How to reduce the complication rate of multiple burr holes surgery in moyamoya angiopathy.

PURPOSE: This study is aimed at analyzing clinical outcome, absence of stroke recurrence, revascularization, and complications and long-term follow-up in the surgical treatment of moyamoya angiopathy (MMA) using the multiple burr holes (MBH) technique with dura opening and arachnoid preservation as a single procedure. To the best of our knowledge, this is the first to describe an MBH technique with arachnoid preservation. METHOD: We retrospectively reviewed all patients operated from June 2001 to March 2021, for a symptomatic and progressive MMA operated with opening of the dura but arachnoid preservation. Clinical examinations were obtained in all patients, and radiological monitoring was performed by cerebral 3D-magnetic resonance angiography (MRA) with perfusion or single-photon emission computed tomography (SPECT) with acetazolamide. RESULTS: In total, 21 consecutive patients (6 children and 15 adults) were included with a mean age of 7.4 years in the pediatric group and 36.9 years in the adult group. Initial presentation was permanent ischemic stroke in 15 cases, transient ischemic attack (TIA) in 5 cases, and cerebral hemorrhage in one case. The MBH with dura opening and arachnoid preservation was performed bilaterally in 9 cases (43%) and unilaterally in 12 cases (57%). One patient died due to intraoperative bilateral ischemic stroke. Of the 20 other patients, 30% demonstrated clinical stability and 70% showed partial or complete recovery. Although one patient experienced a perioperative stroke, we did not observe any pseudomeningocele or postoperative ischemic stroke (IS) recurrence in all surviving cases during the average follow-up period of 55.5 months (range: 1-195). These outcomes emphasize the importance of preoperative monitoring to ensure the effectiveness and safety of the intervention. Postoperative angiography studies showed revascularization in 96.3% of treated hemispheres (100% in the adult group vs 80% in the pediatric group). CONCLUSIONS: Our results on this small cohort suggest that the MBH technique with opening of the dura and arachnoids preservation can prevent recurrent strokes and reduce the risk of pseudomeningocele.

Application of a three-dimensional graft of autologous osteodifferentiated adipose stem cells in patients undergoing minimally invasive transforaminal lumbar interbody fusion: clinical proof of concept.

BACKGROUND: The authors applied a scaffold-free osteogenic three-dimensional (3D) graft made of adipose-derived mesenchymal stem cells (AMSCs) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). METHODS: Three patients (two patients and one patient with 1 and 2 levels, respectively) with degenerative spondylolisthesis underwent MI-TLIF with 3D graft made of AMSCs. To obtain the AMSCs, fatty tissue was collected from the abdomen by lipoaspiration and differentiated afterwards in our Cell/Tissue bank. Clinical outcomes, including the Oswestry Disability Index (ODI) and visual analog scale (VAS) as well as fusion status were assessed preoperatively and up to 12 months postoperatively. RESULTS: At 12 months, all four operated AMSC levels could be assessed (n = 4). Grade 3 fusion could be confirmed at two levels out of four. Mean VAS score improved from 8.3 to 2 and ODI also improved from 47 to 31%. No donor site complication was observed. The final AMSC osteogenic product was stable, did not rupture with forceps manipulation, and was easily implanted directly into the cage with no marked modification of operating time. CONCLUSIONS: A scaffold-free 3D graft made of AMSCs can be manufactured and used as a promising alternative for spinal fusion procedures. Nevertheless, further studies of a larger series of patients are needed to confirm its effectiveness.

Percutaneous pedicle screw implantation for refractory low back pain: from manual 2D to fully robotic intraoperative 2D/3D fluoroscopy.

Many surgical treatments for chronic low back pain that is refractory to medical treatments focus on spine stabilization. One of the main surgical procedures consists of placing an interbody cage with bone grafts associated with pedicle screws [2, 25, 30]. This technique can be performed using different approaches: a large open posterior approach, tubular approaches (minimal open) or percutaneously (minimally invasive percutaneous or MIP) [5, 28]. One of the main difficulties is to precisely locate the screws into the pedicle avoiding especially infero-medial pedicle breaches. This difficulty is even great- er when working percutaneously. This paper focuses on percutaneously placed pedicle screws (PPS), reports the use of a robotic multi-axis 2D/3D fluoros- copy to enhance the accuracy of pedicle screw placement and reviews other strategies and results reported in the literature.

Intra-operative 3.0 T magnetic resonance imaging using a dual-independent room: long-term evaluation of time-cost, problems, and learning-curve effect.

We present a short and comprehensive report of our 39-month experience using a 3.0 T intra-operative magnetic resonance imaging (ioMRI) neurosurgical-MR twin room, including a description of the problems encountered and the associated time-delays. Forty-seven problems were experienced during the 189 ioMRI procedures (two ioMRI were performed in five of the 184 surgical procedures) performed in the 39-month period, including a blocked transfer table, failure of anesthetic monitoring material, and specific MRI-related problems, such as head and coil positioning difficulties, artefacts, coil malfunctions and other technical difficulties. None of these problems prevented the ioMRI procedure from taking place or affected image interpretation, but they sometimes caused a significant delay. Fifteen (32%) of these problems occurred during the initial learning curve period. The mean duration of the ioMRI procedure was 75 min, which decreased slightly with experience, although an average waiting-for-access time of 24 min could not be avoided. These results illustrate that although performing ioMRI at 3.0 T with the dual room is a challenging procedure, it remains safe and feasible and associated with only minor dysfunctions while offering optimal image quality and standard surgical conditions.

Functional Prognostic value of optical coherence tomography in optic chiasmal decompression: A preliminary study.

PURPOSE: To assess the predictive value for functional recovery of Ganglion Cell Complex Layer (GCC) and Retinal Nerve Fiber Layer (RNFL) measurements obtained by Optical Coherence Tomography (OCT) in patients undergoing chiasmal decompression and to define potential OCT thresholds for visual recovery. METHODS: We measured preoperative GCC and RNFL thickness in patients with a sellar and/or perisellar tumor compressing the optic chiasm. Visual recovery was defined as recovery of mean deviation (MD) and pattern standard deviation (PSD) using Humphrey visual field testing after 12 successful decompressions (24 eyes). Receiver operating characteristic curve (ROC) analysis was used to identify the best thresholds. RESULTS: Robust global and focal OCT thresholds were found. Superior GCC≥63µm had the best functional prognostic value (AUC=1) for visual improvement. Mean GCC ≥ 67µm and mean RNFL≥75µm also had excellent predictive values (AUC>0.9). CONCLUSION: In this preliminary study, significant preoperative OCT thresholds for early visual recovery after chiasmal decompression were identified, mainly regarding GCC measurements. Further studies on larger cohorts with closely scheduled follow-up could refine our results.

[Visceral leishmaniasis in Cameroon. Report of various cases and clinical study in the region of Kousseri, far-north of Cameroon]. / La leishmaniose viscérale au Cameroun. A propos de quelques observations et d'une prospection clinique dans la région de Kousseri, extrême-nord camerounais.

The far-North province of Cameroon is highly infested with cutaneous leishmaniasis. From October 1987 to January 1988, a prospective study was done in this region (specifically in Kousseri) to diagnose cases of visceral leishmaniasis (VL). Out of 120 patients examined, 46 presenting symptoms related to VL were retained. Diagnosis of VL was confirmed serologically and/or through the presence of leishmanias on bone marrow slides from 9 patients. A retrospective study was also carried out in the pediatric and internal medicine units of the university teaching hospital and the Central Hospital in Yaoundé; 3 pediatric cases of VL were found. No significant difference as regards age and sex of these patients was recorded.

[Central neurocytoma. A report of 4 cases]. / Le neurocytome central. A propos de 4 observations.

We report 4 cases of central neurocytoma removed by a transfrontal approach with no recurrence after a mean follow up of 3 years. This uncommon lesion of the supratentorial ventricles (150 cases reported) occurs in young adults, and often induces intracranial hypertension secondary to an obstructive hydrocephalus. The CT scan, MRI and histopathological features are related. This neuronal origin tumor is difficult to distinguish from other intraventricular processes as oligodendroglioma or ependymoma. However, the immunopositivity for the neuronal markers as synaptophysin, calcineurin and microtubul associated protein 2, and the negativity for the glial fibrillary acidic protein, allow the diagnosis of this neuropathological entity. The prognosis is favorable though some cases of recurrence (14 cases) and cerebrospinal dissemination (2 cases) has been reported in the literature.

[Dysembryoplastic neuroepithelial tumors. Analysis of 16 cases]. / Tumeurs neuro-épithéliales dysembryoplasiques. Analyse de 16 observations.

OBJECTIVES: We report on 16 cases of dysembryoplastic Neuroepithelial tumor (DNT) treated in the Nancy University Hospital from 1987 to 1997. PATIENTS AND METHODS: There were 9 males and 7 females. Mean age at onset of symptoms was 9.5 years (range: 3 months to 29 years) and the mean age at surgery was 16 years. Nine patients experienced partial complex seizures, 5 patients generalized seizures, 1 patient partial seizures with secondary generalization and one patient ataxia. The diagnosis of DNT was made under consideration of clinical, radiological and neuropathological features. All patients underwent surgery. RESULTS: Removal of the tumor was complete for 10 patients, subtotal or partial for 6 patients. Histological examination revealed that 7 cases were specific forms of DNT due to the presence of the specific glioneuronal element. For the 9 remained cases, the diagnosis of DNT could only be made with the consideration of clinical and radiological features. Mean post-surgical follow-up was 3.5 years (range: 1-8 years). Eight patients were seizures-free, 7 had a significative reduction in seizures frequency with minimal anti-convulsivant treatment. The patient with ataxia remained unchanged. For the patients with partial resection of the tumor, follow-up MRI and CT scan showed no significant growth of the remnant and the remaining patients have had no recurrence to date. CONCLUSION: The recognition of this surgically curable entity is mandatory. Knowledge of the good prognosis associated with the DNT is essential to avoid deleterious side effects of overtreatment by radiotherapy and/or chemotherapy.

Spontaneous submucosal sphenoidal fistula discovered intraoperatively. A case report.

BACKGROUND AND IMPORTANCE: Skull base spontaneous cerebrospinal fluid fistulas have been recently recognized as secondary to pseudotumor cerebri. In most cases, they occur in the ethmoid region and the sphenoid bone which is much less affected. Regardless of their etiology, the clinical manifestation of skull base fistulas is usually the same and includes a rhinorrhea and less frequently an otorrhea. We report a case of a cryptic sphenoid cerebrospinal fluid fistula discovered intraoperatively during the excision of a pituitary ACTH-secreting microadenoma (2mm in diameter). CLINICAL PRESENTATION: A 54-year-old female was admitted to our neurosurgery department for Cushing's disease due to a pituitary microadenoma. Six months prior to admission, she complained of severe fatigue, polyphagia and weight gain. Clinical examination revealed central obesity with a body mass index of 45kg/m(2) and other symptoms suggestive of Cushing's disease. Hormonal tests and a MR scan revealed a pituitary ACTH-secreting microadenoma. During the operative procedure via a transnasal approach, her nasal and sphenoid sinus mucosa appeared unusually edematous. After removal of the latter in order to approach the sellar floor, a millimetric hole in the bone at the level of the optic groove was visualized which let out cerebrospinal fluid under pressure without interruption. The microadenoma was macroscopically completely removed without any cerebrospinal fluid coming from the pituitary surgical cavity. The closing procedure of the sphenoid groove millimetric opening was performed by injecting fibrin glue and a lumbar drain was placed indwelling for four days. CONCLUSION: This case report describes a cryptic sphenoid submucosal cerebrospinal fluid fistula in a patient with Cushing's syndrome. This type of case raises the question of the natural evolution of the skull base cerebrospinal fluid fistula from its formation to an externalization such as rhinorrhea.