[Surgical management of the capsular contraction syndrome]. / Manejo quirúrgico del síndrome de contracción capsular.

PURPOSE/METHODS: To describe a surgical technique to treat severe capsular contraction syndrome. A secondary continuous curvilinear capsulorhexis was performed in four cases of capsular phymosis, attended in our clinic. CONCLUSIONS/RESULTS: All of them resolved with good anatomic and functional results, no recurrence occurred and best correct visual acuity BCVA was preserved after a twelve- month follow-up. This surgical procedure could solve severe capsular contraction syndrome occurring after continuous curvilinear capsulorhexis, phacoemulsification and intraocular lens implantation.

Chemotherapy for spinal cord astrocytoma.

BACKGROUND: The optimal management of spinal cord astrocytomas remains to be defined, as aggressive surgery and radiotherapy are associated with a high risk of morbidity. The value of chemotherapy has not been assessed. PROCEDURE: The patient in the present report harbored an infiltrating spinal cord tumor causing paraplegia. A limited biopsy showed a grade II astrocytoma. Following biopsy, the patient received sequential chemotherapy with vincristine and carboplatin. RESULTS: Full neurological recovery and complete radiologically-confirmed remission were achieved after eight months of treatment. Chemotherapy was discontinued after eleven months due to carboplatin hypersensitivity. No adjuvant radiotherapy was given, and the patient remains in complete remission fourteen months after completion of treatment. CONCLUSIONS: Chemotherapy demonstrates a promising activity and could change the standard practice if its efficacy is confirmed in larger studies. It could be used alone or combined with radiotherapy when post-operative treatment is recommended.

Management of unruptured cerebral aneurysms.

A series of 62 patients treated surgically for one or several unruptured intracranial aneurysms is reported. 83 aneurysms were treated in 65 operations. The main locations of the aneurysms were: MCA 35%, ICA (posterior communicating) 22%, carotido-ophthalmic segment 12%, carotid bifurcation 11%, anterior communicating artery 11%, verterbro basilar artery 5%. The circumstances of discovery were: incidental 28%, multiple aneurysm 22%, headache 18%, ischemic episode 9%, mass effect 8%, seizures 6%. Overall, 8% of these unruptured aneurysms were certainly symptomatic, 58% were certainly asymptomatic, and for 34% the relationship with the mode of discovery was uncertain. The overall outcome of surgery was: good recovery 94%, moderately disabled 1.5%, severely disabled 1.5%, and death 3%. The post-operative complications were related to surgical technique in 2 cases, to a severe atherosclerotic state of the ICA in 1 case, and to the general arteriopathy of the patient in 1 case. The discussion reviews in the literature the various arguments developed in favor of an active treatment of the unruptured cerebral aneurysms. Three arguments are proposed. 1. The overall severity of the aneurysm rupture, with a mortality rate over 60%. 2. The cumulative risk of rupture of an unruptured aneurysm, which may be high in young patients (from 16 to 30% lifetime risk). 3. The good outcome of the surgical treatment of the unruptured aneurysm (mortality rate under 4%, morbidity rate approximately 6%). The operative risk is higher for large or giant aneurysms, for a patient with a history of ischemic cerebrovascular accident as mode of discovery, for elderly patients with arteriosclerotic thickening of ICA wall and aneurysm neck. The decision to treat or not to treat may be easier (mass-effect, multiple aneurysm, acute headache) or more difficult (chronic headache, hemorrhage of other origin, seizures, incidental discovery). The endovascular treatment with occlusion of the aneurysms sac by means of coils is more and more an alternative to surgical treatment, but requires a long follow-up to ensure the absence of reexpansion of the coil-embolized aneurysms. The screening for unruptured aneurysms, especially in cases with familial intracranial aneurysms is more and more often proposed. The authors' opinion now is surgical clipping of small and middle-sized aneurysms in young patients, without severe associated pathology, and clearly agreeing with surgery. The limit of age for surgery is usually 65 years except for those aneurysms discovered after a mass-effect. Elderly patients, giant aneurysms, patients with contra-indication for surgery, are proposed for endovascular treatment.

Complications after multidisciplinary treatment of cerebral arteriovenous malformations.

PATIENTS AND TECHNIQUES: A series of 67 patients treated for cerebral AVMs with a multidisciplinary approach is reported, with special attention for the complications due to treatment. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery (30%), either alone or after embolization or surgery. The following eradication rates were obtained: overall 80%, after resection (with or without embolization) 91%, after embolization alone 13%, after radiosurgery 87%. CLINICAL OUTCOME: The outcome was evaluated in terms of deterioration due to treatment. A deterioration after treatment occurred in 19 patients (28%), and was a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was responsible for deterioration (minor) in 17% of all cases operated upon. Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization gave a complication in 25% of all embolized cases (minor or neurological deficit, or death). The mechanism of the complications was: resection or manipulation of an eloquent area during surgery, radionecrosis after radiosurgery, ischaemia and haemorrhage (50% each) following embolization. In most cases of haemorrhage due to embolization, occlusion of the main venous drainage could be demonstrated. DISCUSSION: The haemodynamic disturbances to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms admitted at the beginning of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, the disturbances of the venous drainage (venous overload or occlusive hyperaemia), and the retrograde thrombosis of the feeding arteries. CONCLUSIONS: According the authors' experience, the emphasis of treatment for cerebral AVMs has now shifted from surgical resection to endovascular embolization. One of the explanations is that endovascular techniques are now employed in the most difficult cases (high grade AVMs). As severe complications of endovascular embolization may also occur for low-grade malformations, the question arises whether surgery or radiosurgery should not be used first for this low-grade group even if embolization is feasible.

[Therapeutic risk in multidisciplinary approach of cerebral arteriovenous malformations]. / Le risque thérapeutique dans l'approche multidisciplinaire des malformations artério-veineuses cérébrales.

PATIENTS AND TECHNIQUES: A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported, paying special attention to the complications due to treatment. The malformations were classified according to the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery, (30%) either alone or after embolization or surgery. The following eradication rates were obtained: 80% overall, 91% after resection (with or without embolization), 13% after embolization alone, 87% after radiosurgery. CLINICAL OUTCOME: The outcome was evaluated in terms of deterioration due to treatment. Treatment-related deterioration occurred in 28% of cases and consisted of a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was followed by deterioration in 20% of all operated cases (minor 17%, deficit 3%). Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization resulted in complication in 25% of all embolized cases (minor 12.5%, neurological deficit 5%, or death 7.5%). The mechanism of the complication was: resection on manipulation of a functional area and the haemorrhage for cases treated by surgery, radionecrosis for radiosurgery, ischemia and haemorrhage (50% each) for embolization. In 4 out of the 5 cases of haemorrhage due to embolization, an occlusion of the main venous drainage could be demonstrated. DISCUSSION: The haemodynamic disturbances relating to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms at the origin of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, venous drainage defects (venous overload or occlusive hyperemia), and retrograde thrombosis of the feeding arteries. CONCLUSIONS: Improved treatment of cerebral AVMs has been achieved through the multidisciplinary approach, and especially through the endovascular embolization technique. Such an improvement is especially visible in the field of high-grade malformations, which are the most difficult and the most dangerous to treat. As a consequence, the risk of the treatment has naturally shifted from surgical resection towards endovascular embolization which is the first procedure to be performed in difficult cases. Careful consultation between the various specialists is necessary in this pathology, particularly as some of these AVMs are a good indication for each of the three available methods of treatment.

Multidisciplinary treatment of cerebral arteriovenous malformations.

A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary Bartholin gland cancer and etiopathogenetic role of human papillomavirus. Report of a new case]. / Cancer primitif de la glande de Bartholin et rôle étiopathogénique du papillomavirus humain. Rapport d'un nouveau cas.

The authors report a new case of Bartholin's gland carcinoma and its link with human papillomavirus. Should women with HPV have Pap smears the accessory glands of the vulva in addition to cervical smears?

Level of consciousness and age as prognostic factors in aneurysmal SAH.

The prognostic value of the level of consciousness and the patient's age for the outcome of aneurysmal subarachnoid haemorrhage (SAH) is studied in 74 patients admitted on day (D) 0 to D3 after aneurysm rupture. For the level of consciousness three groups of patients are compared: grade I+II (alert patients), grade III+IV (drowsy patients), and grade V (comatose patients). For the age, two groups are compared: patients aged under 50, and patients aged 50 and over. The timing of surgery was: D0-D3 51%, D4-D6 20%, D7 and later 18%, and No surgery 11%. The overall management results were: Good (satisfactory result) 43%, Fair (moderately disabled) 18%, Poor (severely disabled+vegetative survival) 19%, and Death 20%. The outcome was strongly related to the level of consciousness, the rates of Good result decreasing from 71% (grades I-II) to 14% (grades III-IV) and to zero (grade V), and the mortality rates increasing respectively from 5% to 14% and 61%. The relationship between outcome and age was less marked: 54% Good result under 50 and 30% over 50. Out of the Grade V group, 56% could be operated upon and 44% died before surgery. No patient from the other two groups died before surgery. The literature concerning the Grading Systems published so far and the various prognostic factors are discussed.

The use of Teflon as wrapping material in aneurysm surgery.

Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping is a well-known alternative technique when aneurysm clipping is not feasible, or is not completely satisfactory. We present a technique of wrapping using fibres of Teflon material shaped in strings or in pledgets, arranged on or around the area to be treated and fixed by fibrin glue. This Teflon technique was used during the years 1990 to 1992, in 44 treated aneurysms (33% or all aneurysms treated during the same period), and in 3 situations: 1) to reinforce a residual or additional ectasia next to the clipped aneurysm, usually proximal to the clip (25 cases, i.e., 57%), 2) to treat an arterial ectasia, so called preaneurysmal ectasia, which proved not clippable at surgery (10 cases, 23%) and 3) to protect a nervous or vascular neighbouring structure which was compressed by the clip grip (9 cases, 20%). No complication was noted in relation to this technique. Up to now, no other know wrapping material has received worldwide approval for being completely innocuous and effective. The Teflon material has been widely used in neurosurgical microvascular decompression and in cardiovascular surgery. In these fields, its reliability, safety, and lack of harmful effects have been widely recognized and should also apply in aneurysm surgery. A very long follow-up will be necessary to assess the outcome for this new wrapping technique.

Long term outcome after treatment of the ruptured intracranial aneurysm: 73 cases admitted from day 0 to day 3 after subarachnoid haemorrhage.

73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in Hunt and Hess grades I to IV after aneurysm rupture, were studied. All admitted patients were operated upon. The timing of surgery was neither systematic early nor systematic late surgery, but modulated surgery. Patients in good grades (I and II) and under 50 years of age were operated on early. Patients in poor grade and over 50 years of age were operated late. Other patients were operated on preferably early if they were young, even in poor grade, or late if they were old even in good grade. The overall immediate outcome was: good and fair--85%, poor--4%, and death--11%. For those patients operated on early after SAH (D0-3) the good and fair outcome rate went up to 90%. The long term outcome was evaluated after 1 year (from 1 to 6 years, average 1 year 8 months). 97% of patients were available for follow-up. The long-term neurological outcome was identical to the immediate outcome. The resumption of activity was the criteria chosen to evaluate the long term outcome. The long term ability to work in 63 followed-up surviving patients was: normal activity--57%, reduced level of activity--16%, no resumption of activity--27%. This rate of activity resumption was not improved in patients operated on early. Among patients with a good long term neurological outcome, only 67% resumed their previous activity at the same level.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of the Spetzler's grading system in a series of cerebral AVMs treated by a combined management.

The prognostic value of the Spetzler's grading system is studied in a series of 52 AVMs treated by a combined management, using one or several of the 3 available techniques: surgical resection, endovascular embolization, radiosurgery. The symptoms at the time of treatment were haemorrhage 50%, seizures 31%, headache and deficit 19%. Three grade groups were considered: I and II (31%), III (33%), IV and V (36%). Overall, AVMs were managed as follows: resection alone 25%, embolization plus resection 23%, embolization alone 23%, radiosurgery with various combinations 29%. According to the grade groups, the most frequently used technique was resection alone for grade I-II AVMs (44%), radiosurgery for grade III AVMs (41%) and embolization alone for grade IV-V AVMs (42%). The clinical outcome was evaluated in terms of deterioration due to treatment. The best results were obtained in grade I-II AVMs (81% with no deterioration) then in grade III AVMs (65%) and in grade IV-V (58%). However, when we consider the outcome in terms of favourable results (no or only minor deterioration) we obtained a similar outcome for grade I-II and grade III AVMs (94% each), and only 79% for grade IV-V malformations. The angiographic outcome showed a better eradication rate in grade III AVMs (88% complete eradication), than in grade I-II AVMs (75%) and in grade IV-V (47%). Our conclusion is that the Spetzler's grading system in this series was well correlated with both the clinical and the angiographic outcome. However, we found no real difference between grade I-II and grade III AVMs. So, in terms of prognostic value, the grade I, II, and III AVMs could be considered together as low-grade malformations, with a better prognosis than the high-grade malformations (grade IV and V).

[Criteria for choice of vaginal hysterectomy for lesions other than invasive cancer]. / Critères de choix de la voie vaginale lors des hystérectomies pour lésions autres que cancer invasif.

The authors analyse in retrospect a continuous series of 208 hysterectomies, for lesions other than invasive cancer, in order to try to define precise objective criteria for the choice of the vaginal way. What essentially commands the choice of this way are: high parity, large size of the uterus, the existence of prolapsus, effort-linked urinary deficiency and no annexial pathology.

The combined management of cerebral arteriovenous malformations. Experience with 100 cases and review of the literature.

A series of 100 patients treated for a cerebral arteriovenous malformation (AVM) is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated after the availability of radiosurgery (1989-1992). AVM's were classified in five grades according to the Spetzler's Grading System. Three techniques of treatment were used: surgical resection, intravascular embolization (with cyanoacrylate), and radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization, or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the decrease of the "embolization and resection" group, which until then was predominantly used as well for low-grade (I, II, III) as for high-grade AVM's (IV, V). Overall, for the low-grade AVM's, the treatment of choice was surgical resection (79% of cases), with pre-operative embolization in one-half of these cases; the other low-grade AVM's were irradiated, with various combinations. For the high-grade AVM's, the treatment of choice was intravascular embolization (95% of cases), either alone, or followed by resection (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration following treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%), and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patients' age. More favourable results were obtained for low-grade AVM's (93%) than for high-grade AVM's (60%). For the low-grade AVM's the evolution from 1989 on (favourable outcomes increasing from 89% to 96%) occurred with the lowering of the mortality rate. For the high-grade AVM's, the evolution from 1989 onwards (favourable outcome increasing from 46% to 78%) occurred with the decrease of the cases with deficits. The angiographic results were strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards AVM's. The surgical management which was predominantly used at the beginning gave way progressively to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Routine use of the CO2 laser technique for resection of cerebral tumours.

The CO2 laser technique has been routinely used from 1988 through 1992 for the resection of 93 cerebral tumours (meningiomas 58%, gliomas 15%, neurinomas 9%, miscellaneous 18%). The CO2 laser technique was found the more effective 1) in tumours of hard consistency, 2) in large or giant tumours, 3) in tumours with scarce vascularization. Meningiomas were the indication of choice (54 cases that is 58% of all tumours treated with CO2 laser, and 64% of all meningiomas operated on during the same period). Among the meningiomas treated with the CO2 laser, 54% were located on the skull base. The CO2 laser beam provides good haemostasis of small vessels during the vaporization process. When attached to the operative microscope, the other advantages of the CO2 laser technique are: the absence of a handle-piece, the absence of manual manipulation of the tumour, the coaxiality of the laser beam with the visual beam. The disadvantages are: the rigidity of the coupled microscope-Laser arm, the smoke produced by the vaporization of hard tumours, the noise of the device.

[Peliosis hepatis and oral contraceptives: a case report]. / Peliose hepatique et oestroprogestatifs: a propos d'un cas revele par une ascite.

PIP: Possible hepatic effects of oral contraceptives (OCs) include tumors, intrahepatic cholestasis, and less well known vascular lesions such as Budd-Chiari syndrome and peliosis, a disseminated pseudocystic dilatation of the sinusoid capillaries of the liver. A 29-year-old woman with a history of 4 pregnancies, hypertension and diabetes both requiring daily medication, and use since April 1983 of an oral contraceptive (OC) containing .15 mg levonorgestrel and .03 mg of ethinyl estradiol complained in March 1984 of epigastric pain and increased abdominal volume. Ascitis was diagnosed and the patient was hospitalized. She had experienced a generalized pruritus for several months and had lost weight. The bilirubin, alcaline phosphatase, and Gamma GT levels were slightly elevated. Sonography showed a hypertrophied liver. Incipient esophageal varices were seen with gastric fibroscopy. The small subhepatic venous branches had a cloudy aspect. The peliosis hepatis was diagnosed by a transjugular puncture biopsy of the liver. With discontinuation of the OCs, the ascites did not reappear after puncture and the perturbations of the liver functioning normalized. On follow-up in April 1985, slight hepatomagaly persisted but the patient reported no further symptoms. She continued her medication for hypertension and diabetes. Peliosis hepatis was 1st described in 1964 and several cases related to OC use have been reported since 1972. Peliosis has the aspect of multiple small congestive cavities of 1-3 mm in diameter in the parenchyma. The lesions consist of areas of hepatocellular necrosis secondarily filled with blood. The cysts may be voluminous and subcortical, creating a risk of hemoperitoneum. The lesions may also be associated with a benign or malignant liver tumor. Regression of the lesions is possible with termination of the etiologic agent. Clinically, hepatomegaly, painful or not, sometimes associated with splenomegaly, is often found with peliosis. Moderate jaundice is very frequent. Ascites or edema of the legs are observed. Hyperbilirubinemia and augmentation of phosphatases and Gamma GT are the main laboratory findings. Transaminases may be slightly elevated, and the rate of prothrombin may be diminished. The condition is sometimes diagnosed with laparoscopy, celiomesenteric arteriography, or phlebography, but hepatic puncture biopsy usually establishes the diagnosis. The contition may improve if the etiologic agent is removed or it may worsen because of liver failure or a complication such as hemoperitoneum or an associated tumor.^ieng

Experimental myocardial infarction in the rat as a quantitative model for the study of anti-ischemic interventions.

The identification of metabolic and drug interventions able to reduce myocardial injury after coronary artery occlusion requires experimental models. The rat model of ischemic injury is technically simple, unexpensive, informative and accessible to quantitative studies. In this present study, 41 rats underwent temporary myocardial ischemia of variable duration using left coronary artery ligation. They were sacrificed at 48 hours, and the heart was immediately frozen in liquid nitrogen. Serial 8 micrometer sections of known intervals were tested for succinodehydrogenase (NBT stain). Gross sectional areas measured planimetrically were utilized to calculate total myocardial volume (Vmyocardium) and infarcted myocardial volume (Vinfarct) with the aid of a programmable calculator. The data showed a linear regression for Vinfarct/Vmyocardium according to the time of ischemia (p 0,001). We suggest to test the efficiency of metabolic and drug interventions on the regression curve of the necrotic tissue using a multiple linear analysis. Since ischemic changes evolve more rapidly in this model, the intervention under study should be set up at the time of coronary artery occlusion.