[Ruptured dermoid cyst]. / L'image du mois. Rupture de kyste dermoïde.

We report the case of a 28-year-old male admitted to the emergency department for generalized seizure. A brain computed tomography (CT) revealed a ruptured dermoid cyst of the supra-tentorial stage (multiple drop-shaped fat structures were found in the subarachnoid space, basal cisterns and in ventricular system). An additional magnetic resonance imaging (MRI) was conducted to confirm the CT findings.

Nous rapportons le cas d'un homme de 28 ans admis aux urgences pour une crise comitiale généralisée. Une tomodensitométrie (TDM) cérébrale initiale a mis en évidence une rupture de kyste dermoïde de l'étage supra-tentoriel (de multiples structures graisseuses en forme de gouttelettes ont été trouvées au sein de l'espace sous-arachnoïdien, des citernes de la base et dans le système ventriculaire). Une imagerie par résonance magnétique (IRM) complémentaire a été réalisée afin de confirmer les résultats de la TDM.

[Cytotoxic lesion of the corpus callosum (CLOCC) in a context of viral meningitis]. / Le cas clinique du mois. Lésion cytotoxique du corps calleux (CLOCC) dans un contexte de méningite virale.

We report the case of a young patient of 16 years admitted in the emergency department for headache, nausea and vomiting, of brutal installation. After clinico-biological confrontation, the diagnosis of viral meningitis (aseptic) was made. During the initial assessment several complementary examinations and various brain imaging exams (CT, MRI) were performed in the course of the treatment, showing a focal lesion of the splenium of the corpus callosum, with transient aspect and spontaneously resolving during iterative control. MRI is the modality that formally revealed this callosal lesion. In terms of signaling behavior, this lesion is characterized by an hyperintensity on FLAIR/T2 weighted sequence and a restriction of diffusion (cytotoxic edema). No other signaling abnormalities or malformative lesions are found. The iconographic diagnosis of «cytotoxic lesions of the corpus callosum¼ (CLOCC for «Cytotoxic lesion of the corpus callosum¼) was made.

Nous rapportons le cas d'une jeune patiente de 16 ans admise dans le service des Urgences pour céphalées, nausées et vomissements, d'installation brutale. Après confrontation clinico-biologique, le diagnostic de méningite virale (aseptique) est posé. Lors du bilan initial, plusieurs examens complémentaires et imageries cérébrales (TDM, IRM) ont été réalisées dans le décours de la prise en charge, démontrant une lésion focale du splénium du corps calleux, d'aspect transitoire et spontanément résolutive, lors de contrôles itératifs. L'IRM est la modalité qui a permis de mettre en évidence, de manière formelle, cette lésion calleuse. En termes de signal, cette lésion est caractérisée par une hyperintensité sur les séquences FLAIR/T2 et une restriction de la diffusion (œdème cytotoxique). Aucune autre anomalie de signal ou lésion malformative n'ont été mises en évidence. Le diagnostic iconographique de «lésion cytotoxique du corps calleux¼ (CLOCC pour «Cytotoxic lesion of the corpus callosum¼) a été posé.

[An unexpected finding in a 14-year-old girl]. / Le cas clinique du mois. Découverte inattendue chez une jeune fille de 14 ans.

A 14-year-old girl was admitted to the Emergency department for abdominal pain. An abdominal mass of 7-8 cm was detected and surgically resected. At anatomopathology a solid pseudopapillary neoplasm of the pancreas was observed. This tumour is rare and is included in the pancreatic cystic neoplasms. It frequently concerns 20-30-year-old girls. In all cases, the treatment consists of surgical resection, even in the rare cases with metastases. Prognosis is usually good, but careful follow-up is mandatory.

[Esthesioneuroblastoma: a case report and literature review]. / Esthésioneuroblastome: à propos d'un cas et revue de la littérature.

Esthesioneuroblastoma (ENB) or olfactive neuroblastoma is a rare cancer arising from the neuroepithelium of the olfactory epithelium of the nasal cavity. Sinusal, orbital and intracranial expansions are common. The anatomopathological diagnosis will frequently require immuno-histochemical tests and sometimes electron-microscopy as well as genetic testing. Medical imaging with CT scan and MRI is essential for the stadification. Treatment will generally associate debulking or curative surgery (with combined rhino-neurosurgical accesses) and conformal stereo-tactic radiotherapy. Chemotherapy was generally reserved for palliative cases; it can be now proposed as neoadjuvant treatment. Most patients will relapse; thus the follow-up will remain ad vitam.

[Clinical case of the month. Computerized tomographic diagnosis of hematoma of the rectus abdominis muscle]. / Le cas clinique du mois. Diagnostic scanographique d'un hématome du muscle droit de l'abdomen.

The development of an acute abdominal pain and of a palpable mass following a muscular strain, such as after coughing or sneezing, are features higly suggestive of an abdominal wall hematoma in the patient with predisposing factors. The diagnosis is often difficult since the condition mimics the clinical features of other abdominal pathologies. The diagnostic accuracy has significantly improved however after the advent of ultrasonogarphy and of computed tomography. Once the diagnosis is confirmed, the patient should be treated conservatively since surgery entails the risk of various complications.

Spontaneous tracheal rupture: a case report.

We report the case of a spontaneous posterior tracheal wall rupture following a cough. A 67-year-old woman with a history of longstanding treatment with corticosteroids (8 years) for Giant Cell Arteritis had general anesthesia for cataract removal. Surgery and anesthesia were uneventful. In the recovery room, the patient coughed and soon after developed subcutaneous emphysema of the neck. Chest radiography confirmed the clinical diagnosis of marked subcutaneous emphysema and showed huge pneumomediastinum and minor right pneumothorax. A thoracic CT scan revealed a large laceration of the posterior tracheal wall (a 4 cm longitudinal tear), extending from the middle of the trachea to the level of the carina. Surgical repair consisted in closure of the dilaceration using an autologous pericardial patch. It seems reasonable to suspect the facilitating role of connective tissue fragility due to chronic corticosteroid administration in the development of this tracheal rupture following cough. Tracheal rupture is a potentially lethal injury, which can be repaired successfully if the diagnosis is made early. Risk factors, diagnosis and principles of treatment of this lesion are discussed.

Duplex ultrasound as first-line screening test for patients suspected of renal artery stenosis: prospective evaluation in high-risk group.

Our objective was to assess how far the progress in ultrasound devices has increased feasibility and accuracy of Duplex ultrasound (DUS) for the diagnosis of renal artery stenosis (RAS), in a population with high prevalence of atherosclerotic renovascular lesions. Ninety-one hypertensive patients with atherosclerotic disease were prospectively evaluated by both DUS and digital subtraction angiography (DSA) of the renal arteries. Only proximal criteria (peak systolic velocity >180 mm/s or renal-to-aortic ratio >3.5) were used for the diagnosis of significant RAS (>60% narrowing). For both techniques, two readers were involved for interobserver variability study. Two hundred one arteries were demonstrated by DSA on 182 available kidneys. The prevalence of RAS among the study group was 37%. Sixteen of the 19 accessory arteries were not seen at DUS; in 8 patients, one renal artery was not seen at DUS (feasibility 91%). On the 177 arteries assessed, in comparison with DSA, DUS yielded 96, 91, and 97% mean values of accuracy, sensitivity, and specificity, respectively. Kappa for interobserver agreement was 0.95 for DUS and 0.92 for DSA. Although still unreliable for the detection of accessory arteries, DUS is in our experience an accurate and reproducible diagnostic test for RAS.

[Carotid endarterectomy without arteriography: only dedicated to urgent procedures?]. / La thrombendarteriectomie carotidienne sans arteriographie, une procedure reservee aux seules indications urgentes?

Duplex examination is presently established as a safe non-invasive and accurate method of evaluating patients with extracranial cerebrovascular disease which usually provides complete information about the extent of carotid artery narrowing Arteriography, in this indication, is an invasive procedure with a total complication rate of 3-4% with 1% of permanent stroke. If it is currently accepted that in emergency conditions (ictus ingravescens, pre-occlusive plaque) or if iodinated contrast media are contraindicated, thrombendarteriectomy can be performed without arteriography it could be extended to most cases. The authors stress the criteria to increase the number of those patients, summarize the pre-requisites to achieve this goal, and comment on the future alternative position of MRA.