Spontaneous spinal epidural hematoma in a toddler presenting with torticollis: case report and literature review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare entity, especially in toddlers and infants. The nonspecificity of its presenting symptoms in children may be a source of delayed diagnosis.

CASE DESCRIPTION

We report the case of a 20-month-old young boy without medical history who presented with irreducible torticollis, worsened a few days later by severe tetraplegia and respiratory distress. Spinal magnetic resonance imaging (MRI) showed a posterior epidural hematoma, extending from C3 to T1 and compressing the spinal cord. An urgent decompressive surgery via an extensive laminectomy and evacuation of the clot was performed. The patient demonstrated a partial neurological recovery on follow-up.

CONCLUSION

SSEH is a rare and serious condition that may compromise the functional and vital prognosis of the patient, hence the importance of prompt diagnosis and urgent treatment.

Multiple Cerebral Hydatid Cysts: A Case Report

Hydatidosis is an endemic disease in Morocco. Intracranial localization is relatively unaccustomed and usually occurs in a solitary form. It is even rarer to find multiple intracranial hydatid cysts. Patients are frequently children and young adults. We report the case of a 22-year-old woman with recurrent multiple cerebral hydatid disease occurring seven years after resection of a primary cyst. She was admitted due to high intracranial pressure and generalized seizures. Brain CT scan showed several intracranial multivesicular cysts in the left parieto-occipital region with localized calcifications. According to the radiological results and patient story, the diagnosis of cerebral hydatidosis was presumed. The patient underwent complete excision of the cysts followed by medical therapy. The parasitological and histological examination of the surgical specimen confirmed the diagnosis. The transient neurological deficit was the only postoperative complication improved, thanks to reeducation in the early phase. The patient was discharged in good condition with no other complications at the follow-up.

Complex craniosynostosis in the context of Carpenter's syndrome

Carpenter's syndrome or acrocephalopolysyndactyly type II is a rare genetic autosomal recessive disease, with an incidence estimated at 1 per 1 million births. Common findings of a brachydactyly, polysyndactyly, and a trefoil-like skull with extreme brachycephaly due to fusion of the bilateral coronal, sagittal and lambdoid sutures. We report a 12-month-old male who was referred to our care for evaluation of a craniofacial deformity-a trefoil-like skull, flattened and receding forehead, bulging of temporal bones, hypertelorism, exorbitism, and polysyndactyly in the upper and lower limbs and psychomotor delay. Head computed tomography (CT) with 3D reconstruction revealed craniosynostosis with fusion of the coronal, metopic, and sagittal sutures. Correction of the craniofacial deformity was performed with satisfactory aesthesis of the craniofacial bones at 2 years of follow-up. Early correction of craniofacial deformity in Carpenter's syndrome is usually safe within 6 to 12 months. Venous drainage abnormalities and ectatic emissary veins can lead to significant bleeding and may be detected on MR angiography. Significant skull weakening may lead to bony fragmentation while creating cranial flaps and is best evaluated with 3D CT imaging. Taking these pitfalls into consideration decreases the chances of aborting the surgery and may lead to better overall outcomes.

Ruptured intraventricular tuberculous brain abscess mimicking cystic neoplasm: a case report

Central nervous system (CNS) tuberculosis is a potentially life-threatening condition that may manifest in different forms and simulate other pathologies. It rarely involves the ventricles and the occurrence of primary intraventricular tuberculous brain abscess (TBA) has exceptionally been reported. As far as we know, ruptured intraventricular TBA has not been described before. An immunocompetent 56-years-old man was admitted for sub-acute intracranial hypertension with behaviour disorders. Cranial magnetic resonance imaging (MRI) showed a cystic lesion of the third ventricle containing fluid-fluid level with biventricular hydrocephalus and debris in the occipital horns. A ruptured cystic neoplasm was first considered. The patient underwent surgery via a right transcortical transventricular approach, combining both microscope and endoscope. The puncture of the lesion brought pus and the Ziehl-Neelson (ZN) staining demonstrated acid-fast bacilli. Intraventricular tuberculous abscess is an extremely rare condition that can take an unusual radiological appearance. This observation highlights the consideration of tuberculosis within the list of differential diagnosis of intraventricular cystic lesions in immunocompetent hosts.

Unusual association of COVID-19, pulmonary tuberculosis and human immunodeficiency virus, having progressed favorably under treatment with chloroquine and rifampin

Infection with the new coronavirus has been declared an international health emergency. Its curative treatment is unknown and is the subject of several clinical trials. In addition, the concomitant association of COVID-19 with tuberculosis and the human immunodeficiency virus, hitherto never described, is potentially fatal. We report the illustrative case of a 32-year-old patient who presented this trifecta of infections and who did well under treatment with chloroquine and anti-mycobacterial drugs. This patient arrived at the ER with respiratory discomfort that had been evolving over a month with symptoms of flu and deterioration of her general condition. A chest CT scan revealed an aspect of lung miliary tuberculosis with isolation of Koch’s bacilli in the sputum. A polymerization chain reaction (PCR) was positive for COVID-19 on a nasopharyngeal swab. HIV serology was positive. The course was marked by a spectacular clinical improvement and two negative COVID-19 PCR controls at the end of treatment (at days 9 and 10). Anti-tubercular drugs (especially, rifampin) are powerful enzyme inducers that can reduce the effectiveness of chloroquine in our patient. This therapeutic success may be linked to the effect of anti-tubercular drugs against SARS ncov-2, especially rifampin, inhibiting the formation of messenger RNAs of SARS ncov-2 or to the synergistic effect of chloroquine and rifampin. Researchers should explore the effect of these drugs on SARS ncov-2.

Awake Craniotomy with Functional Mapping for Glioma Resection in a Limited-Resource-Setting: Preliminary Experience from a Lower-Middle Income Country

BACKGROUND

Awake craniotomy with brain mapping aims to maximize resection of gliomas located within eloquent regions while minimizing the risk of postoperative deficits. This technique is common practice in the developed world but has yet to be implemented in most low- and middle-income countries (LMICs). We assessed the feasibility, safety, and efficiency of functional-based glioma resection using minimal facilities in a limited-resource institution.

METHODS

This is a retrospective review of patients harboring gliomas within eloquent regions who underwent awake craniotomy and tumor resection guided by cortico-subcortical mapping at a tertiary hospital of an LMIC. Patient characteristics, surgical results, and functional outcomes were studied.

RESULTS

Twenty consecutive patients with a mean age of 37 years were enrolled in the study. Seizure, present in 70% of patients, was the major presenting symptom. Eighteen patients had diffuse low-grade gliomas and 2 patients had high-grade gliomas. Intraoperative events were dominated by seizures, occurring in 5 patients (25%). The average extent of tumor removal was 89.5% and the rate of total and subtotal removal was 85%. New postoperative deficits were observed in 5 patients (25%), and permanent deficits were found in 1 patient (5%). The main hurdles encountered were the difficulties in investigating patients and human resource availability.

CONCLUSIONS

Awake craniotomy with brain mapping for functional-based resection of gliomas can be safely achieved in a limited-resource institution with good functional and oncologic results.

Diagnosis and management of intracranial tuberculomas: about 2 cases and a review of the literature

Central nervous system tuberculosis is a major cause of morbidity and mortality in developing countries. Intracranial tuberculoma is rare and is one of the most severe cases of tuberculosis. We present two cases. The first one is about a girl of 7 years, followed for 5 months for lymph nodes tuberculosis on anti-TB treatment that presents generalized tonic-clonic seizures associated with progressive intracranial hypertension syndrome. Brain MRI has objectified necrotic nodules in left hemisphere. The surgical approach of the lesions was direct with complete excision. The diagnosis of tuberculoma was confirmed by anatomopathological examination. The second case is about a 6-year-old girl with no particular medical history, which presents for three months progressive and treatment-resistant cervico-occipital headaches associated with walking difficulties. The MRI objectified left cerebellar tumor process interpreted preoperatively as medulloblastoma. The patient was operated on intraoperative, appearance was that of a nodular lesion. Anatomopathological examination confirmed the diagnosis. The intracranial tuberculoma is an unusual variety of the central nervous system tuberculosis and remains a topical issue in Morocco. The prognosis depends on prompt diagnosis, quality of surgical resection and anti-TB treatment. The diagnostic confirmation is histological and should therefore be evoked infront of any intracranial process mimicking a brain tumor.

Acute Lumbar Spinal Subdural Hematoma Inducing Paraplegia After Lumbar Spinal Manipulation: Case Report and Literature Review

BACKGROUND

Traumatic spinal subdural hematoma is an extremely rare occurrence that requires urgent investigation and most often prompt intervention. To our knowledge, this is the first reported case related to a spinal manipulative therapy.

CASE DESCRIPTION

This report describes a case of traumatic lumbar subdural hematoma after a spinal manipulative therapy without any predisposing factor. A 23-year-old man was admitted to the emergency department for partial cauda equina syndrome after a spinal manipulation performed by a physiotherapist. Magnetic resonance imaging showed an acute spinal subdural hematoma at L2-L3 level with cauda equina compression. The patient underwent an emergency L2 laminectomy with evacuation of the hematoma. He recovered completely his neurologic functions after 1 week.

CONCLUSION

Practitioners of spinal manipulations should be aware of spinal subdural hematoma as a possible complication. A rapid diagnosis with magnetic resonance imaging is mandatory, and emergency surgical decompression is usually the optimal treatment for spinal subdural hematomas with severe neurologic deficit.

Foramen magnum meningioma's management: the experience of the department of neurosurgery in Marrakesh

Our study is a retrospective analysis of the clinical data, surgical outcomes, histological finding and prognosis of foramen magnum meningiomas through a serie of 8 cases operated at the department of neurosurgery at Mohammed VI medical university hospital, Marrakesh. From January 2002 to December 2015. There were 3 male and 5 female patients (mean age, 46.75 years). Cervico-occipital pain (100%) and motor deficit (100%) were the most common presenting symptoms. MRI was the most appropriate diagnostic tool in visualizing tumors of this region. All operations were performed by the posterior approach and gross total resection was achieved in 7 cases. Surgical mortality was 20%. 3 other patients had complications like CSF leak (25%), meningitis (12,5%) and transient worsening of neurological deficit (12.5%) but made neurological recovery later. Foramen magnum meningiomas have long been regarded as difficult lesions both in terms of diagnosis and management. However, with the availability of MR imaging, newer surgical techniques and skull base exposures, the excision of these lesions is becoming easier and safer.

Epilepsy: unusual presentation of cerebral hydatid disease in Children

Cerebral hydatid disease is very rare, representing only 2% of all cerebral space occupying lesions even in the countries where the disease is endemic. Intracranial hydatid cysts are more common in children and occur more frequently in the supratentorial space. The aim of this paper is to describe the characteristic features of computed tomography (CT) and magnetic resonance imaging (MRI), and to determine the clinical presentation and surgical outcome of cerebral hydatid disease. A 7-year-old girl was admitted to the emergency department because of an epileptic attack. On radiological examination a round, cystic lesion appeared in the parietal lobe and caused shift of the midline structures. The cyst was successfully removed using the dowling technique. The postoperative period was uneventful and seizures were not seen during follow up. Hydatid cyst of the brain presents clinically as intracranial space occupying lesion and is more common in children, it is well demonstrated by CT and MR examinations, and Surgery is the treatment option with affordable morbidity and low mortality.

[Hemangiopericytoma of the cerebellopontine angle: case report and review of literature]

Les hémangiopéricytomes primitifs du système nerveux central sont rares et représentent moins de 1% des tumeurs intracraniennes. La localisation au niveau de l'angle ponto-cerebelleux est très rare, pouvant simuler un neurinome de l'acoustique ou un méningiome. Le diagnostic de certitude est basé sur l’étude histologique et immunohistochimique. Notre but est d'illustrer avec une revue de la littérature les aspects clinico-radiologiques, anatomopathologiques et la prise en charge thérapeutique de ce type de lésion.

[Lipoblastoma of the subtemporal fossa]

Le lipoblastome est une tumeur bénigne rare, formée d'adypocytes immatures associés à la présence d'une matrice myxoide, de septas fibreux, et d'une architecture lobulaire. Il survient généralement chez le nourrisson et l'enfant. Cette tumeur touche dans la majorité des cas les tissus sous-cutanés des extrémités et du tronc. Elle est extrèmement rare au niveau de la tète et du cou. Un total de moins de 100 cas a été rapporté précédemment dans la littérature.

[Bone odontoideum: about a case and review of the literature]

L'os odontoideum ou apophyse odontoïde mobile est une malformation rare de la charnière cervico-occipitale (MCCO) qui met en jeu le pronoctic vital et fonctionnel par le risque de compression de la junction bulbo-médullaire. Nous rapportons le cas d'un patient âgé de 22 ans, victime d'un traumatisme cervical à l’âge de 2 ans, chez qui cette affection a été révélée par des torticolis récidivants, puis par l'installation d'une tétraparésie. Bien qu'une symptomatologie déficitaire soit fréquemment révélatrice, la notion de cervicalgie récidivante (même isolée) doit attirer l'attention. Le bilan fait appel aux clichés radiographiques dynamiques, à la TDM et l'IRM. L’étiopathogénie reste méconnue congénitale ou traumatique. Le traitement est chirurgical chez les patients symptomatiques et repose sur l'arthrodèse et l'ostéosynthèse postérieure, tandis que chez les sujets asymptomatiques une simple surveillance est préconisée. Un diagnostic et un traitement précoces permettent d'obtenir une stabilisation et une amélioration clinique dans la majorité des cas.

Diagnostic and management of pediatric brain stem abscess, a case-based update

PURPOSE

Authors report their experience of a pediatric brain stem abscess with a literature review.

METHODS

A 2.5-year-old girl first displayed bacterial otitis 3 months before admission. Diagnosis of brain stem abscess was delayed, despite plethoric neurological signs. She complained of right hemiparesis, headache, squint, dysphagia, and false way inhalation pneumopathy. Brain magnetic resonance imaging revealed presence of an abscess in the pons, prompting for a microsurgical pus aspiration. Postoperative course was regular with a total neurological recovery. Clinical and radiological screening showed progressive regression of the pontine lesion after 4 months, despite persistence of a mild contrast enhancement. Present case is the 18th pediatric brain stem abscess reported in literature.

RESULTS

Mean age of occurrence is 8.1 ± 4 years (range 0.75-16) without gender predominance. High morbidity is typical and essentially involves motor functions. The most common clinical signs are raised intracranial pressure, motor limbs deficit, and cranial nerve palsies. Fever was found in 10 out of 18 cases (56%). Three patients received conservative medical treatment. Three patients underwent stereotactic aspiration and 12 others underwent microsurgical aspiration or excision. No mortality was reported since the eighties. However, morbidity is still high.

CONCLUSION

High clinical index of suspicion is necessary to improve functional outcome. Stereotactic-guided or microsurgical aspiration are still good therapeutic options. The rarity of pediatric brain stem abscesses and the need of optimal management make this case-based update very peculiar.

[Intracranial hydatid cysts in children: a report of 9 cases]

PURPOSE

To illustrate the value of cross-sectional imaging (CT, MRI) for the diagnosis and follow-up of intracranial hydatid cysts in children.

MATERIALS AND METHODS

Retrospective study of 9 cases of intracranial hydatid cysts in children seen over a period of 8 years. Precontrast and postcontrast 5 mm thick axial CT images were obtained in 7 cases. Noncontrast sagittal, axial and coronal T1W and T2W images were obtained in 2 cases.

RESULTS

Mean patient age was 7.5 years. Intracranial hypertension was the main presenting clinical symptom. A single supratentorial cyst with significant mass effect upon the ventricular system and midline structures was observed in all cases. All patients underwent surgery with good outcome in all cases.

CONCLUSION

CT is the imaging modality of choice for diagnosis and postoperative follow-up of intracranial hydatid cysts in children. MRI is most helpful for further characterization when multiple or atypical cysts are present to optimize management.

[Benign sacrococcygeal teratoma in a child: a case report with a review of the literature]

Sacrococcygeal teratomas are rare congenital tumors, generally discovered at birth. These tumors are seldom observed in children. Radical resection must be performed to avoid potentially malignant recurrence even if the primary lesion is benign. We report a case in an 8-year-old girl who did not have a past medical history. Since the age of 2 years, she presented a progressive sacral tumefaction with no neurological deficit. The MRI showed a large sacrococcygeal cyst in hypointense-signal T1-weighted imaging with no contrast enhancement, and a hyperintense signal in T2-weighted imaging. At surgery, the tumor was totally removed. The intraoperative aspect was that of a viscous cyst. The histological study showed a sacrococcygeal teratoma.

Management of a severe cranio-orbito-facial trauma with a dislocation of the globe into the maxillary sinus

We report two cases of severe cranio-orbito-facial trauma associated with a dislocation of the globe into the maxillary sinus. Simultaneous surgical repositioning the globe in the orbit and reconstruction of the orbital floor defect with an autogenous bone was performed in the first case. Postoperatively, the globe was in a normal position with a moderately reduced motility. The patient's visual acuity was reduced to light perception while indirect ophthalmoscopy was normal. In the second case, no surgery could be attempted because the patient never regained consciousness and died 7 days after the trauma. Although the visual prognosis of such conditions is usually considered to be extremely poor, avoiding primary enucleation and deploying all efforts to preserve the eye, aims at helping the patient to recover psychologically from the trauma and allows to improve her/his cosmetic aspect.

Spinal intramedullary arachnoid cyst in children

The authors report an unusual case of a child who presented with progressive paraparesis that lasted 15 days, revealing an intramedullary cystic lesion extending from T(3) to T(4) as detected with spine magnetic resonance imaging. A laminotomy from T(3) to T(4) was performed and the lesion removed. Histopathological findings confirmed the diagnosis of arachnoid cyst. After surgery, the patient's neurological status improved. At the 4-month follow-up examination, the results of his neurological examinations remained normal. Arachnoid cyst is an entity that should be included in the differential diagnosis of intramedullary cystic lesions.

[Cystic meningioma. Case report and literature review]

BACKGROUND

Cystic meningioma is a rare variety of meningioma. It represents 1,6 to 10% of intracranial meningiomas, the authors report a case of intracranial cystic meningioma with a review of literature.

CASE REPORT

A 46-year-old female presented with left parietooccipital headache followed by right side hemiparesis. CT scan brain showed a left parietal tumor with double solid and cystic components thought to be glioma or metastasis preoperatively. At surgery the extraaxial solid and cystic lesion had a well defined capsule that could be easily separated from the perilesional cortical surface. The tumor was totally removed. The histological study showed a cystic meningioma.

CONCLUSION

Cystic meningioma is an uncommon tumor that should be considered in the differential diagnosis of brain tumors with a cystic component.

[Cerebral hydatic cyst and psychiatric disorders. Two cases]

The hydatidosis is an endemic illness in regions of the Middle Orient, Mediterranean, south of America, north Africa and the Australia. The preferential localization of cyst hydatic is the liver (48%), the lung (36%) and in 6% of cases it localizes in unaccustomed place as the brain. Intracerebral localization is relatively rare, its impact is 1 to 5% of all cases of hydatidose. This localization is the child's appendage with a masculine predominance. The cyst hydatic intracranien is often lone, of localization usually supratentorielle, sometimes infratentorielle. Symptoms are especially the diffuse headache associated to various neurological signs in relation with sits of the tumor. The psychiatrics symptoms depends on its localization, sides, intracranial hypertension, and the previous personality. In 15 to 20% of cases these tumors can appear in the beginning of their evolution by the isolated psychiatric symptoms. We report the case of two patients that have been hospitalized first in the Academic Psychiatric Unit of Marrakech for isolates psychiatric disorders and whose scanning revealed the presence of cerebral hydatic cyst and that required a surgical intervention in neurosurgery. Case 1 - Patient 29 years old, bachelor, uneducated, leaving in country outside, fermar, in permanent contact with dogs. No particular medical history. The patient has been brought by his family to the psychiatric emergencies after behavior disorders. The beginning of his symptomatology was one year ago by behavior disorders: instability, violence, isolation, and a corporo-sartorial carelessness. His symptomatology worsened and the patient became very aggressive. In psychiatric unit, he was disregarded, sad, anguished, indifferent to his state, very dissonant, completely detached, depersonalized. He brought back some visual and auditory hallucinations with attitude of monitoring. He was raving with delirium of persecution, of ideas of reference and delirium of bewithment. He was unconscious of his disorders. The patient has first been put under classical neuroleptic 9 mg/day of Haloperidol and 200 mg/day of chlorpromazine. The diagnosis of schizophrenia has been kept according to criteria of DSM IV. The PANSS (Positive and Negative Syndrome Scale) was to 137 (score on a positive scale was to 34, score on a negative scale was to 35 and the general psychopathologie scale was to 58). One week after his hospitalization, he developed headache with subconfusion, a cerebral scanning has been made in emergency and showed a voluminous cyst in oval foramen compressing the mesencephalon strongly. The cyst was well limited, hypodense, not taking the contrast, and without intracerebral oedema, the diagnosis of cerebral hydatic cyst has been made. The complementary exploration didn't show any other localizations, and biologic exam results didn't show any particular anomalies. The patient has been operated in neurosurgery. The immediate evolution was favorable with disappearance of confusion and absence of complications. The patient was lost of view. Six months after, the patient has been readmitted to the psychiatric emergency. He dropped his neuroleptic treatment. He was aggressive, raving, hallucinated and depersonalized. The global score to the PANSS was 63. He has been put back under neuroleptics. Three weeks after improvement and passage of the PANSS to 30, the patient went out. We couldn't have a cerebral scanner of control because the patient had no medical assurance and no money for cerebral scanner. Case 2 - Patient aged of 53 years, father of four children, uneducated, native and resident of Marrakech, confectioner as profession. He is in contact with dogs since 12 years. He has been brought to the psychiatric emergencies by his family after an agitation. The history of his illness seemed to go back at eight months ago, by the progressive apparition of an instability, sleep disorders, hostility, associated with an emotional lability. To the interview he was agitated and had a delirium of persecution. He was convinced that his wife and his children plotted against him. He had sad mood. He was anguished and had auditory and visual hallucinations. The patient was not confused but it had a hypoproxie, an fixing amnesia, a disorders of judgment and a light left hemiparesia. Cerebral scanner revealed three cerebral cyst. The first measuring 42 x 40 mm, sitting at the level parietal right, to the contact of the occipital horn, dragging his/her/its amputation and an effect of mass on ventricle homolateral, the median line and ventricle controlateral. The two other, at the level of the center semi oval, behind the first, measuring 23 mm and 15 mm on the big axis. The patient has been addressed in neurosurgery. He had a completeray exploration to search other localizations. The thoracic x-ray showed 2 pulmonary cyts. The abdominal scan and imagery by magnetic resonance showed liver cyst, peri-heart cyst and mediastinal cyst. The patient has been operated for these three cysts with good recuperation on the psychiatric and neurological symptoms. He has been addressed in heart surgery for the heart localization. The hydatidose is an endemic illness in Morocco and constitute a public health problem. The cerebral localization is rare and appear by signs of cerebral hypertension and signs of focusing. The psychiatric demonstrations are rare but preserve a major interest, by the therapeutic measure specificity that they impose. Of course, the surgical ablation of the tumor can be sufficient to attenuate the psychiatric symptoms but the recourse to a specific treatment can prove to be necessary to act on the precise targets. We are conscious of the methodological difficulties that present these 2 cases but there are unfortunately due to the financial difficulties of our patients.

Kyste arachnoïdien intramédullaire symptomatique. À propos de deux cas et résumé de la littérature

OBJECTIVE

The objective of this work is to present and discuss the rare situation of curable medullary compression with favorable prognosis.

MATERIAL AND METHOD

Two cases of thoracic intramedullary arachnoid cysts are described. Clinical, paraclinical, therapeutics and outcome features are discussed with a review of the literature.

RESULTS

Two children, 4 and 8 years old, with an uneventful history were admitted for progressive spastic paraparesia. MRI demonstrated a thoracic intramedullary cystic lesion at level T3-T4 in both patients. The cyst was emptied with partial cyst wall resection via dorsomedial myelotomy. The pathology examination confirmed the diagnosis of arachnoid cyst. The initial clinical signs resolved completely in both patients.

CONCLUSION

Thought in children, intramedullary arachnoidian cyst is a potential cause of medullary compression. Direct surgery is the treatment of choice.

Analyse d'une série de cavernomes du système nerveux central: 39 cas non opérés, 39 cas opérés et un cas décédé

Cavernomas are vascular malformations frequently localized in the central nervous system. Debate remains open concerning proper treatment. We reviewed a series of cavernomas in order to collect information concerning the natural history. This retrospective study concerned 79 patients seen over a 15-year period. The epidemiologic, clinical, radiological, therapeutic and follow-up data were analyzed. The cavernomas were encephalic (including brain stem and cerebellum) in 74 patients, and in the spinal cord in 5 patients. Average age was 40.08 years, without sex predominance. The most frequent clinical sign was a focal neurological deficit. The cavernoma was solitary in 71 patients. The subtentorial localization was most frequent (44 cases). Bleeding was observed in 31 patients giving a hemorrhagic risk of 0.013%/patient/year. One patient died at admission, 39 were operated and surgical abstention with clinical and radiological follow up was decided for 39 patients (no bleeding in 64.2%). The course in these patients was marked by bleeding in six during 29.5 months follow-up of (rate of hemorrhagic risk 6.27%/patient/year). These results are not in total agreement with the literature. They demonstrate the difficulties for an exact evaluation of the hemorrhagic risk in cavernomas of the central nervous system. So, it is very important to meticulously discuss surgical indications.

[Surgical anatomy of the brain stem]

We reviewed the literature on brain stem anatomy, to identify possible and non-hazardous entry zones with a minimum of functional risks. Using the reticular formation defined as a median structure in a coronal plane, we determined six anatomic zones, 3 ventral, 3 dorsal (mesencephalic, pontic, medulla-oblongata). Considering the functional structures surrounding each zone, the possible penetration points are described. There are ventral, one for the mesencephale, one for the pons, one for the medulla oblongata; and dorsal, one for the mesencephale, two for the floor of the 4th ventricle, one for the medulla oblongata.