Four legs. Illusory reduplication of the lower limbs after bilateral parietal lobe damage.

OBJECTIVE: To report an unusual disorder of body schema and its neurologic and neuropsychological correlates. DESIGN AND METHODS: We describe a patient with a reduplicative phantom illusion of her lower limbs. Motor and sensory functions, as well as mental representation of body and space, were studied during the reduplication experience until its resolution. SETTING: Clinical neurology department in a primary care hospital. PATIENT: A 64-year-old, left-handed woman who experienced the uncontrollable and distressing feeling of having 4 legs, without delusional belief, after surgical removal of a right-predominant parasagittal parietal meningioma. This phenomenon spontaneously resolved after 2 weeks. INTERVENTION: None. MAIN OUTCOME MEASURES: Clinical neurologic examinations and standardized neuropsychological tests, with emphasis on tests assessing orientation to body parts, right-left discrimination, and mental orientation in space. RESULTS: The patient had severe weakness and proprioceptive sensory loss in both lower limbs. She had no disturbances of body schema knowledge but a striking impairment in tasks requiring mental orientation in space, particularly for right-left laterality discrimination. Resolution of the reduplication experience correlated with improvement in the affected spatial abilities, while motor, sensory, and other cognitive functioning did not significantly change. CONCLUSION: This patient's reduplicative phantom illusion might be related to the combination of the severe somatosensory loss with an underlying impaired mental representation of relative positions in space.

Ventilatory dysfunction resulting from bilateral anterolateral high cervical cordotomy. Dual beneficial effect of aminophylline.

Because of metastatic pain resistant to medical treatment after left pneumonectomy for squamous cell carcinoma, a 46-year-old patient underwent a bilateral cervical cordotomy at the C1-C2 anterolateral level, in two phases. The second intervention was followed by severe ventilatory problems requiring mechanical ventilation, and at a later stage, the implantation of a phrenic pacemaker on the right side. Analysis of the ventilatory pattern during spontaneous breathing and during phrenic pacing and measurement of the transdiaphragmatic pressure during phrenic nerve stimulation revealed the existence of a beneficial effect of aminophylline on both the regulation of ventilation and diaphragmatic contractility.

Blunt carotid artery injury: difficult therapeutic approaches for an underrecognized entity.

GOALS: To assess the damage inflicted by carotid artery injuries, to attempt to explain some differences between published series, and to summarize the management of different types of lesions. METHOD: Retrospective analysis of patients treated for nonpenetrating injury of the carotid arteries in our hospital from 1985 to 1991. RESULTS: Seven patients (all men, with ages ranging from 19 to 55 years) had eight injuries to the carotid arteries. One patient was asymptomatic; another patient had neurologic symptoms unrelated to the carotid artery injury; severe neurologic deficits developed in the remaining five patients, of whom three died. Symptoms occurred immediately in one patient, after a few days in two patients, and after a few weeks in two patients. Arterial damage included dissection (four cases), pseudoaneurysm (two cases), local contusion (one case), and occlusion (one case). Surgical treatment consisted of aneurysmorraphy and extraintracranial bypass in one patient each. Surgical intervention was not considered in the other patients because of the severity of their neurologic symptoms. Besides collective reviews, very few series pertaining to this pathologic condition exist in the literature; however, some report good overall results. These reports comprise a high proportion of asymptomatic cases; the internal injury is usually only discovered incidentally on thoracic aortograms or by scanning the neck during head computed tomography scans. CONCLUSIONS: Nonpenetrating trauma to the carotid arteries carries significant morbidity and mortality rates. Wide-scale screening for carotid lesions in victims of blunt trauma would be necessary to determine the true incidence and gravity of this pathologic condition. A search for carotid artery injury should be performed in patients with a history of neck or head trauma to detect whether the correction of any lesion would lead to improvement or prevention of neurologic deficits.

Radicular compression due to lumbar intraspinal gas pseudocyst: case report.

A case of sciatic pain syndrome is reported. Computed tomography showed evidence of gas in the spinal canal, and at operation a gas-filled pseudocyst was found in the spinal canal, without herniated disc. The cause of this unique case is discussed in relation to the spinal vacuum phenomenon.

Posterior lumbar interbody fusion with cages: an independent review of 71 cases.

OBJECT: The authors conducted a retrospective study to provide an independent evaluation of posterior lumbar interbody fusion (PLIF) in which impacted carbon cages were used. Interbody cages have been developed to replace tricortical interbody grafts in anterior and PLIF procedures. Superior fusion rates and clinical outcomes have been claimed by the developers. METHODS: In a retrospective study, the authors evaluated 71 consecutive patients in whom surgery was performed between 1995 and 1997. The median follow-up period was 28 months. Clinical outcome was assessed using the Prolo scale. Fusion results were interpreted by an independent radiologist. The fusion rate was 90%. Overall, 67% of the patients were satisfied with their outcome and would undergo the same operation again. Based on the results of the Prolo scale, however, in only 39% of the patients were excellent or good results achieved. Forty-six percent of the work-eligible patients resumed their working activity. Clinical outcome and return-to-work status were significantly associated with socioeconomic factors such as preoperative employment (p = 0.03), compensation issues (p = 0.001), and length of preoperative sick leave (p = 0.01). Radiographically demonstrated fusion was not statistically related to clinical outcome (p = 0.2). CONCLUSIONS: This is one of the largest independent series in which PLIF with cages has been evaluated. The results show that the procedure is safe and effective with a 90% fusion rate and a 66% overall satisfaction rate, which compare favorably with those of traditional fixation techniques but fail to match the higher results claimed by the innovators of the cage techniques. The authors' experience confirms the reports of others that many patients continue to experience incapacitating back pain despite successful fusion and neurological recovery.

Synovial cyst and degeneration of the transverse ligament: an unusual cause of high cervical myelopathy. Case report.

A case of cystic degeneration of the transverse ligament located posteriorly to the dens and causing compression to the lower medulla and upper cervical spinal cord is reported. The clinical, pathological, and radiological findings are described and compared to the literature to characterize this syndrome more fully. The advantages of a posterolateral surgical approach are stressed.

Preoperative silk suture embolization of cerebral and dural arteriovenous malformations.

OBJECT: The aim of this study was to evaluate the use of silk sutures as a medical implant when applied for the embolization of cerebral and dural arteriovenous malformations (AVMs). The facility of surgery and the clinical significance of complications related to preoperative silk suture embolization were evaluated immediately after surgery and at long-term follow up. METHODS: Thirty-four patients harboring 29 cerebral and five dural AVMs underwent embolization in which silk alone or in association with other agents was used. Medical and radiological records obtained in these 34 patients were reviewed retrospectively. The cerebral AVMs were classified according to the Spetzler-Martin grading system and the dural AVMs to the Djindjian grading system. The facility of the resection and the adverse outcomes, including new neurological deficits, hemorrhage, and fever, as well as histopathological evidence of vessel inflammatory changes, were determined in each case. In all 23 surgical cases, the AVM could be easily manipulated and excised. New temporary neurological deficits occurred in three patients. A high Spetzler-Martin grade was not associated with a higher incidence of new neurological deficits. One delayed-onset hemorrhage was detected after embolization. Fever was present in 24% of the patients. No sign of significant vasculitis or perivascular inflammation was found on radiological or histopathological examination. CONCLUSIONS: Silk sutures are safe embolic agents especially for proximal occlusion of AVM feeding vessels. New permanent neurological deficits were not encountered in this series. Fever was considered to be a minor, temporary side effect of silk suture embolization.

[Pituitary adenoma secreting prolactin. Results of their surgical treatment]. / Les adénomes hypophysaires sécrétant de la prolactine. Les résultats de leur traitement chirurgical.

A retrospective study of 75 patients operated for pituitary prolactin-secreting adenomas between 1972 and 1992 is presented. 57 were women, 18 males. The major symptom was amenorrhea for women and impotence for men. Prolactinemia is correlated to the size of adenoma and thus permits a prediction of surgical results. Most of the patients with a prolactinemia under 300 ng/ml were cured by surgery alone. Surgical treatment alone at the-term follow-up cure 87% of the micro-adenomas, 17% of the enclosed adenomas, and none of the invasive adenomas. In this study there is only 7% of true recurrence. According to the high cure rate and low frequency recurrence after transphenoidal surgery for micro-adenomas we suggest this approach as the first choice treatment. On the other hand the best treatment for macro-prolactinomas is medicamentous.

[Myelopathies in a context of generalized infection: myelitis or compression?]. / Médullopathies dans un contexte d'infection généralisée: myélite ou compression?

Four patients with rapidly progressive tetraparesis in relation with skin or joint infection and septicemia are reviewed. Clinical signs of medullary compression was present in all cases, confirmed by neuroradiological examinations. However, all surgical approaches failed to demonstrate clear evidence of compression. Within three weeks, the neurological picture of severe tetraparesis had an excellent clinical evolution in all cases. One of the patients died after developing pulmonary complications: necropsy did not show any signs of compression. The difficulty of differential diagnosis between an infectious compressive surgical pathology and an inflammatory disease (acute transverse myelitis type) is emphasized, with review of literature.

[Study of the deterioration factors in adult patients with cranio-cerebral injuries who "talk and die"]. / Etude des facteurs de détérioration des traumatisés cranio-cérébraux adultes qui "parlent et meurent".

Between 1978 and 1984, the University Hospital of Geneva (Hôpital Cantonal Universitaire) received 46 head injured patients who "talked and died" after their brain insult. Only 14 of them had associated systemic lesions whilst two thirds of the series had an isolated head injury. Detailed review of the case records shows that death was preventable in a quarter of the cases. For 28 patients (60%), the factors contributing to death are avoidable or, at least, their management should be greatly improved. The diagnosis was confirmed by autopsy in 31 patients (67%).

[Late complications of closed injuries of the extracranial carotid artery. Apropos of 2 cases]. / Complications tardives de traumatismes fermés de la carotide extracrânienne. A propos de deux cas.

Closed injury with lesions of the great vessels of the neck are rare and usually due to high energy mechanisms with severe secondary deficit. 2 cases are reported, concerning young patients with relatively mild injury, neurological deficit not developing before 6 months after the traumatism in the first case and 8 months in the second. At this stage, the neurological signs were immediately severe, with cerebral infarction, leading to death in the first case. Pathological lesion of lesion of pseudo-anevrismal type, localised at the right carotid and subclavian artery bifurcation, was evidenced in the first case. In the second case, a bilateral intimal lesion of the carotid arteries at C1 level is illustrated on angiography. The mechanism of these lesions as well as the delayed manifestation of neurological deficits are discussed.

[Tumors of aqueduct of Sylvius. Presentation of 5 cases and review of the literature]. / Tumeurs de l'aqueduc de Sylvius. Présentation de 5 observations et revue de la littérature.

The authors reports their experience of 5 cases of intra- and peri-aqueductal tumors. With the exception of 1 case, a subependymoma of the aqueduct discovered at autopsy in a 77 year old woman, the 4 other patients (2 females and 2 males) are relatively young (respectively 14, 23, 14 and 26) at the time when they presented with signs of chronically raised intracranial pressure due to a triventricular hydrocephalus. One patient presented with a partial Parinaud's sign, but the focal and long tract signs were conspicuously absent in the other patients. The diagnosis of a space occupying lesion in the tectum mesencephali or in the aqueduct could only be ascertained with the recent use of M.R.I. The radiological work-up of the cases suggest that theses lesions, presumably of glial origin, are very slowly growing tumors. Four patients have been treated for their symptomatic hydrocephalus, but no treatment of the tumor has been proposed, as the clinical state and the images remain remarkably stable. (Mean duration of follow up from the time of shunting = 3.7 years, extremes = 1.5-8 years). A review of the literature shows that not more than 48 cases of tumors of the aqueduct have been reported. Because of the small number of such observations, there are, until now, no precise informations on the management of such cases to decide if the patient will benefit of an open or stereotactic biopsy associated with radiotherapy or if one can rely on serial clinical and radiological examinations. Further information on the long term follow up is needed.

Early surgery for brainstem cavernomas.

BACKGROUND: The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome. METHOD: We retrospectively reviewed 22 patients harboring a BSC, who underwent 23 procedures. FINDINGS: Surgery was carried out during the early stage after the last haemorrhage, with a mean delay of 21.6 days (range 4-90 days). Sixteen procedures were performed after a first bleeding event while seven after multiple bleedings. Complete resection was achieved in 19 patients (86.4%). Early after surgery, 12 patients (52.2%) improved neurologically, 5 (21.7%) were stable and 6 (26.1%) worsened. New postoperative deficits were noted after 9 procedures (39.1%). Statistically significant factors for postoperative aggravation were: late surgery (P = 0.046) and multiple bleedings (P = 0.043). No patient operated on within the first 19 days after bleeding did worsen (n = 11), as opposed to 6 out of 12 who did when operated on later. After a mean follow-up of 44.9 months, 20 patients (90.9%) were improved, 1 patient (4.6%) was worse and 1 patient was lost to follow-up (4.6%), after reoperation for rebleeding of a previously completely resected cavernoma. Late morbidity was reduced to 8.6%. The mean Glasgow Outcome Scale (GOS) at the end of the follow-up period was 4.24, compared to a mean preoperative GOS of 3.22 (P<0.001). Complete neurological recovery of motor deficits, sensory disturbances, cranial nerves (CNs), internuclear ophtalmoplegia and cerebellar dysfunction were respectively 41.7%, 38.5%, 52.6%, 60.0% and 58.3%. Among the most affected CNs: CN 3, CN 5 and CN 7 were more prone to completely recover, respectively in 60.0%, 70.0% and 69.2%. CONCLUSIONS: Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome. Early surgery and single bleeding were associated with better surgical results.

Idiopathic symptomatic epidural lipomatosis of the lumbar spine.

BACKGROUND: Symptomatic spinal epidural lipomatosis (SEL) of the lumbar spine is a rare disease, often associated with steroid overload. Idiopathic lipomatosis is even much less frequent. Signs and symptoms depend upon the level and degree of nerve root compression. Diagnosis is best based on MRI. Weight reduction can be curative, however after failure of medical treatment or in severe cases surgical decompression should be performed. METHOD: Four patients with severe symptoms of lumbar spinal epidural lipomatosis were treated by surgical decompression. Patient history and neurological examination are described, diagnostic imaging is demonstrated, surgical treatment and outcome are documented. Different surgical techniques including laminectomy, interlaminar fenestration and lateral recess decompression were applied and are discussed. FINDINGS: All four patients improved after surgery. No surgical complications were observed. Even though limited to four cases this is the second largest series of operated idiopathic spinal epidural lipomatosis. INTERPRETATION: Surgical decompression was effective in improving symptoms in severe lumbar idiopathic spinal epidural lipomatosis.

Blunt carotid artery injury: devastating consequences of undetected pseudoaneurysm.

A case of delayed embolization of a traumatic pseudoaneurysm of the right common carotid artery, resulting in fatal cerebral infarction, is reported. This case emphasizes the importance to detect occult lesions to the carotid arteries after blunt neck injuries and to treat aggressively pseudoaneurysms located upstream to a cerebral vessel to prevent embolic complications.

Non convulsive status epilepticus following intrathecal fluorescein injection.

We report a case of non convulsive status epilepticus after an intrathecal injection of fluorescein. The clinical presentation was a confusional state--the epileptic origin of which was confirmed by the electroencephalogram. This rare and relatively benign complication should not bring about worry concerning the fluorescein test used for the diagnosis of a dural defect and the identification of the site of a CSF leak.

Diagnosis of cerebellopontine angle tumors.

Between 1980 and 1990, 9,176 patients suffering from otoneurological disorders were investigated in our clinic. Sixty-six (0.72%) internal auditory canal or other cerebellopontine angle tumors (CPAT) were diagnosed. Brainstem auditory evoked potentials (BAEP), interaural time discrimination, and magnetic resonance imaging (MRI) revealed to be the most sensitive and efficient tests for the detection of CPAT. However, the investigation of otoneurological symptoms cannot be limited to BAEP and MRI on the a priori of a hypothetical CPAT. Electrophysiologic tests such as impedancemetry, and electronystagmographic testing are also needed to elucidate the many causes of otoneurological symptoms.

[Full-contact and dissecting aneurysm of the thrombosed left internal carotid artery associated with encephalomalacia]. / Full-contact et anévrysme disséquant de l'artère carotide interne gauche thrombosée avec ramollissement cérébral. Etude d'un cas.

Full-contact, a sport which is becoming more and more popular in our society as a means of self-defence, is not without its hazards. We describe the case of a 32-year-old man who, shortly after an intensive practice match, presented symptoms consistent with cerebral damage which resulted in his death within three days. The main pathological findings were confined to the left internal carotid artery, which presented a dissecting aneurysm as a result of rupture of its intima with thrombosis of its lumen. The thrombus extended as far as the intracranial portion of the artery, resulting in massive cerebral infarction as cause of death. Furthermore, there were histological modifications of both main carotid arteries and their branches which suggested repeated microtraumatic events. The causal relation between the lesions observed and the practice of full-contact are discussed.