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Studying 2,413 cases of supratentorial brain tumors operated on a 30 years period, the author emphasizes appealing signs, pitfalls, and tumoral relapses. Epilepsy is the most frequent initial sign preceding headache and focal signs. We discuss the frequency of the epilepsy, the age of the first seizure, the location and the histological nature of the epiletogenic tumor, and the type of the seizures. In the end, we study diagnosis pitfalls such as long-standing epilepsy, ictal presentation, pitfalls due to metastases and the difficult problem of tumoral relapses.

SUMMARY This etiological and clinical study concludes with the following propositions. 1 In cases of cranial trauma, those having had severe hemispheric lesions with anatomically proven damage are predisposed to epilepsy. 2 A delay in the maturation of the epileptogenic focus is necessary; this delay is longer the younger the patient and the further the initial lesion from the motor area; it is shorter when the brain lesions are more numerous and diffuse. 3 Generalized seizures are frequently signs of traumatic epilepsy, but not exclusively; they also stem from frontal lesions and to a slightly lesser degree from temporal lesions, but any cortical lesion may induce them. Psychomotor seizures are seen mainly after temporal lobe lesions but less frequently after injury to neighbouring lobes; Bravais-Jacksonian attacks are more rare. 4 Seizures with partial clinical expression do not necessarily indicate a single lesion confined to the corresponding cortical area. 5 Although the predominance of cortical lesions in determining traumatic epilepsy is accepted, the role of the brain stem lesion is still to be determined. RESUME Les auteurs ont etudie 247 epileptiques sur une serie de 2331 traumatises crâniens. La duree d'observation a ete de 3 a 16 ans. 1 Parmi les traumatises crâniens sont predisposes a l'epilepsie ceux qui ont eu des lesions hemispheriques severes laissant des dommages anatomiques demonstrables; 2 Un delai de maturation du foyer epileptogene est necessaire, d'autant plus long que le blesse est plus jeune et que la lesion initiale est a distance de la zone motrice, d'autant plus court que les lesions encephaliques sont plus nombreuses et diffuses; 3 Les crises generalisees sont l'expression frequente de l'epilepsie traumatique mais non exclusive; elles relevent essentiellement des lesions frontales, a un degre un peu moindre des lesions temporales, mais toute lesion du cortex peut les induire; les crises psycho-motrices s'observent essentiellement apres lesion temporale, mais aussi avec une moindre frequence apres alteration des lobes voisins; les crises bravais-jacksoniennes sont plus rares; 4 Des crises d'expression clinique partielle ne signent pas obligatoirement une seule lesion confinee a l'aire corticale correspondante; 5 Si Ton admet la preeminence des lesions corticales dans le determinisme de l'epilepsie traumatique, la place tenue par les lesions du tronc cerebral reste encore a apprecier.

The authors report 90 cases of space occupying lesions originating in the occipital lobe, including 58 primary (26 malignant gliomas, II "benign" gliomas, 19 meningiomas, I sarcoma nad I hémangioblastoma (and 32 secondary masses (i. e. 16 metastatic tumors, 15 abcesses and I hydatid cyst). The onset of clinical features was progressive (gradual increase of intracranial pressure : 59 p. 100) rather than acute (41 p. 100 mostly as a visual (II) or a non visual (10) epileptic seizure). The time elapsed between the first symptom and the surgical procedure in any case appeared to be much shorter than in masses with other hemispheric localisation. This is thought to be due to the precocity and the intensity of the increased intracranial pressure, in relation to the blocage of posterior venous drainage. Increased intracranial pressure : only 7,7 p. 100 of the patient were free of IIP. Fundal changes are of little value in excluding this finding since no less than 3 months of evolution are necessary for their appearence. Visual disturbances consisted of acute obscurations (7.7 p. 100), controlateral deviations of head and eyes (3.3 p. 100) and visual field defects = 10 p. 100 of the patients were comatose and unable to be examined, 16.6 p. 100 had normal visual field. All the others had visual field defects wich could be evaluated by campimetric examination in only 26.6 p. 100. These included 14 hemiopias (7 without macular sparing) and 10 quadranopsia, always with incongruence (4 superior and 6 inferior). When the mass was strictly occipital, the same disparity was observed. Finally these visual field defects appeared to be variable and could well recover after surgery. Visual hallucinations were mostly of elementary type (21 p. 100) and always controlateral in cases of strictly occipital lesions. Elaborate hallucinations were rare (2 patients with extensive lesions). 8.8 p. 100 suffered from visual illusions wich always were related to large and right-sided masses. Disturbances of higher functions : Alexia was seen in 33 p. 100 of the left-sided masses (24 p. 100 "agraphic", 9 p. 100 "pure word blindness") Space agnosias of different type was found in 10 p. 100 of the patients, sometimes with purely occipital tumors.

Between 1975 and 1983, 17 patients who underwent surgery for haemangioblastomas of the brain (16 lesions occurring in the posterior fossa) were studied with CT scans (17 cases) and vertebral angiograms (15 cases). The CT scans were superior for demonstrating a cystic tumour, its topography in the posterior fossa, its relationship to the fourth ventricle, and the presence and degree of an obstructive hydrocephalus. The vertebral angiographies were more sensitive and specific than CT for revealing the vascular nature, and were imperative in order to establish the supply and drainage of the tumours. It is clear that CT and angiography each make an important contribution toward defining these tumours. Their association is necessary.

✓ The results of the surgical treatment of cerebral hemorrhage in 250 cases are reported. Preoperative diagnosis, the selection of patients, and the favorable moment to operate are discussed.