lateral ventricles. MRI showed that the tumor had an heterogeneous hyposignal on T1-weighted images and an hypersignal on T2-weighted images, without associated edema; the roof of the fourth ventricle was displaced upward and the brain stem forward. At operation, an encapsulated epidermal cyst, developed from the cerebellar vermis, without attachment to the floor of the fourth ventricle, was totally removed. Epidermal cysts of the fourth ventricle are unusual lesions; their capsule often adhere to the floor and cannot be totally removed. Those developed from the cerebellar vermis seem to be rarer. With the use of MRI, their true origin could be suspected. In these cases, the cysts can be totally removed, reducing the risk of recurrence

[Ossification of ligamentum flavum unmasked by acute paraplegia]. / Ossification des ligaments jaunes révélée par une paraplégie brutale.

A 30-year-old black man presented sudden-onset paraplegia during a foot-ball match, after a movement of hyperextension of the trunk. Moreover, the patient exhibited an hypoesthesia below the T11 level, with sphincter disturbances. The MRI and the CT-scan showed a stenosis of the spinal canal related to an ossification of hypertrophied ligamenta flava from T10 to T12. Intramedullary abnormal signals on MRI images were compatible with a spinal cord hemorrhage. A laminectomy with removal of abnormal ligamenta flava was carried out, and their endochondral ossification was confirmed by pathological examination. Two months later, the patient was able to walk alone and exhibited a mild spasticity associated to sensory disturbances of lower limbs. Ossification of ligamenta flava is usually observed in Japanese patients, sometimes in Caucasians, more rarely in black people. Its mechanism is unclear except when associated with metabolic or endocrine diseases. The patients usually present with clinical features of chronic spinal cord compression. Our case seems to be the first one disclosed by an acute spinal cord injury on ossified ligamenta flava. In this patient, because of remaining adjacent ossified ligamenta flava and the development on postoperative MRI of an intramedullary cavity, a long-term clinical and radiological follow-up is particularly necessary.

[Spontaneous temporo-sphenoidal encephalocele. A case report]. / Encéphalocèle temporo-sphénoïdale spontanée.

A case of anteromedial temporo-sphenoidal meningo-encephalocele in a 43-year-old woman is reported. She was referred to us after a five-year history of rhinorrhea of CSF. Three years ago, she presented an epileptic seizure. CT scan showed an empty sella and an opacity of the right part of the sphenoid sinus. On coronal sections, a defect was visible in the superior wall of the right lateral recess of the sphenoid sinus. The lateral sphenoidal rhinorrhea was confirmed by a CT cisternography. The patient was operated on via a frontotemporal approach with an orbitozygomatic removal. The dural defect was filled by a patch of pericranium. The patient is without evidence of cerebrospinal fluid leak 2.5 years later. Fifteen cases of anteromedial temporosphenoidal meningo-encephaloceles have been reported. They probably are of a developmental origin. Some cases have been successfully treated via a transsphenoidal route. However, surgical failures related to this approach can be due to the lack of control of the lateral recess of the sphenoid sinus. Therefore, the frontotemporal approach seems more adequate.

[Vertebral osteomyelitis with epidural abscess in a child with sickle cell disease]. / Ostéomyélite vertébrale avec abcès épidural chez une enfant drépanocytaire.

A case of paraplegia due to a thoracic epidural abscess in a 6-year-old black girl with sickle cell anemia is reported. MRI and CT scan showed abnormalities involving T6 vertebra which were consistent with osteomyelitis. A laminotomy, associated to antibiotic administration, permitted rapid neurological improvement. Although cultures were negative, the infection was probably due to salmonellae. Salmonellosis is a well-known complication in children with sickle cell disease but spinal localization is unusual. Its pathogenesis is unclear but immunological abnormalities associated to vascular obstructions by abnormal blood red cells have been advocated. The underlying etiology of vertebral abnormalities in these children is difficult to determine, but early diagnosis with modern investigations, as CT scan and MRI, is crucial to promptly begin therapy for osteomyelitis, minimizing the risk of spinal cord compression.

[Epidermoid cyst of the third ventricle. Report of a case]. / Kyste épidermoïde du troisième ventricule. Une observation.

We report a case of epidermal (or epidermoid) cyst, in a 36-year-old man which developed in the third ventricle. Clinical manifestations were headaches and memory disturbances. On CT scan the tumor occupied the entire third ventricle but was mainly developed on the left side. On CT reconstructed images, the floor of the third ventricle was clearly visible. Using a trans-ventricular approach, the tumor, closely related to the left part of hypothalamus, was totally removed. Later on, because of persistent hydrocephalus, a ventricular shunt was inserted. An aseptic meningitis occurred and resolved spontaneously. The patient exhibited a postoperative transitory Korsakoff's syndrome. Postoperative endocrine investigations showed hypopituitarism. Some intra-ventricular epidermal cysts have been reported, especially involving the fourth ventricle. Their development into the third ventricle is unusual, and in early reports their precise origin appears doubtful. Although they have no characteristic radiological features, the location of epidermal cysts is clearly defined by the CT scan and especially MRI. It would be possible to totally remove epidermal cysts of the third ventricle, avoiding the risk of recurrence.

Intramedullary neurenteric cyst without any associated malformation. One case evaluated by RMI and electron microscopic study.

A 46 years old woman presented with several years history of low back pain. For five years she suffered from weakness of the left lower limb and three years later she experienced an episode of right foot weakness. She suffered too from occasional urinary urgency. The examination showed decreased power and diminished sensory perception in the left leg. On myelography, a block at L2 level was observed. RMI evaluation showed an intramedullary cyst in the anterior part of the spinal cord without any enhancement of its wall by the Gadolinium. At operation a thin-wall cyst was found containing clear fluid. After a biopsy of the wall, a cystosubarachnoid shunt was performed. Histological examination of the surgical sample showed a simple cuboidal epithelium lying on collagen fibrills. Electron microscopic studies showed ciliated cells with a clearly-visible basement membrane. The diagnosis of neurenteric cyst was confirmed. In the postoperative course the patient complained about sensory loss of the legs and the perineal area. Six months later, she exhibited a sensory disturbance of the feet and the right sacral area, a motor deficit of the distal left leg without urinary disturbance. Neurenteric cysts are dysraphic lesions which can be observed without other abnormalities. They are usually extramedullary and the intramedullary forms are very rare: among 5 cases reported in the literature, one has been evaluated by RMI. In the absence of enhancement by the Gadolinium, the other possible diagnosis seems an ependymal cyst. Contrary to extramedullary forms the postoperative course of intramedullary neurenteric cysts are not always eventful. Because the cyst wall cannot be removed, repeated RMI are desirable in the follow-up.

[Forestier disease disclosed by dysphagia. Apropos of a case]. / Maladie de Forestier révélée par une dysphagie. A propos d'une observation.

A 74-year-old man presented with a several year history of dysphagia and dysphonia. X-ray examination showed prevertebral ossification, from C2-C3 to C3-C4, associated with a calcification of the anterior longitudinal ligament. The same abnormalities were present in the thoracolumbar spine. There was no hypertrophy nor ankylosis of the articular joints or the sacroiliac articles, and no biological abnormalities. These characteristics are typical of Forestier's disease also named "diffuse idiopathic skeletal hyperostosis (DISH)". Because of the consequences of dysphagia, an operation was carried out with a good result at two months. Symptomatic forms of Forestier's disease are uncommon, but in some cases, surgery is indicated because of the importance of dysphagia and respiratory disturbances. The role of direct compression of the esophagus or the pharynx by the ossification is possible but an associated inflammatory reaction cannot be excluded.

[Treatment of frontal interhemispheric arachnoid cysts by fenestration of the lamina terminalis]. / Traitement des kystes arachnoïdiens inter-hémisphériques frontaux par ouverture de la lame terminale.

Two cases of frontal interhemispheric cysts have been treated by fenestration of the Lamina Terminalis. Clinical and radiological results were good with a CT follow-up 6 and 7 years after surgery. This procedure avoids the interposition of prosthesis. Actually it could be simplified by the use of endoscopic technics.

[Symptomatic spinal intra-dural arachnoid cyst. Apropos of a case with magnetic resonance imaging]. / Kyste arachnoïdien intra-dural dorsal symptomatique. A propos d'un cas avec Imagerie par Résonance Magnétique.

The authors report a case of intradural posterolateral spinal arachnoid cyst diagnosed by Magnetic Resonance Imaging (MRI) in a 59-year-old woman. Ten years before, she started to suffer from burning sensation of the left lower limb aggravated by head movements. Physical examination was normal except a sensory dissociation below T10. A myelography was considered as normal. Three years later, motor disturbances occur with progressive weakness. Examination showed asymmetrical spastic paraparesis with a right predominance. On MRI, the spinal cord was displaced at T6-T7 level by a posterior intradural mass with a similar signal than CSF; furthermore, at this level, there was an intramedullary hyposignal on T1 weighted sections. The diagnosis of spinal intradural arachnoid cyst was confirmed at surgery. Microscopic examination of the cyst wall showed fibrous tissue with mild lymphocytic infiltration. Rapid recovery of legs weakness followed, but abnormalities of spinothalamic functions persisted. The clinical characteristics and the MRI data are discussed. The authors conclude that this arachnoid cyst had an inflammatory origin.

Dural arteriovenous fistulas of the posterior fossa draining into subarachnoid veins.

PURPOSE: To describe the clinical presentation, angioarchitecture, and risks and problems of therapy in patients with dural arteriovenous malformations of the posterior fossa draining into subarachnoid veins. PATIENTS AND METHODS: Twelve patients with dural arteriovenous malformations of the posterior fossa draining into subarachnoid veins were studied. RESULTS: These fistulas often presented with intracranial hemorrhage (eight cases) and myelopathy (two cases). They were located in the tentorium (six cases) or at the skull base (six cases). The arterial supply was provided by branches of the external carotid artery (nine cases), by the posterior meningeal branch of the vertebral artery (nine cases), and by the meningohypophyseal trunk (three cases). The fistulas drained directly into a cortical vein (six cases) or into a venous lake (six cases). In two cases, perimedullary draining veins were observed. The treatment modalities were endovascular embolization alone (two cases), surgery alone (five cases), and embolization followed by surgery (three cases). Despite the treatment, four patients died; in two cases, intracranial hemorrhage recurred. CONCLUSIONS: Subtotal occlusion of a fistula by surgery or embolization alone is not protective against further complications, especially hemorrhage. The goal of treatment is to achieve a rapid and complete anatomical cure; combined endovascular and neurosurgical treatment seems to be the therapeutic choice.

[Hydatid cyst of the cavernous sinus. A case]. / Kyste hydatique de la loge caverneuse (une observation).

The authors report a case of hydatic cyst of the cavernous sinus occurring in a young woman operated on 3 months before for an intracerebral controlateral localization. An opthalmoplegia associated to a partial facial hypoesthesia were the dominant symptom. The topographic diagnosis was evocated by C.T. scan and Magnetic Resonance Imaging and confirmed by surgery. As far as we know this localization has not been reported. The precise origin and the surgical management of this hydatic cyst are discussed.

[Chondromyxoid fibroma of the cervical spine. Apropos of a case treated by partial vertebrectomy]. / Fibrome chondro-myxoïde du rachis cervical. A propos d'un cas traité par vertébrectomie partielle.

A case of chondromyxoid fibroma revelated by cervicalgias and involving the right part of the 5th cervical vertebra is reported. This uncommon cartilaginous tumor is usually described in the metaphysis of long bones and appears very rare in the spine. If radiological aspects have been reported, the majors series do not describe a typical appearance of vertebral lesions; our patient is one of the first to have been evaluated by CT scan. Chondromyxoid fibromas are benign tumors, but recurrence is possible especially when treated by curettage alone. In our case, operated on two stages, the resection seemed sufficiently large and CT control on the 10th month did not show evidence of recurrence. Clinical and radiologic findings, and surgical management of these vertebral tumors are discussed.

[Vertebro-dural arteriovenous fistulae of the foramen magnum with perimedullary venous drainage]. / Les fistules artério-veineuses vertébro-durales du trou occipital à drainage médullaire. Deux observations.

Two cases of dural arteriovenous fistulae of the foramen magnum with perimedullary venous drainage are reported. Their arterial component was a dural branch of a vertebral artery. The localization and the origin of these fistulae appeared very uncommon but could be explained by the embryogenesis of the vertebral arteries, of which the third portion corresponds to the first cervical radicular artery. The first patient had signs and symptoms usually described in this disease, but the second presented a subarachnoid haemorrhage with neither motor and sensory deficit not sphincter disturbance. Myelographic findings, M.R.I. abnormalities and treatment of these rare dural arteriovenous malformations are discussed.

Value of electroencephalogram in prediction and diagnosis of vasospasm after intracranial aneurysm rupture.

The Electroencephalogram (EEG) of 151 patients whose ruptured aneurysm was confirmed by CT scan and angiography was recorded on the first day (D1) and the fifth day (D5). On D1, EEG had a prognostic value: among 46 patients with normal EEG, 72% presented neither further electrical ischaemic features nor delayed angiographic vasospasm; on the other hand, when bilateral bursts of slow waves, "axial bursts" or slow delta waves were recorded (78 cases), 97% exhibited EEG signs of ischaemia and angiographic vasospasm a few days later. These data were clearly related to the importance of the haemorrhage, specially when thick clots in the subarachnoid cisterns were found on the CT scan. On D5, EEG had a diagnostic value: focal or asymetrical bilateral delta waves occurring at that date seemed to correspond to ischaemia; among 107 patients with these electrical features, an angiographic vasospasm appeared in 96% of cases, and the importance of electrical abnormalities could be related to the degree of arterial narrowing. We conclude that EEG data are very useful in prediction as well in recognition of post-subarachnoid haemorrhage ischaemia due to vasospasm and are sufficiently precise to postpone control angiography and operation, when delayed surgery is programmed.

[Intradural extramedullary neuro-enteric cysts without associated malformation. 3 cases with magnetic resonance imaging]. / Kystes neurentériques intraduraux extramédullaires sans malformation associée. Trois cas avec imagerie en résonance magnétique.

We report 3 cases of extramedullary neurenteric cyst without associated dysraphic lesions. One of the cases had an ultrastructural study. Magnetic resonance imaging provided a preoperative diagnosis. The embryogenesis of neurenteric cysts, their main clinical aspects and their surgical treatment are reviewed.

Intracranial meningiomas in elderly patients. Postoperative morbidity and mortality. Factors predictive of outcome.

We studied retrospectively a series of 96 patients (36 men, 60 women), older than 65 years of age (mean age: 70 +/- 4 years, range 65-82), operated upon for an intracranial meningioma from October 1978 to December 1988. Fifty-two patients (54%) were under 70, 32 between 71 and 75 and 12 over 75 (46%). The tumours were diagnosed for all the patients by CT scan. Thirty-four (35%) were located over the convexity, 24 (25%) in the falx/parasagittal region, 38 (40%) in the base, tentorium and posterior fossa. Neurological and physical conditions were assessed preoperatively and at the closing date in June 1989. Operative mortality was 16% (15/96). Patients were divided into two groups: poor outcome, defined by the death or a post-operative Karnofsky index less than or equal to 70 (n = 36), and good outcome defined by a Karnofsky index of 80 or more (n = 60). The two groups did not differ regarding age, sex ratio, tumour size and peritumoural oedema. The only predictors of poor outcome were poor preoperative general health condition (stage III of the American Society of Anesthesiology classification), (p less than 0.01), poor preoperative neurological condition (Karnofsky's index) (p less than 0.001), and location of the tumour on the base or in posterior fossa (p = 0.02).

[Ependymoma of the intradural filum terminale in adults. 20 cases]. / Les épendymomes du filum terminal intra-dural chez l'adulte. Vingt observations.

Twenty cases of ependymomas of the intradural filum terminale in adults have been reviewed. Their pathology was quite uniform, of a myxopapillary type, similar to the low grade ependymoma described by Kernohan, which represent about 23% of the tumours of cauda equina. Mean age of the patients was 35.7 years. Mean time between the first symptom and the diagnosis was 46 months. Clinical symptoms were often non specific, with low back pain and radiculalgias. At the time of operation, clinical signs were essentially motor deficits usually moderate (11 cases), sphincter disturbances (10 cases), and sensory loss (9 cases). In 3 patients with rapid worsening, an intratumoral haemorrhage was found. In 2 other cases, intracranial hypertension was the main symptom: in the first, it was related to hydrocephalus probably caused by spinal subarachnoid haemorrhage; in the second, there was no ventricular dilatation. In this series, neuroradiological examinations had consisted mainly in myelographies. C.T. scan has been performed in 3 patients; in only one case it has allowed to visualize a presacral extension. One patient had preoperative M.R.I.: the association of an expansive lesion with upper cyst in conus medullaris and presence of blood in the sacral area permitted the diagnosis of ependymoma of the filum terminalis. The average size of the tumours was 8 cm. Total removal has been possible in 15 cases (and in 2 of the 5 giant tumours), subtotal removal in 2 cases, and partial removal in 3 cases. In 4 patients where existed an intraspinal cord extension above the conus, it has been resected completely, except for one case with recurrence. Patients with a total removal had a good functional recovery (13/15). No recurrence has been observed in this group. In conclusion, with M.R.I., one may hope an earlier diagnosis, condition of radical surgery. So, radiotherapy which is not without risk, could be avoided.