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Brain abscesses and empyemas are severe infections with lethal outcomes in the case of inappropriate treatment. The files of 34 patients with brain abscesses, and nine with intracranial empyemas treated over eight years (1990-1997) were analyzed retrospectively. Cases were evaluated for treatment and compared with data from the literature. Patients with brain abscess underwent either aspiration of the lesion through a burr hole (79.5% of the cases), or craniotomy and excision (8.8% of the cases); 11.7% were treated only with antibiotics. The operative mortality was 2.9% and the outcome was satisfactory in 85% of patients. These results are in agreement with data from the literature. Prognosis is strongly related to the initial clinical status. Current methods of treatment include surgical aspiration of large abscesses with a mass effect, and are usually associated with a poor clinical status. Excision is suggested whenever aspiration procedures have failed, or in the presence of foreign material or fungal abscess. Medical treatment is indicated for small and deeply located abscesses in patients with satisfactory clinical states. Empyemas in our series were treated with burr hole and pus aspiration. The mortality rate was 11%, and 62.5% of the patients made a good recovery. In agreement with other reported studies, the method of treating subdural empyema is much less significant than an aggressive early drainage of the infection. Although brain abscesses and empyema remain a significant neurosurgical concern, aggressive treatment can result in an excellent outcome in the majority of patients.

Cervical spondylotic myelopathy is usually a chronic and progressive disease. In a few cases, however, dramatic tetraplegia sometimes occurs after even minor injury.We report seven patients (6 males, 1 female, aged from 41 to 63), who suffered from acute myelopathy after an injury.In 5 cases, the injury revealed the cervical spondylotic myelopathy. A hyperextension of the cervical spine was found in 5 cases. The injury was severe in only one case, but there was no bony abnormalities, except arthrosis. The most common cause was a fall. In contrast, severe tetraplegia was found in 4 cases. Spontaneous, but incomplete, recuperation occurred in 4 patients. In all 7 cases, CT scan and MRI showed congenital cervical stenosis associated with cervical spondylosis. The level of disco-osteophytic changes was mainly in C4, C5, C6. On T2-weighted spin-echo image, an increased signal intensity was present in the cord of 3 patients, but was not correlated with the severity of the symptoms, nor with improvement. Surgical treatment was performed in 6 cases: 3 laminectomies, 3 anterior or antero-lateral approaches. Improvement after operative decompression was observed in all but one case, even when the motor or sensory deficit persists for more than one year. Motricity of the inferior limbs improved better than the other deficits, perhaps because of the location of non-reversible lesions in the spinal gray matter.The acute medullary syndrome of cervical spondylotic myelopathy is serious and can cause major handicaps. This complication justifies a preventive surgical attitude when medullar signs are moderate, and cervical imagery shows a spondylotic compression of the cord with congenital stenosis.

Six patients with neurological complications in Rendu-Osler-Weber disease were reviewed. There were 4 patients (3 int the same family) with a brain abscess, one patient with a brain abscess and a spinal cord subarachnoid hemorrhage, one patient with a recurrent intracerebral hemorrhage due to a vascular malformation. The infectious complications are related to the presence of pulmonary arterio-venous fistula, which should be treated, whenever diagnosed. Because of the potentially severe outcome of these neurological complications of the Rendu-Osler-Weber disease, screening of the patient's relatives is highly recommended.

Pituitary apoplexy results from necrosis or haemorrhage of a pituitary adenoma. This rare complication occurs in 2 to 10% of operated adenomas. The acute form results from massive intrapituitary bleeding leading to violent headache, meningeal signs, impaired conscience and ophthalmology signs, basically bilateral blindness. Associated signs are frequent including paralysis of the oculomotor nerves, epilepsy seizure, hemiplegia. Diabetes insipidis is exceptional. In less acute forms, the sudden nature of the headache and ophthalmology signs can suggest diagnosis. Standard X-ray reveals destruction of the sella turcica. Computed tomography shows either a haematoma or a cystic cavity in the pituitary gland which must be perfectly described together with the integrity of the bone structures due to the risk of lysis. Magnetic resonance imaging is an essential technique which can be used to describe the volume and suprasellar extension of the tumour, its texture, possible compression of adjacent structures and determine the age of the haemorrhage. This imaging technique can also isolate rare optochiasmatic apoplexia requiring intracranial evacuation. Emergency surgery is mandatory for most all authors. Rhinal-septal decompression is usually used, but the intracranial route may be preferred for very large suprasellar tumours. Medical treatment alone may be successful for small prolactin adenomas. Outcome depends on the time lapse to decompression. Optic nerve recovery is usually possible if the delay is less than 7 days. Cranial nerve recovery is less dependent on the time interval. In all cases hormone substitution is required.

Seventeen patients with subdural empyema were treated from 1985 to 1993. These included 13 males and 4 females with 11 patients aged between 12 and 30 years old. Sinusitis was found to be the primary source of infection in 16 cases. The clinical presentation was classic and the preoperative diagnosis was established on the first CT in 12 cases. In the remaining cases a second or third CT was necessary to demonstrate the empyema, 24 to 48 hours later. Surgical management was first made by burr holes with a small craniectomy in 15 cases. A large craniotomy was performed in 2 patients. Soft catheter drainage was carried out in 6 cases, 9 patients received surgical treatment once (3) or twice (6). Two patients, operated on while in a coma (stage IV of Bannister scale) died and one patient survived with severe disability (operated at stage III). The others (14) made a good recovery (6 in grade A and 8 in grade B of Mauser). These results were compared with those in the literature and we concluded that the mean factor of prognosis is the level of consciousness at the time of initial treatment. In most of the cases, burr holes or a small craniotomy, carried out on the basis of CT or MRI data, are the easiest and most effective method of surgical treatment.

We describe the case of a woman, who presents a spontaneous rhinorrhea. The metrizamid computerized tomographic cisternography proves the precise anatomic location of the dural osseous defect, in the left sphenoidal sinus. Transsphenoidal approach terminated the leakage in a single procedure, without shunt.

The introduction of vascular micro-surgical techniques has allowed to treat cerebral ischemia, through extra-intra-cranial anastomosis, when the causative arterial lesions have a surgically unfavorable location. Thirty patients underwent brain revascularization through extra-intra-cranial micro-anastomosis between the superficial temporal artery (branch of the external carotid artery) and a cortical branch of the middle cerebral artery. Twenty five patients had definite sensitive and motor deficits. Five patients, on the other hand, underwent preventive surgery because of transient cerebral ischemia. In our series, the global rate of the microanastomosis patency is 78%. When the anastomosis is patent, 85% of the cases with motor deficits are cured or improved. The results are even more favorable in case of transient cerebral ischemia, for the anastomosis in such cases was always patent. None of these later patients had ischemia attacks with a one-year follow-up.