Usefulness of flat detector CT (FD-CT) with biplane fluoroscopy for complication avoidance during radiofrequency thermal rhizotomy for trigeminal neuralgia.

INTRODUCTION: Trigeminal neuralgia (TN) is characterized by episodes of shooting pain in the areas innervated by one or more divisions of the trigeminal nerve. The initial treatment of TN is with drugs but the increased frequency and intensity of the neuralgic episodes often force the patient to seek alternative therapies. Microvascular decompression (MVD) and radiofrequency thermal lesioning of trigeminal rootlets (RFTR) offer close to the best results for TN. MVD has the disadvantage of being an open surgical procedure with its attendant risks and longer hospital stay, whereas RFTR is a short, 'day-care' procedure. However this latter procedure involves positioning of the RF needle in the area behind the trigeminal ganglion through the foramen ovale, which can pose significant challenges. OBJECTIVE: To use the fluoroscopic support of a biplane catheter laboratory to access the foramen, and flat detector CT to confirm the location of the tip of the RF needle in the optimal position. METHODS: Fifty-three patients with TN underwent RFTR under local anesthesia with conscious sedation. RESULTS: All patients reported pain relief with hypesthesia over the offending trigeminal division. In seven patients the needle tip required repositioning according to the CT images. Two patients each had loss of corneal reflex and abducens nerve palsy after the procedure. No other complications were seen. CONCLUSIONS: The superior view in two planes coupled with the anatomical confirmation of the position of the needle tip in the Meckel's cave during the rhizotomy reduces the need for multiple passages of the needle to access the foramen ovale and achieves accurate needle tip positioning. The technique increases the safety and precision of such treatments and helps to manage potential complications.

[Cerebral air embolism complicating talc pleurodesis: case report]. / Embolie gazeuse cérébrale compliquant une pleurodèse au talc : à propos d'un cas.

Cerebral air embolism is a severe complication which can occur during many invasive medical procedures. Its prognosis depends on early diagnosis and hyperbaric oxygen therapy. We report a case of cerebral air embolism which occurred during a talc pleurodesis within a chest tube, in chest postoperative period. After early and appropriate treatment, we observed a significant functional recovery.

[Epilepsy surgery during infancy and early childhood in France]. / Chirurgie de l'épilepsie de l'enfant et du nourrisson en France.

BACKGROUND AND PURPOSE: We present the epilepsy surgery activity in infants and children at the Fondation Rothschild Hospital, the main center dedicated to this activity in France. METHOD: A prospective study was conducted from 2003 to 2007 based on three populations: (1) children selected as candidates for surgery, (2) children undergoing presurgical evaluation and (3) children undergoing surgical procedures for epilepsy. RESULTS: Children selected as candidates for surgery: 304 children were referred and discussed by our multidisciplinary staff. They came from Paris and its suburbs (40%), the provinces (43%) or from other countries (14%). Sixty-one percent of them were included in our surgery program and 24% were excluded. Sixty-one percent of them were under 10 years of age. Children undergoing presurgical evaluation: 296 children were recorded: 140 EEG (47%), 46 with foramen ovale electrodes (16%) and 110 with invasive recording techniques (37%). Seventy percent of these children were under 10 years of age. Children undergoing surgical procedures: 316 children underwent surgery; 68% of them were under 10 years of age. The surgical procedures were focal resection (136 children), vertical parasagittal hemispherotomy (77 children), resection and or disconnection for hypothalamic hamartoma (69 children) and 34 had palliative surgery (callosotomy or vagal nerve stimulation). CONCLUSION: Eighty to 100 children undergo surgery each year in our department for drug-resistant partial epilepsy; 70% of them are less than 10 years of age. This activity is part of a network of pediatric neurologists who are deeply involved in treatment of severe epilepsy in children.

Persistent Pulmonary Hypertension of the Newborn

Persistent pulmonary hypertension of the newborn (PPHN) is defined as a failure of normal pulmonary vascular relaxation at or shortly after birth, resulting in impedance to pulmonary blood flow which exceeds systemic vascular resistance, such that unoxygenated blood is shunted to the systemic circulation. Perinatal stressors including hypoxia, hypoglycemia, cold stress, sepsis, and direct lung injury alter the course of transition. The initial clinical picture of PPHN is one of dynamic pulmonary vasospasm, with labile flow through the pulmonary circuit and right-to-left shunting of blood across the ductus arteriosus and foramen ovale. The normal postnatal decline in pulmonary vascular tone is absent following exposure to chronic hypoxia. The pathophysiology of neonatal pulmonary hypertension can involve multiple pathways of injury, from altered circulating agonist balance, to endothelial dysfunction, to smooth muscle dysfunction and phenotypic change. The treatment for PPHN has evolved over the past 10 to 15 years but reported mortality remains at 10% to 20% in newborns with PPHN. Extracorporeal membrane oxygenation (ECMO) has been proven of value for this condition, and several "alternative" therapies such as high-frequency ventilation (HFV), surfactant, and inhaled NO (iNO) have been used in a rescue mode.

Persistent Pulmonary Hypertension of the Newborn

Persistent pulmonary hypertension of the newborn (PPHN) is defined as a failure of normal pulmonary vascular relaxation at or shortly after birth, resulting in impedance to pulmonary blood flow which exceeds systemic vascular resistance, such that unoxygenated blood is shunted to the systemic circulation. Perinatal stressors including hypoxia, hypoglycemia, cold stress, sepsis, and direct lung injury alter the course of transition. The initial clinical picture of PPHN is one of dynamic pulmonary vasospasm, with labile flow through the pulmonary circuit and right-to-left shunting of blood across the ductus arteriosus and foramen ovale. The normal postnatal decline in pulmonary vascular tone is absent following exposure to chronic hypoxia. The pathophysiology of neonatal pulmonary hypertension can involve multiple pathways of injury, from altered circulating agonist balance, to endothelial dysfunction, to smooth muscle dysfunction and phenotypic change. The treatment for PPHN has evolved over the past 10 to 15 years but reported mortality remains at 10% to 20% in newborns with PPHN. Extracorporeal membrane oxygenation (ECMO) has been proven of value for this condition, and several "alternative" therapies such as high-frequency ventilation (HFV), surfactant, and inhaled NO (iNO) have been used in a rescue mode.