Metastasis of the choroid plexuses: A systematic review of the literature and case illustration.

BACKGROUND: Choroid plexus (CP) metastases are an extremely rare condition accounting for less than 1% of brain metastases. Due to its scarcity, little is known about this pathology and its management. Herein, we propose a review of the current literature to help its diagnosis and management. METHODS: Through a literature review based on PubMed/MEDLINE database, we reviewed 94 cases of intraventricular metastasis of solid cancer in 28 full-text articles in English from 1980 to 2010. We have reported epidemiological, clinical, radiological, histological data, as well as management strategies and outcomes. A case report of fourth ventricular pulmonary metastasis illustrates this review. RESULTS: Intraventricular metastases are most often reported in patients in their 6th decade. The clinical presentation is marked by acute hydrocephalus, more rarely lesional bleeding. Three-quarters of intraventricular metastases develop in lateral ventricle, then respectively in the fourth and third ventricles. Kidney cancer accounts for 45% of the cases. The treatment modalities are surgical removal in case of a single lesion and adjuvant radiotherapy and chemotherapy depending on the primary cancer. The prognosis remains poor due to dissemination via the cerebrospinal fluid. CONCLUSION: Multiple choroid plexus metastasis is a rare diagnosis, affecting patients with a specific clinical presentation and a misleading radiological appearance. There is no standard of care for the management of these lesions and surgical approach can be challenging.

Usefulness of circulating tumor DNA from cerebrospinal fluid in recurrent high-grade glioma.

Molecular documentation at relapse of high-grade glioma is an urgent need for patient care. A prospective pilot study was conducted to assess the rate of mutation detection using targeted deep sequencing on circulating tumor DNA from cerebrospinal fluid (CSF) after chemo-radiotherapy based treatment. Fifteen patients were included: 13 patients with glioblastoma, 1 patient with gliosarcoma and 1 patient with anaplastic astrocytoma. At progression, 10/15 patients (67%) had detectable mutations in the CSF. Among them, 5/10 patients harbored at least one common mutation between initial tumor and ctDNA. CSF protein level and cfDNA concentration were higher, although not significant, in the ctDNA positive group versus ctDNA negative group (1.17g/L vs. 0.79g/L). Molecular documentation obtained from ctDNA in CSF at the time of relapse is informative in around two-thirds of the patients.

Ruptured dural arteriovenous fistula and sinus venous thrombosis following surgical resection of a vestibular schwannoma: Case report and review of the literature.

Dural arteriovenous fistula (DAVF) is a rare vascular malformation. Strong evidence suggests that the development of DAVF in adults is acquired and multifactorial. The link between cerebral venous thrombosis and DAVF is probably explained by dynamic changes in the venous drainage pattern. We report the case of a 34-year-old man admitted to the emergency department for seizure and headaches. The patient had a medical history of right vestibular schwannoma resection 9 months earlier, complicated by untreated asymptomatic sigmoid sinus thrombosis. At admission, CT scan revealed a spontaneous temporal intracerebral hemorrhage associated with ventricular hemorrhage due to the rupture of a DAVF diagnosed by complementary CT angiography. External ventricular drainage was performed in emergency, followed by endovascular exclusion of the DAVF. Good neurological outcome was achieved, with complete exclusion of the vascular malformation. This clinical case underlines the absence of guidelines on the use of anticoagulation drugs to treat postoperative venous sinus thrombosis and to potentially prevent DAVF as a late complication following cerebellopontine angle surgery.

Tumor-to-tumor metastases: Latent renal cell carcinoma discovered after elective surgical resection of a convexity meningioma.

BACKGROUND: Tumor-to-tumor metastases are extremely rarely reported lesions, which usually involve an indolent lesion hosting a more aggressive neoplasm. We present an unusual initial manifestation of a previously unknown clear cell renal cell carcinoma as a tumor-to-tumor metastasis in a typical meningothelial meningioma. CASE REPORT: A 73-year old patient with transient left slight monoparesis was addressed to our Neurosurgical Department after being evaluated by his general practitioner and passing a cerebral MRI which revealed a right frontotemporal mass attached to the meninge. At presentation, no deficits were identified; therefore an elective surgery was proposed. Histological analysis revealed a typical meningothelial meningioma containing a metastatic clear cell renal cell carcinoma. Additional thoraco-abdominal computer tomography identified a 6cm diameter lesion within the right kidney with radiological features highly suggestive of a primary clear cell renal cell carcinoma. CONCLUSION: Our case highlights the need for a specialized neuropathological approach to clinical and imagistic indolent meningiomas, as they may require important differential diagnosis that can highly impact the treatment and follow-up of brain tumor patients.

Case report: Mini-invasive surgery assisted by Da Vinci® robot for a recurrent paravertebral schwannoma.

BACKGROUND AND OBJECTIVES: More and more surgeons are changing their surgical procedures by using mini-invasive technology with the aim of reducing morbidity. Robotized technology for the surgery of narrow spinal space, for the resection of intervertebral foramen tumor, is a valuable option that should be considered. The authors report the case of a patient who underwent robotic surgery for the treatment of a paravertebral schwannoma and show the benefits of this approach. CASE REPORT: A 53-year-old man was treated, in 1995, via an open right latero-thoracic approach for a T8-T9 thoracic schwannoma with a complete resection. Twenty years later, the patient complained of recurrent T8-T9 thoracic pain with unilateral radicular irradiation related to a recurrent schwannoma with a right foraminal extension. Using robotic technology (Da Vinci®), a complete resection was achieved and confirmed by a postoperative MRI. The patient, who was free of neurological symptoms, discharged the hospital at day 2. COMMENTS: Robot-assisted surgery by Da Vinci® robot is a very useful approach for the treatment of spinal paravertebral schwannoma. Thanks to multi-directional arms and 3D vision, this technology is safe and effective about quality of resection. The use of mini-invasive technology should be routinely discussed for lesions in that specific location.

Practice of stereoelectroencephalography (sEEG) in drug-resistant epilepsy: Retrospective series with surgery and thermocoagulation outcomes.

OBJECTIVE: The aim of this study was to determine the success rate of sEEG in locating the epileptogenic zone (EZ) in patients with pharmaco-resistant epilepsy. Secondary objectives were to analyze sEEG-related morbidity and outcomes for post-sEEG thermocoagulation and cortical resection. METHODS: Data were collected on 49 sEEGs from 46 consecutive patients between 2010 and 2018. Following sEEG, either resective or palliative surgery with vagus nerve stimulation was performed. In 8 patients, EZ thermocoagulation was performed before EEG leads were withdrawn. Outcomes were collected based on the Engel and ILAE outcome scales. RESULTS: sEEG was contributive in 45 of 49 recordings, with a success rate of 92% in locating the EZ. Minor complications, such as transient neurologic deficit and electrode implantation failures, occurred in 6%. One major complication occurred, with death due to atypical late hematoma. Thermocoagulation was performed in 8 patients and stopped or significantly reduced seizure frequency in 7 (88%). Outcome of surgical resection (n=33) was good, with 20 (61%) seizure-free patients and 32 (97%) with definite improvement. CONCLUSIONS: Our findings suggest that sEEG is an effective technique for EZ location in patients with drug-resistant epilepsy. sEEG was contributive in up to 92% of patients, allowing thermocoagulation and/or surgical resection that resulted in seizure-freedom in two-thirds and seizure-reduction in one-third of cases. This study highlights the need for strict selection of implantation candidates, with strong initial hypothesis as to EZ location.

Sudden paraplegia due to spontaneous bleeding in a thoracic epidural angiolipoma and literature review.

BACKGROUND: Spinal angiolipomas are rare epidural tumours that are usually revealed by chronic symptoms of medullar irritation. We report a case of acute paraplegia caused by spontaneous bleeding revealing a thoracic angiolipoma. CASE DESCRIPTION: A 17-year-old male patient with no previous medical history was admitted for acute onset of paraplegia with bladder retention and loss of sensation in the lower limbs, preceded by dorsal pain during the three previous days. MRI showed an enhanced T1-weighted image of a T7-T12 epidural lesion. The T1-weighted isosignal and the T2-weighted hyposignal suggested haemorrhagic complications. Due to a mass effect on the spinal cord, an emergency laminectomy was performed. Histopathological examination of the lesion revealed an angiolipoma with spontaneous bleeding. Clinical outcome was favourable after two months. CONCLUSION: This case is one of the first to be reported, although the clinical presentation is similar to that of other rare reported cases of paraplegia due to spinal compression by tumoural bleeding.

Usefulness of multidetector-row computerized tomographic angiography for the surgical planning in stereoelectroencephalography.

PURPOSE: Surgical planning of depth electrode implantation in stereo-electro-encephalography (SEEG) routinely uses magnetic resonance imaging (MRI) alone. Accurate visualization of arteries and veins in the vicinity of the electrode is essential to plan a safe trajectory to presumably reduce the risk of intracranial bleeding. The goal of this study was to compare multidetector row computerized tomographic angiography (MDCTA) with MRI for the visualization of vessels along each planned trajectory in patients who undergo SEEG. MATERIALS AND METHODS: Ten consecutive patients who were scheduled to undergo SEEG procedure were included. T1-weighted gadolinium-chelate enhanced MR sequence, stereotactic MDCT and MDCTA were performed after fixation of Leksell's frame. For each of the 106 planned stereotactic trajectories, the number of vessels in a 4.0mm diameter circle around the trajectory from the dura mater to the target that were visible on MDCTA were compared to that of visible vessels in the same areas on MRI. RESULTS: Ten vessels (10/106; 9.4%) were seen on MRI and 66 (66/106; 62.3%) on MDCTA (P<0.0001). All vessels visible on MRI were visible on MDCTA. The difference in number of visible vessels between the two techniques remained significant for the different lobes (i.e., frontal lobe, temporal lobe and parieto-occipital lobe). CONCLUSION: MDCTA enabled visualization of more vessels than MRI based SEEG. MDCTA may help neurosurgeons better define the trajectory of the electrode and reduce the risk of intracranial bleeding.

Pituitary metastasis: is there still a place for neurosurgical treatment?

Pituitary metastases are uncommon, ranging from 1 to 5 % of all metastases. Between 10 and 30 % of pituitary lesions are symptomatic responsible for diabetes insipidus, visual field defect or cranial nerve palsy. Primary sites are lung or breast in two-thirds of cases. There is no current reference concerning treatment of such lesions. Overall survival is poor and depends on primary site. Although the role of surgery is currently limited, discussion is warranted in several indications for diagnostic or symptomatic purposes. We report two cases of symptomatic pituitary metastases in a context of breast cancer and review the litterature concerning the role of surgery and other treatment modalities.

Giant intracranial aneurysms in the paediatric population: Suggested management and a review of the literature.

OBJECTIVES: Intracranial aneurysms are rare in children although giant aneurysms more commonly occur in adolescence. The aims of our study were to perform an extensive review of the literature over the past two decades and assess intracranial aneurysm management. METHODS: Based on a Pubmed search, we carried out a review of the literature from 1990 to 2012 regarding giant intracranial aneurysms diagnosed in the paediatric population. This descriptive study concerned clinical presentation, cerebral aneurysm characteristics, therapeutic management procedures and outcome. RESULTS: Forty-six cases were reported in 31 papers. The male/female sex ratio was 1.15, the clinical presentation was a tumour mass syndrome in 56.6%, followed by rupture in 30.4%. The aneurysm location was the posterior circulation in 41.3%, and microsurgical treatment (52.2%) predominated over endovascular coiling (28.3%). CONCLUSION: To date, no evidence-based medicine recommendation has been accepted for the management of rare intracranial aneurysms. Each reported patient was the object of a multidisciplinary clinical decision. Management of this challenging pathology should be performed on a case-to-case basis.

Impact of deep brain stimulation on pharyngo-esophageal motility: a randomized cross-over study.

BACKGROUND: Bilateral subthalamic nucleus (STN) stimulation is used to alleviate Parkinson's disease (PD) motor symptoms. Recently, it has been shown that this therapeutic also increased gut cholinergic contractions. We therefore investigated the effect of STN stimulation on esophageal motility in an interventional randomized study. METHODS: Sixteen humans PD patients (4 women, 12 men; age: 62.4 ± 9.3-years old) who underwent STN stimulation for at least 6 months were randomly evaluated with either stimulator turned OFF then ON, or inversely. Esophageal high resolution manometry was performed at the end of each ON and OFF period, with a 5 min resting period followed by ten swallows of 5 mL. KEY RESULTS: During the ON, an increase in the distal contractility index was found (OFF: 1750 ± 629 vs ON: 2171 ± 755 mmHg/cm/s; p = 0.03), with no difference in the distal front velocity. A decrease in the integrative relaxation pressure of the lower esophageal sphincter (LES) was noted (OFF: 11.1 ± 1.8 mmHg vs ON: 7.2 ± 1.8 mmHg; p < 0.05) in ON. The LES resting pressure remained unchanged during the two periods. This resulted in a decrease in the intrabolus pressure (p = 0.03). No difference was observed for the upper esophageal sphincter, nor the pharyngeal contraction amplitude and velocity. CONCLUSIONS & INFERENCES: In conclusion, STN stimulation in PD patients increased esophageal body contractions and enhanced the LES opening. This suggests that the nigrostriatal-striatonigral loop is involved in the control of esophageal motility.

French collaborative group series on giant intracranial aneurysms: Current management.

OBJECTIVES: Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management. PATIENTS AND METHODS: This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05). RESULTS: A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion. CONCLUSION: The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.

Neurological form of Erdheim-Chester disease : Case report and review of the literature.

OBJECTIVE: Report an unusual presentation of Erdheim-Chester disease revealed by a severe hypothalamic syndrome due to a hypothalamic infiltration and a review of the literature. METHODS: A 28-year-old man was admitted for a previous three-month history of asthenia, weight loss, and polyuria-polydipsia. Magnetic resonance imaging on gadolinium T1-weighted sequence revealed a contrast-enhancing hypothalamic mass extending to the floor of the fourth ventricle. Cerebrospinal fluid examination was not suggestive of a germinal lesion. Lung nodules were found on thoracic CT-scan but due to their small size, brain stereotactic biopsies were required. RESULTS: Histological examination revealed a diffuse polymorphic inflammatory infiltrate including numerous foamy histiocytes which displayed large eosinophilic CD68-positive, CD1a-negative cytoplasms, and collagen deposition, characteristic of Erdheim-Chester disease. Despite symptomatic and etiologic treatment, death occurred within twelve months. CONCLUSION: Erdheim-Chester disease is a rare multisystem non-Langerhans cell histiocytosis which typically affects long bones, lung, retroperitoneal and orbital spaces and less frequently primary central nervous system. The pathogenesis of the disease remains unknown and no significant prognostic factor has been correlated with survival time. The recently reported BRAF V600E mutation suggests that specific therapeutics (BRAF inhibitors) should be considered.

[Locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma: French national guidelines]. / Traitements locorégionaux de métastase(s) cérébrale(s) chez des patients atteints d'un mélanome cutané métastatique : recommandations nationales françaises.

INTRODUCTION: The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals. OBJECTIVE: The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations. METHODS: The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS: This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.

Cervical spine fractures in patients with ankylosing spondylitis: Importance of early management.

INTRODUCTION: Ankylosing spondylitis (AS) affects 0.5% of the population. Alteration of the biomechanical properties of the spine related to AS explains the high prevalence of traumatic vertebral fractures and risk of instability. At admission, 65% of patients present neurological signs. There are no reported studies regarding secondary neurological deterioration. The aim of this study was to evaluate the rate of secondary neurological deterioration before surgical treatment of spine fracture in a context of AS. METHODS: This retrospective cases series consisted of patients admitted for traumatic cervical spine fractures or luxation in a context of AS between June 2007 and December 2012. Clinical status was evaluated using Frankel classification at time of trauma, at admission to the neurosurgery ward, as well as before and after surgery. Delay between trauma and admission, and between admission and surgery was recorded. Causes of morbidity, mortality and surgical management were discussed. RESULTS: During the study period, seven patients were admitted for traumatic cervical spine fracture or luxation. All patients were autonomous before trauma. Between trauma and transfer to neurosurgery ward, the status of four patients worsened. Mean delay between trauma and admission was 12.9 days (range 1 to 60 days). Between admission to neurosurgery ward and surgical treatment, two more patients worsened and only two patients remained autonomous. Mean delay between admission and surgery was 15.7h (range 2 to 24h). Neurological deterioration was due to both deterioration during transfer despite immobilization with a rigid cervical collar and failure of X-ray to reveal any fractures, in two and three cases respectively. After surgery, clinical status remained unchanged in two patients, four patients improved, and one patient worsened. Two patients died from respiratory failure a few days after surgery due to neurological deterioration. Five patients had a delayed diagnosis (>24h). CONCLUSION: Cervical spine fracture in AS is a serious condition with high instability. Our series emphasizes the necessity of early surgical treatment because of risk of secondary neurological deterioration in cases of delayed treatment. CT scan must be the gold standard for exploration of these patients.

Brain metastasis from renal cell carcinoma.

BACKGROUND: Patients with brain metastasis (BM) from renal cell carcinoma (RCC) have a poorly known prognosis due to the rarity of this disease. The aim of our study was to assess the outcome of patients with a BM due to RCC, and to determine the predictive factors for survival. METHODS: Consecutive patients who underwent treatment between 1997 and 2012 were identified retrospectively from a database (n=28, median age of 57.8 years, sex ratio M/F: 3.7). Main criteria collected concerned survival time. Other data collected were relative to initial histology, clinical findings at the time of BM diagnosis (diagnosis circumstances, KPS), radiological findings and BM characteristics (number, size and localization), treatment of BM (including surgery, stereotactic radiosurgery [SRS], systemic treatments, whole brain radiotherapy [WBRT]) and the outcome of surgery if performed. Statistical analysis of survival was performed using the Kaplan-Meier method. RESULTS: Median survival was 13.3 months, 1-year survival was 60.2%, 2-year survival was 16.4%. Univariate analysis showed the existence of intracranial hypertension (P=0.01), other systemic metastasis (P=0.049), the absence of deep metastasis (P=0.03) which are all linked to shorter survival. Age, KPS, initial histology of RCC, number, size, localization, and hemorrhage in BM were not correlated to survival. The median survival in the surgical resection group was 25.3 months versus 8.6 months (P=0.02). The main criteria for the selection of the surgical group were a single BM (P=0.04), and superficial metastasis (P=0.02). CONCLUSIONS: Three predictive factors for longer survival in BMRCC were the absence of intracranial hypertension, the absence of acute metastasis and the absence of extracranial metastasis. Surgical removal, when possible, seems to benefit patient survival.

[Management of patients with metastatic cutaneous melanoma: French national guidelines. French National Cancer Institute]. / Prise en charge thérapeutique des patients atteints d'un mélanome cutané métastatique : recommandations nationales françaises. L'Institut national du cancer.

BACKGROUND: Recent years have seen the emergence of new molecules for the treatment of patients with metastatic cutaneous melanoma, with significant benefits in terms of survival and the opening of new therapeutic perspectives. In addition, many techniques are currently being developed for locoregional treatment of metastatic sites. Management of metastatic melanoma is thus fast-changing and is marked by innovative therapeutic approaches. However, the availability of these new treatments has prompted debate among healthcare professionals concerning their use and their place in therapeutic strategy. AIMS: Since 2008, the French National Cancer Institute (INCa) has been leading a project to define and diffuse national clinical practice guidelines. It has performed a review of these treatment methods, which it aims to circulate, and it is seeking to develop recommendations in order to allow nationwide implementation of innovative approaches while promoting good use thereof. METHODS: The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts within a multidisciplinary working group, with feedback from specialists in cancer care delivery. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS: This article presents the national recommendations for first- and second-line systemic treatment and for locoregional treatment of metastatic sites in patients presenting metastatic cutaneous melanoma.

Lumbar spinal stenosis: which predictive factors of favorable functional results after decompressive laminectomy?

BACKGROUND AND PURPOSE: Long-term results of decompressive laminectomy in degenerative lumbar stenosis have been studied in only six prospective studies. The objective of our study was to evaluate the functional outcome at long term of patients after decompressive laminectomy in lumbar stenosis and to determine predictive factors of favorable outcome. METHODS: A prospective cohort data were collected by an independent observer five years after decompressive laminectomy for degenerative lumbar stenosis. The endpoint was the assessment of the Beaujon score for functional evaluation. The result was considered as favorable if the Beaujon score increased by at last five points between the preoperative stage and at follow-up examination. Logistic regression was then performed with univariate and multivariate analysis to reveal predictive factors of good long-term outcome (P≤0.05). RESULTS: The preoperative characteristic of our population (n=98) was a mean age of 67.3±8.8 years, a low comorbidity (mean Charlson score=2.8±1.5), overweight status (BMI=29.4±6.3) and the mean Beaujon score was 9.3±3.1. At five years after surgery, the mean Beaujon score became 14.1±4.2. Favorable functional outcome concerned 45.9% of our series. The predictive factor of favorable outcome identified in the univariate analysis the neurological deficit (P=0.05) and in the multivariate analysis the low comorbidity (P=0.01). CONCLUSION: The long-term results of surgical treatment of lumbar spinal stenosis were moderate with an improved outcome in 49.5% of cases in our study. The only independent factor to a favorable outcome was the low comorbidity.

[Clinical and ossification outcome of custom-made hydroxyapatite prothese for large skull defect]. / Tolérance clinique et degré d'ossification des cranioplasties en hydroxyapatite de larges défects osseux.

OBJECTIVE: Cranioplasty is an everyday concern in neurosurgery, especially in decompressive craniectomy cases. Our surgical team uses custom-made hydroxyapatite implants for large and/or complex defects. PATIENTS AND METHOD: Eight patients had a custom-made prosthesis. Each of them has been reviewed by an independent observer. Each patient described his feeling of satisfaction, using a questionnaire, graduated from "A" (really satisfied) to "D" (unsatisfied). Each of them also underwent a CT-scan (helicoidal acquisition, 0.6mm thick for multiplanar reconstruction) to evaluate qualitatively the ossification graduated from "0" (no ossification) to "5" (continuous ossification). Maximal under-prosthetic bone thickness, intra-prosthetic calcic density were also reported. RESULTS: Supervision delay was 43.7 months [6-99 months], average defect surface was 85.5 cm(2) [27.6-137.6 cm(2)], the craniectomy etiologies were intracranial hypertension (seven patients) and calvarial invasion (one patient). Implant tolerance was reparted in "A" score (50%) and "B" score (50%). Concerning ossification, six patients (75%) had a score of "2" or less and two patients had a score of "3" or "4". DISCUSSION: Hydroxyapatite custom-made implants for cranioplasty appear to be ideal for good aesthetic and tolerance results, but their ossification is hardly analyzed due to the prosthesis density higher than the bone's density. This is why we recommend them for children and in cases of complex defects such as pterion location.