Pituitary apoplexy and rivaroxaban.

Pituitary apoplexy (PA), defined by the occurrence of a massive hemorrhagic necrotic rearrangement within a pituitary adenoma, is rare. Its occurrence can be associated with certain risk factors, including anticoagulation. We report the first case of PA with rivaroxaban which is one of the new oral anticoagulants: a 73 year-old patient presenting with severe headache and visual field deterioration. Surgery was performed. Radiotherapy treatment was decided three months after surgery because of tumor residue.

[Facial nerve outcome after vestibular schwannoma surgery: About 89 patients]. / Fonction du nerf facial après chirurgie du schwannome vestibulaire: àpropos de 89 patients.

OBJECTIVES: We evaluated the postoperative facial nerve function after vestibular schwannoma (VS) surgery and analyzed factors causing it. MATERIAL AND METHODS: We included 89 consecutive patients undergoing surgical excision of unilateral VS. Patient and tumor characteristics, surgical approaches, facial nerve function, extent of tumor resection and complications were analyzed. RESULTS: Complete tumor resection was achieved in 85% of cases. Anatomic preservation of the facial nerve was achieved in 96% of patients. In all tumor stages, 88.2% of patients, have a normal or subnormal facial function within one year of the intervention, the rate was 100% in patients carrying a VS stage I or II. No severe complication or death was reported. CONCLUSION: Short- and long-term facial nerve outcome was comparable with results of other recent series reported in literature. The facial nerve function after surgery was better with small VS compared to large VS. The intraoperative decision of near-total excision of the tumor followed by adjuvant radiotherapy, in some cases, can prove to be a good option in the interest of better preservation of the facial nerve function. The adhesion of the facial nerve and its complex relationship with the tumor remain mysterious; RMI can bring significant refinements, helping to get the best preservation offacial function rate, in the coming years.

Surgery versus conservative care for Rathke's cleft cyst.

BACKGROUND: Rathke's cleft cysts are benign cystic lesions of the sellar region, which may cause headache, pituitary deficiencies and visual disturbances from mass effect. Their management is not standardized yet. This study is about establishing a consensus for medical care of RCC. MATERIAL AND METHODS: We performed a retrospective observational study of all patients that were diagnosed or followed for RCC between 2008 and 2018 (11 years), in the neurosurgical and the adult endocrine departments of our institution. The study's average time length of follow-up is 72.9 months (from 2 to 385 months). RESULTS: The 57 included patients were divided into 2 groups: group A, which included 39 patients that were conservatively managed and group B, which included 18 surgically treated patients. Group A showed either an improvement or a spontaneous resolution of headaches in 56.1% of the cases (P<0.01); a resolution of hyperprolactinemia in 70% of the cases (P=0.21); and of hypogonadism, ACTH deficiency, growth hormone deficiency in 100% of the cases. There was no spontaneous improvement of visual disturbances (P<0.01) or diabetes insipidus (P=0.29) during follow-up. Regarding group B, surgery allowed improvement or complete resolution of headaches in 60% of the cases; visual troubles in 100% of the cases (P<0.01); and hyperprolactinemia in 100% of the cases. Pituitary deficiencies were not improved by surgery. CONCLUSIONS: This study offers guidance in decision-making regarding the management of RCC patients. Surgery is particularly suitable for treating visual disturbances caused by RCC. Regular follow-up is more appropriate than surgery concerning headaches, hyperprolactinemia, endocrine disruptions and diabetes insipidus.

Huge intramedullar neurenteric cyst with intrathoracic development in a 1 month-old boy: excision though the anterior approach. A case report and review of the literature.

Spinal neurenteric cyst is a rare congenital lesion that may occur either alone or in the context of a complex malformative disorder. Our case is unusual because of its rare intramedullary location, the association with an important intrathoracic development, and the age of the child at presentation (1 month). An anterior approach through a right-sided lateral thoracotomy was performed for a total resection of the intrathoracic part and a subtotal resection for the intramedullar portion. During 2 years of follow-up, the child presented no neurological deficit and post-operative magnetic resonance imaging found a small residue fixed on the anterior spinal cord without progression.

Anterior skull base reconstruction after tumour resection using the posterior wall of the frontal sinus.

INTRODUCTION: The authors describe their experience of surgical closure of the anterior skull base after tumour resection, using the posterior wall of the frontal sinus. MATERIAL AND METHOD: The authors describe their anterior skull base closure technique performed in three patients after tumour resection. Tumour resection via a transglabellar approach resulted in an anterior skull base defect. Reconstruction consisted of direct implantation of the posterior wall of the frontal sinus without using a bone substitute (except when nasofrontal duct obstruction is required). RESULTS: Three patients were operated by this surgical procedure with complete tumour resection in every case and no infectious complications. This technique was easy to perform, despite one case of persistent CSF leak. Follow-up imaging showed no displacement of the onlay bone graft. CONCLUSION: Anterior skull base reconstruction after tumour resection using autologous frontal sinus bone graft is easy to perform with a low complication rate.

[Intracranial hypotension with subdural hematoma following lumbar puncture: case report]. / Hypotension intracrânienne sévère associée à un hématome sous-dural à la suite d'une ponction lombaire diagnostique: cas clinique.

BACKGROUND AND PURPOSE: Lumbar puncture is a common procedure highly contributive to neurological diagnosis. It can also cause serious adverse side effects including subdural hematoma and intracranial hypotension as illustrated by this case report. CASE REPORT: A 38-year-old women presented severe intracranial hypotension after a lumbar puncture. Magnetic resonance imaging was compatible with intracranial hypotension and revealed an acute subdural hematoma with midline deviation. A first blood patch was unsuccessful. Symptom relief was achieved with a second patch. The patient was, then, discharged but developed recurrent headache subsequent to the transformation from acute to chronic subdural hematoma. Surgical drainage was required. The postoperative imaging and physical examination returned to normal and the patient was discharged with no recurrence. CONCLUSION: The serious adverse effects of lumbar puncture is an easy and common medical procedure that must be kept in mind.

[Intramedullary spinal tuberculoma: report of one case]. / Tuberculose intramédullaire. A propos d'un cas.

Neurological symptoms of tuberculosis are rare, even if there this pathology has been on the rise for a number of years because of HIV. Intramedullary tuberculoma is an exceptional location. We report the case of a patient with no HIV or immunodepression symptoms with intramedullary tuberculoma, revealed by a clinical presentation of insidious onset of myelopathy. We will discuss the diagnosis, treatment and clinical functional follow-up. The optimal treatment seems to be a combination of microsurgical resection and antibiotic therapy.

[Fractionated stereotactic radiotherapy for optic nerve sheath meningioma: eight cases]. / Radiothérapie stéréotaxique fractionnée des méningiomes de la gaine du nerf optique: à propos de huit cas.

UNLABELLED: Optic nerve sheath meningioma (ONSM) accounts for one-third of primary optic nerve tumors, and 2% of all meningiomas. ONSM must be distinguished from other meningiomas, in particular from cavernous meningiomas because of the different prognosis and treatment. The most frequent clinical sign is a progressive or sudden unilateral visual loss. Treatment of ONSM is still subject to discussion. This report covers a series of eight ONSM patients treated with fractionated stereotactic radiotherapy. MATERIAL AND METHODS: Between 2000 and 2006, we managed eight patients with ONSM. The average patient age was 47 years. There were five women and three men. The most frequent clinical signs were visual loss (100%), proptosis (35%), diplopia (25%). One patient was initially treated with surgery. All patient have been treated by fractionated stereotactic radiotherapy. 45 Gy in 25 fractions were delivered on the meningioma area at a rate of 5 fractions of 1.8 Gy per week. We used a Brainlab framework associated with a thermo-formed mask. A computed tomography then magnetic resonance imaging was obtained for each patient. The data was merged and planning took place on a Brainlab dosimetric console. The treatment was performed with a head-only Varion linear accelerator, with a Brainlab multi-blade collimator. RESULTS: The average follow-up was 27 months. Each patient had a complete radiological and ophthalmologic exam every 3 months during the first year, then every 6 months thereafter. Tumor control rate was 100%. Vision was re-established in five patients and three patients had improvement, including one patient during treatment. 100% of proptosis and diplopias regressed. No side effect was reported. CONCLUSION: This is still a preliminary study, but the results suggest that fractionated stereotactic radiotherapy may emerge as a primary treatment for ONSM, delaying surgery, which has proven functionally disappointing.

[Trans-umbilical access and ventriculoperitoneal shunt in adults: preliminary results]. / Abord transombilical et dérivations ventriculopéritonéales de l'adulte: résultats préliminaires.

In spite of the development of endoscopic surgery in hydrocephalus, ventriculoperitoneal shunt remains indicated in many cases particularly for non obstructive hydrocephalus. The peritoneal cavity is always an excellent receptacle for the LCS at the price of an unaesthetic abdominal scar, which may pose a problem, especially for the young adult. The trans-umbilical approach allows us to avoid the unsightly scar. Thus, between May 2004 and September 2006, a ventriculoperitoneal shunt was fashioned in 14 patients using a trans-umbilical access. Average age was 52 years and average post-intervention follow-up was 17 months. No patient developed infection, in particular in the umbilical area. One patient had to undergo a second operation for ventricular repositioning using the same peritoneal drain that could be repositioned via the trans-umbilical access with no particular problem. In one particular case, a full change of the shunt was necessary because of a sore on the shunt chamber, the material was reinstalled via the conventional umbilical access without any particular difficulty. This is the first preliminary study which confirms the feasibility of the trans-umbilical method for adults with no increase in the infectious risk, and with a very satisfactory aesthetic result in children.

Reconstruction of cranioplasty using medpor porouspolyethylene implant.

INTRODUCTION: We describe our experience of cranioplasty after a calvarial defect, following an external decompressive craniectomy, with the Medpor® (Stryker®) porous polyethylene implant for cosmetic cranioplasty and reconstruction. METHODS: A retrospective chart review was performed on 23 consecutive patients who underwent cranioplasty at a single institution between January 2013 and January 2016: 9 patients after head injury and 14 patients after vascular event (ruptured aneurysm, intraprenchymal haematoma, malignant cerebrovascular accident). All patients with cranioplasties after oncological resection or infection were excluded. These cranioplasties were performed using porous polyethylene sheet (Medpor®) and contoured with a burr or scissors in the sterile field, and fixed to the calvarial bone with screws. RESULTS: Porous polyethylene sheet (Medpor®) is a proven material used for cranial reconstruction in neurosurgery and maxillofacial surgery with a biocompatibility advantage. The implant can be directly used in an emergency context. The average operating time was 72minutes. An average delay of 527 days (1 year and 5months) with a median of 985 days (43; 4206) occurred between craniectomy and the cranioplasty. There was only one set back implant due to scalp necrosis with infection for a recovery-unit patient. CONCLUSION: Porous polyethylene is an excellent restorative material for the reconstruction of large sized cranial defects and can be also used safely in reconstruction of the cranium. The cosmetic results are good, easy to perform, with a low complication rate.

Ectopic bone formation with joint impingement after posterior lumbar fusion with rhBMP-2.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) was recently licensed for local administration during posterior lumbar fusion. In this indication, considerable uncertainty remains about the nature and mechanisms of the many adverse effects of rhBMP-2, such as ectopic bone formation. We report a case of ectopic bone formation with impingement on a facet joint and incapacitating low back pain after minimally invasive transforaminal L5-S1 interbody fusion with local application of rhBMP-2 (InductOs(®)). Revision surgery was eventually performed to alleviate the symptoms by removing the ectopic bone. Caution is in order regarding the use of rhBMP-2 during posterior lumbar fusion. Every effort should be made to minimise the risk of complications.

Spontaneous epidural hematoma due to cervico-thoracic angiolipoma.

Epidural angiolipomas are uncommon benign tumors of the spine. Their clinical presentation is usually a progressive spinal cord compression. We report the case of a 22-year-old patient who presented with an acute paraparesis and a spontaneous epidural hematoma, which revealed a epidural angiolipoma which extended from C7 to T3. The patient underwent a C7-T3 laminectomy, in emergency, with evacuation of the hematoma and extradural complete resection of a fibrous epidural tumor bleeding. The postoperative course was favorable with regression of neurological symptoms. Epidural angiolipomas can be revealed by spontaneous intratumoral hemorrhage without traumatism. The standard treatment is total removal by surgery.

Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases.

INTRODUCTION: Transoral odontoidectomy is the treatment of choice in cases of anterior bulbo-medullary compression. The development of endoscopic procedures has made it possible to perform odontoidectomy via a minimally invasive endoscopic endonasal approach. We discuss the feasibility, advantages, and limitations of this surgical approach. MATERIALS AND METHODS: We report a two-center retrospective series of patients who underwent endoscopic endonasal odontoidectomy between September 2011 and February 2013. Preoperative characteristics, intraoperative data, clinical course, and postoperative complications were studied. The patients were followed for a minimum of 6 months. Cervico-occipital posterior fusion was performed during the same hospital stay in cases of preoperative instability. RESULTS: Nine patients underwent decompressive odontoidectomy, for rheumatoid pannus in five cases and basilar impression in four cases. All had progressive neurological symptoms. Seven patients also underwent posterior fusion. In six patients, the C1 anterior arch was preserved. Decompression was achieved satisfactorily in all nine cases. The patients were able to resume oral feeding the day after the intervention. No patient required tracheostomy. We observed no dural fistulae or infectious complications. One patient died 2 months after the intervention of a pulmonary embolism. All patients improved in terms of their preoperative neurological status. CONCLUSION: This short series shows the feasibility of the endoscopic endonasal approach for resection of the dens. This approach allows optimal viewing when using angulated instrumentation and seems to result in low morbidity. In some cases, this approach makes it possible to preserve the C1 anterior arch, thus limiting the risk of cranial settling. LEVEL: IV retrospective study.

Anterior minimally invasive extrapleural retroperitoneal approach to the thoraco-lumbar junction of the spine.

BACKGROUND: The anterior approach to the thoraco-lumbar junction of the spine allows therapeutic interventions on post-traumatic, infectious, and neoplastic vertebral lesions from T11 to L2 combining spinal cord decompression, corporectomy, and vertebral body fusion. However, this approach also has a reputation for damaging the intervening anatomic structures (lungs, peritoneum, and diaphragm). The objective of this study was to show that both nervous structure decompression and anterior vertebral reconstruction can be achieved via an anterior minimally invasive extrapleural retroperitoneal (AMIER) approach. MATERIAL: We describe each of the steps of the AMIER approach to the thoraco-lumbar junction of the spine. RESULTS: The AMIER approach ensures excellent exposure that allows full decompression and satisfactory anterior anatomic reconstruction. The main difficulties and complications relate to the lungs, and a painstaking and rigorous technique limits the complications compared to conventional thoraco-phreno-lumbotomy.

[Minimally invasive extrapleural retroperitoneal approach for thoracolumbar junction. Prospective study of 40cases]. / Abord mini-invasif de la charnière thoracolombaire du rachis par voie extrapleurale, rétropéritonéale. Étude prospective sur 40cas.

STUDY DESIGN: Prospective study. BACKGROUND AND PURPOSE: The anterior spinal cord decompression and spinal interbody fusion is considered an effective therapeutic procedure for thoracolumbar spine junction (TLSJ) (T11 to L2) fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that neural elements decompression and anterior reconstruction at the TLSJ can be performed via a minimally invasive extrapleural retroperitonal approach (MIERA). METHODS: The authors studied prospectively the hospital records and radiological data obtained in 40 patients (mean age: 43.6 years, range: 16-74 years) who all underwent first a posterior fixation followed by a thoracic (T11 or T12) or lumbar (L1 or L2) corpectomy and spinal fusion via a MIERA. RESULTS: The MIERA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. More than 2years follow-up record is available for 24 patients, a one year follow-up record for 14 others, and six months follow-up for the last two ones. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the 24patients for whom a minimum of 2years follow-up records was available. CONCLUSIONS: The MIERA allows the surgeon to perform anterior thoracolumbar spine surgery via a less invasive approach. The authors demonstrate the efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery or thoracophrenolombotomy.

[Cerebrospinal fluid rhinorrhea following endocopic trans-sphenoidal pituitary surgery: Experience from 337 patients]. / Rhinorrhée cérébrospinale après chirurgie hypophysaire endoscopique trans-sphénoïdale : réflexions après 337 patients.

INTRODUCTION: Cerebrospinal fluid (CSF) leak is a frequent complication after trans-sphenoidal pituitary surgery. We try to determine the incidence, risk factors, diagnostic procedures, and management of CSF leaks following trans-sphenoidal pituitary macroadenoma surgery. METHODS: A retrospective analysis of 337 patients data. RESULTS: Postoperative CSF leaks occurred in 11 patients (3,1%). Ten patients had to be reoperated. Three patients had meningitis. Intraoperative CSF leak is the only significant predictive factor of postoperative CSF leak. Revision surgery, wide opening of the sella turcica and insufficient reconstruction of the sellar floor also seem to play a role (for six cases of postoperative CSF leak, the closure material had been excluded). CONCLUSION: Prevention of the postoperative CSF leak needs screening of intra-operative CSF leak. The strength of the sellar floor is essential in order to avoid the ejection of the closure material, related to the intracranial pression.

[Management of WHO grade II and II meningiomas: retrospective study of surgical series of 36 cases at a single institution]. / Prise en charge des méningiomes OMS grade II et III : étude rétrospective monocentrique d'une série chirurgicale de 36 cas.

INTRODUCTION: Atypical and malignant meningiomas are a rare disease whose histological definition is still recent. Their management is not consensual. The aim of this study was to review the outcome, prognostic factors and the role of complementary therapies. PATIENTS AND METHODS: Between 1999 and 2007, 36 patients with atypical or malignant meningiomas were managed in our hospital. All surgical specimens were reviewed according to the 2007 WHO classification system. The sex ratio was 1.25 male, the median age was 59 years. The median follow-up was 55 months. Thirty meningiomas were atypical and six were malignant. RESULTS: Five and 10 years overall survival rate are respectively 72 and 41%, whereas 5 and 10 years progression free survival rate are 61 and 23%. We only identify female sex, age over 70 years and Karnofsky status under 70% as negative prognostic factors. CONCLUSION: Atypical and malignant meningiomas are difficult to manage and have high recurrence and poor survival rates. The prognostic of OMS II meningiomas is heterogeneous. Adjuvant radiation therapy is recommended in case of malignant menigioma or in case of atypical meningioma if incomplete surgical excision is performed.

Spinal cord compression due to C4 vertebral arch osteochondroma.

Osteochondromas are usually benign bone tumors found on the metaphysis of long bones. These tumors are rarely located on the spine especially at cervical level. This report presents the case of a 23-year-old man who had previously developed tetraparesis at the age of 13 after infectious myelitis. Recent severe clinical neurological deterioration revealed the diagnosis of osteochondroma arising in the C4 vertebral arch compressing the spinal cord and associated with syringomyelia. Of note in his past history was a treated hip localization. The patient underwent complete surgical excision of the osteochondroma. Postoperative outcome was good with slow clinical recovery from the spinal cord compression. We report this rare cause of spinal cord compression and other cases reported in the literature.

[Intradiploic cavernous hemangioma of the calvaria: case report and review of the literature]. / Hémangiome caverneux intradiploïque du vertex: à propos d'un cas et revue de la littérature.

We report the case of a 31-year-old patient who had had frontal cephalalgias for several years. CT and MRI anatomical imaging objectified a frontal osteolytic tumor respecting the osseous external table but compressing the superior sagittal sinus. Total en bloc resection of the tumor associated with titan cranioplasty was performed. The postoperative course was uneventful. Three months after surgery the patient no longer reported headache. The anatomical and pathological results concluded in intradiploic cavernous hemangioma. We discuss this case and others described in the literature.