[Which psychiatric symptoms must raise suspicion about a possible brain tumor ?] / Quels symptômes psychiatriques doivent alerter sur la possible présence d'une tumeur cérébrale ?

Many case studies reported psychiatric symptoms during the months before a brain tumor (BT) is diagnosed. Unfortunately, these symptoms are rarely considered as a warning of an organic problem and patients are regularly misoriented towards psychiatric care. Knowing better what psychiatric symptoms look like in patients with a BT would help to diagnose it sooner, which would obviously benefit the patient. The present study aims to quantify the prevalence and further describe psychiatric symptoms occurring before a BT diagnosis. The presence of psychiatric manifestations was systematically investigated in 100 patients with a first diagnosis of BT. Overall, 85 % of the patients reported at least one psychiatric symptom present before the BT diagnosis, most often depressive ones. Somatic manifestations of depression (loss of energy, changes in appetite...) were more often reported than affective or cognitive ones (no negative thought content: no pessimism, no guilty feelings, no worthlessness…). The present research stresses the high prevalence of psychiatric symptoms, especially depressive-like ones, occurring before a BT is diagnosed and provides a first description of these symptoms, as a basis of practical recommendations.

De nombreuses études de cas ont rapporté la présence de symptômes psychiatriques dans les mois qui précèdent le diagnostic d'une tumeur cérébrale (TC). Malheureusement, ces symptômes restent rarement considérés comme renseignant un possible problème organique et les patients sont régulièrement orientés vers une prise en charge psychiatrique. Une meilleure connaissance de la présentation psychiatrique des TC favoriserait un diagnostic précoce, évidemment profitable au patient. L'objectif de cette étude est de quantifier la fréquence des symptômes psychiatriques présents avant le diagnostic de TC et de les décrire. Chez 100 patients adultes avec un premier diagnostic de TC, la présence de manifestations psychiatriques a été évaluée de façon systématique. 85 % des patients ont souffert d'au moins un symptôme psychiatrique avant que la TC ne soit diagnostiquée, avec, à l'avant-plan des éléments dépressifs. Parmi les symptômes dépressifs, les expressions somatiques sont le plus souvent rapportées (perte d'énergie, changement de l'appétit…), au contraire des manifestations cognitives et affectives (pas de contenu de pensées négatives : pessimisme, culpabilité, dévalorisation...). Cette recherche souligne la prévalence élevée de symptômes psychiatriques évoquant le plus souvent un état dépressif avant le diagnostic de TC et apporte une première description de ces symptômes, permettant l'ébauche de certaines recommandations pratiques.

Familial adhesive arachnoiditis associated with syringomyelia.

Adhesive arachnoiditis is a rare condition, often complicated by syringomyelia. This pathologic entity is usually associated with prior spinal surgery, spinal inflammation or infection, and hemorrhage. The usual symptoms of arachnoiditis are pain, paresthesia, and weakness of the low extremities due to the nerve entrapment. A few cases have had no obvious etiology. Previous studies have reported one family with multiple cases of adhesive arachnoiditis. We report a second family of Belgian origin with multiple cases of arachnoiditis and secondary syringomyelia in the affected individuals.

Unexpected entropy response to saline spraying at the end of posterior fossa surgery: a few cases report.

The Spectral Entropy proposed to monitor the depth of anesthesia includes the State Entropy (SE) computed from the EEG (0.8-32 Hz frequency band), and the Response Entropy (RE) computed from EEG and facial muscles activity (0.5-47 Hz frequency band). We report an unexpected Entropy response to saline spraying at the end of posterior fossa surgery. Six patients undergoing scheduled functional surgery of the posterior fossa were included in this report. They were anesthetized with propofol and remifentanil using TCI and received an intubation dose of rocuronium. At the end of surgery, saline spraying, performed for hemostatic purpose and wreckage elimination, resulted in a sustained increase in RE and SE without hemodynamic modification in four patients, while no change was observed in the two other ones. In one of the responding patients, 0.1 mg kg(-1) rocuronium attenuated the Entropy response. In the two non responders, repetition of spraying or rocuronium administration did not change Entropy value. Recovery from anesthesia was comparable in all patients and none of them complained from awareness. We conclude that Entropy can increase during posterior fossa surgery in non-paralyzed patients. This response probably reflects an increase in facial muscle activity rather than a change in depth of anesthesia, as far as it can be attenuated by a small dose of rocuronium. While this hypothesis requires further investigation, these observations suggest that saline spraying may confound interpretation of Entropy during posterior fossa surgery.

Comparison of the surgical Pleth Index™ with haemodynamic variables to assess nociception-anti-nociception balance during general anaesthesia.

BACKGROUND: The Surgical Pleth Index (SPI) is proposed as a means to assess the balance between noxious stimulation and the anti-nociceptive effects of anaesthesia. In this study, we compared SPI, mean arterial pressure (MAP), and heart rate (HR) as a means of assessing this balance. METHODS: We studied a standard stimulus [head-holder insertion (HHI)] and varying remifentanil concentrations (CeREMI) in a group of patients undergoing neurosurgery. Patients receiving target-controlled infusions were randomly assigned to one of the three CeREMI (2, 4, or 6 ng m⁻¹), whereas propofol target was fixed at 3 µg ml⁻¹. Steady state for both targets was achieved before HHI. Intravascular volume status (IVS) was evaluated using respiratory variations in arterial pressure. Prediction probability (Pk) and ordinal regression were used to assess SPI, MAP, and HR performance at indicating CeREMI, and the influence of IVS and chronic treatment for high arterial pressure, as possible confounding factors. RESULTS: The maximum SPI, MAP, or HR observed after HHI correctly indicated CeREMI in one of the two patients [accurate prediction rate (APR)=0.5]. When IVS and chronic treatment for high arterial pressure were taken into account, the APR was 0.6 for each individual variable and 0.8 when all of them predicted the same CeREMI. That increase in APR paralleled an increase in Pk from 0.63 to 0.89. CONCLUSIONS: SPI, HR, and MAP are of comparable value at gauging noxious stimulation-CeREMI balance. Their interpretation is improved by taking account of IVS, treatment for chronic high arterial pressure, and concordance between their predictions.

[Intracranial hypertension in Proteus syndrome]. / Syndrome Proteus et hypertension intracrânienne.

Proteus syndrome, described for the first time in 1979, is a sporadic congenital poly-malformation syndrome named for its highly variable manifestations. We report the case of a 36-year-old male patient with several malformations including skull hyperostosis and huge frontal sinus hypertrophy compressing the brain. He complained of increasing headache for 5 years. Cerebrospinal fluid pressure monitoring revealed severe hypertension. The patient underwent frontoparietal craniectomy, which allowed partial decompression. Postoperatively headaches decreased and the intracranial pressure normalized. Proteus syndrome is a genetic disease with a mosaic pattern. Only a hundred cases have been reported, mostly in childhood. Common manifestations include disproportionate overgrowth of the limbs and the skull, various subcutaneous tumors, vascular, renal and pulmonary malformations. Brain abnormalities are not common in this syndrome. When present, retardation or seizure disorders are typically seen. Intracranial hypertension is described for the first time in this syndrome.

[Management of medulloblastoma in children: the experience of a single institution in Liege from 1991 to 2005]. / Prise en charge du médulloblastome de l'enfant.

We present the experience of the Citadelle Hospital (Liege, B) in the diagnosis, treatment and follow-up of medulloblastoma in children. A retrospective study of 10 cases of medulloblastoma was performed. Five years after diagnosis, the event-free survival was 77%.

[Spontaneous ossification of the cervical spine after subtotal surgery spondylotic myelopathy]. / Ossification spontanée du rachis cervical après somatotomie subtotale pour myélopathie.

Subtotal corporectomy without fusion (SCWF) is a misunderstood surgical procedure used in the treatment of spondylotic myelopathy. This clinical study was performed to evaluate the efficiency of the SCWF. Long term neurological status and cervical spine ossification were specially studied. Sixty-four patients, operated between 1990 and 2003, were evaluated. The average follow-up period was five years. To assess the severity of neurological symptoms, a functional seven-point classification scale was used. Discriminant analysis was applied as statistic. There was a significant correlation between outcome, functional preoperative score, age, duration of the compression and intramedullary lesion in NMR. After SCWF, no secondary cervical instability was observed. Conversely, we show, for the first time in the literature, that on the twenty-one patients who were the subject of late 3D CT scan, there exists a true rebuilding of the cervical bone with spontaneous fusion and respect of cervical cord decompression. We conclude that the SCWF is a safe and efficient treatment for cervical spondylotic myelopathy. No fusion is required regardless of the number of levels, providing there is no preoperative instability. This surgical procedure which does not require any cervical immobilization considerably decreases surgical risks and costs imposed by the society.

[Anaesthetic management of awake craniotomy]. / Prise en charge anesthésique des craniotomies en état vigile.

This review article presents a detailed analysis of patients' management for awake craniotomy, at the light of the available data in the literature and the authors' experience. Indications of this type of surgery are discussed as well as anaesthetic management itself, from preoperative assessment of the patient to peroperative concerns. Anaesthetic strategy, choice of anaesthetic agents, anaesthetic technique, and management of the airway and possible complications are discussed. The authors emphasize the tricky aspect of the procedure, the necessity of rigorous patient selection and good preparation. They emphasize the need for controlled studies to validate the proposed techniques.

The emperor's clothes description of a new epidemic related to diagnostic imaging.

In 1835, Hans Christian Andersen published "The Emperor's New Clothes", one of the 164 fairy tales that earned him worldwide fame. A little more than 25 years ago, drawing inspiration from that tale, F. Gross reported the existence of an ailment capable of affecting multiple systems, "the Emperor's clothes syndrome". This syndrome primarily affects students and physicians for whom career success is of paramount importance. Based on actual experience, we are describing a new epidemic of this ailment, for which the radiological image is the principal vector. We wish to draw attention to the danger of basing a diagnosis solely on diagnostic testing. In an age dominated by technology, we would like to emphasize that anamnesis and clinical examination are still the cornerstones of diagnosis. Any clinical or radiological information, any laboratory phenomenon is subject to variable interpretation by different observers. We also suggest that there are statistical methods for evaluating the reliability of a clinical test.

[Arterial aneurysm within a tumor in a pediatric patient]. / Anévrisme artériel intra-tumoral chez l'enfant.

A middle cerebral artery aneurysm, completely enclosed in a large frontotemporal anaplastic astrocytoma, is demonstrated in a 11-month-old girl admitted for intracranial hypertension. Clipping of the aneurysm along with radical resection was successfully performed. Five years later, follow-up neurological examination is normal, aneurysm occlusion and no evidence of tumor recurrence are demonstrated by angiogram and MRI. The association of brain tumor and aneurysm is discussed, and documented with the only two cases of a neoplasm surrounding on aneurysm reported in the literature.

[How I treat ... facial paralysis by hypoglosso-facial anastomosis]. / Comment je traite ... la paralysie faciale par anastomose hypoglosso-faciale.

Thirteen patients underwent a hypoglosso- or a spino-facial nerve anastomosis between 1990 and 1996. Facial palsy was the result of surgery in 12 cases and of radiosurgery in 1 case. The mean interval between facial palsy and anastomosis was 12 months. Facial nerve function is determined on the basis of clinical examination according to the classification of House-Brackmann and our own evaluation. According to House, 10 patients are classified grade III and 3 grade IV. Our evaluation defines in 10 grade III, 7 good results and 3 fair results. As far as the good results are concerned, the mean interval between palsy and anastomosis is short (< 3 months). The permanent eating and swallowing dysfunctions are consecutive to multiple cranial nerve deficits. The post-paralysis hemifacial spasm is facilitated by prolongated electric stimulations.

[Perioperative management of blood loss during surgical treatment for craniosynostosis]. / Prise en charge périopératoire des pertes sanguines au cours du traitement chirurgical des craniosténoses.

Blood saving is the major challenge during the surgical repair of craniofacial deformities. Treated patients have a low reserve volume and the techniques available to lower homologous blood transfusions are limited or insufficiently evaluated in this particular case. The most important factor determining blood loss is the quality of the surgical haemostasis. Blood saving begins with early preoperative evaluation of the patient's bleeding risk, which is a function of the type of surgery, of the surgical technique, of the number of sutures involved, of the length of surgery, and of the patients age, weight and physical status. Elaborated blood saving techniques such as preoperative autologous blood donation, erythropoietin administration, normovolaemic haemodilution, and peroperative autologous blood saving and reinfusion have revealed disappointing where used alone. These techniques require a heavy setup and still need to be evaluated extensively. They should be used in selected cases such as in patients with a very high risk of bleeding or face to Jehovah Witnesses. Monitoring during surgery should include precise evaluation of blood losses and haematocrit measurements at regular intervals. The haematocrit threshold allowing homologous blood transfusion should be set at 21%, provided that any other source of autologous blood is exhausted. Postoperative monitoring should also include precise evaluation of blood losses and haematocrit measurements. The 21% threshold should remain the reference during that period.

[Trigeminal neuralgia and hemifacial spasm. Vessel-nerve antagonism]. / Névralgie du trijumeau et hémispasme facial. Réalite du conflit vasculo-nerveux.

In the last 30 years, the concept of microvascular compression has achieved widespread acceptance. Still, some remain unconvinced. A review of our 182 operations, 104 trigeminal neuralgia and 78 hemifacial spasms, shows that microvascular decompression of the trigeminal and facial nerves is effective in alleviating trigeminal neuralgia and hemifacial spasm, because it removes the actual cause of the disorder rather than simply causing local injury to the nerve. Our neurophysiological investigations, the so-called abnormal muscle response, performed intraoperatively in twenty patients with hemifacial spasm, confirm that compression of the facial nerve at the root exit zone, by a blood vessel, causes pathological and clinical responses. Microvascular decompression is an extremely safe and effective treatment, even for the older patients without severe disabilities.

[Anterior and antero-lateral surgery for degenerative cervical spine diseases. Role of graft and osteosynthesis. Analysis of practices of the French-speaking european neurosurgeons]. / Chirurgie antérieure et antéro-latérale du rachis cervical dégénératif. Place de la greffe et de l'ostéosynthèse. Analyse de la pratique des neurochirurgians européens francophones.

The neurological complications of cervical spondylosis depend on the direct or indirect effects of the mechanical compression of the spinal cord and roots. Nobody questions the interest of a surgical decompression, when the medical treatment is ineffective, but there is no consensus on the choice of the surgical approach and on the necessity of performing a graft with or without osteosynthesis after an anterior decompression. On the initiative of the French Speaking Neurosurgical Society (SNLF), we have analyzed the practices of its European members in 1998 and report here the results of this study which collects 3 645 surgical procedures for degenerative pathology of the lower cervical spine responsible for radiculopathy or myelopathy. An anterolateral approach was used in 85.3 % of all cases, among which 87.9 % of extensive discectomy (Smith Robinson or Cloward technique) and 12.1 % of median somatotomy. In case of discectomy, no grafting was performed in 34.7 % of cases, grafting without fixation in 25.7 %, grafting with plating in 14.9 %, interbody cages in 21.9 %, other techniques in 2.8 %. In case of somatotomy, no grafting was performed in 17.8 % of cases, grafting without fixation in 15.5 %, and grafting with plating in all other cases. When a graft was performed, an autograft was used in 59.5 % of cases, hydroxyapatite in 24.4 %, and many other bone substitutes in rare cases every time. For the fixation, monocortical screwing was used in 75 % of all cases, and bicortical in 25 %. The reasons for these practices are equivocal and not based on scientific attitude. The reasons given are : to avoid discal plucking, to prevent or treat kyphosis and postoperative spinal instability, to prevent cervical postoperative pain, to help eliminate osteophytes and hypertrophy of the ligamentum flavum.

Target-controlled infusion of propofol and remifentanil combined with bispectral index monitoring for awake craniotomy.

We describe the target-controlled administration of propofol and remifentanil, combined with monitoring of the bispectral index, during an awake craniotomy for removal of a left temporo-parietal tumour near the motor speech centre. Target concentrations of the two drugs were adjusted according to the patient's responses to painful stimuli and surgical events, and the need for speech testing. Allowing the effect-site concentrations of propofol and remifentanil to decrease during surgery allowed the performance of cortical speech mapping and the testing of the patient's ability to speak. Although the bispectral index was not used as a guide for the administration of the drugs, its value correlated better with the patient's responsiveness than did the predicted effect-site concentrations of propofol. Side-effects, comprising hypotension, respiratory depression and airway obstruction, were related to rapid increases in drug infusion rates and were easily managed.

Evaluation of acute normovolemic hemodilution for surgical repair of craniosynostosis.

This clinical report investigated the potential benefit of acute normovolemic hemodilution (ANH) as a blood-saving technique in the surgical repair of craniosynostosis. Over a 4-year period, 34 healthy children undergoing surgical repair of scaphocephaly or pachycephaly were randomly assigned to two groups of 17 patients each. Patients of the first group (ANH group) were submitted to ANH (target Ht: 25%) immediately before surgery and patients of the second group (Control group) were not. During surgery, estimated blood loss was compensated with a 5% albumin solution and no autologous or homologous blood was transfused. At the end of surgery, intraoperative blood loss (mean +/- SD) calculated on the basis of the Ht value and the children weight was 21.3+/-8% of the estimated blood volume (EBV) in the ANH group and 24+/-6.6% in the Control group. Children of the ANH group received their autologous blood (18.9+/-3.3% of EBV) systematically at the end of surgery. In the postoperative period, homologous blood was transfused when the Ht value was equal or less than 21%. Both groups were comparable regarding age, weight, type of craniosynostosis, duration of surgery, EBV, and preoperative Ht value. No difference was observed between ANH and Control groups in the number of patients who received homologous blood (15/17 and 14/17, respectively), in the amount of homologous blood transfused (17+/-4.7% and 19.6+/-6.3% of the EBV, respectively), and in the Ht value before hospital discharge (29.4+/-5.0% and 30.7+/-4.9%, respectively). In conclusion, this report suggests that ANH reduces neither the incidence of homologous transfusion nor the amount of homologous blood transfused in this series of children undergoing surgical repair of craniosynostosis.

[Evaluation and treatment of cervical spondylotic myelopathy by subtotal corporectomy without grafting]. / Evaluation et traitement de la myélopathie cervico-arthrosique par somatotomie subtotale sans greffe.

These experimental and clinical studies were performed to evaluate the efficiency of a new surgical procedure in the treatment of spondylotic myelopathy, the subtotal corpectomy without fusion. In a first step, the biomechanic analysis of eleven human cadaveric cervical spines, before and after corpectomy without grafting, demonstrated that this procedure does not reduce significantly the cervical stiffness. In a second step, we prospectively evaluate 77 patients operated between 1990 and 1998. The average follow-up period was 53 months (range: 10 to 111 mo). We conclude that this procedure is a safe and efficient treatment for cervical spondylotic myelopathy. No fusion is required regardless of the number of levels, providing there is no preoperative instability. We showed that clinical myelopathy severity and age are significant predictors of the outcome.

Effects of two calculated plasma sufentanil concentrations on the hemodynamic and bispectral index responses to Mayfield head holder application.

The effects of two calculated plasma sufentanil (SUF) concentrations on the hemodynamic and bispectral index (BIS) responses to Mayfield head holder (MH) application were studied in 20 patients scheduled for intracranial surgery. Premedication consisted of hydroxyzine, alprazolam, and atropine given orally 1 hour before surgery. Anesthesia was provided with propofol (PPF) and SUF using a target-controlled infusion device. Patients were randomly assigned to one of two groups according to calculated plasma concentrations: 3 microg/mL(-1) of PPF and 0.5 ng/mL(-1) of SUF in group I (GI) and 3 microg/mL(-1) of PPF and 1 ng/mL(-1) of SUF in group II (GII). The MH was fixed 33.0+/-6.6 minutes (mean +/- SD) after induction. Systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) as well as heart rate (HR) and BIS were recorded 1 minute before pinning (baseline) as well as 1 minute (P1), 2 minutes (P2), and 3 minutes (P3) after pinning. Multivariate repeat-measured analyses of variance were applied to the baseline-subtracted measurements of hemodynamic and BIS values. Groups were compared using the Student's t test, and P < .05 was considered to be statistically significant. Patients' characteristics, baseline hemodynamic values, and BIS values were similar in both groups. A significant overall time effect was observed for all variables, but no significant overall SUF effect was detected. Increases in SAP, MAP, DAP, and HR did not differ significantly between groups. The increase in hemodynamic variables did not exceed 20% of baseline value in either group. In contrast, at P1, the increase in BIS over the baseline value was significantly higher in GI (15.0+/-7.9) than in GII (6.7+/-6.5). In conclusion, MH application was associated with a significant, although not clinically relevant, increase in hemodynamic variables whatever the calculated plasma SUF concentration (0.5 or 1.0 ng/mL(-1)). In contrast, the increase in BIS observed at pinning was significantly higher in patients with the lowest calculated plasma SUF concentrations. This suggests that the BIS response to noxious stimulation is modulated by the analgesic regimen.