Search

Background Cerebral cavernous malformations (CCMs) are common sporadic and inherited vascular malformations of the central nervous system. Although familial CCMs are linked to loss-of-function mutations in KRIT1 (CCM1), CCM2, or PDCD10 (CCM3), the genetic cause of sporadic CCMs, representing 80% of cases, remains incompletely understood. Methods We developed two mouse models harboring mutations identified in human meningiomas with the use of the prostaglandin D2 synthase (PGDS) promoter. We performed targeted DNA sequencing of surgically resected CCMs from patients and confirmed our findings by droplet digital polymerase-chain-reaction analysis. Results We found that in mice expressing one of two common genetic drivers of meningioma - Pik3ca H1047R or AKT1 E17K - in PGDS-positive cells, a spectrum of typical CCMs develops (in 22% and 11% of the mice, respectively) instead of meningiomas, which prompted us to analyze tissue samples from sporadic CCMs from 88 patients. We detected somatic activating PIK3CA and AKT1 mutations in 39% and 1%, respectively, of lesion tissue from the patients. Only 10% of lesions harbored mutations in the CCM genes. We analyzed lesions induced by the activating mutations Pik3ca H1074R and AKT1 E17K in mice and identified the PGDS-expressing pericyte as the probable cell of origin. Conclusions In tissue samples from sporadic CCMs, mutations in PIK3CA were represented to a greater extent than mutations in any other gene. The contribution of somatic mutations in the genes that cause familial CCMs was comparatively small. (Funded by the Fondation ARC pour la Recherche contre le Cancer and others.).

Meningiomas represent about 20% of intracranial tumors. Involvement of the medial sphenoid wing includes anterior clinoid, cavernous sinus and superior orbital fissure meningiomas. Due to the proximity of these tumors to the optic nerve, typically progressive unilateral vision loss, over several months to years, is the classic clinical presentation. We report three cases of acute monocular vision loss, two transient and one permanent, ipsilateral to a sphenoid meningioma. Ophthalmological involvement with sphenoid meningiomas is most often chronic, due to interruption of axoplasmic flow and demyelination of the optic nerve by local compression. However, vascular involvement with ischemia of the optic nerve or transient low blood flow secondary to compression of the carotid branches vascularizing these structures is another possible mechanism. In our series, two patients had amaurosis fugax, and one patient had sudden, persistent visual loss in relation to acute anterior ischemic optic neuropathy on the side of the meningioma. The mean age of patients with acute visual manifestations was 62 years. These ischemic and non-compressive visual symptoms, ipsilateral to sphenoid meningiomas, are difficult to interpret. Whether these temporary visual disturbances of vascular origin should be considered an early sign of future severe or permanent visual impairment when no optic nerve compression is observed is not certain. The place of these acute visual disturbances in the therapeutic decision, particularly surgical, remains to be defined. Larger multicentric prospective studies are needed to better understand the role of local circulatory factors attributable to meningioma in the occurrence of these acute visual signs.

Un trauma cranico grave e definito dalla presenza di un punteggio di Glasgow inferiore o uguale a 8 dopo normalizzazione dello stato emodinamico. La misurazione della pressione intracranica (PIC) e spesso indicata ed e, quindi, opportuno conoscere le situazioni per le quali non lo e. I pazienti non monitorati devono essere rivalutati regolarmente clinicamente e mediante diagnostica per immagini neurologica. Durante il periodo di ipertensione intracranica, il monitoraggio neurologico deve essere multimodale: la misurazione della PIC, il Doppler transcranico ripetuto, la microdialisi e la pressione tissutale in ossigeno sono gli strumenti piu usati. Per la maggior parte dei pazienti, dopo l’intervento iniziale, la lotta contro le aggressioni cerebrali di origine sistemica, terapia di prima linea, caratterizzata da una bassa morbilita, e sufficiente per mantenere la PIC al di sotto del valore soglia di 20 mmHg e a quello della perfusione cerebrale. In alcuni casi, questo trattamento e insufficiente ed e necessario instaurare terapie piu importanti come un’ipotermia o una sedazione con barbiturico. Infine, quando questi trattamenti si rivelano superati, possono essere prese in considerazione misure chirurgiche come la craniectomia decompressiva. Al di fuori del contesto dell’ipertensione intracranica, alcune lesioni post-traumatiche richiedono un trattamento chirurgico, come le fratture infossate o gli ematomi extradurali. Queste terapie di salvataggio presentano effetti secondari molto gravi e il rapporto rischio-beneficio deve essere valutato caso per caso. Gli attori di questa gestione sono il neurochirurgo, il neurorianimatore e il neuroradiologo. La perfetta conoscenza della fisiopatologia delle varie lesioni cerebrali post-traumatiche e un prerequisito per lo sviluppo di una strategia terapeutica individualizzata e adattabile, che consenta la stratificazione delle diverse opzioni terapeutiche. Le ultime raccomandazioni riguardanti la gestione del traumatizzato cranico risalgono al 1998; sono state aggiornate nel 2016. La maggior parte di queste raccomandazioni resta valida; tuttavia, alcuni campi relativi agli obiettivi di perfusione cerebrale, all’ipotermia o al Doppler transcranico sono stati modificati. Occorre prendere in considerazione il fatto che queste raccomandazioni riguardano la gestione del traumatizzato cranico in fase precoce, quindi entro le prime 24-48 ore.

Meningiomas represent about 20% of intracranial tumors. Involvement of the medial sphenoid wing includes anterior clinoid, cavernous sinus and superior orbital fissure meningiomas. Due to the proximity of these tumors to the optic nerve, typically progressive unilateral vision loss, over several months to years, is the classic clinical presentation. We report three cases of acute monocular vision loss, two transient and one permanent, ipsilateral to a sphenoid meningioma. Ophthalmological involvement with sphenoid meningiomas is most often chronic, due to interruption of axoplasmic flow and demyelination of the optic nerve by local compression. However, vascular involvement with ischemia of the optic nerve or transient low blood flow secondary to compression of the carotid branches vascularizing these structures is another possible mechanism. In our series, two patients had amaurosis fugax, and one patient had sudden, persistent visual loss in relation to acute anterior ischemic optic neuropathy on the side of the meningioma. The mean age of patients with acute visual manifestations was 62 years. These ischemic and non-compressive visual symptoms, ipsilateral to sphenoid meningiomas, are difficult to interpret. Whether these temporary visual disturbances of vascular origin should be considered an early sign of future severe or permanent visual impairment when no optic nerve compression is observed is not certain. The place of these acute visual disturbances in the therapeutic decision, particularly surgical, remains to be defined. Larger multicentric prospective studies are needed to better understand the role of local circulatory factors attributable to meningioma in the occurrence of these acute visual signs.

BACKGROUND AND PURPOSE: Paragangliomas of the cauda equina are rare tumors. The standard treatment is surgical resection. Our study aims to compare our clinical, radiological, prognostic data to the literature and to offer management and follow-up recommendations. METHODS: In this retrospective study, six patients with paraganglioma of the cauda equina region were treated. Symptoms included radicular nerve pain and low back pain with occasional sphincter dysfunction and motor deficit. MRI showed well-circumscribed lesions with homogeneous enhancement following gadolinium injection. Treatment involved complete surgical resection of the tumor under electrophysiological control. In addition to the characteristics of the tumor, we assessed operating results as well as postoperative morbidity and follow-up. RESULTS: All patients had complete removal of the tumor, which required in most cases the resection of the carrying root. The intervention allowed a regression of the initial symptoms, with possible postoperative regressive sphincter disorders. Clinical and radiological follow-up (19 months on average), showed no tumor recurrence. CONCLUSIONS: The reference treatment of these tumors is complete surgical resection, usually requiring the sacrifice of the carrying nerve root. Intra-operative nerve roots stimulation is recommended to reduce the risk of motor deficit linked to this radical treatment. A long-term clinical and radiological follow-up is recommended.

International audience; We report a late dural relapse of a resected and irradiated pineal parenchymal tumor of intermediate differentiation

Trepanation is known to be the first surgical procedure ever performed. Its origins date from the Neolithic Age in Europe and the operation was particularly performed in South America at the Pre-Colombian era, a few thousand years later. Based on many archeological studies on trepanned skulls, we compare the differences and similarities of these two periods through epidemiological, topographical, and technical approaches. Signs of bony regeneration are assessed in an attempt to understand the postoperative survival of trepanned patients. The literature in surgery and archeology does not mention the possible relation between trepanations and growing skull fractures. However, it is reasonable to think that these cranial holes, occurring after a pediatric skull fracture, could mimic real trepanation orifices. The possible connections between these two entities are discussed. The etiological hypotheses on prehistoric trepanation are reviewed.

Resume Nous avons realise un etat des lieux de l’enseignement de l’ethique lors des premier et deuxieme cycles des etudes medicales en France. Pour ce faire, les programmes ont ete consultes et un questionnaire a ete adresse aux 39 facultes metropolitaines. L’ethique beneficie d’un enseignement specifique dans 38 des 39 facultes. Cet enseignement prend place le plus souvent en premier cycle des etudes medicales 1 (PCEM1), plus rarement dans les annees ulterieures. Le volume horaire cumule des cours obligatoires est tres variable, allant de 0 a 112 heures (moyenne 34 heures). Les themes abordes sont, avant tout, la relation medecin–malade (82 %), des concepts philosophiques (70 %), des questions sensibles (70 %), des notions de deontologie (66 %), du droit medical (53 %). Les enseignants sont majoritairement des medecins hospitaliers, mais des philosophes, des psychologues, des sociologues, des juristes, des historiens et des theologiens participent souvent a l’equipe educative. Si la forme traditionnelle par cours magistraux a encore sa place, notamment dans les premieres annees, de nombreuses experiences plus interactives sont a l’honneur dans les facultes. Ces experiences temoignent de la vitalite d’une discipline en plein developpement et qui fait aujourd’hui partie de plein droit de la formation medicale initiale.

We present the first case of early epidural hematoma after CSF shunt probably caused by defective material. A 26-year-old man was treated for obstructive hydrocephalus associated with a tonsillar herniation, revealed by headaches and papillary edema. Ventriculoperitoneal shunt was preferred to endoscopic ventriculostomy. Three hours after the operation, the patient fell into a coma, developing a voluminous bifrontal epidural hematoma that was evacuated immediately. The patient completely recovered neurologically. One month later, to treat persistent hydrocephalus, endoscopic ventriculostomy was performed without incident. Then the shunt was removed and an opening threshold close to zero was discovered. Distant MRI showed a reduction in ventricular size, normalization of the tonsils’ position and a tumor of the tectal plate. To our knowledge, this is the only case of early epidural hematoma after ventriculoperitoneal shunt. We discuss the choice of treatments for obstructive hydrocephalus and its risks and complications.

Resume Les debats sur la revision des lois de bioethique mettent en evidence les reticences, fondees ou non, du public vis-a-vis des manipulations genetiques appliquees a l’embryon. Pour mieux comprendre les enjeux qui se cachent derriere ces recherches et ces technologies, nous avons mis en parallele la situation actuelle avec le mythe d’Er de Platon. Cette lecture nous montre les dangers de la maitrise integrale des commencements de la vie, et notamment la menace qu’une telle maitrise fait peser sur l’idee de nature humaine libre, non predestinee. Car le choix, par les parents, des caracteres phenotypiques de leurs enfants (ce qu’on appelle l’eugenisme liberal) pourrait enfermer les nouveaux venus dans un destin biologique contraignant, contraire a la liberte qui est le propre de l’homme. La liberte a besoin d’un avenir ouvert, non entierement determine. L’eugenisme liberal accredite l’idee que les etres humains peuvent etre programmes avant leur naissance comme des produits manufactures, selon un cahier des charges defini par les parents ou par la societe. Il realise une mainmise sur l’avenir qui ne peut qu’etre condamnee. Non seulement il n’est pas au service des generations futures, dont le bien le plus precieux n’est pas la sante parfaite mais la liberte ; mais il tente de les asservir au nom de leur propre bonheur. La prudence est donc de mise, et justifie le maintien d’une grande vigilance des citoyens face aux travaux des laboratoires, vigilance dont le cadre ne peut etre que legal.

Apres avoir travaille sur la sedation terminale et la demande d’euthanasie, la Societe Francaise d’Accompagnement et de Soins Palliatifs a suscite la mise en place d’un groupe de soignants pour s’interroger sur les situations qui paraissent extremes aux yeux du malade, de sa famille, de l’environnement social ou soignant. Si l’enjeu est general et donc ramene a l’universel et a la vie ensemble, chaque situation est bien singuliere. Comment vivre ces tensions ? Est-il possible de surmonter, d’une quelconque maniere, ces situations tragiques et paraissant, par essence, insurmontables ? Apres avoir echange sur des situations extremes que chacun avait pu rencontrer, il a ete tente de faire surgir les vrais enjeux et les tensions profondes de chacune d’elles pour, dans un second temps, reperer les dilemmes et donc les defis a relever. Reactiver, reanimer la notion d’equipe, sont au coeur de la prevention de l’enfermement face a de telles situations. Mieux etre a l’ecoute de toute situation difficile aide l’equipe entiere a anticiper, a partager ses doutes et ses projets, en confrontation positive avec ceux du patient et de sa famille, veritable partenaire de la demarche de soin. La transgression de la loi (juridique ou morale) est souvent le fait d’une personne isolee (reellement ou mentalement).

Un trauma cranico grave si definisce per la presenza di un punteggio di Glasgow inferiore o uguale a 8 dopo normalizzazione dello stato emodinamico. Il controllo delle vie aeree e della ventilazione meccanica sono allora obbligatori. Il sospetto di erniazione cerebrale deve provocare un trattamento immediato. La misurazione della pressione endocranica (PIC) e spesso indicata, se possibile mediante derivazione ventricolare esterna. I pazienti non monitorati devono essere rivalutati regolarmente mediante neuroradiologia. Durante il periodo di ipertensione endocranica, il monitoraggio neurologico deve essere multimodale: la misurazione della PIC, il Doppler transcranico ripetuto, la registrazione continua dell’elettroencefalogramma, la microdialisi e il monitoraggio biologico mediante la proteina S-100b sono gli strumenti piu utilizzati. Nella maggior parte dei pazienti, dopo la chirurgia iniziale il mantenimento dell’omeostasi, terapia di prima linea caratterizzata da una scarsa morbilita, e sufficiente al mantenimento della PIC sotto al valore soglia di 20 mmHg e a quello della perfusione cerebrale. In alcuni casi, questo trattamento e insufficiente ed e necessario mettere in atto rimedi terapeutici piu pesanti, a volte in associazione, come la somministrazione di propofol a flusso continuo, l’ottimizzazione della pressione di perfusione cerebrale o l’osmoterapia. Quando questi trattamenti si mostrano superati, misure di salvataggio come la somministrazione di barbiturici in continuo, l’ipotermia moderata, la craniectomia decompressiva e l’iperventilazione possono essere proposte. Tutti questi presidi terapeutici di salvataggio presentano effetti secondari molto gravi e il bilancio beneficio-rischio deve essere valutato caso per caso. La cattiva evoluzione dei pazienti traumatizzati cranici non e piu una fatalita e le nuove sequenze di neuroradiologia con risonanza magnetica diventano importantissime per la valutazione della prognosi. La perfetta conoscenza della fisiopatologia delle differenti lesioni cerebrali posttraumatiche e un prerequisito per sviluppare una strategia terapeutica individualizzata e adattabile, permettendo la stratificazione delle diverse opzioni terapeutiche.

Los traumatismos craneales graves se definen por la presencia de una puntuacion en la escala de Glasgow inferior o igual a 8 tras la normalizacion del estado hemodinamico. El control de las vias respiratorias y la ventilacion mecanica son obligatorios en tales casos. La sospecha de una herniacion cerebral debe hacer que se aplique un tratamiento inmediato. La medicion de la presion intracraneal (PIC) suele estar indicada, si es posible mediante una derivacion ventricular externa. Los pacientes no monitorizados deben revalorarse con regularidad mediante pruebas de neuroimagen. Durante el periodo de hipertension intracraneal, la monitorizacion neurologica debe ser multimodal: las pruebas mas utilizadas son medicion de la PIC, ecografia Doppler transcraneal repetida, registro continuo del electroencefalograma, microdialisis y monitorizacion analitica de la proteina S 100β. En la mayoria de los pacientes, tras la cirugia inicial, el mantenimiento de la homeostasis (un tratamiento de primera linea caracterizado por una baja morbilidad), basta para mantener la PIC por debajo del valor umbral de 20 mmHg y el de la perfusion cerebral. En algunos casos, este tratamiento es insuficiente y se deben aplicar medidas terapeuticas mas complejas, en ocasiones asociadas, como la administracion de propofol en flujo continuo, la optimizacion de la presion de perfusion cerebral o la osmoterapia. Cuando estos tratamientos se ven desbordados, pueden proponerse medidas de rescate, como la administracion continua de barbituricos, hipotermia moderada, craniectomia descompresiva e hiperventilacion. Todos estos tratamientos de rescate presentan efectos secundarios muy graves y el balance beneficio-riesgo debe evaluarse caso por caso. La mala evolucion de los pacientes con un traumatismo craneal ya no es inevitable, y las nuevas secuencias de neuroimagen por resonancia magnetica se han convertido en una herramienta primordial para la evolucion del pronostico. El conocimiento perfecto de la fisiopatologia de las distintas lesiones cerebrales postraumaticas es un prerrequisito para desarrollar una estrategia terapeutica individualizada y adaptable, que permita la estratificacion de las distintas opciones terapeuticas.

Myopericytoma is a benign tumour generally arising in the subcutaneous and superficial soft tissues of the extremities. Very few cases have been reported in other locations and intracranial examples are exceptional. We now report on three cases of primary intracranial myopericytoma and review the literature on that rare entity. The patients were women in their fifties who presented with decreased visual acuity in two cases and raised intracranial pressure in one case. The tumour involved, respectively, the anterior cranial fossa, the orbital apex and the pineal region. Gross total resection was achieved in all three cases. Histological analysis revealed oval-to-spindle shaped myoid-appearing cells with a striking tendency for concentric perivascular growth. The lesional cells showed apparent differentiation towards perivascular myoid cells as witnessed by smooth muscle actin expression. In one case, an epithelioid differentiation was also present. None of the patients received adjuvant therapy. One patient died of unrelated causes 6 months after surgery. The other two are alive and well at 9 and 12 month follow-up respectively. Myopericytoma is a recently described neoplasm, and it is likely that reappraisal of intracranial haemangiopericytoma with which it shares many histopathologic features will lead to more case reports of primary intracranial myopericytoma.

High Intensity Focused Ultrasound (HIFU) therapy is an innovative approach for tissue ablation, based on high intensity focused ultrasound beams. At the focus, HIFU induces a temperature elevation and the tissue can be thermally destroyed. In fact, this approach has been tested in a number of clinical studies for the treatment of several tumors, primarily the prostate, uterine, breast, bone, liver, kidney and pancreas. For transcranial brain therapy, the skull bone is a major limitation, however, new adaptive techniques of phase correction for focusing ultrasound through the skull have recently been implemented by research systems, paving the way for HIFU therapy to become an interesting alternative to brain surgery and radiotherapy.

International audience; Purpose: This study aims to demonstrate, using human cadavers the feasibility of energy-based adaptive focusing of ultrasonic waves using magnetic resonance acoustic radiation force imaging (MR-ARFI) in the framework of non-invasive transcranial high intensity focused ultrasound (HIFU) therapy.Methods: Energy-based adaptive focusing techniques were recently proposed in order to achieve aberration correction. The authors evaluate this method on a clinical brain HIFU system composed of 512 ultrasonic elements positioned inside a full body 1.5 T clinical magnetic resonance (MR) imaging system. Cadaver heads were mounted onto a clinical Leksell stereotactic frame. The ultrasonic wave intensity at the chosen location was indirectly estimated by the MR system measuring the local tissue displacement induced by the acoustic radiation force of the ultrasound (US) beams. For aberration correction, a set of spatially encoded ultrasonic waves was transmitted from the ultrasonic array and the resulting local displacements were estimated with the MR-ARFI sequence for each emitted beam. A noniterative inversion process was then performed in order to estimate the spatial phase aberrations induced by the cadaver skull. The procedure was first evaluated and optimized in a calf brain using a numerical aberrator mimicking human skull aberrations. The full method was then demonstrated using a fresh human cadaver head.Results: The corrected beam resulting from the direct inversion process was found to focus at the targeted location with an acoustic intensity 2.2 times higher than the conventional non corrected beam. In addition, this corrected beam was found to give an acoustic intensity 1.5 times higher than the focusing pattern obtained with an aberration correction using transcranial acoustic simulation-based on X-ray computed tomography (CT) scans.Conclusions: The proposed technique achieved near optimal focusing in an intact human head for the first time. These findings confirm the strong potential of energy-based adaptive focusing of transcranial ultrasonic beams for clinical applications.

Clinical manifestations of hydrocephalus vary according to the level of intracranial pressure, the speed of onset, and the etiological mechanism involved. We report the case of a 32-year-old patient with isolated compressive optic neuropathy associated with a dilated third ventricle, revealing congenital hydrocephalus.

Trepanation is known to be the first surgical procedure ever performed. Its origins date from the Neolithic Age in Europe and the operation was particularly performed in South America at the Pre-Colombian era, a few thousand years later. Based on many archeological studies on trepanned skulls, we compare the differences and similarities of these two periods through epidemiological, topographical, and technical approaches. Signs of bony regeneration are assessed in an attempt to understand the postoperative survival of trepanned patients. The literature in surgery and archeology does not mention the possible relation between trepanations and growing skull fractures. However, it is reasonable to think that these cranial holes, occurring after a pediatric skull fracture, could mimic real trepanation orifices. The possible connections between these two entities are discussed. The etiological hypotheses on prehistoric trepanation are reviewed.

Suicide, burn out, conduites addictives, comportements perturbateurs, prise de retraite anticipee... les reactions des medecins aux pressions qu’ils subissent dans l’exercice de leurs fonctions sont parfois violentes et, a la fois pour eux-memes et pour autrui, violemment destructrices. « Craquer » dans l’exercice d’un si noble metier semblait autrefois impossible, ou au moins indicible. Mais le temps n’est plus au deni d’un probleme que de nombreuses etudes ont situe a sa vraie dimension, c’est-a-dire considerable : d’apres des publications recentes (1)-(3), le burnout affecterait pres de 30 % des medecins, et meme 40 % des chirurgiens americains ! S’il a surtout fait l’objet de travaux aux Etats-Unis, le stress professionnel n’epargne cependant pas la France : nombreux sont ceux dans la profession qui souffriraient de « blues » (4) ou qui seraient « au bord de la crise de nerf » (5). Ce stress peut etre lie aux « conditions structurelles », c’est-a-dire provoque par une mauvaise organisation du travail et par les contraintes qui lui sont associees (eparpillement des taches, surcharge horaire, harcelement moral, non-reconnaissance sociale, tensions dans l’equipe, pression administrative, etc.) ; ou, plus profondement, il peut etre da la frequentation quotidienne des personnes en detresse physique, morale ou sociale, frequentation qui induit une douleur morale « par compassion ».

In the framework of HIFU transcranial brain therapy, it is mandatory to develop techniques capable of assessing the focusing quality and location before the treatment. Monitoring heat deposition in real time and verifying the extension of the treated area are also important steps. In this study, an imaging protocol is proposed to:1/ locate the US radiation force induced displacement in tissues and quantify the acoustic pressure at focus prior to HIFU; 2/ monitor the temperature rise during HIFU; and 3/ assess the changes in elasticity in the treated area. A 7T MRI scanner was equipped with a home‐made stereotactic frame for rats and a US focused transducer working at 1.5 MHz. Such a tool is key for the evaluation of the biological effects of HIFU on brain tissue and tumors. The proposed protocol was successfully tested on 12 rats with and without injected tumors. The accurate localization of the focal point prior to HIFU was demonstrated in vivo. Furthermore, the pressure estimation in situ allowed to acc...

We present the first case of early epidural hematoma after CSF shunt probably caused by defective material. A 26-year-old man was treated for obstructive hydrocephalus associated with a tonsillar herniation, revealed by headaches and papillary edema. Ventriculoperitoneal shunt was preferred to endoscopic ventriculostomy. Three hours after the operation, the patient fell into a coma, developing a voluminous bifrontal epidural hematoma that was evacuated immediately. The patient completely recovered neurologically. One month later, to treat persistent hydrocephalus, endoscopic ventriculostomy was performed without incident. Then the shunt was removed and an opening threshold close to zero was discovered. Distant MRI showed a reduction in ventricular size, normalization of the tonsils' position and a tumor of the tectal plate. To our knowledge, this is the only case of early epidural hematoma after ventriculoperitoneal shunt. We discuss the choice of treatments for obstructive hydrocephalus and its risks and complications.

An endovascular treatment of vasospasm following a subarachnoid aneurysmal haemorrhage is to be implemented if the patient presents clinical or biological symptoms arguing for brain ischemia in conjunction with increased Doppler velocities despite well controlled systemic haemodynamic. Treatment might be either pharmacological or haemodynamic. Calcium and phosphodiesterase inhibitors can be administered. The former could also provide a neuroprotective effect as compared to the latter. In Europe, nimodipine is widely used whereas nicardipine and verapamil are the major molecules administered in North America where iv nimodipine is not FDA approved. Papaverine is less used nowadays because of its short duration of action and of the risk of aggravation of raised intracranial pressure. Balloon angioplasty has a long lasting effect but can be applied only to proximal spasm. Complications of its use are rare but life threatening. In some cases, both the pharmacological approach and the mechanical approach are used in combination.

Craniopharyngiomas are rare benign epithelial tumors, arising from the pituitary stalk or gland and developing in the sellar and suprasellar region, affecting both adults and children. Incidence is 0.5 to 2 new cases per million inhabitants. Clinical features essentially include visual disturbances, endocrine deficiencies, and neurological signs. Initial signs are often visual loss and increased intracranial pressure in children, growth and pubertal delay in teenagers, visual disturbances or cognitive impairment in adults. Diagnosis is made on MRI and CT scan, demonstrating a sellar or suprasellar tumor, heterogeneous, with frequent calcifications. Craniopharyngiomas can be classified depending on their locations from the sella, the diaphragma sellae, and upon their origins from the pituitary stalk or the infundibulum. They can also be classified depending on the location from the optic chiasm and the third ventricle. This classification allows surgical series comparison, which is of importance since developments and extensions of the tumor can explain surgical difficulties. The management of this lesion is still controversial. Because it is an extra-cerebral benign lesion, the ideal goal of treatment should be complete tumor removal with improvement of altered visual functions, minimal deterioration of endocrine function, and no neuropsychological impairment. But the situation of the tumor, its relationship with third ventricle, hypothalamus, optic tract, vascular structures make its removal often difficult. However, great progresses have been realized in surgical treatment, resulting in a dramatic improvement of the prognosis of craniopharyngiomas. Nowadays, one can expect total removal in 60 to 70% of patients, subtotal removal in 20 to 30%, and partial removal in 10%. When total removal is impossible, radiotherapy may reduce the risk of a poor evolution. Recurrences are a problem in 15% of patients with total removal, 35% in subtotal removal, 70% in partial removal. If radiotherapy has not been performed as first treatment, it is efficient in 80% of recurrences. Long term follow up is necessary in these patients, due to medical management of endocrine, visual and psychological problems, and risk of late recurrence. With close involvement in this management, most of patients may enjoy a good outcome, 80% being able to return to normal active life.

Objective: To determine the compensatory mechanisms involved in the recovery of motor function following surgical lesions of the supplementary motor area (SMA) and their relation to the clinical characteristics of recovery.Subjects and Methods: Twelve patients were referred for surgery of low-grade gliomas located in the SMA, and compared to eight healthy controls using fMRI before and after surgery during self-paced movements of both hands, successively. Magnitude and volume of activation within regions of interest (primary sensorimotor cortex, premotor cortex, SMA, preSMA, and parietal lobes) were compared and tested for correlation with anatomic characteristics of the tumor and resection, and clinical data.Results: Tumor growth induced preoperative underactivity in the adjacent SMA and overactivity in the opposite SMA. Postoperative recovery was associated with recruitment of a premotor network located in the healthy hemisphere including the SMA and the lateral premotor cortex. Postoperative premotor recruitment in the healthy hemisphere increased with the percentage of resection of preoperative SMA activation. Shortened onset and duration of recovery was associated with increased preoperative changes in activation levels.Conclusions: These findings suggest a dysfunction of the SMA ipsilateral to the tumor, partially compensated by a recruitment of the contralesional SMA which correlated with shortened postoperative recovery. SMA resection was compensated by the recruitment of a medial and lateral premotor circuitry in the healthy hemisphere.

Preliminary results of an attempt at correlation between objective parameters computed on video compressed sequences and subjective scores are reported. The measurement of the objective parameters is performed on sub-areas of the frame singled out taking into account spatial information and motion detection. The results show that the division of the frame into sub-areas can improve correlation performances provided by objective measurements; future planned studies are also reported.

Introduction Les meningiomes de grade II multi-recidivants et de grade III presentent une morbi-mortalite accrue par rapport aux meningiomes de grade I. En raison du manque de connaissances concernant l’histoire naturelle de ces meningiomes multi-recidivants, l’evaluation de l’efficacite de nouvelles armes therapeutiques reste difficile. Materiel/methode Une revue retrospective de l’ensemble des meningiomes multi-recidivant (au moins deux chirurgies) a ete menee dans notre service. Le temps de progression tumorale (TPT) est defini comme le temps necessaire pour constater une augmentation de 20 % du volume tumoral par rapport au volume de base. Tous les volumes tumoraux ont ete mesures a l’aide d’IRM 3D T1 gadolinium. Resultats Vingt-neuf patients, 14 femmes (48 %) et 15 hommes (52 %) presentant des meningiomes multi-recidivants ont ete inclus. Le suivi a dure 91 mois en moyenne (31–211). Nous avons divise notre cohorte en trois sous-groupes selon le grade histologique : meningiomes de grade II (11 patients), grade III de novo (5 patients) et grade III secondaire (13). La PFS mediane etait de 16 mois pour les meningiomes de grade II. Les meningiomes de grade III de novo avaient une PFS mediane de 4 mois contre 7 mois pour les grades III secondaires. L’analyse volumetrique a concerne 95 nodules tumoraux pour 50 rechutes. Le taux de croissance moyen etait de 45,8 cm3/an. Trois modeles de recidive tumorale ont ete observes : « classique », ou un nouveau nodule tumoral apparaissait sur le site originel, pour 9 patients (31 %) ; « local multi-nodulaire », ou de multiples nodules tumoraux recidivaient pres du site d’insertion dural, pour 6 patients (21 %) et « multi-nodulaires metastatiques », ou de multiples nodules tumoraux se developpaient sur plusieurs sites distants, pour 14 patients (48 %). En considerant tous ces nodules, le TPT etait de 3,7 mois. Conclusion Les futurs essais cliniques sur les meningiomes multi-recidivants devraient se concentrer sur les meningiomes presentant une progression histologique et des recidives radiologiques sur un mode « multi-nodulaire metastasique », en raison de leur frequence. Une PFS de 6 mois et un TPT de 4 mois semblent etre des criteres de jugement acceptables pour ces futurs essais cliniques.

Endoscopic third ventriculostomy has been found to be successful for treating occlusive hydrocephalus. The complication rate ranges from 6 to 12%. Intraoperative bleeding is the most common incident. Endocrinological failures are rare, mainly due to the proximity of the hypothalamic structures. We report the case of a 33-year-old man who was referred in emergency for subacute hydrocephalus related to a tentorium meningioma. The hydrocephalus was treated by endoscopic third ventriculostomy. During the procedure, the floor of the third ventricle was found to be thick but fenestration was performed without incident. After surgery, the clinical signs of hydrocephalus disappeared but diabetes insipidus was diagnosed the same day. There were no other endocrinology disorders. Medical treatment with vasopressin allowed resolution of the diabetes insipidus in fifteen days. Surgical debulking of the meningioma was then achieved via a subtemporal approach. There was no recurrence of the endocrinology disorder. Diabetes insipidus is an unpredictable complication of third ventriculostomy. The mechanism is not well known. It is however a transient disorder that can easily be treated with vasopresin and therefore should not modify the indications of third ventriculostomy, especially in tumor-related hydrocephalus.

We report two cases of glossopharyngeal neuralgia associated with a vascular loop of the postero-inferior cerebellar artery, diagnosed by magnetic resonance imaging. Reviewing the literature, we found this to be the first report of a magnetic resonance-validated vascular abnormality related to such a condition. One patient was cured by surgical decompression, confirming the role of the abnormal vessel in the pain. As with trigeminal neuralgia, a possible vascular aetiology should be considered in glossopharyngeal neuralgia.

The paper reports three cases of optic chiasmal radionecrosis due to radiotherapy of the sellar region. These three cases are compared with 34 ones found in literature. The use of M.R.I. is shown to dramatically improve diagnosis. Corticoids are useful in the treatment. The gravity of the complication, which implies visual prognosis, focuses on a strict use of radiotherapy. For benign or slowly evoluting lesions, surgery and/or regular controls by modern imaging techniques would often be more eligible than systematic earliest irradiation.

Objectifs Etudier l’apport de la cartographie des fibres de substance blanche dans le bilan pre-operatoire des lesions cerebrales neurochirurgicales. Materiels et methodes Trente et un patients presentant des lesions cerebrales ont beneficie d’une IRM pre-operatoire avec une sequence de tenseur de diffusion (IRM 1,5 Tesla, sequence EPI-SE, TR : 10 sec, TE : 88 msec, epaisseur de coupes : 3 mm, b-value : 900 sec/ mm2, 6 directions). Les fibres creees a l’aide d’un logiciel dedie ont ete superposees a l’imagerie anatomique et les resultats des cartographies compares aux stimulations per-operatoires des fonctions motrices ou du langage (19 patients) et au suivi post-operatoire. Resultats Les cartographies des faisceaux de substance blanche ont ete obtenues pour tous les patients (faisceau pyramidal : 23 patients, voies visuelles : 2 patients, autres : 6 patients) permettant l’analyse anatomique des fibres par rapport a la lesion. Les stimulations per-operatoires etaient concordantes chez la majorite des sujets. Conclusion La technique de cartographie des fibres de substance blanche offre un interet dans le bilan pre-operatoire des lesions cerebrales. Elle permet la localisation des faisceaux de fibres et l’etude du retentissement de la lesion. Elle contribue a evaluer la possibilite d’une resection maximale de cette lesion.

Objectifs Definir le risque de survenue du syndrome de l’aire motrice supplementaire (AMS), son expression clinique et les caracteristiques de la recuperation fonctionnelle. Materiels et methodes Trente-trois patients operes d’un gliome de bas-grade frontal median ont ete examines par IRMf pre-operatoire (mouvement des mains, des pieds et fluence verbale) et post-operatoire apres recuperation du deficit (IRM anatomique et fonctionnelle avec mouvements des mains). Resultats Vingt-trois patients ont presente un deficit caracteristique d’un syndrome de l’AMS. Les deficits moteurs et du langage survenaient quand les regions activees dans l’AMS lors des tâches motrices et de la fluence dans l’hemisphere dominant etaient resequees. L’exerese de la region de la main etait plus importante que celle du pied en rapport avec une severite du deficit plus marquee au membre superieur. Le recrutement de l’AMS saine sur l’IRMf pre-operatoire etait correle a une recuperation plus precoce et plus rapide. La recuperation etait associee a un recrutement post-operatoire du cortex premoteur lateral de l’hemisphere sain. Conclusion L’IRMf a permis de comprendre les circonstances de survenue du syndrome de l’AMS et son expression clinique. L’IRMf a montre le role du cortex premoteur de l’hemisphere sain dans la recuperation fonctionnelle.

Objectifs Definir le risque de survenue du syndrome de l’aire motrice supplementaire (AMS), son expression clinique et les caracteristiques de la recuperation fonctionnelle. Materiels et methodes Trente-trois patients operes d’un gliome de bas-grade frontal median ont ete examines par IRMf pre-operatoire (mouvement des mains, des pieds et fluence verbale) et post-operatoire apres recuperation du deficit (IRM anatomique et fonctionnelle avec mouvements des mains). Resultats Vingt-trois patients ont presente un deficit caracteristique d’un syndrome de l’AMS. Les deficits moteur et du langage survenaient quand les regions activees dans l’AMS lors des tâches motrices et de la fluence dans l’hemisphere dominant etaient resequees. L’exerese de la region de la main etait plus importante que celle du pied en rapport avec une severite du deficit plus marquee au membre superieur. Le recrutement de l’AMS saine sur l’IRMf pre-operatoire etait correle a une recuperation plus precoce et plus rapide. La recuperation etait associee a un recrutement post-operatoire du cortex premoteur lateral de l’hemisphere sain. Conclusion L’IRMf a permis de comprendre les circonstances de survenue du syndrome de l’AMS et son expression clinique. L’IRMf a montre le role du cortex premoteur de l’hemisphere sain dans la recuperation fonctionnelle.

The considerations involved in the evaluation of the suitability of any geological formations for the disposal of radioactive wastes are illustrated by summarizing some of the studies performed in ...