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The authors are reporting on a study drawn from unpublished dissertation done by the corresponding author when he completed his neurosurgical training in Paris, France in 2004, few years before the advent of flow diverters. The study was a retrospective review of giant intracranial aneurysms treated by superficial temporal artery to middle cerebral artery bypass combined with endovascular occlusion of the parent artery. From 1990 to 2003, 29 consecutive cases of giant cerebral aneurysms, not suitable to selective treatment were managed in that way. Twenty-one medical records had enough data to allow objective evaluation. Sixteen female and five male patients bearing 21 giant aneurysms were involved. Their mean age was 46 years. The aneurysm was revealed by mass effect in 13 cases and subarachnoid hemorrhage in one case. On admission 19 patients presented with unruptured aneurysms and two have sustained a subarachnoid hemorrhage. The balloon occlusion test before the bypass operation was not tolerated in 18 patients. The treatment was completed in 19 patients and 17 of them had parent artery occlusion with latex detachable balloons. The only death of the series occurred before the endovascular treatment. The mean follow-up period was 30 months. After completion of the treatment, 16 (84%) patients had no symptom. Aneurysm recanalization or rupture was not observed after the parent artery occlusion. With the combination of superficial temporal artery to middle cerebral artery bypass + endovascular parent artery occlusion, 90% of giant intracranial aneurysms untreatable selectively were permanently excluded with a good outcome in 95%.

Background. A consensus conference recommended empirical antibiotic therapy for all patients with postoperative meningitis and treatment withdrawal after 48 or 72 h if cerebrospinal fluid culture results are negative. However, this approach is not universally accepted and has not been assessed in clinical trials. Methods. We performed a cohort study of all patients who received a diagnosis of postoperative meningitis from January 1998 through May 2005 in a teaching hospital. From January 1998 through September 2003 (control period), guidelines were lacking or were not implemented. From October 2003 through May 2005 (interventional period), all patients received a predefined intravenous antibiotic therapy that was discontinued on the third day if the meningitis was considered aseptic. Clinical outcome and duration of antibiotic therapy were analyzed for each patient. Results. Seventy-five episodes of postoperative meningitis (21 cases of bacterial meningitis and 54 cases of aseptic meningitis) were investigated. Patients with aseptic meningitis received antibiotic treatment for a mean ± standard deviation duration of 11 ± 5 days during the control period and 3.5 ± 2 days during the intervention period (P = .001). The duration of antibiotic treatment for bacterial meningitis was not significantly different between the 2 periods. All episodes of bacterial and aseptic meningitis were cured, and complications were rare during both periods. Conclusions. Stopping antibiotic treatment after 3 days is effective and safe for patients with postoperative meningitis whose cerebrospinal fluid culture results are negative.

We report a case of infratentorial primary paraganglioma for which we have a 10-year incomplete pretreatment clinical and radiological follow-up. Partial surgical removal followed by external radiotherapy resulted in stable disease at 6 years follow-up. We compare our patient's case with similar cases reported in the literature.

Lipomatous meningiomas are rarely encountered and are included in the World Health Organization's (WHO) group of metaplastic meningiomas. We report two cases of these tumors. The presenting symptoms were headaches in one case and seizure in the other. Radiologically, these tumors were extra-axial and unique. One tumor displayed fat accumulation, while the other had the appearance of a conventional meningioma. Microscopically, these tumors corresponded to meningothelial and transitional meningiomas containing a variable proportion of adipose tissue composed of mature adipocytes or lipoblasts. Fat content was high in one case and moderate in the other, thus explaining the radiological findings. Expression of epithelial membrane antigen and progesterone receptors was present in meningothelial, adipocyte-like, and lipoblast-like cells. These immunohistochemical results suggest that lipid accumulation in meningioma should be considered a transformation of meningothelial cells rather than a true metaplasia.

OBJECTIVE To assess the value of cerebrospinal fluid pressure as a decisional factor for immediate surgical revision in cerebrospinal fluid leakage after acoustic neuroma removal. STUDY DESIGN Prospective study. SETTING Tertiary referral center. PATIENTS Between 1998 and 2001, 220 patients were operated on for acoustic neuroma by different transpetrosal approaches. Among 24 patients (12%) presenting postoperative cerebrospinal fluid leakage, those with meningitis or with hydrocephalus were excluded. Fifteen patients were included in this study. METHODS Each patient had initial conservative treatment with serial depletive lumbar punctures and cerebrospinal fluid pressure measurements associated with oral acetazolamide. Surgical revision was decided on in case of persistent cerebrospinal fluid leakage. RESULTS In eight patients with high cerebrospinal fluid pressure (18+/-1.4 cm H2O; range, 14-28 cm H2O), cerebrospinal fluid leak disappeared in 3 days after conservative treatment. Seven other patients required surgical revision for persistent cerebrospinal fluid leakage. Revision surgery was efficient in six patients with low cerebrospinal fluid pressure (8+/-1.3 cm H2O, range, 3-12 cm H2O). In the remaining patient with high cerebrospinal fluid pressure (18 cm H2O), cerebrospinal fluid leakage continued despite surgical revision, requiring lumboperitoneal shunting. CONCLUSION The cerebrospinal fluid pressure value may be used as a decisional indicator for cerebrospinal fluid leakage treatment after acoustic neuroma surgery. Low cerebrospinal fluid pressure leakage would imply a revision surgery procedure without delay, whereas high cerebrospinal fluid pressure leakage would imply conservative treatment.

A case report of an adult patient with an osteoid osteoma of the lamina of 9th thoracic vertebra is presented. The long history of progressively worsening nocturnal dorsal pain which was relieved by non-steroid anti-inflammatory drugs, and an essentially clinical examination, are typical of this condition in which the CT and radionuclide bone scans are the investigation of choice. Complete relief was obtained following excision of the lesion. The literature is reviewed.

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

Background Supratentorial hemangioblastomas are rare lesions, occurring either sporadically or in von Hippel-Lindau disease. Objective Following recent advances in our understanding of the natural history of von Hippel-Lindau-associated cerebellar and spinal hemangioblastomas, we conducted a study of the natural history of supratentorial hemangioblastomas in von Hippel-Lindau disease. Methods We reviewed a series of 18 supratentorial hemangioblastomas in 13 patients with von Hippel-Lindau disease. Clinical, genetic, and serial imaging data and operative records were analyzed. Results Hemangioblastomas were most commonly seen in the temporal lobe. Only 6 tumors had a cyst at diagnosis or during follow-up, and only 6 patients had associated symptoms at presentation or during follow-up. The most frequent clinical presentations were intracranial hypertension and visual loss. Of 14 tumors with documented serial imaging, 13 demonstrated tumor growth. Rates and patterns of tumor growth were unique to each patient. The mechanism of cyst formation described in other locations was also demonstrated in the supratentorial region. Patterns of peritumoral edema and rate of cyst formation seemed to be influenced by the presence of anatomic barriers. Germline VHL mutation was identified in all patients, but no specific genotype-phenotype correlation was found, although a familial predisposition is suggested. Conclusion This series illustrates the wide variation in tumor locations, patterns of growth, and edema progression seen in supratentorial hemangioblastomas and adds to our knowledge of the natural history of hemangioblastomas.

OBJECTIVE AND IMPORTANCE: The cavernous sinus is an exceptional location for intracranial tuberculomas. A rapid diagnosis, based on pathological findings, improves the prognosis. CLINICAL PRESENTATION: A case of left cavernous sinus tuberculoma, revealed by frontal headaches and ipsilateral palsies of Cranial Nerves III and V, in a 48-year-old patient is reported. The lesion mimicked an aggressive meningioma in radiological examinations. INTERVENTION: The lesion was excised through a subtemporal approach. The diagnosis was based on the pathological examination of the mass. Postoperative antituberculous chemotherapy completed the treatment. Neurological symptoms regressed rapidly. CONCLUSION: Although the incidence of intracranial tuberculomas is decreasing in developed countries, a high index of suspicion must be maintained for the diagnosis of intracranial masses in the presence of risk factors for tuberculosis.

Objectives Postoperative spondylodiscitis (POS) is poorly characterized, partly owing to its rarity. The aim of this prospective study was to compare the clinical, biological, bacteriological, and imaging features of postoperative and spontaneous spondylodiscitis (SS). Methods A multidisciplinary spondylodiscitis cohort follow-up study was conducted between February 1999 and June 2003 in a 500-bed teaching hospital. All patients hospitalized in internal medicine, orthopedic, and neurosurgery wards with a culture-proven diagnosis of pyogenic spondylodiscitis were included. Clinical and bacteriological data were collected. All patients underwent computed tomography and/or magnetic resonance imaging of the spine. Results Sixteen patients had SS and 7 patients had POS. Patients with POS tended to be younger (52 versus 69 years), with less frequent underlying diseases (29 versus 75%) and a more prolonged interval between symptom onset and diagnosis (16 versus 3.4 weeks) than patients with SS. Blood cultures were positive in 14 and 81% of cases in the POS and SS groups, respectively, and invasive diagnostic procedures were necessary in 86% of patients with POS and 19% of patients with SS ( P = 0.005). Staphylococci were the more frequent isolates in both groups but were more frequently coagulase-negative in POS patients than in patients with SS ( P = 0.01). Vertebral edema tended to be more frequent in POS and was located more posteriorly than in SS ( P = 0.023). Conclusions POS is associated with specific clinical, microbiological, and imaging features possibly related to pathophysiologic characteristics. Knowledge of these characteristics should help reduce the current delay in the diagnosis of POS.

Osteoid osteoma is a benign bone tumour which rarely occurs in the skull. A case of such a tumour in the posterior ethmoid region bulging into the anterior cranial fossa is reported in a 42-year-old woman who presented with intense frontal headaches. Excision of the tumour was performed through a subfrontal approach.

This retrospective study analyzed 29 cerebral abscesses of ear, nose, and throat (ENT) origin. The mean follow-up of patients was 37 months. ENT etiologies included 45% otitis media (n = 13), 48% sinusitis (n = 14), and 7% ethmoidal sinus tumors (n = 2). Thirty-eight percent (n = 5) of otogenic abscesses occurred within 15 days after a mastoidectomy. Sinogenic abscesses were never due to surgery but were associated in 31% of cases (n = 5) with anterior skull base defects. The main locations of otogenic abscesses were the temporal lobe (54%; n = 7) and the cerebellum (23%; n = 3), whereas sinogenic abscesses were located in the frontal lobe in 75% of cases (n = 12). Because of this location, sinogenic abscesses were less symptomatic than otogenic ones and had greater size and encapsulation at the time of diagnosis. Thus, they required longer antibiotic treatment (p = 0.05) and more numerous surgical drainages (p = 0.02). Bacteriologic abscesses samples were positive in 90% of cases. Bacteria found in brain abscesses were different from the ones found in ENT samples in 62% of cases. Thus, the results of ENT bacteriologic samples were not helpful for choosing adequate antibiotic agents in case of negative brain abscess samples. Although mortality was not significantly higher in otogenic abscesses (31%; n = 4) than in sinogenic ones (6%; n = 1, p = 0.08), otogenic abscesses appeared more threatening. Indeed, they represented 80% (n = 4) of lethal cases and encompassed more clinical or radiological prognosis pejorative factors than sinogenic ones (p = 0.006). In conclusion, higher danger of otogenic abscesses mainly resulted both from their temporal or cerebellous locations and from the bacteria that were more frequently resistant to antibiotics.

We evaluated a 56-year-old man for a spinal cord syndrome of progressive bilateral leg weakness with dysuria and paresthesias of the lower limbs. T2-weighted MRI showed a hyperintensive signal of the dorsal medulla and mild vascular dilations at the surface of the spinal cord. The suspected diagnosis of spinal dural arteriovenous fistulas (SDAVF) was confirmed by spinal angiography. The fistula was fed by the right T-6 intercostal artery and drained into the posterior spinal vein. When the patient was informed of his diagnosis, he replied that he had known about the anomaly for 2 years. Two years before, he had undergone a body CT scan for an unrelated condition. Tubular contrast enhancement of the spinal canal had prompted a spine MRI and MR angiography (MRA). MRI showed vascular dilations at the surface of the spinal cord …