Microsurgical anatomy of the cisternal course of the perforating branches of the posterior communicating artery.

Both the perforating branches--especially the extracerebral segments--and the arachnoidal anatomy at the level of the posterior communicating artery were studied in 60 human brains previously fixed in formalin. The close relationships between this artery and the oculomotor nerve are described, and it is noted that each of them is enclosed in its own arachnoidal compartment, which in the case of the posterior communicating artery is to be distinguished from the interpeduncular cistern. The latter cistern was found to contain only the terminal segments of the posterior communicating artery. The hypothalamic branches were within the inner wall of the arachnoidal cistern surrounding the posterior communicating artery. The variations in diameter of this artery are explained by its embryological development and are not related to the number and the diameter of the perforators. The posterior communicating artery was absent at times. The surgical implications of such a variable anatomical arrangement are discussed in the light of the literature.

Perforating branches of the basilar bifurcation.

The perforating branches of the upper basilar artery and of the first (P1) segment of the posterior cerebral artery were studied in 50 fixed brains obtained from human cadavers. No vertical branches arose from the basilar bifurcation. The upper basilar artery gave rise to horizontal branches, which were studied with reference to their angle of origin. Perforating arteries arising from P1 segments were found in all specimens. Rare branches were found to come from the inferior and anterior surfaces of P1 segments. The anatomical patterns of these branches are discussed in the light of previous reports. Preoperative knowledge of some anatomical aspects (the position of the basilar apex, the angle between the right P1 and left P1 segments, and relationships to the dorsum sellae and the mammillary bodies) can help in the selection of a neurosurgical approach and may improve the operative results in the surgical treatment of basilar apex aneurysms.

Arterial vascularization of the spinal cord. Recent studies of the anastomotic substitution pathways.

This study of the arterial blood of the spinal cord indicates that, of the 62 radicular branches (rami radiculares), at the most seven or eight truly participate in the vascularization of the spinal cord. The authors have observed that the situation and distribution of these branches enable the distinction of three large arterial areas: cervicothoracic, midthoracic, and thoracolumbar. The fixed nature of the intramedullary arterial distribution contrasts with the variability of the afferent arterial supplies. No demarcation permits separation of the vascularization of the spinal cord into anterior and posterior parts. The anastomotic systems situated on the arterial pathways are potentially valuable, but their functioning is problematical. The anterior spinal artery is not continuous, for in the midthoracic region there exists a critical narrow zone. The perimedullary anastomotic system appears insufficient while intramedullary anastomoses are without functional value.

Extracerebral course of the perforating branches of the anterior communicating artery: microsurgical anatomical study.

Damage to the perforating branches arising from the anterior communicating artery, because of their blood supply to the septal nuclei and anterior hypothalamus, explains the memory impairment and the electrolyte disturbances that often follow the surgery of aneurysms located in this part of the circle of Willis. The microsurgical anatomy of these branches was studied on 60 fixed human brains, with special attention to their number, caliber, and vascular territory. The direction of the branches was evaluated, measuring the angle formed by them with the postcommunicating segment of the anterior cerebral artery. The variability of this anatomical region is discussed in light of the literature.

Cerebellar hemangioblastoma and primary hyperparathyroidism.

The authors report the case of a 52-year-old woman presenting with cerebellar hemangioblastoma and primary hyperparathyroidism. It is the second reported case involving this new association. The relationship between these two tumors is discussed.

[Selective paralysis of downward gaze with permanent conjugated upwards deviation : report of a new case (author's transl)]. / Un nouveau cas de paralysie sélective de l'abaissement des yeux avec déviation conjuguée permanente vers le haut.

Permanent upward conjugated ocular deviations are exceptional in conscious subjects : 8 cases only have been reported. They are always associated with a more or less selective paralysis of downward gaze. A further case is reported, with results of oculographic and computed tomography examinations. The latter showed a median or bilateral lesion at the diencephalo-mesencephalic junction. The mechanism provoking the deviation was clarified by studying vestibular movements which appeared abnormally ample and rapid. The authors suggest that the deviation of the eyes could result from this release of movements of vestibular origin, which can only be expressed as upwards movements because of complete paralysis of all lowering movements.

[Ocular flutter: really a cerebellar sign?]. / Le flutter oculaire: un signe réellement cérébelleux?

Two post-operative cases of ocular flutter with electro-oculographic recordings are reported. In both cases, the lesion was unique and restricted, suggesting that a cerebellar damage was responsible for this abnormal eye movement. In both cases, ocular flutter was directed toward the healthy side. Therefore it is suggested that flutter may result from a focal cerebellar lesion and in that case be an oriented eye movement.

[Intracerebral hematoma in gamma-angio-encephalography]. / Les hématomes intracérébraux en gamma-angio-encéphalographie

The radionuclide angiography, of gamma-angio-encephalography (gamma-A.E.G.), a non invasive method, is able to bring specific information for the diagnosis of intracerbral hematoma (I.C.H.). In 25 out of 32 verified cases of I.C.H. the rapid sequential imaging shows from the arterocapillary time a deeply seated avascular area, which is a quite different aspect from the defect observed in ischemic A.C.V., or malignant tumors. The transit curves confirm the regional of circulating blood pool.

[The circle of Willis in children and the factors shaping it]. / Le polygone de Willis de l'enfant et les facteurs de son modelage

The pattern of the circulus arteriosus cerebri was studied on the sagittal plane in 41 brains taking off on children from birth to 14 years. Internal diameters were measured on the segments of the circulus, on the cortical efferent vessels and on the internal carotid afferent arteries. In only 17/41 cases, a symetry of the segment of the cortical efferent branches and of the carotid arteries. We found different factors associated with the assymetry of the circulus arteriosus, namely cerebral conditions as demonstrated in our pathological cases and embryological dispositions. Three grades are proposed according anatomic criteria. They are related to a greater complexity and interaction of the conditions mentionned above:-grade 1 "foetal" : symetry is complete;-grade 2 : there is a symetry of the cortical branches, but an assymetry of the circulus arteriosus, which is obtained by compensatory modelling of the circulus arteriosus, working to equalize the cerebral flow; -grade 3 : there is an assymetry of the circulus and of the cortical efferent branches suggesting a failure of adaptation. It is assumed that this modelling of the circulus has consequences on adult anatomic and functional conditions. Indeed, the other modelating factors which affect the adult circulus refer mainly to the grade obtained in childhood.

[Extra dural hematoma complicating ventricular decompression during posterior fossa exploration (author's transl)]. / Hématome extra-dural après ponction ventriculaire au cours d'une intervention sur la fosse postérieure.

A new case of bilateral frontal extra dural hematoma following ventricular decompression during posterior fossa exploration is reported. Hazards of such ventricular drainage are discussed with a review of relevant literature. The authors emphasize the role of non communicating hydrocephaly in pathogenesis of these complications.

[Meningeal hemorrhage disclosed by the initiation of Prinzmetal's angina]. / Hémorragie méningée révélée par un tableau inaugural d'Angor de Prinzmetal.

The association of a cardiac disturbance and a subarachnoïd hemorrhage is well known but the cardiac signs seldom look the most important. When studying a case which was very particular because the cardiac signs consisted in a Prinzmetal's variant angina, it finality appears that the Prinzmetal's angina is not so rare as could be thought in such circumstances. Therefore a neurological pathology hidden by a cardiac one has been rarely reported such as it was seen in that case. In the literature, the influence of the parasympathetic and especially the sympathetic nervous system is emphasized as a probable cause of the most frequent cardiac abnormalities. All the authors think the medical cardiac treatment and the surgical treatment of the subarachnoïd hemorrhage have to be done at once.

[Primary intra-cerebral hemorrhage in the new born, nursling and child (author's transl)]. / Hémorragies cérébrales du nouveau-né, du nourrisson et de l'enfant d'allure primitive.

The authors report 6 cases of intracerebral hemorrhages in 6 children, of what appears to be, of primary origin. 3 cases concern children between the ages of 4 and 14 years; the 3 others are situated shortly after birth or during the first months of life. A review of the literature emphasizes the sporadic nature of these cases and the persistance of diagnostic and etiological problems as to the cause of these hemorrhages. In the course of reviewing articles as well as our own personal series, it is evident that the cat scanner has demonstrated its qualifications as a diagnostic tool in the early detection of the lesions, permitting a better adapted treatment, thus improving their prognosis. The prognosis appears to be linked : --to an early diagnosis --to whether or not the hemorrhage is of massive nature or not --to the precise location of the hematoma --to the neurological state of the patient at the time of treatment --to the absence of an associated pathologie (severe prematurity, coagulation pathology). The long distance prognosis in the case of these apparently primary hemorrhages remains uncertain, due to the high rate of recidivism at a later unpredictable date (one month or several years later); to the occurence or not of a hydrocephalus especially in the case of young infants; and frequent sequels affecting superior functions. This long distance prognosis seems, however, to be little affected by the recent acquisitions in diagnostic testing.

[Radicular artery thrombosis after cervical anterior approach for cervico-brachial neuralgia (author's transl)]. / Thrombose d'une artère radiculaire après exérèse disco-ostéophytique par voie antérieure pour névralgie cervico-brachiale.

An anterior cervical approach completed by a bone graft is performed on a man suffering from cervico brachial neuralgia which did not improve by medical treatment and rest. During four months, the post operative course is excellent, with complete disappearance of pain and regression of the pre-existing neurological deficit. At the end of this period, the appearance of a major deficit within the field of the concerned root led to a selective brachial angiogram which revealed the existence of a radicular artery thrombosis.

[Outcome of intracranial meningioma in adults. Retrospective study of a medicosurgical series of 161 meningiomas]. / Devenir des méningiomes intracrâniens chez l'adulte. Etude rétrospective d'une série médico-chirurgicale de 161 méningiomes.

The authors report the retrospective study of a medico-surgical series of 161 patients with intracranial meningiomas, diagnosed over a period of 9 years, with a follow-up period varying from 18 months to 9 years. Out of 185 cases studied, 24 were excluded because information or perspective were inadequate. Of the 161 cases retained, 133 (82.6%) were given surgical treatment and 28 (17.4%) were given conservative treatment because the clinical state was poor or the location was deemed inoperable. The sex ratio was 3 women to 1 man. The average age was 58 years. The most frequent locations were the convexity (27.9%) and the sphenoid ridge (24.7%). Among the clinical signs, apart from the usual general seizures or pyramidal signs should be noted the importance of psychological disorders. The operative mortality rate was 14.3% with a very high peak in the sixth decade, reaching 27%, while it was only 9% in the seventh decade and 13% in those over seventy. The internal sphenoid ridge location had a mortality rate of 31.5%, which is significantly higher than for all the other locations. Quality of survival was identical for all age groups. Complications were mainly seizures, functional deficits and psychological disorders. Recurrences were relatively few (10%), but insufficient lapse of time and the presence of only one malignant meningioma explain the lowness of this figure. The use of scanner was not determinant in our series, neither on the earliness of diagnosis, nor on prognosis, comparison of figures before and since scanning showing no significant differences.

[Micro-anatomy of collateral perforating branches of the middle cerebral artery]. / Etude micro-anatomique des branches collatérales perforantes de l'artère cérébrale moyenne.

The lenticulostriate arteries are the subject of a microanatomical study on 50 formalin fixed human brains. A single trunk arising from the middle cerebral artery is rarely found. In fact the branches are numerous and they are found to ramify before penetrating the anterior perforated substance. The length of the sphenoidal segment is variable and this aspect is discussed in the light of the literature data. The origin of the perforating branches is spread from the internal carotid artery to the bifurcation branches of the middle cerebral artery (M2 segment). On the other hand lenticulostriate arteries arising from the cortical branches of the middle cerebral artery are often found. These anatomical patterns are of essentially surgical interest. No branches must be damaged during the opening of the Sylvian fissure or during the dissection of an aneurysm in this region.

[Anterior sacral meningocele. Report on 2 cases treated by the abdominal approach]. / Méningocèle sacrée antérieure. Présentation de 2 cas traités par voie abdominale.

Anterior sacral meningocele is a rare affection (150 cases published) that is frequently misdiagnosed with resulting inappropriate, always dangerous treatment. Diagnosis should however be simple to establish on the finding of a fluid hypogastric mass attached to the sacrum with associated radiologic anomalies of the sacrum. Two cases are reviewed and diagnostic and surgical therapy features discussed.