Multimodal management of ruptured cerebral micro-arteriovenous malformations: A retrospective series of 19 cases and a review of the literature.

BACKGROUND: Micro-arteriovenous malformations (micro-AVMs) are defined as AVMs just visible on angiography with a nidus size between 0.5 and 1cm. Their principal manifestation is intracranial hemorrhage and their diagnosis and therapeutic management are still unclear. METHODS: The aim of our work was to show the clinical presentation, treatment and outcome of ruptured cerebral micro-AVMs in a retrospective cohort study of 19 patients and a systematic review of the literature. RESULTS: We obtained a total of 20 micro-AVMs in 19 patients. The mean age was 47.3 years. Clinical presentation was acute bleeding. The mean volume of hematoma was 12.9 mm3 (0 - 60.4), with topographic distribution as follows: 64% cortical with supratentorial bleeding, 26% deep, and 10% in the posterior fossa. Among the 20 micro-AVMs of the series, 11 (55%) had endovascular management, 6 (30%) had surgical treatment and 3 (15%) had GK radiosurgery alone. All of our patients have been cured at the end of the follow up without re-permeabilization. In our series, clinical outcome showed good recovery with a mean score of 4.6 on Glasgow Outcome Scale (GOS). In the literature, 88% of patients had a GOS of 4 or 5. DISCUSSION: Intracerebral hematoma (ICH) was the main clinical manifestation. In the case of negative initial angiographic assessment, patients must have supraselective angiographic exploration. In the case of conservative treatment of hematoma, endovascular obliteration and microsurgical exclusion seems to be reasonable therapeutic options, according to our observations.

[Candida albicans cerebral granuloma in an immunocompetent patient. A case report]. / Granulome cérébral àCandida albicans chez un patient immunocompétent. Cas clinique.

We report a case of temporal lobe granuloma caused by Candida albicans in an immunocompetent patient. This 54-year-old patient had experienced headaches and some memory disorders for two to three months before his admission to the neurosurgical department. Cerebral-computer tomography and magnetic resonance imaging showed a single right-temporal lesion with a large peritumoral edema. We operated on the patient via a temporal approach using neuronavigation and resected the lesion. The anatomopathological result and the cultures of the granuloma showed C. albicans species. The patient received antifungal therapy for three months. No predisposing factors or immunosuppression was found. After seven months, he presented an ischemic cerebrovascular accident of the brain stem and then chronic meningitis complicated by hydrocephalus. The patient's condition progressively deteriorated and he died 18 months later in an other department. C. albicans can be found even in the immunocompetent patient, but is seldom observed. Surgery can provide an accurate diagnosis and therapeutic management in the initial phase, completed by antifungal therapy.

[Surgical treatment of cortical and subcortical cavernomas. General principles and personal series of 20 cases treated between 2000 and 2006]. / Traitement chirurgical des cavernomes corticaux et sous-corticaux. Principes généraux et série personnelle de 20 cas opérés entre 2000 et 2006.

The surgical treatment of cortical or subcortical hemispheric cavernomas is founded on a series of questions: Is the cavernoma located in an eloquent or non-eloquent area? Is the cavernoma tangent to the cortex and visible immediately after the dura opening or deep seated in the hemisphere? Does the cavernoma lie in the depth of a sulcus and identifiable on the pretrans-sulcal approach MRI? Will perilesional tissue have to be removed to cure the epilepsy? What is the appropriate technology for each particular case: preoperative functional MRI, angiography, preoperative stereotactic guidance, peroperative ultrasonography, neuronavigation, peroperative neurophysiology and cortical stimulation, preoperative MRI? Based on a personal series of 20 cases operated on between 2000 and 2006, we describe our personal experience.

Burst-fractures and cementoplasty.

Percutaneous acrylic cement vertebroplasty is known for its pain-relieving effect in spinal tumors and recently in osteoporotic vertebral collapse. To our knowledge no study has been published reporting the treatment of acute high energy post-traumatic fracture (mainly single burst fracture) by vertebroplasty. Our purpose was to evaluate the technical feasibility of the cement injection at this acute phase, assess its the impact on the pain and monitor spinal stability, by quantifying potential kyphosis modification. Twelve patients with relative contraindication of the orthopaedic treatment were treated by early injection after the trauma for an A type fracture of the Magerl classification, without neurological sign. Patients surveys revealed a significant pain reduction within the first day. Half of them reduced the kyphosis angle, and the anterior height vertebral body significantly improved after the vertebroplasty. The mean reduction in the kyphosis angle was 8. No complication occurred except one extravertebral asymptomatic leak, with secondary increase of the kyphosis. Vertebroplasty performed in reduction position may allow a complete stabilization without pain and furthermore can reduce the kyphosis angle.

[Giant extradural epidermoid cyst of the posterior fossa]. / Kyste épidermoïde extra-dural géant de la fosse postérieure.

We report an unusual case of giant extradural epidermoid cyst of the posterior fossa in a 73-year-old man. The patient presented headache and gait disturbance for 3-4 months, cerebellar ataxia, left cerebellar dysmetria, and perturbed balance. The CT-scan showed a huge posterior fossa extradural lesion with a small area of peripheral contrast enhancement. Outcome was good after total resection of the lesion via a suboccipital approach. Pathology reported an epidermoid cyst. Extradural epidermoid cyst is a rare benign tumor of the skull which sometimes can reach considerable size. It is a slow growing lesion and may cause mild neurological deficits. The goal of surgical treatment is total resection of the tumor with its capsule. The long-term prognosis is excellent after successful resection.

[Metabolic imaging for supratentorial oligodendrogliomas]. / Les oligodendrogliomes supra-tentoriels: imagerie métabolique.

Metabolic imaging with positron emission tomography (PET) provides, in neuro-oncology, information complementary to that provided by anatomic imaging obtained with CT-scanner or MRI. Only a few publications have yet reported its use in oligodendroglial tumors. These findings and partial results obtained in ongoing work, suggest some preliminary conclusions: 11C-MET (L-methyl-methionine) is a more appropriate tracer than 18F-FDG (fluoro-deoxy-glucose), in terms of both specificity and sensitivity, for the assessment of patients with this category of tumor. PET/MET allows differentiation between grade II and grade III oligodendrogliomas; better targeting for stereotactic biopsy; more accurate assessment of the post-operative residual tumor; identification of progression from low-grade to anaplastic grade during the disease course; differentiation between recurrence and a post-radiation processes. PET/MET allows, to some extent, prediction of response to radiotherapy; and, probably, to chemotherapy.

[Bradycardia as a unique sign of an increase in the extradural haematoma volume]. / Quand une bradycardie isolée révèle l'augmentation de volume d'un hématome extradural.

The commonest presentation of an extradural haematoma implies a head trauma with transient loss of consciousness followed by a lucid interval then rapid neurological degradation. Some of these haematomas including small ones with no midline shift and few neurological symptoms can be managed without surgical evacuation. Whilst clear recommendations have been issued regarding surgical indications, guidelines for medical supervision are still needed. We report a case of an eight-year-old girl who presented to our hospital emergency department with headache, vomiting but no neurological deficit, 3 hours after a head trauma without loss of consciousness. The CT-scan proved an extradural haematoma of 6mm width. The patient was monitored in paediatric reanimation and was scoped. Seventeen hours after the fall, the patient presented with severe isolated bradycardia. The CT-scan showed an enlargement of the haematoma with brain herniation, which was evacuated. Therefore, electrocardiogram abnormalities can reveal infraclinic raised intracranial pressure. Systematic continuous ECG monitoring during the first 24 to 48 hours would optimize the surgical management of this disease and then limit its morbi-mortality.