Hydrocephalus despite extra ventricular drainage in adults: a new description of multiloculated hydrocephalus.

Multiloculated hydrocephalus constitutes a challenging pathology due to intracerebral haemorrhage or ventriculitis leading to iterative shunt revision frequently described in paediatric neurosurgery, but poorly reported in adults. Nevertheless, this potential complication of intraventricular haemorrhage, already drained in emergency, should be considered with special interest, as ideal management of cerebrospinal drainage remains debated in such situation. We thus report herein the case of intraventricular haemorrhage in an adult complicated of multiloculated hydrocephalus, as an illustrative plea for endoscopic surgery.

Long-term surgical oncological and functional outcome of large petroclival and cerebellopontine angle epidermoid cysts: a multicenter study.

Cranial nerve (CN) disorders are the foremost symptoms in cerebellopontine angle (CPA) and petroclival area (PCA) epidermoid cysts (EC).The aim of this work was to  assess the long-term surgical results on CN function and tumor control in these patients. We performed a retrospective cohort study about 56 consecutive patients operated on for a CPA or PCA EC between January 2001 and July 2019 in six participating French cranial base referral centers. Sixteen patients (29%) presented a PCA EC and 40 a CPA EC (71%). The median clinical and radiological follow-up was 46 months (range 0-409). Preoperative CN disorders were present in 84% of patients (n = 47), 72% of them experienced CN deficits improvement at the last follow-up consultation (n = 34): 60% of cochlear and vestibular deficits (n = 9/15 in both groups), 67% of trigeminal neuralgia (n = 10/15), 53% of trigeminal hypoesthesia (n = 8/15), 44% of lower cranial nerve disorders (n = 4/9), 38% of facial nerve deficits (n = 5/8) and 43% of oculomotor deficits (n = 3/7) improved or were cured after surgery. New postoperative CN deficits occurred in 48% of patients (n = 27). Most of them resolved at the last follow-up, except for cochlear deficits which improved in only 14% of cases (n = 1/7). Twenty-six patients (46%) showed evidence of tumor progression after a median duration of 63 months (range 7-210). The extent of resection, tumor location, and tumor size was not associated with the occurrence of new postoperative CN deficit or tumor progression. A functional nerve-sparing resection of posterior fossa EC is an effective strategy to optimize the results on preexisting CN deficits and reduce the risk of permanent de novo deficits.

Chronic subdural hematoma under local anesthesia with manual burr hole.

CONTEXT: Burr hole evacuation (BHE) of symptomatic chronic subdural hematoma (CSH) carries significant morbidity and mortality in the elderly because they are a fragile population. As military neurosurgeons, we perform a simplified technique under local anesthesia using a manual craniotome. METHODS: We present the case of an 85-year-old woman suffering from a right-sided CSH causing confusion and severe left-sided hemiparesis. CONCLUSION: After the procedure, the patient presented immediate neurological improvement. Performing manual BHE of symptomatic CSH under local anesthesia is safe, and it is of great interest for very old patients or in case of strained resources, thus we think that this technique should be taught to every young neurosurgery resident.

Neurosurgery for intracranial meningioma in patients aged more than 80 years: benefits and rationale.

BACKGROUND: Elderly patients with symptomatic benign intracranial tumours such as meningioma pose particular problems in decision making. We report on the outcome, morbidity and mortality in patients aged over 80 years after undergoing cranial surgery for meningiomas. METHODS: In this retrospective study, 37 patients aged more than 80 years underwent surgery at our neurosurgery department. The Karnofsky Performance Scale (KPS) was used to assess functional status. The American Society of Anesthesiologists (ASA) classification system, the Geriatric Scoring System, the Clinical-Radiological Grading System and the Sex, Karnofsky, ASA, Location and Edema score were used to define clinical status and tumour characteristics. The Charlson Comorbidity Index and Clavien-Dindo classification scores reflected therapeutic morbidity. RESULTS: Preoperative KPS scores were generally higher than 60 (n = 32). Of the 37 patients, 24 (64.8%) were in ASA class I or II, and 27 (73.0%) had one or more comorbidities. The median length of follow-up was 80.0 months (range: 1-96 months). The 1-year mortality rate was 2.7% (n = 1). Tumour control was achieved in 33 patients. At discharge, KPS scores were improved in 21 patients (with an average gain of +18.1 ± 8.7), stable in 10 patients and poorer in 6 patients. KPS scores improved or were stable in patients with shorter lengths of hospital stay (15.5 ± 17.9 days vs 51.4 ± 25.4 days; p < 0.01), those with Clavien-Dindo scores lower than 2 (p < 0.01) and those with less favourable preoperative KPS scores (69.4 ± 10.9 vs 82.0 ± 11.0; p = 0.04). CONCLUSION: Historically, surgery for intracranial meningiomas in patients aged >80 years has been feasible; this series demonstrated decreasing rates of postoperative mortality. Functional benefit should be the main goal of surgery. Perioperative morbidity should be better assessed and predicted because it significantly influences functional outcomes.

A summer wave of vertebral fractures: the "deck-slap" injury.

BACKGROUND: Every summer, several patients who suffer from vertebral fractures are hospitalized at the Sainte-Anne Military Hospital after going on a boat trip around the French Riviera. The uniqueness of these fractures lies in their mechanism of injury, called the "deck-slap" injury. The aim of this study is to describe the characteristics of the "deck-slap" injury. METHODS: The data of 26 vertebral fractures that occurred during boat trips between January 2010 and September 2017 were collected and analyzed. RESULTS: The mechanism of injury observed was similar for every patient. Patients sitting on the front of the boat, or bow, (77% of cases, n = 20); patients being on a rigid-inflatable boat (65% of cases, n = 17); and when the sea state was calm (62% of cases, n = 16). The patients were bounced up in the air because of a strong wave and landed in a sitting position. The affected population was young (mean age of 42.5 years) and women were the main victims (sex ratio of 0.3). The lesion topography was found near the thoracolumbar junction in each case. It was always a vertebral body compression. Twenty-three percent of them (n = 6) suffered from neurologic complications. CONCLUSION: This type of fractures, frequently encountered during the summer, has not previously been described in the literature, yet is a relevant cause of hospital admissions to the emergency departments of the south of France. A better knowledge of this mechanism would provide a more efficient approach to prevention measures that should be imposed to potential boat passengers.

Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment.

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.

Fatal acute disseminated encephalomyelitis (ADEM) after third ventricle colloid cyst resection with ultrasonic aspirator during neuroendoscopic procedure.

We present the case of a patient who died of a fatal meningoencephalitis after removal of a third ventricle colloid cyst. Postoperative clinical and iconographic evolution let us think about an acute disseminated encephalomyelitis probably due to cerebrospinal fluid contamination by inflammatory proteins contained in the colloid cyst. This case raises the question of a possibility of colloid cyst content spraying while using an ultrasonic aspiration device.

Duret Brainstem Hemorrhage Secondary to Large Supratentorial Meningioma.

A 75-year-old female patient was admitted following head trauma responsible for an acute-onset neurological worsening with a Glasgow Coma Scalescore of 6. Computed tomography scan revealed a large bifrontal meningioma with extralesional bleeding causing cranio-caudal transtentorial brain herniation. Despite emergency surgical excision of the tumor using craniotomy, the patient remained comatose. The brain magnetic resonance imaging revealed a Duret brainstem hemorrhage of the upper and middle pons, associated with supratentorial decompression-related brain injuries. One month later, the patient was withdrawn from life support. To our knowledge, tumor-induced Duret brainstem hemorrhage has never been reported.

The Origin of Surrealism: Rethinking Apollinaire's Penetrating Brain Injury with Current Knowledge Regarding White Matter Tracts.

The French poet Apollinaire enrolled in the French army during World War I. In 1916, he sustained a penetrating brain injury when a fragment of shrapnel pierced his helmet in the right temporal region. Neurosurgical techniques were at that time standardized to manage the significant number of war-related neurosurgical casualties. Apollinaire, who experienced transient fainting followed by left-sided hemiparesis 2 months after his trauma, underwent trepanation. The poet's personality and behavior changed dramatically after his trauma. These neurobehavioral changes, associated with preserved cognition and no other neurologic dysfunction, were later described as Apollinaire syndrome. These personality changes were accompanied by flourishing writing changes. Hence, 15 months after his penetrating brain injury, the poet introduced the term "surrealism" to the world in his play The Breasts of Tiresias, giving birth to a major movement that paved the way for the 20th century. Linguistic shifts such as phonologic and semantic word games were at the forefront of the narrative process of the play. Traumatic brain injury often leads to cognitive impairment. In the case of Apollinaire, if the ballistic trauma were also responsible for diffuse axonal injury, it could have also led to semantic and social cognition impairment, in addition to the neuropsychological disorders that had already been widely documented by his friends and family. The world will always remember Apollinaire's writing genius as deeply associated with the birth of surrealism. But what if the poet's new writing style was caused, at least in part, by the unexpected help of a lost shrapnel fragment?

Neurosurgical Consultation Referral from the Forces: Regarding 328 Patients Referred to the Department of Neurosurgery, Sainte Anne Military Hospital, France.

INTRODUCTION: There are little data regarding elective referral to the military specialist, especially considering common pathologies such as spinal diseases, which, in the French forces, involve military neurosurgeons. An overview of the management of the military patient referred to neurosurgery consultation, especially considering spinal diseases that both constitute an operational healthissue in the forces and appear of special interest. The objective was to describe the reasons, demographics, and care pathways, addressed to the neurosurgeon. MATERIALS AND METHODS: This retrospective, single-center study focused on all military patients referred for neurosurgery consultation at Sainte Anne Military Hospital in Toulon. Extracted data included demographic characteristics, army, unit, military specialty, the reason for referral, the diagnosis by the neurosurgeon, treatment, and outcome. RESULTS: From January 2018 to December 2019, 352 patients were referred for neurosurgical consultation by the unit general practitioner. Spinal disease (n = 297, 91%) was the most frequent reason. Lumbar degenerative disk disease accounted for 20% of consultations, regardless of the patient's unit or specialty. Most of the patients seen in consultation received nonsurgical management (n = 271, 82.6%). These patients mainly presented with cervical or lumbar degenerative disk disease (n = 99, 36.5%) or cervical or lumbar herniated discs (n = 57, 21.0%). Ninety-eight patients (29.9%) were referred exclusively for medical fitness assessment. Few patients experienced full resolution of their presenting complaint after management (n = 9, 2.8%). CONCLUSIONS: This descriptive study demonstrates the predominance of degenerative spinal diseases in military patients referred to neurosurgery. It reflects the importance of the medical and military competence required to maintain operational capability upstream and downstream of war traumatology. The description of the care pathways invites us to define more proactive multidisciplinary pathways for the management of these diseases in the armed forces.

Application of a Near-infrared Spectroscope by an Extreme Forward Medical Team for the Triage of Casualties With Traumatic Brain Injury.

BACKGROUND: During deployment of military medical teams similarly to prehospital practice, without immediate computed tomography scan access, identifying patients requiring neuro-specific care to manage pragmatic triage proves crucial. We assessed the contribution of this portable near-infrared spectroscope (NIRS) handheld device, Infrascanner Model 2000 (InfraScan Inc.; Philadelphia, PA), to screen patients suspected to require specific neurosurgical care. MATERIALS AND METHODS: This single-center retrospective analysis was based on the data from the medical records of the traumatic brain injured patients. We analyzed all the patients strictly over 18 years old presenting a clinical history of traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) < 15. RESULTS: Thirty-seven medical records of patients admitted for TBI met the inclusion criteria for our analysis. The median GCS was 9 [3-14]. Eight patients (21.6%) underwent neurosurgery and 25 (67.6%) required intensive care unit (ICU) admission, after initial assessment and resuscitation. The NIRS was the most sensible to detect intracranial hematoma (n = 21), intracranial hematoma leading to surgery (n = 8), and intracranial hematoma leading to admission in ICU (n = 25). Its negative predictive value was 100% regarding hematomas leading to surgery. False-positive results were encountered in 10 cases (27.0%). Excluding cases harboring confounding extracranial hematomas, parietal area was still the most represented (n = 3). CONCLUSION: The NIRS was relevant to detect hematoma leading to prompt surgery in our study. The lack of specificity in a nonselected cohort of patients underlines the need to associate simple clinical feature such as neurological deficit and NIRS results to perform rational triage.

Neurosurgical management of penetrating brain injury during World War I: A historical cohort.

During World War I, 25% of penetrating injuries were in the cephalic region. Major Henri Brodier described his surgical techniques in a book in which he reported every consecutive penetrating brain injury (PBI) that he operated on from August 1914 to July 1916. The aim was to collate his data and discuss significant differences in management between soldiers who survived and those who died. We conducted a retrospective survey that included every consecutive PBI patient operated on by Henri Brodier from August 1914 to April 1916 and recorded in his book. We reported medical and surgical management. Seventy-seven patients underwent trepanation by Henri Brodier for PBI. Regarding injury mechanism, 66 procedures (86%) were for shrapnel injury. Regarding location, 21 (30%) involved the whole convexity. Intracranial venous sinus wound was diagnosed intraoperatively in 11 patients (14%). Postoperatively, 7 patients (9%) had seizures, 5 (6%) had cerebral herniation, 3 (4%) had cerebral abscess, and 5 (6%) had meningitis. No patients with abscess or meningitis survived. No significant intergroup differences were found for injury mechanism or wound location, including the venous sinus. Extensive initial surgery with debridement must be prioritized. Infectious complications must not be neglected. We should not forget the lessons of the past when managing casualties in present-day and future conflicts.

Spinal Fractures during Touristic Motorboat Sea Cruises: An Underestimated and Avoidable Phenomenon.

PURPOSE: Each summer, many vacationers enjoy the Mediterranean Sea shores. Among the recreational nautical activities, motorboat cruise is a popular choice that leads to a significant number of thoracolumbar spine fractures at our clinic. This phenomenon seems to be underreported, and its injury mechanism remains unclear. Here, we aim to describe the fracture pattern and propose a possible mechanism of injury. METHODS: We retrospectively reviewed the clinical, radiological, and contextual parameters of all motorboat-related spinal fracture cases during a 14-year period (2006-2020) in three French neurosurgical level I centers bordering the Mediterranean Sea. Fractures were classified according to the AOSpine thoracolumbar classification system. RESULTS: A total of 79 patients presented 90 fractures altogether. Women presented more commonly than men (61/18). Most of the lesions occurred at the thoracolumbar transition region between T10 and L2 (88.9% of the levels fractured). Compression A type fractures were seen in all cases (100%). Only one case of posterior spinal element injury was observed. The occurrence of neurological deficit was rare (7.6%). The most commonly encountered context was a patient sitting at the boat's bow, without anticipating the trauma, when the ship's bow suddenly elevated while crossing another wave, resulting in a "deck-slap" mechanism hitting and propelling the patient in the air. CONCLUSIONS: Thoracolumbar compression fractures are a frequent finding in nautical tourism. Passengers seated at the boat's bow are the typical victims. Some specific biomechanical patterns are involved with the boat's deck suddenly elevating across the waves. More data with biomechanical studies are necessary to understand the phenomenon. Prevention and safety recommendations should be given before motorboat use to fight against these avoidable fractures.

Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study.

INTRODUCTION: To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS: We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS: The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION: Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

Far-Lateral Approach for Foramen Magnum Meningioma: An Anatomical Study with Special Reference to Bulbopontine Junction.

Intracranial meningiomas are sometimes located anteriorly to the foramen magnum and can cause disabling long tract symptoms. The far-lateral approach has been developed to provide an extensive view over the bulbopontine junction and the surrounding lower cranial nerves and upper spinal nerves with a good control on the vertebral artery, allowing the safe resection of such tumors. It is the report of a case with anatomical study before and after the removal of the meningioma. The use of the far-lateral approach allowed us to (1) control the vertebral artery in its V3 (Atlantic extradural) and V4 (intradural) portion (2) have an optimal visibility on the lower cranial nerves, the upper spinal nerves, and the bulbopontine junction, and (3) perform a Simpson 2 resection of the tumor that was inserted between the lower clivus and the upper odontoid process. Beyond its interest for the safe resection of tumors located anteriorly to the foramen magnum, the far-lateral approach is of particular anatomical interest. It allowed us to review the anatomy of the craniocervical junction.

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept.

Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods: A scoping review was conducted on Medline database from inception to September 2021. Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.