[Long-term results of facial palsy's rehabilitation by end-to-end hypoglossal-facial anastomosis]. / Résultats à long terme de la réhabilitation des paralysies faciales périphériques par anastomose hypoglosso-faciale termino-terminale.

OBJECTIVE OF THE STUDY: To evaluate the long term functional and esthetical results of the patients who underwent a facial palsy rehabilitation surgery by a hypoglossal-facial anastomosis. PATIENTS AND METHODS: In this retrospective study, 11 patients (8 males and 3 females) with a complete facial palsy (grade VI House-Brackmann) due to an otoneurosurgery performed between 1985 and 2006 (6 vestibular schwannomas, 1 facial schwannoma of the geniculate ganglion and 4 meningiomas) were evaluated (with the help of an auto-questionnary, a physical exam and electromyography) between July and september in 2008. RESULTS: The voluntary palpebral closure was obtained in 8 cases out 11 (grade III of House-Brackmann). The lingual hemiatrophy was constant. It was major for the patients who didn't take part in a specific re-education. In these cases patients had troubles during feeding and elocution. CONCLUSION: The hypoglossal-facial is a dynamic surgical rehabilitation of choice for the facial palsy. It nearly achived 80% of good palpebral results. The end-to-end anastomosis gives a lingual hemiatrophy which is not the case with a side to end anastomosis. This atrophy can be reduced with an intensive and specific reeducation. Moreover this re-education improves the functionnal and the esthetical results for the patients who underwent an hypoglossal-facial anastomosis. This lingual hemiatrophy was then responsible for troubles for feeding and elocution.

Identification of carriers by screening for delta F508 deletion in a multi-generation cystic fibrosis family.

Samples from 30 members of a french cystic fibrosis (CF) family had to be typed with probes for restriction fragment length polymorphisms (RFLPs) known to be linked to the CF gene, to fulfill the expectations of twenty-two low-risk relatives who were asking for carrier testing. Classical linkage-disequilibrium data between KM-19 and XV-2c polymorphisms and the CF locus were not informative enough for some individuals, and other RFLPs had to be analyzed to determine which chromosomes carried the deficient gene in the family. We report the retrospective screening for delta F508 mutation in this extended family to illustrate the drastic improvements that the direct detection of the major mutation responsible for CF has on genetic counselling of relatives of patients with cystic fibrosis.

Multimodal anatomic, functional, and metabolic brain imaging for tumor resection.

OBJECTIVE: Improvement of neurosurgical techniques with a more detailed description of brain tumors and their functional environment. METHODS: We performed: (1) anatomical magnetic resonance imaging (MRI) for reference, (2) functional sequences dedicated to the adjacent cortical structures (sensorimotor, visual, language paradigms), and (3) thallium 201 cerebral tomoscintigraphy to visualize active tumor invasion. Data were transferred to a workstation for automatic registration. RESULTS: All data were combined into one synthetic image showing the foci of high proliferative activity, which have to be completely resected, and the peritumoral functional structures, which have to be spared in order to minimize postoperative sequelae. This trimodal image is entered into a surgical neuronavigation computer for preoperative planning in order to outline tumoral target and functional risk areas. All this information is displayed in the operative microscope (Zeiss MKM) optically linked to MR images. This multimodality technique diminishes operative time by reducing electrocorticography and improves the operative short-term outcome. CONCLUSION: Multimodal imaging is useful for optimization of neurosurgical tumor resection.

MRI and stereotaxis. Choice of an approach route on an independent console.

The authors report their experience of cerebral stereotaxis for biopsy purposes. Since January 1990, they have been using MRI which provides vascular images and makes it possible to simulate surgical procedures beforehand. The authors have developed a specific program on an independent console. MRI sections are acquired with a 1.5 Tesla Sigma (G.E.) apparatus in 3DFT volume and T1-weighted SPRG sequence, after gadolinium injection. The sections are memorized and reconstructed by a SUN computer. After automatic recognition of the referential of a Leksell G plane, the target and the puncture vector are chosen by a radiologist and a neurosurgeon. The X, Y, Z co-ordinates of the point of puncture and the angles of penetration into the cerebral volume are delivered automatically. Provided the entire measurement chain is constantly tested and corrected if necessary, the precision of the system is of the order of one millimetre.

[Toxic aluminum encephalopathy. Predominant involvement of the limbic system on MRI]. / Encéphalopathie toxique à l'aluminium. Atteinte prédominante du système limbique en IRM.

Two patients underwent acoustic schwannoma surgery by transmastoid approach. Petrous bone defect was filled in with aluminium-containing bone cement (Ionocem). A pseudomeningocele by CSF accumulation in subcutaneous temporoparietal area appeared after the procedure and, in subsequent weeks, encephalopathy with confusion and seizures. MRI showed cerebral involvement with herpes-like disposition. Temporal stereotactic biopsy in a case did not confirm viral encephalitis but disclosed cellular accumulation of lipofucsin and particles highly suggestive of aluminum-inclusions. Aluminium's levels in blood and CSF of both patients were very high and confirm the brain's toxic involvement. Aluminium's toxicity would be advocated in patients with neurologic disorders who have undergone maxillofacial or skull bone-cementoplasty by an aluminum-containing biomaterial, if this cement is in contact with CSF.

[Clinical application of functional MRI: a strategic tool for neurosurgery]. / Application clinique de l'IRM fonctionnelle: aide à la stratégie neurochirurgicale.

The purpose was to incorporate preoperative functional imaging data into anatomic data of operative microscope for neurosurgical procedures of patients suffering from lesions contiguous to eloquent brain areas. The day before surgery, patients bearing scalp markers underwent fMRI, just before anatomical contrast-enhanced MR images. FMRI data analysis were realised using a t test (p<0.0001). The resulting functional-anatomical images were downloaded onto a surgical neuronavigation computer in order to outline tumoral target and functional areas. At surgery, cortical stimulation has been used to confirm functional data. Functional image-guided surgery of lesions abutting functional cortex can be safely performed.

[Imaging networks, surgical simulation, computer-assisted neurosurgery]. / Réseaux d'imageurs, simulation chirurgicale, neurochirurgie guidée par ordinateur.

OBJECTIVE: In 1988, the neurosurgeons and neuroradiologists at the Val-de-Grâce hospital decided to create a stereotaxis site using advanced medical imaging date (CT-scan or MRI). METHODS: Two MRI machines and on CT unit were linked to a network (ETHERNET) available for radiologists in 1989. Neurosurgeons adapted stereotaxis sites using Leksell, Fisher and CRW software for MRI. A data processing program recognizing these sites was developed for stereotaxic biopsies based on MRI data. The network was extended in 1992 to the radiotherapy unit for multiple beam stereotaxic irradiations. Finally from 1994, when a computer-guided microscope (Zeiss MKM) was installed, nearly all neurosurgical procedures were conducted under stereotaxic conditions. RESULTS: Since 1989, approximately 900 computer-guided stereotaxic biopsies have been performed with precision in the millimeter range. Since 1994, the Zeiss MKM microscope has been used for 120 computer-guided procedures with the frameless stereotaxic technique guided from landmarks on the outer cranium or attached to the scalp. Mean precision obtained with landmarks was 1.2 mm and 2.8 mm with scalp markers. CONCLUSION: These techniques of computer-assisted neurosurgery based on advanced medical imaging techniques has been revolutionary for surgical approach to intracranial and intracerebral diseases. Smaller assess routes and precise pathways allow an approach to formerly inoperable lesions with minimal risk.

[Emergency stereotaxic cerebral punctures]. / Ponctions cérébrales stéréotaxiques en urgence.

Based on a series of about a hundred CT-guided stereotactic biopsies, the basic principles of stereotaxic approach of the brain are reviewed. The authors also report their preliminary experience of stereotaxic aspiration in the management of brain abscesses and hypertensive intracerebral hematomas. CT-guided stereotaxic aspiration is useful in the management of brain abscesses and is a viable treatment modality of hypertensive hematomas.

[CFTR gene analyis in 207 patients with cystic fibrosis in southwest France: high frequency of N1303K and 1811+1.6bA>G mutations]. / Etude du gène CFTR chez 207 patients du Sud-Ouest de la France atteints de mucoviscidose: fréquence élevée des mutations N1303K et 1811 + 1,6 kbA > G.

UNLABELLED: The large molecular heterogeneity in cystic fibrosis (CF) represents the main difficulty for the genotype characterization. Moreover, numerous studies have reported considerable variations in frequencies of cystic fibrosis transmembrane conductance regulator (CFTR) mutations in different populations. MATERIAL AND METHODS: We analyzed the genotype of 207 CF children living in southwest France. RESULTS: Among 50 identified mutations, we report for some of them a widely modified incidence compared with those observed in other regions of France. These differences were more significant in the subset of the CF chromosomes originating in southwest France. Thus, the 1811 + 1.6 kbA > G mutation, rarely observed in the other French regions (< 0.5%), proved to be, with a frequency of 8.8%, the most frequent mutation after the F508 deletion (57%). The frequencies of N1303K, 1811 + 1.6 kbA > G and R334W mutations were also clearly increased: 7.9 and 2.6%, respectively. CONCLUSION: We show that the southwest of France is characterized by a specific mutational spectrum. We consider that these regional data on the spectrum of CF mutations are crucial to develop more accurate and less expensive molecular screening strategies for cystic fibrosis in France.

[Anatomo-radiological classification of meningioma of the posterior skull base]. / Classification anatomo-radiologique des méningiomes de la partie postérieure de la base du crâne. 140 cas.

Between 1972 and february 1993, 140 posterior skull base (clivus and posterior aspect of the petrous bone) meningiomas were seen and treated in our department. Since 1982, we use an anatomo-radiological classification system which is suggested here as a standard classification method for comparison among series of these tumors. Once a meningioma of this region has been discovered the problem is to establish as precisely as possible: its site of origin which will provide evidence of the likely direction of displacement of the blood vessels and nerves of the region. Its exact area of attachment is of prime importance in selecting the best surgical approach. Its size and tumoral extensions which will often dictate the addition of other approaches to allow complete removal. THE SITE OF ATTACHMENT (140 CASES): The posterior skull base may be subdivided into four zones: the clival zone: which comprises the clivus itself and that part of the petrous apex situated medial to the trigeminal impression; the posterior surface of the petrous bone itself subdivided into three roughly equal zones; *an anterior zone (zone A) situated between the trigeminal impression and the anterior lip of the IAM, *a median zone (zone M) from the anterior lip of the IAM to a line immediately posterior to the labyrinthine block, *a posterior zone (zone P) extending from this line to the sigmoïd sinus. In our series, we find meningiomas of the posterior skull base with a discrete site of attachment in the clival zone (10 cases), zone A (29 cases), zone M (31 cases), zone P (19 cases) others have a much wider attachment encompassing two or even three zones, zone A. M (29 cases), zone M. P (15 cases), zone A. M. P (7 cases). THE STAGE OF THE TUMOR: The tumor's base of implantation having been precisely defined, the stage of the tumor is then determined by measuring the distance between the tumor surface and the line of attachment. In our series, 131 tumors were measured: 13 tumors were stage I (tumors with an encroachment into the angle of less than 1 cm), 38 tumors were stage II (1-1.9 cm), 37 tumors were stage III (2-2.9 cm), 43 tumors were stage IV (more than 3 cm). TUMOR EXTENSIONS: These are appreciated on axial, coronal and sagittal images (MRI). Meningiomas of the clivus may extend [8 cases]: very commonly to the petrous apex (zone A) [7 cases], almost always to the tentorium [7 cases], often to the cavernous sinus [5 cases].(ABSTRACT TRUNCATED AT 400 WORDS)

[Surgery of large neurinomas of the acoustic nerve performed only by the translabyrinthine approach. Apropos of 50 cases]. / La chirurgie des gros neurinomes de l'acoustique opérés uniquement par voie translabyrinthique. A propos de 50 cas.

A combined otoneurosurgical team has operated upon 68 patients with acoustic nerve neurinomas over a period of 13 months (Sept. 1982-Oct. 1983). Exploration and operation in this homogeneous series were carried out under the same conditions, and a CT scan was performed in each patient before and after surgery. The size of the neuroma was less than 2 cm in diameter in 18 cases, between 2 and 3 cm in 28 cases, between 3 and 4 cm in 10 and 4 cm or more in 12. This report relates to the 50 neurinomas over 2 cm in diameter, these requiring multidisciplinary co-operation during surgical removal. The translabyrinthine approach was used exclusively in 48 cases, and was combined with a retrosigmoid approach in the other 2 cases. Total tumoral excision was possible in 46 cases (92%) and partial removal in 4 patients (8%). Complications included one death (bilateral giant neurinomas), resolving purulent meningitis (2 cases), 3 patients with cerebrospinal fluid fistulae which healed after lumbar drainage, and 1 case of postoperative hematoma in the ponto-cerebellar angle requiring further surgery. The facial nerve was undamaged in 48 cases (96%). Postoperative facial palsy developed in 39 cases, and 15 have recovered subnormal motility. Follow up is insufficient in the other 17 patients. It is suggested that the translabyrinthine approach enables ablation of neurinomas of whatever size. This approach is reliable since it avoids injury to neighboring nerve structures. The facial nerve is detected immediately and can be protected throughout operation. The latter is, however, a long and difficult procedure, and otoneurosurgical collaboration is advisable.

[Ballistic approach in head injuries caused by missiles]. / Approche balistique des plaies crânio-cérébrales par projectiles.

If the missile head injury treatment is relatively well codified, wound ballistic, on the other hand, is not well known of neurosurgeons. Different means of study and tissue simulants are being listed. In face of numerous contradictory results, we shall only retain the M.L. Fackler method with 10% gelatin. Experimental results will depend on: 1. Missile parameters. For instance, in soft homogeneous tissue, one can discern shells with an uncertain path, full jacketed bullets which tumble after a variable "neck", and non jacketed missiles which cause wound through "mushrooming" and/or fragmentation effect. Buckshot wounds obey the rule "all or none". 2. Body reactions, particularly the clash with a hard material like bone, which can overturn everything described in soft tissues. These wound ballistic notions have lead us to formulate two pathogenic hypothesizes, allowing us to understand sometime case reports which had first seemed paradoxical: the brain structure, enclosed in the skull will not able to survive any major temporary cavity, the more or less deep missile pathway through the skull will be very different according to the type and energy of the missile, and to the hardness of pierced bone.

[Postoperative quality of life for patients with a vestibular schwannoma]. / Qualité de vie chez les patients opérés d'un schwannome vestibulaire.

OBJECTIVES: To determine the prognoses criteria of quality of life's impairment after vestibular schwannoma surgery. STUDY DESIGN: Our study includes retrospectively 104 consecutive patients operated between 1991 & 2000 of a vestibular schwannoma. Patients with bilateral tumors were not included, neither patients lost of follow-up. The french version of the Short Form-36 self assessment questionnaire was sent to all patients. RESULTS: The response rate was 68% (71 patients). The patients' postoperative quality of life was lower of the norm, especially for psychical dimensions. This impairing of health whatever age, tumor size, operative approach or follow-up time. Sex and 2nd surgery were the only factors associated with a lower score. Women had worse rating of physical functioning. CONCLUSION: To operate small tumors should not assume that the impact on patients'life would be necessary less than following the removal of larger tumors. Women should have particularly clear explications before surgery and while follow-up.

[Surgery of acoustic neuroma and other tumors of the internal auditory canal and cerebellopontile angle. Apropos of 602 cases]. / Chirurgie du neurinome de l'acoustique et autres tumeurs du conduit auditif interne et de l'angle ponto-cérébelleux. A propos de 602 cas.

During the last two decades, 602 tumors of the internal auditory canal and of the cerebello-pontine angle were operated on, using the trans-temporal approaches. Among these tumors, 548 were unilateral acoustic neuromas, that were removed by the trans-labyrinthine approach (57%), the retro-labyrinthine-retro-sigmoid approach (33%) and the middle fossa approach (M.F.) (6%). Five fatalities occurred (1%). The facial nerve was preserved in 94% with an immediate normal function in 58%. The auditory function was preserved in 23% (51 cases).

[Surgical approach to petroclival meningioma. Value of translabyrinthine approach extended to the petrous apex]. / Voies d'abord des méningiomes pétro-clivaux. Intérêt de la voie trans-labyrinthique étendue à l'apex pétreux.

Petro-clival meningiomas are rare tumors. Because of their deep location in the posterior fossa, many surgical approaches have been proposed, generally with severe post-operative morbidity and mortality. Thirty-six meningiomas of the petrous apex (34 posterior surface of petrous bone meningiomas, 2 clivus meningiomas) were operated, via a trans petrosal approach, from 1983 to 1993. In 14 cases, the trans-labyrinthine (TL) approach, extended by drilling the bone above the internal auditory canal (IAC) was performed (39%). In 18 cases the TL approach was extended in a subtemporal, transtentorial approach (50%). In one case (2.5%), after rerouting the facial nerve posteriorly, the TL approach was extended anteriorly in a transcochlear approach. The retro-sigmoïd approach was performed in one case (2.5%). The extended middle fossa approach was performed in two cases of clivus meningiomas (5%). Total excision was obtained in 27 cases (75%). By using the Laser, quality of resection is increased. Most complications and morbidity were encountered with tumors extending towards the cavernous sinus. Extended translabyrinthine approach allows total excision in most of cases of petro-clival meningiomas. For clivus tumors or tumors invading the cavernous sinus, the extended middle fossa approach and subtotal petrosectomy are proposed respectively.

[Arachnoid cysts of the middle fossa and associated subdural hematoma. Three case reports and review of the literature]. / Hématomes sous-duraux chroniques et kystes arachnoïdiens temporaux sylviens. A propos de trois cas et revue de la littérature.

BACKGROUND AND PURPOSE: We report 3 cases of subdural hematoma associated with arachnoid cyst of the middle fossa, and discuss the treatment. METHODS: Three males aged 33, 63 and 68 were treated in our institution. Before this event the cyst was asymptomatic and unknown. Magnetic resonance imaging was the most contributive radiologic exam. Surgical procedure was limited to subdural hematoma evacuation. The internal wall of subdural hematoma was opened in all cases. RESULTS: The clinical outcome was good for all patients. The CT or MRI scan follow-up 3 months later revealed nearly total disappearance of subdural hematoma for 2 out of 3 cases. For one patient the volume of arachnoid cyst decreased. CONCLUSIONS: We propose subdural hematoma drainage without any specific treatment (shunt or fenestration) of the arachnoid cyst, for this category of patient.

[Atlanto-axial lateral mass osteoarthritis. Three case reports and review of the literature]. / Arthrose atloïdo-axoïdienne unilatérale. A propos de 3 cas et revue de la littérature.

This report describes three cases of symptomatic unilateral C1-C2 mass osteoarthritis. The patients were all female aged 67, 62 and 59 years. One patient had a history of rheumatoid arthritis. Unilateral occipital pain was the main symptom. Neuroradiological work-up included open mouth anteroposterior radiograph, flexion/extension lateral radiograph of the cervical spine, CT scan with coronal and sagittal reconstruction and MRI. Findings allowed differential diagnosis with tumoral or infectious disease of upper cervical spine and ruled out C1-C2 instability. CT scan and MRI permitted precise operative planning by determining the course of vertebral artery in the C1 and C2 vertebrae. Two patients were treated by CT scan guided steroid injection. The third patient was treated by C1-C2 arthodesis after failure of conservative treatment.

[Pathology and surgery of tumors located under the internal auditory canal. 1. Neurinoma of mixed nerves]. / Pathologie et chirurgie des tumeurs situées sous le conduit auditif interne. I. Les neurinomes des nerfs mixtes.

The schwannomas of foramen jugulare are infrequent although progress in diagnosis of these tumors have been obtained by CT scan. We report five cases of the caudal nerves that where developed into the foramen jugulare. One may suspect these tumors in presence of any minimal, unilateral defect of otological, facial and pharyngo-laryngeal functions. The surgical approach to the tumors depends of both its location and its symptomatology. The mastoid-retro-sigmoid approach allow in most cases to preserve the eight and seven nerve functions.

[Early syringomyelia following benign cervical injury. Contribution of postoperative MRI]. / Syringomyélie précoce après traumatisme cervical bénin. Apport de l'I.R.M. post-opératoire.

The authors show an observation of a post traumatic syringomyelia syndrome which gradually developed a few months after a cervical sprain. The diagnosis has been mentioned after the discovery of a "big medulla" with myelography and computed tomography. The presence of a cervical cystic cavity with viscous liquid has been confirmed by surgery. A syringosubarachnoïd shunt has been carried out with excellent post operative results as the patient has recovered all his sensory and motor functions. For the pathogenic hypothesis mention is made of a small subclinic early hematomyelia which then develops on its own to form a genuine syringomyelic cavity. The authors emphasize the future interest of M.R.I. for the pathogenic diagnosis as well for the post operative effects.

[Acute staphylococcal epidural inflammation. Apropos of 2 cases]. / Les épidurites staphylococciques aiguës. A propos de deux cas.

Two cases of staphylococcal infection of the epidural space are presented and on this purpose a review of literature is done to remind of this pathology and to plead for early diagnosis.