Early Detection of Underlying Cavernomas in Patients with Spontaneous Acute Intracerebral Hematomas.

BACKGROUND AND PURPOSE: Early identification of the etiology of spontaneous acute intracerebral hemorrhage is essential for appropriate management. This study aimed to develop an imaging model to identify cavernoma-related hematomas. MATERIALS AND METHODS: Patients 1-55 years of age with acute (≤7 days) spontaneous intracerebral hemorrhage were included. Two neuroradiologists reviewed CT and MR imaging data and assessed the characteristics of hematomas, including their shape (spherical/ovoid or not), their regular or irregular margins, and associated abnormalities including extralesional hemorrhage and peripheral rim enhancement. Imaging findings were correlated with etiology. The study population was randomly split to provide a training sample (50%) and a validation sample (50%). From the training sample, univariate and multivariate logistic regression was performed to identify factors predictive of cavernomas, and a decision tree was built. Its performance was assessed using the validation sample. RESULTS: Four hundred seventy-eight patients were included, of whom 85 had hemorrhagic cavernomas. In multivariate analysis, cavernoma-related hematomas were associated with spherical/ovoid shape (P < .001), regular margins (P = .009), absence of extralesional hemorrhage (P = .01), and absence of peripheral rim enhancement (P = .002). These criteria were included in the decision tree model. The validation sample (n = 239) had the following performance: diagnostic accuracy of 96.1% (95% CI, 92.2%-98.4%), sensitivity of 97.95% (95% CI, 95.8%-98.9%), specificity of 89.5% (95% CI, 75.2%-97.0%), positive predictive value of 97.7% (95% CI, 94.3%-99.1%), and negative predictive value of 94.4% (95% CI, 81.0%-98.5%). CONCLUSIONS: An imaging model including ovoid/spherical shape, regular margins, absence of extralesional hemorrhage, and absence of peripheral rim enhancement accurately identifies cavernoma-related acute spontaneous cerebral hematomas in young patients.

Prognostic factors for progression-free survival of the filum terminale ependymomas in adults.

OBJECTIVE: To define the prognostic factors for progression and to determine the impact of the histological grading (according to the World Health Organization) on the progression-free survival (PFS) of filum terminale ependymomas. METHODS: A retrospective chart review of 38 patients with ependymoma of the filum terminale was performed, focusing on demographic data, preoperative symptoms, tumor size, quality of resection, presence of a tumor capsule, and histological grade. RESULTS: Gross total resection (GTR) was achieved in 30 patients (78.9%). Histopathological analysis found 21 (55.3%) myxopapillary grade I ependymoma (MPE), 16 (42.1%) ependymoma grade II (EGII), and 1 (2.6%) ependymoma grade III. There was no significant difference between the mean±SD volume of MPE (5840.5±5244.2mm3) and the one of EGII (7220.3±6305.9mm3, p=0.5). The mean±SD follow-up was 54.1±38.4 months. At last follow-up, 30 (78.9%) patients were free of progression. In multivariate analysis, subtotal resection (p=0.015) and infiltrative tumor (p=0.03) were significantly associated with progression. The PFS was significantly higher in patients with encapsulated tumor than in patients with infiltrative tumor (log-rank p=0.01) and in patients who had a GTR in comparison with those who had an incomplete resection (log-rank p=0.05). There was no difference in PFS between patient with MPE and EGII (p=0.1). CONCLUSION: The progression of ependymoma of the filum terminale highly depends on the quality of resection, and whether the tumor is encapsulated. Except for anaplastic grade, histopathological type does not influence progression.

Intraoperative cerebral blood flow monitoring in neurosurgery: A review of contemporary technologies and emerging perspectives.

Intraoperative monitoring of cerebral blood flow (CBF) has become an invaluable adjunct to vascular and oncological neurosurgery, reducing the risk of postoperative morbidity and mortality. Several technologies have been developed during the last two decades, including laser-based techniques, videomicroscopy, intraoperative MRI, indocyanine green angiography, and thermography. Although these technologies have been thoroughly studied and clinically applied outside the operative room, current practice lacks an optimal technology that perfectly fits the workflow within the neurosurgical operative room. The different available technologies have specific strengths but suffer several drawbacks, mainly including limited spatial and/or temporal resolution. An optimal CBF monitoring technology should meet particular criteria for intraoperative use: excellent spatial and temporal resolution, integration in the operative workflow, real-time quantitative monitoring, ease of use, and non-contact technique. We here review the main contemporary technologies for intraoperative CBF monitoring and their current and potential future applications in neurosurgery.

Surgical management of anterior clinoidal meningiomas: consensus statement on behalf of the EANS skull base section.

BACKGROUND: The optimal management of clinoidal meningiomas (CMs) continues to be debated. METHODS: We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations. RESULTS AND CONCLUSION: This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient's counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section.

BACKGROUND: The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist. METHODS: A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group. RESULTS: The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

How to differentiate spinal cord hemangiopericytoma from common spinal cord tumor?

INTRODUCTION: Tumors of the spinal cord are rare and some can be confused with each other. We report a rare spinal cord solitary fibrous tumor/hemangiopericytoma (SFT/HPC), and propose keys to differentiate spinal cord tumors from each other. CASE REPORT: A 67-year-old man presented weakness with recent diffuse sensory disorders in the right lower limb. Spinal MRI revealed a T8-T9 intradural extramedullary mass with spinal cord compression. Gross total resection of a poorly vascularized intradural tumor was achieved. It was an encapsulated extramedullary tumor, which was difficult to separate from the spinal cord due to the presence of pial adhesions. Definitive diagnosis was grade 1 SFT/HPC of the spinal cord. One-year follow-up MRI revealed complete excision without any evidence of residual tumor. CONCLUSION: SFT/HPC is a very rare spinal tumor that can be extramedullary, intramedullary or both. It may perfectly mimic meningioma. The maximal resection is the best treatment, but can be challenging because of the tumor's firm consistency and pial adherences to the spinal cord. Outcome is good in case of gross total resection, but there is a risk of very late recurrence, requiring long-term follow-up.

Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery.

BACKGROUND: When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS: A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS: 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION: Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.

DIABETES INSIPIDUS IN A PATIENT WITH BRONCHOGENIC CARCINOMA AND SECONDARIES TO THE HYPOTHALAMUS - CASE REPORT.

We present a middle-aged man with features of diabetes insipidus, visual and mental impairments as a result of metastases from bronchogenic carcinoma. This case is being presented because it is uncommon; high index of suspicion and the relevant imaging techniques are required for diagnosis. Surgical resection of the pituitary secondaries with post-operative chemo-radiation brought resolution of symptoms. CONCLUSION: In conclusion, hypothalamic metastases are uncommon and are often associated with compression of the pituitary gland and optic chiasma leading to diabetes insipidus, visual impairment and mental defects. MRI for diagnosis and surgical resection followed with chemoradiation lead to improvement of symptoms but mortality is high.

Headholders' - complications in neurosurgery: A review of the literature and recommendations for its use.

Several types of headholders are routinely used in neurosurgical practice to secure the head in a precise position, providing better security during surgical dissection as well as an absence of eye compression during prone positions. Nevertheless, potentially lethal complications might occur. We performed a review of the literature via PubMed and Google Scholar using the terms "Mayfield skull clamp", "Sugita headholders", "headholder complications" and "skull clamp complications". Twenty-six complications directly related to the use of headholders were identified through 19 papers published from 1981 to 2014: mainly skull fractures with or without a dural laceration (50%), epidural hematomas (23.8%), skull fractures with or without a dural laceration (50%), and air embolism (9.5%). The authors propose recommendations for the safe use of headholders.

Primary pituitary lymphoma: an update of the literature.

Primary intracranial lymphomas (Weller et al. in Neuro Oncol 14(12):1481-1484, 2012) are an emerging disease and an isolated localization in the pituitary gland i.e. primary pituitary lymphoma (PPL) represents a rare condition. We present an update of the most recent evidence for PPL through a systematic review of the literature. A systematic literature review was conducted using PubMed database up to October 2015. The population was defined as immunocompetent patients with a pathologically confirmed diagnosis of PPL. Patients' characteristics, clinical presentation, radiological features, pathology reports, adjuvant treatment and follow-up data were analyzed. We reported one case of PPL and included our data in this analysis. A total of 33 cases of PPL were identified, including ours. A slight not significant female prevalence was evident, with a mean age of 59 years at diagnosis. Visual troubles and headaches were the most common presenting symptoms. About 80 % of patients presented a cranial nerve (CN) deficit. The most frequently involved were the II and III CN. Anterior hypopituitarism was present in 70 % of cases and a diabetes insipidus in 36 % of cases. PPL was rarely limited to the sella and most often extended to the suprasellar and parasellar space. 70 % of cases underwent resection, 21 % a biopsy. A B-cell lymphoma was isolated in 82 % of cases, a T-cell lymphoma in 15 % and a NK/T cell lymphoma in one case. Overall mean survival rate was 14.4 months (95 % confidence interval 9.0-19.8 months) and there was no difference in terms of survival rates when patients were stratified according to the treatment they received. PPL is an emerging clinical entity. Literature data are too scarce to allow the definition of specific protocols of treatment and the management is based on the guidelines present for PCNSL. The role of surgery aiming at a complete resection of PPL should be reevaluated in wider studies including only this category of patients, to establish the real role of each therapeutic strategy.

[Surgical approaches of tumors of the posterior cone of the orbit]. / Voies d'abords des tumeurs du cône postérieur de l'orbite.

The surgical management of posterior orbital tumors is complex because it is an anatomical area located at the borders between the face and the skull base. The goal of the procedures carried-out in this area is to resect the tumor while preserving vision by using the safest possible approach. The aim of our work was to determine, in the light of our experience and of a review of the literature, the advantages and drawbacks of the numerous approaches described.

Update on the management of pineal cysts: Case series and a review of the literature.

OBJECTIVE: The natural history of pineal cysts still remains unclear. Incidental pineal cysts have become more common which raises the question of their management. Symptomatic pineal cysts may require a surgical solution but therapeutic indications have not yet been clearly established. METHOD: From 1986 to 2012, 26 patients with pineal cysts were identified. Their medical records were retrospectively assessed focusing on the initial symptoms, imaging characteristics of the cyst, management strategy, operative technique and their complications, as well as the latest follow-up. A systematic review of the literature is also presented. RESULTS: Twenty-six patients with pineal cysts were identified. The mean age was 23.5 years ranging from 7 to 49 years. Symptoms included intracranial hypertension with obstructive hydrocephalus in 18 cases and oculomotor anomalies in 12 cases. Two adult cases presented with non-specific headaches and did not require surgery. Twenty patients were operated via a suboccipital transtentorial approach with total removal of the cyst in 70% of the cases, while the remaining 4 cases were treated with an intraventricular endoscopic marsupialization associating a third ventriculostomy. Four patients required a preoperative ventriculo-peritoneal shunt due to life-threatening obstructive hydrocephalus. Overall, peri-operative mortality was nil. In the two non-operated patients, the cyst remained stable and no recurrences were observed in all operated patients with a mean follow-up of 144 months. CONCLUSION: In the majority of incidental pineal cysts, a clinical and imaging follow-up is sufficient but occasionally not required especially in adults as very rare cases of increase in size have been reported.

The minimally invasive endoscopic management of septated chronic subdural hematomas: surgical technique.

BACKGROUND: Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients. In this work, we describe a minimally invasive endoscopic alternative. METHODS: Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization. CONCLUSIONS: The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy.

[Interest of optic nerve sheath diameter ultrasonography in dectecting non-invasively raised intracranial pressure]. / Intérêt de l'échographie du diamètre de l'enveloppe du nerf optique pour la détection non invasive de l'hypertension intracrânienne.

Intracranial hypertension is an emergency suspected from clinical symptoms, imaging data and ophthalomologic signs. Intracranial hypertension is confirmed by invasive intracranial monitoring, which is the gold standard technique to measure intracranial pressure (ICP). Because of complications, hemorrhage or infection, non-invasive methods have been developed such as neuroimaging, transcranial Doppler sonography and optic nerve sheath diameter (ONSD) ultrasonography. We have reviewed ONSD technique that detects intracranial hypertension related volume variations of subarachnoid space along the retro bulbar segment of the optic nerve. Technique, indications and prospects are discussed.

[Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches]. / Chirurgie endoscopique endonasale des tumeurs de la base du crane : historique, état de l'art et perspectives d'avenir.

During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.

[Surgical management of solitary eosinophilic granuloma of the calvaria. Two case reports]. / Traitement chirurgical des granulomes éosinophiles solitaires de la voûte du crâne. A propos de deux cas.

Langerhans cell histiocytosis is a systemic disease resulting from the oligoclonal proliferation of Langerhans cells, occurring most commonly in children and young adults. The focal form of the disease, also known as eosinophilic granuloma, most frequently involves the calvaria. We present two cases of calvarial eosinophilic granulomas that were surgically removed. These tumors are reputed to have an excellent prognosis, even if local recurrences and systemic dissemination can occur during the follow-up. The authors discuss the pathogenesis and the evolutive profile but also the therapeutic management of solitary eosinophilic granuloma of the calvaria.

[Management of intramedullary spinal cord tumors: surgical considerations and results in 45 cases]. / Prise en charge neurochirurgicale des tumeurs intramédullaires : à propos de 45 cas.

BACKGROUND AND PURPOSE: Intramedullary spinal cord tumors (IMSCT) are relatively rare neoplasms, accounting for less than 5% of all central nervous system tumors. The optimum management of these tumors still remains controversial. Many decades ago, partial surgical resection followed by radiotherapy was the conventional management for IMSCT. Nowadays, maximal surgical resection of IMSCT without adjuvant therapy is the rule. We discuss the management of our cohort of 45 patients and review retrospectively the surgical outcome and survival. METHODS AND RESULTS: We reviewed the charts of 45 patients who underwent surgery for IMSCT in our institution since 1990. The study included 23 female and 22 male with a mean age of 28.7 years (range: 18 months-64 years). In 40 patients, the final diagnosis was based on the results of MR imaging. The cervical location of the tumor was the most common (20 cases). Surgical procedures included a gross-total resection in 31 cases, subtotal resection in six cases, partial resection in five cases and a biopsy in three cases. The large majority of patients had histologically-proven low-grade tumors composed essentially of astrocytomas (44,4%) and ependymomas (28,8%). There was no mortality related to surgery. Concerning the functional outcome at six months, we noted that 22.2% of our patients deteriorated, 47.3% stayed the same and 30.5% improved. We found that patients with mild or no preoperative deficits were exceptionally damaged by the surgical procedure. CONCLUSIONS: The gold-standard treatment of IMSCT remains maximal microsurgical resection without adjuvant therapy. For malignant or rapidly recurrent IMSCT, the optimum management is still controversial. Determinant predictors for a good outcome after surgery of IMSCT are histological type of lesion, total removal of the tumor and a satisfactory neurological status before surgery.