Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study

BACKGROUND

Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis.

OBJECTIVE

To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years.

RESULTS

Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection.

CONCLUSION

Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BACKGROUND

Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment.

METHODS

This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge.

RESULTS

The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi² test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment.

CONCLUSION

Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

[Oculoplastic complications of the excision of meningiomas with orbital extension]

INTRODUCTION

Meningiomas with orbital extension are the most frequent benign orbital tumors. The few studies available on the postoperative complications of their excision focus on the postoperative evolution of proptosis, visual acuity and visual field deficits. The goal of our study was to highlight the oculoplastic complications secondary to their excision.

MATERIAL AND METHOD

We identified all cases of meningiomas with orbital extension undergoing excision either neurosurgically or via an orbital approach in the ophthalmology and neurosurgery departments of Pasteur university medical center in Nice between February 2011 and January 2017. The data collection included the postoperative presence of proptosis, oculomotor disturbance, lid disorders, dry eye and trigeminal nerve damage.

RESULTS

Twenty-nine patients were included; 89.7 % were women. The mean age was 55 years. Postoperative complications included 25 % residual proptosis; 40.7 % oculomotor disturbance, 75 % of which regressed at least partially; 50 % ptosis, 21 % of which did not regress; 40 % dry eye; and in 21.4 % the trigeminal nerve was involved.

CONCLUSION

The management of meningiomas with orbital extension is difficult due to their anatomical location and requires joint neurosurgical and oculoplastic management. Sufficient follow-up is required before recommending surgery for oculomotor disturbances. The frequency of occurrence of ptosis with potential recommendation for surgery requires caution given the occurrence of trigeminal nerve involvement and dry eye syndrome.

Modification of cerebral vascular anatomy induced by Leo stent placement depending on the site of stenting: A series of 102 cases

BACKGROUND AND PURPOSE

Recent studies demonstrated the capacity of stents to modify cerebral vascular anatomy. This study evaluates arterial anatomy deformation after Leo stent placement according to the stenting site and the impact on the immediate postoperative and six-month degree of aneurysmal occlusion.

MATERIALS AND METHODS

A total of 102 stents were placed against the neck of aneurysms situated in the anterior cerebral circulation. Aneurysms were classified into two groups: The first was called the distal group (n = 62) and comprised aneurysms situated in the middle cerebral and anterior communicating arteries and the second was called the proximal group (n = 40) and comprised aneurysms in other sites. The stented arterial segment was classified as deformed or non-deformed by blinded review and superimposition of anonymised films before and after stenting. The degree of occlusion was determined immediately postoperatively and at six months.

RESULTS

Significantly, anatomical deformity was observed in the distal group compared to the proximal group (85% vs 28%). No significant difference was observed between the two groups in terms of postoperative degree of occlusion. At six months, a significant difference was observed between the two groups: three recurrences in the distal group vs 10 recurrences in the proximal group. Two (3%) recurrences were observed in the deformed group vs 11 (31%) recurrences in the non-deformed group.

CONCLUSIONS

Arterial deformity induced by stenting is even more marked for distal aneurysms. The recurrence rate is smaller when the stent placement results in an arterial anatomical change. The percentage of recurrence is lower when anatomy was amended by stent implantation.

French collaborative group series on giant intracranial aneurysms: Current management

OBJECTIVES

Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management.

PATIENTS AND METHODS

This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05).

RESULTS

A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion.

CONCLUSION

The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.

Endovascular treatment of recurrent coiled aneurysms: assessment of complications and rebleeding during a decade in a single center

Recurrence is the main drawback of aneurysmal coiling. Additional coiling must sometimes be considered in patients with reopened aneurysms and expose the patient to the risk of a new procedure. Our purpose was to assess the procedural complications of additional endovascular treatments in patients with previously coiled but recurrent aneurysms treated by two neurointerventionalists during a decade in a single center. Between 1999 and 2009, 637 intracranial aneurysms were coiled and had a clinical and angiographic follow-up at our institution. Following the first embolization, 44 aneurysms were retreated with coils and 11 were retreated a second time. Retreatment was decided when a recurrence showed at angiographic follow-up. Early retreatments, performed in the first month after an incomplete or failed initial coiling, were excluded. We retrospectively analysed the procedural complications, rebleeding, clinical and angiographic outcomes of the retreatments. No death or bleeding occurred in these 55 additional procedures. We had three periprocedural thromboembolic complications and the procedural permanent morbidity was 1.8%. Clinical and angiographic follow-ups ranged from six months to nine years (mean: 37 months, median: 36 months). Thirty-seven of the 44 retreated aneurysms (84%) showed a stable occlusion at follow-up. Seven showed a recurrence but were not retreated due to the stability of the packing. No rebleeding was observed during the follow-up period. Our results show that endovascular treatment of recurrent aneurysms is associated with a low procedural risk.

[Clinical factors in glioblastoma and neuroradiology]

Glioblastoma is found preferentially in men (1.5/1), nearing age 60, but all ages can be concerned. Clinical symptoms are intracranial mass without specificity, intracranial hypertension and localization signs. From the clinical history, the essential prognosis factors are: age, Karnofsky score and cognitive dysfunction. Conventional MRI sequences, including T1-FSE with and without contrast injection and T2-FSE or Flair-weighted sequences, provide the diagnosis in most cases, showing an intraparenchymal mass with a heterogeneous, irregularly enhanced signal. Other sequences define the tumor more precisely. Diffusion sequences provide the differential diagnosis with an abscess or a highly cellular tumor such as lymphoma. Perfusion sequences allow appreciation of tumor microvascularization outlining the tumor's most active areas. Magnetic resonance spectroscopy (SRM) sequences allow noninvasive exploration of tumor metabolism. Beyond its diagnostic role, imagery assists the surgical procedure itself, particularly with functional MRI, allowing a precise preoperative mapping of functional cortical areas. Biopsy can also be guided toward the most active areas of the tumor. In the postoperative period, MRI completes the surgeon's impression on whether or not there is residual tumor. Finally, this exam has become essential in follow-up to diagnose recurrence, radionecrosis, or pseudoprogression.

[Second surgery for glioblastoma. A 4-year retrospective study conducted in both the Montpellier and Nice Departments of Neurosurgery. A literature review]

BACKGROUND AND PURPOSE

Glioblastoma, the most common malignant primary brain tumor in adults, is usually rapidly fatal. The current care standards for newly diagnosed glioblastoma consist, when feasible, in surgical resection, radiotherapy, and chemotherapy, as described in the Stupp protocol. Despite optimal treatment, nearly all malignant gliomas recur. If the tumor is symptomatic for mass effect, repeated surgery may be proposed.

METHODS

We retrospectively analyzed the survival of patients with histologically confirmed primary glioblastoma (WHO grade 4) who were operated in two centers between January 2004 and December 2007. All patients who underwent a second resection for recurrent glioblastoma were included.

RESULTS

During this period, 320 patients were operated in the two centers, with 240 surgical resections and 80 surgical biopsies. In the surgical resection group, 8.3% (20 patients) underwent a second surgical resection for glioblastoma. The mean age was 52 years. At the end of the study, seven patients were alive. The median survival was 24 months and progression-free survival was 7.5 months.

CONCLUSIONS

The effect of resection of recurrent glioblastoma on survival has not been extensively studied. No randomized trials have been conducted. Our data were globally identical to other retrospective studies. Selected patients with recurrent glioblastoma may be candidates for repeated surgery when the situation appears favorable based on assessment of the individual patient's factors. Factors such medical history, neurological status, location of the tumor, and progression-free survival have been proven in retrospective studies to give better results.

Giant intracerebral telangiectasia in a case of blue rubber-bleb nevus syndrome

Blue rubber-bleb nevus syndrome is a rare condition that consists of multiple venous malformations involving several organ systems, mainly the skin and gastrointestinal tract. Involvement of the central nervous system is particularly rare. We describe a patient with a huge intracerebral telengiectasia revealed by a progressive neurological deficit.

Dissection of the posteroinferior cerebellar artery: clinical characteristics and long-term follow-up in five cases

BACKGROUND AND PURPOSE

Spontaneous isolated posteroinferior cerebellar artery (PICA) dissection is very rare. The aim of the study was to investigate the clinical manifestations, the neuroradiological aspects and the treatment of 5 cases collected in 5 years.

METHODS AND RESULTS

From 1999 to 2003, five patients (40-71 years old) were hospitalized for PICA dissection. Two patients presented symptoms after cervical manipulation. No predisposing factor or traumatic cause was described in the other cases. The diagnosis was carried out by cerebral angiography in all the cases: in 4, angiography showed focal stenosis with saccular or fusiform dilatation of the artery at the site of the dissection; in 1 a double lumen aspect was described. One patient presented ischemic manifestations; he was treated with heparin. The others presented subarachnoid hemorrhage (SAH) and were treated by embolization (endovascular sacrifice of the PICA). No ischemic complication and no rebleeding were observed after sacrifice of the PICA. Three patients presented acute hydrocephalus and were treated with surgical derivation. The angiographic and clinical follow-up lasted more than 3 years. We assessed the long-term results with the Glasgow Outcome Score and the modified Rankin Score. A good recovery was achieved for 4 patients (modified Rankin Score 0); one patient who presented SAH and who was in bad clinical state on admission had a Glasgow Outcome Score of 3 and a modified Rankin Score of 4 three years later.

CONCLUSION

Clinical course and prognosis are variable in PICA dissections. The treatment depends on the existence of a hemorrhagic event. In the group of patients presenting SAH, endovascular treatment was safe and effective. The long-term clinical results depend mainly on the clinical status on admission.

Treatment of newly diagnosed symptomatic pure low-grade oligodendrogliomas with PCV chemotherapy

Based on studies relating to anaplastic oligodendroglioma (OG) chemosensitivity and benefit of time to progression or overall survival, chemotherapy for pure OG has been proposed. Several studies have reported the efficacy of various chemotherapeutic agents in a small number of patients with low-grade gliomas, e.g. pure astrocytomas, OG or mixed histologies. The 5-year survival rate varies from 61% to 89% with a mean time to progression of 5 years. We report the outcome of 33 consecutive patients with pure low-grade OG diagnosed between 1990 and 2006 systematically treated for residual or non-removable tumor with PCV chemotherapy regimen as the front-line treatment after surgery. All the tumors were low grade (grade II) pure OG according to the WHO classification. All patients were symptomatic at presentation and underwent neurosurgical procedure for histological diagnosis. Response was evaluated by clinical assessment and brain magnetic resonance imaging. Twenty-one men and 12 women with a mean age at pathological diagnosis of 46.5 years were studied. The most common first symptom was partial epileptic seizure (73.7%). Six patients (18%) had initial gadolinium enhancement, associated with methoxyisobutyl (MIBI) hypermetabolism (P < 0.001). The resection was partial in seven cases (21%), and 26 patients (79%) had biopsy only. Eleven patients (36%) had a malignant transformation during the follow-up with a median time to progression of 19 months. Favorable prognostic factors were lack of contrast enhancement (P < 0.0001), and age <40 years (P < 0.0003); 90% of patients were progression-free at 1 year. Survival rates at 2, 5 and 10 years were 85%, 75% and 50%, respectively. Up-front chemotherapy with PCV regimen is a good treatment for symptomatic pure low-grade OG, as it increases the number of progression-free patients and time to progression. These results suggest that radiotherapy could be postponed until the malignant transformation occurs to delay cognitive side effects of irradiation.

Stretched platinum coil during cerebral aneurysm embolization after direct carotid puncture: two case reports

We describe two cases of coil unraveling that occurred during cerebral aneurysm embolization after direct carotid puncture. The unraveled coil was stretched and buried in the subcutaneous part of the neck. No immediate or long-term complication was observed.

[Natural history of intramedullary cavernomas. Results of the French Multicentric Study]

INTRODUCTION

The prevalence of cerebral cavernomas is about 0.5% in the general population. In contrast, spinal cord cavernomas are considered as rare. The objective of this study was to determine the natural history of spinal cord cavernomas in a multicentric study.

METHODS

Clinical and neuroradiological findings were retrospectively collected. Diagnosis was based on pathological criteria or magnetic resonance (MR) findings.

RESULTS

Fifty-three patients were included (26 males, 27 females). Mean age at onset of symptoms was 40.2 years (range: 11-80). Initial symptoms were progressive (32) and acute myelopathy (20). One patient was asymptomatic. Clinical symptoms were related to spinal cord compression (24) and hematomyelia (19). Cavernoma location was dorsal (41) and cervical (12.). MR findings consisted of hyperintense signal on T1 and T2 sequences (19 cases), mixed hyperintense and hypointense signal (33 cases), and hypointense signal on T1 and T2 sequences in 1 case. Mean size was 16.3 mm (range: 3-54). Forty patients underwent surgical resection. Improvement was observed in 20 patients and worsening of neurological symptoms in 11. Length of follow up was 7.1 years. At the end of the study, 26 patients were autonomous, 18 handicapped and 1 bedridden.

CONCLUSION

This study provided precise data on the clinical and MR patterns of these lesions. The natural history is associated with a higher risk of hemorrhage recurrence, but is favorable in many operated patients. Microsurgery is the treatment of choice for most of these lesions.

Prenatal diagnosis of a craniopharyngioma: a new case with radical surgery and review

CASE REPORT

A case of the antenatal diagnosis of a craniopharyngioma with radical surgery in the neonatal period is reported.

REVIEW OF THE LITERATURE

We have reviewed the literature of such cases in an attempt to isolate specific features in this age group and to determine the appropriate management. Only six cases of the truly antenatal diagnosis of craniopharyngiomas have been reported. Diagnosis has resulted from routine ultrasound during pregnancy or from polyhydramnios. Clinically, there is often macrocephaly due to hydrocephalus or a significant-sized tumor.

CONCLUSIONS

Management of these rare cases is controversial with high postoperative mortality and significant morbidity, including panhypopituitarism, visual disturbance, and neuropsychological disorders. From the available literature, no conclusions concerning the management can be drawn at present, due to the rarity of early surgical intervention. Our case, despite the lack of important follow-up, seems to confirm the possibility of attempting radical surgery in the neonatal period as a result of advances both in surgical techniques and in neonatal intensive care.

Mutations within the programmed cell death 10 gene cause cerebral cavernous malformations

Cerebral cavernous malformations (CCMs) are hamartomatous vascular malformations characterized by abnormally enlarged capillary cavities without intervening brain parenchyma. They cause seizures and cerebral hemorrhages, which can result in focal neurological deficits. Three CCM loci have been mapped, and loss-of-function mutations were identified in the KRIT1 (CCM1) and MGC4607 (CCM2) genes. We report herein the identification of PDCD10 (programmed cell death 10) as the CCM3 gene. The CCM3 locus has been previously mapped to 3q26-27 within a 22-cM interval that is bracketed by D3S1763 and D3S1262. We hypothesized that genomic deletions might occur at the CCM3 locus, as reported previously to occur at the CCM2 locus. Through high-density microsatellite genotyping of 20 families, we identified, in one family, null alleles that resulted from a deletion within a 4-Mb interval flanked by markers D3S3668 and D3S1614. This de novo deletion encompassed D3S1763, which strongly suggests that the CCM3 gene lies within a 970-kb region bracketed by D3S1763 and D3S1614. Six additional distinct deleterious mutations within PDCD10, one of the five known genes mapped within this interval, were identified in seven families. Three of these mutations were nonsense mutations, and two led to an aberrant splicing of exon 9, with a frameshift and a longer open reading frame within exon 10. The last of the six mutations led to an aberrant splicing of exon 5, without frameshift. Three of these mutations occurred de novo. All of them cosegregated with the disease in the families and were not observed in 200 control chromosomes. PDCD10, also called "TFAR15," had been initially identified through a screening for genes differentially expressed during the induction of apoptosis in the TF-1 premyeloid cell line. It is highly conserved in both vertebrates and invertebrates. Its implication in cerebral cavernous malformations strongly suggests that it is a new player in vascular morphogenesis and/or remodeling.

Long-term outcome of oligodendrogliomas

BACKGROUND

Favorable prognostic factors for oligodendroglial tumors include age younger than 40 years, low tumor grade, and extent of resection.

OBJECTIVE

To assess survival time and prognostic factors of 100 patients with oligodendrogliomas diagnosed between 1995 and 2002.

METHODS

The tumors were rated histologically by the WHO classification as low grade (grade II) or anaplastic (grade III). One hundred patients were categorized into three groups: group A: grade II, group B: secondary grade III (low grade with anaplastic transformation during the follow-up), group C: de novo grade III. All patients were symptomatic at presentation and underwent neurosurgical procedure for histologic diagnosis. Follow-up was performed with clinical assessment, brain MRI, and MIBI scintigraphy.

RESULTS

There were 66 men and 34 women (mean age at diagnosis 46.7 years). The most common first symptom was partial epileptic seizure (75%). Fifty-six patients had initial gadolinium enhancement (A: 15.6%; B: 36.8% as grade II, 95% as grade III; C: 90%), generally associated with MIBI hypermetabolism (p < 0.0001). Survival rates at 2, 5, and 10 years were A: 88%, 88%, 85%; B: 79%, 64%, 42%; C: 43%, 16%, 15%.

CONCLUSIONS

Secondary anaplastic oligodendroglioma patients were younger than patients with de novo anaplastic oligodendrogliomas. Histologic confirmation is mandatory because some low grade oligodendrogliomas had gadolinium enhancement on MRI and some anaplastic did not. Survival time was longer for secondary than for de novo anaplastic oligodendrogliomas without difference in the duration of the malignant phase of the disease.

Chimiothérapie néoadjuvante dans les astrocytomes fibrillaires de grade II symptomatiques non opérables de l’adulte

We collected 6 case-reports of symptomatric non removable low grade fibrillary astrocytoma of adults treated with a procarbazine-CCNU-vincristine chemotherapy regimen. All patients had drug-resistant epilepsy but brain imaging was stable. Total gross resection was rejected because of Volume or tumor location. After 4 to 7 cycles of chemotherapy, 2 patients had partial response and one minor response on brain MRI. All of them were seizure-free. Progression free survival was not reached at 5 Years. Up-front chemotherapy for low-grade astrocytomas may be useful and has to be prospectively evaluated.

[Unilateral neurogenic pulmonary edema. A case report]

A vascular lesion was identified in the posterior cerebral fossa in a 65-Year-old stroke victim. The patient suddenly developed unilateral pulmonary edema. Bilateral alveolar opacities is the usual radiological aspect of neurogenic pulmonary edema but a unilateral presentation is extremely rare. The differential diagnosis includes excessive vascular filling, infectious pneumonia, gastric fluid aspiration edema, and cardiogenic pulmonary edema. The mechanisms underlying neurogenic pulmonary edema are discussed.

Alteration of striatal dopaminergic function induced by glioma development: a microdialysis and immunohistological study in the rat striatum

Tumoral growth effects on brain circuitry and neurochemical activities remain poorly documented. This study evaluates C6 graft effects on striatal dopaminergic afferent projections at both anatomical and functional levels. Immunohistochemistry was performed to investigate changes in neurofilament (NF), tyrosine hydroxylase (TH) and dopamine transporter (DAT) expression. Dopaminergic turnover was assessed using multiprobe microdialysis in freely-moving rat. In C6 graft striatum, dopamine (DA) catabolites were reduced in glioblastoma (DOPAC: -61%, HVA: -62%). In contrast, the DA level remained unchanged. Staining for NF, TH and DAT was drastically decreased inside the tumor. Our histological data report that striatal tumoral growth is associated with a decrease in the density of dopaminergic endings which can explain, at least in part, the decrease in DA turnover. The decrease in DAT transporter expression and the lack of change in DA level may result from an increase in DA diffusion from the peripheral areas of the tumor. In conclusion, glioblastoma growth has major consequences on the local neuronal circuitry and its neurochemistry. Changes in inter-connections and neurotransmitter turnover may result in abnormal neuronal firing activity and participate in clinical disorders associated with glioblastoma diagnosis.

[Castleman's disease located in the central nervous system]

A 26-year-old woman complained of trijeminal nevralgy and ocular symptoms revealing a paracavernal tumor which had progressed for three months. Histopathological analysis after partial resection led to the diagnosis of Castleman's disease. Six months later, the patient was considered cured after focal adjuvant radiotherapy. Castleman's disease is a lymphoproliferative disorder. Solitary intracranial involvement is unusual. Unlike multifocal disease, localized Castleman's disease has an excellent prognosis.

Endovascular treatment of ruptured intracranial aneurysms in patients aged 65 years and older: follow-up of 52 patients after 1 year

BACKGROUND AND PURPOSE

We sought to describe the clinical outcome and results obtained in the endovascular therapy of ruptured cerebral aneurysms in the elderly over an 8-year period. We compared endovascular therapy results in patients aged > or =65 and <65 years.

METHODS

During 1993-1999, 52 patients aged 65 to 85 years (mean age, 71.5+/-4.7 years) were embolized with the use of Guglielmi detachable coils (group I). During the same period, 143 patients aged <65 years (mean age, 47+/-11 years) with ruptured cerebral aneurysm were treated with the same technique (group II). A clinical assessment was made on admission with the Hunt and Hess (HH) classification and again in the 12th month with the Glasgow Outcome Scale (GOS), with arteriographic control in months 3 and 12.

RESULTS

In group I, clinical grades on admission were as follows: HH 1, 9.5%; HH 2, 33%; HH 3, 21%; HH 4, 34.5%; HH 5, 2%. Outcome was favorable in 48% of patients (GOS 1 or 2); the mortality rate was 23%. No rebleeding was observed. Patients presenting lesions > or =10 mm had an unfavorable outcome in >77% of cases. Thromboembolic complications were present in 13% of cases. In group II, clinical grades on admission were as follows: HH 1, 14.5%; HH 2, 47%; HH 3, 11%; HH 4, 24%; HH 5, 3.5%. Favorable outcome (GOS 1 or 2) was observed in 77% of cases, with 14% mortality. Complications due to the endovascular procedure were present in 4.2% of cases. Patients with HH grades 1 or 2 on admission showed a positive outcome (GOS 1 or 2) in 77% of cases in group I and in 88.5% of cases in group II. Mortality was 9% in the first subgroup compared with 2.8% in the second. Patients who had a high clinical grade on admission (HH 4 or 5) showed a favorable outcome (GOS 1 or 2) in 16% of cases in group I compared with 41% in group II.

CONCLUSIONS

Endovascular treatment of ruptured intracranial aneurysms in patients aged > or =65 years appears to be effective against rebleeding and represents an alternative to surgery. However, perioperative thromboembolic complications are more frequent in the elderly population.

Stroke after chiropractic manipulation as a result of extracranial postero-inferior cerebellar artery dissection

OBJECTIVE

To describe a case of dissection of the postero-inferior cerebellar artery (PICA) after cervical manipulation.

CLINICAL FEATURES

After cervical manipulation, a 42-year-old woman had a cerebellar syndrome related to an infarct in the area supplied by the PICA, confirmed by computed tomography of the brain. Cerebral angiography showed a normal appearance of the vertebral artery, a cervical extradural origin of PICA, and a dissection of the latter at the C1-C2 level.

INTERVENTION AND OUTCOME

Anticoagulant treatment with heparin was implemented. A positive outcome was achieved after 3 weeks.

CONCLUSION

Anatomical variations of the vertebral arteries and their branches are not infrequent and may constitute a predisposing factor to complications after neck manipulation.

[Value of endonasal endoscopic surgery in the treatment of sphenoid cerebrospinal rhinorrheas. 15 cases]

Surgical management of cerebrospinal fluid leaks (CSFL) has improved these few past years with the development of paranasal sinus surgery under optical guidance. CSFL localized in the sphenoid sinus represent only 5 to 15% of all CSFL. The authors have analyzed a serie of 15 patients having undergone surgery from 1992 to 1999 for CSFL: 10 cases followed pituitary gland surgery realized through sublabial-transsphenoidal approach, 2 cases followed head trauma, 1 case followed a secondary neurosurgical procedure following recurrence of a rathke's cleft cyst, 1 case followed medical treatment of a bulky pituitary gland adenoma and 1 case was associated to an empty sella syndrome. The surgical procedure has relied on sphenoid sinus approach through the sphenoethmoidal recess (SER) (n = 8), transethmoidal approach (TE) (n = 2) or transseptal approach (TS) (n = 7) followed by a filling of the defect by a graft of fat with biological glue (n = 17). Sometimes it was associated to a cartilagenous graft (n = 7) when there was a bone defect. The average period of hospitalisation was 5.2 days (4-21), mean follow-up was 2.9 years (6 months-7 years).

RESULTS

The success rate was 80% (3 failures were observed), 2 patients underwent secondary procedures by TS approach with success. Our results combined with the literature data led us to propose an alternative surgical strategy adapted to each case. Endonasal surgery under optic guidance compared to the transrhinoseptal approach represents an attractive alternative with less undesirable iatrogenic consequences.

[Factors influencing recurrence and role of radiotherapy in filum terminale ependymomas. 14 cases and review of the literature]

PURPOSE

We reviewed a series of 14 cases of filum terminale ependymoma and 264 cases in the literature, to study the characteristics of these tumors and specifically to determine factors influencing recurrence.

MATERIAL AND METHODS

This series analyzed data between 1984 and 1998. The mean follow-up period was 5.5 years and the median age 40 years. Pain was the first symptom, except in one case, with progressive sensitive-motor deficit. Four patients had a myelography and a CT scan, and ten a MRI. All patients were operated with a total resection in 12 cases. All tumors, except one, were a myxopapillary ependymoma.

RESULTS

Clinical results were excellent in 2 cases, good in 8, stable in 2 and worse in 2. Two patients had a recurrence after an initial sub-total resection, both were operated on again, followed by post-operative radiotherapy. Among the 278 filum terminale ependymoma, removal was total in 200 (72%). A recurrence occurred in 15% of them after total removal, and in 43% after partial removal (p<0.001). Among patients with partial removal, recurrence was observed in 33% of them if they had post-operative radiotherapy, and in 55% of them if they did not have post-operative radiotherapy (p<0.05).

CONCLUSION

The extent of tumor removal has a statistically significant effect upon recurrence. This review is in favor of post-operative radiotherapy in case of partial removal, but this systematic attitude can be discussed after a critical analysis of this study. Long term follow-up is mandatory due to the possibility of late recurrence.

Effects of hypothermic deep-anaesthesia on energy metabolism at brain and peripheral levels: a multi-probe microdialysis study in free-moving rat

Reduction of central energy metabolism is a strategy to protect brain against neurotoxic events. The aim of this microdialysis study in rats is to evaluate changes in energy metabolite levels at central level (striatum) comparatively to peripheral level (subcutaneous adipose tissue) during hypothermic barbituric deep-anaesthesia (sodium pentobarbital 60 mg/kg intraperitoneally). At brain level, extracellular glucose increases (+14.9%) while lactate decreases (-16.6%); opposite results were observed at subcutaneous level (-29.2% for glucose and +68.3% for lactate). Lactate/pyruvate ratio remains unchanged at brain level, but increases at subcutaneous level (+73.5%). In light of previous studies on the effects of pentobarbital on regional blood flow and tissue glucose consumption, our data correlates the fact that pentobarbital reduces preferentially brain energetic metabolism. We suggest that those regional effects are explained, at least for a part, by the fact that central isoform glucose transporters (Glut1 and Glut3) are known to be more sensitive to pentobarbital than peripheral isoforms. Such facts can be involved in the protection of brain tissue against ischemic risk due to decreased cerebral blood flow decrease.

In vivo study of tumor metabolism: an application of new multi-probe microdialysis system in the striatum of freely moving rats grafted with C6 cells

The purpose of this study is to investigate the in vivo tumoral brain metabolism in free moving rats using microdialysis. Cells from C6 glioma cell line were inoculated in one striatum 15 days before the microdialysis experimentation. Then, using a new system allowing perfusion of several microdialysis probes in free moving rat, normalised dialysate levels of glucose, lactate and pyruvate were monitored in both glioma and control striatum. At the end of the procedure, animals were sacrificed for histological study. Data shows that probe functioning is similar in both tissues. The results for normalised glucose level were in striatum control: 2.14 mM, in tumoral striatum: 1.71 mM (P>0.1); for lactate, respectively, 0.86 and 1.65 mM (P<0.05) and for pyruvate, respectively, 65.56 and 140. 94 microM (P<0.05). This data clearly shows a significant increase of pyruvate and lactate in tumoral striatum compared to normal striatum, correlating previous in vitro studies on glioma metabolism. We conclude that this microdialysis technique is of value in tumoral brain and could constitute an interesting tool for a better understanding of glioma metabolism.

Up-front chemotherapy with fotemustine (F) / cisplatin (CDDP) / etoposide (VP16) regimen in the treatment of 33 non-removable glioblastomas

Despite combinations of surgery, radiotherapy (RT) and chemotherapy used in the treatment of glioblastomas, mean and median survival rates in most patients remain 12 months or less after diagnosis. RT and nitrosourea after surgery are the standard combination for glioblastomas. They may induce acquired resistance and, consequently, non-operable glioblastomas is a unique biological and clinical situation allowing evaluation of intrinsic chemosensitivity. We assess the fotemustine (F) (100 mg/m2 day 1)/ cisplatin (CDDP) (33 mg/m2 days 1-3)/etoposide (VP16) (75 mg/m2 days 1-3) monthly regimen for efficacy in non-removable glioblastomas at presentation. Between 1995 and 1998, 33 consecutive patients with symptomatic non-removable histologically proven glioblastomas were treated: none of them had previously received chemotherapy, irradiation or surgical debulking. Objective response was evaluated by contrast enhancement with magnetic resonance imaging (MRI) scan after each treatment. Toxicity was moderate and mainly haematological (grade III-IV thrombopenia = 20/171 cycles; leucopenia = 25/171). Neutropenic fever was rare and no intracranial haemorrhages or treatment-related deaths were noted. Nausea and vomiting (grade 1), and asymptomatic hearing loss were common. Peripheral neuropathy occurred in 3 patients. Objective response rates were 9/33 (27%) (stabilisation = 17/33). Mean survival time was 14.4 (11.2 months in the 26 deceased patients) with a median survival of 10 months. Median survival rates at 6 and 12 months were 88% and 42%, respectively. 7/33 patients are still alive with median survival of 34.6 months. 7/33 (4/7 alive) were long-term survivors (range: 19-67 months). Neoadjuvant chemotherapy in non-resectable patients is safe allowing delayed RT. Phase II chemotherapy trials should include studies with a subgroup of non-resectable tumours.

[Chemotherapy of malignant inoperable gliomas. The association of fotemustine-cisplatine-etoposide as neoadjuvants]

Efficiency of chemotherapy (CT) on non removable HGG has not been proven and neoadjuvant brain irradiation (RT) following biopsy is the standard treatment. We aimed to define whether combination of polychemotherapy and radiotherapy is synergistic in non removable HGG. It has been proven that F, CDDP and VP16 can reach therapeutic levels in brain after intravenous standard dose injections. The aim of this study was to assess that (i) neoadjuvant CT is safe; (ii) feasibility and efficacions of F (100 mg/m2.d1)/CDDP (100 mg/m2.d1-3 TD)/VP16 (75 mg/m2.d1-3) q21-28d regimen; (iii) Delayed RT is not unsafe: RT was performed when tumor progression or toxicity appeared. This study included 16 patients with symptomatic non removable HGG. Two of them had anaplastic gliomas and 14 glioblastomas multiforme. None of them had a prior chemotherapy regimen. Objective response was evaluated with CT scan or MRI during chemotherapy. Toxicity was moderate and mainly hematological (grade III-IV thrombopenia = 10/67 cycles; leukopenia = 13/67). Objective response rates were 5/16 (31 p. 100) (CR = 1; PR = 4; Median duration of response: 20 weeks). Median survival was 55 weeks in the 14 grade IV patients. Three/16 patients are still alived with respectively 22, 30, 40 months survival: These results confirm the neoadjuvant chemotherapy efficacy. It may be a useful tool before RT for non removable HGG.

[Brain metastases and chemotherapy]

INTRODUCTION

The epidemiology of brain or central nervous system metastases is poorly documented. Retrospective studies based on autopsies that were aimed at investigating the incidence and prevalence of brain metastases have revealed the shortfalls in tumour registers. The exact role of cerebral metastases has not been addressed within the scope of cancer considered as a public health issue.

CURRENT KNOWLEDGE AND KEY POINTS

The prognosis of brain metastases should not be considered either on general or a priori basis as being poorer than that of other metastatic sites. Evaluation of the role of focal radiation therapy and chemotherapy is still in progress. Appropriate use of therapeutical strategies directed at brain tumors generally improves the condition of most patients. It also usually increases survival and enhances the quality of life.

FUTURE PROSPECTS AND PROJECTS

The role of chemotherapy in current therapeutical strategies has not yet been defined and should be investigated and developed.

Occipitocervical fixation using hooks and screws for upper cervical instability

OBJECTIVES

Occipitocervical fixation is used for the treatment of nontraumatic upper cervical instabilities. To date, plates have been fixed with screws or wires. However, these devices are not indicated in the treatment of patients with severe osteoporosis or in instances of significant thinning of the occipital bone. We performed a clinical trial of a new type of fixation that uses cervical interlaminar hooks and occipital claws with hooks or with screws (CCD type; Sofamor-Danek, Roissy, France) for the treatment of nontraumatic upper cervical instabilities.

METHODS

Five women and one man ranging in age from 28 to 72 years (average age, 54 yr) were thus treated. The CCD type material had two rod plates and hooks allowing the proper placement of interlaminar and occipital claws. The occipital plate can also be directly screwed to the bone. Occipital hooks were used in four patients. The other two patients, who had occipitocervical congenital abnormalities that required an occipitocervical opening and an additional dural enlargement, underwent occipital screw fixation because of the previous opening of the foramen magnum. A cancellous iliac autograft allowed the usual fusion.

RESULTS

No postoperative complications were observed, and all patients experienced significant improvement of their neck pain. Four patients had neurological symptoms. The condition of two patients improved, and the condition of the other two stabilized.

CONCLUSION

This report confirms the interest of the CCD method to correct all types of upper cervical instabilities, even in cases of unusual thinning of the occipital bone or in osteoporotic states.

Boron neutron capture enhancement (BNCE) of fast neutron irradiation for glioblastoma: increase of thermal neutron flux with heavy material collimation, a theoretical evaluation

Despite the fact that fast neutron irradiation of glioblastoma has shown on autopsies an ability to sterilize tumors, no therapeutic windows have been found for these particles due to their toxicity toward normal brain. Therefore, the Boron Neutron Capture Enhancement (BNCE) of fast neutron beam has been suggested. This paper addresses the problem of fast neutron beam collimation, which induces a dramatic decrease of the thermal neutron flux in the depth of the tissues when smaller irradiation fields are used. Thermoluminescent dosimeter TLD-600 and TLD-700 were used to determine the thermal neutron flux within a Plexiglas phantom irradiated under the Nice Biomedical Cyclotron p(60)+Be(32) fast neutron beam. A BNCE of 4.6% in physical dose was determined for a 10 x 10 cm2 field, and of 10.4% for a 20 x 20 cm2 one. A Dose Modification Factor of 1.19 was calculated for CAL 58 glioblastoma cells irradiated thanks to the larger field. In order to increase the thermal flux in depth while shaping the beam, heavy material collimation was studied with Monte Carlo simulations using coupled FLUKA and MCNP-4A codes. The use of 20 cm width lead blocks allowed a 2 fold thermal neutron flux increase in the depth of the phantom, while shielding the fast neutron beam with a fast neutron dose transmission of 23%. Using the DMF of 1.19, a BNCE of 40% was calculated in the beam axis. This enhancement might be sufficient to open, at least theoretically, a therapeutic window.

Chiari Type I malformation and syringomyelia in unrelated patients with blepharophimosis. Report of two cases

Syringomyelia is a rare, mainly sporadic disease of the spinal cord, which is associated with 80% of cases in which a Chiari Type I malformation is also present. A mendelian transmission of syringomyelia (autosomal dominant or recessive) has been proposed in approximately 2% of reported cases. The association of syringomyelia with hereditary diseases (Noonan's syndrome, phacomatoses) has been mentioned frequently in the literature. The authors report the presence of a Chiari Type I malformation accompanied by syringomyelia in two unrelated patients affected by a familial Type II blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). The first patient was a 35-year-old woman who presented with a right C-8 root paresia. The second case involved a 20-year-old man who complained of cervical radicular pain. Both belong to families in which BPES was segregated in an autosomal dominant modality, but other family members had no known neurological symptoms. To the authors' knowledge, such a combination has never been described. Perhaps the possible involvement of a genetic component in some cases of Chiari Type I-associated syringomyelia will someday be debated.

Intramedullary spinal cord ependymomas in children: treatment, results and follow-up

A retrospective review of 20 pediatric patients with intramedullary spinal cord ependymomas, all of whom underwent operative resection between 1985 and 1996, was undertaken to determine surgical results, long-term follow-up and tumor recurrence. Twelve children operated on in the same period with filum or cauda equina ependymomas were not included in this study. Nine children had had previous treatment before referral. Gross total resection was achieved in 14 patients and subtotal in 6. None of these had a post-operative radiation therapy. The median follow-up period was 67 months (range 25-177 months). All children were clinically evaluated before and after operation and at the last follow-up. The clinical grade at the last follow-up showed improvement in 8 patients (40%), was unchanged in 10 (50%) and deteriorated in 2 (10%). Three patients had a recurrence, 2 at the primary site (2 and 3 years after our surgery) and 1 at a distant site (3 years after). The actuarial 5- and 10-year survival rates were both 90%; 5- and 10-year progression-free survival rates were 93 and 70%, respectively. We conclude that a complete removal can be achieved in almost all cases of intramedullary spinal cord ependymomas in children, and that the long survival rates justify avoiding post-operative radiation therapy.

[Use of the CCD (Sofamor-Danek) rod plates for instabilities of the craniospinal junction]

We report our experience with the CCD material (Sofamor-Danek) for the treatment of cranio-cervical instability. In this method, rod-plates are fixed to the occipital bone and to the cervical spine with hooks. This technique is mainly indicated for the treatment of patients with severe osteoporosis or with significant thinness of the occipital bone. Four cases are presented. Three of them suffered from a inflammatory rheumatism. The fourth patient had been previously treated by an occipito-cervical fixation with a Roy-Camille plate for a C2 metastasis and presented a failure of the occipital screws fixation. In all cases, no post operative complications were observed and all patients had a significant improvement of their cervicalgia. We confirm the interest and the fiability of the CCD method which has simplified the procedure and is specially suitable for the treatment of all types of cranio-cervical instability, even in the most adverse conditions.

Endodermal cyst of the foramen magnum: case report and review of the literature

The majority of endodermal cysts occur in the cervicothoracic spine, ventral to the cord. Intracranial locations are rare. We report a case involving the foramen magnum in a 14-year-old child, which was an incidental finding following a traumatic head injury. A review of the literature revealed six other cases involving this same location. These lesions are asymptomatic for a long time, and may cause brain stem medullary compression. Treatment is surgical. Effective simple removal can be achieved by a posterior approach.

[Extracranial trigeminal schwannomas with middle temporal fossa development]

Schwannomas of trigeminal nerve account for 0.07% to 0.36% of all intra-cranial tumors. We report three observations about Jefferson's type D tumors, mainly extra-cranial with only small intra-cranial extension, concerning two men and one woman, who were respectively 36, 60 and 63 years old. Two of them presented with facial pain and hypoesthesia in the same territory. The third one developed a diplopia. In all cases, CT scanner analysis evidenced a large hypodense tumor extending in the infratemporal fossa. Temporal lobe and cavernous sinus were pushed aside by the intra-cranial extension. Tumors were hypo intense in T1-weighted image with significant enhancement after gadolinium injection. One of the tumors was a cystic form and in that case, an hyper signal in T2-weighted image was detected in the middle of the lesion. A combined subtemporal and transmaxillary approach was performed in 2 cases. In the third case, the removal of the tumor was only performed by a transmaxillary approach. In this series, there was no surgical mortality. One patient presented a postoperative residual painful anesthesia. In conclusion, extra-cranial schwannomas with intra-cranial extension are specially rare lesions. The most common early symptoms are facial neuralgia, facial hypoesthesia or diplopia. Neuroradiologic investigations, including CT and MRI evidence the precise anatomic site of the lesions. With the help of these techniques, total surgical tumor removal is possible in the majority of cases.

Boron neutron capture irradiation: setting up a clinical programme in Nice

Neutron capture irradiation aims to selectively destroy tumor cells using 10B(n,alpha)7Li nuclear reactions produced within themselves. Following the capture reaction, an alpha particle and a, 7Li ion are emitted. Carrying an energy of 2.79 MeV, they destroy all molecular structures along their path close to 10 microns. These captures, used exclusively with a 'slow' neutron irradiation, provide a neutron capture therapy (BNCT). If they are used in addition to a fast neutron beam irradiation, they provide a neutron capture potentiation (NCP). The Centre Antoine-Lacassagne in Nice is actively involved in the European Demonstration Project for BNCT of grade IV glioblastomas (GBM) after surgical excision and BSH administration. Taking into account the preliminary results obtained in Japan, work on an 'epithermal' neutron target compatible with various cyclotron beams is in progress to facilitate further developments of this technique. For NCP, thermalized neutron yield has been measured in phantoms irradiated in the fast neutron beam of the biomedical cyclotron in Nice. A thermal peak appears after 5 cm depth in the tissues, delayed after the fast neutron peak at 1.8 cm depth. Thus, a physical overdosage of 10% may be obtained if 100 ppm of 10B are assumed in the tissues. Our results using CAL 58 GBM cell line demonstrate a dose modification factor (DMF) of 1.19 when 100 ppm of boric acid are added to the growth medium. Thus for the particles, issued from neutron capture, a biological efficiency at least twice that of fast neutrons can be derived. These results, compared with historical data on fast neutron irradiation of glioblastoma, suggest that a therapeutic window may be obtained for GBM.