Surgical therapy for frontal epilepsies.

We have described our 25 years experience concerning 100 patients operated on for frontal epilepsy. Results show that 55% of patients are practically cured of their seizures and that 76% benefited from cortectomy (reduction of more than 75% of seizures). These results are the worst in the total series of St. Anne. Reasons for success and especially failure were analyzed in detail: 1. SEEG methods gave good indications along three dimensions of the limits and borders of the cortical excision. 2. When clinical semiology and organization of ictal discharges give evidence for rapid bilateral discharge, with involvement of axial musculature and generalized tonic-clonic manifestations, experience shows that it is necessary to combine cortectomy with a section of the adjacent cortico-subcortical fibers of the corona radiata, as if propagation of ictal discharges were impeded if not interrupted by sectioning such fibers and the primary site were incapable of expressing itself clinically. 3. If the characteristics of seizures suggest the quasisimultaneous involvement of the two frontal lobes and the existence of bilateral multifocal epilepsy, we suggest that a systematized anterior callosotomy might lead to useful results. 4. Finally, we propose general criteria for indications and contraindications for surgery.

[Current significance of stereotactic exploration in the diagnosis and therapy of space-occupying cerebral processes]. / Heutige Bedeutung der stereotaktischen Exploration für die Diagnostik und für die Therapie bei raumfordernden cerebralen Prozessen.

To reach good functional results in patients with spaceoccupying processes--especially with those localized in the dominant hemisphere operative treatment should be planned individually, which is impossible if all diagnostic assessments are followed by the same surgical procedure. The choice of appropriate method of therapy in case of brain tumor depends on various factors, such as the histological nature, extent and volume, relationship to the brain structures and vessels, and spatial form of the growth. The synthesis of all neuroradiological information from stereotactic exploration, together with the histological findings from stereotactic serial biopsies yields a three-dimensional representation of the brain with the tumor. This method seems to offer the optimal basis for the choice of appropriate treatment--especially for gliomas--between surgery, radiotherapy (external or/and interstitial), endocavitary radiation therapy or drainage.

[Acute transient Korsakoff's syndrome caused by hematoma of the floor of the 3rd ventricle]. / Syndrome de Korsakoff aigu et transitoire par hématome du plancher du 3e ventricule.

A forty four year-old woman had had an amenorrhea-galactorrhea syndrome for 3 months when a Korsakoff's syndrome with headache suddenly appeared. Neuroradiological investigations revealed a hematoma involving the anterior part of the IIIrd ventricle. After a short period of neurogenic hypernatremia the lesion disappeared with the development of a spontaneous ventriculocisternostomy. Simultaneously, the Korsakoff's syndrome decreased until it went off almost completely, but a diabetes insipidus appeared and the hyperprolactinemia remained unchanged. Four years later, those are the only symptoms which are still present. This case, particular by its aetiology and evolution, illustrates well the possibility of functional Korsakoff's syndromes.

[Familial forms of intracranial cavernous hemangioma. Apropos of 5 cases in 2 families]. / Formes familiales des hémangiomes caverneux intracrâniens. A propos de 5 cas dans deux familles.

The authors report five cases of cavernous hemangioma belonging to two families. In the first family, an 8 year old child was operated on in 1970 for a left frontal location. His mother, aged 39, was operated on in december, 1981, with stereotaxic approach, for two locations: one was frontal location, the other one was in the pineal region. Among the second family, a 21 year old woman was operated on in december 1976, for a cerebellar cavernous hemangioma. Her sister, aged 18, presented with subarachnoid hemorrhage in january 1980. C.T. scan showed a right temporal high attenuation area. This patient was not operated on. The aunt to those two sisters was operated on in october, 1981, for a left temporal cavernous hemangioma. Those five cases represent about half of the intracranial cavernous hemangiomas operated on in the Lille Neurosurgery Department since 1967. Even, unusual, the familial occurrence of this affection must be admitted. It shows a nosological interest, but also allows prevention by searching and surveying the asymptomatic cases, or genetic evaluation of disease risk.

[Reliability of a simplified method of localization of CT images. Correlation with stereotaxic results in 30 cases]. / Fiabilité d'une méthode simplifiée de transposition des images TDM. Corrélations au repérage stéréotaxique dans 30 cas.

A simplified method of localization of cerebral lesions by reference to CT Scan images was compared systematically in 30 cases, with localization obtained under stereotaxic conditions. The comparison was made in reference to the pineal gland and certain ventricular landmarks. The uncertainty of the method in an angular plane is less than or equal to 2,5 degrees; it is less than or equal to 3 mm in a linear plane in more than 90% of the cases.

[Definition of limits and 3D configuration of cerebral gliomas. Histological data, therapeutic incidences (author's transl)]. / Délimitation et configuration spatiale des gliomes cérébraux. Données histologiques, incidences thérapeutiques.

In neurosurgical common practice, the only histological informations usually taken into account for the treatment of gliomas are the histological type and degree of malignancy. Nevertheless, from a therapeutic point of view the spatial development of the tumor should be considered as a point of paramount importance. This spatial development can be evaluated in vivo with the help of C.T. scan and stereotaxic biopsic exploration. From the study of 150 astrocytic, oligodendrocytic or composed which have been explored by serial stereotactic biopsies, we tried to codify the histological informations so as to express, in a simple and practical way, both the histological type and malignancy together with the 3 D configuration of the tumor. This codification is a useful contribution to the choice of therapy, further more, it helps to assess and to compare therapeutic protocols on homogeneous tumor groups.

[Current experience of stereotaxic irradiations in the treatment of hemispheric gliomas (author's transl)]. / L'expérience actuelle des irradiations stéréotaxiques dans le traitement des gliomes hémisphériques.

Authors present a short review of the techniques and results of the stereotactic focal irradiations (S.I.) used at present in France for the treatment of small "active" gliomas localized in high risk areas (functional and vital) of the brain. These techniques include the temporary interstitial implantation of 192Ir wires, possibly associated with external irradiation and the treatment of active glioma cysts by intracystic injection of colloidal beta emitters such as 90Y and 186Re. The risk of immediate (surgical) and late (radiation) functional loss is low and the overall results at 3 years are satisfactory in particular with small well delimited astrocytomas. Such treatments can be associated to surgical reduction of the tumor volume or to other forms of irradiation according to the data of stereotactic localization studies including biopsy.

Circadian patterns of growth hormone, prolactin and corticotrophin secretion in hypothalamic and extra-hypothalamic lesions localized by stereotactic neuro-radiology in humans.

The integrity of mediobasal hypothalamus for the maintenance of normal circadian rhythms has been clearly established in the animal. Using precise stereotactic neuroradiologic localisations of various brain tumors, the authors demonstrate that in human, cortical lesions induce no significant modifications of the circadian variation of GH, prolactin or ACTH. In contrast subcortical lesions displacing the 3rd ventricle result in an inhibiton of the nocturnal rise in GH and prolactin, whereas the circadian rhythm of ACTH remains normal.

Application of stereotactic concepts to the surgery of epilepsy.

For the authors, the essential feature of stereotaxis is the three-dimensional representation of the entire brain, including the central gray nuclei as well as the cerebral cortex. Stereotactic neurosurgery, which in this conception might be called "global", associates data from indirect localization (basic reference lines, proportional grid) to direct individual localization (performed by bidirectional, orthogonal teleradiography, with stereoscopy). The obtained high precision radiographic documents allow to establish the three coordinates (X, Y, Z). This method, also used in localization of tumours and interstitial irradiation of tumours, led to the definition of a special methodology for epilepsy surgery (threefold correlation of the clinical seizure patterns, electrical anomalies and the concerned anatomical structures). The stereotactic implantation of several acute and chronic electrodes (stereo-EEG) gives a 3-dimensional definition of the epileptogenic area and of its propagation pathways. These data, as well as the individual anatomy of the patient's brain are represented by the neurosurgeon on a surgical diagram. The transfer of these data to the surgical field is facilitated by the accuracy of the diagram. A double postoperative control is made (photographs--teleangiography). The described methodology increases the precision of open surgery. It is also used to localize and to remove "incipient" lesions evidenced by the CT scan (accurate anatomical localization--vascularization). In the opinion of the authors, the use of a common stereotactic geometry applied to the collection of paraclinical data will lead in the future to an increased precision of surgery and hence, to a better respect of the brain and of its function.

[Role of the amygdala in the occurence of oro-alimentary signs of during epileptic seizures in man (author's transl)]. / Röle du noyau amygdalien dans la survenue de manifestations oro-alimentaires au cours des crises épileptiques chez l'homme.

The authors study the role of amygdala dysfunction in cases of oro-alimentary signs occuring in seizures recorded during a series of stereo-electroencephalographic investigations (S.E.E.G.) carried out for neurosurgical purposes. The patients under study have an epilepsy that is resistant to drug therapy. This work concerns 89 seizures with "oro-alimentary motor activity" recorded in 59 patients with whom it was possible to establish sufficiently rigourous anatomical - electrical - clinical correlations. This study enabled us to show that : --a seizure characterized by "oro-alimentary motor" signs (with the exclusion of swallowing movements) is related to a discharge that directly involves the amygdala. --a critical discharge affecting the anterior temporal region is expressed as : oro-alimentary activity either accompanied or not by other signs (breaking contact is exceptional). --late "oro-alimentary motor activity" also indicates disorganization of the amygdala, but offers no conclusion on the origin of the discharge.

Distribution of beta2-microglobulin in cerebrospinal fluid and in cystic fluid of brain tumors. A preliminary study.

The concentrations of immuno-reactive beta2-microglobulin (beta2m) were measured in the cerebrospinal fluid (CSF) and the cystic fluid (CF) of Central Nervous System (CNS) tumours (gliomas, n = 5; craniopharyngiomas, n = 5) and in the culture medium of established cell lines derived from CNS tumors. These data are compared with plasma and CSF values of beta2m in normal subjects (n = 15) and in a group of peripheral solid tumors (metastatic breast carcinomas, n = 9). In the control group the absence of correlation between plasma and CSF values, suggests an independant production of beta2m in the two compartments considered. The capacity of CNS tumor cells to synthesize beta2m is demonstrated in vitro. In vitro beta-2m concentrations in the CF embryonic tumors (craniopharyngiomas) is significantly more elevated than in non malignant astrocytomas.