[Case report of a cystic lung disease: From a rarity to the discovery of an unknown genetic variant]

INTRODUCTION

Cystic lung diseases are rare, with numerous differential diagnoses. Iconographic discovery consequently necessitates medical examinations in view of proposing an etiological orientation.

CASE REPORT

A 57-year-old woman consulted in pulmonology following fortuitous detection of a cystic lung disease on an abdominal CT scan. Complementary medical examinations did not allow orientation towards a particular diagnosis. During a follow-up consultation, the patient informed her pulmonologist of the recent detection of a monoallelic variant of a FAT4 gene in one of her daughters, who was suffering from edema of the lower limbs secondary to a disease of the lymphatic system. As our patient had a similar history, she likewise received a genetic analysis. A monoallelic variant not described in the genetic databases was observed, and considered as a probable pathogenic variant (class 4/5 on the pathogenicity scale of genetic variants).

CONCLUSION

After analyzing the available literature data, we raise questions about a possible link between this variant of the FAT4 gene, chronic lymphedema and our patient's cystic lung disease.

High-Density Lipoprotein Particles and Torque Teno Virus in Stable Outpatient Kidney Transplant Recipients

Torque teno virus (TTV) is emerging as a potential marker for monitoring immune status. In transplant recipients who are immunosuppressed, higher TTV DNA loads are observed than in healthy individuals. TTV load measurement may aid in optimizing immunosuppressive medication dosing in solid organ transplant recipients. Additionally, there is a growing interest in the role of HDL particles in immune function; therefore, assessment of both HDL concentrations and TTV load may be of interest in transplant recipients. The objective of this study was to analyze TTV loads and HDL parameters in serum samples collected at least one year post-transplantation from 656 stable outpatient kidney transplant recipients (KTRs), enrolled in the TransplantLines Food and Nutrition Cohort (Groningen, the Netherlands). Plasma HDL particles and subfractions were measured using nuclear magnetic resonance spectroscopy. Serum TTV load was measured using a quantitative real-time polymerase chain reaction. Associations between HDL parameters and TTV load were examined using univariable and multivariable linear regression. The median age was 54.6 [IQR: 44.6 to 63.1] years, 43.3% were female, the mean eGFR was 52.5 (±20.6) mL/min/1.73 m2 and the median allograft vintage was 5.4 [IQR: 2.0 to 12.0] years. A total of 539 participants (82.2%) had a detectable TTV load with a mean TTV load of 3.04 (±1.53) log10 copies/mL, the mean total HDL particle concentration was 19.7 (±3.4) μmol/L, and the mean HDL size was 9.1 (±0.5) nm. The univariable linear regression revealed a negative association between total HDL particle concentration and TTV load (st.β = -0.17, 95% CI st.β: -0.26 to -0.09, p < 0.001). An effect modification of smoking behavior influencing the association between HDL particle concentration and TTV load was observed (Pinteraction = 0.024). After adjustment for age, sex, alcohol intake, hemoglobin, eGFR, donor age, allograft vintage and the use of calcineurin inhibitors, the negative association between HDL particle concentration and TTV load remained statistically significant in the non-smoking population (st.β = -0.14, 95% CI st.β: -0.23 to -0.04, p = 0.006). Furthermore, an association between small HDL particle concentration and TTV load was found (st.β = -0.12, 95% CI st.β: -0.22 to -0.02, p = 0.017). Higher HDL particle concentrations were associated with a lower TTV load in kidney transplant recipients, potentially indicative of a higher immune function. Interventional studies are needed to provide causal evidence on the effects of HDL on the immune system.

Surgical evolution in spinal dural arteriovenous fistula treatment-a 7 years monocentric experience

Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.

Selective clipping of giant anterior communicating artery aneurysms remains a reliable therapeutic option

BACKGROUND

Giant anterior communicating artery (AcomA) aneurysm represent a significant surgical challenge. Our study aimed to discuss the therapeutic strategy in patients with a giant AcomA aneurysm treated by selective neck clipping through a pterional approach.

METHODS

Among all operated patients from an intracranial aneurysm between January 2015 and January 2022 (n = 726) in our institution, three patients with a giant AcomA aneurysm treated by neck clipping were included. Early (<7days) outcome was noted. Early postoperative CT scan was performed in all patients to detect any complications. Early DSA was also performed to confirm giant AcomA aneurysm exclusion. The mRS score was recorded 3 months after treatment. The mRS≤ 2 was considered as a good functional outcome. Control DSA was performed one year after treatment.

RESULTS

In the three patients, after a large frontopterional approach, a selective exclusion of their giant AcomA aneurysm was obtained after a partial pars orbitalis of the inferior frontal gyrus resection. Ischemic lesion was noted in 1 patient and chronic hydrocephalus in 2 patients with ruptured aneurysm. The mRS score after 3 months was good in 2 patients. Long term complete occlusion of the aneurysm were noted in the three patients.

CONCLUSION

Selective clipping of a giant AcomA aneurysm is a reliable therapeutic option after a careful evaluation of local vascular anatomy. An adequate surgical exposure is frequently obtained through an enlarged pterional approach with an anterior basifrontal lobe resection, especially in an emergency situation and/or in case of high position of anterior communicating artery.

A multicentre, patient- and assessor-blinded, non-inferiority, randomised and controlled phase II trial to compare standard and torque teno virus-guided immunosuppression in kidney transplant recipients in the first year after transplantation: TTVguideIT

BACKGROUND

Immunosuppression after kidney transplantation is mainly guided via plasma tacrolimus trough level, which cannot sufficiently predict allograft rejection and infection. The plasma load of the non-pathogenic and highly prevalent torque teno virus (TTV) is associated with the immunosuppression of its host. Non-interventional studies suggest the use of TTV load to predict allograft rejection and infection. The primary objective of the current trial is to demonstrate the safety, tolerability and preliminary efficacy of TTV-guided immunosuppression.

METHODS

For this purpose, a randomised, controlled, interventional, two-arm, non-inferiority, patient- and assessor-blinded, investigator-driven phase II trial was designed. A total of 260 stable, low-immunological-risk adult recipients of a kidney graft with tacrolimus-based immunosuppression and TTV infection after month 3 post-transplantation will be recruited in 13 academic centres in six European countries. Subjects will be randomised in a 1:1 ratio (allocation concealment) to receive tacrolimus either guided by TTV load or according to the local centre standard for 9 months. The primary composite endpoint includes the occurrence of infections, biopsy-proven allograft rejection, graft loss, or death. The main secondary endpoints include estimated glomerular filtration rate, graft rejection detected by protocol biopsy at month 12 post-transplantation (including molecular microscopy), development of de novo donor-specific antibodies, health-related quality of life, and drug adherence. In parallel, a comprehensive biobank will be established including plasma, serum, urine and whole blood. The date of the first enrolment was August 2022 and the planned end is April 2025.

DISCUSSION

The assessment of individual kidney transplant recipient immune function might enable clinicians to personalise immunosuppression, thereby reducing infection and rejection. Moreover, the trial might act as a proof of principle for TTV-guided immunosuppression and thus pave the way for broader clinical applications, including as guidance for immune modulators or disease-modifying agents.

TRIAL REGISTRATION

EU CT-Number: 2022-500024-30-00.

Supraorbital transciliary approach as primary route to fronto-basal high grade glioma resection with 5-Aminolevulinic Acid use: Technical note

BACKGROUND

Gliomas are diffuse intra-axial lesions, which can be accessed by multiple surgical corridors for a same location depending on the surgeon's preference. 5-Aminolevulinic Acid use facilitates the extend of resection in case of high-grade gliomas, especially when differentiating normal brain from tumor periphery is challenging.

METHODS

Complete resection of glioblastoma via a supraorbital transciliary approach with 5-Aminolevulinic Acid use was performed without any complications, as demonstrated on postoperative MRI.

RESULTS

Patient was discharged on the third postoperative day. Wound follow-up shows good cosmetic result. Patient underwent concomitant chemo-radiation (Temozolomide- 60Gy) and adjuvant chemotherapy (Temozolomide). No tumor recurrence was noted at six months follow-up.

CONCLUSION

In selected cases, supraorbital transciliary approach could be proposed as primary approach as it provides the advantage of full control over all the vasculo-nervous structures at skull base without the necessity of protective brain retractor use while the 5-Aminolevulinic Acid use allows a gross total resection.

Formation of intracellular vesicles within the Gram+ Lactococcus lactis induced by the overexpression of Caveolin-1β

Background

Caveolae are invaginated plasma membrane domains of 50–100 nm in diameter involved in many important physiological functions in eukaryotic cells. They are composed of different proteins, including the membrane-embedded caveolins and the peripheric cavins. Caveolin-1 has already been expressed in various expression systems (E. coli, insect cells, Toxoplasma gondii, cell-free system), generating intracellular caveolin-enriched vesicles in E. coli, insect cells and T. gondii. These systems helped to understand the protein insertion within the membrane and its oligomerization. There is still need for fundamental insights into the formation of specific domains on membrane, the deformation of a biological membrane driven by caveolin-1, the organization of a caveolar coat, and the requirement of specific lipids and proteins during the process. The aim of this study was to test whether the heterologously expressed caveolin-1β was able to induce the formation of intracellular vesicles within a Gram+ bacterium, Lactococcus lactis, since it displays a specific lipid composition different from E. coli and appears to emerge as a good alternative to E. coli for efficient overexpression of various membrane proteins.

Results

Recombinant bacteria transformed with the plasmid pNZ-HTC coding for the canine isoform of caveolin-1β were shown to produce caveolin-1β, in its functional oligomeric form, at a high expression level unexpected for an eukaryotic membrane protein. Electron microscopy revealed several intracellular vesicles from 30 to 60 nm, a size comparable to E. coli h-caveolae, beneath the plasma membrane of the overexpressing bacteria, showing that caveolin-1β is sufficient to induce membrane vesiculation. Immunolabelling studies showed antibodies on such neo-formed intracellular vesicles, but none on plasma membrane. Density gradient fractionation allowed the correlation between detection of oligomers on Western blot and appearance of vesicles measurable by DLS, showing the requirement of caveolin-1β oligomerization for vesicle formation.

Conclusions

Lactococcus lactis cells can heterologously overexpress caveolin-1β, generating caveolin-1β enriched intracellular neo-formed vesicles. These vesicles might be useful for potential co-expression of membrane proteins of pharmaceutical interest for their simplified functional characterization.

Manual Lymphatic Drainage Increases the Number of Opened Lymphatic Pathways in Patients with Lower Limb Lymphedemas: A Sequential Research on 80 Patients

The purpose of this study was to lymphoscintigraphically assess the effect of skin mobilization, nonspecific massage, and manual lymphatic drainage (MLD) on the root of the lower limb in patients with lower limb lymphedema. Lower limb root lymphoscintigraphical exams of 80 patients with lower limb lymphedema were analyzed. All patients underwent our stand 3 phase protocol and then were subjected to the 4th phase which included 3 subphases. Images were taken directly after the injection (subphase 1), after pinching and stretching the injection site (subphase 2), after nonspecific massage was applied to the injected site (subphase 3) and after manual lymphatic drainage of the injected site (subphase 4). The number of opened lymphatic pathways was analyzed and compared after and between each subphase (SP). SP 1 displayed open lymphatic pathways in 22 of the 80 cases (27.5%). SP 2 displayed newly opened lymphatic pathways in 48 of the 80 cases (60.0%). SP 3 displayed newly opened lymphatic pathways in 57 of the 80 cases (71.3%). Only 9 of these 57 cases did not show improvement following the next SP. SP 4 displayed newly opened lymphatic pathways in 60 of the 80 cases (75.1%). MLD improved the visualization of the lymphatic pathways in 48 cases (60%) compared to phase 3. MLD was the only technique to allow visualization of the lymphatic drainage at the level of the root of the edematous limb in 6 cases (7.5%). Physical therapy leads to a greater number of lymphatic collaterals opening in a region where no other complex decongestive therapy technique can be applied.

Preliminary report of patients with meningiomas exposed to Cyproterone Acetate, Nomegestrol Acetate and Chlormadinone Acetate - Monocentric ongoing study on progestin related meningiomas

INTRODUCTION

The relationship between meningioma and progestins has not been elucidated. Meningioma regression after acetate cyproterone (CA) withdrawal has been reported. Our purpose was to evaluate the meningioma evolution after withdrawal of progestins in patients who underwent long-term exposure to CA, nomegestrol acetate (NA), chlormadinone acetate (ChlA).

METHODS

Our study retrospectively included 69 patients with intracranial meningioma and exposed to one of these 3 progestins between December 2006 and March 2019. In each patient, clinico-radiological (MRI) follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. Statistical analyses were applied to compare tumor location and respect of prescription rules between the 3 groups.

RESULTS

The mean hormonal exposure was 16 years in CA group (n = 46), 16 years in NA group (n = 12) and 9.7 years in ChlA group (n = 11). A higher rate of "out of label" use was observed in the CA group (p = 0.003). Multiple meningiomas were demonstrated in more than 60% of cases in each group. Anterior skull base location was noted in 60.5% of cases in CA group, 25% of cases in NA group and 36.7% of cases in ChlA group (p = 0.05). Incomplete tumor regression was recorded in 11 cases of CA group and in 2 cases of ChlA group.

CONCLUSION

In CA group, our results suggest a strong relationship between this treatment and development of intracranial meningioma. In presence of voluminous asymptomatic meningioma, treatment can be delayed due to the potential regression after withdrawal. On the contrary in NA and ChlA groups, further studies are needed.

Spontaneous disappearance of brain arteriovenous malformation: A case series

OBJECTIVE

Brain arteriovenous malformation (BAVM) is defined as abnormal communication between cerebral of arteries and veins, without capillaries. Clinically, it may involve intracranial hemorrhage or seizures. Complete spontaneous resolution, known as BAVM disappearance, has been reported in rare cases.

METHODS

We retrospectively collated all cases of BAVM in Lille University Hospital, from 2005 to 2018, and identified all cases of spontaneous BAVM disappearance on angiography (nidus and early venous drainage).

RESULTS

There were 4 cases of spontaneous BAVM disappearance, in 3573 patients: i.e., prevalence of 0.1%. Sex ratio was 2:2; ages ranged from 14 to 46 years; nidus size was generally small (<20mm); 3 of the 4 patients had superficial venous drainage. Revelation of BAVM was by hemorrhage in 3 cases and by seizure in 1. There were no cases of recanalization at 1 year's follow-up.

CONCLUSION

Spontaneous BAVM disappearance is rare. Associated factors may include small nidus, superficial venous drainage and hemorrhage.

Ruptured blood blister like aneurysm: does the best therapeutic option really exist?

Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3 months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3 months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.

Absence of bacteria in intracranial aneurysms

OBJECTIVE

This study aimed to detect the presence of bacteria in the walls of both unruptured and ruptured aneurysms in a French population.

METHODS

Patients treated between January 2018 and July 2018 were included in a prospective study when specimens from ruptured or unruptured aneurysm walls were obtained intraoperatively. Samples from superficial temporal artery, dura mater, and middle meningeal artery were obtained from each patient during the same surgical procedure to be used as a negative control. Direct bacterial analysis, aerobic and anaerobic bacterial culture, and bacterial DNA detection were performed on each sample.

RESULTS

There were 21 women and 9 men with a mean age at treatment of 54 years (range 31–70 years). Eighteen patients were smokers. Hypertension was present in 18 patients and hyperlipidemia in 5 patients. Chronic alcoholism was found in 6 patients. Polycystic kidney disease was present in 1 patient. Fifteen patients had multiple intracranial aneurysms. Ten patients had a ruptured aneurysm and 20 had an unruptured aneurysm. The mean diameter of all aneurysms was 8.5 mm (range 2.5–50 mm). No presence of bacteria was detected with direct bacterial analysis and culture in any of the samples. No bacterial DNA was detected in any of the samples.

CONCLUSIONS

Unlike in Finnish patients, no bacterial presence was found in the wall of aneurysms in French patients. This absence of bacterial infection might explain the lower risk of aneurysm rupture in the French population compared to the Finnish population.

Is endoscopic third ventriculostomy safe and efficient in the treatment of obstructive chronic hydrocephalus in adults? A prospective clinical and MRI study

BACKGROUND

In case of suspected normal pressure hydrocephalus, MRI is performed systematically and can sometimes highlight an obstruction of the flow pathways of the CSF (aqueductal stenosis or other downstream obstruction). It seems legitimate for these patients to ask the question of a treatment with endoscopic third ventriculostomy (ETV), even if the late decompensation of an obstruction may suggest an association with a CSF resorption disorder. The aim of this study was to evaluate clinical and radiological evolution after ETV in a group of elderly patients with an obstructive chronic hydrocephalus (OCH).

METHODS

ETV was performed in 15 patients with OCH between 2012 and 2017. Morphometric (callosal angle, ventricular surface, third ventricular width, and Evans' index) and velocimetric parameters (stroke volume of the aqueductal (SVa) CSF) parameters were measured prior and after surgery with brain MRI. The clinical score (mini-mental status examination (MMSE) and the modified Larsson's score, evaluating walking, autonomy, and incontinence) were performed pre- and postoperatively.

RESULTS

SVa was less than 15 μL/R-R in 12 out of the 15 patients; in the other three cases, the obstruction was located at a distance from the middle part of the aqueduct. Fourteen out of 15 patients were significantly improved: mean Larsson's score decreased from 3.8 to 0.6 (P ≤ 0.01) and mean MMSE increased from 25.7 to 28 (P = 0.084). Evans' index and ventricular area decreased postoperatively and the callosal angle increased (P ≤ 0.01). The mean follow-up lasted 17.9 months. No postoperative complications were observed.

CONCLUSION

ETV seems to be a safe and efficient alternative to shunt for chronic hydrocephalus with obstruction; the clinical improvement is usual and ventricular size decreases slightly.

Grade 1 Spetzler and Martin cerebral ruptured arteriovenous malformations treated by microsurgery: Poor functional outcome is related to injury from haemorrhage

INTRODUCTION

Ruptured arteriovenous malformations (rAVM) are life-threatening diseases.

OBJECTIVE

To evaluate the outcome of patients with grade 1 SPM rAVM after microsurgical treatment.

MATERIALS AND METHOD

We retrospectively included 64 consecutive operated patients with a grade 1 SPM rAVM in our institution between 2002 and 2012. Complications related to the surgical procedure were recorded. All patients were re-evaluated 3months after treatment using the modified Rankin Scale score (mRS). Persistent neurological disorders were evaluated 1year after bleeding. Conventional cerebral angiography was performed for each patient immediately after surgical treatment and 1year later.

RESULTS

The mean age at diagnosis was 30.8 years. Initial WFNS score was grade 1 in 25 patients, grade 2 in 11 patients, grade 3 in 10 patients, grade 4 in 9 patients and grade 5 in 9 patients. No remnant was left and a new surgery was performed only in a single patient who was initially operated-on under emergency conditions with limited preoperative investigations due to a poor clinical grade. Early postoperative complications related to the surgical procedure were recorded in 7 patients. The mRS score 3months after treatment was ≤2 in 53 patients (83%). Persistent neurological disorders were recorded in 40 patients (62.5%). High initial WFNS score (>2) and the hydrocephalus were significantly associated (P<0.05) to a bad functional outcome (mRS>2).

CONCLUSION

Grade 1 rAVM is a life-threatening disease concerning in most cases young patients. Long-term morbidity is often related to the hemorrhagic brain damage and rarely to the AVM resection.

Indocyanine green fluorescence-guided surgery after IV injection in metastatic colorectal cancer: A systematic review

OBJECTIVE

Indocyanine green fluorescence-guided surgery (ICG-FGS) has emerged as a potential new imaging modality for improving the detection of hepatic, lymph node (LN), and peritoneal metastases in colorectal cancer (CRC) patients. The aim of this paper is to review the available literature in the clinical setting of ICG-FGS for tumoral detection in various fields of metastatic colorectal disease.

METHODS

PubMed and Medline literature databases were searched for original articles on the use of ICG in the setting of clinical studies on colorectal cancer. The search terms used were "near-infrared fluorescence", "intraoperative imaging", "indocyanine green", "human" and "colorectal cancer".

RESULTS

ICG fluorescence imaging (ICG-FI) is clearly supported as an intraoperative technique that allows the detection of additional superficial hepatic metastases of CRC. Data on the role of ICG-FI in the intraoperative detection of peritoneal metastases and LN metastases are scarce but encouraging and ICG-FI could potentially improve the staging and treatment of these patients.

CONCLUSION

ICG-FI is a promising imaging technique in the detection of small infraclinic LN, hepatic, and peritoneal metastatic deposits that may allow better staging and more complete surgical resection with a potential prognostic benefit for patients.

Internal and external spheno-orbital meningioma varieties: different outcomes and prognoses

BACKGROUND

Internal variation among spheno-orbital meningiomas (SOM) is surgically challenging. Optic canal invasion management is discussed.

METHOD

This retrospective study includes 70 patients with SOM who underwent surgery between 1995 and 2012. Preoperative ophthalmological, neurological and aesthetic clinical signs were collected. All patients benefitted from repeated tomography and magnetic resonance imaging (MRI). The surgical team consisted of a neurosurgeon and a plastic surgeon. In the majority of cases, resection was followed by bone reconstruction using an autologous iliac crest graft. The extent of resection was evaluated on the dural and osseous sides. Early clinical outcomes, long-term follow-up, recurrence and adjuvant therapies were reported.

RESULTS

The mean age was 52 years old, and 91 % of the patients were women. Initial symptoms primarily included proptosis (65 %), decreased visual acuity (39 %) and soft tissue tumefaction (16 %). We classified 40 cases as the internal variety when considering the inner third of the greater wing of the sphenoid, optic canal, anterior clinoid process or cavernous sinus. The remaining cases were described as the external variety. The complete resection rates for the internal and external varieties were 12 % and 61 %, respectively (P < 0.001). In total, 90 % of cases were grade I meningiomas. For grade I, we reported 30 % recurrence, and 50 % of these cases recurred in the first 2 years. Grade II cases without early adjuvant radiotherapy increased at 2 years. We did not observe any difference in recurrence rate among grade I tumours with or without tumour remnants. At the end of follow-up, visual acuity was stabilised or increased in 88 % of patients. In addition, 14 % of patients experienced persistent pain at the location of the iliac harvesting site.

CONCLUSIONS

The internal SOM variety exhibited a reduced total resection rate and a shorter progression-free survival (PFS). Unroofing of the optic canal extended PFS. Among grade I cases, the persistence of a negligible tumour remnant did not alter the probability of recurrence. For superior grades, radiotherapy must be administered in addition to surgery as soon as possible. SOMs require prolonged follow-up. Autologous iliac reconstruction is related to substantial morbidity and could be replaced by prosthetic bone three-dimensional reconstruction.

Reappearance of arteriovenous malformations after complete resection of ruptured arteriovenous malformations: true recurrence or false-negative early postoperative imaging result?

OBJECTIVE Ruptured arteriovenous malformations (AVMs) are often obliterated after emergency microsurgical treatment. However, some studies have reported AVM recurrence after the obliteration of ruptured AVMs. The authors report their experience with AVM recurrence after successful microsurgical treatment of ruptured AVMs. METHODS The authors reviewed the medical data of 139 consecutive patients who underwent microsurgery at the authors' institution for ruptured AVM between 2002 and 2012. Each patient underwent a conventional cerebral angiography examination immediately after the surgery. Subsequent follow-ups were performed with MR angiography after 6 months, and, if there was no indication of AVM recurrence, patients were followed up with conventional cerebral angiography between 1 and 2 years after the treatment; pediatric patients were followed up until age 18 years. Recurrence was defined as new radiological evidence of an AVM at the site of a ruptured AVM or a new hemorrhage in patients with angiographically documented AVM obliteration on postoperative angiograms. RESULTS The mean age of the patients at the time of ruptured AVM diagnosis was 30.8 years (SD ± 5, range 4-69 years), and 44 of the patients were younger than 18 years (the mean age at diagnosis in this pediatric subgroup was 11.4 years [range 4-17.9 years]). Complete AVM obliteration after the initial microsurgery was observed in 123 patients (89.5%). Reappearance of an AVM was noted in 7 patients between 12 and 42 months after the treatment, and all of these patients were younger than 18 years. The recurrent AVM was located in an eloquent zone in 4 patients, and deep venous drainage was noted in 3 patients. Radiosurgery was performed in 6 of these patients, and 1 patient underwent another microsurgical procedure. The authors noted only one rebleeding due to an AVM recurrence during the latency period after radiosurgery. CONCLUSIONS The recurrence of an AVM is fairly rare and affects mostly pediatric patients. Therefore, especially in children, long-term angiographic follow-up is required to detect AVM recurrence or an AVM remnant. The authors stress the need for discussion involving a multidisciplinary neurosurgical team to decide on treatment in cases of any AVM recurrence or remnant.

Vertebral artery-posterior inferior cerebellar artery convergence aneurysms treated by endovascular or surgical treatment: Mid- and long-term outcome

INTRODUCTION

Management of vertebral artery-posterior inferior cerebellar artery convergence (VA-PICA) saccular aneurysms requires a specialized neurovascular team. The objective is to preserve the functional outcome while performing a complete and reliable long-term exclusion of the aneurysm.

OBJECTIVE

The aim of our study was to evaluate the outcome of patients with VA-PICA saccular aneurysms after treatment.

MATERIALS AND METHODS

This was a retrospective series of 21 consecutive patients with a VA-PICA saccular aneurysm treated between 2000 and 2012 at our institution. Treatment option (endovascular or microsurgical) was decided for each patient following a multidisciplinary discussion.

RESULTS

Twenty-one patients were treated for a VA-PICA saccular aneurysm including 16 for a ruptured aneurysm and 5 for an asymptomatic aneurysm. Among all patients, 11 underwent endovascular treatment and 10 had microsurgical treatment. Our results showed a major aneurysm recurrence after endovascular treatment in 3 patients that required a further endovascular treatment in 2 cases. These 3 major recurrences occurred after treatment of a ruptured aneurysm when the initial angiography demonstrated the origin of the PICA at the neck of the aneurysm. After microsurgery, angiography showed a remnant neck in 2 patients including 1 treated by further endovascular procedure.

CONCLUSION

VA-PICA aneurysms are rare and require multidisciplinary management. Microsurgical treatment should be discussed when the PICA originates from the aneurysmal neck, particularly in patients with a ruptured small aneurysm, in order to obtain a reliable and long-term exclusion of the aneurysm.

Care-related pain in hospitalized patients: severity and patient perception of management

BACKGROUND

Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP.

METHODS

All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included.

RESULTS

From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases.

CONCLUSIONS

Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

Predictors of functional outcomes and recurrence of chronic subdural hematomas

We aimed to evaluate the functional outcome and risk factors of recurrence in patients operated on for a chronic subdural hematoma (CSH), and discuss systematic early postoperative CT scans. CSH is a very common disease in neurosurgical practice, especially in elderly patients who are treated with anticoagulation. The challenge is to rapidly restore the independence of these patients. We retrospectively analyzed data from 164 consecutive surgical procedures performed on 140 CSH patients, including recurrent surgery, at our institution from June 2011 to June 2012. Pre- and postoperative CT scans, and medical records, were systematically reviewed using the institutional computing database. A poor functional outcome was defined by a modified Rankin scale (mRS) score>2 at 3 months. Among the 140 patients (mean age 76 years; 64% men), a single burr hole craniostomy was performed in 122 patients, and a craniotomy in 18. A poor functional outcome was recorded in 39 patients (28%; 95% confidence interval [CI] 20-35%). In multivariate analyses, an increased risk of poor functional outcome was associated with age >75 years (odds ratio [OR] 5.88; 95% CI 1.96-17.63), residual hematoma thickness >14 mm (OR 3.79; 95% CI 1.47-9.77), and GCS<15 (OR, 2.96; 95% CI, 1.18-7.40). Recurrences occurred in 24 patients (17%; 95% CI 11-23%), with a median delay to reintervention of 13 days. The independent predictors of CSH recurrence were preoperative anticoagulant therapy (OR 3.68; 95% CI 1.13-12.00), and persistence of mass effect on the postoperative CT scan (OR 5.61; 95% CI 1.52-20.66). Three months after surgical treatment, more than one quarter of the CSH patients had a mRS⩾3. The loss of independence was associated with older age, initial GCS<15, and residual hematoma thickness postoperatively. Anticoagulant therapy and persistence of postoperative mass effect heightened the risk of recurrence.

Pericallosal aneurysm: A difficult challenge for microsurgery and endovascular treatment

INTRODUCTION

Pericallosal artery aneurysms (PAA) represent 2 to 9% of intracranial aneurysms and their management remains difficult.

OBJECTIVE

We aimed to report our experience to evaluate the outcome of patients with ruptured and unruptured PAA, when the treatment modality is decided in a multidisciplinary fashion.

MATERIALS AND METHODS

In this retrospective study, we included 28 patients (8 men and 20 women) treated for a PAA in our institution between 2002 and 2012, among the 2430 patients who underwent the treatment of an intracranial aneurysm in the same period. Fifteen patients harbored a ruptured aneurysm while 13 benefited from a prophylactic treatment. The mean age at diagnosis was 52 years (range 37 to 75 SD: ± 5) in patients with ruptured aneurysm and 54.2 years (range 35 to 66 SD: ± 5) in patients with unruptured aneurysm. Endovascular treatment has been performed in 9 patients while 19 patients underwent a microsurgical treatment. Clinical outcome has been assessed using the modified Rankin scale (mRS) at 3 months. Long-term imaging follow-up included a CT angiography at 36 months for clipped aneurysms and MR angiography at 6, 18 and 36 months for coiled aneurysms.

RESULTS

The median follow-up was 3.4 years (range 2.8 to 4.2). The mRS was ≤ 2 in all patients with unruptured aneurysms. In patients with ruptured aneurysm, the mRS was ≤ 2 at 3 months in 13 patients (87%). Persistent cognitive disorders were noted in 8 patients with ruptured aneurysm, 2 of them were considered as possibly related to the treatment. Aneurysm recurrence has been depicted in 4 patients (at 6 months in 3 patients and 1 year in 1 patient) requiring further treatment in all cases; all of them had an aneurysm remnant on immediate conventional angiography. No recurrence was noted in patients without remnant on immediate post-treatment angiography.

CONCLUSION

Both endovascular and microsurgical treatment are challenged in this location. Multidisciplinary discussion is essential to optimize the management of patients with PAA.

Radiological pitfalls of a large intracranial dissecting aneurysm

We report the case of a large dissecting aneurysm of the anterior cerebral artery revealed by cerebral infarction in 38-year-old man. The volume and aspect of the aneurysm initially led us to the diagnosis of saccular aneurysm. Given the complete thrombosis, the risk of bleeding was low and antithrombotic therapy was started. Surgery could be discussed later. However radiological monitoring by MRI (magnetic resonance imaging) showed a rapid decrease in volume of the aneurysm. The final angiography found an aspect of stenosis followed by a little arterial dilatation. The diagnosis of dissecting anterior cerebral aneurysm was a posteriori established.

Efficacy and safety of oral ketamine for the relief of intractable chronic pain: A retrospective 5-year study of 51 patients

BACKGROUND

This work summarizes the efficiency, failures and adverse effects of oral administration of ketamine at home for intractable pain.

METHODS

This 5-year retrospective study involved testing ketamine by intravenous in-hospital administration, then a conversion to an oral route, or oral treatment directly administered at home. The daily intravenous dose was increased by steps of 0.5 mg/kg to attain an effective daily dose of 1.5-3.0 mg/kg. Pain was evaluated on a numeric scale from 0 to 10, and evidence of adverse effects was collected every day. The effective daily dose was delivered orally (three to four intakes). If effective, ketamine was continued for 3 months. Short infusions or direct oral treatment began with a 0.5-mg/kg dose, then the daily ketamine dose was increased in 15- to 20-mg increments.

RESULTS

Among 55 cases (51 patients, neuropathic pain 60%), the mean effective oral dose was 2 mg/kg. Ketamine was effective in 24 patients (44%, mean pain reduction 67 ± 17%), partially effective in 20% (mean pain reduction 30 ± 11%), with a mean opioid sparing of 63 ± 32%, and failure in 22%. Half of the patients experienced adverse effects, but only eight had to stop treatment. For patients with opioid therapy, failure of ketamine was less frequent (7% vs. 36%; p < 0.02), with fewer adverse effects (33% vs. 68%; p < 0.01).

CONCLUSIONS

Pain was reduced or abolished in two-thirds of patients under ketamine therapy; ketamine was effective for patients taking opioids and resulted in few adverse effects.

Short time effects of radiotherapy on lymphatic vessels and restorative lymphatic pathways: experimental approaches ina mouse model

Radiotherapy (RT) is an important component in the therapeutic approach to oncologic conditions. This study presents the investigative results on the impact of RT on lymphatic vessels and on the regenerative response of the lymphatic system in a mouse model. We first irradiated 3 groups of ten mice using brachytherapy in a single treatment of 20 Gy. We then performed morphological examination of the irradiated lymphatic vessels using an in vivo microscopic transillumination technique at 2, 4, and 6 weeks. Next we evaluated lymphatic flow using lymphoscintigraphy and in vivo microscopy at 6 to 11 weeks in: 10 additional mice following irradiation as above (IR), in 10 mice following incision of a lymphatic vessel (I), and in a non-treated control group of 10 mice (N). Intact lymphatic vessels were observed in all mice at 2, 4, and 8 weeks following the single dose of radiotherapy in the first group of mice and normal lymphatic flow was fully restored in the irradiated (IR) and incised (I) mice indicating that the reparative substitution lymphatic pathways are functioning normally. We found that following irradiation with one dose of 20 Gy, lymphatic vessels were not visibly damaged and also that lymphatic flow was consistently restored and substitutive lymphatic pathways formed.