Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space. Report of four cases.

Four patients with tentorial arteriovenous malformations (AVM's) were treated surgically. The operative findings in the first case suggested that clipping of the draining vein close to the AVM may result in complete cure. The three subsequent cases were treated with this technique. The clinical and radiological implications are discussed.

Biochemical characterization of 17 beta-hydroxysteroid dehydrogenase in human meningioma.

17 beta-Hydroxysteroid dehydrogenase (E2-DH) activity was characterized on a semipurified microsomal preparation of human meningioma tissue (mean Km of 2 microM and Vmax of 500 pmol/mg protein/10 min) and then assayed in 49 meningioma specimens with high progesterone receptor and low estrogen receptor levels. Of these 49 tumors, 36% contained an E2-DH activity greater than 1,000 pmol/mg protein/10 min and similar to that of uterine myometrium. In this limited series of tumors, no correlation between E2-DH activity and progesterone receptor levels was noted.

[Progesterone receptors in normal human leptomeninges in adults]. / Récepteurs de la progestérone de la leptoméninge humaine normale chez l'adulte.

Cytosolic and/or nuclear 3H-R 5020 binding sites were detected in 6/6 samples of normal leptomeninges obtained at the time of operation in human adults. The levels of binding sites were higher in leptomeninges samples (range of values: 140-1780 fmol/gT) than in the corresponding intracranial tumors (one meningioma, two neurinomas, one metastasis) in 3 out of the 4 cases that were simultaneously studied. The 3H-R 5020 binding systems were characterized in 2 groups, A and B, of pooled samples representing respectively 4 and 17 samples of normal leptomeninges. The study of A (cytosolic and nuclear binding sites) and B (cytosolic binding sites) groups showed that binding systems had a limited capacity and a high affinity (Kd were respectively 2 X 10(-9) and 5.3 10(-10) M) as previously noted for the progestin receptor in human meningioma. Biochemical data and ultrastructural pictures obtained in the present study as well as in previous works, allow to consider the presence of the progestin receptor in normal leptomeninges.

[Cushing's disease successfully treated by transphenoidal hypophysectomy since eight years (author's transl) (proceedings)]. / Maladie de Cushing traitée par hypophysectomie transphénoïdale. Guérison avec 8 ans de recul

The authors show a case of true Cushing's disease by bilateral adrenal hyperplasia without pituitary tumor which is cured for eight years by only treated with transphenoidal hypophysectomy. They think that reaching by surgery, the nervous afferences from hypothalamus to hypophysis could play a part in ameliorating the pathologic relations which existed between two centers.

[Neurotraumatology of sportive origin (author's transl)]. / Neurotraumatologie d'origine sportive.

In our Statistics, accidents in sports represent only 2,3% of the trauma cases hospitalized in the neurosurgical service of Marseille La Timone; of these cases 57% are cranio-cerebral injuries, 43% are vertebral or spinal cord injuries. The type and severity of trauma are of course directly related to the type of sport concerned. Cranio cerebral and spinal cord injuries occur with the same frequency in rugby. Horse back riding and foot-ball are responsible for severe cranio-cerebral injuries (respectively 90% and 92% of the total number of these accidents). Diving is the cause of spinal cord injuries in 79% of the cases. Close supervision of accident victims and systematic and technical analysis of accidents related with sports practice should improve the safety for both amateurs and professionals.

[Arterio-veinous malformations located within the occipito-cerebello-mesencephalic dihedral (author's transl)]. / A propos des malformations artério-veineuses du diedre occipito-cérébello-mésencéphalique.

About 4 cases of arterio-veinous malformations located within the occipito-cerebello-mesencephalic dihedral (which is this region of the brain including the cistern of Galen and the surrounding formations : the quadrigeminal bodies forwards, the splenium of the corpus callosum upwards, the upper face of the cerebellum and the pedonculus cerebellaris superior below) the authors related their own experience. These 4 cases are detailed from a clinical point of view. Them, a synthetic study is undertaken in which a comparison is done between the literature and the clinical features encountered : headache, sub-archnoid hemorrhage, impairment of consciousness, clinical features such as cranial nerve impairment, nystagmus motor impairment, cerebellar deficit, hydrocephaly. The value of angiography, ventriculography and CAT is discussed. All these patients have been operated upon as far as the authors think that a better chance can thus be offered to them. The choice of the technique is discussed. For one patient, the sub-temporal route was performed ; but it seems worth using the posterior inter-occipital route : this allows a better view on the lesion and an easier treatment of the malformation. These 4 patients suffered post operatively of a visual defect. The control angiography revealed no more arterio-venious malformation in two patients, a mild one in two others.

[Traumatic obliteration of the sylvian artery]. / Les oblitérations traumatiques de l'artère sylvienne.

Traumatic thrombosis of the middle cerebral artery have been rarely reported and documented. Eight personal cases provide us an opportunity to stress the common features of this rare entity: onset of symptoms several hours after severe head-trauma, in young men; computerized tomography combined with carotid angiography are decisive for the diagnosis. Prognosis is poor-six deaths out of eight patients. Anticoagulantherapy is useless even dangerous. Extra-intra cranial anastomosis may appear a better solution in selected cases.

[Post-traumatic intracerebral hematomas. Apropos of a series of 38 cases]. / Les Hématomes intracérébraux post-traumatiques. A propos d'une série de 38 cas.

Our study is based on the analysis of traumatic I.C.H. 38 cases observed since we have had a C.T. Scan at our disposal (1975). Those cases (recorded in the departments of Paillas, Vigouroux, Sedan, Combalbert) represent 2,3% of the brain traumas, 6,5% of the traumatic intra-parenchymatous lesions and 9,5% of the traumatic intra-cranial hematomas. Most of the cases reported deal with male patients, with on average age of 46, who are often victims of traffic accidents. In half the cases of skull fractures, the hematoma is located in the opposite side of the fracture. In almost all cases, initial loss of consciousness is observed, followed by consciousness alterations, with few free intervals and with neurological focal signs depending on the site of the lesion. The C.T. Scan data of the those traumatic hematoma have been studied.

[Radiation-induced meningioma. 3 cases]. / Méningiomes radio-induits. 3 observations.

During the same year (1984), we have seen 3 cases of meningiomas following radiation therapy of the brain for previously diagnosed tumors. A causal relationship between irradiation and meningioma has been postulated. Nevertheless, the coincidental occurrence in same patient of two different histological lesions is possible. The neoplasms developed after irradiation are of mesenchymal origin; they are fibrosarcomas, osteogenic sarcomas and meningiomas.

[Surgical posterior approach in spondylolisthesis (author's transl)]. / Opérations des spondylolisthesis par voie postérieure.

The authors report their experience about 60 patients who suffered of a spondylolisthesis and who were treated by a surgical procedure. A posterior approach has been used for all the patients. After a brief review of the clinical and radiological features of the disease, the authors emphazise the advantages of the posterior approach; only this technique allows a correct access both to the bone and the nerve roots lesions. Two types of operations are proposed:--the ablation of the posterior arch of the concerned vertebra (Gill's operation).--a posterior arthrodesis by mean of an homograft, using one of the following technique: an Albee grafting a Bosworth grafting an ilio-transversary grafting. The results are considered from a clinical, and an anatomo-radiological point of view.

[Fracture dislocation of the sacral spine with cauda equina lesion. Report of two cases (author's transl)]. / Fractures transverses du sacrum avec lésions de la queue de cheval. Considérations à propos de 2 cas.

Transverse sacral fractures with cauda equina lesion appear only sporadically in the world literature. In our medical center 667 spine fractures were admitted during a twelve year period and we report only 2 cases of sacral fractures with neurological lesions (0,20%). The neurological abnormalities that occur are a perianal sensory loss with bladder and anal sphincters disturbance. Sphincters electromyographic studies and cystometric examination show a lower motor neuron lesion. In one of our cases, the nervous lesion was more spread with an unilateral sensory loss S1-S2 and a motor loss L4-L5 S1 in the same side. The high level of sacral lesion (S1-S2), the association with other pelvic fractures and fractures of the lower lumbar transverse processes, suggests the mechanism of injury (sudden flexion). Radiological studies show that sacral fractures are often difficult to detect (necessity of lateral view). Lumbar metrizamide exploration seems not very interesting. Sacral laminectomy which permits the decompression of sacral roots appears like the best treatment. The post-operative course, studied by clinical findings, electromyographic and cystometric examinations, shows the habitual resolution of neurological deficit (incomplete nevertheless in our 2 patients).

[Aneurysm of the internal carotid artery bifurcation. Technical reflections apropos of a series of 10 cases]. / Anévrysmes de la bifurcation de la carotide interne. Réflexions techniques à propos d'une série de 10 cas.

Cerebral aneurysms at the bifurcation of the internal carotid artery are uncommon and represent less than 10% of intracranial aneurysms. A recent series of 10 cases (out of a total of 221 aneurysms over a period of five years, from 1983 to 1988, i.e. 4.5%) treated via a microsurgical approach is presented. Anatomical and operative aspects are discussed. These malformations are located at the point of union of the carotid artery, sylvian and lamina terminalis cisterns. They are close to perforating vessels which usually lie on their deep aspect. Surgery is performed via the standard pterional approach and, as Yasargil points out, two specific dissecting times are required for the opening of the sylvian and lamina terminalis cisterns, in order to avoid dangerous traction on the brain. In our experience, deep hypotension was used in the four cases of large malformations, and there was no need for a temporary dip. All aneurysms were clipped at the neck and the sac then punctured or removed. Post-operative evolution was completely asymptomatic in 9 cases (grade I-II--Hess and Hunt), one patient (grade IV) died from an apparent vascular spasm, confirmed by CT scan.

[Clinical pathological study of two cases of gliosarcoma (author's transl)]. / Gliosarcomes cérébraux. Etude anatomo-clinique de deux observations.

The authors report 2 cases of frontal tumors in adult men with neuroradiological signs of malignant glial tumor. Histological study allowed to diagnose a mixed gliosarcomatosis tumor. Scannographical, histological and ultrastructural signs are specifically studied.

[Evaluation of 138 fractures of the cervical spine during a recent 5-year period (1979 to 1983). Therapeutic approaches]. / Bilan de 138 fractures du rachis cervical sur une période récente de 5 ans (1979 à 1983). Attitudes thérapeutiques.

138 cervical spine fractures are reviewed during a recent period of 5 years (1979-1983). Their frequency stay high. The serial concern 67% of men and 33% of women. We observe a peak age between 20 and 30 (23%). 65% of lesions are caused by a traffic injury, 27% by a falling down, 10% by a diving. 45% of cases interest the upper cervical spine (C1-C2) with a high proportion of odontoid process fractures (60%) and Hangman's fractures (30%); 54% of cases concern the lower cervical spine (C3-C7) with an important part of fracture-luxation (72%), specially C5-C6 (35%). Clinically, we note almost a same part of fractures without neurological disturbances (54%) and with neurological abnormalities (46%). In this situation, the sensitive and motor loss are often severe (78%). In 40%, the injuries are polytraumatism and association spine lesion, cranio-cerebral lesion is the most frequent (61%). In upper cervical spine fractures, after Crutchfield or Gardner traction, posterior fixation was performed (62%). The treatment was conservative in 30%. In lower cervical spine lesions, a secondary surgical approach by an antero-lateral way was made (53%). The treatment was initially surgical in 13% and conservative in 28%. The mortality rate of this pathology is important (22%; i.e. 30 deaths on 138 cases).

[Value of computerized axial tomography in cranio-cerebral injuries]. / Intérêt de la tomographie axiale commandée par ordinateur (tacographie) dans les traumatismes crânio-cérébraux

Since May 1975 was have been working in the field of C.A.T. and its application to study head injuries. We are presenting differents groups of patients studied by C.A.T. I. -- DATA OF C.A.T. IN THE CASES OF EMERGENCY AND IMMEDIATE POST-OPERATIVE FOLLOW-UP OF HEAD INJURIES A) EMERGENCY STATE As soon as the clinical state of an head injured patient was supposed to need an operation, C.A.T. was realized; so differents abnormal scanners may be observed: 1. epidural hematoma, 2. subdural hematoma, 3. intra-cerebral hematoma, 4. acute subdural hematoma or contusion. We must do some comments: -- The Emi-scanner is pre-eminent in showing the exact topography of the lesion : so, the flap is easier to realise. -- In most cases the Emi-scanner is easier to interpret than angiogram for example contusion and hematoma. We know the goods results in hematomas and the poors results in surgery of contusions. -- But the senior advantage of C.A.T. is to provide all the informations in the totality of skull content. Emi-scanner shows bilateral lesions, ipsilateral lesion. C.A.T. is pre-eminent in showing the presence of this two lesions, more accurately than senior methods of investigations, so C.A.T. permits emergency neurosurgical treatment. B) C.A.T. AND FOLLOW-UP Repeated studies at post-intervals can be accomplished without risk to the patient, thus making follow-up simpler and more effective to the neurosurgical attitude. C) POST-OPERATIVE CONTROL AND C.A.T. Post-operative complications are always hard to diagnosis. C.A.T. is painless, quick and safe, and easier to interpret than an angiogram. II -- SEQUELLAE STADE AND C.A.T. In this field certains advantages of C.A.T. are immediatly apparents. In most cases the C.A.T. is the best screening method. Patients carried out are: -- psychiatric troubles, -- post-traumatic epilepsy. The results are not reliable. There is no anatomical-clinical relation in most cases. Differents pictures are observed: -- asymetrical ventricle enlargment, -- global ventricule enlargment, -- partial cerebral atrophy. III -- DISCUSSION 1. We are at the beginning of our study. 2. This not always possible to obtain a C.A.T. in emergency for a head injury, especialy at night. 3. Patients investigated following head trauma are among the most difficult to study with C.A.T. These invididuals send to be restless and uncooperative. Numerous artefacts produced by patient motion may lead to erroneous negative or positive diagnosis, so general anesthesia is often helpful. It is hoped that as a more rapid scanners become available this problem will be obviated. The C.A.T. alone is not capable, to provide all the necessary date concerning head injury. The C.A.T. is, however, re-adjusting our total investigation (E.E.G., angiograms) philosophy and practice rather than replacing the standard neuroradiological technique, except, may be, with epidural hematoma.

[Meningeal fibrosarcomas]. / Fibrosarcomes méningés.

The authors present 4 operated cases of primary fibro sarcomas of the dura mater. Only, a few number of cases had been described in the literature. In Zulch's classification (1957) of 6000 brain tumors, there were 162 cases of sarcoma (i.e. 2,7%) and among sarcoma, 30 cases of fibrosarcoma of the dura mater. In according with the WHO classification of brain tumors (Zulch, 1979), the primary fibrosarcoma of the dura mater takes place in the group of meningeal sarcomas with the polymorphic cell sarcoma and the primary meningeal sarcomatosis. The pre-operative diagnosis is difficult, because neither clinical data, neither neuroradiological findings are characteristics. The prognosis of the patients with this tumor is poor, however some examples are known to have had a long post-operative survival. The association: complete surgical extirpation--post-operative radiation appears like to best treatment. Pathological examination showed in our four tumours, the features of fibroblastic sarcomas with haemorrhagic zones and foci of osteoid metaplasia. The ultra-structural study in 2 cases, confirmed the specificity of tumoral cells which did not display any histological similarity to the arachnoïdal cells. In one case, a myofibroblastic differentiation was evident, and thus, confirmed the plasticity of tumoral fibroblastic cells. The immuno-histochemical reaction of GFAP revealed reactive astrocytic areas in one case inside the immuno-histochemical sarcomatous tissue.

[Micro-anatomy of collateral perforating branches of the middle cerebral artery]. / Etude micro-anatomique des branches collatérales perforantes de l'artère cérébrale moyenne.

The lenticulostriate arteries are the subject of a microanatomical study on 50 formalin fixed human brains. A single trunk arising from the middle cerebral artery is rarely found. In fact the branches are numerous and they are found to ramify before penetrating the anterior perforated substance. The length of the sphenoidal segment is variable and this aspect is discussed in the light of the literature data. The origin of the perforating branches is spread from the internal carotid artery to the bifurcation branches of the middle cerebral artery (M2 segment). On the other hand lenticulostriate arteries arising from the cortical branches of the middle cerebral artery are often found. These anatomical patterns are of essentially surgical interest. No branches must be damaged during the opening of the Sylvian fissure or during the dissection of an aneurysm in this region.