Extradural and hourglass cervical neurinomas: the vertebral artery problem.

Eleven cases of cervical neurinomas with an extradural component were operated on with control of the vertebral artery as the first step of the surgical procedure. The lateral anterior approach was used first in each case with excellent results. In the case of hourglass tumors (seven cases), a complementary posterior approach was performed to remove the intradural portion. Primary control of the vertebral artery in cases of extradural or hourglass neurinoma is a logical and safe procedure in the attempt to achieve complete and bloodless tumor removal.

Esthesioneuroblastoma with intracranial extension.

The authors present five cases of olfactory neuroblastoma with intracranial extension operated on in the Department of Neurosurgery in collaboration with otorhinolaryngologists. This tumor is most frequently reported as growing inside the nasal cavities, and it can extend to the paranasal sinuses. Cases presenting initially as intracranial tumors have been infrequently reported. At present, histological diagnosis of this tumor is aided by the use of electron microscopy and immunocytochemistry. Total resection combined with radiation therapy remains the most satisfactory treatment.

A new radionuclide method for the diagnosis of posttraumatic cerebrospinal fistulas. A study of 308 cases.

The authors describe their technique for identifying and localizing posttraumatic cerebrospinal fluid fistulas. The method entails injection of radionuclide tracer into the subarachnoid frontal space with the patient in a sitting position followed by gamma camera scintigraphic recordings. The results in 308 patients are presented; these are compared with those of suboccipital radionuclide cisternography in 40 cases and metrizamide computerized tomography cisternography in nine cases. Transient complications occurred in only three patients.

Abnormal cerebral vasodilation in aneurysmal subarachnoid hemorrhage: use of serial 133Xe cerebral blood flow measurement plus acetazolamide to assess cerebral vasospasm.

A patient with cerebral vasospasm following subarachnoid hemorrhage (SAH) was investigated by serial measurement of cerebral blood flow (CBF) using the xenon-133 emission tomography method. The CBF was measured before and after acetazolamide injection. On Day 2 after SAH, there was early local hyperperfusion in the middle cerebral artery (MCA) territory, ipsilateral to the left posterior communicating artery aneurysm. The regional CBF of this arterial territory decreased slightly after acetazolamide injection, probably because of vasoplegia and the "steal" phenomenon, and thus surgery was delayed. A right hemiplegia with aphasia and disturbed consciousness occurred 4 days later (on Day 6 after SAH) due to arterial vasospasm, despite treatment with a calcium-channel blocker. The initial hyperemia of the left MCA territory was followed by ischemia. The vasodilation induced by acetazolamide administration was significantly subnormal until Day 13, at which time CBF and vasoreactivity amplitude returned to normal and the patient's clinical condition improved. Surgery on Day 14 and outcome were without complication. It is concluded that serial CBF measurements plus acetazolamide injection are useful for monitoring the development of cerebral vasospasm to determine the most appropriate time for aneurysm surgery.

Selective endovascular treatment of 71 intracranial aneurysms with platinum coils.

Seventy-one intracranial aneurysms were treated by endovascular techniques, with the placement of minicoils inside the aneurysmal sac. Most aneurysms were manifest by hemorrhage (67 cases), and 43 of these were treated within the first 3 days after presentation. At the 1-year follow-up examination, the outcome was scored as good in 84.5% of cases, but the morbidity and mortality rates were 4.2% and 11.3%, respectively. Twenty-nine aneurysms in the anterior circulation and 42 in the posterior circulation were treated. In this series, 23 patients were classified as Hunt and Hess neurological Grade I, 27 as Grade II, 12 as Grade III, nine as Grade IV, and none as Grade V. Thirty-three aneurysms were less than 10 mm in diameter, 28 were 10 to 25 mm, and 10 were larger than 25 mm. The preliminary results from this study appear to justify the emergency treatment of aneurysms by this approach. Aneurysms in the posterior circulation are particularly well suited for this type of surgery.

The effect of somatostatin analogue on chiasmal dysfunction from pituitary macroadenomas.

The long-acting somatostatin analogue SMS 201-995 has been shown to be efficient in the treatment of somatotropic and thyrotropic adenomas. In some cases, it can suppress adenoma secretion and lead to tumor shrinkage. Pituitary macroadenomas are often associated with a vision-threatening chiasmal syndrome. In this series, SMS 201-995 was administered subcutaneously to eight patients with pituitary macroadenomas of various types responsible for severe long-lasting visual defects. An obvious improvement of both visual fields and acuity occurred in six patients, in two of these during the first 4 to 6 hours of treatment; in two patients, gonadotropic adenomas were unresponsive. Maximal improvement (normalization of visual fields in three cases) occurred within 6 to 45 days and was sustained during the 1- to 12-month follow-up period. This effect seems independent of the type of adenoma since the adenomas secreting growth hormone (GH) and thyroid-stimulating hormone and silent corticotropic-secreting adenomas responded as well as did two of the non-functioning adenomas. In one acromegalic patient visual improvement was obtained while the abnormal GH secretion remained unaltered. In all cases but one, no tumor shrinkage could be demonstrated. These data demonstrate that SMS 201-995 can rapidly improve the chiasmal syndrome due to pituitary macroadenoma, and suggest that this effect might be independent of a reduction in tumor volume.

Reversible hearing loss in a patient with cryptococcosis.

A 16-year-old girl had hearing loss, paroxysmal tremor, gait disorders, and psychiatric disturbances as the initial manifestations of a cryptococcal meningoencephalitis. Imaging demonstrated an obstructive hydrocephalus, and neuro-otological explorations showed a retrocochlear deafness and diffuse brainstem involvement. Emphasis is on the deafness, which rarely occurs as a presenting symptom in this condition, and on its dramatic improvement following antimycotic therapy.

Lateral approach to the anterior portion of the foramen magnum. Application to surgical removal of 14 benign tumors: technical note.

In surgery, better access to the anterior part of the foramen magnum with less risk to the lower brainstem can be obtained by lateral enlargement of the usual posterior opening. This requires exposure and control of the vertebral artery (VA) and the sigmoid sinus (SS) and, for further enlargement, medial transposition of the VA and section of the SS with inferior petrosal resection. This technique has been applied fully or partially in 14 cases of anteriorly located tumors of the foramen magnum. It widens exposure on the anterior aspect of the neural axis and allows work in a nearly frontal plane.

Orbital expansion for anophthalmia and micro-orbitism.

In severe cases of microphthalmos or anophthalmos, the bony orbital cavity is often too small to allow one to create a satisfactory socket for a prosthesis. An omnidirectional expansion of the orbit, by osteotomies done in a step-like fashion, allows the creation of a larger bony cavity and improves the symmetry of the face. The risks of the craniotomy and of the mobilization of the free bone pieces are discussed.

[Point of view of the neurosurgeon]. / Le point de vue des neurochirurgiens.

Stereotactic radiosurgery, a term introduced by Leksell, was born more than 40 years ago, but has made great strides for the last 15 years. There is no consensus among neurosurgeons as to the best device (gamma knife, linear accelerator), the treatment doses, and the clinical indications of stereotactic radiosurgery. Therefore, this report is the viewpoint of one neurosurgical team only. In the radiosurgery literature, there is no clear evidence of better results with the gamma-knife or the linear accelerators. With regard to clinical applications, cerebral arteriovenous malformations are the more widely accepted indications of radiosurgery, since a cerebral angiography can confirm the disappearance of the nidus of an arteriovenous malformation treated by stereotactic radiosurgery. Usually, small and deep arteriovenous malformations can be treated by stereotactic radiosurgery only. Nevertheless, the treatment of the other arteriovenous malformations more often require procedures including one or several of the following treatment methods: microneurosurgery, interventional neuradiology, stereotactic radiosurgery. Stereotactic radiosurgery in acoustic schwannomas, skull base meningiomas, especially those involving the cavernous sinus, brain metastases, and pituitary tumors seem attractive. Contrary to arteriovenous malformations, the lack of criteria for cure requires a long follow-up and carefully controlled trials to confirm the efficiency of stereotactic radiosurgery for these tumors. On the other hand, experience of stereotactic radiosurgery for astrocytomas and glioblastomas is limited, and few publications are available. Furthermore, because of the infiltrating growth, a major impact of stereotactic radiosurgery for these tumors is presumably not to be expected. Lastly, a close multidisciplinary approach seems absolutely necessary to define the best indications of stereotactic radiosurgery and to improve its clinical results.

Management of intracranial aneurysms by surgical and endovascular treatment--modalities and results from a series of 395 cases.

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysms were treated either by surgery (n = 102) or by endovascular coiling (n = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfying results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12, and 36 months were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfying results were observed after surgery in seven cases and in 25 cases after embolization. After retreatment, it remains three post-surgical and two post-endovascular cases. Good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones. Mortality is of 4.8% in the overall series. In a series in which were applied both types of treatment, surgery in 25% and endovascular techniques in 75%, good results in terms of efficiency and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.

[Cavernous hemangioma of the orbit]. / Hémangiome caverneux de l'orbite.

Cavernous hemangioma is one of the commonest primary orbital tumors. Painless and progressive reducible unilateral proptosis causing a variable degree of hyperopia is the usual clinical presentation. The case of a 39-year-old-female patient is reported. The clinical presentation was unilateral left axial proptosis with acquired hyperopia. Imaging studies showed a well circumscribed mass in the orbit, a superior neuro-surgical approach allowed complete resection of the tumor, and histopathology revealed the diagnosis of cavernous hemangioma.

[Palpebral form of mixed tumor of the lacrimal gland. Apropos of a case]. / Forme palpébrale d'une tumeur mixte de la glande lacrymale. A propos d'une observation.

The clinico-pathological findings in a 45-year-old male patient with a lacrimal gland tumor are reported. This tumor had a spontaneous course of about nine years before it was resected. The clinical presentation was unusual as the tumor appeared as a nodular well-circumscribed swelling of the lateral part of the left superior eyelid. Imaging techniques did not reveal any involvement of the orbital part of the lacrimal gland. However a wide supero-lateral approach was chosen to achieve monobloc resection. Histopathology showed the typical features of an encapsulated pleomorphic adenoma, with no suspicious cytologic changes. Complete resection had a total curative effect for the patient. A wide lateral approach seems to be mandatory for tumors of the lacrimal gland to avoid partial resection and local recurrences.

[Orbital localization of clear-cell sarcoma of tendons and aponeuroses. Apropos of a case report]. / Localisation orbitaire d'un sarcome à cellules claires des tendons et aponévroses. A propos d'une observation.

Clear cell sarcoma of tendons and aponeuroses actually is a well identified soft tissue tumor. A primary orbital involvement is presented, with an optical and electron microscopic study. The orbital topography of such a tumor seems to be an exceptional opportunity. The histological study showed the typical pattern of this clear cell tumor. Ultrastructurally, there are not absolute specific features to establish the diagnosis, except the finding of intra-cellular melanosomes. Histogenesis has been debated for a long time between a melanotic or a synovial origin. According to present knowledge, this tumor may be attributed to a neural crest origin.

[Unusual preseptal location of an orbital cavernous hemangioma in African patient]. / Localisation inhabituelle préseptale d'un hémangiome caverneux orbitaire chez une patiente d'origine africaine.

Cavernous hemangioma is the most common primary vascular orbital tumor in adults. Generally the benign tumor arises within the muscle cone, revealed by proptosis with choroidal folds, and more rarely develops in other orbital localizations. We report the case of a 42-year-old female African patient who had a cavernous hemangioma in an unusual anterior localization. Clinically, a small superficial tumor was palpated in the right superior nasal orbital angle. After complete surgical excision, the histopathological study established the diagnosis of cavernous hemangioma

[Residual left orbital phlebolith. An anatomic-clinical observation]. / Phlébolithe résiduelle orbitaire gauche. A propos d'une observation anatomo-clinique.

A 29-year-old female patient displayed a dense and hard left orbital mass, inferiorly, 3 years after she was treated through a neurosurgical approach for a left orbital varix. The lesion was hyperdense on CT-scan and was removed through a trans-conjunctival approach, with an excellent result. The histological diagnosis was a phlebolith.

[Pleomorphic adenoma mimicking dacryoadenitis]. / Adénome pléomorphe simulant une dacryoadénite.

A 56-year-old female patient displayed an increased volume of her left lacrimal gland with pain and inflammation. On CT scan, a hyperdense lacrimal mass was found in the left lacrimal fossa. Observation was the first course, for no steroid therapy could be applied because of evolving digestive ulcers. After 9 months of observation, the gland was surgically removed en bloc through a wide anterolateral approach. Pathological analysis of the gland showed a pleomorphic adenoma. This case illustrates the advantage of a wide surgical approach in treating lacrimal gland tumors, in order to avoid or limit the risk of recurrence.

[Two cases of FSH secreting adenomas (author's transl)]. / Deux cas d'adénome hypophysaire à FSH.

The authors report two cases of FSH secreting adenomas in men and attempt to draw out some features of these very uncommon pituitary tumors. Absence of gynecomastia is emphasized. Diagnosis proceeds from systematic radio-immunoassay of pituitary hormones. Evidence of FSH secretion results from paradoxical gonadotropin stimulation by TRH and secretory granules seen by electronic microscope. Immunofluorescence studies are still to perform. Dynamic testicular secretion and, in one case, histologic examination were performed.

[Intracranial arterial aneurysm. Differences in origin and prognosis in men and women]. / L'anévrysme artériel intra-crânien. Une origine et un pronostic différents chez l'homme et chez la femme.

A statistical model was defined from a series of 144 patients referred for a subarachnoid hemorrhage due to intracranial aneurysm rupture, occurred less than 3 days before admission. This model was then prospectively applied on a second series of 70 patients and allowed to find out four datas predicting the final functional result: age (p = 0.02), clinical status (p = 0.001), angiographic evidence of spasm (p = 0.01) and sex (p = 0.001). Concerning sex, functional result appears worse in women than in man. This more severe prognosis of aneurysmal rupture in woman is explained by the higher frequency of spasm (p less than 0.0005). This fact and the predominance of multiple aneurysms and localizations on the supraclinoid internal carotid artery (38.3% in females and 17.7% in males) suggest a different origin of intracranial aneurysms according to sex. Fibromuscular dysplasia might correspond to the datas here observed, and is currently explored.

[Enlarged transbasal approach by mobilization of the medial fronto-orbital ridge]. / Voie transbasale élargie par mobilisation du bandeau fronto-orbitaire median.

Tumors involving the base of the skull are best approached by the transbasal route as described by Derome. However this approach can be improved by mobilization of the medial part of the supra-orbital ridge according to the technical principles used in treatment of craniosynostosis. This allows a wide exposure of the ethmoido-sphenoidal area with minimal retraction of the frontal lobes. The axis of working becomes parallel and even inferior to the plane of the cribriform plate and gives a better access to the upper part of the clivus. Rhinologic complementary approach (rhinoseptal or transfacial) can be associated with this technique. However a more anterior part of the nasal mucosae is exposed by this procedure: one can control the mucosae in front of the tumor and avoid a complementary rhinoseptal route. This simple technical trick has been used in seven cases with satisfactory results.