Time dependence of serial diffusion-weighted imaging features in a case of pyogenic brain abscess.

Both signal intensity on trace images and apparent diffusion coefficient measurements on mapped images evolved rapidly on serial diffusion-weighted sequences in a case of pyogenic brain abscess that was monitored primarily by MRI before a biopsy was performed. Considering only the signal intensities on the trace images would have led to an underestimation of the intrinsic tissue changes.

Pre- and peroperative misdiagnosed sellar tumour.

We describe the case of a 76-year old woman complaining of headaches and progressive sight loss. Cerebral CT scan and MRI disclosed a large sellar tumour. Endocrine evaluation showed no evidence of pituitary hypersecretion, but a slight hyperprolactinemia related to stalk compression. A non-functioning pituitary adenoma was suspected. The pathological diagnosis was however a meningioma. In the literature, about 5% of sellar tumours are not pituitary adenomas and this is an alternate diagnosis to consider in the presence of non-secreting macroadenomas.

[Craniostenosis and craniofacial dysmorphia]. / Craniosténoses et dysmorphies cranio-faciales.

The paper gives a brief historical survey of craniostenosis and the first operative approaches. The authors describe a classification of various types of cranio-facio-stenosis and facio-cranio-stenosis and present a detailed study of their experience in this area. Operative results are discussed in function of the selected surgical procedure, the immediate per- and post-operative complications and the short and long term morbidity. The authors present their current attitude for each dysmorphic type. They underline the heavy nature of this long-lasting and bleeding surgical procedure that concerns small children. They have recorded 31 incidents in relation with surgical procedure, 10 complications at short and long term, and 1 death. Such surgery requires an experienced and vigilant team, associating surgeons, anesthetists and intensive-care physicians.

Pathogenetic factors in chronic subdural haematoma and causes of recurrence after drainage.

The radiological aspect, pathology, treatment and results of 132 subdural haematomas observed in 100 patients, are discussed. The majority of these cases were characterized by a nonhomogenous CT scan picture, resulting from repeated bleeding in a previous subdural haematoma evolving to chronicity, or in a pre-existent subdural hygroma. Taking aspirin may have constituted a predisposing factor in 16% of our patients, whilst coagulation disturbances, including anticoagulant treatment, were observed in another 6%; ethylism was present in 11%. A traumatic origin was ascertained in 80% of the patients. The treatment consisted of burr hole evacuation and drainage in 91.5% of the haematomas, corresponding to 92% of the patients; it was eventually repeated once or twice in some cases. In 6% of the patients, a subduro-peritoneal drainage had to be placed ultimately and in 2%, a membranectomy had to be performed because the haematoma had become nearly completely fibrous. The necessity for repeated evacuation and eventual subduro-peritoneal drainage seems to depend mainly on a slow brain re-expansion in some elderly people, who are actually more frequently referred. Two patients died; one was deeply comatose and another in poor general condition. Morbidity in the 96 remaining patients, 2 being lost to follow-up, was 11%: 5% related to the haematoma or to the causal trauma, and 6% from other concomitant neurological disease. The functional result was satisfactory in 85%.

Brain glucose utilisation in acquired childhood aphasia associated with a sylvian arachnoid cyst: recovery after shunting as demonstrated by PET.

Regional brain glucose utilisation was investigated with PET and fluorodeoxyglucose (FDG) in a case of epileptic aphasia (Landau-Kleffner syndrome) associated with a left sylvian arachnoid cyst. CT and MRI had failed to disclose any mass effect of the cyst on surrounding brain structures. Sequential metabolic measurements showed a comparable pronounced hypometabolism in cortical regions around the cyst, involving speech areas, and suggested mild but chronic compression of the developing brain. After placement of a cyst-peritoneal shunt system, significant metabolic improvement occurred in all cortical regions, especially the inferior frontal gyrus and the perisylvian area, with predominant residual deficit in the left superior temporal gyrus. These findings were correlated with a pronounced increase in word fluency and slower progress in verbal auditory comprehension. This report suggests that PET is able to evaluate the functional disturbances associated with expanding arachnoid cysts, and to follow the neurological improvement after drainage.

[Orbito-fronto-temporal approach to tumors at the base of the skull. Our experience in the creation of orbito-zygomatic-malar flap]. / Abord orbito-fronto-temporal des tumeurs basicrâniennes. Notre expérience dans la création d'un volet orbito-zygomatico-malaire.

The authors describe the technique of mobilization of the osseous orbito-zygomatico-malar complex pedicled to the masseter muscle. In some affections it is justiciable to use this approach which provides an excellent view of the lateral region of the medial cranial fossa and orbit and permits the access to the base of the tumor by a intra- and extracranial approach without traumatic injury for the brain and easy reconstruction.

[Juxtabulbar neurinoma of the spinal accessory nerve]. / Neurinome juxtabulbaire du nerf spinal.

A 27-year-old woman presented with right spinal accessory juxtabulbar schwannoma, associated with hydrocephalus. The only specific clinical symptom was long-standing weakness of the right trapezius. C.T. scan evoked a cerebellar tumor, whilst the jugular foramen appeared normal. Vertebral angiography was not decisive. M.R.I. suggested an extra-axial tumor. Post-operative evolution was entirely favourable. Schwannomas of the 9th, 10th and 11th cranial nerves are generally located at the level of the jugular foramen but can also be observed along the extracranial path of these nerves. An intracranial paramedial, or so-called "intracisternal" localization is rare and is best diagnosed by magnetic resonance imaging.

Intraneural ganglionic cyst of the common peroneal nerve: case report and review of the literature.

The authors report a case of compression of the peroneal nerve by an intraneural ganglionic cyst. The chief complaint is generally a lateral upper leg pain occasionally associated with foot drop and swelling of the upper tibiofibular joint. In our case, the disease was revealed by a tentative intraarticular injection of betamethasone. Early microsurgical treatment remains the only way to avoid permanent motor sequellae.

[Spontaneous hematoma of the cerebellum]. / L'hématome spontané du cervelet.

Forty spontaneous cerebellar hematomas have been observed in 39 patients whose age ranged from 13 to 82 years, 26 being older than 60. Arterial hypertension is the most frequent aetiological factor. Amongst the other causes, vascular malformations, which may also be present in older people, anticoagulant therapy, metastatic tumor, sepsis were found; one case remained unsolved. Diagnosis is no longer a challenge since the introduction of C.T. scan, whilst M.R.I. may give most valuable informations concerning aetiology, especially when a vascular malformation is present. In this study, the influence of the hematoma size and of hydrocephalus on consciousness was demonstrated; development of hydrocephalus is favoured by the size and by a rather median location of the hematoma. In the future, M.R.I. should give better precisions concerning an eventual extension of the hemorrhage to the brainstem. The purpose of surgical treatment is twofold: alleviating brainstem compression and correcting hydrocephalus; yet, divergent opinions have been put forward in retrospective studies, concerning evacuation of the hematoma and drainage of hydrocephalus. In this series, direct attack doesn't seem to be indicated in hematomas less than 3.5 cm diameter, unless a causal lesion has to be removed. The ideal moment for hematoma evacuation is, finally, dictated by the clinical status and its evolution; however, the authors prefer, if possible, to delay it for at least 48 hours. Amongst the 39 patients, 14 deceased; of the 25 survivors, 19 were autonomous, 7 being nearly asymptomatic, 6 patients remained handicapped. Consciousness is a main prognostic factor, whilst coma in the first hours has a clearly unfavourable significance.

Unusual complication of peritoneal drainage: migration of a shunt in the subdural space.

Quite a number of cases of upward shunt migration have already been reported in the literature. The authors report the case of a newborn boy who presented a sequential alternate change of pressure gradients based, according to their opinion, on fields of pressures exerted by fluids in different compartments of the patient's body. The authors propose a physicoanatomical explanation on the basis of the surgical findings.

[Papilloma of the choroid plexus of the lateral ventricle without generalized hydrocephalus]. / Papillome du plexus choroïde du ventricule latéral sans hydrocéphalie généralisée.

A benign papilloma of the choroid plexus of the left lateral ventricle is found in a five-month old infant. An important dilatation of the isolated occipital horn is observed, without generalized enlargement of the ventricles. The clinical signs are limited to a moderate macrocephaly with deviation of head and eyes to the left. The absence of global hydrocephalus is rather exceptional in such cases, where overproduction of cerebrospinal fluid, in an amount proportional to the tumoral mass, is generally admitted. Nevertheless, the literature offers no absolute proof of the role of oversecretion alone in the origin of hydrocephalus, whilst an eventual obstruction of the circulatory pathways and resorption areas of the C.S.F. must be kept in mind. The absence of hydrocephalus, in the present case, suggests that the subarachnoid spaces and arachnoid villi remained patent.

Treatment by aspiration of brain abscesses.

Sixteen patients, with a total of 18 abscesses, were treated by aspiration and systemic antibiotic therapy, to which antiepileptic prophylaxis and corticosteroids were added. Diagnosis of the abscesses and monitoring of their evolution relied principally upon computed tomography; this technique was also used per-operatively when aspirating small abscesses. Bacteriological examinations were positive in all our cases and a polymicrobial flora was found in half of these. One or, eventually, two aspirations within the same week were sufficient, in most cases, to promote healing. Nevertheless, in three patients, the abscesses, however sterilized, did not show any volume reduction, probably because of adhesions to the dura mater, of a large part of the abscess surface area. One patient died from concomitant cardiac disease and one patient remained seriously disabled. Epilepsy was observed as a sequela, in six patients. This study emphasizes the role of neuroradiological and bacteriological examinations, whilst surgery may be restricted, in most cases, to a simple aspiration.

[Long-term results of the surgical treatment of myelopathy in cervical arthrosis]. / Résultats à long terme du traitement chirurgical des myélopathies cervicarthrosiques.

After a lapse of not less than two years the authors study the functional and clinical evolution of 62 patients presenting myelopathy in cervical arthrosis treated by surgery. A scoring system for evaluating the functional deficit of the patients is used for quantitative assessment of the disorders. Surgery brought a frank improvement in 38 patients: it left the sensorimotor deficits of 19 patients unchanged. The handicap continued to deteriorate in three patients. Two patients died from non-neurological disorders. The data are compared with those in the literature which indicate an improvement rate of the same order of magnitude. Within certain limits, age and the degree of initial handicap do not seem to influence the long-term result of surgery. However, the time lapse between the appearance of the first signs of deficiency and surgery seem to constitute an important prognostic factor. The shorter the time lapse, the better the result.

Sciatic neuropathy at the popliteal fossa: clinical, ultrasonographic and computed tomographic diagnosis.

A 22-year-old female had been suffering from sciatica-like pain in the left leg for four years. Clinical findings strongly directed further investigations to the popliteal fossa. Ultrasonography located a hypoechogenic mass in the upper lateral popliteal space. Guided by these data, computerized tomography (CT) with vertical reconstructions made the tentative diagnosis of a common peroneal nerve tumor, which was confirmed at operation. Microscopic examination showed a neurinoma of the mixed neurilemmoma-neurofibroma type. In the presence of atypical features of sciatica, a high index of suspicion seems advisable. Emphasis is laid on the complementary contribution of ultrasonography and CT in this type of ill-defined lower limb pain.

[Postmeningitic pericerebral effusion in infants]. / Les épanchements péricérébraux postméningitiques du nourrisson.

Agar-gel electrophoresis of the pericerebral fluid and more recent data obtained from CT-Scan examination suggest the presumably important role of external subarachnoid hydrocephalus in postmeningitic pericerebral effusions of infancy. Postmeningitic subarachnoid hydrocephalus results very likely from an impeded resorption at the level of the arachnoid villi and venous sinuses; in some cases, however, there could be a coincidental occurrence of meningitis and pericerebral effusion from a distinct origin. The presence of a pericerebral effusion correlates badly with the seriousness of the clinical condition, whilst its spontaneous tendency to resorption is obvious in many cases, leading to a more conservative attitude. Fontanometry seems helpful when discussing the indication to operate. If surgery is required, it will usually be limited to a minor procedure; we perform, in such cases, an external drainage that can be transformed, if necessary, into an internal shunt.

[Progressive enlargement and thrombosis of an anterior communicating artery aneurysm. Clinical, radiological and histological study (author's transl)]. / Accroissement progressif et thrombose d'un anévrysme de la communicante antérieure. Etude clinique, radiologique et histologique.

A non operated aneurysm of the anterior communicating artery enlarged considerably over a seven years period; it finally thrombosed and behaved like a suprasellar tumor. The clinical course, the angiographic evolution and the anatomical examination allowed, in this case, to account for the increase in volume by progressive stretching of the wall, and not by incorporation of a false aneurysmal sack resulting from an encapsulated haematoma. Histologically, the wall of this giant aneurysm showed various changes : on the inner aspect, progressive thickening occurs, due to fibrous organization of mural thrombosis; in the depth, far from the nutrient sources, necrotic atheromatous like foci occur, which isolate an inner leaflet, prone to become nectrotic at a later stage. Distension of such a weakened wall may lead to several consequences; a progressive increase in volume of the aneurysm, partial ruptures with haemodissection starting from the aneurysmal lumen, or even complete rupture of the wall and subarachnoid haemorrhage. On the other hand, circulatory stasis, due to the important increase in volume, may facilitate progressive thrombosis of the aneurysm. The living character of the wall is emphasized by the coexistance of these unfavourable (degeneration, ruptures) and favourable (thrombosis, fibrous organization) features, which continuously influence the spontaneous evolution of the aneurysm.

[Success and failure of the ventriculoperitoneal shunt in the treatment of hydrocephalus]. / Succes et échecs de la dérivation ventriculo-péritonéale dans le traitement de l'hydrocéphalie

In ventriculoperitoneal shunting, the intraperitoneal location of the drainage site can be an additional cause of failure. In our series of 70 ventriculoperitoneal shunts, performed in infants and adults for treatment of hydrocephalus from various cause and of various type, failures of this kind manifested themselves usually early in the postoperative period either as a reflux of liquid, not attributable to the operative technique, into the subcutaneous pericatheter tract, or as a reappearance of the intracranial hypertension, without faulty functioning of the ventricular drain. The total success rate was 61% (43/70) but the age of the patient made a clear difference. In patients aged less than 5 months, we observed 11 successes in 33 cases (33%), in those aged less than 1 year, 14 successes in 36 (39%); patients with myelomeninogocele, wherein the shunting was usually done during the first month of life, fared badly; the role of age seems herein predominant. In patients aged more than 1 year, 29 successes in 34 cases (85%) were obtained; results were notably good in nearly all hydrocephalus of tumoral origin. We think the possible role of the "tightness" of the hydrocephalus has to be invoked as also the possibility of spontaneous remission. Ventriculoperitoneal shunting, devoid of the serious complications of ventriculocardiac shunting, is a simple and effective procedure in many cases of hydrocephalus. Means for more accurate prediction of the chances of success in the individual case are needed.