[Contribution of technological aids to the extraction of orbital foreign bodies]. / Apport des aides technologiques dans l'extraction des corps étrangers orbitaires.

BACKGROUND: Removal of orbital foreign bodies is a surgical challenge. The purpose of this study is to report our experience in the removal of orbital foreign bodies and to evaluate the usefulness of various technological aids in their removal. MATERIALS AND METHODS: We conducted a single-center retrospective study at Nice University Hospital (France) from January 2017 to December 2023. All patients undergoing surgery for an orbital foreign body during the study period were included. Data recorded included the nature of the orbital foreign body, its size, location, surgical route, outcome (success, partial success, failure), and technological aids used (intraoperative navigation, intraoperative imaging scope, orbital magnet). Concurrently, we designed a dedicated orbital magnet, which was tested in the anatomy laboratory and in two of our patients. RESULTS: Six patients, all young men, were included during the study period. Removal was successful, partially successful, or unsuccessful in one-third of cases, respectively. Failure was associated with orbital foreign bodies located in the intraconal or posterior orbital space. Preoperatively, the use of a "low-artifact" scanner allowed us to better determine the exact size and shape of the orbital foreign body. Intraoperative navigation was not accurate enough, due to the mobility of the orbital bodies within the orbital fat. In our experience, intraoperative scope imaging was more accurate. The use of a dedicated orbital magnet was successfully tested in the anatomy laboratory and allowed the removal of a small orbital foreign body in one of our patients. Intraoperative surgical videos are provided. CONCLUSION: Vegetal orbital foreign bodies must be systematically removed. Removal of non-vegetal orbital foreign bodies should be considered on a case-by-case basis based on their size, best assessed using a "low artifact" scanner, their location, and their intrinsic ferromagnetism. Intraoperative navigation does not appear useful, while intraoperative scope imaging does. A dedicated orbital magnet might be helpful in removing ferromagnetic orbital foreign bodies. However, an orbital magnet may be ineffective in removing intraorbital bullets, since they are made primarily of an alloy of copper and lead.

Identification of demyelinating lesions and application of McDonald criteria when confronted with white matter lesions on brain MRI.

INTRODUCTION: White matter lesions (WML) on magnetic resonance imaging (MRI) are common in clinical practice. When analyzing WML, radiologists sometimes propose a pathophysiological mechanism to explain the observed MRI abnormalities, which can be a source of anxiety for patients. In some cases, discordance may appear between the patient's clinical symptoms and the identification of the MRI-appearing WML, leading to extensive diagnostic work-up. To avoid misdiagnosis, the analysis of WML should be standardized, and a consensual MRI reading approach is needed. OBJECTIVE: To analyze the MRI WML identification process, associated diagnosis approach, and misinterpretations in physicians involved in WML routine practice. METHODS: Through a survey distributed online to practitioners involved in WML diagnostic work-up, we described the leading causes of MRI expertise misdiagnosis and associated factors: clinical experience, physicians' subspecialty and location of practice, and type of device used to complete the survey. The survey consisted of sixteen T2-weighted images MRI analysis, from which ten were guided (binary response to lesion location identification), four were not shown (multiple possible answers), and two were associated with dissemination in space (DIS) McDonald criteria application. Two independent, experienced practitioners determined the correct answers before the participants' completion. RESULTS: In total, 364 participants from the French Neuro Radiological (SFNR), French Neurological (SFN), and French Multiple Sclerosis (SFSEP) societies completed the survey entirely. According to lesion identification, 34.3% and 16.9% of the participants correctly identified juxtacortical and periventricular lesions, respectively, whereas 56.3% correctly identified non-guided lesions. Application of the 2017 McDonald's DIS criteria was correct for 35.3% of the participants. According to the global survey scoring, factors independently associated with correct answers in multivariate analysis were MS-expert subspecialty (P<0.001), young clinical practitioners (P=0.02), and the use of a computer instead of a smartphone to perform WML analysis (P=0.03). CONCLUSION: Our results highlight the difficulties regarding WML analysis in clinical practice and suggest that radiologists and neurologists should rely on each other to ensure the diagnosis of multiple sclerosis and related disorders and limit misdiagnoses.

Optic nerve sheath fenestration: Current status in France and comparison of 6 different surgical approaches.

PURPOSE: Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-Saxon countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We chose to compare 6 different trans-orbital surgical approaches to ONSF. We also desired to determine the number of optic nerve decompression procedures performed in France in 2019 and 2020. METHODS: Four fresh frozen orbits were dissected at the University of Nice anatomy laboratory. We performed the following surgical approaches: (i) eyelid crease, (ii) lid-split, (iii) medial transconjunctival with medial rectus disinsertion, (iv) medial transconjunctival without rectus disinsertion, (v) lateral transconjunctival and (vi) lateral orbitotomy. For each surgical approach, we measured the distance between the incision and the optic nerve dura mater. We also extracted data from the French National PMSI (Programme de Médicalisation des Systèmes d' Information) database from January 2019 through December 2020 to determine the annual number of optic nerve decompression procedures. RESULTS: The lid crease and medial transconjunctival approaches provided the shortest distance to the optic nerve (average 21mm and 24mm, respectively) and the lowest levels of difficulty compared to the other surgical routes. A total of 23 and 45 optic nerve decompressions were performed in France in 2019 and 2020, respectively. Among them, only 2 and 7 procedures, respectively, were performed through a trans-orbital approach. CONCLUSION: Upper lid crease incision and medial transconjunctival approaches are the most direct and easiest surgical routes when performing an ONSF. We found that ONSF was rarely performed in France. We strongly recommend close cooperation between ophthalmologists, neurologists, neurosurgeons and interventional radiologists.

Post-traumatic cerebral venous sinus thrombosis associated with epidural hematoma: A challenging clinical situation.

Post-traumatic cerebral venous sinus thrombosis (ptCVST) is often associated with brain hemorrhage; consequently, the anticoagulation may be challenging. We report the case of a 42-year-old man who presented with post-traumatic epidural hematoma and rapidly developed transverse sinus thrombosis extending to the internal jugular vein. As the patient was asymptomatic, we decided not to use anticoagulants: close clinical and radiological monitoring was implemented. The hematoma resolved within 2 months, and the CVST diminished by the third month. Such a good outcome is not always the case in ptCVST. The present article also discusses pathophysiological mechanisms and treatment options when hematoma is associated with ptCVST.

Papilledema secondary to vestibular schwannoma: An atypical case without intracranial hypertension.

In most cases, vestibular schwannomas with papilledema are associated with intracranial hypertension secondary to hydrocephalus (obstructive or communicating). We describe the atypical case of a 39-years-old man who presented with bilateral papilledema revealing a vestibular schwannoma, but without hydrocephalus and with normal intracranial pressure. Ophtalmologic signs were completely resolved after tumor removal. The pathophysiological mechanism generally described to explain bilateral papilledema in such cases is tumor-induced hyperproteinorachia. However, in the absence of hydrocephalus or intracranial hypertension, this case raises the question of the mechanisms involved in the visual impairment related to vestibular schwannoma.

Alexithymia in multiple sclerosis: Clinical and radiological correlations.

BACKGROUND: Alexithymia, meaning no words for emotions is a common problem that could affect up to 53% of patients in multiple sclerosis (MS). OBJECTIVES: To determine the frequency of alexithymia in MS and investigate MS-related abnormalities in structural magnetic resonance imaging (MRI) and their associations with fatigue and cognitive functions. METHODS: Ninety-five patients at all stages of the disease were examined: 21 with clinically isolated syndromes (CIS), 30 with relapsing-remitting MS (RRMS), 21 with primary (PP) and 23 with secondary progressive MS (SPMS). Alexithymia was measured with the Toronto alexithymia scale (TAS-20) and correlated to cognitive functions, depression, and fatigue. Voxel-based morphometry MRI was analyzed to determine lesion load, cerebral and regional atrophy. RESULTS: Fifty-seven of patients had alexithymia with no significant difference between the clinical phenotypes. Alexithymic patients differed from non-alexithymic patients on fatigue, depression and information processing speed. Compared to non-alexithymic patients, alexithymic patients had decreased volumes of cerebral and cerebellar white matter and there was a significant relationship between alexithymia and decreased brainstem, thalamic and corpus callosum volume. CONCLUSION: Regardless of the phenotype of MS, alexithymia is associated with atrophy of cerebral and cerebellar white matter, brainstem, corpus callosum, and thalami.

Thalamic atrophy correlates with dysfunctional impulsivity in multiple sclerosis.

BACKGROUND: Recent studies highlight the central role of thalamic atrophy in Multiple Sclerosis (MS) related disorders. Behavioural aspects of (MS) are rarely explored but their investigation is of high interest. Dickman's Impulsiveness Inventory (DII) allows distinguishing functional impulsivity (FI) which is the ability to react fast and properly when necessary, from dysfunctional impulsivity (DI) which is a behavioural symptom corresponding to the tendency to miss forethought before acting. OBJECTIVE: This paper aims to explore whether MS patients show significantly high and pathological DI, and to evaluate the impulsivity frequency in the different forms of MS including at the early stage of the Clinically Isolated Syndrome. Furthermore, this study focused on the factors that may induce abnormal impulsivity, and the link between thalamic atrophy and dysfunctional impulsivity in patients with MS. METHODS: 95 patients with demyelinating diseases including 21 Clinically Isolated Syndrome (CIS), 30 Relapsing-Remitting MS (RRMS), 23 Secondary Progressive MS (SPMS) and 21 Primary Progressive MS (PPMS) were prospectively recruited, and covered by extensive cognitive evaluation including the BCCogSEP (French version of the Brief Repeatable Battery for Neurological disease), the CSCT (Computerized Speed Cognitive Test) for processing speed of information (PSI), the DII to measure FI and DI, the Fast BDI to evaluate depression, and the EMIF-SEP scale to study physical, cognitive and social fatigues. 3D T2-FLAIR and 3D T1-weighted MRI were analyzed using automatic segmentation tools to quantify the T2 lesion load and to measure the whole and regional brain atrophy. RESULTS: 7% showed a pathologically high DI. The level of DI tended to differ significantly depending on the MS phenotype. There was no significant difference between RRMS, SPMS and PPMS, but RRMS showed significantly higher DI than CIS patients. Cognitive fatigue (r:-0.27, p<.01), depression (r:-0.21, p=.04) but mainly PSI (r:.33, p<.001) showed a significant correlation with DI. Among the brain regions of interest, the strongest significant correlation with DI was with thalamic atrophy (r:.33, p<.001). CONCLUSION: Some MS patients show a pathologically high DI, mainly RRMS compared to CIS. Previous study highlighted impulsive traits in MS patients only in relation with the presence of depression. The present study demonstrates that depression tends to correlate with DI, but that cognitive fatigue, and mainly slowing of PSI, which is the most early and severe cognitive impairment in MS, have a stronger impact on the rise of pathological impulsive behaviour. DI in MS is linked to frontal regions but even more strongly to thalamus atrophy. This is in line with the hypothesis of a disconnection syndrome in MS that causes cognitive impairment to trigger and could have the same impact on behaviour. Hence, impulsive behaviour should be evaluated and taken into account in the care of patients with MS.

Video-oculography in multiple sclerosis: Links between oculomotor disorders and brain magnetic resonance imaging (MRI).

BACKGROUND: Eye movement abnormalities (EMA) are common in multiple sclerosis (MS). However, type and severity according to the MS stage are poorly known, especially in Radiologically Isolated Syndrome (RIS) and in Clinically Isolated Syndrome (CIS). Although MRI has been included in the MS diagnostic criteria, there may be clinical-radiological dissociation. OBJECTIVE: To analyze by video-oculography (VOG) prevalence of EMA in different MS phenotypes and study correlations with brain and cervical cord MRI T2 lesions location. METHODS: 76 participants were prospectively recruited (12 RIS, 10 CIS, 11 relapsing-remitting-MS, 10 secondary progressive-MS, 10 primary progressive MS and 23 gender and age-matched healthy controls). We analyzed fixations, anti-saccades, horizontal and vertical reflex saccades and smooth pursuit. RESULTS: EMA were frequent and of gradual severity from RIS to progressive forms. Internuclear ophthalmoplegia (INO) and centripetal hypermetria were strong arguments for the diagnosis of a demyelinating disorder versus a control population. Some EMA were linked to infratentorial T2 lesion location, but others like INO were not. CONCLUSION: This study confirm that EMA are common in all MS phenotypes, even at the earliest stages. VOG can be useful to detect demyelinating process at preclinical stage by highlighting subclinical EMA even in absence of characteristic lesions visible on MRI.

Meningeal SWI/SNF related, matrix-associated, actin-dependent regulator of chromatin, subfamily B member 1 (SMARCB1)-deficient tumours: an emerging group of meningeal tumours.

AIMS: Bi-allelic inactivation of SWI/SNF related, matrix-associated, actin-dependent regulator of chromatin, subfamily B member 1 (SMARCB1; also known as INI1) and loss of immunohistochemical expression of SMARCB1 define the group of SMARCB1-deficient tumours. Initially highlighted in malignant rhabdoid tumours, this inactivation has subsequently been observed in several intra and extracranial tumours. To date, primary meningeal SMARCB1-deficient tumours have not been described. We report two cases of meningeal SMARCB1-deficient tumours occurring in adults. METHODS: We performed immunohistochemical analyses, comparative genomic hybridization, fluorescence in situ hybridization and targeted next-generation sequencing. RESULTS: The first meningeal tumour was a solitary mass, composed of rhabdoid, adenoid, chordoid and sarcomatoid areas. The second case presented as multiple, bilateral, supra and infratentorial nodules, was composed of fusiform and ovoid cells embedded in a myxoid stroma. Tumour cells were positive for epithelial membrane antigen (EMA), vimentin and CD34 and negative for SMARCB1 and meningothelial, melanocytic, muscular, glial markers. In the first case, one allele of SMARCB1 was completely deleted, whereas in the second case, loss of expression of SMARCB1 was observed as a consequence of a homozygous deletion of SMARCB1. CONCLUSIONS: The phenotype and genotype of these two cases did not fit diagnostically with entities already known to be SMARCB1-deficient tumours. As both tumours shared common features, they are regarded as belonging to an emerging group of primary meningeal SMARCB1-deficient tumours, not described to date. To facilitate the identification and characterization of these tumours, we recommend SMARCB1 immunohistochemistry for primary meningeal tumours which are difficult to classify, especially if immunopositive for EMA and CD34.

Modification of cerebral vascular anatomy induced by Leo stent placement depending on the site of stenting: A series of 102 cases.

BACKGROUND AND PURPOSE: Recent studies demonstrated the capacity of stents to modify cerebral vascular anatomy. This study evaluates arterial anatomy deformation after Leo stent placement according to the stenting site and the impact on the immediate postoperative and six-month degree of aneurysmal occlusion. MATERIALS AND METHODS: A total of 102 stents were placed against the neck of aneurysms situated in the anterior cerebral circulation. Aneurysms were classified into two groups: The first was called the distal group (n = 62) and comprised aneurysms situated in the middle cerebral and anterior communicating arteries and the second was called the proximal group (n = 40) and comprised aneurysms in other sites. The stented arterial segment was classified as deformed or non-deformed by blinded review and superimposition of anonymised films before and after stenting. The degree of occlusion was determined immediately postoperatively and at six months. RESULTS: Significantly, anatomical deformity was observed in the distal group compared to the proximal group (85% vs 28%). No significant difference was observed between the two groups in terms of postoperative degree of occlusion. At six months, a significant difference was observed between the two groups: three recurrences in the distal group vs 10 recurrences in the proximal group. Two (3%) recurrences were observed in the deformed group vs 11 (31%) recurrences in the non-deformed group. CONCLUSIONS: Arterial deformity induced by stenting is even more marked for distal aneurysms. The recurrence rate is smaller when the stent placement results in an arterial anatomical change. The percentage of recurrence is lower when anatomy was amended by stent implantation.

Neuromyelitis optica: Contribution of therapeutic responses markers monitoring in patients given rituximab.

Neuromyelitis optica (NMO) is a central nervous system inflammatory autoimmune disease characterized by medullary and/or optical nerve damage. It is rare but life-threatening. Concerning the treatment of NMO, many drugs have been used in background therapy. Some studies have shown efficacy of rituximab (an antiCD20 monoclonal anti-body) either on the reduction of the annual number of exacerbation or the mean score EDSS. In 2013, a Korean team reported a new protocol during which they administered rituximab only when memory B lymphocytes CD27+ were detectable in the bloodstream. In our patient, institution of this protocol led to clinical benefit with a major decrease in the EDSS score over time (7 in August 2012 vs. 1 in October 2015), a reduction of the total administered dose (4g in 2013 vs. 1.375g in 2014 vs. 0g in 2015) and side effects. Compared with the rate of theoretical administration, health expenditure savings reached 1700 Euros per month over the 11-month treatment. Monitoring therapeutic response markers with memory B lymphocyte counts appear to be an efficient cost-effective way to measure clinical efficiency, reduce total doses, and limit side effects.

Multiple lung parenchymal abnormalities: Don't panic, let's be pragmatic! The 6 question rule - a checklist strategy.

Analysis of multiple lung parenchymal abnormalities on HRCT is a real diagnostic challenge. These abnormalities may be due to a disease of the pulmonary interstitial tissue, the bronchial tree, the cardiovascular system or to abnormal alveolar filling with fluid, blood, cells or tumor, several of these etiologies possibly being concomitant. Systematic pathophysiological reasoning, in the form of a logical checklist, guides reflection and covers many of the most frequent diagnoses and potentially treatable emergencies that can be identified by the non-specialist radiologist. This approach also provides a basis for deepening knowledge of each area. The use of the mnemonic FIBROVAKIM (fibrosis-bronchi-vascular-cancer-infection-medication) is easy to apply and summarizes this strategy.

Primitive cerebral melanoma: a diagnostic and management challenge. About 2 cases.

In this report of two cases of solitary cerebral meningeal melanoma, a rare tumor that presents both diagnostic and management challenges, the diagnosis of these lesions was based on a solitary leptomeningeal mass on MRI, a high mitotic rate on histology and the absence of extracerebral localizations. Although the radiological patterns can mimic those of other melanocytic tumors, MRI is a useful diagnostic tool for narrowing the differential diagnosis. Surgical removal remains the only effective treatment of these lesions, and can lead to prolonged survival in a few cases.

[Bevacizumab for the treatment of cerebral radionecrosis]. / Bévacizumab dans le traitement des radionécroses cérébrales.

Bevacizumab is a monoclonal antibody, which neutralizes the effect of vascular endothelium growth factor (VEGF) allowing regression of tumour vessels and a decrease in the permeability of the blood-brain barrier. Already used in oncology as adjuvant treatment for certain metastatic cancers and in second line for high-grade gliomas, it has been recently used as a treatment of cerebral radionecrosis resisting conventional drug treatment and hyperbaric oxygen. This article presents three patients with cerebral radionecrosis and treated by monthly infusions of bevacizumab (10 mg/kg per month). The patients had developed cerebral radionecrosis after radiation therapy for a malignant brain tumour. The radionecrosis was proved by magnetic resonance imaging and spectroscopy. The first patient received only one perfusion of bevacizumab, as the development of a lymphopenia prevented the patient from continuing with the treatment. The second patient received four infusions, but the absence of improvement of the clinical symptoms and progression of the radiolesion led to discontinuation of the treatment. The third patient developed several severe side effects, a transient ischemic accident and a perforated corneal ulcer, resulting again in premature discontinuation of treatment. The development of severe side effects, combined with the absence of notable clinical and radiologic improvements resulting from the use of bevacizumab as a treatment resulted in the premature interruption of such treatment, in all three patients.

[Clinical factors in glioblastoma and neuroradiology]. / Chemins cliniques des glioblastomes et neuroradiologie.

Glioblastoma is found preferentially in men (1.5/1), nearing age 60, but all ages can be concerned. Clinical symptoms are intracranial mass without specificity, intracranial hypertension and localization signs. From the clinical history, the essential prognosis factors are: age, Karnofsky score and cognitive dysfunction. Conventional MRI sequences, including T1-FSE with and without contrast injection and T2-FSE or Flair-weighted sequences, provide the diagnosis in most cases, showing an intraparenchymal mass with a heterogeneous, irregularly enhanced signal. Other sequences define the tumor more precisely. Diffusion sequences provide the differential diagnosis with an abscess or a highly cellular tumor such as lymphoma. Perfusion sequences allow appreciation of tumor microvascularization outlining the tumor's most active areas. Magnetic resonance spectroscopy (SRM) sequences allow noninvasive exploration of tumor metabolism. Beyond its diagnostic role, imagery assists the surgical procedure itself, particularly with functional MRI, allowing a precise preoperative mapping of functional cortical areas. Biopsy can also be guided toward the most active areas of the tumor. In the postoperative period, MRI completes the surgeon's impression on whether or not there is residual tumor. Finally, this exam has become essential in follow-up to diagnose recurrence, radionecrosis, or pseudoprogression.

[Evaluation of two classifications systems for pelvic prolapse on dynamic MRI]. / Evaluation de deux systèmes de cotation des prolapsus pelviens en IRM dynamique.

PURPOSE: To determine the usefulness of two classification systems for pelvic prolapse on MRI. MATERIALS AND METHODS: Prospective study of 30 patients with symptoms of pelvic prolapse performed in a single center. All patients underwent clinical evaluation followed by dynamic pelvic MRI within 15 days. All MR examinations were reviewed by three readers using both classification systems based on different anatomical landmarks. The first used the pubococcygeal line and the second used the midpubic line. RESULTS: For prolapse detection, the correlation between clinical examination and MRI was good to very good, ranging between 74 and 89%. For prolapse staging, the correlation was poor to moderate. Inter-observer agreement was good to very good (kappa between 0.67 and 0.95). It was slightly better at the mid stage, with both systems (kappa between 0.83 and 0.97). Comparison of the inter-observer agreement between both MRI classification systems showed better results for the system using the pubococcygeal line (p<0.005). CONCLUSION: The classification system based on the pubococcygeal line appeared more reliable and simple for th eevaluation of pelvic prolapse on MRI.