Somatotropic adenoma manifested by galactorrhea without acromegaly.

In two of eight premenopausal women with somatotropic adenomas, galactorrhea was the earliest clinical feature, associated in one patient with amenorrhea. These two patients did not have clinically evident acromegaly. Mean basal serum GH levels were elevated and did not decrease after glucose ingestion. Both patients had modest hyperprolactinemia. Histological and immunocytological studies of the adenomas showed numerous adenomatous somatotropic cells and some alpha-subunit- and PRL-containing cells. In these patients, the origin of the hyperprolactinemia was not clear. In one patient, elevated GH secretion was probably responsible for the galactorrhea, since it disappeared after surgical treatment despite persistence of hyperprolactinemia. In conclusion, galactorrhea, isolated or associated with amenorrhea, can be the only clinical manifestation of a somatotropic adenoma.

Selective posterior rhizotomy in the dorsal root entry zone for treatment of hyperspasticity and pain in the hemiplegic upper limb.

The authors report a series of 16 hemiplegic patients suffering from harmful spasticity in the upper limb and treated with selective posterior rhizotomy (SPR) in the dorsal root entry zone (DREZ). This severe spasticity was associated with irreducible abnormal postures in flexion in 11 cases and painful manifestations in 12. The method was introduced in 1972 on the basis of anatomical studies of the DREZ in humans, in which a topographical segregation of the root afferents, according to their anatomicofunctional destinations, has been shown. It consists of a DREZ microsurgical lesion 1 to 2 mm in depth and directed at a 45 degree angle, performed ventrolaterally in the posterolateral sulcus of the spinal cord and into the internal part of the Lissauer's tract. The procedure is carried out in each rootlet of the posterior roots considered to be responsible for the harmful spasticity. SPR interrupts selectively the (lateral) nociceptive and (central) myotactic afferent fibers connecting the motor neurons, while sparing most of the (medial) lemniscal fibers and the inhibitory circuitry of Lissauer's tract and the dorsal horn. The results were evaluated after a 1- to 12-year follow-up. There were no deaths and no general complications; in 1 case a loss of motility in the leg ipsilateral to the procedure occurred. The excess of spasticity was slightly diminished (2 cases), markedly reduced (9 cases), or totally abolished (5 cases), making possible an improvement in voluntary movements in 8 patients and at least a good passive mobilization in 7 further cases. In 1 case only, a marked tendency for spasticity to return was observed. Of the 12 patients with painful manifestations, 9 were completely relieved and 3 improved. These beneficial effects on both spasticity and pain led to a gain in functional status in 93% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical outcome and pathological effects of bromocriptine preoperative treatment in prolactinomas.

The case histories of 40 patients with prolactinomas were retrospectively reviewed. Twenty patients treated preoperatively with bromocriptine were compared to 20 untreated patients. The two groups were comparable according to tumor size and sex. All the patients had an immuno-cytochemically confirmed prolactin adenoma. They were operated on by a transsphenoidal approach. Intraoperative findings were studied. The surgical cure rates (serum PRL level less than 30 micrograms/l) of the bromocriptine-treated group were higher than those of the control group, both in microprolactinomas (87.5% vs 50%) and macroprolactinomas (33% vs 17%). This improvement of surgical success rate may not be due solely to bromocriptine. Surgical cure also depends on preoperative serum PRL levels (less than 500 micrograms/l) and tumoral size (less than grade II0). Tumoral tissue remained in all cases. No increase in fibrosis was observed. By inducing tumoral shrinkage, bromocriptine makes surgical removal of macroprolactinomas easier and safer. This tumoral shrinkage could be explained not only by reduction of cell size, but also by decrease in intratumoral hemorrhage. Preoperative bromocriptine treatment does not adversely affect surgical outcome. Moreover, it may be useful in cases of macroprolactinomas with suprasellar extension.

Results of surgical treatment for cervicobrachial neuralgia. A retrospective study of 122 patients with long-term follow-up.

Surgical nerve root decompression is rarely needed in the treatment of cervicobrachial neuralgia. In patients with prolonged and resistant pain or neurological deficits, or when signs of associated spinal cord suffering have been found, various surgical procedures can be used, but is most cases the disco-arthro-radicular conflict can be solved by the anterior approach with or without bone graft. This review of long-term résults in a series of 122 patients operated upon and re-examined more than 3 years later shows that the radicular symptoms were relieved in 95% of the cases. Evaluation of anatomical results did not reveal any instability or aggravation of discarthrosis at the site of surgery. However, in 30% of the cases disc degeneration was increased in the over- and underlying levels but without recurrence of clinical symptoms; 4% of the patients in this series were reoperated upon for this aggravated or de novo disc disease. The authors underline the importance of a thorough radioanatomical examination not only to decide whether or not a "soft hernia" or an arthrotic hypertrophy should be operated, but also to evaluate the extent of the decompressive operation to be performed.

[Multiple erosive discopathies associated with ankylosing spondylitis (author's transl)]. / Discopathies érosives mutifocales au cours d'une spondylarthrite ankylosante.

The authors report a case of ankylosing spondylitis affecting a woman with low-back pains. Although initial X-rays did not show any lesions of the spine, one year later, radiographs prove the existence of multiple lesions mimicking spondylodiscitides and characterized by erosions diffusely involving end-plates of cervical, dorsal and lumbar vertebrae. Surgical biopsy at the lumbar site provides an histological evidence of non specific inflammatory lesions.

[Surgical treatment of pituitary adenomas. An analysis of 188 cases (author's transl)]. / La chirurgie des tumeurs hypophysaires, Analyse de 188 observations.

The authors report on a series of 188 patients operated upon for pituitary tumour. Since 12 operations were performed because of local recurrence, the total number of operations was 200 : 27 by the intracranial route and 173 by the naso-sphenoidal route. Four deaths (17%) followed surgery by the former route and three (1.8%) by the latter route. During the decade under review surgical indications have decreased for large tumours belatedly diagnosed and increased for micro-adenomas giving rise to endocrine symptoms only, notably prolactin-secreting adenomas. Improved knowledge of histopathology has resulted in the classification being altered : the conventional division into eosinophilic and chromophobe adenomas has been abandoned to be replaced by cellular types corresponding to the various hormone-producing and functional adenomas. Also a new type has appeared : oncocytoma. Secreting adenomas generally have a better prognosis than non-secreting adenomas, would it be only because they are smaller. Technical advances in operations almost exclusively performed nowadays by the naso-sphenoidal route have improved the results with regard to sight. Sight is now improved in 70.5% of the cases and completely restored in 32.4%.

[Extra-intracranial shunts by venous grafts interposed on the carotid system]. / Pontages extra-intracrâniens par greffons veineux interposés sur le système carotidien.

Patients with occlusive arterial diseases, tumors invading the vascular structures of the skull base or giant aneurysms may benefit from an EICB. Most of the time this can be achieved using a scalp artery. But in cases of a thrombotic ECA, excessively short or thin scalp branches or destruction of those by prior cranial surgery, an interposed venous graft is needed. In the author's series, which consists of 16 patients, the bypass was performed for ICA occlusive diseases in 5, before complete removal of cavernous sinus tumours in 4 and prior to cervical internal carotid ligation for giant aneurysms in 7. The grafts were always harvested from the internal saphenous vein. The proximal site of implantation was CCA (2 cases), ECA (6 cases), ICA (1 case), superior thyroid A (2 cases)--i.e. 11 long grafts--and the trunk of the occipital A--i.e. short grafts in 5 cases. In this series, there was no mortality and no morbidity related to revascularization. The early patency rate, checked with arteriography, was 62.5% (10 cases) and the late one 56.2% (9 cases). Causes of failure, partially related to technical difficulties in 2 cases, were almost always due to an insufficient extra-intracranial pressure gradient (4 cases). Excepted in one case, there was no correlation between patency and the use or not of anti-aggregant and/or heparin. Literature data are summarized and discussed. They all confirm the importance--besides the absence of technical errors--of a sufficient extra-intracranial gradient for obtaining a good patency rate.

[Lumbosciatica caused by spondylolisthesis. Results of the surgical treatment by facetolaminectomy and interbody arthrodesis by the posterior approach in a series of 66 cases]. / Lombo-sciatique par spondylolisthésis. Résultats du traitement chirurgical par facetto-laminectomie et arthrodèse inter-somatique par voie postérieure dans une série de 66 cas opérés.

66 patients with spondylolisthesis were reviewed after surgical procedure with a follow-up period of more than a year postoperatively. The indication for the operation was disabling sciatica in all patients. 4 patients had undergone prior excision of the herniated disc. All the patients underwent a removal of the loose posterior element as suggested by the Gill procedure and intervertebral body fusion using a posterior surgical approach. The surgical procedures with only one regressive neurological complication are described. The results are considered from a clinical and anatomo-radiological point of view. In this series 86.5 percent of 66 patients became sciatica-free. 62 percent of the total series rated the end result as excellent or good. 92.4 percent of the patients demonstrated bony fusion between the two grafted vertebrae. The benefits of posterior laminectomy with interbody fusion are also attractive for spondylolisthesis with sciatica.

[Parasellar chondrosarcoma: report of a case operated on through a pteriono-temporal approach and review of the literature]. / Chondrosarcome parasellaire: rapport d'un cas opéré par voie ptériono-temporale et revue de la littérature.

Cartilaginous tumours represent 0.16% of all intracranial tumours; among them 14% are chondrosarcomas (Ch-S). A majority (56%) arise from the skull base, especially from the spheno-occipital and spheno-temporal synchondroses. The others develop at the level of the dura mater convexity, falx and choroid plexuses, probably from ectopic cartilages or mesenchymatous cells with multiple potentialities. Parasellar Ch-S originate from the spheno-temporal synchondrosis and expand inside the cavernous region. With 21 published cases, they represent 51.2% of the 41 skull base Ch-S and 28.7% of the whole 73 intracranial primary Ch-S. The authors report a recent case of such a parasellar Ch-S, revealed by a left progressive, and finally total, ophthalmoplegia. The responsible mass, which eroded the lateral part of the sella turcica, was shown partially calcified and not enhanced by contrast medium at CT-scan, and was avascular on angiogram. The tumour, which was identified as a low grade myxoid Ch-S, could be entirely removed through an intradural pteriono-temporal approach. After a two-year follow-up, the clinical status was unchanged (total ophthalmoplegia) and the CT-scan did not show any sign of recurrence. The 21 cases of parasellar Ch-S published in the literature are reviewed.

[Neurinoma of the trigeminal nerve. Excision by combined suboccipital and pteriono-temporal approach]. / Neurinome du trijumeau. Exérèse par abord mixte sous-occipital et ptériono-temporal.

The authors report a recent personal case of trigeminal neurinoma with a topographical extension both in the cerebello pontine angle and the middle cerebral fossa. This 33 year-old female suffered from progressive sensory disturbances of her right hemiface associated with a right fifth nerve motor deficit, a right VI nerve palsy and a tinnitus. CT scan and angiogram were evocative of a right hourglass trigeminal neurinoma. Two successive operative stage through suboccipital route and a pteriono-temporal extra and intradural approach allowed a complete removal of the tumour. A post-operative rhinorrhea dried up with 10 days. The patient complained with a right hemiface anesthesia and a palsy of the masseter muscles; the VI nerve palsy recovered within 3 months. From the review of the literature (118 cases) the authors summarize the anatomical, clinical and radiological features of these tumours and point out. The difficulty of their surgical removal that was only complete in half of cases. The high frequency of hourglass neurinomas explains that a single suboccipital or subtemporal approach--even with opening of the tentorium--only allowed 23 complete removal among the 58 published or quoted interventions. This justifies that in a majority of cases a combined approach must be preferred, using successively a suboccipital and an intradural subtemporal route, the latted giving access to the cavernous sinus in case of its invasion.

[Intramedullary mature teratoma associated with an attached cord and an intradural lipoma. Apropos of a surgically treated case. Review of the literature]. / Tératome mature intramédullaire associé à une moelle attachée et à un lipome intradural. A propos d'un cas opéré. Revue de la littérature.

The authors report the case of a 33 year-old male with urinary disturbances referred for removal of a spinal intradural mass associated with a L4 spina bifida occulta. At operation three types of lesions were present: a tethered cord, an intradural lipoma of the cauda equina and conus medullaris and an intramedullary mature teratoma. A total removal of teratoma and lipoma and a section of the filum terminale achieved a normalization of urological function. Such mature teratoma that consists of all three germ layers only represent 2% of all intramedullary tumors. Pathogenesis is dysembryoplastic but still remains unclear: germinal cells might have been displaced into the dorsal midline during their normal migration from yolk sac to gonadal ridges. Their association with other dysgenetic lesions such as lipoma or spina bifida is not rare but the links between these different pathologies remain unknown.

["De novo" aneurysms. Apropos of a surgically treated case]. / Anévrysmes "de novo". A propos d'un cas opéré.

The authors report the case of a 26 years old woman who developed four "new" T aneurysms, ten years after the successful clipping of a vertebro-basilar system aneurysm. This observation is discussed in relation to the literature; current views supporting that aneurysms may result from a combination of inherent and acquired tissue weakness associated with hemodynamic effects are cited. Another twelve cases of "de novo" aneurysms developed in patients without previously carotid ligation and reported in the literature are reviewed. Their characteristics in relation to their localisation and their interval time discovery are discussed. The advisibility of repeated angiograms in some patients with aneurysm is discussed as these patients are at an increased risk of hemorrhage from another "new" aneurysm.

[Reliability of the results of the ultrasonic hemodynamic recording (Doppler effect) in the diagnosis of cerebral ishemic ischemia of carotid origin]. / Fiabilité des résultats du bilan hémodynamique ultrasonographique (effet Doppler) dans le diagnostic de l'ischémie cérébrale d'origine carotidienne.

The Doppler ultrasound diagnosis of carotid artery stenosis (asymetrical systolic and diastolic flows; elevated resistance index: ratio of flow pulse amplitude to systolic and diastolic values; flow reversal in the ophtalmic artery) is compared, in 52 patients, to the clinical, angiographic (40 patients) an surgical findings and to the peroperative measure of intra-arterial pressure and flow (30 patients). Its reliability is proved as a guide for angiographic exploration and for postoperative watching, but it is restricted to great vessels (cervical carotid artery) and is unable to detect ulcerated plate without stenosis.

[Treatment of spastic foot by selective neurotomy of the tibial nerve. Results of a series of 31 cases]. / Traitement du pied spastique par la neurotomie sélective du nerf tibial. Résultats sur une série de 31 cas.

A large number of patients suffering from various neurological diseases remain disabled because of spastic disorders in their foot. These disorders--which are responsible for abnormal postures and painful disturbances for walking and standing--can be corrected by an effective procedure: the so-called Selective Neurotomy of the Tibial Nerve (T.N.), developed in its modern form by Gros in 1972. The procedure aims at sectioning the T.N. branches corresponding to the muscles, the spasticity of which is considered harmful, i.e. the soleus (and/or gastrocnemius) nerves for equinus and ankle clonus, the posterior tibialis branch for varus, and the flexor fascicles for tonic flexion of the toes. After dissection of each T.N. branches at the lower part of the popliteal region and their identification with bipolar electro-stimulation, the selected nerves are sectioned partially (about two-third of their caliber) under the operative microscope. The present series consists of 37 operations--performed 25 times unilaterally and 6 bilaterally--in 31 patients, 17 to 68 year old (39 on average). In 11 patients spasticity was from spinal cord origin and in the 20 others from vascular or traumatic cerebral damages. The spastic disorders--installed for 2 to 17 years (4 on average)--were due to one, several or all the following components: equinus, ankle clonus, varus, flexion of the toes. Surgery obtained complete suppression of the disabling spastic components, total pain relief and consequently improvement of the residual voluntary movements by achieving balance between agonist and antagonist muscles, in 33 out of the 37 cases, i.e. in 91% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of stenosis-thrombosis of internal carotids by extra-intracranial arterial anastomosis and endarterectomy]. / Traitement chirurgical d'une sténose-thrombose des carotides internes par une anastomose artérielle extra-intracrânienne et une endartériectomie.

The surgery of the remaining carotid artery is a very difficult procedure considering the high risk related to the peroperative clamping. Extracranial to intracranial by pass of the thrombosed side permit to carry out in better conditions the contralateral endarterectomy without using intravascular shunt.

[Idiopathic giant cell granulomas of the pituitary gland. Apropos of 2 cases]. / Les granulomes idiopathiques à cellules géantes de l'hypophyse. A propos de 2 cas.

Two cases are reported of two women who had developed progressive hypopituitarism without visual disturbances. Pituitary tumors were evoked by radiological findings. The patients underwent surgical removal of invasive intrasellar tumor by transphenoidal route. Giant-cell granuloma was histologically demonstrated with negative special staining for tuberculosis acid-fast bacilli, bacteria and fungi. Secondary granuloma due to tuberculosis, brucellosis or neurosarcoidosis was ruled out by serological grounds. The prognosis was discusses through a follow-up of 7 years in the first case and 7 months in the second one. The appropriately documented 31 cases collected from the literature were compared with our two cases.