An unusual superolateral origin of ophthalmic artery: an anatomic case report.

BACKGROUND AND IMPORTANCE: If ophthalmic artery's (OphA) origin anomalies are frequent, the superolateral origin of the OphA was rarely described. CLINICAL PRESENTATION: During an aneurysmal surgery, a superolateral origin of the left OphA was found. This variation was associated with a sylvian aneurysm. The anatomical, embryological features, the neurosurgical implications of this origin such as treatment of carotid-ophthalmic aneurysm or intra arterial retinoblastoma chemotherapy are discussed. CONCLUSION: To the best of our knowledge, this is a very rare operative case of both superolateral origin and initial course of OphA.

Correlation between tap test and CSF aqueductal stroke volume in idiopathic normal pressure hydrocephalus.

INTRODUCTION: The diagnosis and management of idiopathic normal pressure hydrocephalus (INPH) remains unclear despite the development of guidelines. In addition, the role of cerebrospinal fluid (CSF) aqueductal stroke volume (ASV) remains unspecified. OBJECTIVES: The aim of this study was to compare the results of the tap test (TT) and ASV in patients with possible INPH. MATERIALS AND METHODS: Among 21 patients investigated with both TT and phase-contrast (PC) MRI, we identified two groups, with either (1) a positive TT (PTT) or (2) a negative one (NTT), and we compared their ASV as measured by PC-MRI. ASV cutoff value was set at 70 µL/cardiac cycle (mean value +2 standard deviations in age-matched healthy subjects). RESULTS: In the PTT group (n = 9), the mean ASV was 175 ± 71 µL. Among these patients, four were shunted, and improved after surgery. In the NTT group, two patients were finally diagnosed with aqueductal stenosis and excluded. Among the remaining patients (n = 10), the mean ASV was 96 ± 93 µL (p < 0.05). However, three of these patients presented with hyperdynamic ASV, and an associated neurodegenerative disorder was diagnosed. Two patients had ventriculoperitoneal shunting despite their NTT, and improved. DISCUSSION/CONCLUSIONS: In our patient population, the noninvasive measurement of hyperdynamic ASV correlated with PTT, suggesting PC-MRI could be utilized to select those patients who would benefit from shunting. ASV may therefore be an interesting supplemental diagnosis tool.

[Paraclinoid region: descriptive anatomy and radiological correlations with MR imaging]. / La région paraclinoïdienne: anatomie descriptive et corrélations radiologiques en imagerie par résonance magnétique.

OBJECTIVE: The paraclinoid region has a complex anatomy. The purpose of this study was to depict in details its anatomical landmarks and their radiological translations with magnetic resonance imaging (MRI). MATERIAL AND METHOD: Ten anatomical specimens (20 paraclinoid regions) were prepared, then dissected and further analyzed with MRI in order to describe their important radio-anatomical structures (dural folds, osseous surfaces, arteries and nerves) along with their course and measurements, and the reference points of the carotid distal dural ring. The paraclinoid MR protocol consisted in a T2 high-resolution sequence with thin and contiguous slices acquired in a coronal (diaphragmatic) and sagittal oblique (carotid) plane. Reproducibility in living subjects was evaluated on 15 patients (30 paraclinoid regions). Statistical comparison was made between laboratory and MR measurements obtained on cadavers. RESULTS: A detailed description of paraclinoid anatomy and structures was provided. Its landmarks were satisfactorily identified with the dedicated MR protocol. Reproducibility in living subjects was obtained. No statistical difference was found between laboratory and MR measurements. CONCLUSION: This study provides a precise description of paraclinoid anatomical structures and their radiological correlations. This paraclinoid MR protocol allows locating paraclinoid lesions in comparison with the cavernous sinus roof, which is of paramount importance for the management of paraclinoid carotid artery aneurysms.

[Vertebroplasty: 10 years clinical and radiological follow-up]. / Vertébroplastie: évaluation clinique et radiologique à plus de dix ans.

OBJECTIVES: Ten years follow-up of the first patients treated with percutaneous vertebroplasty. PATIENT AND METHODS: Eighteen patients were retrospectively reviewed having undergone vertebroplasty in our centre between 1989 and 1998. Eight were treated for angioma, eight for osteoporotic compression and two followed for myeloma. They all underwent clinical and radiological evaluation in 2007 (standard X-rays, CT scan and MRI). These examinations were compared to prior baseline pre- and post-therapeutic images. RESULTS: Radiological characteristic of cement remained unchanged in the long term and there was no modification of anatomical structures in contact with it. Even if the distribution of cement was asymmetrical there was no fracture of the treated vertebras at distance. Degenerative changes of discs facing the vertebroplasty were not more pronounced than for distant discs. We found no significant signal or density anomaly of disc in contact direct with cement. 38.8 % of the patients presented new fractures (n=30). Seventy percent of the fractures were multiple and contiguous. In the long term, all patients reported improvement of pain after the procedure. CONCLUSION: In our series, we found a good stability of treatment over time. This study shows the long-term safety of percutaneous acrylic vertebroplasty, in particular harmlessness of cement for bone and discs in contact.

[Intra cranial abscess and empyemas from E.N.T. origin]. / Abcès et empyèmes intracrâniens d'origine O.R.L.

OBJECTIVES: The purpose of this study was to evaluate the diagnosis criteria, the bacteriology and the evolution after adapted treatment of intracranial abscess of ENT origin. MATERIAL AND METHODS: It was a retrospective study from 1985 to 2003 concerning 22 patients who had brain abscesses secondary to an ENT infection. RESULTS: The infectious origin was sinusoid in 32% of cases, otologic in 32% of cases, pharyngeal or dental in 27% of cases and cutaneous in 9% of cases. The clinical symptoms were: fever in 55% of cases, headache in 73% of cases (Intra cranial hypertension syndrome in 23% of cases), epilepsy in 32% of cases and various other neurologic symptoms. Bacteria were identified in 82% of cases. In 50% of cases multibacterial associations were found. All the patients had bi antibiotherapy associated to surgical excision of the abscess (16 cases) or single (or more) punction (stereotaxic guided or not) of the abscess. 3 patients (14%) died and 50% are alive and well. CONCLUSION: The diagnosis of cerebral abscess is often difficult. The "classical" intracranial hypertension associated to high fever is usually incomplete and sometimes absent. There is no predominant bacteria involved and multibacterial infections are frequent. Despite abscesses are serious and potentially lethal, an early diagnosis, a medical (antibiotics) and surgical treatment (punction and/or surgical excision) may completely be cured in more than 50% of cases.

The external laryngeal nerve: surgical and anatomic considerations. Report of 50 total thyroidectomies.

This surgical anatomy study aimed to evaluate the possibility of identifying the external laryngeal nerve during thyroid surgery and the possible variations of nerves at risk. Fifty patients underwent total thyroidectomies during a period of 12 months. Using a neurostimulator, the distal motor branch of the external laryngeal nerve was searched. Electrical stimulation of a nervous branch aimed to provoke a global contraction of the cricothyroid in order to identify with certitude the external laryngeal nerve. The external laryngeal nerve was identified in 20% of cases. Its course was, with almost equal frequency, either (1) between the vessels of the superior thyroid pedicle or (2) superficial and anterior to the fascia of the cricothyroid muscle. The external laryngeal nerve is hard to find during thyroid surgery, even with a neurostimulator. It can be vulnerable during thyroid surgery but only in cases of anatomic variations. Searching for the nerve systematically during thyroid surgery does not seem to be useful. Several precautions when dissecting the superior pole of the thyroid gland seem to be necessary and sufficient to respect the external laryngeal nerve.

[Spontaneous otorrhea involving defects of the tegmentum tympani]. / Les otoliquorrhées spontanées par fistules ostéo-dure-mériennes du tegmen tympani.

OBJECTIVE: We report two cases and a review of the literature concerning spontaneous otoliquorrhea involving congenital bone defects of the tegmen tympani. CASE REPORTS: Both patients were managed by a cooperative otological and neurosurgical team. Otological symptoms predominated. The bilateral bone defects of the tegmen tympani were highlighted by high-resolution computed tomography. Surgery was undertaken via the middle fossa approach. DISCUSSION: Spontaneous cerebrospinal fluid otorrhea related to tegmen tympani defects is rare. It occurs in adults with no previous otological history. The anomaly is congenital. Otological symptoms (differential diagnosis with serous media otitis) are usually predominant. Infectious meningitis may occur. The diagnosis is based on high resolution computed tomography and surgical treatment is required. Numerous technical approaches are possible (transmastoid and/or middle fossa approach) depending on the extent of the defect. Complete recovery is usual after adapted surgical treatment.

[Lenticulostriate aneurysms. Radioclinical study]. / Anévrysme des artères lenticulostriées. Etude radioclinique à propos de quatre observations et revue de la littérature.

The authors report four cases of aneurysm of the lenticulostriate arteries, three idiopathic and one with underlying MoyaMoya disease. This unusual pathology, which often affects young patients, is revealed by a meningeal syndrome and sometimes focal neurological signs. The bleeding is highlighted by a CT scan without contrast injection, even by MRI, these examinations making it possible to evaluate its repercussion. Arteriography or MRA show the aneurysm and eliminate vascular malformation. According to literature (15 cases published) and our experience, considering the difficulty of a surgical or endovascular approach, morbidity and the frequency of spontaneous thromboses, it seems that a conservative management is justified after a negative etiologic check-up and under radio-clinical monitoring.

Pediatric cerebral aneurysms.

OBJECT: The exceptional pediatric aneurysm can be distinguished from its adult counterpart by its location and size; however, patient outcomes remain difficult to evaluate based on the published literature. METHODS: Twenty-two children, all consecutively treated in three neurosurgery departments, were included in this study. Each patient's preoperative status was determined according to the Hunt and Hess classification. Routine computerized tomography scanning and angiography were performed in all children on the 10th postoperative day. Each patient's clinical status was evaluated 2 to 10 years postoperatively by applying the Glasgow Outcome Scale (GOS). Twenty-one children presented with a subarachnoid hemorrhage (SAH) and one child harbored an asymptomatic giant aneurysm. Thirteen patients were in good preoperative grade (Hunt and Hess Grades I to III) and eight in poor preoperative grade (Hunt and Hess Grade IV or V). The symptomatic aneurysms were located on the internal carotid artery bifurcation (36.4%); middle cerebral artery (36.4%), half of which were found on the distal portion; anterior communicating artery (18.2%); and within the vertebrobasilar system (9.1%). A giant aneurysm was observed in 14% of patients. Overall outcome was favorable (GOS Score 5) in 14 children (63.6%) and death occurred in five (22.7%). Causes of unfavorable outcome included the initial SAH in four children, a complication in procedure in three children, and edema in one child. CONCLUSIONS: Pediatric aneurysms have a specific distribution unlike that of aneurysms in the adult population. The incidence of giant aneurysms and outcomes were similar to those in the adult population. The major cause of poor outcome was the initial SAH, in particular, the high proportion of rebleeding possibly due to a delay in diagnosis.

[Clinico-radiological data of 48 cases of immunocompetent primary cerebral lymphoma]. / Données clinico-radiologiques de 48 cas de lymphomes cérébraux primitifs immunocompétents.

In this article clinical and neuroradiological features from a cohort of 48 immunocompetent patients who have a histologically proved primary cerebral lymphoma are considered. Our series consisted of 27 men and 21 women with an average age of 59. The clinical results gave 73% patients with a focal deficit, 46% with deterioration of vigilance, 35% intracranial hypertension, and only 8% with epilepsy, which was never revealing. We observed 4 uveitis of which 3 revealed, and preceded by several months, the neuroradiological manifestations. Histological classification using the criterias of the Working Formulation showed that 92% of our patients had a large cell lymphoma (class G or H). Precise analysis of computed tomography features of 40 patients revealed 46 lesions (most of them were isodense) before contrast medium administration. In all the cases, the lesion enhancement was intense and homogeneous. In 50% of the cases, there were multiple lesions. Sixty lesions were of the supra tentorial compartment, lobar in 32 cases, deep in 28 cases. Fifteen were infratentorial. From our experience, we can put forward the following suggestions: 1) Neuroradiological aspects suggesting primary cerebral lymphomas exist but none of them are specific. 2) Research of an uveitis is important, as this makes the histological diagnosis more simple. 3)The prescription of corticosteroids should be delayed until the histological diagnosis is certain because the primary cerebral lymphoma, which is very corticosensitive, is likely to disappear with this treatment and then change the biopsy results.

When is spinal fusion warranted in degenerative lumbar spinal stenosis?

This study, conducted by a group of neurosurgeons who devote a large portion of their professional time to the treatment of degenerative lumbar spine lesions, was prompted by the dramatic increase in the number of lumbar spinal fusion procedures performed over the last few years in a broad spectrum of disorders ranging from chronic incapacitating low back pain to lumbar spinal stenosis. In the authors' experience, lumbar spinal fusion is rarely warranted and often of dubious efficacy. To investigate this contradiction, the authors reviewed the medical literature on lumbar spinal fusion for the treatment of degenerative spinal stenosis. They have defined lumbar instability as objectively as possible, reviewed clinical and roentgenographic features, described spinal fusion techniques with the drawbacks of each, and evaluated outcomes of surgery for degenerative lumbar spinal stenosis with or without fusion. Findings demonstrate that spinal fusion is a technique of unproven benefit that should be used only in carefully selected patients until results of reliable, prospective, comparative clinical trials become available. In the authors' opinion lumbar spinal fusion should be used as the first-line treatment only in young patients with clinical manifestations directly related to lumbar instability as defined in this study, when decompression requires removal of both facet joints and of the disk (which is rarely the case) or when simple decompression is followed by a recurrence of symptoms ascribable to worsening vertebral slippage.

Primary lymphoma of the central nervous system. An unresolved therapeutic problem.

From January 1979 to December 1987, 35 cases of primary central nervous system lymphoma (CNS-L) were treated. We recently reviewed these cases focusing on treatment results, treatment modalities, and radiotherapy (RT) or chemotherapy-radiotherapy (CT-RT). Variables such as age, risk factors, presenting symptoms, and histologic condition (all were high-grade or intermediate-grade non-Hodgkin's lymphomas [NHL]) and radiologic data were similar to those of series reported previously. The median survival time was 36 months (+/- 0.2 months) and the disease-free survival (DFS) time was 16 months (+/- 0.12 months). Twelve of 32 patients evaluable for treatment results experienced a recurrence (all but one occurred in the CNS). The DFS rate was 70% for the CT-RT group and 50% for the RT group (median follow-up time, 24 months). Therapeutic results in CNS-L are discussed with special emphasis on a putative role of CT in the management of this rare type of tumor.

[Destructive spondylarthropathy with amyloid deposits in 3 patients on chronic hemodialysis]. / Spondylarthropathie destructrice avec dépôts amyloïdes chez 3 patients en hémodialyse chronique.

Destructive spondyloarthropathy is a recently described complication of chronic hemodialysis. Three patients presenting spondyloarthropathy with destructive discovertebral lesions of the cervical or lumbar sections of the spine underwent surgery due to neurologic complications: persistent radiculalgia (two cases), regressive tetraparesis (one case). Discal lesions were associated with dislocation of the posterior intervertebral articulations and slipping of vertebrae. These patients had been receiving chronic hemodialysis for more than ten years; two presented hyperparathyroidism and blood aluminum was markedly increased in all cases. Two patients had undergone surgery for bilateral carpal tunnel syndrome. Anatomopathological examination of surgical specimens demonstrated the presence of amyloid deposits in the intervertebral disc. This suggests that amyloidosis, which is frequently seen with carpal tunnel syndrome in patients receiving prolonged hemodialysis, also plays a role in the development of spondyloarthropathy.