Intraoperative use of diffusion tensor imaging-based tractography for resection of gliomas located near the pyramidal tract: comparison with subcortical stimulation mapping and contribution to surgical outcomes.

INTRODUCTION: For gliomas, the goal of surgery is maximal tumour removal with the preservation of neurological function. We evaluated the contribution of the combination of diffusion tensor imaging-based fibre tracking (DTI-FT) of the pyramidal tract (PT) integrated to the navigation and subcortical direct electrical stimulations (DESs) to surgical outcomes. METHOD: Ten patients underwent surgery for gliomas located in close relationship with the subcortical course of the PT. Preoperative DTI was performed with a three-Tesla magnetic resonance scanner applying an echo-planar sequence with 20 diffusion directions. DTI-FT data were systematically loaded into the navigation for intraoperative guidance. When the resection closely approached the PT as illustrated on navigation images, subcortical DESs were used to confirm the proximity of the PT by observing motor responses. The location of all subcortically stimulated points with positive motor response was correlated with the illustrated PT. Motor deficits were evaluated pre- and postoperatively, and compared with the extent of tumour removal. RESULTS: DTI-FT of the PT was successfully performed in all patients. A total of fifteen positive subcortical DESs were obtained in 8 of 10 patients; in these cases, the mean distance from the stimulated point to the PT was 6.2 ± 3.6 mm. The mean tumoural volumetric resection was 90.8 ± 10.4%, with a gross total resection in four patients. At one month after surgery, only one patient had a slight impairment of motor function (decreased fine motor hand skills). CONCLUSIONS: DTI-FT is an accurate technique to map the PT in the vicinity of brain tumours. By combining anatomical (DTI-FT) and functional (subcortical DES) studies for intraoperative localization of the PT, the authors achieved a good volumetric resection of tumours located in eloquent motor areas, with low morbidity. Careful use of this protocol requires the knowledge of some pitfalls, mainly the occurrence of brain shift during removal of large tumours.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study.

BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

[Evaluation of the clinical and radiological results of cervical longitudinal median somatotomy without graft]. / Evaluation des résultats cliniques et morphologiques de la somatotomie cervicale médiane longitudinale sans greffe.

OBJECTIVES: To evaluate the clinical and radiological results of cervical longitudinal median somatotomy without graft, used for the treatment of cervical myelopathy and radiculopathy, and compare it to techniques with graft and to laminectomies. MATERIAL AND METHOD: Thirty-four patients (25 males and nine females), with a mean age over 60 years, were included in a study comparing pre- and postoperative clinical status on the Japanese Orthopaedic Association (JOA) functional scale and radiological status with evaluation of the cervical curve on plain films and dynamic tests in flexion and extension. RESULTS: No significant difference was found with the clinical and anatomical results published in the literature concerning median somatotomies performed with graft and/or osteosynthesis and laminectomies and their variants. CONCLUSIONS: The cervical longitudinal median somatotomy without graft is an easy and reliable technique that can be proposed as first-line treatment for cervical spondylotic myelopathy related to anterior compression. It decreases the cost and the duration of the surgical procedure, it protects the patient from the complications and sequelae related to graft harvesting and the use of implants. It should be limited to patients without preoperative kyphosis who are over 50 years old.

[Cranial nerve functional neurosurgery: evaluation of surgical practice]. / La neurochirurgie fonctionnelle des nerfs crâniens Evaluation de l'activité

We report the results of an investigation carried out on the activity of functional neurosurgery of the cranial nerves in the French-speaking countries, based on the analysis of a questionnaire addressed to all the members of the SNCLF. Eighteen centers responded to this questionnaire, which showed that activities and indications varied greatly from one unit to another. The results appear homogeneous and comparable with those reported in the literature. The questionnaire sought to provide a global perspective, open to the comments and questions of all responders on the various techniques raised, with the objective of establishing a common decisional tree for these pathologies and providing if possible to a consensus for better dissemination of these therapies.

Propionibacterium acnes contamination in lumbar disc surgery.

Previous studies have shown that Propionibacterium acnes may be responsible for low-grade infection of the intervertebral discs of patients with severe sciatica. The aim of this study was to prospectively investigate the presence of bacteria in disc fragment samples obtained during surgery for lumbar disc herniation. P. acnes was cultured from disc fragments in two (3.7%) of 54 patients studied. In addition, control cultures taken from ligamentum flavum and muscle from these two patients were also positive for P. acnes. Similar control cultures were positive for P. acnes from a further ten (18.5%) patients. Four air samples taken during surgery all contained P. acnes; the organism was also found from three of 54 laminar flow control cultures. Sample contamination appears the most likely cause for the presence of P. acnes in the lumbar disc fragment cultures.

[Results of surgical treatment]. / Résultats du traitement chirurgical.

In this chapter we report the results of the main papers of the international literature, but it is difficult to make an objective synopsis because only the best results are published and failure and complications remain confidential. Few papers describe "general complications" as thrombo phlebitis, wound infection, cardio respiratory insufficiency... which are probably as frequent as for all intracranial or spinal surgical procedures. The postoperative neurological status depends essentially on the location of the lesion. In non eloquent area, the postoperative neurological status is almost always excellent. But in a hemispheric functional area, basal ganglia and brain stem it is frequent to observe neurological sequellae; in the better series of the literature, 80% of the patients achieve a good outcome equivalent to or better than before the operation, but 20% are worsened. It is important to remember this fact before discussing the surgical indication. The risk of hemorrhage disappears after total surgical resection; and it is one of the benefits of the treatment, but this objective can be reached only when the lesion is unique. The risk persists in multiple forms and "de novo" cavernomas are always possible especially in familial forms. The main benefit is the treatment of epilepsy for seizure control. In case of good concordance between the location of the cavernoma and the clinical and electrical data, lesionectomy alone or lesionectomy with resection of the perilesional hemosiderin ring provide good results. In the event of severe epilepsy without good concordance between the site of the cavernoma and symptoms, the surgical approach may be functional and outcome less satisfactory.

[Natural history of cavernomas of the central nervous system]. / Histoire naturelle des cavernomes du système nerveux central.

We present a critical review of the literature on the central nervous system cavernomas in order to highlight their natural history and to define the most appropriate management of these rare lesions. The prevalence is now estimated from 0.3 to 0.7% in the general population without any significant difference by gender; 25% of cases are pediatric. Two forms of the disease can be described: sporadic forms in 80% of cases, characterized by isolated or rare lesions and familial dominant autosomic forms characterized by multiple and evolutive lesions. The incidence is not well known, the consultation of the French PMSI database suggests that 50 to 100 cases are operated on each year (1 to 2 per million). Cavernomas are dynamic lesions: growing in many cases, seldom remaining quiescent and disappearing in rare cases. The anatomical evolution is more pejorative in familial forms. "De novo" cases are now well known, either in familial or sporadic forms and after radiotherapy. Many lesions are totally asymptomatic, but the frequency of symptomatic forms is debated in the literature from 3 to 90%... The hemorrhagic risk is evaluated from 0,5 to 3% each year, depending on the localization, and the risk of rebleeding is more important but not well known. The epileptic risk is correlated to the localization, more frequent for temporal and frontal lesions from 4,5 to 11% each year, but these data are controversial. The natural history depends on the topography: hemispheric, deep-seated, brain stem, cerebellum or intramedullary and in pediatric situations. Each situation will be treated in this report.

[Histopathology of central nervous system cavernomas]. / Anatomie pathologique des cavernomes du système nerveux central.

Central nervous system cavernomas are vascular malformations, which occur in two circumstances: sporadic forms and familial autosomal dominant forms. The lesion consists of enlarged, closely packed vessels without interposition of brain parenchyma, surrounded by hemosiderin and gliosis, calcified in few cases. In 80% of sporadic forms the lesion is unique, multiple lesions are rare (median: 4). In familial forms the lesions are always multiple. Cavernomas are often associated with other vascular malformations, especially with venous developmental anomalies. The size of cavernomas is variable from 1 mm to several centimeters. About 70% of cases are supratentorial and 30% in the posterior fossa, particularly in the brain stem. Macroscopic and histopathological findings are typical and the diagnostic is generally easy.

Carbapenemase-producing Acinetobacter baumannii: An outbreak report with special highlights on economic burden.

OBJECTIVE: We aimed to describe the management of a carbapenemase-producing Acinetobacter baumannii (CP-AB) outbreak using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. We also aimed to evaluate the cost of the outbreak and simulate costs if a dedicated unit to manage such outbreak had been set-up. METHODS: We performed a prospective epidemiological study. Multiple interventions were implemented including cohorting measures and limitation of admissions. Cost estimation was performed using administrative local data. RESULTS: Five patients were colonized with CP-AB and hospitalized in the neurosurgery ward. The index case was a patient who had been previously hospitalized in Portugal. Four secondary colonized patients were further observed within the unit. The strains of A. baumannii were shown to belong to the same clone and all of them produced an OXA-23 carbapenemase. The closure of the ward associated with the discharge of the five patients in a cohorting area of the Infectious Diseases Unit with dedicated staff put a stop to the outbreak. The estimated cost of this 17-week outbreak was $474,474. If patients had been managed in a dedicated unit - including specific area for cohorting of patients and dedicated staff - at the beginning of the outbreak, the estimated cost would have been $189,046. CONCLUSION: Controlling hospital outbreaks involving multidrug-resistant bacteria requires a rapid cohorting of patients. Using simulation, we highlighted cost gain when using a dedicated cohorting unit strategy for such an outbreak.

Robot-guided neuronavigated rTMS as an alternative therapy for central (neuropathic) pain: Clinical experience and long-term follow-up.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) appears as a useful tool to alleviate neuropathic pain but only few data are available for the long-term benefit of this treatment. METHODS: Here we report the effects of rTMS sessions, considered as a possible therapy for pain relief after a failure of different medications in patients with central (neuropathic) pain. We review here the prospectively collected data of the first forty patients treated as follow: 20 Hz stimulation delivered over the contralateral primary motor cortex (M1), each 3-4 weeks. RESULTS: A total of 440 rTMS sessions was collected (mean sessions number: 11, range: 1-37, follow-up 312 days on average, maximum 2.8 years). After four sessions, nine patients (22.5%) discontinued rTMS because of a lack of efficiency (<10% pain-relief). The other 31 patients (77.5%) had a cumulative effect across sessions leading to a mean pain relief of 41% for a duration of 15.6 days. A correlation was observed between pain relief in the first session and long-term pain relief (R = 0.649. p = 5.6*10(-6) ). Both intensity and duration of pain relief were significantly better for patients with persistent laser evoked potentials (LEPs, p = 0.049 and 0.0018). We did not observe any adverse-effects. CONCLUSION: These results suggest that repeated sessions of 20 Hz rTMS over M1 are interesting in clinical practice for the treatment of selected patients with central pain. Both the cumulative effects across the first sessions and the long duration of pain-relief should impact further randomized trials that are warranted to conclude formally on rTMS efficiency in central pain.

[Young French neurosurgeons: Working conditions and outlook]. / Jeunes neurochirurgiens français: conditions de travail et perspectives.

INTRODUCTION: Due to the increase in the number of French neurosurgeon residents the neurosurgical workforce is changing. The main objective of this survey was to assess working conditions and perspectives for young French neurosurgeons. METHOD: An on-line survey was sent to young French neurosurgeons based on a mailing-list (219 mail addresses of Residents and Fellows obtained during previous meetings). The form contained questions about career, amount of work, salary, quality of life, teaching and university work. RESULTS: We received 78 replies from January to March 2014. A total of 56% from fellows saying they had undergone difficulties in obtaining a fellowship, although 78% were satisfied. Fellows considered a private career more often than residents. Overall, young neurosurgeons were worried about future employment. Some 33% admitted contemplating a different career from one they originally wanted. The average weekly working time of 76.8 hours was deemed to be excessive. Security rests after overnight shifts were lacking or incomplete in 91% of cases. The work atmosphere was good overall (3.7/5), and so was the quality of life (3.2/5). Theoretical teaching was unsatisfactory (2.43/5) as well as the time allowed for academic work (approximately 1.58 half-days per month). However, practical teaching was considered rewarding (3.63/5). CONCLUSION: This study provides some guidance for upcoming reforms, and should be considered again at a later date to evaluate progress.

[Multidisciplinary treatment of neurologic pain and indications for antalgic surgery]. / Prise en charge de la douleur neurologique en équipe pluridisciplinaire et décision de chirurgie antalgique.

We present our multidisciplinary approach systematically adopted for patients with resistant pain. All the anatomic, pathophysiological, clinical, radiographical, electrophysiological and psychological aspects of pain should be considered before deciding on treatment indication. These principles are illustrated by a description of different available medical and surgical techniques for the treatment of paraplegic pain. We emphasize the importance of pain centers in caring for these patients. All possibilities for antalgic treatment can be considered in such centers, providing a better approach to all aspects of pain.

[Adenoid cystic carcinomas of the maxillary sinus with intracranial invasion. Review of the literature, apropos of a case]. / Les carcinomes adénoïdes kystiques du sinus maxillaire à développement intracrânien. Revue de la littérature, à propos d'un cas.

We report a case of adenocystic carcinoma (cylindroma) of the maxillary sinus with intracranial extension in a 35-year-old man with no previous clinical history. The patient underwent primary neurological and maxillofacial surgery. He then developed two successive recurrences of the tumor in the temporo-parietal area of the brain treated by surgery and radiotherapy for the first one and surgery alone for the second. The patient finally died 4 years and 2 months after the diagnosis. Adenoid cystic carcinomas are malignant epithelial neoplasms that arise mainly from salivary glands (14% of the salivary tumors), and less frequently from other structures. Their histological pattern can be either tubular, cribriform or solid, with different prognosis. They invade local areas (perineural spaces) and also metastasize to the lung, liver, bone, regional lymph nodes. Treatment mainly consists in combined surgery and radiation therapy. Chemotherapy might be also used.

[Complications of lumboperitoneal shunts. A retrospective study of a series of 195 patients (214 procedures)]. / Complications des dérivations lombo-péritonéales. Etude rétrospective d'une série de 195 patients (214 interventions).

BACKGROUND AND PURPOSE: We report our experience with the lumboperitoneal shunt (LPS) in 195 patients. The aim of this retrospective study was to assess and compare the rate of complications and to discuss 4 indications. MATERIAL AND METHOD: Between January 1983 and July 1994, 195 patients including 14 pediatric cases were treated with a LPS. Sex ratio was 1.24. The mean age at insertion was 59.5 years (from 6 months to 88 years) and the follow-up in this series was from 6 months to 12.5 years. The indications for a LPS were: chronic idiopathic hydrocephalus (115 cases), post-hemorrhagic hydrocephalus (37 cases), cerebrospinal fluid fistula (11 cases), post-traumatic hydrocephalus (9 cases), post-surgical hydrocephalus (8 cases), hydrocephalus of the child (6 cases), post-meningitis hydrocephalus (4 cases), benign intracranial hypertension (4 cases), post-radiotherapy hydrocephalus (1). Forty patients (20.5%) presented with at least one complication. A total of 47 complications were observed: chronic subdural effusion (8 cases), meningitis (10 cases), mechanical failures (28 cases), acquired Chiari abnormality (1 case). Mechanical complications varied with the type of shunt. CONCLUSION: Complications of LPS in adults are less frequent than is usually reported after ventricular atrial or peritoneal shunting. In adults, LPS can be used as the first valuable treatment in case of chronic communicating hydrocephalus. LPS is also valuable in the treatment of benign intracranial hypertension or recurrent CSF fistulae. Conversely, in the pediatric cases general and specific complications are frequent, so an indication for LPS must be strictly discussed.

[Non traumatic spinal epidural hematomas. Report of twenty cases. Review of the literature and outcome aspects]. / Hématomes épiduraux non traumatiques du rachis. Présentation de 20 cas. Revue de la littérature et étude des aspects évolutifs.

BACKGROUND AND PURPOSE: We report a personal series of 20 non traumatic spinal epidural hematomas and study outcome aspects with a review of data in the literature. METHOD: Clinical presentation of non-traumatic spinal epidural hematomas observed between January 1980 and December 1998 was acute in 17 cases (85%) and chronic in 3 (15%). Symptoms were spinal and/or radicular pain, sensorimotor and sphincter dysfunction. Radiological evaluation consisted in myelography (n=6), myelography-CT scan (n=5), CT scan (n=1) and MRI (n=9). Patients underwent surgery in 15 cases, between 8 hours and 2 months after the first symptoms. All our patients were clinically reevaluated between 2 and 4 months after either surgery or admission for cases of spontaneous resolution. RESULTS: Good results (complete neurological resolution or moderate sequelae) were observed in 14 patients (70%). A partial recovery with major persistent neurological impairment was observed in 1 patient (5%), an initial persistent neurological impairment in 1 (5%). Three patients (15%) died and 1 (5%) was lost to follow-up. Complete spontaneous resolution were observed in four patients. CONCLUSION: Postsurgical outcome is mainly related to the preoperative neurological impairment, the duration of spinal cord compression and the time interval between the onset of symptoms and maximal deficit. A prompt laminectomy is necessary except in the cases where a spontaneous resolution can be expected from the early neurological course.

Isolated primary central nervous system lymphoma arising from the optic chiasm.

A 58-year-old previously healthy woman rapidly developed progressive bilateral visual loss. Magnetic resonance imaging revealed a bulging appearance of the optic chiasm, with homogeneous enhancement after gadolinium administration, which suggested an optic glioma or inflammatory disease. In the absence of (para)clinical clues for a specific diagnosis despite extensive investigation, a biopsy of one optic nerve was performed, resulting in a diagnosis of non-Hodgkin B-cell lymphoma. There was no evidence of any other ocular or systemic involvement, therefore the conclusion was that this immunocompetent patient had a primary central nervous system lymphoma isolated in the anterior visual pathway. Treatment included two cycles of polychemotherapy (rituximab, methotrexate, carmustine, etoposide, methylprednisolone), followed by autologous peripheral blood stem cell transplantation and rituximab plus cytarabine consolidation therapy. Subsequently, the patient exhibited significant improvement in vision, and was still disease-free at the 1-year follow-up examination. The aim of the present paper was to provide well-documented clinical, radiological, and intraoperative features of isolated primary malignant lymphoma arising from the anterior visual pathway. A better recognition of this rare pathological entity is necessary for clinicians who may encounter similar presentations, as prompt management is crucial for both a visual and vital prognosis.

Nosocomial transmission of NDM-1-producing Escherichia coli within a non-endemic area in France.

Two patients with no travel history and sharing the same room were colonized by the same strain of New Delhi metallo-ß-lactamase 1 (NDM-1)-producing Escherichia coli within a geographical area not endemic for this highly multidrug-resistant bacterium. It was documented an absence of an epidemiological and bacteriological link with a third patient returning from India after surgery and found to be infected by an NDM-1-producing Citrobacter strain during the same period. Despite extensive investigation, the source of contamination of the two former patients was not elucidated. This case report illustrates the need of investigating rapidly the emergence of highly multidrug-resistant Enterobacteriaceae, to stop their dissemination in a nosocomial setting.

White matter anatomy of the human deep brain revisited with high resolution DTI fibre tracking.

BACKGROUND AND PURPOSE: Deep white matter (WM) fascicles play a major, yet poorly understood, role in the overall connectivity of human brain. Better knowledge of their anatomy is requisite to understand the clinical correlates of their lesions and develop targeted treatments. We investigated whether MR-based diffusion tensor imaging (DTI) and fibre tracking could reveal in vivo, in explicit details, the 3D WM architecture within the subthalamic region and the internal capsule. METHODS: High-resolution DTI images were acquired on six healthy volunteers on a three Tesla MR scanner. We studied using single-subject analysis WM fascicles within the subthalamic region and the internal capsule, as follows: DTI deterministic fibre tracking (FT) of fascicles; embedding fascicles in the volume-rendered brain coupled with a triplanar view; rigorous anatomic labelling of each fascicle according to classical knowledge as described by pioneer neuroanatomists. Deterministic FT effects were taken into account. RESULTS: We charted most of WM fascicles of the deep brain, in particular large and complex fascicles such as the basal forebrain bundle and the ansa lenticularis. A topographic classification of subthalamic fascicles was proposed into three groups: the cerebellorubral, the reticulo-dorsal and the tegmento-peripheral one. CONCLUSIONS: Beyond to demonstrate the feasibility of imaging the deepest WM fascicles in vivo, our results pave the way for a better understanding of the brain connectivity and for developing targeted neuromodulation.

[Benefit of a prolonged adjuvant treatment with temozolomide for the management of patients with glioblastoma]. / Intérêt d'un traitement d'entretien prolongé par témozolomide dans la prise en charge des patients atteints d'un glioblastome.

PURPOSE: Temozolomide has significantly improved the outcome of patients with glioblastoma. However, the optimal duration of continuation treatment after chemoradiation remains uncertain. This retrospective analysis aims at assessing the feasibility, the tolerance, and the potential benefit of prolonging adjuvant temozolomide more than six months, which is the reference protocol. PATIENTS AND METHODS: Forty-six patients were included in the analysis. Median age at diagnosis was 61 years old (range 40 to 77). Forty-five patients received a conformal external beam radiation with concurrent temozolomide-based chemotherapy. Then, 37 patients received adjuvant chemotherapy with temozolomide. The treatment was continued until progression or toxicity. RESULTS: During the adjuvant phase, no treatment discontinuation for toxicity was necessary. Eight patients required dose adaptation because of toxicity. Thirty-two patients presented tumor progression during the adjuvant phase. Overall median survival was 12.3 months (range 11-13.2 months) and progression-free survival (PFS) was 7.6 months (range 5.6-9.6 months). CONCLUSION: These results suggest feasibility of delivering temozolomide beyond the six months of the standard protocol, with mild toxicity and survival data at least comparable to those from literature. Prospective assessments are ongoing.