A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS: Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS: Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS: Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.

Repeat resection in recurrent glioblastoma (3rGBM) Trial: A randomized care trial.

BACKGROUND: The prognosis for patients with recurrent glioblastoma (GBM) is dismal, and the question of repeat surgery at time of recurrence is common. Re-operation in the management of these patients remains controversial, as there is no randomized evidence of benefit. An all-inclusive pragmatic care trial is needed to evaluate the role of repeat resection. METHODS: 3rGBM is a multicenter, pragmatic, prospective, parallel-group randomized care trial, with 1:1 allocation to repeat resection or standard care with no repeat resection. To test the hypothesis that repeat resection can improve overall survival by at least 3 months (from 6 to 9 months), 250 adult patients with prior resection of pathology-proven glioblastoma for whom the attending surgeon believes repeat resection may improve quality survival will be enrolled. A surrogate measure of quality of life, the number of days outside of hospital/nursing/palliative care facility, will also be compared. Centers are invited to participate without financial compensation and without contracts. Clinicians may apply to local authorities to approve an investigator-led in-house trial, using a common protocol, web-based randomization platform, and simple standardized case report forms. DISCUSSION: The 3rGBM trial is a modern transparent care research framework with no additional risks, tests, or visits other than what patients would encounter in normal care. The burden of proof remains on repeat surgical management of recurrent GBM, because this management has yet to be shown beneficial. The trial is designed to help patients and surgeons manage the uncertainty regarding optimal care. CLINICAL TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov. Unique identifier: NCT04838782.

[The management of unruptured intracranial aneurysms]. / La prise en charge des anévrismes intracrâniens non rompus.

The rupture of an intracranial aneurysm is a sudden, unpredictable and potentially severe event. The responsible aneurysm has to be excluded from the cerebral circulation to avoid recurrence. More and more commonly, intracranial aneurysms are detected by coincidence. How to react to these fortuitous discoveries is unclear, because the risk of rupture is difficult to estimate. We present our approach to patients facing this situation and the decision-making process.

La rupture d'un anévrisme intracrânien est un événement aigu, imprévisible et aux conséquences potentiellement gravissimes. Le traitement passe par l'exclusion de la malformation anévrismale de la circulation sanguine afin d'éviter une nouvelle rupture. De plus en plus fréquemment, en raison des progrès de l'imagerie, les anévrismes sont découverts fortuitement. L'attitude à adopter dans ce type de situation reste incertaine, car le risque de rupture est difficile à évaluer. Nous présentons notre manière de prendre en charge cette situation, notre approche du patient, les facteurs qui conditionnent notre décision, et comment nous orientons notre démarche en cas de traitement prophylactique.

[Primary "pseudotumor cerebri" syndrome or idiopathic intracranial hypertension: clinical features and treatment]. / LE SYNDROME "PSEUDOTUMOR CEREBRI" PRIMAIRE OU HYPERTENSION INTRACRÂNIENNE IDIOPATHIQUE: aspects cliniques et thérapeutiques.

"Pseudotumor cerebri" generally refers to a syndrome associating signs and symptoms of intracranial hypertension, increased cerebrospinal fluid (CSF) pressure and normal CSF composition, without any identifiable intracranial abnormality, particularly by neuroimaging studies. Although the "idiopathic" variant of the syndrome is most common, there are secondary forms where a cause can be found. The term "benign intracranial hypertension" should be abandoned, since permanent visual impairment can complicate the condition. This disaster can be avoided by early recognition and medical or surgical treatment of the disease. This article discusses the terminology, as well as diagnostic and therapeutic aspects of the syndrome.

[Multidisciplinary treatment of glioblastoma]. / Le traitement multidisciplinaire du glioblastome.

Glioblastoma is a primary brain tumor that occurs most often in elderly patients. Despite improved management, the prognosis of this cancer remains poor. This review describes the multidisciplinary management of the patient with glioblastoma. It includes surgery, radiation therapy and chemotherapy.

[Paralysing lumbar disc herniation: a surgical emergency? Reflexion about a series of 24 patients and literature data]. / La hernie discale lombaire paralysante : une urgence chirurgicale ? Réflexion à propos d'une série de 24 patients et des données de la littérature.

BACKGROUND AND PURPOSE: Paralysing lumbar disc herniation (LDH): what and when to do? Few studies have analyzed the optimal timing of surgery in case of paralysing LDH. METHODS: Twenty-four charts were retrospectively reviewed of patients suffering of LDH with severe motor deficit. RESULTS: There were 16 men and eight women. Mean age was 45.1 years. Seventeen patients suffered of lumbar pain, 15 of radicular pain and all of a severe motor deficit, implying mostly the ankle flexion (17 patients). LDH was most frequently located at L4/L5 or L5/S1 level. Surgery was proposed to all patients at the end of the consultation. Nine patients were operated within 48 hours. The mean interval between onset of motor deficit and operation was 20 days. The statistical analysis did not reveal any significant difference among different prognostic factors between the 17 patients with good motor recovery and the seven patients with poor motor recovery. In particular the operative delay did not appear to influence the degree of motor recovery. Literature review on paralysing LDH provides five published series since 1996, including 28 to 116 patients. Two series, including the single prospective one, conclude that the degree of recovery of motor function is inversely related to the degree and duration of motor deficit. CONCLUSIONS: Our retrospective series of 24 operated paralysing LDH did not reveal any prognostic factor for motor recovery. There is no evidence based medicine data in the literature about the optimal timing of decompressive surgery. A relative consensus exists among spine surgeons for paralysing LDH: since operative indication is obvious, surgery should be done as soon as possible.

Spinal cord injury and its treatment: current management and experimental perspectives.

Clinical management of spinal cord injury (SCI) has significantly improved its general prognosis. However, to date, traumatic paraplegia and tetraplegia remain incurable, despite massive research efforts. Current management focuses on surgical stabilisation of the spine, intensive neurological rehabilitation, and the prevention and treatment of acute and chronic complications. Prevention remains the most efficient strategy and should be the main focus of public health efforts. Nevertheless, major advances in the understanding of the pathophysiological mechanisms of SCI open promising new therapeutic perspectives. Even if complete recovery remains elusive due to the complexity of spinal cord repair, a strategy combining different approaches may result in some degree of neurological improvement after SCI. Even slight neurological recovery can have high impact on the daily functioning of severely handicapped patients and, thus, result in significant improvements in quality of life.The main investigated strategies are: [1] initial neuroprotection, in order to decrease secondary injury to the spinal cord parenchyma after the initial insult; [2] spinal cord repair, in order to bridge the lesion site and reestablish the connection between the supraspinal centres and the deafferented cord segment below the lesion; and [3] re-training and enhancing plasticity of the central nervous system circuitry that was preserved or rebuilt after the injury.Now and in the future, treatment strategies that have both a convincing rationale and seen their efficacy confirmed reproducibly in the experimental setting must carefully be brought from bench to bedside. In order to obtain clinically significant results, their introduction into clinical research must be guided by scientific rigour, and their coordination must be rationally structured in a long-term perspective.

[Very small intracranial aneurysms: Clip or coil]. / Les anévrismes de très petite dimension : clip ou coil.

INTRODUCTION: It is not unusual for very small aneurysms (≤3mm) to be responsible for subarachnoid haemorrhage. In addition, modern imaging has increased diagnosis of those that are asymptomatic. Because of their spatial configuration and thin and fragile walls, very small aneurysms can be a sizeable challenge for both open surgical and endovascular treatment. Based on recent literature data, the present manuscript reviews treatment indications and the choice of treatment strategy to occlude these particular aneurysms. METHODS: Literature review concerning surgical and endovascular treatment of very small aneurysms (≤3mm). Arterial dissections and blister aneurysms were excluded. RESULTS: We found no study that systematically and specifically assessed surgical treatment of very small aneurysms. Investigations of endovascular treatment are almost exclusively retrospective, usually evaluating a small number of patients, and are limited by selection bias. Despite often contradictory results, it appears that very small aneurysms carry a higher risk of rupture during endovascular procedures and higher ensuing mortality, as compared to larger aneurysms. The use of more flexible coils and additional endovascular tools appears to reduce this risk. There is no study comparing surgical to endovascular treatment. CONCLUSION: Very small aneurysms carry higher treatment risks than larger aneurysms. A prospective randomised trial is justified for those very small aneurysms for which treatment is indicated.

Strategical implications of aneurysmal cranial nerve compression.

Intracranial aneurysms may manifest clinically by inducing neurological symptoms, including cranial nerve dysfunction. In unruptured aneurysms, this may result from mass effect and the pulsation of the sac. Aneurysm rupture and sudden expansion of a pseudo-sac may precipitate the appearance of cranial nerve deficits. Symptomatic aneurysms should be treated. Surgery reduces mass effect and arterial pulsations, and removes clot after rupture. Endovascular treatment decreases pulsatility of the sac. Recovery has been reported after both treatments. It appears more reproducible after surgery, but the data of current literature remains weak. The possible advantage of surgery is an argument among others that must be considered in the choice of the most adequate therapeutic approach.

Endoscopic endonasal resection of the odontoid process as a standalone decompressive procedure for basilar invagination in Chiari type I malformation.

BACKGROUND: The expanded endonasal approach of the cranio-cervical junction provides comfortable working space while avoiding some of the disadvantages of the transoral route. We report a purely endonasal endoscopic resection of the odontoid process for basilar invagination in a patient with a Chiari type I malformation, without posterior decompression or fusion. CASE REPORT: A 54-year-old female patient presented with cranial nerve and brainstem deficits. CT and MRI showed a Chiari type I malformation and compression of the medulla by basilar invagination of the odontoid process. The tip of the latter was displaced up to the bulbo-pontine sulcus. The odontoid process was resected via the expanded endoscopic endonasal approach, without additional posterior decompression or fusion. The post-operative course was uneventful, including the absence of velopharyngeal insufficiency. Neurological deficits regressed rapidly. The preoperative cervical pain virtually disappeared. At 9 months follow-up, the patient had normal activity with minimal residual neurological deficits. Post-op dynamic radiography and CT showed stability of the cranio-cervical junction. CONCLUSION: Decompression of the bulbomedullary junction by purely endoscopic transnasal resection of the odontoid process is well tolerated and efficient. Immediate stabilization is not mandatory in all cases of congenital causes of basilar invagination.

Angiographic pitfall: duplicated tapered A1 segment of the anterior cerebral artery mimicking an anterior communicating artery aneurysm.

We describe a misleading case of a partially occluded A1 segment duplication that mimicked an ACoA aneurysm on computed tomography angiography and conventional angiography and led to surgical intervention. The location of such an anomaly at the ACoA on the side of least hemodynamic stress may provide a clue to recognizing this variant.

[Gilliatt-Sumner hand or true neurogenic thoracic outlet syndrome. A report on seven operated cases]. / La main de Gilliatt-Sumner ou le syndrome de défilé cervicothoracique neurogène vrai. À propos de sept cas opérés.

BACKGROUND AND PURPOSE: The clinical picture of hand atrophy related to a cervical rib or elongated C7 transverse process was well described in the modern literature by Gilliatt and Sumner; in 1970, they reported a series of nine patients whose motor status was stabilized following brachial plexus decompression. We report here seven patients suffering from thoracic outlet syndrome (TOS), who developed hand atrophy, sometimes because of diagnostic delay. METHODS: The patient's charts were analysed retrospectively. RESULTS: The seven patients were all female; the mean age was 43 years. The first complaints were arm pain and paresthesias lasting six months to 5 years. Three patients were treated with C56/C67 discectomy plus disc prosthesis (one patient), ulnar neurolysis at the elbow (the same patient), carpal tunnel release (one patient), and intravenous immunoglobulins (one patient) before TOS diagnosis. Hand atrophy, severe in five patients, was present at presentation. All patients underwent brachial plexus decompression by the anterior (four), posterior (two), or transaxillary (one) approach. This last approach was completed 18 months later by brachial plexus neurolysis via the anterior approach. Postoperatively, motor deficit was improved in two patients and stabilized in five patients. CONCLUSIONS: Physicians' unfamiliarity with TOS diagnosis or their reluctance to accept the diagnosis without electrical confirmation can lead to hand atrophy. Brachial plexus decompression at this stage usually stabilizes the deficit.

Post-mortem assessment of rat spinal cord injury and white matter sparing using inversion recovery-supported proton density magnetic resonance imaging.

STUDY DESIGN: This was an experimental study. OBJECTIVES: White matter sparing influences locomotor recovery after traumatic spinal cord injury (SCI). The objective of the present post-mortem magnetic resonance imaging (MRI) investigation was to assess the potential of a simple inversion recovery (IR) sequence in combination with high-resolution proton density (PD) images to selectively depict spared white matter after experimental SCI in the rat. SETTING: This study was conducted at University of Liège and Centre Hospitalier Universitaire, Liège, Belgium and Hasselt University, Diepenbeek, Belgium. METHODS: Post-mortem 9.4 tesla (T) MRI was obtained from five excised rat spines 2 months after compressive SCI. The locomotor recovery had been followed weekly using the standardized Basso-Beattie-Bresnahan scale. IR MRI was used to depict normal white matter as very hypo-intense. Preserved white matter, cord atrophy and lesion volume were assessed, and histology was used to confirm MRI data. RESULTS: MRI showed lesion severity and white matter sparing in accordance with the degree of locomotor recovery. IR MRI enhanced detection of spared and injured white matter by selectively altering the signal of spared white matter. Even subtle white matter changes could be detected, increasing diagnostic accuracy as compared to PD alone. MRI accuracy was confirmed by histology. CONCLUSION: High-resolution IR-supported PD MRI provides useful micro-anatomical information about white matter damage and sparing in the post-mortem assessment of chronic rat SCI.

[Clinical case of the month. Traumatic bilateral orbital encephalocele]. / Le cas clinique du mois. Encéphalocèle orbitaire post-traumatique bilatéral.

Acute traumatic orbital encephalocele is a rare entity, with less than 25 cases reported. We hereby describe the first bilateral orbital encephalocele through a blow-in orbital fracture after a blunt cranial traumatism. Early treatment of the orbital traumatic encephalocele is necessary in order to avoid the increase of the intra orbital pressure that might damage the optic nerve. Repairing the orbital roof has to be performed in a rigid manner in order to avoid the transmission of the intracranial pressure variation to the orbit. In the present case, the reconstruction of orbital roof was performed using a subfrontal approach supported by a titanium mesh fixed with screws and a mixture of bone powder mixed and fibrin glue.

[Palpebral and lacrimal system injuries in children]. / Plaies palpébro-lacrymales de l'enfant.

The authors report the different palpebral and lacrimal wounds found in children and their treatment. Early microscopic surgery is important for good prognosis. The eyelids must be thoroughly examined searching for a marginal injury, superior palpebral levator muscle resection, and lacrimal system injury after ocular injuries have been investigated. The treatment is microscopic surgery of the eyelid and the canaliculus with most often a monocanalicular intubation. The authors present two clinical studies conducted in the Reims Hospital that show the frequency of this traumatology and the main characteristics. In children, most injuries come from dog bites with canalicular laceration in the left lower eyelid. In palpebral injuries without canalicular section, the injury was most often located on the right lower eyelid. Preliminary treatment of childhood palpebral and lacrimal injuries is necessary with microscopic surgery. It is important to repair the canaliculus with or without canalicular intubation and the eyelid margin.

[Cerebral venous thrombosis (CVT)]. / ..... la thrombose veineuse cerebrale (TVC).

Cerebral venous thrombosis is a rare cause of stroke. Clinical presentation is not very specific and can be very variable. Imaging establishes the diagnosis in the majority of cases. Specially, magnetic resonance venography has high sensitivity and is presently the gold standard. Long term prognosis of cerebral venous thrombosis is generally good and few patients remain handicapped in the long term. Evolution is however unpredictable. Treatment strategies follow three axes: anti-thrombotic treatment, symptomatic measures and treatment of the cause if one is found.

[How I explore ... dystonic troubles: a simple and practical guide]. / Comment j'explore ... les troubles dystoniques: un guide simple et pratique.

The discovery of dystonia as an isolated abnormality or as a symptom involved in a larger neurological or systemic disease is not unfrequent in clinical practice. Dystonia can occur at any age, from childhood to elderly. A rapid diagnosis is very important to optimise the managing of those chronical and often invalidating diseases. We should point out the pre-eminent role played by MRI techniques in the diagnosis and follow-up of dystonic patients. We present here an overview of most frequent dystonic troubles and an attempt of classification to simplify their diagnosis.

[Assessment of macular profile using optical coherence tomography after epiretinal membrane surgery]. / Analyse maculaire en tomographie à cohérence optique après chirurgie de membrane épirétinienne.

PURPOSE: The aim of this study was to analyze the quality and functional result of epiretinal membrane (ERM) surgery using optical coherence tomography (OCT). PATIENTS AND METHOD: We conducted a retrospective, non comparative study between January 2004 and June 2006. Thirty-two eyes were included and operated by vitrectomy for ERM. The OCT assessment of the macular profile was evaluated postoperatively on day 8, day 30 and every 3 months thereafter. The first outcome measure was postoperative abnormality of the OCT profile. The secondary outcome measure was analysis of the functional result with macular thickness and best visual acuity. The Student t-test and the paired series comparison were used for the statistical analysis. RESULTS: After surgery, 23 eyes (72%) showed abnormality of the reflectivity signal as assessed by OCT. Only nine eyes (28%) had or showed restored foveal depression and normal macular thickness. Dissociated optic nerve fiber layer appearance was observed in 43.7% (14 eyes). The best visual acuity increased from 0.58+/-0.23 LogMar to 0.25+/-0.24 after ERM surgery (p<0.001). The macular thickness decreased from 374.6+/-78.7 microm to 271+/-44.6 microm postoperatively (p<0.001). CONCLUSION: Epiretinal membrane surgery is safe and effective in terms of the functional result but most cases do not recover normal microanatomy. This feature does not influence the functional result. Mechanical traction due to peeling of the epiretinal membrane associated with peeling of the internal limiting membrane may be the cause of these microanatomical results.

Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia.

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.