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.

Transcutaneous pressure adjustable valve for the treatment of hydrocephalus and arachnoid cysts in adults. Experiences with 75 cases.

The authors report a series of 75 adults treated over the last four years for hydrocephalus (69 cases) or arachnoid cysts (6 cases) by using a transcutaneous pressure adjustable valve (Sophy SU 8), the mechanism of which is recalled. The shunt was ventriculo-atrial 46 times, ventriculo-peritoneal 23 times and cysto-peritoneal 6 times. The opening pressure of the valve was initially adjusted 56 times to the medium, 9 times to the high, and 10 times to the low position, according to each particular patient's needs. Following the evolution of the neurological status and/or the CT findings, the opening pressure was secondarily modified in 27 patients (i.e., in 36%), and in some of them several times. It was raised 16 times: 10 times because of subdural hygroma(s) (complicated by a subdural haematoma which required surgical removal, in one case), and 6 times because of clinical symptoms of intracranial hypotension associated with hyperdrainage signs on CT. It was diminished 20 times because of the absence of clinical improvement and persistence of dilated ventricles on CT. In these 27 patients the Sophy SU 8 valve allowed modification of its opening pressure according to the clinical and CT evolution, without need for re-operation. It is concluded that the patients who can benefit most from this valve system are patients with normal pressure hydrocephalus or with arachnoid cysts.

[Neurinoma of the trigeminal nerve. Excision by combined suboccipital and pteriono-temporal approach]. / Neurinome du trijumeau. Exérèse par abord mixte sous-occipital et ptériono-temporal.

The authors report a recent personal case of trigeminal neurinoma with a topographical extension both in the cerebello pontine angle and the middle cerebral fossa. This 33 year-old female suffered from progressive sensory disturbances of her right hemiface associated with a right fifth nerve motor deficit, a right VI nerve palsy and a tinnitus. CT scan and angiogram were evocative of a right hourglass trigeminal neurinoma. Two successive operative stage through suboccipital route and a pteriono-temporal extra and intradural approach allowed a complete removal of the tumour. A post-operative rhinorrhea dried up with 10 days. The patient complained with a right hemiface anesthesia and a palsy of the masseter muscles; the VI nerve palsy recovered within 3 months. From the review of the literature (118 cases) the authors summarize the anatomical, clinical and radiological features of these tumours and point out. The difficulty of their surgical removal that was only complete in half of cases. The high frequency of hourglass neurinomas explains that a single suboccipital or subtemporal approach--even with opening of the tentorium--only allowed 23 complete removal among the 58 published or quoted interventions. This justifies that in a majority of cases a combined approach must be preferred, using successively a suboccipital and an intradural subtemporal route, the latted giving access to the cavernous sinus in case of its invasion.

[Intra-spinal ganglioglioma. A case and review of the literature]. / Le gangliogliome intra-médullaire. Une observation, revue de la littérature.

A case of intra medullary ganglioglioma is reported in a 25 year old woman, who had presented an acute poliomyelitis when she was 2 years old. Since 7 years, new neurological signs occurred with spastic paraplegia, sensitive and sphincter disturbances. Cervical and lumbar myelography showed an intra medullary tumor, extending from C2-C3 to T7-T8. Macroscopically, the lesion was well circumscribed, except on the cervico-dorsal junction where it engulfed the anterior spinal artery. Histologically, the tumor was a ganglioglioma, grade I. Two years after surgery, the patient remains paraplegic. This case is compared with the 13 other cases of the literature.

[Intrapetrous neurinoma of the facial nerve. Removal by the oto-neurologic route]. / Neurinome intrapétreux du nerf facial exérèse par voie oto-neurologique.

A case of a 33 year-old woman presenting an intrapetrous facial nerve neurinoma is reported. The neurological finding was a quickly progressive facial nerve palsy without hearing loss which the initial diagnosis was a Bell's palsy. The radiological findings showing an petrous bone erosion located at the third portion of the facial nerve gave the diagnosis. It was confirmed by CT scan and arteriography that allows a pre-operative embolisation. A one stage operation performed by a triple retromastoid, transpetrous and retroparotid approach, allowed a complete removal. The post-operative course was uneventful and a reconstructive facial surgery was performed to restore a facial symmetry six months later. The authors review the literature about this tumor which remains rare and point out two facts: --A non regressive or recurrent or atypical facial nerve palsy had to be checked up by neuroradiology and even by surgical exploration. --The triple retromastoid, transpetrous and retroparotid approach is very interesting, allowing a one stage complete removal of the tumor and a check up of the facial nerve repair possibilities.

[Use of Cotrel-Dubousset material in C1 C2 instabilities]. / Utilisation du matériel de Cotrel Dubousset dans les instabilités C1 C2.

The authors report their experience with the C.D. material for the atlantoaxial displacement. Four cases are presented. The characteristics and advantages of this material are discussed, and compared with the other methods of fixation specially the Knodt-Chirossel.

["De novo" aneurysms. Apropos of a surgically treated case]. / Anévrysmes "de novo". A propos d'un cas opéré.

The authors report the case of a 26 years old woman who developed four "new" T aneurysms, ten years after the successful clipping of a vertebro-basilar system aneurysm. This observation is discussed in relation to the literature; current views supporting that aneurysms may result from a combination of inherent and acquired tissue weakness associated with hemodynamic effects are cited. Another twelve cases of "de novo" aneurysms developed in patients without previously carotid ligation and reported in the literature are reviewed. Their characteristics in relation to their localisation and their interval time discovery are discussed. The advisibility of repeated angiograms in some patients with aneurysm is discussed as these patients are at an increased risk of hemorrhage from another "new" aneurysm.

[Multiple metastases during the course of a pineal germinoma]. / Métastases multiples au cours de l'évolution d'un germinome pinéal.

The clinical findings and course of a patient with a germinoma of the pineal region is presented. After a surgical procedure and radiation treatment, ten months after, the patient develops successively peritoneal, ventricular, spinal metastasis. Effective treatment was either radiation treatment or chemotherapy. The frequency of metastasis with germinomas of the posterior part of the third ventricle are discussed, following a review of the literature, prevention and treatment are discussed.

[Excision of a glomus jugulare tumor after embolization]. / Exérèse d'une tumeur du glomus jugulaire après embolisation.

The authors report the case of a patient with a glomus jugulare tumor. After embolization of the external carotid artery branches feeding the tumor, a complete removal had been performed by a combined otoneurological approach. Although clearly defined and cleavable at the jugulare foramen, the chemodectoma had invasive characteristics in its intrapetrous extension, indicative post operative radiotherapy. In addition a review of publications support preoperative embolization and otoneurosurgical cooperation.