[Deep brain stimulation as a treatment for severe multidrug-resistant obsessive compulsive disorder]. / La stimulation cérébrale profonde comme traitement du trouble obsessionnel compulsif sévère multi-résistant.

Obsessive compulsive disorder (OCD) is a common and disabling psychiatric condition. About 10 % of patients are considered to be severely affected and refractory to the usual treatments, combining antidepressants and psychotherapy. Deep brain stimulation (DBS) is a promising treatment, reserved for specialized university centers. It is based on the implantation of electrodes aimed at modulating dysfunctional cortico-striato-thalamo-cortical circuits. After studying the different targets to be used, it is now proposed to rethink DBS in terms of networks. The improvement of pathophysiological knowledge of OCD and the development of functional neuroimaging techniques should allow the design of individualized treatment protocols.

Le trouble obsessionnel compulsif (TOC) est une pathologie psychiatrique fréquente et invalidante. Environ 10 % des patients sont considérés comme très sévèrement atteints et réfractaires aux traitements habituels, combinant antidépresseurs et psychothérapies. Réservée à des centres universitaires spécialisés, la stimulation cérébrale profonde (SCP) est un traitement prometteur qui repose sur l'implantation d'électrodes visant à moduler des circuits cortico-striato-thalamo-corticaux dysfonctionnels. Après l'étude des différentes cibles à utiliser, il est aujourd'hui proposé de reconsidérer la SCP en termes de réseaux. L'amélioration des connaissances physiopathologiques du TOC et le développement de techniques de neuro-imagerie fonctionnelle devraient permettre de dessiner des protocoles de traitement individualisé.

[Traumatic subcutaneous emphysema of the face: the hazard of holding a sneeze]. / L'image du mois. Emphysème sous-cutané traumatique de la face : le danger de retenir un éternuement.

In this period of pandemic, protective measures and social distancing, sneezing might not be well received and trying to suppress a sneeze is tempting. It's not always a good idea. We here report the case of a patient suffering from minor facial trauma. The next day after the accident, while trying to hold back a sneeze, the patient caused sudden swelling of the right cheek, associated with subcutaneous emphysema and disturbances in sensitivity, revealing an unrecognized fracture of the right maxillary sinus. Post-traumatic subcutaneous emphysema of the face, caused by suppressed sneezing, is rarely described.

En cette période de pandémie, de gestes barrières et de distanciation sociale, éternuer peut être mal perçu et chercher à réprimer un éternuement est tentant. Ce n'est pas toujours une bonne idée. Nous rapportons ici le cas d'un patient victime d'un traumatisme facial mineur. Le lendemain de l'accident, en essayant de retenir un éternuement, le patient provoqua un brusque gonflement de la joue droite, associé à un emphysème sous-cutané et à des troubles de la sensibilité, révélant ainsi une fracture méconnue du sinus maxillaire droit. L'emphysème sous-cutané post-traumatique de la face, provoqué par un éternuement réprimé, est rarement décrit.

[Epidural lipomatosis : management proposal]. / Comment je traite la lipomatose épidurale.

Epidural lipomatosis is a rare condition characterized by excessive accumulation of normal fat in the epidural space. This paper presents the results of a retrospective study of the charts of 20 patients. The 20 patients - 17 men and 3 women - were on average 64 years old. They suffered from radiculopathy and/or neurogenic claudication. Lipomatosis was idiopathic in 6 patients and secondary in 14 patients. Lipomatosis was MRI grade 2 in 30 % of cases and grade 3 in 70 % of cases. The patients have all been improved thanks to decompressive surgery by laminectomy and resection of epidural fat. According to our experience and to the literature, surgical decompression is an effective and safe procedure for patients with symptomatic lumbar epidural lipomatosis in case of failure of conservative treatment or in case of neurological deficits. We present a decision tree that can help in the management of this disease.

La lipomatose épidurale est une affection rare caractérisée par une accumulation excessive de graisse normale dans l'espace épidural. Ce travail présente les résultats d'une étude rétrospective des dossiers de 20 patients. Les 20 patients, 17 hommes et 3 femmes, étaient âgés en moyenne de 64 ans. Ils souffraient d'une radiculopathie et/ou d'une claudication neurogène. La lipomatose était idiopathique chez 6 patients et secondaire chez 14 patients. L'IRM a démontré une lipomatose de grade 2 dans 30 % des cas et de grade 3 dans 70 % des cas. Les patients ont tous été améliorés grâce à la chirurgie de décompression par laminectomie et résection du tissu épidural. D'après notre expérience et selon la littérature, la décompression chirurgicale est une procédure efficace et sûre pour les patients présentant une lipomatose épidurale lombaire symptomatique en cas d'échec du traitement conservateur ou en cas de déficits neurologiques. Nous présentons un arbre décisionnel pouvant aider à la prise en charge de cette pathologie.

Refractory neuropathic pain from a median nerve injury: spinal cord or peripheral nerve stimulation? A case report.

Spinal cord stimulation (SCS) is the most frequently used neuromodulation technique even for neurogenic pain from a peripheral nerve injury although peripheral nerve stimulation (PNS) has been designed for this purpose. PNS appears less invasive than SCS or deep brain stimulation. It provides greater and specific target coverage and it could be more cost-effective than SCS because low electrical stimulation is exclusively delivered to the precise painful territory. We report a case of excellent result following median nerve stimulation at arm level after SCS failure and a 10-year history of intense pain. PNS would certainly have been considered much earlier if it was accepted and reimbursed by the Belgium National Insurance. PNS is a safe, simple, and efficient technique available for decades but it is still considered as experimental and underemployed. Belgian National Insurance fears an explosion of indications on neuromodulation if PNS was reimbursed. We consider that PNS aside SCS and other neuromodulation techniques should be made available in Belgium in case of peripheral chronic neuropathic pain.

[Gilliatt-Sumner hand or true neurogenic thoracic outlet syndrome. A report on seven operated cases]. / La main de Gilliatt-Sumner ou le syndrome de défilé cervicothoracique neurogène vrai. À propos de sept cas opérés.

BACKGROUND AND PURPOSE: The clinical picture of hand atrophy related to a cervical rib or elongated C7 transverse process was well described in the modern literature by Gilliatt and Sumner; in 1970, they reported a series of nine patients whose motor status was stabilized following brachial plexus decompression. We report here seven patients suffering from thoracic outlet syndrome (TOS), who developed hand atrophy, sometimes because of diagnostic delay. METHODS: The patient's charts were analysed retrospectively. RESULTS: The seven patients were all female; the mean age was 43 years. The first complaints were arm pain and paresthesias lasting six months to 5 years. Three patients were treated with C56/C67 discectomy plus disc prosthesis (one patient), ulnar neurolysis at the elbow (the same patient), carpal tunnel release (one patient), and intravenous immunoglobulins (one patient) before TOS diagnosis. Hand atrophy, severe in five patients, was present at presentation. All patients underwent brachial plexus decompression by the anterior (four), posterior (two), or transaxillary (one) approach. This last approach was completed 18 months later by brachial plexus neurolysis via the anterior approach. Postoperatively, motor deficit was improved in two patients and stabilized in five patients. CONCLUSIONS: Physicians' unfamiliarity with TOS diagnosis or their reluctance to accept the diagnosis without electrical confirmation can lead to hand atrophy. Brachial plexus decompression at this stage usually stabilizes the deficit.

[Clinical case of the month. Traumatic bilateral orbital encephalocele]. / Le cas clinique du mois. Encéphalocèle orbitaire post-traumatique bilatéral.

Acute traumatic orbital encephalocele is a rare entity, with less than 25 cases reported. We hereby describe the first bilateral orbital encephalocele through a blow-in orbital fracture after a blunt cranial traumatism. Early treatment of the orbital traumatic encephalocele is necessary in order to avoid the increase of the intra orbital pressure that might damage the optic nerve. Repairing the orbital roof has to be performed in a rigid manner in order to avoid the transmission of the intracranial pressure variation to the orbit. In the present case, the reconstruction of orbital roof was performed using a subfrontal approach supported by a titanium mesh fixed with screws and a mixture of bone powder mixed and fibrin glue.

[How I explore ... dystonic troubles: a simple and practical guide]. / Comment j'explore ... les troubles dystoniques: un guide simple et pratique.

The discovery of dystonia as an isolated abnormality or as a symptom involved in a larger neurological or systemic disease is not unfrequent in clinical practice. Dystonia can occur at any age, from childhood to elderly. A rapid diagnosis is very important to optimise the managing of those chronical and often invalidating diseases. We should point out the pre-eminent role played by MRI techniques in the diagnosis and follow-up of dystonic patients. We present here an overview of most frequent dystonic troubles and an attempt of classification to simplify their diagnosis.

[Invasive pulmonary mucormycosis with invasion of the thoracic spine in a patient with myelodysplastic syndrome]. / Mucormycose invasive du poumon et du rachis dorsal.

We report the case of a 67-year-old patient who presented with a myelodysplastic syndrome and who developed a pulmonary mucormycosis with a rare extension to the dorsal spine. A decompressive laminectomy was attempted after failure of broad-spectrum antifungal treatment (Cancidas, V-Fend). The diagnosis was obtained after surgical biopsy. The scheduled lobectomy could not be performed because of altered clinical condition. The patient eventually died despite adapted antifungal treatment (Abelcet, Posaconazole). Pulmonary mucormycosis is a rare cause of mycotic infection that reaches most of the time immunocompromised patients. The pathogenic agent is part of zygomyces that have angio-invasive ability. Perineural propagation was recently described. Immunodepression, late diagnosis and lack of response to new generation antifungal drugs (V-Fend, Cancidas) are responsible for therapeutic failure in this disease. This case emphasizes the risk inherent to empirical antifungal treatment and the need of early biopsy in cases that do not respond to treatment.

[Clinical case of the month. Pierre Marie Bamberger syndrome]. / Le cas clinique du mois. Le syndrome de Pierre-Marie Bamberger.

We report the case of a lung adenocarcinoma revealed by clubbing and secondary hypertrophic osteoarthropathy or Pierre-Marie Bamberger syndrome.

Preoperative evaluation of 54 gliomas by PET with fluorine-18-fluorodeoxyglucose and/or carbon-11-methionine.

UNLABELLED: This study evaluates the usefulness of PET for the preoperative evaluation of brain gliomas and methods of quantification of PET results. METHODS: Fifty-four patients with brain gliomas were studied by PET with 18F-fluorodeoxyglucose (FDG) (n = 45) and/or 11C-methionine (MET) (n = 41) before any treatment. Results of visual analysis, calculation of glucose consumption and five tumor-to-normal brain ratios for both tracers were correlated with two histologic grading systems and with follow-up. RESULTS: Visual analysis (for FDG) and tumor-to-mean cortical uptake (T/MCU) ratio proved to be the best tools for the evaluation of PET results. Methionine was proven to be better than FDG at delineating low-grade gliomas. Tumor-to-mean cortical uptake ratios for FDG and MET were clearly correlated (r = 0.78), leading to the equation T/MCU(FDG) = 0.4 x T/MCU(MET). We showed a good correlation between FDG PET and histologic grading. MET uptake could not differentiate between low-grade and anaplastic astrocytomas but was significantly increased in glioblastomas. Low-grade oligodendrogliomas exhibited high uptake of FDG and MET, probably depending more on oligodendroglial cellular differentiation than on proliferative potential. Uptake was decreased in anaplastic oligodendrogliomas, probably due to dedifferentiation. Care must be taken with peculiar histologic subgroups, i.e., juvenile pilocytic astrocytomas and oligodendrogliomas, because of a discrepancy between high PET metabolism and low proliferative potential (good prognosis). Both tracers proved useful for the prediction of survival prognosis. Methionine proved slightly superior to FDG for predicting the histologic grade and prognosis of gliomas, despite the impossibility of differentiation between Grades II and III astrocytomas with MET. This superiority of MET could be explained by patient sampling (low number of Grade III gliomas submitted to examination with both tracers). The combination of both tracers improved the overall results compared to each tracer alone. CONCLUSION: Both tracers are useful for the prediction of the histologic grade and prognosis. The apparent superiority of MET over FDG could be due to the small number of Grade III gliomas studied with both tracers.

Oncological applications of positron emission tomography with fluorine-18 fluorodeoxyglucose.

Positron emission tomography (PET) is now primarily used in oncological indication owing to the successful application of fluorine-18 fluorodeoxyglucose (FDG) in an increasing number of clinical indications at different stages of diagnosis, and for staging and follow-up. This review first considers the biological characteristics of FDG and then discusses methodological considerations regarding its use. Clinical indications are considered, and the results achieved in respect of various organs and tumour types are reviewed in depth. The review concludes with a brief consideration of the ways in which clinical PET might be improved.

Radiation-induced gliosarcoma. Case report and review of the literature.

A 13-year-old boy presented with a cerebral gliosarcoma 12 years after having acute lymphoblastic leukemia treated by chemotherapy and central nervous system prophylaxis treated by radiation therapy (24 Gy) and intrathecal methotrexate. A review of the literature disclosed 129 possible radiation-induced gliomatous and/or sarcomatous brain tumors: namely, 89 gliomas, 36 sarcomas, and four gliosarcomas, including the present case. An analysis of these cases revealed several characteristics that differentiate them from similar spontaneous brain tumors, thus providing arguments for the carcinogenic effect of radiation therapy on intracranial tumors.

Detection of Epstein-Barr virus in a case of undifferentiated nasopharyngeal carcinoma by in situ hybridization with digoxigenin-labelled PCR-generated probes.

A case of nasopharyngeal carcinoma is presented. Epstein-Barr viral genome was identified in the neoplastic cells by in situ hybridization with digoxigenin-labelled polymerase chain reaction-generated probes. We report the development of this technique in paraffin-embedded sections and propose that such identification may prove valuable for the diagnosis of this tumour in routine material.

[Neuroendocrine tumor of the nasal cavity (esthesioneuroblastoma). Apropos of a case with paraneoplastic Cushing's syndrome]. / Tumeur neuroendocrine de la cavité nasale (esthésioneuroblastome). A propos d'un cas avec syndrome de Cushing paranéoplasique.

Presentation of a 48-y old woman who developed a neuroendocrine tumor of the nasal cavities. This lesion progressed rapidly despite an extensive resection and repeated chemotherapy. The patient refused radiotherapy. Before her death, 28 months later, she exhibited a paraneoplastic Cushing-like syndrome. At autopsy, restricted to the brain, there was a 5 cm diameter tumor invading the frontal area without alteration of the hypothalamus or the pituitary gland. Routine histology and electron microscopy confirmed the neuroendocrine nature of the tumor. Immunohistochemistry revealed the tumor to be positive only for neurone specific enolase, negative for S-100 protein, neurofilament and ACTH. The pituitary gland was positive for most usual hormones (GH, PRL, TSH, LH, FSH) but only few cells were slightly positive for ACTH. Many Crooke cells were observed. These findings suggest that the tumor secreted an ACTH-like substance (not detected actually by immunochemistry) that stimulated the activity of the adrenal cortex but inhibited normal production of ACTH at the pituitary gland level.