Second surgery after vertical paramedian hemispherotomy for epilepsy recurrence.

Background: Vertical Paramedian Hemispherotomy (VPH) is considered an effective surgical treatment for drug-resistant epilepsy with 80% of patients experiencing seizure freedom or worthwhile improvement. Identifying persistent connective tracts is challenging in failed VPH. Methods: We reviewed our series of consecutive patients undergoing VPH for hemispheric drug-resistant epilepsy and included cases with recurrent epileptic seizures undergoing second surgery with at least 6 months of postoperative follow-up. The cases were extensively assessed to propose a targeted complementary resection. Results: Two children suffering from seizure recurrence following hemispherotomy leading to second surgery were included. After complete assessment, persisting amygdala residue was suspected responsible for the epilepsy recurrence in both patients. Complementary resection of the amygdala residue led to seizure freedom for both patients (Engel IA/ILAE Class 1) without complication. Different diagnostic tools are used to assess patients after failed hemispherotomy including routine EEG, prolonged video EEG, MRI (particularly DTI sequences), SPECT or PET scans and clinical evaluation. These tools allow to rule out epileptic foci in the contralateral hemisphere and to localize a potentially persisting epileptogenic zone. Assessment of these patients should be as systematic and integrated as the initial workup. Although our two patients suffered from Rasmussen's encephalitis, seizure recurrence after VPH has been described in other pathologies. Conclusion: Lying deep and medially in the surgical corridor of VPH, the amygdala can be incompletely resected and cause recurrent epilepsy. Complementary selective resection of the amygdala residue may safely lead to success in epilepsy control.

Granulomatous Reaction on a Double-Level Cervical Total Disc Arthroplasty.

BACKGROUND: Cervical total disc arthroplasty (TDA), or cervical artificial disc replacement, is an alternative technique to anterior cervical discectomy and fusion for treatment of symptomatic degenerative cervical spine disease. The main goal of TDA is to maintain cervical motion and lower the risk of deterioration of adjacent levels. Granuloma formation on a cervical TDA is exceptional. CASE DESCRIPTION: A 48-year-old woman with left cervicobrachialgia underwent a double-level TDA (M6-C Artificial Cervical Disc) on C5-C6 and C6-C7 at another hospital in 2010. Two years later, she reported a recurrence of cervicalgia, which was refractory to conservative treatment by rigid collar and analgesics. Cervical magnetic resonance imaging suggested a granulomatous formation on the C6-C7 prosthesis. She underwent removal of the C6-C7 prosthesis, which showed a rupture with nylon thread extrusion. An arthrodesis with plate was subsequently performed. Follow-up showed improvement of her clinical status. Histopathologic studies showed a giant cell granulomatous formation in contact with nylon threads described in hip, shoulder, and ankle arthroplasty. It has been described in 6 cases following lumbar TDA and 2 cases following cervical TDA. CONCLUSIONS: We report a third case of granulomatous reaction on nylon thread extrusion after partial breakdown of a prosthesis for cervical TDA.

Chromothripsis in an Early Recurrent Chordoid Meningioma.

BACKGROUND: Chromothripsis is characterized by a multitude of chromosomal rearrangements during a unique cataclysmic event in a cell life. Disintegration of one or several chromosomes is followed by a chaotic rearrangement of generated fragments. It might play a role in oncogenesis and tumor progression. It is observed in 2%-3% of cancers and is rarely reported in benign tumors. We report a case of massive chromothripsis in a fast growing chordoid meningioma. CASE DESCRIPTION: A 55-year-old woman was admitted for a meningeal mass developing in the right parietal parasagittal area. She underwent subtotal resection of the tumor. Histologic analysis revealed a chordoid meningioma (World Health Organization grade II). Six months later, magnetic resonance imaging showed a large bilateral tumor recurrence. After a second surgery, the patient received radiotherapy. Thereafter, the clinical course was uneventful. Comparative genomic hybridization showed only a monosomy X in the primary tumor. In the recurrent meningioma, this anomaly was associated with a massive chromothripsis including more than 370 chromosomal abnormalities affecting chromosomes 1-22. CONCLUSIONS: Chromothripsis is rarely described in benign tumors and especially in meningiomas. In the presented case, the high number of chromosomal rearrangements and the onset of this phenomenon at a later stage of tumor progression are very unusual. The role of surgical stress on the emergence of chromothripsis and its relation with tumor aggressiveness are discussed.