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Retrospective analysis of the results of 52 children irradiated for a medulloblastoma.Between 1974 and 2012, 52 children with an average age of 6 years and a half (11 months-17 years and a half) were treated with surgery then with radiotherapy at the Comprehensive Cancer Centre of Strasbourg (France). For 44 children, the treatment consisted of a chemotherapy.After a mean follow-up of 106.6 months (7-446 months), 13 relapses and 24 deaths were observed. Overall survival at 5 years and 10 years were 62% and 57%, respectively. Disease-free survival at 5 years and 10 years were 80% and 63%, respectively. Univariate analysis found the following adverse prognostic factors: the existence of a postoperative residue, the positivity of the cerebrospinal fluid, the metastatic status and medulloblastoma of high-risk. Positivity of the cerebrospinal fluid remains a negative factor in multivariate analysis.These results confirm the survival rate obtained by a conventional approach (surgery then irradiation). Insufficiency of results and rarity of medulloblastoma require the establishment of international protocols.

Retrospective analysis of the results of 21 adults treated for medulloblastoma.Between 1978 and 2011, 21 adults with an average age of 31 years (18.3-50) were treated with surgery then with radiotherapy (n=20) at the Comprehensive Cancer Center of Strasbourg. For some (n=12), treatment consisted of chemotherapy.After a mean follow-up of 122 months (19-423), six relapses and seven deaths were observed. Overall survival at 5 years and 10 years was 89.4 ± 7.1% for both. Disease-free survival at 5 years and 10 years was 79.6 ± 9.2% and 85.7 ± 7.6% and 60.6 ± 17.7%, respectively.The rarity of medulloblastoma, especially in adults and these results confirm the necessity of international protocols.

Caudal appendage is a rare malformation which has since ever been interesting. We present the case of a girl in which a caudal appendage was discovered before birth. A throughout checking found an extension from this abnormality to the cordal spine. The baby is operated when 2months old. Differential diagnosis are spina bifida, teratoma and pilonidal sinus. Caudal appendage is one of the typical cutaneous finding with underlying spinal dysraphism, such as hair tuft or pigmented macule. The risk is a tethered cord syndrome that can lead to severe complication. The treatment is either surgery or expectation.

Our current development strategy integrates clinical pharmacy activities prioritized in surgical services. Patients in these services are typically risk patients: transfers, multiple prescribers, frequent medication change, pharmacotherapeutic risk classes.Three clinical pharmacy activities (admission reconciliation, pharmaceutical analysis, participation doctors round) have been developed in orthopaedic surgery and neurosurgery. Pharmacists prospectively recorded data describing their activities: number of reconciliations and analyzed requirements and time required to achieve them. Data on pharmaceutical interventions were recorded on the basis ActIP®. The clinical significance of interventions was retrospectively rated by a team of two pharmacists and two physicians on the scale adapted Hatoum et al.Four thousand five hundred pharmaceutical analysis and 248 reconciliations were conducted. One hundred and fifty-six pharmaceutical interventions were issued. The average acceptance rate was 80%. A total of 5.8% of pharmaceutical interventions have been listed with a very significant clinical importance and 48.1% with at least significant clinical importance. The activities and documentation required pharmaceutical average daily time (senior pharmacist, resident and external pharmacist) about 6 hours.Other studies, including comparative and medico-economic, must be conducted to support these results. Nevertheless, the indicators obtained attend a better readability of the clinical importance of the activities performed by clinical pharmacists and this particularly in surgical services, both by prescribers and authorities.

Medulloblastoma are cerebellar tumours belonging to the group of primitive neuroectodermal tumours (PNET) and are the most common malignant brain tumours of childhood. These tumours are rare and heterogeneous, requiring some multicentric prospective studies and multidisciplinary care. The classical therapeutic approaches are based on clinical, radiological and surgical data. They involve surgery, radiation therapy and chemotherapy. Some histological features were added to characterize risk. More recently, molecular knowledge has allowed to devise risk-adapted strategies and helped to define groups with good outcome and reduce long-term sequelae, improve the prognostic of high-risk medulloblastoma and develop new therapeutic tools.

Clinical pharmacy has been developed and evaluated in various medical hospital activities. Reviews conducted in this area reported a higher value of this discipline. In surgical services, evenly adverse drug events may occur, so clinical pharmacy activities must also help to optimize the management of drug's patient. The objectives of this literature review is to determine the profile of clinical pharmacy activities developed in surgical services and identify indicators. The research was conducted on Pubmed(®) database with the following keywords (2000-2013), "surgery", "pharmacy", "pharmacist", "pharmaceutical care", "impact" and limited to French or English papers. Studies dealing on simultaneously medical and surgical areas were excluded. Twenty-one papers were selected. The most frequently developed clinical pharmacy activities were history and therapeutic drug monitoring (antibiotics or anticoagulants). Two types of indicators were identified: activity indicators with the number of pharmaceutical interventions, their description and clinical signification, the acceptance rate and workload. Impact indicators were mostly clinical and economic impacts. The development of clinical pharmacy related to surgical patients is documented and appears to have, as for medical patients, a clinical and economical value.

To assess the contribution of ictal SPECT to the definition of the epileptogenic zone (EZ) prior to surgery in focal drug-resistant epilepsies, we investigated the effect of the timing of injection and seizure semiology on patterns of perfusion and cerebral blood flow changes (CBF) beyond the EZ. In the rat model of amygdala-kindled seizures, we measured CBF changes with the quantitative [(14)C]-iodoantipyrine autoradiographic method during secondary generalized (SGS, n=26 fully-kindled rats) and focal seizures (FS, n=19 partially kindled rats), according to sequential timing of injection with respect to seizure onset. During SGS, the correct lateralization and rough localization of the focus within limbic structures was only possible at the early ictal and post-ictal times, in between we observed widespread rCBF increases. The switch from hyper to hypoperfusion occurred at the time of late ictal injection. The accurate localization of the EZ was obtained in the study of the more subtle FS (stage 0). At stage 1 of the kindling, there was already a remote widespread spreading of hyperperfusion. In patients surgically cured from a mesio-temporal lobe epilepsy (mean post-operative follow-up: 66 months), we retrospectively studied 26 pairs of ictal and interictal pre-operative SPECTs, classified in 3 groups according to the progression of ictal semiology. Using visual analysis of subtracted SPECTs (SISCOM) and group comparisons with a control group (using SPM), we observed more widespread combined hyper and hypoperfusion with the increasing complexity of seizures. In simple partial seizures, the SISCOM analysis allowed a correct localization of the focus in 4/8 patients, whereas the SPM analysis failed to detect significant changes, due to individual variation, spatial normalization and small magnitude of CBF changes. In complex partial seizures with automatisms, SISCOM and SPM analysis showed antero-mesial temporal hyperperfusion (overlapping the EZ), extending to the insula, basal ganglia, and thalamus in the group of patients having dystonic posturing (DP group) in addition to automatisms. Ictal hypoperfusion involved pre-frontal and parietal regions, the anterior and posterior cingulate gyri, to a greater extent in the DP group. In both human and animals studies, we observed a correlation between the extent of composite patterns of hyper/hypoperfusion and the severity of seizures, and the recruitment of remote sub-cortical structures. Hypoperfused areas belong to neural networks involved in perceptual decision making and motor planning, whose transient disruption could support purposeless actions, i.e. motor automatisms.

The surgical treatment of epilepsy requires careful preparation and presents a certain number of technical specificities. The neurosurgeon must master not only the technical aspects but also the therapeutic and functional trade-off in order to modulate the procedure according to morphological and electrophysiological intraoperative data. A large number of technical variants have been developed to correspond to epileptological or functional anatomical considerations. Until this point, the choice of a particular technique does not seem to have a significant impact on the therapeutic effectiveness of surgery, and differences in results can be related to the presurgical evaluation and surgical indications. On the other hand, technical development promises to play an important role in limiting the long-term neurocognitive consequences of surgery.

To evaluate the different therapeutic solutions for the management of periorbital hemangioma of infancy and childhood.and methods: A retrospective study conducted between 2000 and 2006, including nine children (five girls and four boys), aged from 1 month to 9 years old. All children underwent a complete clinical evaluation, orbital ultrasonography, computerized tomography, and magnetic resonance imaging scans. The different histopathological forms and the different management options were analyzed: surgical excision, intralesional steroid injection, and oral steroids.Surgery was performed in three cases and the results are discussed. Intralesional corticosteroid injections are effective and lead to complete reduction of tumoral volume and to the disappearance of the initial symptoms. With oral steroids, regression of the tumor was noted, followed by regrowth of the hemangioma at reduction or termination of therapy; complementary therapy such as surgery or intratumoral corticoid injection was often needed.It therefore seems necessary to establish therapeutic processes adapted to the age of the child, the tumoral histology, the location of the tumor, as well as the clinical and functional impact, in order to offer the patient the best chances of healing, taking into account that surgery and intralesional corticotherapy remain the methods of choice in the treatment of periorbital hemangioma in infancy and childhood.

We describe a rare case of parietal intradiploic encephalocele in a 51-year-old woman with no history of head trauma. The patient presented with a 1-month history of left hemiparesthesia. A hard indolent scalp lesion was palpable on examination in the right parietal area. Skull x-rays and cranial computed tomography examination demonstrated a lytic lesion that was consistent with a malignant osteolytic skull lesion. Magnetic resonance imaging of the head revealed an intradiploic cyst that included a round tissue mass contiguous with the parietal cortex. Surgery confirmed the diagnosis of encephalocele and the patient underwent surgical resection of the herniated brain, duraplasty, and cranioplasty. The presenting hemiparesthesia persisted at the 6-month follow-up. Encephaloceles of the cranial vault are a rare complication of skull fractures and rarely occur in adults. These lesions can be difficult to distinguish from congenital encephaloceles in patients with no history of head trauma. The pathogenesis, clinical and radiological nuances and the role of surgery are discussed.

Memory for the past has been much less explored than anterograde memory in temporal lobe epilepsy. No data are available about the course after surgical treatment. Moreover, case-reports showing isolated memory deficit for publics events with preserved autobiographical memory are notorious for their paucity.We report the case of a patient with a left hippocampal lesion associated with intractable temporal lobe epilepsy. Comprehensive neuropsychological assessments were carried out before and after temporal lobectomy, stressing particularly memory for the past by means of standardised and tailor-made tests.The patient exhibited preserved memory for autobiographical events and facts but impaired scores on several public event tests, in the context of preserved general abilities. Furthermore, we found an accelerated forgetting rate for verbal and non verbal material.Our findings suggest that the patient's impaired long-term consolidation might have contributed to the impaired performance on public event memory tests. We discuss the specific features of new events processing that may contribute to its increased vulnerability relative to autobiographical memory, in the event of accelerated forgetting.

Systemic maternal-fetal Candida albicans infections are uncommon diseases with a poor outcome. An associated cerebromeningeal infection increases morbidity. We present a case of neuromeningeal candidiasis following systemic neonatal infection in a premature infant. Management and therapeutic difficulties are outlined.The patient was a male infant born preterm at 30 weeks gestation. During his first week of life, he developed a systemic infection with an associated symptomatic hydrocephalus. Systemic candidaisis with neuromeningeal complication was diagnosed five weeks later. Despite treatment including cerebrospinal fluid (CSF) shunting and antimycotic medications (flucytosin and amphotericin B), the candidal infection did not resolve. Infectious and mechanical complications of the CSF drainage were treated by several surgical interventions during the following months. At 10 months of life, there was clinical and laboratory evidence of active persistent neuromeningeal candidaisis. Finally, candidal infection was eradicated with intravenous administration of fluconazole. After five year follow-up, the intellectual and psychological status of the patient was quite satisfactory, and no neurological deficits were found on clinical examination.Management of neuromeningeal candidaisis in premature infants is a challenging task particularly because of delayed diagnosis. Candida infection should routinely be suspected in cases of systemic infection with neurological impairment in premature infants. Fluconazole may constitute an efficient therapeutic option.

Rarely children with Wilms' tumor develop spinal cord dysfunction by metastatic spread into the epidural space or the cord parenchyma. In the case reported here, the mechanism of spinal compression was different.The authors report the clinical course of a 2-month-old boy with retroperitoneal extrarenal Wilms' tumor below the left kidney, characterized with a spinal cord compression developed through the intervertebral foramina.Abdominal tumor, usually corresponding to neuroblastoma, may be a nephroblastoma.

To compare the outcome between operated and non-operated brainstem cavernomas.Clinical and radiological data of 30 patients harboring 35 brainstem cavernomas were retrospectively reviewed. The mean follow-up period was 47 months. Relationship between the cavernoma and the pi maer was graded. The histology of each operative case was systematically confirmed. The Karnofsky mean score was calculated at admission and at the end of the follow-up period. Patients were classified in three groups according to their outcome grade (Group I=good; Group II=unchanged; Group III=worse). We compared the outcome between operated and non-operated patients. For operated cases, we found several factors of poor outcome. Statistical tests used to compare the groups of patients were Yates modified chi(2) with calculation of the exact probability. Chosen risk was 5%.Thirty-eight percent of operated patients were permanently disabled after surgery whereas the same proportion was improved. None of the patients in the control group worsened at the mean 47-month follow-up despite the occurrence of two hemorrhagic events. Statistical study showed that treatment modality affected clinical outcome in these patients. Only patients presenting with multiple deficits and progressive neurological deterioration were improved with surgery. Surgical access through the floor of the fourth ventricle was correlated with a poor outcome. Partial removal of the cavernoma increased the risk of future hemorrhage.Surgery showed no proof of its efficiency in the management of brainstem cavernomas at the end of the follow-up period. Indications of surgical treatment must be restricted to cases with a severe and progressive neurological deterioration.

We present four cases of cerebral cavernous angioma that developed after radiatherapy for brain tumor in three cases and for cavernous angioma in one case. The time interval between irradiation and the detection of the cavernous angioma varied from three to nine years and the doses from 24 to 60 Grays. Brain hemorrhage appeared in two cases. Explanation for the formation of cavernous malformations is unclear but is probably related to proliferation and dilatation of the vascular endothelium with formation of capillary telangiectasis with evolution to cavernous angiomas. The pediatric brain appears particularly vulnerable to radiation injury. The risk of hemorrhage appears higher than with spontaneous cavernous malformations.

This report describes the use of the recent three-dimensional Fourier transform constructing imaging in the steady state (CISS) MR sequence in the management of obstructive hydrocephalus. It is a gradient-echo imaging technique with high resolution which remains sensitive to flow. It enables locating the obstruction and determining the upstream impact. It provides anatomical information about third ventricle (V3) morphology and relationships useful before ventriculostomy. Twenty patients with obstructive hydrocephalus at the level of cerebral aqueduct or posterior V3 underwent sagittal 3DFT-CISS acquisition, supplemented by frontal, axial and coronal reformations in the cerebral aqueduct axis. 9 patients were examined after ventriculostomy with the same protocol. CISS-3DFT allows good visualization of the cerebral aqueduct and diagnosis of the underlying cause of obstruction (malformation, tumor), sometimes better than classical sequences. In case of complete obstruction, the flow-related signal void is usually absent in the cerebral aqueduct or V3. The position of V3 floor and its relationship with the tip of basilar artery are well analyzed. The dilatation of the anterior V3 recesses is a better sign of activity of hydrocephalus - and then of therapeutical indication - than classical transependymal resorption signs which are not always present in chronic longstanding adult hydrocephalus. Of the 9 ventriculostomy patients seven had linear flow-related signal void through V3 floor, from anterior V3 to basal cisterns on the postoperative MR study. This flow void confirms patent ventriculostomy.

We report a case of acute spinal subdural hematoma which developed then regressed spontaneously. MR imaging contributed essential information for diagnosis and follow-up after conservative treatment. We made a short review of the literature and discuss the causes, pathogenesis, clinical presentation and usual treatment of acute spinal subdural hematoma. The differential diagnosis with the more frequent and extradural hematoma requiring immediate surgical evacuation is fundamental.

The origin of the ophthalmic artery exhibits several variants which can be explained by a vascular morphogenesis study. The particular relations of the ophthalmic artery with the optic nerve and the cranial meninges are examined using serial histological sections.

The incidence of intracerebral metastasis is largely underestimated. They appear to be the most frequent cause of intracerebral tumors with an average incidence of probably more than 12/100 000 inhabitants per year. Depending on reports, 25 to 35% of cancer patients will develop brain metastasis. In neurosurgical series, the frequency of cerebral metastasis among surgical procedures for brain tumors increased from 3.5 to 12%. We reviewed the literature in order to better know the frequency of intracerebral metastasis depending on the type of primary cancer. The rate of other metastatic lesions, the duration between discovery of the primitive cancer and brain metastasis were found to be useful for selection of patients for neurosurgical treatment. Three types of cancers could be defined, regarding the incidence of brain metastasis. While occurrence of brain metastases is very high, surgery should often be useless; if brain metastases only occur in the late stage of a cancer, then, surgery should be discussed according to the general status of the patient; although brain metastasis is rare in a cancer, surgery will often be required for diagnosis and treatment.

Brain metastasis results from complex interactions between host cells and primitive tumor cells. An analysis of the molecular pathways at the cellular level is provided in this review of the literature. The principal new therapeutic modalities are directly based on our comprehension of those molecular biology hypothesis.

The posture of the neurosurgical patient depends first on the approach and working position of the surgeon, and the spatial orientation during surgery. Venous outflow is probably the major factor for optimal brain retraction and for preventing venous haemorrhage. No one of the postures presently in use is fully free from the risk of air embolism. Respiratory and cardiac diseases are often limiting factors for the choice of a posture. Thoracic and abdominal compression must be cautiously avoided.

The sitting position offers the benefits of better access to the apex of the posterior fossa, and an improved exploration and dissection because blood and cerebral spinal fluid drain away from the operative site. Specific complications of the sitting position include cardiovascular instability, jugular venous obstruction, airway oedema, quadriplegia, displacements of catheters and the endotracheal tube, ulnar, sciatic and lateral peroneal nerve compression, venous air embolism, and tension pneumocephalus. In the only existing comparative study, the differences were an increased bleeding in the horizontal position and a better cranial nerve preservation in the sitting position. This argues strongly for teaching and use of the sitting position whenever surgically indicated.

The prone position for posterior fossa and cranio-spinal surgery is becoming the standard posture for neurosurgical teams. We analyze the reasons of such a change and specify indications of this posture. Thereafter, the procedure for optimal positioning is considered and the benefits of the prone position for the neurosurgeon and the anaesthetist are discussed. The selected references originate from Medline search (1991-1997), the Year Book of Neurology and Neurosurgery and the major neurosurgical review articles published between 1980 and 1996.

The lateral posture (Park Bench) is now widely used. It provides a comfortable position for the surgeon and a convenient brain relaxation. However the positioning is complex and carries a risk of stretching of the brachial plexus. Spatial orientation is more difficult and requires surgical experience. The lateral position does not modify the haemodynamic and respiratory function in healthy patients. In the opposite, various cardiac or respiratory effects of right or left lateral position can occur in patients with cardiac and/or respiratory pathology.

The arterial vascularization of the dura mater of the anterior cranial fossa belongs to the middle meningeal artery, branch of the external carotid artery, and to the ophthalmic artery issued from the internal carotid artery. This vascular diagram presents numerous variations, whose complexity may be explained by the vascular morphogenesis. The distribution of the dural arteries and the dural microvasculature are described.

We report one case of radio-induced meningiomas revealed by an intracranial hypertension in an 46 year-old woman. A history of cephalic irradiation during infancy for a vascular nevus, not spontaneously reported by the patient, had been discovered because of the association with a radio-induced cataract. Meningiomas are a rare, severe and late complication of cephalic radiotherapy. The history of irradiation is not always spontaneously reported by the patient.

The aim of this study was to describe the histological specificities of posterior lumbar epidural fat (PLEF) considered a "semi-fluid" tissue. We performed axial histological sections of posterior lumbar epidural fat through the abdomen of two foetuses, as well as histological sections on several planes in 11 adults. For comparison, we simultaneously cut sections in subcutaneous fat of adults (SCF). In the foetuses the epidural fat was arranged around the dural sac and extended along the entire lumbar spine, whereas in adults the epidural fat was discontinuous and the fat pads were located at intervertebral disc level, in a trianglular space with posterior apex, limited by the ligamenta flava laterally and by dural sac anteriorly. The PLEF was a homogeneous tissue in both size and shape and consisted of regular adipocytes and little connective tissue. In contrast, the SCF was made of adipocytes which varied in size and shape and were accompanied by numerous connective fibers (fibrous cones) subdividing the hypodermis into lobules. But the main specificity of the PLEF was the oriented empty spaces or slits found and observed in all samples with a special arrangement. These slits subdivided the fat into several layers enabling them to slide and could be regarded as "sliding spaces". They were never observed in the SCF samples. PLEF, therefore, is not a simple filling tissue. Its histological features (homogeneity, scarcity of connective tissue and oriented slits) explain the "semi-fluid" characteristic and confirm the specialization of this fat tissue. Its location at the level of the mobile segment of the lumbar spine suggests that it plays a role of sliding structure between the posterior surface of the thecal sac and the anterior surface of the vertebral arch.

The present study has been carried out in order to better understand the so-called cavernous sinus lateral wall anatomy. Special attention has been drawn at the sheaths of the cranial nerves running through it. Serial sections of the parasellar region of four human embryos (7, 10, 11, 12 week-old), two fetuses (14 week-old and 7 month-old), one adult and cadaveric microdissections (14 cavernous sinus) have been used. We could observe that the oculomotor and the trochlear nerve possess meningeal sheaths, which accompany the nerves into the parasellar lodge up to the anterior clinoid process for the oculomotor nerve. However, the remaining distal portion of these nerves are embedded in a peripheral sheath. Conversely, the meninges of the Meckel's cave stop at the trigeminal ganglion, its branches have only peripheral sheaths and are located, as the venous system, in an "interperiosto-dural space". The presence of arachnoid granulations into the lateral and superior walls of the lodge, around the trigeminal ganglion, near the oculomotor, trochlear and ophthalmic nerves explains the location of meningiomas in these areas. These anatomical findings could provide the basis for a classification of meningiomas of the cavernous sinus and help the surgeon to preserve the uninvolved cranial nerves.