Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

An evidence-based information booklet helps reduce fear-avoidance beliefs after first-time discectomy for disc prolapse.

OBJECTIVE: We aimed to assess the impact of a booklet integrating the biopsychosocial model of chronic pain management on reducing disability among patients undergoing lumbar discetomy. METHODS: In a prospective, controlled, time-series study with an alternate-month design, we enrolled 129 patients from a tertiary care university hospital after they underwent uncomplicated lumbar discectomy for the first time. The intervention group received the biopsychosocial evidence-based booklet and the control group a biomedical-based booklet; the booklets differed only in information content. Patients were blinded to treatment group. The main outcome was disability at 2 months (measured by the Quebec back-pain disability scale [QBPDS]). Secondary outcomes were fear and avoidance beliefs measured by the Fear-Avoidance Beliefs Questionnaire (FABQ). All data were collected by self-reporting questionnaires. RESULTS: At 2 months, disability did not differ between the 2 groups (QBPDS score 32.4±22.8 vs 36.1±18.7, P=0.36). FABQ physical activity score was lower with the evidenced-based booklet as compared with controls (8.0±7.14 vs 11.2±6.3, P=0.008). CONCLUSIONS: Providing an evidence-based booklet had no effect at 2 months after surgery on disability but reduced fear-avoidance beliefs about physical activity. This booklet could be an effective tool for health care professionals in helping with patient education. CLINICALTRIALS. GOV IDENTIFIER: NCT00761111.

[Intra cranial meningiomas and long term use of cyproterone acetate with a conventional dose in women. A report of two cases of tumor decrease after treatment withdrawal]. / Méningiomes intracrâniens et utilisation prolongée d'acétate de cyprotérone à dose conventionnelle chez la femme: à propos de deux cas de régression tumorale après arrêt du traitement.

The action of synthetic progestogens, prescribed at a conventional dose in women, for a meningioma, is still poorly understood, and could be related to progesterone receptors. We report two cases illustrating multiple meningiomas with stabilization or tumor reduction after withdrawal of cyproterone acetate originally prescribed for a long term period. We also review the influence of synthetic progestogens on meningiomas, particularly the impact of treatment withdrawal.

[Medico-economic analysis of a neurosurgery department at a university hospital]. / Analyse médico-économique d'un service de neurochirurgie en centre hospitalier et universitaire.

OBJECTIVE: Economic and societal constraints require to take into account the economic dimension and medical performance of hospital departments. We carried out a self-assessment study, which we thought could be useful to share with the neurosurgical community. MATERIAL AND METHODS: Care and research activities were assessed from 2009 to 2013. We used institutional and assessment-body parameters in order to describe activities and perform a financial evaluation. It was a retrospective descriptive study based on the guidelines of the DHOS/O4 circular No. 2007/390 of October 29, 2007. RESULTS: The average annual, analytic income statement was +1.39 millions euros, for 63 beds with a 92% occupancy rate, including 6.7 full-time equivalent neurosurgeons (and assistants), for 2553 patients and 1975 surgeries. The average mortality rate was 2.74%. The annual mean length of stay was 6.82 days. Per year, on average 15.6% of patients were admitted in emergency and 76.9% returned home. The annual, act-related-pricing and publication-related incomes represented 77% and 0.6%, respectively of the total funding. Difficulties to find downstream beds for the most severe patients induced 1401 "waiting days" in 2012. CONCLUSION: Medico-economic analysis of a neurosurgery department at a university hospital was useful in order to take into account the care, teaching and research activities, as well as its related financial value.

French collaborative group series on giant intracranial aneurysms: Current management.

OBJECTIVES: Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management. PATIENTS AND METHODS: This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05). RESULTS: A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion. CONCLUSION: The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.

[Transversal fractures in spinal ankylosis: a case series of 17 patients]. / Fractures transversales du rachis ankylosé : une série de 17 cas.

PURPOSE: Transverse fractures of the spine are rare. They occur in ankylosed spine and may lead to neurological complications. We report a series of 18 cases observed in 17 patients with ankylosing spondylitis (AS). The objective of this study were to describe the clinical, diagnostic and therapeutic features of our series and to compare our results with those of the literature. METHODS: We conducted a retrospective study from 1975 to 2008 in the neurosurgery and rheumatology departments of the university hospital (CHU) of Clermont-Ferrand. RESULTS: Eighteen transverse spine fractures were documented in 17 patients (one female patient had two fractures of the lumbar vertebrae). The 13 male and four female patients included in this series had a mean age of 57.4 ± 17.2 years and AS for a mean time of 21.3 ± 12 years (5-40). All patients had spinal ankylosis with a "bamboo" spine appearance. The reasons for hospital admission were suspicion of AS flare (n=10) and suspected traumatic fracture (n=8). Trauma, in most cases minor, was noted in 15 patients. Fourteen patients presented with mechanical spinal pain and three had both mechanical and inflammatory pain. Three patients experienced severe pain on mobilization. Two patients had pyramidal syndrome. The mean time to diagnosis of the fracture was 6.8 ± 8.4 weeks (0-22). The fracture was located in cervical spine (n=2), dorsal spine (n=8) and lumbar spine (n=8). It was transdiscal and transcorporeal in nine cases each. Standard radiographs (n=18) identified the fracture in nine cases. The fracture was demonstrated in all CT-scan (n=13). Magnetic resonance imaging (MRI) (n=6) showed the fracture in five cases and epidural hematoma in one. Eleven patients had orthopedic treatment and six underwent surgery. Outcome was favorable in 16 patients. One paraplegic patient died of pulmonary embolism. CONCLUSION: Transverse fractures of the spine are rare and diagnosis should be considered in a patient with AS and ankylosed spine who presented mechanical spine pain following even minor trauma. If standard radiographs are normal, further investigations should be performed using MRI, CT-scan, or both.

Radiotherapy of pituitary adenomas: state of the art.

Pituitary adenomas represent approximately 12% of intracranial tumors. They are defined as tumors that are functional or nonfunctional and invasive or noninvasive. Therapeutic strategies rely on surgery, medical treatment, and radiotherapy depending on histology. Neither the role of external radiotherapy nor the technique to be used are firmly established. Nonfunctioning adenomas must be operated on to relieve the compression. Prolactin-secreting adenomas are first treated with dopamine agonists, and GH-secreting adenomas are first treated by surgery if excising the complete tumor is possible; otherwise medical treatment is started. The first-line treatment of ACTH-secreting adenomas is surgery; however, in many cases, insufficient control of either secretion or tumoral volume leads to consideration of irradiation. Complications of conventional radiotherapy are well known and fractionated stereotactic radiotherapy appears to be as safe as radiosurgery. The volume to irradiate is still difficult to define, and this parameter can influence the technique chosen for treatment. Because the indications of radiotherapy are still debated, irradiation of pituitary adenomas must be decided by the complete team of endocrinologists, neurosurgeons, radiologists and radiotherapists.

Interleukin-6 gene amplification and shortened survival in glioblastoma patients.

Interleukin-6 (IL-6) is known to promote tumour growth and survival. We evaluated IL-6 gene amplification in tumours from 53 glioma patients using fluorescence in situ hybridisation. Amplification events were detected only in glioblastomas (15 out of 36 cases), the most malignant tumours, and were significantly associated with decreased patient survival.

Empowering humanitarian medical development using grid technology.

BACKGROUND: The training of local clinicians is the best way to raise the standard of medical knowledge in developing countries. This requires transferring skills, techniques and resources. OBJECTIVES: Grid technology opens new perspectives for preparation and follow-up of medical missions in developing countries as well as support to local medical centers in terms of teleconsulting, telediagnosis and patient follow-up. Indeed, grids allow to hide the complexity of handling distributed data in such a way that physicians will be able to access patient data while ignoring where these data are stored. METHODS: To meet requirements of a development project of the French NPO Chain of Hope in China, we propose to deploy a grid-based federation of databases. FIRST RESULTS AND CONCLUSIONS: A first protocol was established for describing the patients' pathologies and their pre- and post-surgery states through a web interface in a language-independent way. This protocol was evaluated by French and Chinese clinicians during medical missions in the fall of 2003. The first sets of medical patients recorded in the databases will be used to evaluate grid implementation of services.

[Cervical and para-pharyngeal bone tumors: two cases report]. / Tumeurs cervicales et para-pharyngées d'origine osseuse.

OBJECTIVE: The purpose of the study was to report two cases of cervical and para-pharyngeal bone tumors. MATERIAL AND METHODS: Patients were two 29 and 67-year-old men. Presentation of the lesions included respectively a right cervical mass and a left para-pharyngeal mass. Clinical features and radiological, anatomopathological and therapeutic characteristics of the tumors were retrospectively studied. RESULTS: A cervical approach was made in both cases. Tumor biopsies revealed a vertebral aneurismal cyst and a corporeo-pedicular chordoma respectively. CONCLUSION: Vertebral bone tumors with cervical expression are very uncommon entities. Diagnosis could be systematically evoked in patients with a cervical or para-pharyngeal tumor presenting vertebral lysis.

Mutations within the programmed cell death 10 gene cause cerebral cavernous malformations.

Cerebral cavernous malformations (CCMs) are hamartomatous vascular malformations characterized by abnormally enlarged capillary cavities without intervening brain parenchyma. They cause seizures and cerebral hemorrhages, which can result in focal neurological deficits. Three CCM loci have been mapped, and loss-of-function mutations were identified in the KRIT1 (CCM1) and MGC4607 (CCM2) genes. We report herein the identification of PDCD10 (programmed cell death 10) as the CCM3 gene. The CCM3 locus has been previously mapped to 3q26-27 within a 22-cM interval that is bracketed by D3S1763 and D3S1262. We hypothesized that genomic deletions might occur at the CCM3 locus, as reported previously to occur at the CCM2 locus. Through high-density microsatellite genotyping of 20 families, we identified, in one family, null alleles that resulted from a deletion within a 4-Mb interval flanked by markers D3S3668 and D3S1614. This de novo deletion encompassed D3S1763, which strongly suggests that the CCM3 gene lies within a 970-kb region bracketed by D3S1763 and D3S1614. Six additional distinct deleterious mutations within PDCD10, one of the five known genes mapped within this interval, were identified in seven families. Three of these mutations were nonsense mutations, and two led to an aberrant splicing of exon 9, with a frameshift and a longer open reading frame within exon 10. The last of the six mutations led to an aberrant splicing of exon 5, without frameshift. Three of these mutations occurred de novo. All of them cosegregated with the disease in the families and were not observed in 200 control chromosomes. PDCD10, also called "TFAR15," had been initially identified through a screening for genes differentially expressed during the induction of apoptosis in the TF-1 premyeloid cell line. It is highly conserved in both vertebrates and invertebrates. Its implication in cerebral cavernous malformations strongly suggests that it is a new player in vascular morphogenesis and/or remodeling.

[Spontaneous intrasphenoidal encephalocele. Report of two cases revealed by rhinorrhea]. / Encéphalocèle spontanée intrasphénoïdale. A propos de deux cas révélés par une rhinorrhée.

We report two cases of spontaneous anteromedial temporo-sphenoidal meningo-encephalocele. The first patient was a 67-year-old man with a history of treated epiglotic cancer 6 years ago, was referred to us for CSF rhinorrhea. Lateral sphenoidal CSF fistula was confirmed by CT cisternography. Four lumbar taps were performed and rhinorrhea stopped for 2 years. At relapse of rhinorrhea, the patient was operated on via a subtemporal approach. The dural defect was filled by an intradural patch of pericranium. Four years later patient showed no evidence of cerebrospinal fluid leakage. The second patient was a 54-year-old woman referred to us after a one year history of CSF rhinorrhea. CT cisternography confirmed lateral sphenoidal CSF fistula. The patient was operated on via a subtemporal approach. The dural defect was filled by a patch of pericranium. Three years later the patient had no evidence of cerebrospinal fluid leakage. Twenty-one cases of anteromedial temporosphenoidal meningo-encephaloceles have been reported in the literature. They probably are of a developmental origin. Some cases have been successfully treated via a transsphenoidal route. However surgical failures related to this approach can be due to the lack of control of the lateral recess of the sphenoid sinus. Therefore, the frontotemporal approach seems more adequate but the transphenoidal endoscopic approach will probably be used in the future.

High-dose BCNU followed by autologous hematopoietic stem cell transplantation in supratentorial high-grade malignant gliomas: a retrospective analysis of 114 patients.

Conventional treatment of high-grade glioma includes maximal surgical resection followed by external radiation therapy. Despite this treatment, the prognosis for patients is poor. High doses of chemotherapy might be another way to increase the response rate and median survival. Increasing doses of BCNU might be more effective, but also provokes unacceptable myelotoxicity. This dose-limiting toxicity can be circumvented by using autologous blood stem cell rescue. We report our experience of high-dose BCNU followed by transplantation of autologous hematopoietic stem cells in 114 patients with high-grade gliomas. Of the 114 gliomas, 78 were glioblastoma multiforme (GM) (68%), 24 anaplastic astrocytomas (AA) (21%), and 12 anaplastic oligodendrogliomas (OD) (11%). Complete surgical resection was performed for 22 patients (18 GM and 4 AA). The median age was 44 years (range 17-65). A total of 84 patients received autologous hematopoietic stem cells from bone marrow harvest, while 30 patients received granulocyte colony-stimulating factor followed by apheresis and received peripheral blood progenitor cells (PBPC). High dose of BCNU (800 mg/m(2)) was given at least 1 month after neurosurgery. Bone marrow or PBPC was transplanted 48-72 h after chemotherapy. Radiotherapy was started approximately 40 days after transplantation to a total of 60 Gy. Median follow-up was 89 months (19-163). The overall survival (OS) was, respectively, 12 months for GM, 37 months for OD and 81 months for AA. Histological type appeared to be the main discriminating factor, with a worse prognosis for GM. Within the GM population, age, completeness of surgery, and response appeared to be one important prognostic factors. The AA and OD populations were small to reliably assess prognostic factors. On multivariate analysis, the main prognostic factors were histologic type, quality of surgery, and age (P<0.005). Five of 114 patients had lethal complications from the procedure. Four of these patients had a Karnovsky performance score (KPS) of 60%. The protocol thus appears to be feasible but patients should be selected for KPS more than 70%. We observed long-term survivors, although the OS and the time to treatment failure seem to be comparable to that described for other treatment. Additional pilot studies are unlikely to reveal more than a modest benefit from this procedure and therefore a randomized study should be performed.

Clinical implications of quantitative real-time RT-PCR analysis of hTERT gene expression in human gliomas.

The presence of telomerase activity in a glioma may be a predictor of its malignant potential. Activation of telomerase is regulated at the transcriptional level of the human telomerase reverse transcriptase (hTERT). Here, we evaluated whether the amount of hTERT mRNA provides a molecular marker of glioma malignancy that would have clinical utility. We used a real-time RT-PCR to assess the number of hTERT transcripts in primary tumour samples derived from 70 glioma patients. Results were standardised by quantifying the number of ABL transcripts as internal control and expressed as hTERT/ABL ratio. The percentage of patients with detectable hTERT mRNA markedly increased with enhanced malignancy: low-grade gliomas expressed hTERT in one out of 14 cases (7.1%), anaplastic gliomas in four out of 13 cases (30.8%) and glioblastoma multiforme (GBM) tumours in 30 out of 43 cases (69.8%). The mean hTERT/ABL ratio was significantly higher in GBMs than in non-GBMs. Subdividing hTERT/ABL ratios as low (< pr = 25%) and high (>25%), we found that the overall survival among hTERT-positive GBMs was significantly worse in high hTERT expressors than in low hTERT expressors (P=0.0082). We conclude that the amount of hTERT mRNA may represent a diagnostic and prognostic indicator for GBM patients.

[Radiation-induced temporary hair loss after endovascular embolization of the cerebral arteries: six cases]. / Alopécie transitoire d'origine radique après embolisation artérielle cérébrale: 6 cas.

BACKGROUND: Intraoperative fluoroscopy imaging during coronaroplasty or transjugular intrahepatic portosystemic shunt may induce chronic radiodermatitis. Temporary hair loss is a peculiar form of radiodermatitis following endovascular surgery of the cerebral arteries. CASE REPORTS: Six patients (2 women, 4 men, age range: 27-47 years old) were seen for a solitary plaque of alopecia. In all of the cases, the plaque had appeared two weeks after a neuroradiologically guided embolization procedure. No other skin lesions were seen. Alopecia spontaneously and completely regressed within three to four months. However, it reappeared after a subsequent embolization (one case) but not after arteriographies (five cases). DISCUSSION: Five similar cases have been reported in the literature. Transient alopecia often occurs after neurologically guided endovascular surgery of the cerebral arteries. This side-effect is well known by neurosurgeons and thus, these patients are rarely referred to a dermatologist. Two differential diagnoses must be evoqued: alopecia aerata and anticonvulsant - induced alopecia. The role played as cofactor by carbamazepine which is a photosensitivant drug, is discussed.

Slow pressure waves in the cranial enclosure.

Slowly varying pressure oscillations in the cranial enclosure are well known, especially intracranial pressure waves as best described by the pioneering works of Janny and Lundberg. Nevertheless, in spite of over twenty five years research on intracranial pressure waves, their origin and regulation remain unclear but are often considered only as pathological. Our aim was to review data on these phenomena to clarify their biological status and the role that they could play in the management of patients suffering from such intracranial neurosurgical diseases as intracranial hypertension, severe head injury, and hydrocephalus. It appears that these pressure waves reveal important information on the function of the cerebral vasculature and as such have significance for influencing intracranial compliance. Pressure waves are also closely associated with autoregulation, in particular dynamic autoregulation. It seems evident that they are not only pathophysiological but also physiological, linked with other biological parameters such as the neurovegetative cardiovascular system, breathing, and sleeping. This study shows that it is not only important to continue to explore these slow waves, but also the methods of analysis in order to more fully clarify their clinical significance.