Carotid artery stenting to prevent stroke in a patient with bilateral extracranial internal carotid dissection and vasospasm following rupture of an intracranial aneurysm.

SUMMARY: The stenting of carotid dissection has been described for the prevention of cerebral ischemia in patients who remain symptomatic despite therapeutic anticoagulation, in those who present contraindications for anticoagulation therapy, or who present a local or extensive stenosis, with an associated pseudoaneurysm. We here report a case associating a high clinical grade aneurysmal rupture with a bilateral extracranial carotid dissection. Because of the haemodynamic risk due to the acute bilateral stenosis-induced dissection and the occurrence of a vasospasm, the carotid dissections were treated with self-expendable stents.

Contribution of MR-angiography to the diagnosis and the therapeutic indication and follow-up of intracranial aneurysms.

The purpose of this study was to evaluate MR-Angiography (MRA) in comparison with digital angiography in the diagnosis, therapeutic indication and therapeutic follow-up of cerebral aneurysms. Out of 27 patients explored by angiography and MRA, 17 had aneurysm, 5 had an aneurysm excluded by a detachable balloon, and 5 without aneurysm were used as controls. MRA, performed by the paradoxical enhancement technique, required a 3 DFT acquisition with short TR and TE (40-8 ms) in gradient echo, with a 15 degrees flip angle. Analysis of angiograms and partitions was compared with that of angiography. Sixteen of the 17 aneurysms were found by a study of both angiograms and partitions. The result was doubtful in 1 patient. No false-negative result was recorded. Spasm was always detected, but the neck of the aneurysm was never sufficiently well defined. The quality of angiogram depends on the type of balloon used in the patients treated: only the balloon without metallic index did not induce an artefact. Thus, MRA seems to be useful in the detection of cerebral aneurysms, and the absence of artefact induced by detachable balloons without metallic index could allow a therapeutic follow-up. But for the moment, arteriography remains the reference for pretherapeutic evaluation.

[Intradural spinal metastasis from visceral neoplasms. Apropos of 4 cases. Review of the literature]. / Métastases spinales intradurales de néoplasies viscérales. A propos de 4 cas. Revue de la littérature.

Four patients were referred during the last year for treatment of an intradural metastasis. Primary sites were a bronchogenic carcinoma (one case), a prostatic carcinoma (one case) and in the two other cases the primary tumor was not found. In all cases Noot pain had lasted 1 to 5 months, despite CT examination during this painful period. Except in case n.4, diagnosis was not established until the onset of myelopathy. Surgical removal was complete in one case and subtotal in the three other cases, with complete postoperative relief of the pain in all cases and significative improvement of neurological status. The authors emphasize the importance of root pain as an early sign in these patients as well as the difficulty in establishing diagnosis. They discuss the different pathogenic mechanisms and the methods of treatment.

[Neurosurgical treatment of trigeminal neuralgia. Direct approach of percutaneous method?]. / Traitement neuro-chirurgical de la névralgie trigéminale. Abord direct ou méthode percutanée?

During the fifteen past years, the treatment of trigeminal neuralgia resistant to medical therapy has benefited from several neurosurgical techniques, either with percutaneous methods (RF-thermorhizotomy, cisternal injection of glycerol, balloon compression of the gasserian ganglion) or direct approach (microsurgical selective section of pars major, microvascular decompression). The respective advantages and disadvantages of these techniques are presented, both from the authors' experience (609 thermocoagulations, 150 direct approaches in the cerebello-pontine angle) and a review of some important series of the literature.

[Microsurgical treatment of trigeminal neuralgia. Results and prognostic factors of microsurgical vascular decompression]. / Traitement microchirurgical de la névralgie du trijumeau. Résultats et facteurs pronostiques de la décompression vasculaire microchirurgicale.

The authors have reviewed 100 cases of trigeminal neuralgia operated upon at the cerebello-pontine angle using microsurgical techniques, i.e. 20% of their total series of 513 patients with tic douloureux, 413 of them having been submitted to percutaneous R.F.--thermocoagulation. In 10 of the above 100 patients, a tumour or an angioma have been found and with its removal a total relief of pain has been obtained. In all but three of the other 90 patients, a neurovascular conflict has been revealed. In 17 of them a selective section of the trigeminal root had to be performed, as its cross-compression could not be eliminated. A total cure was achieved in all but three cases in which the result was only partial. In 70 patients a microvascular decompression (MVD) was performed and in 68 of them a follow-up of 1 to 5 years has been analyzed. In 82.4% the results were excellent. Further 7.3% thought to be benefited by the operation; although they still had some pain, they were well controlled by medical treatment. In 10.3% an unsatisfactory improvement, failure or recurrence were noted. Then a critical study of the whole material has been made in search for the causes of unsatisfactory results and for the possibilities of making the efficacity of MVD ascertained in a higher percentage of patients. The results of this study lead to definite conclusions, a part of which is quoted below: Some of clinical findings showed to be of paramount importance for the prognosis. The most evident has been a highly significant difference in the percentage of a total cure in patients with attacks of tic douloureux only (94.5%) and in those with the same type of attacks, but associated with permanent pain (58.3%). The analysis of the operative findings and of the details of the surgical procedure indicated to a necessity of restitution of the normal shape and course of the trigeminal root from the petrous ridge up to the entry-zone and of an adequate root protection (for instance with Dacron), after the Vth nerve had been detached from the conflicting vessel. A correlation of the above findings with the angiographic ones has been made. A measurable method has been used to make available data which could be informative as to the presence of a conflict, as well as to its anatomical cause. But this still needs a further critical elaboration.

Prognostic factors in microvascular decompression for trigeminal neuralgia.

The results of microvascular decompression (MVD) in 68 patients with trigeminal neuralgia followed for 1 to 5 years were compared with the clinical and operative findings and with the surgical modalities. Among 20 factors analyzed, the mode of pain manifestation proved to be the only factor significantly related to prognosis (p less than 0.001). In patients with paroxysmal pain only, a cure was obtained in 95%, whereas in those with paroxysmal and permanent pain, 58% were cured. None of the remaining factors showed any unfavorable influence on the results of MVD in cases of paroxysmal pain only. Some factors seemed to be related to prognosis in patients with a permanent pain component, and the following conclusions concern this group of patients only. Two factors proved to be statistically significant. First, patients with pain extending to two or three branches responded to MVD less favorably than those with pain in one branch only. The interposition of a piece of periosteum to separate a conflicting artery from the root led to worse results than the use of a square of Dacron. Other conclusions were based on small numbers and should be verified. A sensory deficit extending to two or three branches was related to worse results that a sensory deficit in one branch or its absence; a prior surgical procedure plays an additional unfavorable role. The patients with the least advanced degree of vasculonervous conflict (VNC) responded to MVD less favorably than those with severe cross compression; a posterosuperior site of VNC seems to play an additional unfavorable role. The distribution of some factors among types of pain manifestation showed marked differences, which seem to relate to results. The clinical and operative findings indicate that the sensory deficit corresponds to the extent of compression by the conflicting vessel. The necessity of distinguishing various clinical forms of trigeminal neuralgia for practical and cognitive reasons is emphasized.

[Clinico-echoencephalographic-electroencephalographic-angiographic correlations in supratentorial glioma]. / Niektóre korelacje kliniczno-echoencefalograficzno-elektroencefalograficzno-angiograficzne w glejakach nadnamiotowych mózgu.

The paper contains conclusions from a comparative evaluation of neurological, echoencephalographic, electroencephalographic and angiographic investigations in supratentorial cerebral gliomas. The results of the analysis were based on 55 cases and were related to the whole material as well as to various localization groups. The usefulness of A echoencephalography is discussed from the standpoint of possibility of indicating the cerebral hemisphere involved by the tumour and in comparision with the results of other investigations.