[Epidural intracranial hematomas: practical issues revealed by management of 100 recent cases]. / Hématomes intra-crâniens extra-duraux: à propos de 100 cas récents. Notre expérience et considérations pratiques.

We present a retrospective study on the management of 100 patients who presented epidural hematoma over a four-year period. Our goal was to provide an update on management of this injury. Computed tomography was performed because of the clinical presentation. Results provided information on the type of injury and appropriate treatment. A three-phase clinical progression was observed in only 6% of the patients. Despite state-of-the-art management, mortality remained high in these brain-injured patients (21%). No progress appears to have been achieved in the last ten years. This paradoxical fact probably results from the enhanced severity observed in our patients, who often suffered from associated intracranial injuries as well as multiple trauma (thoracic, abdominal trauma). Analysis study of the results confirms an improvement in mortality among patients with isolated epidural hematoma (6.6%), but great concern remains about the high mortality among patients with associated intracranial lesions (33.3%) or multiple trauma (32%).

[Bilateral tumors of the acoustic nerve and Recklinghausen's disease observed in several generations. Considerations on heriditary acoustic nerve tumors]. / Tumeurs bilatérales de l'acoustique et maladie de recklinghausen observées dans plusieurs générations. Considérations sur les tumeurs de l'acoustique héréditaires

Since 1933, four families have been found in Marseilles with bilateral tumours of the acoustic nerve spread over three generations in three families. The fourth only showing a cutaneous neuro-fibromatosis in the second generation. The authors recall briefly the clinical characteristics and compare their cases with similar ones found in the literature. Bilateral and familial neurinomas of the VIIIth cranial verbes were found in 21 families, making a total of 111 cases, unilateral neurinoma being used as a term of comparison. Among the groups of cases published, the family observed by Gardner and Frazier is the most remarkable (43 cases over 6 generations). From the hereditary point of view, the phenomenon of antiposition is not always constant. From the evolutionary point of view, bilateral neurinomas manifest themselves earlier clinically than unilateral ones. As far as associations are concerned, cutaneous manifestations of neuro-fibromatosis are the most frequent if the neurinomas are bilateral and non familia. Among tumors of the nervous system, meningiomas and gliomas have been found, other dysembryoplastic or degenerative tumoral associations being rare. The incidence of cutaneous symptoms is very low when the neurioma is unilateral. The association of cutaneous symptoms with bilateral and familial neurinomas does not worsen the prognosis, but the presence of such cutaneous signs is significantly more serious if the neurinoma is isolated. These considerations do no more than touch the fringes of the problems raised by these sporadic or hereditary tumours of the VIII the cranial nerves, developing within the framework of phacomatosis. Great caution is necessary in assessing the correlations observed in view of the narrow range of statistics available.

[Triple tumor association: breast cancer, meningioma and glioblastoma]. / Triple association tumorale: cancer du sein, méningiome, glioblastome.

A 38 year-old woman treated for breast cancer had 10 months later a cerebral tumor diagnosed as a frontal metastasis. Neurosurgical operation showed a meningioma and a malignant glioma. Although exceptional, such an association, is probably not due to chance.

[Distal aneurysm of the postero-inferior cerebellar artery. Anatomical and surgical considerations]. / Anévrysme distal de l'artère cérébelleuse postéro-inférieure. Considérations anatomiques et chirurgicales.

A patient with a rare peripheral aneurysm of the posterior inferior cerebellar artery (P.I.C.A.) was treated by microsurgery. Anatomical features and surgical procedures are discussed. The aneurysm was located in the retromedullary, tonsillomedullary segment of the right P.I.C.A. and formed a caudal or infratonsillar loop in the cisterna magna close to the inferior part of the tonsil. The operation was performed with the patient in the sitting position using a median suboccipital approach through a cervical 1 (C1) laminectomy. The widened neck of the aneurysm was clipped successfully and the post-operative course was completely asymptomatic. A vertebral angiogram control showed the P.I.C.A. to be patent. The surgical approach should be related to the site of the aneurysm. Those affecting the telovelotonsillar segment of a P.I.C.A., forming cranial or supratonsillar loops, and those involving its cortical segment can be effectively operated using the same median suboccipital approach. Aneurysms arising from the anterior or lateral medullary segment of a P.I.C.A. should be approached through a unilateral suboccipital craniectomy extending down to the foramen magnum. Although clipping the neck of the aneurysm is preferable, trapping is possible for lesions arising from or distal to the telovelotonsillar segment, this preserving the small arteries arising from the lateral and posterior medullary segments.

[Unusual extra-axial infra-tentorial localization of a cavernoma in the cisterna magna]. / Localisation infra-tentorielle inhabituelle extra-axiale d'un cavernome au niveau de la cisterna magna.

A case of an extra-axial cavernous angioma of the cisterna magna is described. The clinical presentation, radiographic features, treatment of that unusual location in the posterior fossa are discussed. The patient is a 31 years old man admitted for the sudden onset of occipital headache and instability. A CT scan demonstrated a slightly calcified lesion, minimally enhanced after intravenous injection of a contrast agent, located within the posterior fossa. A T2-weighted MR image showed a well circumscribed mass, located between medulla oblongata and left cerebellar tonsil, of mixed signal intensity surrounded by a rim of decreased signal intensity related to the presence of hemosiderin. Cerebral arteriography was normal. A medial suboccipital craniectomy was performed, with the patient in the ventral position, in which a 1.5 x 1 cm solid dark-red mass was encountered arising from the cisterna magna and was easily removed "en bloc". The operative extra-axial aspect of that lesion was evident excluding a medulla oblongata tumor protruding into the cisterna magna. Histologically, the lesion was a cavernous angioma consisting of numerous vascular channels with collagen fibrous walls filled with fibrin thrombi and hemosiderin. Few elastic fibers were found in vascular walls. The patient's post-operative course was unremarkable.

[Extracranial aneurysm of the posterior inferior cerebellar artery. A case report]. / Anévrysme extra-crânien de l'artère cérébelleuse postéro-inférieure. Une observation.

A case is presented of an aneurysm arising in an extracranial loop of the left posterior inferior cerebellar artery (P.I.C.A.). Two similar cases can be found in a review of the literature. It is essential to obtain clear visualization of both P.I.C.A.s. in the evaluation of patients with subarachnoid hemorrhage. Surgical treatment of this aneurysm, located distal to the lateral medullary segment, involves a midline approach with retraction or subpial resection of the tonsillar tip.

[Tuberculous abscess of the cerebellum. Apropos of a case]. / Abcès tuberculeux du cervelet. A propos d'un cas.

A 22-year-old Asian man developed intracranial hypertension with a 38 degrees C fever. Two months earlier, he had undergone surgery and medical treatment for tuberculous otomastoiditis and pulmonary tuberculosis. The CT scan revealed multiple tuberculous abscesses of the cerebellum. Histological, microbiological and biological proof of diagnosis was obtained. We advocate surgical treatment of intracranial tuberculous abscesses associated with antituberculosis chemotherapy for 18 months. The earlier the treatment, the better the prognosis. This pathology must be kept in mind when treating patients from countries with a high endemic rate of tuberculosis and suffering from immunodeficiency syndrome.

[Extradural hematoma of the posterior fossa]. / Hématome extradural de la fosse postérieure.

Extradural hematoma of the posterior fossa (EDHPF) is considered to be a rare complication of head injuries. In early reports, diagnosis was made only at the time of autopsy. Today, CT scanning prompts early diagnosis leading to better outcome. We report 20 consecutive patients observed over the last ten years who underwent surgery for EDHPF. This localization was found in 14,3% of all trauma patients operated for extradural hematoma. In our experience, EDHPF occurs in young adults with a clear male predominance. Vehicle accidents are the most frequent mechanism of injury. The main clinical presentation is subacute onset of signs (50% of our cases). Postoperative outcome was favorable in 19 of our patients (95%). We propose mandatory CT scanning that may have to be repeated as needed, to prevent delay in diagnosis and decision for surgery. Surgical removal of the EDHPF must be carried out as soon as possible as this is the only way to reduce morbidity and mortality.

[Subperiosteal hematoma of the orbit. Three cases]. / Hématome sub-périosté de l'orbite.

Orbital subdural hematoma should be considered in victims of head and face trauma with signs of exophthalmia. Early diagnosis and treatment, consisting of decompression, is mandatory to avoid long-term functional complications.

[Cranio-encephalic traumatisms in Senegal. A review from 1,039 cases (author's transl)]. / Les traumatismes crânio-encéphaliques au sénégal. A propos de 1,039 observations.

Frequency of cranio-encephalic traumatisms in Senegal raises rapidly, mostly as a consequence of the development of motor circulation (54 p. 100 of the cases). Main features observed in other countries are recalled as well as the relation between high mortality and polytraumatisms. Original aspects are related to the conditions prevailing in developing countries, poor public health facilities, delays for transportation and emergency cares. Consequently many fatal cases are not recorded.

[Suppurative intracranial infections in Africa]. / Les suppurations collectées intra-crâniennes en milieu africain.

The purpose of this study was to review recent African literature on suppurative intracranial infection and its implications for neurosurgery. In order of decreasing frequency the main lesions are brain abscess, subdural empyema, and epidural abscess. Despite progress in diagnostic imaging and availability of antibiotic therapy, these lesions still cause disturbingly high morbidity and mortality especially in sub-Saharan Africa where diagnosis is often delayed. The male-to-female ratio was 3.6:1 and 70 to 80% of patients were under the age of 20 years. Spread from the paranasal sinus or ear was the most common mechanism of infection. Hematogenous processes accounted for 22% of cases and the origin was undetermined in 11% to 26% of cases. Staphylococcus aureus and enteric gram-negative bacilli were the most common bacteria identified but cultures were reported as sterile in 30% to 50% of cases. While ultrasonography can be useful in newborns with an open fontanelle, arteriography is often the only feasible procedure for diagnosis in Black Africa. The diagnostic modality of choice is computed tomography which allows precise mapping prior to neurosurgery. Introduction of computed tomography in some African cities has led to a decrease in mortality ranging from 4.7% to 43%. The most effective treatment is a combination of appropriate antimicrobial therapy and surgical decompression of expanding lesions. The main procedures are aspiration through burr holes and craniotomy. Use of this combined strategy requires close cooperation between the neurosurgeon, infectious disease specialist, and microbiologist. Therapeutic indications are discussed within the context of Black Africa.