[Evaluation of the clinical and radiological results of cervical longitudinal median somatotomy without graft]. / Evaluation des résultats cliniques et morphologiques de la somatotomie cervicale médiane longitudinale sans greffe.

OBJECTIVES: To evaluate the clinical and radiological results of cervical longitudinal median somatotomy without graft, used for the treatment of cervical myelopathy and radiculopathy, and compare it to techniques with graft and to laminectomies. MATERIAL AND METHOD: Thirty-four patients (25 males and nine females), with a mean age over 60 years, were included in a study comparing pre- and postoperative clinical status on the Japanese Orthopaedic Association (JOA) functional scale and radiological status with evaluation of the cervical curve on plain films and dynamic tests in flexion and extension. RESULTS: No significant difference was found with the clinical and anatomical results published in the literature concerning median somatotomies performed with graft and/or osteosynthesis and laminectomies and their variants. CONCLUSIONS: The cervical longitudinal median somatotomy without graft is an easy and reliable technique that can be proposed as first-line treatment for cervical spondylotic myelopathy related to anterior compression. It decreases the cost and the duration of the surgical procedure, it protects the patient from the complications and sequelae related to graft harvesting and the use of implants. It should be limited to patients without preoperative kyphosis who are over 50 years old.

Ethics and meningiomas: From prudence to obstinacy? The position of the neurosurgeon (for treatment or insurance purposes) in the case of complaints concerning post-operative clinical deterioration.

To treat or not to treat an asymptomatic or pauci-symptomatic benign meningioma, that is the question. And if treatment is necessary, what is the best technique: radical resection, sub-total resection or radiotherapy? This question is also pertinent for meningiomas of the skull base, posterior part of the sagittal sinus, anterior part of the foramen magnum and cerebellopontine angle. When the results of the treatment are good, the patient and the surgeon are satisfied. But when a new neurological deficit appears after the treatment, the patient is entitled to obtain compensation. What should be the position of the specialist medical assessor in this situation when the prognosis of these benign tumors is unknown? Is the preoperative information that is due to the patient complete, objective and sufficient? Is the therapeutic indication unquestionable? Is the technique irreproachable? For meningiomas, there is no "evidence-based medicine"; the therapeutic option is often based on the personal experience and/or the education of the surgeon and thus is, in fact, highly subjective.

Propionibacterium acnes contamination in lumbar disc surgery.

Previous studies have shown that Propionibacterium acnes may be responsible for low-grade infection of the intervertebral discs of patients with severe sciatica. The aim of this study was to prospectively investigate the presence of bacteria in disc fragment samples obtained during surgery for lumbar disc herniation. P. acnes was cultured from disc fragments in two (3.7%) of 54 patients studied. In addition, control cultures taken from ligamentum flavum and muscle from these two patients were also positive for P. acnes. Similar control cultures were positive for P. acnes from a further ten (18.5%) patients. Four air samples taken during surgery all contained P. acnes; the organism was also found from three of 54 laminar flow control cultures. Sample contamination appears the most likely cause for the presence of P. acnes in the lumbar disc fragment cultures.

[Results of surgical treatment]. / Résultats du traitement chirurgical.

In this chapter we report the results of the main papers of the international literature, but it is difficult to make an objective synopsis because only the best results are published and failure and complications remain confidential. Few papers describe "general complications" as thrombo phlebitis, wound infection, cardio respiratory insufficiency... which are probably as frequent as for all intracranial or spinal surgical procedures. The postoperative neurological status depends essentially on the location of the lesion. In non eloquent area, the postoperative neurological status is almost always excellent. But in a hemispheric functional area, basal ganglia and brain stem it is frequent to observe neurological sequellae; in the better series of the literature, 80% of the patients achieve a good outcome equivalent to or better than before the operation, but 20% are worsened. It is important to remember this fact before discussing the surgical indication. The risk of hemorrhage disappears after total surgical resection; and it is one of the benefits of the treatment, but this objective can be reached only when the lesion is unique. The risk persists in multiple forms and "de novo" cavernomas are always possible especially in familial forms. The main benefit is the treatment of epilepsy for seizure control. In case of good concordance between the location of the cavernoma and the clinical and electrical data, lesionectomy alone or lesionectomy with resection of the perilesional hemosiderin ring provide good results. In the event of severe epilepsy without good concordance between the site of the cavernoma and symptoms, the surgical approach may be functional and outcome less satisfactory.

[Natural history of cavernomas of the central nervous system]. / Histoire naturelle des cavernomes du système nerveux central.

We present a critical review of the literature on the central nervous system cavernomas in order to highlight their natural history and to define the most appropriate management of these rare lesions. The prevalence is now estimated from 0.3 to 0.7% in the general population without any significant difference by gender; 25% of cases are pediatric. Two forms of the disease can be described: sporadic forms in 80% of cases, characterized by isolated or rare lesions and familial dominant autosomic forms characterized by multiple and evolutive lesions. The incidence is not well known, the consultation of the French PMSI database suggests that 50 to 100 cases are operated on each year (1 to 2 per million). Cavernomas are dynamic lesions: growing in many cases, seldom remaining quiescent and disappearing in rare cases. The anatomical evolution is more pejorative in familial forms. "De novo" cases are now well known, either in familial or sporadic forms and after radiotherapy. Many lesions are totally asymptomatic, but the frequency of symptomatic forms is debated in the literature from 3 to 90%... The hemorrhagic risk is evaluated from 0,5 to 3% each year, depending on the localization, and the risk of rebleeding is more important but not well known. The epileptic risk is correlated to the localization, more frequent for temporal and frontal lesions from 4,5 to 11% each year, but these data are controversial. The natural history depends on the topography: hemispheric, deep-seated, brain stem, cerebellum or intramedullary and in pediatric situations. Each situation will be treated in this report.

[Histopathology of central nervous system cavernomas]. / Anatomie pathologique des cavernomes du système nerveux central.

Central nervous system cavernomas are vascular malformations, which occur in two circumstances: sporadic forms and familial autosomal dominant forms. The lesion consists of enlarged, closely packed vessels without interposition of brain parenchyma, surrounded by hemosiderin and gliosis, calcified in few cases. In 80% of sporadic forms the lesion is unique, multiple lesions are rare (median: 4). In familial forms the lesions are always multiple. Cavernomas are often associated with other vascular malformations, especially with venous developmental anomalies. The size of cavernomas is variable from 1 mm to several centimeters. About 70% of cases are supratentorial and 30% in the posterior fossa, particularly in the brain stem. Macroscopic and histopathological findings are typical and the diagnostic is generally easy.

[The origins of the French neurosurgery]. / Aux origines de la neurochirurgie française.

Modern French neurosurgery starts at the beginning of the XXth century under the motivation of Joseph Babinski. He submitted his patients to Thierry de Martel who had learned this new specialized area of medicine with H. Cushing in the États-Unis and V. Horsey in Great Britain. His first successfully treated case of an intracranial tumor was published in 1909. But the true founding father was Clovis Vincent, initially a neurologist and collaborator of de Martel, who became the first chairman in 1933 of the neurosurgical department at the Pitié hospital of Paris and the first professor of neurosurgery in 1938. After the Second World War, many departments were created outside of Paris. Neurosurgery was definitively recognized as a specialized area in medicine in 1948. Currently, more than 400 neurosurgeons work in France. Because I had the very great privilege to be present at the birth of this society in 1970 and to still be in contact with some of the second and third generation of French neurosurgeons who led it to its high international recognition, the Chairman of the French Neurosurgical Society asked me to write this short historical vignette.

Expression of the bcl-2 oncoprotein in meningiomas.

The purpose of this study was to assess the expression of the bcl-2 oncoprotein in meningiomas and to compare it with the phenotype, the Ki-67 proliferative index and the sex hormone receptor status of the tumors. The expression of the bcl-2 oncoprotein was studied by Western blotting and immunohistochemistry. A quantitative study of the Ki-67 proliferative index and the expression of estrogen and progesterone receptors was performed. Western blot detected the bcl-2 oncoprotein in nearly all meningiomas. Immunohistochemistry detected the oncogene in only 43.5% of the cases. Expression of bcl-2 was essentially by spindle cells of transitional and fibrous meningiomas expressing neural cell adhesion molecule. There was neither correlation between the expression of bcl-2 and Ki-67 proliferative index of meningiomas nor statistical concordance between the expression of bcl-2 oncoprotein by meningiomas and their sex hormone receptor protein status. Inhibition of apoptosis could be involved in the growth of meningiomas with a mesenchymal differentiation.

Expression of beta2 integrins and macrophage-associated antigens in meningeal tumours.

This study assessed the expression of leukocyte integrins and macrophage-associated antigens in meningiomas. Fourteen benign meningiomas, ten atypical/anaplastic meningiomas, two hemangiopericytomas and one solitary fibrous tumour (SFT) were included. Frozen sections were immunostained using antibodies directed against leukocyte integrins, CD68, CD14, CD2, CD1a, DRC1 and CD34. Their expression was evaluated semi-quantitatively. Ki67 positive cells were counted. Arachnoid membranes served as controls. Arachnoid cells expressed the beta2-integrin subunit and KP1. Beta2 was detected in the tumour cells of 14 meningiomas. In nine cases, this was associated with an alpha-integrin subunit. There was no statistical difference in the expression of beta2 between benign and atypical/anaplastic meningiomas. KP1 was constantly expressed by the tumour cells of meningiomas. It was not expressed by other meningeal tumours. CD34 was detected in the fibrous meningiomas, hemangiopericytomas and the SFT. In each tumour, macrophages were more numerous than T lymphocytes. There was no statistical difference in the density of macrophages and T lymphocytes between the benign and atypical/anaplastic meningiomas. There was no correlation between the Ki67 proliferation index and macrophage infiltration. Meningiomas, through the expression of leukocyte antigens, have a very particular phenotype. The expression of beta2 integrins could play a role in the attraction of immunocompetent cells in the stroma of meningiomas.

Phase II study of a radiotherapy/etoposide combination for patients with newly malignant gliomas.

PURPOSE: Etoposide, a semisynthetic derivative of podophyllotoxine, is a topoisomerase II inhibitor. This drug is currently used in several types of human cancer. The aim of this study was to evaluate the efficacity and tolerance of a near-concurrent association of radiotherapy and etoposide for newly malignant gliomas. METHODS: From May 1995 to December 1996, 30 malignant glioma patients were included in this phase II study; 16 patients underwent surgical tumor resection, and a stereotactic biopsy was performed in 14 patients. Standard cranial irradiation and six courses of etoposide (100 mg/m2, x days 1-3) were administered. The first course of etoposide was administered on days 1-3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks. RESULTS: Only 26 patients could be evaluated for the purpose of our study. The median age was 60.1 years, and the median Karnofsky performance score (KPS) was 80.2. The rate of objective response for evaluable patients was 34.6%, and four complete responses (CR) and five partial responses (PR) were noted. The median survival (MST) was 12 months, and the average overall survival was 12.5 months. Hematological toxicity was mild, and grade 3 or 4 neutropenia (white blood cell count < 1500/ml) was noted in three patients, without any sepsis or bleeding. CONCLUSIONS: The results obtained in this study are comparable to the best reported results on the combination of radiotherapy and nitrosoureas. The near-concurrent combination of radiotherapy and etoposide seems to be effective and well tolerated in the treatment of newly malignant gliomas.

Gonadotropic pituitary carcinoma: case report.

A 37-year-old man developed multiple intracranial, intraspinal, and general metastases from an invasive nonfunctioning pituitary adenoma after surgery and radiation therapy. This is the first gonadotropic pituitary carcinoma reported in literature.

Cervical root compression by a loop of the vertebral artery: case report.

A case of an abnormal loop of the extracranial vertebral artery enlarging the intervertebral foramen at C5-C6 and the transverse foramen at C5 is reported. This occurrence is rare and was associated with cervicobrachial neuralgia caused by neurovascular compression of the C6 root. The patient was cured by microvascular decompression.

Development of an intracerebral glioma model in whole body irradiated hairless rats.

AIMS: To study the in vivo radiosensitivity of malignant gliomas, an animal glioma model was developed using the implantation of glioma cell lines into the brain of the Hairless rat (a mutant from the Sprague-Dawley strain, characterised by its complete absence of hair). METHODS: 10(6) malignant cells were suspended in 10 microliters phosphate buffered saline (PBS) and injected at a 4 microns depth into the left frontal lobe of an anaesthetised animal through a small craniotomy hole without opening the dura mater. The glioma cell line C6 (obtained from a chemically-induced rat glioblastoma) was introduced into 11 animals, and the human glioblastoma line G5 into 12 animals. RESULTS: The tumour take was checked using histological criteria. It was poor: 0% for the G5 line and only 27.3% for the C6 line. To improve the tumour growth rate, rats were subjected to a single dose (3.5 Gray) total body irradiation, 24 hours prior to injection, causing a marked immunosuppression. 84.6% of the rats grafted with the C6 line then produced tumours. Similar results (75% tumour take) were obtained using a stereotactic inoculation of the tumour cells. CONCLUSIONS: Thanks to the contribution of whole body irradiation, an animal intracerebral glioma model was establish, which can be used for clinical and biological studies.

99mTc-MIBI uptake in a primitive leptomeningeal melanoma.

Primitive leptomeningeal melanoma is a rare and aggressive condition. The authors report on a case of primitive leptomeningeal melanoma imaged with 99mTc-Sestamibi (MIBI). There was an intense accumulation of the radiotracer in the frontal and parietal leptomeningeal regions and even after injections of gadolinium the MRI continued to reveal a cystic image of the brain. In view of the diagnosis, MRI demonstrated only limited usefulness. On the other hand, this case highlights the important role of MIBI for the imaging of malignant tumors.

Bilateral thrombosis of the transverse sinuses: microsurgical revascularization with venous bypass.

The present paper reports a case of intracranial hypertension secondary to thrombophlebitis of the two transverse sinuses and internal jugular veins in which microsurgical revascularization was attempted. This was carried out by means of a bypass graft inserted between the right transverse sinus and the superficial jugular vein. As early as the first post-operative week, intracranial pressure improved and visual disorders regressed. This type of venous revascularization using microsurgical techniques should contribute to more successful and lasting results in cases of sinus occlusions of thrombophlebitic, traumatic or tumorous origins.

[Sensitivity to etoposide of human malignant glioma cell lines. Mechanisms of action]. / Etude de la sensibilité à l'étoposide de lignées humaines de gliomes malins. Mécanismes d'action.

AIM OF THE STUDY: Etoposide, a Topoisomerase II inhibitor agent, is currently being explored as a therapeutic agent for brain tumors. The aim of this experimental study was to compare the in vitro etoposide sensitivity of human glioma cells vs human squamous cell carcinoma (SCC) cells. MATERIAL AND METHODS: Twelve human cell lines (six malignant glioma cell lines and six head and neck SCC cell lines) were used for this comparative study. A standard colony formation assay was used to assess cell survival. Since Topoisomerase II is the critical target for etoposide, it was of interest to determine Topoisomerase II activity and etoposide induced inhibition of Topoisomerase II activity for the glioma cells vs the SCC cells. RESULTS: Except for etoposide-induced inhibition of Topoisomerase II activity, no difference was found for etoposide sensitivity and Topoisomerase II activity between the both type of cells. CONCLUSION: These results suggested that the Topoisomerase II reactive agents may prove to be clinically a useful drug for patients presenting with malignant gliomas.

[Is cerebral tomoscintigraphy with 99mTc-MIBI useful in the diagnosis of local recurrence in patients with malignant gliomas?]. / La tomoscintigraphie cérébrale au 99mTc-MIBI est-elle utile au diagnostic de récidive locale chez les patients atteints de gliomes malins.

PURPOSE: 99mTc-MIBI, an alternative radiopharmaceutical for myocardial perfusion study has been proposed for use as a tumor imaging agent, including breast cancer, lung cancer, lymphomas, melanomas, and brain tumors. After routine radiation therapy, deteriorating clinical status or treatment failure may be due to either radiation changes or recurrent tumor. CT and MRI offer imperfect discrimination of tumor viability and radionecrosis. MATERIALS AND METHODS: Thirty-five malignant glioma patients with clinical deterioration were studied retrospectively. Tomoscintigraphy was performed 15 minutes after intravenous injection of 1110 Mbq 99mTc-MIBI. The images were obtained from a dual headed gamma camera using fan beam collimator. Transverse, coronal and sagittal views were reconstructed. RESULTS: A dramatic MIBI uptake was found in 31 patients. This uptake was correlated to tumor recurrence proven by histological fragments and/or the rapid, fatal evolution of these patients. Death occurred after the brain SPECT had been performed for those cases showing MIBI uptake, an average 5.48 months later. No MIBI uptake was found for these four remaining patients: their evolution can be currently considered to be a disease-free time. CONCLUSIONS: According to our results, the sensibility and specificity of 99mTcMIBI brain SPECT seems to be high. Moreover, this investigation is more accurate for discriminating tumor recurrence from radionecrosis than a CT scan or MRI.

[Microcystic meningiomas: comparison of histology and computed tomography]. / Aspects histologiques et tomodensitométriques des méningiomes microkystiques.

INTRODUCTION: Microcystic meningiomas are defined by large vacuolated and stellate shaped cells. We recently examined a microcystic meningioma mimicking a malignant tumor on computed tomography (CT). The aim of the current study was to compare the radiological features of microcystic meningiomas with their histological patterns. METHODS: We have diagnosed 7 intracranial microcystic meningiomas among 204 meningiomas registered in the files of our Department of Pathology from 1994 to 2001. All CT scans performed before surgery were reviewed. RESULTS: Three of the microcystic meningiomas appeared as entirely microcystic tumors. Two of them were homogeneously hypodense or isodense on CT scan. The third mening was heterogeneous, containing some blood. The histologic pattern of the 4 other meningiomas showed microcystic tumor cells associated with meningothelial or fibrous tumor cells. These meningiomas were heterogeneous on CT scan. All meningiomas seemed to be connected to the dura mater. Three tumors were strongly and homogeneously enhanced after contrast media injection while 3 others were heterogeneously enhanced. No enhanced CT scan was available for 1 case. Astrocytomas were incorrectly diagnosed by CT scan in the 3 heterogeneously enhanced tumors. Meningiomas were correctly diagnosed in the 3 strongly enhanced tumors. CONCLUSION: The presence of microcystic tumour cells in meningiomas often results in erroneous diagnosis on CT scan, particularly for those which are heterogeneously enhanced. In these cases, a diagnosis of astrocytoma is often made.

[A patient with white matter involvement and superficial hemosiderosis of the central nervous system]. / Atteinte de la substance blanche et hémosidérose marginale du névraxe.

We present a patient with a superficial siderosis and a white matter involvement on MRI and a demyelinating pattern on visual evoked potentials. White matter involvement is supposed to be secondary to vascular modifications induced by superficial siderosis.

[Solitary fibrous tumor of the meninges]. / Tumeur fibreuse solitaire des méninges.

We report a case of solitary fibrous tumor (SFT) of the meninges. SFTs have been initially described in the pleura. SFTs show similar histological findings as in other locations. SFTs show a diffuse positive staining for vimentin and CD34. Meningeal SFTs have usually a favourable outcome. These tumors have to be essentially distinguished from hemangiopericytomas and fibrous meningiomas. Immunostaining for CD34 is of value for this purpose. CD34 expression is often patchy and weaker in hemangiopericytomas whereas it is rarely observed in fibrous meningiomas. It is of great interest to isolate SFTs from hemangiopericytomas because of their favourable outcome.