[Study of the normality of the orbito-naso-frontal bandeau]. / Étude de la normalité du bandeau orbito-naso-frontal.

INTRODUCTION: Craniosynostoses are cranio-facial malformations affecting about 1/2100 newborns in France. The involvement of anterior sutures (coronal and metopic) leads to orbito-frontal deformities. The treatment calls upon surgery the goal being, on an esthetic point of view, to restore a normal anatomy. The purpose of our work was to establish if some facial and/or frontal measures easy to perform on a CT are correlated to the global shape of the normal orbito-naso-frontal bandeau (ONFB). MATERIAL AND METHOD: Cranial CTs of 123 consecutive non-malformed children aged between 4 and 12 months were selected in the database of Department of Radiology of the University Hospital of Besançon - France. The CTs were all relocated by rigid transformation in an orthonormal coordinate system. On each of the 123 CTs, 21 reproducible measures representative of the global shape of the ONFB were made. Statistical analyses of these measures were achieved, considering age and gender, in order to determine the correlation between each measure and the ONFB shape. RESULTS: The only measure statistically correlated to the ONFB shape was the distance between the fronto-zygomatic sutures (FZD). The FZD was independent from age (in an interval of 4 months) and from gender. The 20 other measures did not show any correlation with age or gender. DISCUSSION: The FZD allows in itself to determine the ONFB global shape. This measure, easily available on a CT, can help the surgeon to perform a customized reshaping of the ONFB. The development of a surgical template using this measure is ongoing.

[Thoracic spine pseudarthrosis treated by transpleural corporectomy and bone morphogenic protein]. / Pseudarthrose du rachis thoracique, traitée par corporectomie transpleurale et protéine ostéo-inductrice.

BACKGROUND AND PURPOSE: Traumatic thoracic spine instability is a rare but difficult-to-treat entity, particularly above T5 where pedicle screwing is widely regarded as an unsatisfactory option and anterior surgery is considered difficult because of the anatomic relationship with the shoulder and large vessels. METHODS: A case of T4 and T5 pseudarthrosis after posterior fixation is reported. It was treated with transpleural corpectomy and fixation, with bone morphogenic protein used to obtain rapid arthrodesis between T3 and T6. No bracing or second posterior fixation was used. RESULT: At 45 days of follow-up, the patient was without pain and the neurologic examination was normal. The CT scan showed bony bridges across all fracture lines. Complete cure of this pseudarthrosis was achieved with a single surgery. At the 12-month follow-up, the clinical status was normal. CONCLUSIONS: The use of bone morphogenic proteins might be of great help in rare but challenging cases of spinal pseudarthrosis, with a quick return to normal activity after a single-stage surgery.

Predicting the outcome of shunt surgery in normal pressure hydrocephalus.

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

[Prenatal diagnosis and management of a case of rapidly involuting congenital hemangioma. Review of literature]. / Diagnostic prénatal et prise en charge d'un cas d'hémangiome congénital du cuir chevelu.

Rapidly involuting congenital hemangioma (RICH) is a rare vascular lesion, identified in 1996, of elective localization in the dermal-hypodermic tissue. Its name comes from its particular natural course: it is fully developed at birth and then completely involutes, usually in the first year. We present a case of a RICH of the scalp discovered with a screening ultrasonography in the 31st week of gestation. We list the differential diagnoses. After birth, positive diagnosis lies preferably on pathology examination of a biopsy specimen in order to eliminate the hypothesis of a less favorable vascular lesion, teratoma or malignant tumor.

[Use of polyester urethane (Neuro-Patch) as a dural substitute. Prospective study of 70 cases]. / Utilisation du polyester urethane (Neuro-Patch) comme substitut dural. Etude prospective sur 70 cas.

Between October 1995 and March 1998, 70 patients were treated with a microporous polyester urethane dura substitute (Neuro-Patch), after brain or spinal surgery. These patients were assessed clinically and radiologicaly 10 days, 6 weeks and 1 year after surgery. Radiological evaluation used CT scan or MRI. All dura substitutes were fixed by continuous suture to the surrounding dura-mater. We studied the handling properties, the incidence of infection and of CSF leakage. Eleven patients underwent craniotomy again. This gave us the opportunity to examine the adhesion to the brain tissue and the integration of the dura substitute. Six sheets underwent histological examination. Our results show good handling properties of the material; 3 infections; 6 out of 9 radiological CSF leakage occurred from infratentorial surgery. During reoperation, no adhesion to the brain tissue or injury to the brain while detaching the dura substitute was noticed. An excellent histological integration was observed: pores of the Neuro-Patch were colonized by fibroblasts synthesizing collagen, and there was no immune or inflammatory reaction, with an actual 4 to 6 years follow-up. A Neuro-Patch can therefore be recommended as a dura substitute to repair spinal or cranial dural defects.

Hypervascular intracisternal acoustic neuroma.

The diagnosis of acoustic neuroma is usually evoked in a patient presenting with a long history of hearing disturbance in whom an enhancing lesion within the internal auditory canal and/or the cerebellopontine angle is found on MRI. Hypervascularity with arteriovenous shunting and early filling of enlarged veins is a common feature of malignancy and has been reported very rarely in benign acoustic neuroma. We present the case of a patient without hearing disturbance, who showed a highly vascular lesion with no component in the internal auditory canal, making the preoperative diagnosis of acoustic neuroma very challenging. We discuss here the intracisternal site of origin and hypervascularity of acoustic neuroma, and also the differential diagnoses and management of such tumors.

Primary intracerebral hemorrhages in the Besançon stroke registry. Initial clinical and CT findings, early course and 30-day outcome in 350 patients.

The purpose of this study was to estimate the risk factors, early course, outcome and neuroimaging patterns in primary intracerebral hemorrhages (PIH). Using the Besançon Stroke Registry, 350 patients with first PIH documented by computed tomography (CT) between 1987 and 1993 were included in the present study. Patients with hemorrhage secondary to traumatism, brain tumor, thrombolytic treatment, vascular malformation or with hemorrhagic infarction were excluded. All CTs were evaluated to define the location, extension and volume of bleeding (55% of CT were performed within the first 12 h). Causes of death were classified and the 30-day outcome survival was evaluated with a modified Rankin scale (40 patients underwent a noncodified surgical procedure and were excluded from the outcome evaluation). Locations were lobar (36.5%), lenticular (32%), thalamic (15.7%), cerebellar (8.8%), midbrain and pons (2%), intraventricular (2%), caudate (1%) and multiple (2%). Risk factors included hypertension (54.8%), alcohol (18%) anticoagulant treatment (8.8%) and none (31.2%). The largest mean volume was in putaminal (41.7 ml) and lobar (39.8 ml) locations. Among 191 patients admitted before the 12th hour of evolution, 51 (26.7%) experienced an early clinical worsening. In this group, the percentage of patients with anticoagulant treatment (19.6%) was significantly higher (p<0.0001). PIH enlargement was documented in 3 patients. Overall, the 30-day mortality rate was 24.2% with 48% of all deaths occurring in the first 3 days. Death and 30-day survival status were closely associated with PIH volume (p<0.0001). Our study provides information on the natural history of PIH and especially on initial evolution. PIH volume seems to be an interesting indicator for death and functional status at 30 days.

[Intramedullary spread of a cerebral oligodendroglioma. Two case reports]. / Métastases intradurales rachidiennes d'oligodendrogliome. A propos de 2 cas.

We report two cases of leptomeningeal metastatic dissemination to the spinal cord of a grade B oligodendroglioma. Diagnosis was suspected on MRI but imaging findings were nonspecific. The pathways by which the intramedullary part of the spinal is reached by metastatic cells remains controversial. In the reported cases, both frontal and cystic primary intracerebral lesions were observed. Chemotherapy after radiotherapy appears to improve outcome. Nevertheless, prognosis remains very poor.

[Results of cervical interbody fusion with coral grafts]. / Résultats d'arthrodèses intersomatiques cervicales par greffons coralliens.

OBJECTIVES: We present the long term clinical and radiological results of a retrospective series of 46 cervical interbody fusions using coral grafts performed in 38 patients. MATERIAL AND METHODS: The patients were treated for prolapsed discs (19 cases) or cervical spondylosis (19 cases) with a clinical presentation of either radiculopathy (31 cases) or myelopathy (7 cases). We have done a post-operative clinical analysis of cervicoscapulalgia and radiculo-medullary symptoms and a radiological comparison of the change of the cervical spine angulation, the loss of height and the fusion rate at the graft site. RESULTS: The early clinical postoperative outcome showed that 10 out of 20 patients with excellent radiculo-medullary results had cervicoscapulalgia and 13 out of 18 patients with partial improvement had cervicoscapulalgia. No poor results according to our classification were noted. The late clinical outcome (average follow-up of 16 months) showed that 15 patients out of 31 had radiculo-medullary degradation and 24 presented with cervicoscapulalgia. Sixteen out of 20 patients had a loss of lordosis (range 6.2 degrees; SD 1.2) and 17 a loss of height (range 11.3%; SD 1.5). After 2 years, 13 out of 20 grafts were still hyperdense compared to the adjacent bone, and 8 had a hypodense peripheral edge. CONCLUSIONS: Coral grafts of this series have not been able to keep a physiological sagittal balance of the cervical spine, which is probably one of the essential factors to prevent postoperative cervicoscapulalgia. In the same way, the loss of height of the fused segments, by narrowing of the intervertabral foramen, may explain some further radiculo-medullary deterioration.

[The posterior cranium and its dysmorphisms]. / L'arrière-crâne et ses dysmorphies.

The deformation of the posterior part of the skull (occipito-vertebral region) induced directly, occurs in numerous pathological situations. Its significance is frequently overlooked. Lesions of the cranial content, alterations of the lambdoid suture or other premature synostosis, abnormal constraint related to posture or to muscular activity can modify the posterior curvature of the skull, generally flattening it. The authors propose a classification based on three points: intracranial pathology, bone pathology and extrinsic pathology. Concerning intracranial pathology, alterations of the brain or CSF fluid can induce either insufficient (microencephaly) or excessive (hydrocephalus, Dandy Walker or Arnold Chiari malformations) expansion. Concerning bone pathology, sagittal synostosis (scaphocephaly) induces a bulging and coronal synostosis a flatness of the posterior skull. Bilateral premature lambdoid synostosis (pachycephaly) produces total flatness of the back of the skull. Concerning extrinsic pathology, dysmorphism is often asymmetrical and results from extracranial mechanical application dysfunction such as inborn torticollis, cervical spine pathology (Klippel-Feil syndrome), or prolonged decubitus during the first year of life. The different surgical procedures are described and the authors describe a personal technique for correcting this dysmorphism: the turned biparietal flap transposition. The back of the skull is remodelled (either asymmetrical or bilateral flatness), and patients with no need for a helmet can lie on their backs immediately after the operation.

[Advances in the understanding of the etiopathogenesis of non syndromic craniostenoses and therapeutic approaches]. / Avancées dans la compréhension de l'étiopathogénie des craniosténoses non syndromiques et applications thérapeutiques.

The treatment of craniostenoses has not been revolutionized over the last decade, but the methods of investigation, particularly 3D CT scan, histological studies, and refinement of techniques, have allowed substantial progress in the understanding of the aetiopathogenesis and treatment of craniostenoses. The deformities of the components of the base of the skull can now be more precisely analysed. The authors present these elements for each of the various types of craniostenosis. The role of soft tissues has been more clearly defined; the dura mater, corresponding to an internal periosteum, has an osteogenic, but also directional role. The concept of the brain as the essential determinant of cranial morphology has led to the proposal of treatments adapted to each deformity. Specific craniectomies have been completed by mobilization of flaps, and segmentation of the vault allowing almost ideal reconstruction of the skull. In most treated cases, directed osteogenesis results in good consolidation after seven to eight months; partial non-ossification remains frequent in children treated after the age of eighteen months.

[The posterior part of the skull. Classification of dysmorphism. Original treatment: turned biparietal flap transposition]. / L'arrière-crâne. Classification des dysmorphies. Thérapeutique originale: la transposition bipariétale retournée.

The deformation of the posterior part of the skull (occipito-vertebral region), induced directly or indirectly, occurs in numerous pathological situations. Its significance is frequently overlooked. Lesions of the cranial content, alterations of the lambdoid suture or other premature synostosis, abnormal constraint related to posture or to muscular activity can modify the posterior curvature of the skull, generally flattening it. The authors propose a classification based on three points: -Intracranial pathology: alterations of the brain or CSF fluid can induce either insufficient (microencephaly) or excessive (hydrocephalus, Dandy Walker or Arnold Chiari malformations) expansion. -Bone pathology: craniosynostosis: sagittal synostosis (scaphocephaly) induces a bulging and coronal synostosis a flatness of the posterior skull. Bilateral premature lambdoid synostosis (pachycephaly) produces total flatness of the back of the skull. -Extrinsic pathology: dysmorphism is often asymmetrical and results from extracranial mechanical application dysfunction such as inborn torticollis, cervical spine pathology (Klippel-Feil syndrome), or prolonged decubitus during the first year of life. The authors describe a personal technique for correcting this dysmorphism: the turned biparietal flap transposition. The back of the skull is remodelled (either asymmetrical or bilateral flatness), and patients with no need for a helmet can lie on their backs immediately after the operation.

[Torticollis and C1-C2 rotation subluxation. Apropos of a case. The value of a dynamic scanner and of a 3-dimensional scanner]. / Torticolis et sub-luxation rotatoire C1-C2. A propos d'un cas. Intérêt du scanner dynamique et du scanner en trois dimensions.

The authors report the rare and complex case of a girl who had been followed since the age of 3 years for hydrocephalus the cause of which was found only when she was 6-year old. The causative agent was a pilocytic astrocytoma of the cerebellum. On April 10, 1990, she underwent subtotal excision of the tumour, associated with radiotherapy. Four months later she developed an increasingly painful and irreducible torticollis which did not respond to tractions. Dynamic CT scans and 3-dimensional CT scans were performed in the fourth month and provided a diagnosis of right C1-C2 rotatory subluxation. There was no history of injury and no sign of inflammatory process. Rotatory subluxation is a very rare lesion difficult to diagnose, and few cases have been published, although the signs are those of classical torticollis in children. When medical treatment fails, often due to belated diagnosis, the only surgical treatment is uni- or bilateral C1-C2 arthrodesis. If the diagnosis can be made at an early stage, reduction of the rotatory luxation is usually easy and without consequences to the child. It is therefore recommended to perform a dynamic CT scan and a 3D CT scan as soon as possible in all children with lasting painful torticollis.

[Cranial asymmetries. Reflexions on plagiocephalies. Premature sutural synostosis or extracranial origin?]. / Asymétries craniennes réflexions sur les plagiocéphalies. Synostose suturaire prématurée ou origine extra-crânienne?

The authors relate a clinical and radiological (X Ray and TDM tridimensional) study with an anthropological (dry skulls) study of plagiocephaly. The aim is to find with the aid of a physical examination, some anatomic parameters which permit to differentiate cranial asymmetry with coronal premature synostotic suture from functional deformation with extracranial outset. The term plagiocephaly is used to define forehead asymmetry. It is necessary to study orbital rim, nasal root, malar eminence, ear and chin mid point position. The morphology of the skull is important to look: frontal flattering and also occipital flattering or bulging, contra-lateral frontal and pterional aera bulging. The authors conclude that a single parameter is necessary to differentiate the two kinds of plagiocephaly: the petrous bone position on the flattened frontal side: sagittalisation: fonctionnal plagiocephaly; frontalisation: synostotic plagiocephaly.

[Lymphocytic adenohypophysitis. Apropos of a new case]. / Adéno-hypophysite lymphocytaire. A propos d'un nouveau cas.

A new case of lymphocytic adenohypophysitis in a five months pregnant woman is related. The sudden appearance of visual symptoms required a surgical procedure. MRI does not enable a precise preoperative diagnosis. Three months after delivery clinical data as hormonal functions returned to normal and also the CT Scan aspect. Eighteen months later the patient remains totally normal. In our case we don't find any argument in favor of an autoimmune disease.

[Remodeling the cranial vault in anterior craniosynostoses. Our therapeutic experience of trigonocephaly and plagiocephaly]. / Le remodelage de la voûte du crâne des crâniosténoses antérieures. Techniques personnelles de traitement des trigonocéphalies et des plagiocéphalies.

The authors propose two simple techniques to improve the adaptation of the frontal vault after remodeling the orbito-naso-frontal flap in anterior craniostenosis. In trigonocephaly: the metopic suturectomy is enlarged by lateral translation of the two half frontal bones, then to fall the place the coronal suture is used. The temporal plates are moved forward and turned to fill the failure of fronto-temporal junction due to valgisation of orbito-naso-frontal band. In plagiocephaly: the frontal flattened flap is cut with oblique radial osteotomies starting at bregma so called "Daisy petal". The first internal petal is sacrificed. The others are rotated axially in a medial direction. Internal table corticotomies must be performed at two levels to recurve the flattening and to obtain a curve in the coronal plane. In this two techniques the pericranium and dura-mater must be carefully teated to obtain a better adaptation of the new bone shape and to permit the spontaneous reossification.