Surgical hemostatic agents: assessment of drugs and medical devices.

Surgical hemostatic agents are indicated to improve hemostasis when conventional techniques (compression, sutures or electrocoagulation) are inadequate. The National French Authority for Health (Haute Autorité de santé [HAS]) set out to assess these products (medical devices and agents) to determine their optimal utility. This evaluation included one class of products containing some form of human fibrinogen and thrombin and eight classes of medical devices and automated devices to prepare autologous fibrin. The assessment was based on a systematic review of the literature and expert opinion of health care professionals. The main measures of effectiveness of hemostatic agents were the success rate as expressed in terms of the time necessary to obtain adequate hemostasis, the volume of intra and/or postoperative blood loss, the need for blood transfusions, complication rate, duration of operations and hospital stay. A meta-analysis and 52 controlled randomized studies were selected involving cardiac or vascular surgery (19), ENT surgery (11), gastrointestinal surgery (5), urology (4), orthopedic surgery (4). Approximately half of the studies retained in this analysis evaluated blood derived agents (fibrin sealants) while the other half evaluated medical devices. The working group considered that there is not any evidence that these surgical hemostatic agents decrease the rates of transfusion, complications, reoperation, mortality, duration of operation and/or hospital stay. The working group considered that the use of surgical hemostatic agents to improve the safety of hemostasis in the absence of identified bleeding as an alternative to adequate conventional hemostasis was not justified. Surgical hemostatic agents can be used in ad hoc settings, as a complement to conventional methods to control persistent bleeding after conventional hemostatic techniques, or when abundant bleeding has led to biologic hemostatic disorders. The working group also distinguished several particular settings (mouth and dental care in patients under antiagregant or anticoagulation therapy, central nervous system surgery or acute aortic dissection). Comparative data are insufficient to determine if one product is superior to another for a specific use. To evaluate the clinical value of these products, methodologically sound clinical studies are necessary.

Toward improved grading of malignancy in oligodendrogliomas using metabolomics.

In spite of having been the object of considerable attention, the histopathological grading of oligodendrogliomas is still controversial. The determination of reliable biomarkers capable of improving the malignancy grading remains an essential step in working toward better therapeutic management of patients. Therefore the metabolome of 34 human brain biopsies, histopathologically classified as low-grade (LGO, N = 10) and high-grade (HGO, N = 24) oligodendrogliomas, was studied using high-resolution magic angle spinning nuclear magnetic resonance spectroscopy (HRMAS NMR) and multivariate statistical analysis. The classification model obtained afforded a clear distinction between LGOs and HGOs and provided some useful insights into the different metabolic pathways that underlie malignancy grading. The analysis of the most discriminant metabolites in the model revealed the presence of tumoral hypoxia in HGOs. The statistical model was then used to study biopsy samples that were classified as intermediate oligodendrogliomas (N = 6) and glioblastomas (GBMs) (N = 30) by histopathology. The results revealed a gradient of tumoral hypoxia increasing in the following direction: LGOs, intermediate oligodendrogliomas, HGOs, and GBMs. Moreover upon analysis of the clinical evolution of the patients, the metabolic classification seems to provide a closer correlation with the actual patient evolution than the histopathological analysis.

[Acute myelitis and Lyme disease]. / Myélite aiguë et neuroborréliose.

INTRODUCTION: Acute myelitis accounts for 4 to 5 percent of all cases of neuroborreliosis. In the literature, simultaneous spinal MRI and cerebrospinal fluid (CSF) investigations are presented for only 8 cases. We describe here 3 cases of acute Lyme myelitis. METHOD: In a cohort of 45 patients with neuroborreliosis, diagnosed between January 1998 and January 2005, 3 had acute myelitis. Clinical, biological and radiological data were studied. CASE REPORTS: The three patients had motor, sensorial and sphincter involvement. Extra-spinal involvement, such as fever and headache for one, facial nerve palsy for the second and subarachnoid hemorrhage for the third, was also noted. Pleocytosis varied from 10 to 520 white cells per mm3. Lyme serology was positive in CSF for all. Intrathecal anti-Borrelia antibody index was positive or intermediate for all three patients. Spinal cord MRI revealed a large hyperintense zone involving more than 3 vertebral segments. Myelitis was central, posterior or transverse in the axial plane. The clinical course was favorable after a three-week course of appropriate antibiotics. CONCLUSION: These 3 cases and the others from the literature show the diversity of the clinical and radiological features of acute myelitis: transverse, central or posterior myelitis. Thus, Lyme serology in CSF in indicated for patients presenting acute myelitis, particularly in endemic areas.

Predictive value of MRI vertebral end-plate signal changes (Modic) on outcome of surgically treated degenerative disc disease. Results of a cohort study including 60 patients.

OBJECTIVE: To assess the predictive value of MRI vertebral end-plate changes (Modic) on clinical outcome of surgically treated lumbar single-level degenerative disc disease (DDD). METHODS: A cohort of 60 patients was included. Patient groups were similar in respect of age, gender and clinical presentation, allowing comparisons. Patient age ranged from 30 to 72 years (mean: 45.8 years). All patients suffered severe chronic low back pain for more than 6 months, with single-level symptomatic DDD. All patients experienced segmental instrumented interbody (n = 22) or posterolateral (n = 38) fusion. Clinical outcome was assessed by using a visual analog scale (VAS) and the functional disability scale of the Japanese Orthopaedic Association (JOA) for lumbar spine. The number of patients for each Modic group was as follows: Modic type 0, n = 15; Modic type I, n = 22; Modic type II, n = 14; and Modic type I/II, n = 9. Fusion rates were similar for each Modic group of patients. Mean follow-up was 14 months. RESULTS: The pre-operative mean VAS improved by 53.5% (from 8.2+/-2.0 to 3.8+/-1.9, p < 0.05) and the pre-operative mean JOA score by 58% (from 5.5+/-2.1 to 11.0+/-2.4, p < 0.05). Patients harboring Modic type I changes improved much better than others (p < 0.05). Conversely, clinical outcome of patients presenting with Modic type II lesions was poor. CONCLUSION: This study confirms instrumented fusion as an effective treatment in symptomatic lumbar DDD. Preoperative combination of low back pain of discal origin and severe DDD with Modic type I lesion on MRI may lead to excellent results after fusion in a large proportion of patients. Conversely, arthrodesis for patients harboring Modic type II abnormalities implicates smaller benefit of doubtful clinical significance.

[Selective memory impairment for public events associated with accelerated forgetting in a patient with left temporal lobe epilepsy]. / Déficit sélectif de la mémoire des faits publics associé à un oubli accéléré chez un patient atteint d'épilepsie du lobe temporal gauche.

BACKGROUND: Memory for the past has been much less explored than anterograde memory in temporal lobe epilepsy. No data are available about the course after surgical treatment. Moreover, case-reports showing isolated memory deficit for publics events with preserved autobiographical memory are notorious for their paucity. METHODS: We report the case of a patient with a left hippocampal lesion associated with intractable temporal lobe epilepsy. Comprehensive neuropsychological assessments were carried out before and after temporal lobectomy, stressing particularly memory for the past by means of standardised and tailor-made tests. RESULTS: The patient exhibited preserved memory for autobiographical events and facts but impaired scores on several public event tests, in the context of preserved general abilities. Furthermore, we found an accelerated forgetting rate for verbal and non verbal material. CONCLUSION: Our findings suggest that the patient's impaired long-term consolidation might have contributed to the impaired performance on public event memory tests. We discuss the specific features of new events processing that may contribute to its increased vulnerability relative to autobiographical memory, in the event of accelerated forgetting.

[Intradiploic encephalocele in an adult. A case report and review of the literature]. / Encéphalocèle intra-diploïque de l'adulte. A propos d'un cas et revue de la littérature.

We describe a rare case of parietal intradiploic encephalocele in a 51-year-old woman with no history of head trauma. The patient presented with a 1-month history of left hemiparesthesia. A hard indolent scalp lesion was palpable on examination in the right parietal area. Skull x-rays and cranial computed tomography examination demonstrated a lytic lesion that was consistent with a malignant osteolytic skull lesion. Magnetic resonance imaging of the head revealed an intradiploic cyst that included a round tissue mass contiguous with the parietal cortex. Surgery confirmed the diagnosis of encephalocele and the patient underwent surgical resection of the herniated brain, duraplasty, and cranioplasty. The presenting hemiparesthesia persisted at the 6-month follow-up. Encephaloceles of the cranial vault are a rare complication of skull fractures and rarely occur in adults. These lesions can be difficult to distinguish from congenital encephaloceles in patients with no history of head trauma. The pathogenesis, clinical and radiological nuances and the role of surgery are discussed.

[Systemic Candida albicans infection with neuromeningeal complication in a premature infant]. / Complication neuroméningée d'une infection systémique à Candida albicans chez un prématuré

INTRODUCTION: Systemic maternal-fetal Candida albicans infections are uncommon diseases with a poor outcome. An associated cerebromeningeal infection increases morbidity. We present a case of neuromeningeal candidiasis following systemic neonatal infection in a premature infant. Management and therapeutic difficulties are outlined. OBSERVATION: The patient was a male infant born preterm at 30 weeks gestation. During his first week of life, he developed a systemic infection with an associated symptomatic hydrocephalus. Systemic candidaisis with neuromeningeal complication was diagnosed five weeks later. Despite treatment including cerebrospinal fluid (CSF) shunting and antimycotic medications (flucytosin and amphotericin B), the candidal infection did not resolve. Infectious and mechanical complications of the CSF drainage were treated by several surgical interventions during the following months. At 10 months of life, there was clinical and laboratory evidence of active persistent neuromeningeal candidaisis. Finally, candidal infection was eradicated with intravenous administration of fluconazole. After five year follow-up, the intellectual and psychological status of the patient was quite satisfactory, and no neurological deficits were found on clinical examination. DISCUSSION: Management of neuromeningeal candidaisis in premature infants is a challenging task particularly because of delayed diagnosis. Candida infection should routinely be suspected in cases of systemic infection with neurological impairment in premature infants. Fluconazole may constitute an efficient therapeutic option.

[Radicular syndrome and synovial cyst of the zygapophyseal joints: two case-reports]. / Kyste synovial articulaire postérieur lombaire révélé par un syndrome pluriradiculaire: à propos de deux cas.

INTRODUCTION: Multiradicular nerve root compression, and long lasting radicular syndrome occur very often. They happen particularly on degenerative spine. Huge synovial cyst of the zygapophyseal joints may account for it, expand in the epidural area and cause radicular syndrome. EXEGESIS: Two cases of huge synovial cysts spreading into the spinal channel are reported here. Diagnostic and therapeutic modalities are discussed. On degenerative spine, facet joints osteoarthritis may result in synovial cysts. Physical examination findings are radicular syndrome. CONCLUSION: Huge synovial cysts may result in multiple nerve root compression syndrome, as reported in our two cases. Typically, there's no history of preceding trauma and symptoms appear progressively. Magnetic resonance imaging of the spine shows an intra-spinal round mass with typical signal intensity and capsular formation. Treatment consists either in facet joint steroid injection performed with radiologic guidance or in surgical excision.

[Place of the surgery in the management of brainstem cavernomas. Results of a multicentric study]. / Place de la chirurgie dans le traitement des cavernomes du tronc cérébral. Résultats d'une étude multicentrique portant sur 30 cas.

OBJECTIVE: To compare the outcome between operated and non-operated brainstem cavernomas. METHOD: Clinical and radiological data of 30 patients harboring 35 brainstem cavernomas were retrospectively reviewed. The mean follow-up period was 47 months. Relationship between the cavernoma and the pi maer was graded. The histology of each operative case was systematically confirmed. The Karnofsky mean score was calculated at admission and at the end of the follow-up period. Patients were classified in three groups according to their outcome grade (Group I=good; Group II=unchanged; Group III=worse). We compared the outcome between operated and non-operated patients. For operated cases, we found several factors of poor outcome. Statistical tests used to compare the groups of patients were Yates modified chi(2) with calculation of the exact probability. Chosen risk was 5%. RESULTS: Thirty-eight percent of operated patients were permanently disabled after surgery whereas the same proportion was improved. None of the patients in the control group worsened at the mean 47-month follow-up despite the occurrence of two hemorrhagic events. Statistical study showed that treatment modality affected clinical outcome in these patients. Only patients presenting with multiple deficits and progressive neurological deterioration were improved with surgery. Surgical access through the floor of the fourth ventricle was correlated with a poor outcome. Partial removal of the cavernoma increased the risk of future hemorrhage. CONCLUSION: Surgery showed no proof of its efficiency in the management of brainstem cavernomas at the end of the follow-up period. Indications of surgical treatment must be restricted to cases with a severe and progressive neurological deterioration.

Posterior extradural migration of extruded thoracic and lumbar disc fragments: role of MRI.

We report three patients with a sequestrated disc fragment posterior to the thecal sac. The affected disc was lumbar in two cases and thoracic in the third. Disc fragment migration is usually limited to the anterior extra dural space. Migration of a disc fragment behind the dural sac is seldom encountered. MRI appears to be the method of choice to make this diagnosis. The disc fragments gave low signal on T1- and slightly high signal on T2-weighted images and showed rim contrast enhancement. The differential diagnosis includes abscess, metastatic tumour and haematoma.

Sphenoidal sinus mucocele after transsphenoidal surgery for acromegaly.

This report concerns one case of a sphenoid sinus mucocele occurring 17 years after transsphenoidal surgery for acromegaly. In 1979, a 51-year-old man was successfully operated by the transnasal transsphenoidal approach for a growth hormone (GH) adenoma 1 cm in diameter. In 1996, the patient was hospitalized for headaches and diplopia. He presented a loss of right visual acuity with paralysis of the right oculomotor nerve. The basal GH level was normal with a satisfactory decrease after oral glucose ingestion. Pituitary sellar radiography showed a disappearance of the posterior clinoid while magnetic resonance imaging revealed the existence of a bilocular, circular, homogeneous lesion of the sphenoid sinus 3 cm in diameter with a posterior and lateral extension. The diagnosis of mucocele was confirmed by surgical treatment, allowing drainage of the mucocele through a transsphenoidal approach. The drained material was composed of sinus epithelium containing many polynuclear and resorptive cells. Postoperatively, the symptoms decreased dramatically, leading to full recovery of visual function and disappearance of the headaches. Apart from the tumor recurrence, the mucocele of the sphenoid sinus can be evoked as a possible long term complication of transsphenoidal surgery for pituitary adenoma.

Autosomal dominant carpal tunnel syndrome.

Carpal tunnel syndrome is common in adults and is usually sporadic and idiopathic. When carpal tunnel syndrome is inherited, it is often the manifestation of a systemic disease. We report carpal tunnel syndrome in an otherwise healthy woman aged 35 years. Family history reveals that her daughter, her sister and a sister's daughter, an aunt, a first cousin, her father and the paternal grandmother are also affected. The age of onset of the disease in this family was between 9 and 52 years of age. The family in this paper demonstrates an interesting pattern of inheritance with earlier onset of symptoms in subsequent generations, suggestive of anticipation.

[Cerebral risks in surgical position: position of the body, position of the brain]. / Risques cérébraux liés à la position: position du corps, position de l'encéphale.

The posture of the neurosurgical patient depends first on the approach and working position of the surgeon, and the spatial orientation during surgery. Venous outflow is probably the major factor for optimal brain retraction and for preventing venous haemorrhage. No one of the postures presently in use is fully free from the risk of air embolism. Respiratory and cardiac diseases are often limiting factors for the choice of a posture. Thoracic and abdominal compression must be cautiously avoided.

[Surgery of the supratentorial and ventral spine: view-point of the surgeon]. / La chirurgie sous-tentorielle en décubitus ventral: le point de vue du chirurgien.

The prone position for posterior fossa and cranio-spinal surgery is becoming the standard posture for neurosurgical teams. We analyze the reasons of such a change and specify indications of this posture. Thereafter, the procedure for optimal positioning is considered and the benefits of the prone position for the neurosurgeon and the anaesthetist are discussed. The selected references originate from Medline search (1991-1997), the Year Book of Neurology and Neurosurgery and the major neurosurgical review articles published between 1980 and 1996.

[Intracranial surgery in the lateral position]. / Abord intracrânien en position latérale.

The lateral posture (Park Bench) is now widely used. It provides a comfortable position for the surgeon and a convenient brain relaxation. However the positioning is complex and carries a risk of stretching of the brachial plexus. Spatial orientation is more difficult and requires surgical experience. The lateral position does not modify the haemodynamic and respiratory function in healthy patients. In the opposite, various cardiac or respiratory effects of right or left lateral position can occur in patients with cardiac and/or respiratory pathology.

[Intrasellar arachnoid cysts: computed tomography and MRI. Apropos of 2 cases]. / Kystes arachnoïdiens intrasellaires: scanographie et IRM. A propos de deux observations.

We describe the computed tomographic and magnetic resonance imaging findings in two cases of intrasellar arachnoid cysts. The diagnosis of intrasellar arachnoid cyst with suprasellar extension should be evoked in case of a cyst-like formation whose density and signal appear to be identical to those of the cerebrospinal fluid even if contrast uptake is evidenced in the cyst wall. Contrast uptake can be related to compression of the pituitary stalk and normal pituitary displacement. Suspected intrasellar arachnoid cyst modifies the surgical approach which must be made via a subfrontal route. We discuss the differential diagnosis with other intrasellar cystic formations such as necrosed tumor, abscesses, Rathke pouch cysts, cystic craniopharyngiomas, epidermoid cysts and parasite cysts.

Posterior lumbar epidural fat as a functional structure? Histologic specificities.

STUDY DESIGN: A topographic and histologic study was done to describe the location of the lumbar epidural fat and to find potential tissular specificities. OBJECTIVES: To search for possible histologic characteristics of posterior lumbar epidural fat, which so far has been described as semifluid tissue, and to determine whether posterior lumbar epidural fat is not a simple incidental tissue. SUMMARY OF BACKGROUND DATA: The lumbar epidural fat on two fetuses was studied. In adults, subcutaneous fat and posterior lumbar epidural fat were taken from seven corpses. The authors obtained 13 posterior lumbar epidural fat pads (two at L1-L2, three at L2-L3, six at L3-L4, and two at L4-L5) and four subcutaneous fat pads. METHODS: The authors studied abdominal axial histologic sections in two fetuses, histologic multiplanar sections in seven adults, and semithin sections in four adults of posterior lumbar epidural fat and subcutaneous fat. RESULTS: Fetal distribution of epidural fat was circumferential. Adult epidural fat distribution was limited to the posterior part of the vertebral canal and located at the disc level. Fascicles of connective tissue were less numerous and thinner in posterior lumbar epidural fat than in subcutaneous fat. Organized sliding spaces were found in the posterior epidural fat ped. CONCLUSIONS: Posterior lumbar epidural fat is not a simple incidental tissue and shows specific histologic features: sliding spaces and rarefaction of connective tissue that could explain semifluid features of the tissue. These characteristics suggest a functional role of posterior epidural fat in the lumbar spinal unit.

Imaging of thoracic and lumbar spinal extradural arachnoid cysts: report of two cases.

Extradural arachnoid cysts are uncommon expanding lesions in the spinal canal which may communicate with the subarachnoid space. Usually in the lower thoracic spine, they may cause symptoms by compressing the spinal cord or nerve roots. We report cases of thoracic and lumbar arachnoid cysts studied by cystography, myelography, CT and MRI. These techniques showed extradural cystic lesions containing cerebrospinal fluid, with variable communication with the subarachnoid space, causing anterior displacement and flattening of the spinal cord.

Supraorbital minicraniotomy.

The recent use of neuroendoscopy combined to microsurgery allows new surgical approaches. We report our early experience with a supraorbital microcraniotomy. This technique is suitable for small lesions situated in the region of the anterior fossa, suprasellar cisterns, and Sylvian cistern. A 50-mm incision in the eyebrow and a supraorbital minicraniotomy are performed. We report on six patients with different lesions and good cosmetic results. We conclude that this approach is safe and useful in selected cases.

[Fatal hemorrhagic necrosis of pituitary macro-adenoma after a stimulation test]. / Nécrose hémorragique mortelle d'un macro-adénome hypophysaire après test de stimulation.

Pituitary stimulation tests are widely used to explore hypophyseal adenomas. There are few disadvantages, although a few cases of pituitary necrosis have been published. We report a new case with a dramatic outcome. A 30-year-old man with clinical signs of acromegalia and major visual disorders was found to have a voluminous macro-adenoma of the pituitary gland. Thirty minutes after beginning the stimulation test, the patient complained of major headache and experienced persistant vomiting for several hours. Brain magnetic resonance imaging the next day did not reveal evidence of pituitary necrosis. Sudden onset coma occurred one hour later. The CT scan demonstrated hemorrhagic necrosis of the adenoma. The patient died despite emergency surgery. Due to the risk of hemorrhagic necrosis of a pituitary adenoma, baseline assays may be sufficient for diagnosis in patients with clinical signs highly suggestive of pituitary oversecretion, especially when a voluminous tumor is involved. Rigorous clinical surveillance is required after stimulation tests.