[Clinical aspects and treatment of dural-spinal arteriovenous fistulas with perimedullary venous drainage. 10 cases]. / Aspects cliniques et traitement des fistules artério-veineuses durales rachidiennes à drainage veineux périmédullaire. A propos de 10 observations.

BACKGROUND AND PURPOSE: Spinal dural arteriovenous fistulas (SDAVF) are rare but represent the most frequent spinal arteriovenous malformation. Their clinical manifestations are well known, but their management can still be discussed between surgery and endovascular treatment. The purpose of this study is to emphasize the pre-eminence of surgical management for posterior and postero-lateral fistulas, which are the most common location of the malformation. METHODS: We report a consecutive series of 10 patients with SDAVF treated between July, 1995 and July, 1997. Results are compared with other series of the literature. RESULTS: Clinical manifestations were not specific and the diagnosis was established in most cases only one year after the onset of symptoms, as a progressive myelopathy. Low back pain was present in 4 patients, with pseudo-radicular pain in the lower limbs suggesting spinal degenerative disease in 3 cases. At the time of diagnosis, 8 patients had permanent motor weakness of the lower limbs, usually associated with hypesthesia and sphincterial dysfunction (7 cases). In all cases, the diagnosis was established using MRI. In most cases, the intradural draining spinal veins were also visible on MRI images. The location of the SDAVF was always precised by angiography, and was located between T5 and L1 in our series. Seven patients were successfully operated on, with surgical interruption of the intradural draining vein. Three patients underwent an endovascular treatment, but two of them were operated on later, as control angiography showed recurrence of the SDAVF. The clinical status of patients always improved after treatment, but recovery was incomplete in patients with severe and long lasting neurological deficit. CONCLUSIONS: Surgical interruption of the intradural draining vein is a safe and effective method of treatment of SDAVF, especially for posterior and postero-lateral fistulas. Endovascular treatment is recommended for anterior locations of SDAVF.

[Acquired lesions of the corpus callosum]. / Lésions acquises du corps calleux.

Acquired lesions of the corpus callosum may be related to tumoral, vascular, traumatic or degenerative disorders and, one must not forget, can result from surgical access. Currently, the quality of neuroimaging enables a validation or precision of anatomoclinical, neuropsychological and neurophysiological correlations established from experimental and/or autopsy data. However the "specific" signs of acquired lesions of the corpus callosum are often quite complex and may be readily overlooked or masked within a heterogeneous clinical presentation due to more or less important associated lesions of neighboring structures. Therapeutic management (tumors, arteriovenous malformations, cavernomas) depend on the nature and the extent of the lesion more than the functional nature of this inter-hemispheric commissure with an exceptional functional plasticity, particularly when the lesion is limited.

Strategy of craniofacial reconstruction after resection of spheno-orbital "en plaque" meningiomas.

Surgical resection of spheno-orbital "en plaque" meningiomas should be as complete as possible to prevent tumor recurrence and therefore requires a bone reconstruction. We report a series of 20 patients operated on for spheno-orbital "en plaque" meningioma between 1981 and 1993. The surgical treatment included a resection of the involved dura and a wide resection of tumoral bone using a fronto-temporal craniotomy extended to the orbitozygomaticomalar bone ridge. The craniofacial reconstruction was performed in the same operative procedure using iliac bone autograft in 11 patients, internal cortical bone from the bone flap in 8 patients, and a coral graft in 1 patient. The cosmetic result was scored according to the following criteria: superior frontal paralysis, appearance of the orbitomalar bone ridge, shape of the external temporal fossa, and projection of the eyeballs. The cosmetic result was scored as excellent or good in 17 patients, average in 2 patients, and poor in 1 patient. The iliac bone autograft appeared to be the best material for craniofacial reconstruction because it could be modeled easily to the desired shape. However, the reconstruction technique was modified as necessary according to the extent of tumor removal, clinical presentation, and age of the patient.

[Results of hearing preservation in surgery of vestibular schwannoma. Value of combined retrosigmoid and middle fossa approaches]. / Résultats de la conservation de l'audition dans la chirurgie du schwannome vestibulaire. Intérêt de la voie combinée sus-pétreuse et rétrosigmoïde.

We report our experience of hearing preservation in acoustic neurinoma surgery, using combined retrosigmoid and middle fossa approaches. Fifty neurinomas operated on between 1987 and 1994 were included in this retrospective study. Hearing preservation surgery was performed for patients with grade II or grade III tumors (mean average tumor diameter: 14.4 mm), presenting with normal or serviceable pre-operative hearing (pure tonal average decrease less than 50 dB, speech discrimination score better than 50%). Isolated middle fossa approach was used in 3 cases, isolated retrosigmoid approach in 2 cases. The 45 other cases were operated on using both routes during the same procedure. Total removal of the tumor with anatomic facial preservation was performed in all cases. No death occurred. The facial function assessed 3 months after surgery was good in 84% of cases (House-Brackmann grades I or II). The mean follow-up was 42 months. Post-operative hearing was measurable in 48% of cases and serviceable in 30% of cases. The size of the tumor and the level of preoperative hearing appear to be the most important predictive criteria for successful hearing preservation.

[Sacral nerve root cysts. Discussion on the mechanism of nerve root suffering. Apropos of 4 cases]. / Kystes périradiculaires sacrés. Discussion du mécanisme de souffrance radiculaire. A propos de quatre observations.

Low back pain, sciatia or perineal chronic pain are sometimes related to perineural sacral cysts. Surgical treatment is difficult and may lead to pain or neurological worsening. We report four cases of symptomatic perineural cysts; three of them where operated on with two good results and one increasing perineal pain. Anatomical and radiological description are reviewed. From a therapeutical point of view, we can distinguish two clinical types of radicular suffering. Perineural cyst can cause a commun radicular extrinsic compression; in such a case surgical operation will improve radicular pain. The cystic nerve root can present an intrinsic suffering because of on intradural dilaceration. Then surgery must be avoided specially when many roots are involved because it may worsen the pluriradicular suffering.

[Value of peroperative endoscopy in treating giant lumbosacral meningocele]. / Intérêt de l'endoscopie per-opératoire dans le traitement d'une méningocèle géante lombo-sacrée.

Lombosacral meningocele may be responsible for sciatica, low backache, cauda equina syndrome according to their localization and size. When they are symptomatic, the surgical purpose is to close the communication between the meningeal sac and the cyst. For giant meningocele, acute localization of the communication may be difficult. In such cases, peroperative endoscopy may be useful. We present a case of sciatica related to a giant meningocele extended from L2 to S2. MRI, CT scan and myelography were unable to localize the communication. We used peroperative endoscopy for direct visualization of the communication in order to minimize the surgical approach. An intrathecal nerve root was found strangulated in the communication suggesting an original kind of nerve root suffering. The communication was only closed. The patient made an uneventful recovery with complete relief of symptoms. Magnetic resonance imaging 3 months later showed a significant decrease of the meningocele without any further radicular compression.

Cervical myelopathy secondary to Hunter syndrome in an adult.

We present a case of type II mucopolysaccharidosis in which the diagnosis was delayed until the onset of cervical myelopathy in adulthood. Radiographic features were characteristic, with striking dural thickening shown on CT and MR imaging.

Intradural epidermoid cysts of the cerebellopontine angle: diagnosis and surgery.

We report on our recent experience with epidermoid cysts in the cerebellopontine angle. We operated on nine patients since 1985, seven of which were investigated with magnetic resonance imaging. Since the arrival of modern neuroimaging, large lesions can be found with only discrete symptoms, such as isolated tinnitus or unspecific headache. With computed tomography and magnetic resonance imaging, preoperative diagnosis was achieved for most patients; sometimes, however, epidermoid cysts may be very similar to arachnoid cysts. Surgery is the only possible treatment. The decision to operate should be carefully discussed for each patient, particularly if the patient is asymptomatic. The extent of the lesion at the anterior aspect of the brain stem, and sometimes above the tentorium cerebelli, fragile cortex, and vessels, and hazards of postoperative chemical meningitis often make such surgery difficult. The surgeon should not attempt total removal of the cyst membrane. Most patients who undergo surgery, however, recover well, with no or few sequelae. With a mean 3-year follow-up, no recurrence occurred, despite partial removal, as a result of the peculiarly slow growth of these lesions.

[Cranio-cerebral dermoid and epidermoid cysts. Classification and pathogenesis]. / Les kystes dermoïdes et épidermoïdes crânio-encéphaliques. Classification et pathogénie.

The pathogenesis of cranial dermoids and epidermoids is still controversial, owing to the multiple etiologies and locations of these lesions. We reviewed 25 cases, classified as follows: extradural lesion of the calvarium; of the occipital squama; dysraphic occipital lesions; and strictly intradural lesions. In the latter group, all lesions but one were in a paramedian, prenevraxial situation, and could be classified according to their situation relative to the tentorium cerebelli. In our series, strictly intradural dermoids are more often in a rostral situation, and epidermoids in a more caudal situation. Dermoids appear earlier in life than epidermoids, suggesting a more rapid growth due to eccrine secretion. For each group of lesions, the pathogenic hypotheses are studied. Inclusion of epidermal nests at different levels might result from traumatism, dysraphism, or developmental trouble in the lamination of the different layers of the meninges. Most intradural lesions trent to be related to the formation of Rathke's pouch and closure of the anterior neuropore.

Carcinomatous meningitis in a case of anaplastic meningioma.

Malignant meningiomas are associated with a high rate of local recurrence, but seldom give remote metastases. Here, we report a case with carcinomatous meningitis occurring 13 months after treatment of the initial tumor. MRI showed no significant abnormalities. CSF contained abnormal cells, and electronic microscopy after cytocentrifugation confirmed their identity with the initial tumor.

[Long-term results of the surgical treatment of spheno-orbital osteomeningioma]. / Résultats à long terme du traitement chirugical des ostéo-méningiomes sphéno-orbitaires.

The authors report a series of 21 cases of spheno-orbital "en plaque" meningiomas operated on between 1981 and 1993. All patients underwent surgery via fronto-temporal approach with orbito-zygomatic removal, followed by bone reconstruction. A complete tumor resection was performed in 15 cases. In the remaining patients, tumor resection remained subtotal, as the cavernous sinus was involved. Histological examination disclosed a low grade meningioma in 17 cases, high grade meningioma in the other patients. Radiation therapy was performed in 5 patients, when the tumoral resection was incomplete or for high grade meningiomas. The mean follow up was 7 years. One patient died in the post-operative course. Transient ophthalmoparesis occurred in 9 cases, 2 patients had pre-operative oculomotor palsy related to tumoral extension in the cavernous sinus and remained unchanged. Visual acuity remained unchanged after surgery in all patients who presented with normal visual acuity. It was unchanged or improved in 63% of patients who presented with moderate visual impairment. Despite the extent of the bone resection, the cosmetic results were good or excellent in 75% of patients, fair in 17%, and bad in 8%. Recurrence of the tumor occurred in 3 patients, with high-grade meningiomas (2 cases) or after subtotal removal of a low-grade meningioma (1 case). Orbito-fronto-temporal approach is necessary to complete the resection of the tumor extended in the orbit, the orbital fissures or the optic canal. Early operation allows a complete tumor resection before the tumor extends to the cavernous sinus.

Solitary brain metastasis as only recurrence of a carcinoma of the bladder.

A case of solitary brain metastasis from a transitional carcinoma of the bladder occurring 20 months after resection is presented. The patient underwent gross total removal followed by external irradiation and intravenous chemotherapy. The tumor in this quite unusual occurrence had a very characteristic aspect, both operatively and at pathologic examination. We believe that these patients should be managed aggressively whenever possible.

Foraminal lumbar disc herniation. Experience with 83 patients.

STUDY DESIGN: This study analyzed a series of 83 patients operated on for foraminal lumbar disc herniation. OBJECTIVES: This study sought to develop clinical and radiologic diagnoses, evaluate interlaminar and extra-articular exposures, and evaluate postoperative results. SUMMARY OF BACKGROUND DATA: Some authors have reported a specific clinical syndrome, but other reports have indicated the clinical picture is indistinguishable from usual posterolateral disc herniation. Surgical management often has been compared between the interlaminar and extra-articular approaches. METHODS: Clinical findings were reviewed. All patients were evaluated with computed tomography, but radiologic diagnosis required computed tomographic discography for 26 patients. Interlaminar exposure with partial medial facetectomy was performed in 73 patients and an extra-articular approach was necessary in 10 patients. Postoperative results were evaluated with a 2-year follow-up. RESULTS: Foraminal lumbar disc herniations have a specific clinical picture, particularly severe radicular signs. Precise preoperative radiologic evaluation is essential for successful operative procedure. Postoperative results were good in 76% of the patients. The other patients felt mild residual radicular pain, although no residual root compression was found on postoperative computed tomography. Only 21% of the patients that had a radicular deficit recovered totally. CONCLUSIONS: Foraminal lumbar disc herniation involves characteristic clinical features. Radiologic diagnosis requires high-resolution computed tomography, computed tomographic discography, or magnetic resonance imaging. Most foraminal lumbar disc herniations are reached through the interlaminar exposure extended to the upper lamina and medial facet without total facetectomy. An extra-articular approach should be reserved for extra-foraminal herniations.

Association of Lhermitte-Duclos and Cowden disease: report of a new case and review of the literature.

Lhermitte-Duclos disease is a rare entity, and its pathological features are unique. Pathological findings are characteristic of the disease, with global hypertrophy of the cerebellum, coarse gyri, and the typical "inverted cortex" pattern. Several associated lesions were noted in many patients with Lhermitte-Duclos disease. It is only recently that an association between Lhermitte-Duclos disease and Cowden disease was reported. Cowden disease, or multiple hamartomas syndrome, is a familial disease associating breast cancer, cutaneomucous tricholemmomas, and various other tumoural and dysplasic conditions. A new case of Lhermitte-Duclos disease associated with Cowden disease is reported. A review of the literature found 72 cases of Lhermitte-Duclos disease; 26 had conditions suggesting Cowden disease and seven were definite cases of Cowden disease. The association of Lhermitte-Duclos disease and Cowden disease is probably underestimated. Cowden disease represents a new form of phakomatosis; Lhermitte-Duclos disease may occur as a sporadic disease, or as part of familial Cowden disease. The possibility of preneoplastic states in Cowden syndrome stresses the importance of a thorough screening when Lhermitte-Duclos disease is diagnosed.

Association of occurrence of aneurysmal bleeding with meteorologic variations in the north of France.

BACKGROUND AND PURPOSE: Previous reports have established that the incidence of stroke may be influenced by meteorologic variations. However, no significant correlation was clearly demonstrated concerning aneurysmal bleeding. METHODS: From January 1, 1989, to December 31, 1991, 238 patients with angiographically confirmed diagnoses of subarachnoid hemorrhage were registered in the North of France region. For each day, the weather variables were provided by the national meteorologic office (Meteo France). We compared the meteorologic variables of days when subarachnoid hemorrhage occurred with the variables of days without subarachnoid hemorrhage in a multivariate model. RESULTS: We observed a seasonal pattern in the occurrence of subarachnoid hemorrhage, with a low frequency of rupture in June and July and maximum frequency in April and September (P < .05). The days of occurrence were associated with short duration of sunshine (P < .00006), low minimal level of hygrometry (P < .0002), low maximal temperature (P < .005), and low atmospheric pressure the day before the event (P < .05). CONCLUSIONS: Aneurysmal bleeding was significantly associated with weather variables. Cold-induced hypertension may explain these fluctuations in the occurrence of aneurysmal bleeding.

[Cerebral tumors and pregnancy. Apropos of 8 cases]. / Tumeurs cérébrales et grossesse. A propos de huit cas.

Pregnancy is an aggravating factor for brain tumours on which it acts by three mechanism: acceleration of tumour growth, increase of peritumoral oedema and the immunotolerance to foreign tissue antigens that is proper to pregnancy. Histologically, the brain tumour most frequently encountered is glioma, usually revealed during the third trimester. Brain tumours is pregnant women have no special clinical features, and their diagnosis rests on computerized tomography or nuclear magnetic resonance completed, if required, by stereotactic biopsy. Following a review of the literature, the authors present an updated description of the neurological and obstetrical actions to be taken, illustrated by a report of eight personal cases. The indications for surgery depend on the site and histological nature of the tumour. As regards obstetrical measures, induced therapeutic abortion and caesarean section, no longer routinely performed, are now being replaced by vaginal delivery with systematic instrumental extraction. In both mother and foetus the prognosis has improved over the last ten year, but it remains very sombre.

Control of tremor and involuntary movement disorders by chronic stereotactic stimulation of the ventral intermediate thalamic nucleus.

The authors report on the long-term results of chronic stereotactic stimulation of the ventralis intermedius thalamic nucleus performed in 14 cases of disabling and intractable tremor. There were 10 patients with parkinsonian tremor and four with essential tremor. Three of the 10 parkinsonian patients had previously undergone contralateral thalamotomy. Tremor was assessed by clinical evaluation, surface electromyography, accelerometer, and videotape recordings before and after stimulation. The deep-brain electrode was implanted in the ventralis intermedius nucleus according to stereotactic procedure and connected to a subcutaneous pulse generator after a stimulation test period. Tremor suppression or reduction was obtained in all cases with high-frequency (130 Hz) stimulation. Marked functional improvement was maintained in 11 patients with a mean follow-up interval of 17 months. Levodopa-induced dyskinesias observed in five parkinsonian patients prior to surgery were improved or suppressed in four cases by thalamic stimulation. Stimulation was continued during the day and stopped at night in eight cases. Six patients were stimulated night and day to avoid a rebound effect which appeared as soon as the pulse generator was stopped. The only side effects were hand tonic posture in one case and persistent paresthesia in another case. The mechanism of action of this attractive treatment may be a functional alteration of the thalamic discharging area. The authors conclude that this technique is a good alternative to thalamotomy, especially when the risks of high-frequency coagulation are severe in frail and older patients.

[Cerebral aneurysms and pregnancy: 4 cases]. / Anévrysmes cérébraux et grossesse: 4 cas.

Haemorrhagic cerebral accidents are the commonest neurosurgical diagnoses made in pregnancy. The state of pregnancy makes it more likely that an arterial or an arteriovenous aneurysm will rupture and this is the principal cause of most haemorrhages. They occur more often in primiparae in the third trimester of pregnancy. The clinical picture is classical. The conformation of the diagnosis is made by scanning and angiography. The main differential diagnosis is eclampsia. Neurosurgical treatment should be carried out immediately whenever possible in order to avoid the two great risks that follow, namely recurrence of haemorrhage and secondly ischaemia. As far as the obstetric side is concerned, Caesarean section would only be indicated if: the clinical state of the mother is severe with coma and brain stem damage when the child is viable, if there is symptomatic vascular malformation diagnosed at term, if there is haemorrhagic arteriovenous malformation which is highly liable to occur and cannot be operated on without risks for the child if viable, if, finally, the interval between the surgical treatment of the condition and labour is less than 8 days. In all other cases a vaginal delivery is preferable under epidural anaesthetic which should be given if medical induction is carried out, and where instrumental delivery is being carried out systematically, unless radical treatment is being performed. The prognosis which is, in spite of all steps that may be taken, poor, depends on the initial neurosurgical stage and the nature of the causes of lesion and the possibilities of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hydrocephalus with cerebrospinal fluid shunts and pregnancy: 2 cases]. / Hydrocéphalie appareillée et grossesse: 2 cas.

During pregnancy 50% of all cases with a ventriculo-peritoneal shunt malfunction. This is because of anatomo-physiological changes associated with the pregnant state, and shows itself as a rise in intracranial tension. There were no acute neurological complications at term; with the malfunction of the shunt distally, vaginal delivery is preferable. It is not necessary routinely to carry out instrumental delivery.

The stereotactic approach to brain stem lesions: a follow-up of 29 cases.

Stereotactic biopsy is the safest and most reliable method for the histological diagnosis of intraaxial brain stem lesions. The definitive pathological diagnosis permits the selection of adequate therapy. No operative and/or adjuvant therapy must be proposed without a previous histological diagnosis. This approach avoids the complication of inappropriate therapy and provides valuable prognostic information.