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Cerebral air embolism is a severe complication which can occur during many invasive medical procedures. Its prognosis depends on early diagnosis and hyperbaric oxygen therapy. We report a case of cerebral air embolism which occurred during a talc pleurodesis within a chest tube, in chest postoperative period. After early and appropriate treatment, we observed a significant functional recovery.

A fundamental issue in the interpretation of chest CT lies in the ability to determine normality. Technical advances have resulted in an increasing number of submillimeter sections which in turn has resulted in the identification of a large number of minor abnormalities with no significant pathophysiological consequence. These images should be properly interpreted in order to avoid unnecessary follow-up examinations and radiation exposure. Often they are due to respiratory or cardiac motion artifacts. Others are explained by aging, anatomic variants, physiological phenomenon or tobacco use. These borderline imaging features detected on chest CT are described according to the main anatomical compartments of the thorax: lung and vessels, airways, pleura and chest wall, mediastinum and heart.

Numerous respiratory disorders may be responsible for right heart dysfunction, frequently suboptimally assessed in routine clinical practice. Multidetector-row CT systems with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artifacts, enabling improved evaluation of the heart. Moreover, the introduction of fast rotation speed and dedicated cardiac reconstruction algorithms exploiting the multislice acquisition scheme of the data has opened the possibility of integrating right cardiac functional information into a diagnostic CT scan of the chest, without or with ECG gating.

The percutaneous Hartel transoval route goes through an inverted pyramid, with an inferior summit and a superior base that includes three compartments. The danger of the inferior compartment is the parotid duct. The middle compartment contains many branches of the mandibular nerve. The superior compartment is crossed by the internal maxillary artery and its branches, as well as the auditory tube. The base of the pyramid presents not only the foramen ovale, but also the foramen lacerum, where the trocar may injure the internal carotid, and the foramen jugulare, where the trocar may meet the internal jugular vein and nerves of the pars nervosa (IX, X, XI). The trigeminal cave contains, within the trigeminal cistern, the trigeminal ganglion, extended backward by the triangular plexus (the target for thermocoagulation). These structures are undercrossed by the masticatory motor branch of the trigeminal nerve.

The authors present a retrospective study of 121 patients treated with balloon compression of the rootlets behind the Gasser ganglion from 1995 to 2007. The inclusion criteria were drug-resistant idiopathic trigeminal neuralgia. The authors described the surgical technique and compared their results with results from the literature. The following parameters were compared: technical success, pain relief and recurrence, and complications. Balloon compression is considered in the literature to be a safer procedure than other percutaneous surgeries, especially for postoperative sensitive disorders. The best indications seem to be trigeminal neuralgia in older patients or pain due to multiple sclerosis and neuralgia involving the V1 territory. These conclusions should be confirmed by larger series, a longer follow-up (5 years) and statistically better analysis.

64-slice Multi-Detector CT (MDCT) allows evaluating new morphological and functional parameters in patients with COPD. Dedicated software allowing emphysema quantification or shunt detection through a patent foramen ovale can be used together with ECG gating which enables pulmonary vessels and right ventricular analysis at different times of the cardiac cycle.The purpose of our work was to evaluate these new functionalities, including the following objectives: 1- to evaluate a prototype software dedicated for lobar emphysema quantification and volume estimation, 2- to evaluate nongated 64-slice MDCT for shunt detection through a patent foramen ovale and 3- to evaluate ECG-gated MDCT parameters such as the right ventricular outflow tract systolic shortening and myocardial thickness, and the pulmonary artery distensibility, as potential markers of pulmonary hypertension.1- Lobar emphysema quantification and volume estimationWe used a dedicated prototype software (MevisPULMO) allowing lobar quantification of emphysema extent in 47 patients evaluated before bronchoscopic lung-volume reduction. Lobar quantification was obtained following (a) a fully automatic delineation of the lobar limits by the software (b) a semiautomatic delineation with manual correction of the lobar limits when necessary, and was compared to the visual scoring of emphysema severity per lobe, using a 5-point scale grading the proportion of lung parenchyma involved with emphysema: score: 0 (no emphysema), score 1 (< 25%), 2 (25-50%), 3 (50- 75%) and 4 (> 75%). No statistically significant difference existed between automated and semi-automated lobar quantification (p> 0.05 in the 5 lobes). Intraclass correlation coefficients showed good to excellent agreement, except for the middle lobe (moderate agreement).A good agreement was observed between the software and visually assessed lobar predominance of emphysema (kappa: 0.76; 95% CI 0.58 to 0.94).MevisPULMO software was also used to evaluate CT volumes on Inspiratory and expiratory 64-slice MDCT studies. Inspiratory and expiratory CT volumes were compared to the reference volumes on plethysmography, i.e. Total Lung Capacity (TLC) and Residual Volume (RV). Proportion of Low Attenuation Area (LAA) representing emphysema extent was quantified on inspiratory CT. We found a good correlation between Inspiratory CT volume and TLC (r= 0.8, p< 0.0001), and a mean difference between volume values of -7.7% (range: -48.8 to 28.2%). Expiratory CT volume was correlated with RV (r=0.79, p< 0.0001) the mean difference between values was 9.7% (range: - 17.9 to 43.3%). Expiratory CT volume was also correlated with Forced expiratory volume in 1 second (FEV1) (r=-55, pEmphysema extent was correlated with inspiratory and expiratory CT volumes (r= 0.56 and 0.53, respectively p< 0.0001) and with FEV1 (r= -0.69, pWe concluded that automated and semi-automated lobar quantification of emphysema are equivalent and show good agreement with visual scoring. Volume estimation from 64-slice MDCT data also allows functional evaluation in COPD patients, well correlated wtih standard pulmonary function tests.2. Nongated 64-slice MDCT for shunt detection through a patent foramen ovaleWe evaluated 105 patients with a recent stroke referred for transesophageal echocardiography (TEE) who accepted to have a MDCT study on the same day. Following injection of diluted iodinated contrast agent, a series of 128 transverse images centered on the fossa ovalis were acquired simultaneously to the release of a Valsalva maneuver.Foramen ovale patency (FOP) was considered present by two independent readers if left atrial enhancement was detected visually prior to enhancement of the pulmonary veins, or if an early peak of left atrial enhancement was found on time-density curve analysis.PFO was detected with 98% specificity (95% CI, 0.91 to 0.99). Sensitivity was 55% overall (95% CI, 0.38 to 0.70), ranging from 28% for TEE grade 1 shunts to 91% for grade 4 shunts. Interreader agreement was good (kappa: 0.81). Visual assessment was better than time-density curve analysis, which only detected 15 of the 40 cases of PFO. The mean effective radiation dose required was 2.3 mSv.We conclude that nongated MDCT can be used to diagnose high-grade shunts through a patent foramen ovale, with 91% sensitivity and 98% specificity. PFO detection could thus be indicated, in addition to routine CT evaluation of the lungs, in situations such as unexplained hypoxemia.3. ECG-gated 64-slice MDCT for evaluating new parameters to help predict pulmonary hypertension (PHT)Pulmonary artery distensibility (PAD), right ventricular outflow tract (RVOT) myocardial thickness, diameter and cross- sectional area were measured during the cardiac cycle in two groups of patients, 21 with PHT (Group 1, mean pulmonary artery pressure (PAP): 42 mmHg) and 24 without PHT (Group 2, mean PAP: 16.5 mmHg). These patients had undergone thoracic ECG-gated 64-slice MDCT and right-heart catheterization as part of their diagnostic work-up. PAD was calculated from the highest (CSA max) and lowest (CSA min) pulmonary artery cross sectional areas, which were measured at every 10% of the cardiac cycle, as follows: PAD = CSAmax-CSAmin/CSAmax.Simplified PAD was also calculated from only two values at 20 and 80% of the R-R interval where extremes values of CSA were observed in the 2 groups of patients.RVOT myocardial thickness, diameter and cross- sectional area were measured 1 cm below the pulmonary valve at 30% and 90% of the R-R interval.All measurements showed good inter-observer agreement (R> 0.8), except systolic RVOT wall thickness. Median values of PAD, diastolic RVOT wall thickness and systolic RVOT diameter and cross-sectional area were significantly different in Group 1 and Group 2. The largest area under the ROC curve was obtained with PAD (0.951; 95% confidence interval [CI], 0.89 to 1) also showing the closest correlation with mean PAP (r= -0.73, pWe conclude that among all parameters evaluated, PAD shows the best diagnostic value for non invasive evaluation of PHT by ECG-gated MDCT. This parameter could be useful for risk stratification, especially because simplified measurement of PAD can be done in clinical routine and has a similar diagnostic value as standard PAD measurements.; De nouvelles approches quantitatives ou fonctionnelles d'imagerie de la BPCO (bronchopneumopathie chronique obstructive) sont possibles en scanner à 64 coupes par rotation. Elles impliquent l'utilisation de logiciels dédiés, permettant la quantification de l'emphysème ou la détection de shunts via le foramen ovale, plus fréquents dans la BPCO, par analyse des courbes de rehaussement auriculaire gauche.Une autre approche est d'utiliser la synchronisation cardiaque, pour évaluer les structures d'intérêt à différentes phases du cycle cardiaque, ce qui donne une information fonctionnelle utile pour la détection de l'hypertension artérielle pulmonaire (HTAP) de la BPCO.Le but de ce travail, organisé en 3 parties, a été d'évaluer la faisabilité et les performances diagnostiques obtenues avec ces nouvelles applications.1- Quantification des volumes pulmonaires et du pourcentage d'emphysèmeNous avons évalué un logiciel protoytpe (Mevis Pulmo) qui permet un calcul des volumes pulmonaires et une quantification de l'emphysème, après segmentation pulmonaire et seuillage des densités. Les résultats peuvent être obtenus de façon globale, individuellement pour chaque poumon et séparément pour chacun des 5 lobes. Les limites anatomiques lobaires sont reconnues de façon automatique (quantification automatique) mais elles peuvent être corrigées si nécessaire (quantification semi-automatique).Nous avons comparé quantification automatique, semi-automatique et visuelle selon un score classique en 5 grades, chez 47 patients présentant une BPCO sévère. Ces patients étaient évalués avant éventuelle réduction endoscopique, par un scanner sans injection en inspiration et expiration.Il n'y a pas de différence significative du pourcentage d'emphysème estimé par quantification automatique et semi automatique (p>0.05 dans les 5 lobes). Les coefficients de corrélation intraclasse sont supérieurs à 0.8 (concordance excellente) sauf pour le lobe supérieur droit (0.68, bonne concordance) et le lobe moyen (0.53, concordance moyenne). La concordance avec le score visuel est bonne (kappa: 0.76; IC 95% 0.58 à 0.94).Le logiciel utilisé permet également d'évaluer les volumes pulmonaires en inspiration et expiration et de les comparer aux volumes de référence en pléthysmographie. Le volume tomodensitométrique (TDM) inspiratoire est corrélé à la capacité pulmonaire totale (CPT) en pléthysmographie (r= 0.8, p< 0.0001) ; la différence moyenne est de -7.7% (valeurs extrêmes: -48.8 à 28.2%). Le volume TDM expiratoire est corrélé au volume résiduel (VR) (r=0.79, p< 0.0001) ; la différence moyenne est de 9.7% (valeurs extrêmes: - 17.9 à 43.3%). Le volume TDM expiratoire est également corrélé au Volume expiratoire maximal en 1 seconde (VEMS) (r=-55, pLe logiciel testé permet donc une quantification lobaire automatique fiable de l'emphysème et une mesure des volumes pulmonaires en TDM pertinente pour évaluer fonctionnellement la sévérité de la BPCO.2- Détection de la perméabilité du foramen ovale en scanner 64 coupes non synchroniséCette étude a été menée prospectivement chez 105 patients évalués en échographie transoesophagienne (ETO) pour rechercher un foramen ovale perméable et qui donnaient leur consentement pour une exploration tomodensitométrique réalisée le même jour. Après injection de contraste au cours d'une manoeuvre de Valsalva, une acquisition couvrant toute la largeur du détecteur (28.8 mm) était centrée sur la fosse ovale, en continu toutes les 0.5 secondes pendant 7 secondes. Les 128 images résultantes ont été analysées visuellement, à la recherche d'une opacification auriculaire gauche précédant le retour veineux pulmonaire. Les courbes de rehaussement auriculaire gauche (Logiciel DynEva) ont été analysées à la recherche d'un pic précoce de rehaussement.La perméabilité du foramen ovale est détectée avec une sensibilité globale de 55% (IC 95%, 0.38 - 0.70) et une spécificité de 98% (IC 95%, 0.91 - 0.99). Les performances dépendent du grade du shunt en ETO, utilisé comme gold standard. La sensibilité varie entre 28% pour les shunts de grade 1 et 91% pour les shunts de grade 4. L'analyse des courbes de rehaussement n'augmente pas la sensibilité du scanner. La dose moyenne requise est de 2.3 mSv.Ces résultats permettent d'envisager d'associer la recherche de shunts de haut grade via le foramen ovale à l'analyse tomodensitométrique du parenchyme pulmonaire, dans des contextes d'hypoxémie inexpliquée ou paradoxale,3- Proposition de nouveaux critères prédictifs d'HTAP en scanner multi coupes synchroniséLa synchronisation à l'ECG permet d'étudier des paramètres tels que la distensibilité artérielle pulmonaire, l'épaisseur du myocarde infundibulaire et les variations en systole et diastole des mensurations infundibulaires.Ces paramètres ont été analysés dans 2 groupes de patients (groupe 1, 21 patients avec HTAP; groupe 2, 24 patients sans HATP) évalués par cathétérisme cardiaque droit dans le cadre de leur prise en charge clinique. Les données brutes des examens tomodensitométriques (TDM) ont été reconstruites en coupes de 1mm d'épaisseur jointives, tous les 10% du cycle cardiaque.La distensibilité de l'artère pulmonaire droite est calculée à partir de mesures de la surface de section de l'artère, effectuées tous les 10% de l'intervalle R-R. A partir des 10 valeurs obtenues, la valeur maximale de surface de section (SSmax) et la valeur minimale (SSmin) sont repérées. La distensibilité est calculée par l'équation suivante : (SSmax-SSmin)/SSmax.La distensibilité est également calculée selon une méthode simplifiée à partir de deux mesures l'une à 20% du R-R, l'autre à 80%. Ces fenêtres temporelles ont été identifiées comme celles où les valeurs extrêmes de surface de section sont observées dans les deux groupes de patients. L'épaisseur myocardique, le diamètre antéropostérieur et la surface de section infundibulaires sont mesurés en systole et diastole à 30% et 90% du R-R, 1 cm au dessous de la valve pulmonaire. Les mesures de ces paramètres montrent une bonne concordance inter observateur, à l'exception de l'épaisseur systolique infundibulaire. Les valeurs médianes sont significativement différentes pour les deux groupes de patients, à l'exception des dimensions diastoliques infundibulaires. La distensibilité artérielle pulmonaire est le paramètre pour lequel l'aire sous la courbe ROC est la plus large (0.951 ; IC 95%, 0.894 - 1) et qui apparaît le mieux corrélé à la pression artérielle pulmonaire (r=-073, pLa distensibilité calculée selon la méthode simplifiée a les mêmes performances. Ce paramètre pourrait être évalué en routine pour détecter l'HTAP chez les patients présentant une BPCO, afin de restreindre les indications de cathétérisme cardiaque droit, méthode d'exploration invasive.

We present the epilepsy surgery activity in infants and children at the Fondation Rothschild Hospital, the main center dedicated to this activity in France.A prospective study was conducted from 2003 to 2007 based on three populations: (1) children selected as candidates for surgery, (2) children undergoing presurgical evaluation and (3) children undergoing surgical procedures for epilepsy.Children selected as candidates for surgery: 304 children were referred and discussed by our multidisciplinary staff. They came from Paris and its suburbs (40%), the provinces (43%) or from other countries (14%). Sixty-one percent of them were included in our surgery program and 24% were excluded. Sixty-one percent of them were under 10 years of age. Children undergoing presurgical evaluation: 296 children were recorded: 140 EEG (47%), 46 with foramen ovale electrodes (16%) and 110 with invasive recording techniques (37%). Seventy percent of these children were under 10 years of age. Children undergoing surgical procedures: 316 children underwent surgery; 68% of them were under 10 years of age. The surgical procedures were focal resection (136 children), vertical parasagittal hemispherotomy (77 children), resection and or disconnection for hypothalamic hamartoma (69 children) and 34 had palliative surgery (callosotomy or vagal nerve stimulation).Eighty to 100 children undergo surgery each year in our department for drug-resistant partial epilepsy; 70% of them are less than 10 years of age. This activity is part of a network of pediatric neurologists who are deeply involved in treatment of severe epilepsy in children.