Search

Les manifestations neurologiques de la syphilis sont polymorphes et sont actuellement en recrudescence. Nous rapportons cinq cas d´accident vasculaire cérébral ischémique (AVCI) en rapport avec une neurosyphilis. La recherche d´une syphilis doit être systématique devant un accident vasculaire du sujet jeune d´étiologie indéterminée.

Radiation therapy has been one of the pillars of cancer therapy for many years. Many technological advances have been made to improve radiation delivery to the targeted area while reducing damage to the surrounding normal tissue. The spectrum of late radiation-induced injuries is quite heterogeneous but the injuries are usually benign. They may manifest themselves as breast edema, fibrosis, telangiectasia, pulmonary fibrosis, chronic ulceration, rib fractures, fat necrosis or osteonecrosis. We report the case of a 55-year-old woman who presented to the Neurosurgery Department for management of hydrocephalus with a posterior fossa tumor. The patient had a past history of a multifocal adenocarcinoma of the both breast, which were resected 13 years earlier. Further treatment included chemotherapy with six cycles of doxorubicin and cyclophosphamide in combination with cobalt radiation with a total dose of 60 Gy, followed by tamoxifen for a total of 4 years. The first local signs were observed two years after the radiation treatment with the loss of irradiated skin elasticity followed by increasing induration and telangiectasia. Over the one year before presentation, the mass had significantly increased in size and become increasingly painful, restricting the patient psychologically and functionally in her daily activities. Local examination revealed a subcutaneous fat necrosis of the right breast, which had been progressively growing over a period of 02 years (A).

Nous rapportons une observation originale d´un syndrome de Korsakoff révélant une lésion thalamique, chez un patient de 44 ans, ayant bénéficié d´une biopsie stéréotaxique dont l´étude anatomopathologique montrait un tuberculome cérébral. A notre connaissance une telle présentation jamais décrite dans la littérature francophone, nous semble importante d´alerter le clinicien Afin de l´explorer, par une imagerie cérébrale toute l'amnésie korsakovienne atypique.

A 56-year-old diabetic man complains for isolated chronic headaches for many years. He denied any seizure, involuntary limb movements or blurring of vision. Physical examination was unremarkable for any focal neurological deficits. Cranial Computed tomography (CT) scan showed extensive symmetrical calcifications of the bilateral basal ganglia and over the lateral periventricular areas (figure). Laboratory studies including serum calcium, phosphate, parathormone, thyroid hormones and vitamins were within normal range. There was no other obvious etiology or family history of similar illness. Based on these findings, the patient was diagnosed with Fahr´s disease and was managed conservatively. Fahr´s disease (FAD), also known as “familial idiopathic basal ganglia calcification”, is a rare neurological disorder characterized by abnormal calcified deposits in the basal ganglia, cerebellum and subcortical white matter. FAD differs from Fahr´s syndrome in which there is an underlying cause for brain calcifications. Neurological and psychiatric symptoms are variable and may include deterioration of motor function, parkinsonism, seizures, headache, dysarthria, spasticity, visual disturbances, dementia, psychosis, and affective disorders. FAD could be easily confused with other more common neurological and psychiatric disorders. It is particularly important to not miss the treatable etiologies of Fahr´s syndrome. The diagnosis is based on the CT scan because it is difficult to identify calcifications by routine magnetic resonance imaging. Treatment is essentially symptomatic.

Detection of metastases especially intracranial metastases signals a poor prognosis in a patient with cancer. Solitary cystic metastasis is often difficult to differentiate from intra-cerebral abscess which can also occur in these patients. However, the co-existence of an abscess within a CNS metastasis is a rare event. At surgery, a purulent exudate within discrete metastatic tumours was identified. Pathological and microbiological examinations confirmed the coexistence of an abscess within a metastatic carcinoma. This case highlights the importance of considering intratumoral abscesses.

A 45-year-old obese man, previously healthy, presented with a 7-month history of neurogenic claudication of both legs and bilateral sciatic radiculopathy without bowel or bladder disturbances. He had a body mass index of 34.6Kg/m2 but neurological examination was normal. Spinal magnetic resonance imaging (MRI) showed an extensive lumbosacral spinal epidural lipomatosis (SEL) rounding and compressing the thecal sac and nerve roots (A-C). There was no other obvious etiology. After 5 months of follow-up, symptoms resolved by weight loss. Spinal epidural lipomatosis is the result of accumulation of unencapsulated fat tissue in the extradural space of the spinal canal. This unusual disease may impinge on the thecal sac in the lombosacral area and cause spinal cord compression in the cervicothoracic area. Epidural lipomatosis is usually associated with corticosteroid therapy, but a number of etiologies have been reported in patients with Cushing´s syndrome, hypothyroidism, and pituitary prolactinoma. In idiopathic SEL, no obvious etiology was associated. Conservative treatment such as weight reduction may relieve neurologic symptoms in obese patients with idiopathic spinal epidural lipomatosis. However, in the presence of neurological impairment, extradural surgical decompression must be performed.

A 50-year-old woman, previously healthy, presented with a 9-month history of progressive paraparesis with sphincter disturbances and hypoesthesia in lower legs. Several weeks before admission, her paraplegia and urinary dysfunction rapidly deteriorated. She was unsuccessfully treated 4 months prior with analgesics and corticosteroids drugs. Spinal magnetic resonance imaging (MRI) (A) showed central myelopathy of the conus medullaris with posterior dilated perimedullary veins (arrows), suggestive of a spinal vascular malformation. Selective spinal angiogram of the right T11 segmental artery (B) demonstrated a right sided fistulous connection between the segmental artery and the perimedullary venous plexus (dotted oval circle). A thoracic T10-T12 laminectomy and durotomy was performed, which showed engorged venous vessels on the posterior surface of the spinal cord (C). An arterialized draining vein was identified arising from the inner aspect of the dura of the right T11 nerve root. This vessel was completely clipped (arrow). Postoperatively, neurologic examination remained unchanged at the time of discharge. However, at 4-month follow-up, she was able to ambulate with a walker. Postoperative angiography performed 2 months later showed total disappearance of the vascular fistula (D). Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy. This vascular malformation is usually misdiagnosed because its clinical features can mimic more common causes of myelopathy (Neoplams, infections, musculoskeletal, inflammatory and nutritional). Also, MRI may be interpreted as normal for a relatively long period of time. High clinical suspicion for SDAVF when MRI is uncertain should prompt spinal angiography to avoid delay in this treatable disease.

A 75-year-old hypertensive woman presented with 2-day history of right sided weakness and speech disturbances. Neurologic examination revealed right hemiparesis, anosmia and dysfunction of the left third and sixth cranial nerves. Brain computed tomography scan (A,B) followed by magnetic resonance angiography (C,D) discovered an unruptured cavernous carotid aneurysm measuring 40 x 39 mm in diameter (stars) on the left side with a concomitant acute ipsilateral frontal infarction (arrows). The giant calcified saccular aneurysm contained a dense, structured, and intraluminal thrombus. Laboratory studies were within normal range. Based on these findings, the patient was diagnosed with a thrombosed unruptured carotid-cavernous aneurysm with homolateral anterior cerebral artery ischemic stroke. Exploration of the supra-aortic arteries was normal. No other sources of brain infarction were found on electrocardiogram, transthoracic echocardiography and Holter monitoring. The patient was referred to interventional neuroradiology for endovascular coiling of the aneurysm. Intracranial aneurysm is a cerebrovascular disorder in which weakness in the wall of a cerebral artery results in an abnormal widening or ballooning. Rupture of the aneurysm is the most common and most serious complications seen in this disease. The resultant subarachnoid and/or intraparenchymal bleeding can lead to a hemorrhagic stroke, coma and/or death. Cerebral infarction is a rare complication especially seen in unruptured intracranial aneurysms. Possible pathogenic mechanisms of the infarction include parent artery occlusion due to local extension of the luminal thrombus, distal embolization, and increased mass effect. Unruptured aneurysm should be added to the list of etiologies of ischemic strokes.

This 48-year-old man, previously healthy, presented with a six-month history of progressive low back pain and bilateral pseudo-sciatica of the lower extremities without sphincter disturbances. Physical examination revealed fixed kyphotic posture of the lumbar spine. Straight leg test and tendon reflexes were normal without any neurologic deficits. He reported sustaining a traumatic injury two years earlier secondary to a fall from a tree. At that time, he did not seek medical treatment. Plain radiograph (A) demonstrated regional lumbar kyphosis from L1 to L3 as well as a healed burst fracture of L2 vertebra (star). Spinal lumbar computed tomography scan (B-C) confirmed traumatic kyphotic deformity at L1-L2-L3 and moderate central stenosis at L2. There was also a new joint surface formation and vacuum phenomenon between the anterior vertebral bodies of L1 and L3. The patient was counseled on the need for surgery, but he refused any surgical intervention and insisted on conservative management. Neglected lumbar spinal injuries are rare but serious clinical situations. Their etiologies vary from missed injuries, delayed presentation for treatment, and wrong initial management. The clinical symptoms include spinal and/or radicular pain, scoliotic and/or kyphotic deformity, and neurological deficits. Management of these neglected injuries is difficult with respect to intraoperative difficulties, higher incidence of surgical complications, and subsequent rehabilitation.

A 12-year-old girl was involved in a 50 km/h motor vehicle accident that resulted in the deployment of both airbags. She was a front seat passenger well restrained by a three-point seatbelt. The driver (his father) was uninjured but the patient complained of a stiff and painful neck. On arrival in the emergency room, she was alert and hemodynamically stable. Physical examination showed swelling and excoriation of the skin over the anterior cervical area and mandibular region (A). Neurological examination results were normal except for torticollis and neck pain. Cervical spine radiography showed no abnormality except the loss of cervical lordosis. She was admitted for observation and was discharged ten hours later with a cervical collar and symptomatic drugs. At 15-day follow-up visit, the patient had no neck pain, and the neurological examination finding was normal. Airbags drastically reduce both morbidity and mortality from crashes, but a wide range of injuries has been reported as a result of direct contact of hot gas with facial skin and energy transmitted directly from the airbag system to the child´s head and neck. This device may cause ocular and facial injuries, abdomen and chest trauma, upper extremity injuries, and cervical spine lesions especially in pediatric populations. All children below 12 years of age or less than 40 kg of weight must not occupy the front seat passenger. Airbags may induce injuries that vary from minor to fatalities whatever the impact velocities. Practitioners should be aware about lesions induced by airbag deployment.

Brown-Séquard´s syndrome (BSS) is an unusual clinical entity caused by damage to one half of the spinal cord mimicking a classic hemiplegia. This syndrome is characterized by ipslateral loss of motor function (paralysis), proprioception, and vibratory sensation, combined with contralateral loss of pain and temperature sensation. Spinal cord injuries and tumoral diseases were the most frequent etiologies associated with BSS. Spontaneous cervical disc herniation has rarely been considered. This 49-year-old man, previously healthy, presented with a two-year history of progressive left arm and leg paresis associated with decreased pain and thermal sensitivity in the right hemibody below the C5 dermatoma without bladder or bowel complaints. There were bilateral extensor plantar responses. Brain computed tomography (CT) scan performed at another institution was normal. Spinal cervical magnetic resonance imaging and CT-scan showed a voluminous calcified cervical disc herniation at C4-C5 vertebral level (arrows) with marked compression of the left half of spinal cord. A complete surgical spinal cord decompression was performed by an anterior cervical approach with interbody fusion. There was a partial recovery of neurological status after a long time of physical rehabilitation. In some incomplete forms of BSS, hemiplegia or hemiparesis may be confused with those caused by brain damage as seen in our patient. Accordingly, the diagnosis is further delayed. Spinal MRI should be employed early in the diagnostic evaluation of such patients. In addition, cervical disc herniation should be considered in the differential diagnosis of BSS, even in the absence of the typical symptoms.

Intervertebral disc calcification (IVDC) is a rare cause of spinal pain. Both children and adults can be involved, however this affection is more common in cervical and thoracic spine than lumbar column. A 52-year-old man, previously healthy, presented with an acute lumbalgia. He complained of spontaneous low back pain for more than 4 months, aggravated for the last few weeks. He denied any history of injury, important change in weight, systemic disease or recent episodes of fever. Physical examination revealed limitation in low back movements with paraspinal muscle spasm. Straight leg test and tendon reflexes were normal without any neurologic deficits. Computed tomography scan (A, B, C) showed an unusual homogenous, well limited, calcified lesion at the L4-L5 intervertebral level (arrows) with a straightness of the lumbar spine. The calcified structure rather corresponds to the nucleus pulposus: the central portion of intervertebral disc. Laboratory finding showed no inflammatory sign. The patient was treated with rest, analgesic and anti-inflammatory agents. Symptoms resolved few weeks later. The etiology of IVDC still remains uncertain and in most adult patients, this phenomenon is known as an idiopathic rare condition. The majority of cases are pauci or asymptomatic. Calcification in children is usually spontaneously resolved, unlike in adults in whom calcified deposits in discs are rather permanent. As seen in our patient, most symptomatic cases are treated conservatively with an excellent prognosis. Rarely, the calcified discs may occasionally lead to nerve root or spinal cord compression. Thus, neurosurgical decompression with excision can be planned

Isolated orbital roof fractures are raremost of these fractures heal without any complications. Traumatic optic neuropathy (TON) is one of the rare but catastrophic complications of orbital roof fractures. A 37-year-old gentleman was admitted in our emergency department following road traffic accident. He fell down from a motocycle, on presentation to the emergency department he felt a little drowsy, had vomited twice, and complained of pain around his right eye. His Glasgow Coma Scale was 15/15. Clinical examination revealed right periorbital hematoma with edematous lids closing the right eye and ecchymosis, and pupils were equal in size. Eye movements was normal but visual acuity in the right eye was 2/10 and in left 9/10. CT scan of the facial bones (slice thickness 1 mm) demonstrated a comminuted right orbital roof ´blow-in´ fracture (A,B,C,D) with associated non-displaced linear fracture extension towards the optic canal fracture. Magnetic resonance imaging MRI axial T2 flair showed a contusion of the right optic nerve (A,B,C,D). Traumatic optic neuropathy (TON) refers to optic nerve damage secondary to trauma, which occurs in approximately 0.5-5% of head injuries and 2.5% of patients with maxillofacial trauma and facial fractures. It is defined as any damage to the optic nerve secondary to trauma that may occur primarily or secondarily to the initial insult. It is crucial to make an appropriate diagnosis of orbital roof fracture if present because of its possible medical implications like enophthalmos or proptosis, facial asymmetry, visual loss, and eye movement restriction.

Osteoblastoma is an uncommon benign bone tumor. which accounts for approximately 1% of all primary bone tumors. It is commonly seen in the long tubular bones and in the vertebral column, It is rarely found in the calvarium. The tumor has a preference for frontal and temporal bones and has rarely been reported in the occipital bone. In one large study of 306 osteoblastomas, only 11 (4%) were located in the calvarium. To date, only 62 cases of calvarial osteoblastoma, have been reported in the English literature. A 34-year-old man, he had occipital neuralgia with intense pain that feels like a sharp, jabbing, electric shock in the back of the head and neck,he presented a mild tender progressive swelling in the occipital area, which had persisted for 6 months prior to the patient´s admission. The patient appeared otherwise well, and had no significant past traumas or medical history. A physical examination revealed a hard smooth mass, which was fixed to the underlying occipital bone. The skin overlying the lesion was normal and did not adhere to the mass. There were no neurological deficits. Computed tomography (CT) scanning of the brain using bone reconstruction techniques showed a midline occipital suboccipital bony lesion and extending from the torcula (A,B). During surgery, the mass was completely excised by en bloc removal, after making a burr hole in the surrounding normal bone. Postoperative management is straightforward with Immediate disappearance of occipital neuralgia. The findings of histopathological examination were consistent with the diagnosis of a benign osteoblastoma.

Les neurocytomes centraux (NC) sont des lésions bénignes qui se développent généralement à partir des noyaux du septum pellucidum et se présentent sous forme de tumeurs intraventriculaires. Le CN est généralement une tumeur bénigne classée au grade II par l'Organisation mondiale de la santé et associée principalement à une issue favorable. La présentation clinique typique du CN comprend des céphalées, des vomissements des troubles de mémoire ou de vision, des convulsions, parfois révélé par une hydrocéphalie. L´exérèse chirurgicale totale de la tumeur est considérée comme le meilleur traitement et favorise les taux de survie sans récidive. Ici, nous rapportons un cas de NC atypique.

The Dandy-Walker malformation (DWM) is a rare congenital malformation involving the posterior fossa.it was first described in 1914 by Dandy and Blackfan. It is diagnosed when the following 3 main signs are identified: agenesis or hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle, and an enlargement of the posterior fossa. However, the co-existence of the DWM with precocious puberty is rare. Precocious puberty is characterised by premature appearance of secondary sexual characteristics before the age of 7 years in girls and 9 years in boys. There are rare reports of the co-existence of the DWM and precocious puberty. A 6-year-old male child presented with enlargement of penis and appearance of axillary and pubic hair. His parents noticed a recent change in his voice, he was admitted to the hospital with complaints of headache for 3 months. He was free from dizziness, nausea, vomiting, or limb weakness. He had normal vision, muscular strength and muscular ton. Magnetic resonance imaging MRI axial T1, and sagittal T2 flair showed an atrophy of the cerebellar hemispheres, hypoplasia of the vermis, and an enlargement of the fourth ventricle, which communicated with the occipital cistern forming a posterior cerebellar cyst compatible with variant DWM.

Sacral bone tumors usually remain clinically silent for a long period and are often discovered in the context of nerve root compression (S1 or S2 radiculopathy or inflammatory sciatica) or pelvic organ compression. The most common sacral tumors in adults are metastases and intraosseous locations of hematological malignancies (lymphoma or multiple myeloma), while primary bone tumors and meningeal or nerve tumors are less common; Metastatic lesions of the sacrum are rare, but pose a complex problem for surgical management. The clinical pattern of presentation depends on the anatomical location of the tumour and whether it invades or compresses neighbouring structures. We report the case of a 67-year-old man who presented with a 2-year history of intermittent low back pain with sudden urinary retention. Additionally, he was under care for chronic constipation and fecal impaction. A lumbar computed tomography (CT) scan and magnetic resonance imaging shows a heterogenous mass occupying The sacrum to the coccyx with 12-10-8 cm in size (A) . A needle biopsy revealed that this lesion was an infected metastatic carcinoid (B). Sacral tumors usually have reached an advanced stage and a large size by the time that they are diagnosed, and these conditions make the resection of the tumor technically demanding and the chance of achieving a wide margin less likely. The achievement of an adequate margin often leads to pelvic instability as well as to a loss of neurological function.

Spinal anesthesia is a widely used regional anesthesia for many infra-umbilical surgical procedures with proven efficacy and safety. However, although rare, some neurologic complications can occur with potentially life threatening consequences. Among them, lower cranial nerve palsies have been rarely reported in the literature. We report such a case in a 75-year-old man with transient dysphagia, dysphonia and spinal accessory nerve palsy occurring four days after spinal anesthesia for transurethral resection of the prostate. His symptoms completely resolved spontaneously within 2 weeks. The possibility of lower cranial nerve palsies should be added to the potential complications during or following spinal anesthesia with bupivacaine-fentanyl combination. Although transitional, this complication may occur few days after the procedure and need to be promptly recognized, carefully evaluated and treated by conservative measures.

We present a case of a papillary tumour at the cerebellopontine angle in a 54-year-old man. He presented with right-sided ear pain associated with dizziness and hearing loss. The radiological diagnosis was in favor of acoustic neurinoma. Surgical excision was performed and the diagnosis of the endolymphatic sac tumour was made. Endolymphatic tumour is a low grade adenocarcinoma that originates from the endolymphatic sac. The definitive diagnosis requires a combination of clinical features, radiological finding and pathological correlation.

A 15-year-old adolescent presented to us with mild headache, progressive dizziness and recent vomiting since 2 weeks without seizures. There was a history of head injury (neglected) following a stone-throwing incident 2 months earlier. On examination, he was conscious with a left cerebellar syndrome but without other neurologic deficit. Routine biologic data were normal. CT-scan revealed left posterior fossa extradural lesion with hypodensity in the center and calcified wall (A). MRI showed that the lesion was liquid with homogeneous ring enhancement following gadolinium injection and cerebellar compression (B and C). A sub-occipital craniotomy was done and a chronic liquefied hematoma was removed. There was a thick hard calcified wall relatively adherent to the duramater (D). Postoperative period was uneventful and the patient was discharged symptoms free. Histologically, the wall contains large areas of ossification. Ossified chronic epidural hematoma is a very rare complication following head injury. The blood accumulates slowly from a venous source becomes chronic extradural hematoma and becomes calcified or ossified due to an inflammatory reaction of the dura especially in children. This rare phenomenon should be considered in the differential diagnosis of other traumatic epidural and subdural hematomas.

L'abcès hypophysaire est une pathologie rare et fatale en absence de traitement adéquat .Il est à évoquer devant un tableau clinique d'hypertension intracrânienne, une dysrégulation hormonale hypophysaire et un contexte infectieux. Une conduite thérapeutique basée sur une antibiothérapie pourrait être tenté si diagnostic précoce. Nous rapportons un cas d'abcès hypophysaire survenant chez un hémodialysé chronique pris en charge par une antibiothérapie seule dont l'évolution était favorable avec un recul de 2 ans.

A 10-year-old boy presented with torticollis and neck pain for 2 months without fever. His physical examination showed torticollis and limitation of flexion/extension and cervical rotation without neurological deficit. Family and past histories were unremarkable. Cervical spine radiographs showed a cervical scoliosis with loss of the normal cervical lordosis and partial collapse of C3 vertebral body (A and B). Cervical computed tomography-scan and magnetic resonance imaging demonstrated a destruction of C3 vertebral corpus (vertebra plana) without discitis or spinal cord compression (C and D). A malignant bony tumor was suspected. Routine blood tests showed a mildly elevated erythrocyte sedimentation rate. Other skeletal X-rays revealed a well-defined solitary metaphyseal lytic lesion in the medial femoral condyle (E). An anterior cervical corporectomy was performed and the spine was stabilised with a tricortical iliac crest graft with plate/screws fixation (F). Histological features were consistent with eosinophilic granuloma. The patient was discharged home pain free with a good outcome. Eosinophilic granuloma (EG) is a benign and solitary bony lesion of unknown etiology. EG, Letterer-Siwe, and Hand-Schuller-Christian disease represent a spectrum of the same disease entity now known as Langerhans cell granulomatosis or histiocytosis X. EG predominantly affects the skull, the ribs, the pelvis, the mandible, and the metaphyses of other long bones. Although rare, EG should always be included in the differential diagnosis for osteolytic lesions of the spine in children.

A 49 years old man, with a history of aggression at the age of 18 years by a pair of scissors, who consulted for unilateral migraine headaches look straight. Paraclinical explorations concluded that trauma to anterior pituitary by a metallic foreign body from the right nostril to the sella, responsible for panhypopituitarism and sinusitis. The headaches are frequent causes of consultation, often treated symptomatically but rarely explored. The direct trauma to the pituitary gland, by a metallic foreign body, is exceptional. We report the case of neglected panhypopituitarism, discovered 31 years after injury with a pair of scissors.

A 53-year-old man, previously healthy, presented with a slow-progressive enlarging mass in the midfrontal area which had developed 14 years previously without headache. On physical examination, this nodular reddish mass (11 x 7 x 5 cm) was fluctuant to pressure and tethered to the underlying frontal bone (A). There was no neurological deficit and no superficial lymph nodes. Cranial computed tomography scan showed an irregular median calvarial defect with poorly bony defined margins and left frontal sinus invasion (B-C). Magnetic resonance imaging revealed intracranial extension of the tumour which invaded the dura and the superior longitudinal sinus (D-E). Local biopsy was performed and histological study consisted with a dermatofibrosarcoma. In this specific case, radiotherapy was planned before surgical excision and craniofacial reconstruction. Dermatofibrosarcoma is a slow-growing mesenchymatous tumour of the skin with high local malignancy and great opportunity of recurrence. It usually occurs in the trunk or extremities. In the majority of cases the tumour remains asymptomatic for a long time. Head (scalp) and maxillofacial involvement is rare particularly with skull vault and intracranial extension. To improve local control after surgery, wide excision is recommended but difficult in significant anatomic region as in our case.

Intracerebral hemorrhage is one of the most devastating forms of stroke especially in the posterior fossa. Expansion of cerebral hematomas was common in the acute phase ( 6 hours) but rarely reported 24 hours later. A 70-year-old man, with history of hypertension, was admitted to the emergency service with the complaint of headache, dizziness and vomiting. He was neurologically intact except for neck stiffness. A cranial CT-scan demonstrated a left hemispheric cerebellar hematoma (about 2 cm in diameter) and a fourth ventricular hemorrhage without hydrocephalus (A). The patient was kept under observation. About 32 hours of onset, the patient complained of severe occipital headache and sudden loss of consciousness. He was brought to the ICU, where he appeared drowsy and bradipnoic. Neurological examination showed anisocoria. An emergency CT-scan revealed an increase of hematoma volume, the diameter was about three times as large with acute hydrocephalus (B). The patient was transferred to the operating room but unfortunately died before performing any surgery. This case shows that we should always consider the risk of hematomas enlargement or re-expansion following a hemorrhagic stroke. This secondary phenomenon can occur late and may be cause a rapid fatal outcome if not detected and managed early.

Gas production as a part of disc degeneration can occur but rarely causes nerve compression syndromes. The clinical features are similar to those of common sciatica. CT is very useful in the detection of epidural gas accumulation and nerve root compression. We report a case of symptomatic epidural gas accumulation originating from vacuum phenomenon in the intervertebral disc, causing lumbo-sacral radiculopathy. A 45-year-old woman suffered from sciatica for 9 months. The condition worsened in recent days. Computed tomography (CT) demonstrated intradiscal vacuum phenomenon, and accumulation of gas in the lumbar epidural space compressing the dural sac and S1 nerve root. After evacuation of the gas, her pain resolved without recurrence.

Il s'agit d'un patient de 48 ans suivi depuis 4 ans au service d'ORL pour une otite séromuqueuese droite pour laquelle il a était mis plusieurs fois sous traitement médical à base de corticoïdes et d'antibiotiques locaux et systémiques. A la lumière d'un bilan radiologique ce patient a été déclaré porteur d'une métastase temporale d'un cancer primitif pulmonaire- comprimant la trompe d'eustache, lysant l'os temporal et responsable d'une fuite du liquide cérébrospinal dans le conduit auditif externe (prise à tord comme étant une otomastoïdite). Ce diagnostique de métastase a été confirmé par une biopsie stéréotaxique. Le patient est décédé 4 mois après sa première séance de radiothérapie conventionnelle. Le cancer du poumon est le premier cancer prometteur de métastases cérébrales, la localisation temporale de ces métastases est pourvoyeuse de crises comitiales avec ou sans déficit neurologique. A notre connaissance, il n'a pas été déjà décrit qu'une otomastoïdite peut révélée ce type de lésion qui reste de mauvais pronostique.

This 32-year-old-man was admitted to the emergency department because of S1 left acute sciatica. An emergency, CT-scan showed highly probable appearance of herniated disc in L5-S1 level (A). The patient was operated without founding disc herniation, but an aspect of anterior and posterior epidural abscess compressing the dural sheath at L5-S1. Medullary MRI showed after the up and the down extention of disease process (B). Histological examination of samples found a B lymphoblastic leukemia (C). The patient died 3 weeks after because of systemic infection. After review of literature, it was never been described that the sciatic pain can be a mode of revelation of B acute lymphoblastic leukemia. Only two cases reported this mode of revelation but for lymphoma requiring a surgical intervention -as our case- firstly to relieve the patient by a radicular decompression and secondly for histological diagnosis.

Pedicle screws are the main type of instrumentation used in the lumbar spine via the posterior approach. The accuracy of their insertion is always a concern because the malposition of screws is associated with a potential risk of iatrogenic injury of any neurovascular structure they pass. Fortunately, spinal cord and cauda equina injuries are rare. This 18-year-old paraplegic woman presented more than one year after a posterior spinal fusion (extended from L2 to L5 using mono-axial pedicle screws and rods) was performed at another institution following a spinal injury. She complained of atypical mild pain to the lumbar spine, while plain radiographs were suspicious for a L2 left transpedicular screw misplacement. Lumbar spinal CT-scan demonstrated a misplaced L2 left transpedicular screw which penetrated the spinal canal. The patient and her family were concerned about the intra and perioperative risks of the procedure and denied any further intervention at the moment. Late detection of pedicle screw misplacement into the spinal canal is exceptional and the complexity of revision surgery should be balanced especially if the patient presented with a total paraplegia since the first traumatism. To prevent these serious surgical complications, the surgeon must have a clear understanding of the anatomy of the affected pedicles and to use some imaging guidance (fluoroscopy or radiographs).

A 48-year-old man was referred to our unit for assessment of recurring episodes of painful torticollis. Family and past histories were unremarkable. There was no traumatic antecedent. During the previous three years he had experienced several episodes of torticollis and painful cervical movements without radiculopathy. His neurological examination was normal, except for a head tilt, decrease range of cervical motion and local tenderness on the right lateral side of the neck. Cervical spine radiographs showed a cervical scoliosis with right unilateral C5-C6 facet joint hypertrophy (A). Cervical computed tomography-scan and magnetic resonance imaging demonstrated a small bone regular tumor in the right C6 articular process and important amyotrophia of the neck musculature on the right side without nerve root or spinal cord compression (B and C). A posterior cervical approach was performed and the mass was completely removed without facet joint sacrifice. At surgery, the tumor appeared well-circumscribed, firm, and calcified with a cartilaginous-cap like appearance (D). Histological features were consistent with benign osteochodroma. The patient was discharged home pain free and referred for physiotherapy care with a good outcome. Osteochondroma is the most common benign tumor of bone (especially long bones), but the spine is rarely involved and usually indicates a hereditary cause such as osteochondromatosis (hereditary multiple exostosis). As seen in our case, this lesion is slow growing, and therefore significant spinal deformation can occur before the symptoms are recognized.

A 13-year-old boy was brought by his mother for neglected toes wounds. There was a history of self-mutilation from first years of life with absence of normal reaction to painful stimuli. He had scars from injuries and he had self-mutilation of the distal thumb of the second finger on the right hand (A) and the first toe was missing on the left foot (B). Neurologic examination revealed decreased tactile sensitivity. The child seemed to respond appropriately to thermal stimuli. However, there was no reaction to pain stimuli. It was noted that he had normal mental development. Hands and feet radiograph showed destruction and amputation of the second right finger (C) and the first left toe (D). Biologic data were normal. There was no consanguinity but one of his paternal uncles seems to have a similar medical history. The infected wounds were treated conservatively with antibiotics and local care. Congenital insensitivity to pain with anhidrosis is extremely rare entity also known as hereditary sensory and autonomic neuropathy type IV. This autosomal recessive disorder is characterized by the congenital lack of pain sensation, inability to sweat, episodes of recurrent hyperpyrexia, mental retardation, and self-mutilating behavior. Patients are subjected to repeated injuries which are often neglected. There is no specific treatment but patient training and parent education are keys to avoid further neglect and damage.

A 59-year-old man with a history of chronic ankylosing spondylitis for many years, developed neck pain and left cervico-brachial neuralgia following a road traffic accident sustained one week before. Plain radiographs of cervical spine were initially misinterpreted. On examination, he had severe neck pain on mobilization without any neurological deficits. Delayed cervical computed tomography scan showed ossification of the anterior longitudinal ligament, calcification of the intervertebral discs and complete vertebral fusion (so called bamboo spine) with transversal fracture at C5-C6 disc level (so called carrot-stick fracture) causing a luxation of the cervical spine with significant compromise in canal space (A and B). A transcranial spinal traction was performed followed by anterior decompression and stabilization via an anterolateral cervical approach. The outcome was favourable. Transverse fractures of the spine are rare in patients with ankylosing spondylitis and diagnosis should be considered following even minor trauma. These atypical unstable fractures occur because of the loss of flexibility and fragility of the osteoporotic spine. Early diagnosis for possible intervention is important because of the high mortality rate.

Unintentional foreign bodies ' swallowing is a fairly common occurrence in ENT consultation especially among children. They usually pass through the gastrointestinal tract without complications. Migration of a foreign body through the esophageal wall is rare. It represents about 1% to 4% of all cases of foreign bodies ' ingestion. A 16 year's old female patient has presented to ENT emergency with a painful dysphagia following an accidental ingestion of a metallic pin. Cervical X ray confirmed the presence of the pin while endoscopic investigations have shown no foreign body. Cervical CT scan revealed the migration of the foreign body through the esophageal wall with left vertebral artery dissection. Endoscopic management has been sufficient with an uneventful post operative follow up. Esophageal foreign bodies are very diverse mainly dominated by fish bones (60%) and chicken bones (16%). Metallic pins are rare. The major risks of migration of those foreign bodies are cervical abscess, mediastinitis and oeso-vascular fistulae. Cases of self extrusion through the skin have been reported. Migration of a foreign body through the esophageal wall is rare. Endoscopic management has been sufficient.

A 52-year-old man, previously healthy with no known metabolic or systemic illness, presented acutely following a direct trauma of the right foot. On examination there was soft tissue swelling and tenderness around the dorsum of the foot without neurological deficit. Plain radiography of the foot and the leg revealed a 10 centimeters ossification within the right Achilles tendon without fracture. The patient had no previous ankle problems. Local examination revealed a painless palpable gap and hard edges in the Achilles tendon but there are no disorders in walking. Because the patient was asymptomatic, no surgery was performed. Ossification of the Achilles tendon is an unusual clinical condition to be distinguished from the more frequently occurring tendon calcification. It is characterized by the presence of one or more segments of variable sized ossified mass within the fibrocartilaginous substance of the Achilles tendon. The etiology of this local ossification is unknown. The major contributing factors are trauma (especially repetitive microtrauma) and surgery with other minor causes such as systemic diseases, metabolic conditions, and infections. A large and extensive ossification for more than half of the tendon is rare and should not be misdiagnosed as a fracture or a foreign body particularly following an injury.

A 15-year-old adolescent, previously healthy, presented with right peroneal nerve palsy sustained after a direct closed knee injury in a soccer game. The physical examination revealed a marked weakness to dorsiflexion of the right ankle and toes without sensory loss. A bony mass was noted in the right postero-lateral area of the knee. Plain radiographs and a computed tomography-scan of the knee showed a large osteophytic mass in the proximal metaphyse of the right tibia with an important mass effect on the fibular head which is deformed (A-D). Electrophysiological studies confirmed denervation of the muscles supplied by the right peroneal nerve. The patient underwent surgical decompression of the nerve after resection of the osseous mass. Postoperatively, there was a progressive improvement of the nerve function. The patient was referred for physiotherapy care. Histological features were consistent with benign osteochodroma. Osteochondromas (exostosis) frequently develop around the knee in the distal femur and the proximal tibia and fibula. These osteocartilaginous tumors are usually asymptomatic, but can occasionally impinge on the surrounding nerves and vessels and cause various clinical manifestations. Tibial osteochondroma compressing both the fibular head and the peroneal nerve is rarely seen especially following a direct injury.

A 6-year-old boy, with no past medical history, presented with progressive headache, vomiting, right side weakness since 3 months without fever or seizures. On examination, he was conscious with a stiff neck and right hemiplegia. Brain computed tomography-scan showed a heterogeneous calcified large mass-like lesion in the left fronto-temporo-parietal region, irregular contrast enhancement and extensive perilesional edema with important mass effect (A-C). There was a strong suspicion of malignant tumor. Routine blood tests and chest X-ray were normal. Magnetic resonance imaging was requested but not made because of the rapid deterioration of the state of consciousness of the child. The patient was operated urgently. At operation there was a large intra-axial yellowish, firm, and relatively avascular lesion. Total excision of the mass was done (D). Histological features were consistent with tuberculoma. Serological test for HIV was negative. The patient improved progressively and was discharged on antituberculous treatment with a good outcome. Intracranial tuberculoma should always be considered in the differential diagnosis of solitary and large focal brain lesions, particularly in patients of tuberculosis endemic areas. In our patient, surgical excision not only helped to establish the histological diagnosis but also helped to resolve the compressive symptoms.

A 37-year-old previously healthy man presented with a localized headache and a progressive enlarging mass in the left frontal area for more than 8 months. He also reported a history of head injury in the same area sustained two years before. On physical examination, the mass (about 28 mm in diameter) was hard to pressure with freely mobile skin above the lesion in the left frontal sus-orbital region. Ophthalmologic and neurologic examinations were normal. Cranial computed tomography scan showed an osteolytic intradiploic lesion with poorly defined margins (A and B). Magnetic resonance imaging showed hyperintense lesion on T2-weighted image and hypointense on T1-weighted image with gadolinium enhancement (C). The lesion was extradural with slight brain mass effect. Surgery consisted of total resection of the bony bluish lesion (D) and cranioplasty. The postoperative course was uneventful. Histological study revealed a cavernous hemangioma of the diploe. Bone hemangioma is a vascular hemartoma: a benign tumor arising from the intrinsic vasculature of the bone, commonly seen in long bones and vertebrae. Skull cavernous hemangiomas are rare tumors for which the origin is not yet clear. We suspected that in our case head injury may have been the cause of cavernous hemangioma in the cranial vault.

A 40-year-old woman, previously healthy, presented with a 6-month history of foreign body sensation of the pharynx with recent progressive dysphagia when swallowing both solid and liquid foods. A lateral cervical radiograph showed severe anterior osteophytosis on C3-C4, which was confirmed on computed tomography scan (Figures A, B and C). The posterior pharyngeal wall was compressed by the anterior spurs at the C3-C4 level. Anterior resection of the ventral spinal osteophytes was performed via an antero-lateral extrapharyngeal approach. After the operation, the dysphagia resolved. Cervical osteophytes are common but osteophytes causing dysphagia due to compression of pharynx and oesophagus are unusual. The most common aetiologies are diffuse idiopathic skeletal hyperostosis (Forestier's disease) and ankylosing spondylitis. Initial treatment includes diet modifications, non-steroidal anti-inflammatory and muscle relaxants medications. Osteophytectomy may be considered in certain patients where conservative management fails. Stabilization of the spine is not advocated.

A 37-year-old woman, previously healthy with no history of trauma, presented with a scalp swelling of the left frontal region. The swelling was present for the last one year and had gradually increased in size with recent localized headache. The patient had no neurologic deficit. Local examination showed a painful local swelling of about 25 mm in diameter in the left frontal area and appeared to arise from the bone. Hematological and biochemical investigation results were within the normal range. Computed tomography scan revealed a left frontal intradiploic mass with bone defect (figure A). Magnetic resonance imaging showed that the lesion was soft with homogeneous enhancement following gadolinium injection. There was erosion of both inner and outer table of the cranial vault with extracranial and intracranial extradural extension (figures B and C). The tumor was excised completely and the surrounding bone was removed (figure D), followed by cranial reconstruction. There was no intradural extension of the lesion. Histologically, the tumor was diagnosed as meningothelial meningioma. The patient has been well for 1 year following the operation with no evidence of recurrence. Meninigiomas are primary tumors of arachnoid cell layers and the lesions are in purely settled intradural locations. Meningiomas in extradural locations are very rare and should be considered in the differential diagnosis of osteolytic skull vault lesions.

A 26-year-old man, previously healthy, presented with a 6-month history of bilateral sciatic pain and frequent constipation but no urinary symptoms. Physical examination revealed tenderness of the lumbosacral region with radiating pain along the sciatic nerve and the perinea without motor weakness of the inferior legs. No cutaneous lesions were noted especially no café-au-lait macules. Magnetic resonance imaging of the lumbosacral area showed multiple intracanalar lesions of the lumbosacral spine causing scalloping of posterior parts of all the sacral vertebrae and neural foraminal widening with bilateral and symmetric extension to the pelvic region. Biologic data were normal. Chest radiography followed by computed tomography revealed an axillary thoracic tumor (5 cm on diameter) which was biopsied and histologically identified as benign neurofibroma. Brain MRI showed no other cranial nerve tumors and there was no family history of neurocutaneous lesions. Because the patient had mild symptoms without neurological deficits, no surgery was performed for the sacral neurofibromas. Neurofibromas are one of the major characteristics of type 1 neurofibromatosis. They can develop from the Schwann cells or fibroblasts of any peripheral nerve. Massive intra-extraspinal cases characterized by dumbbell neurofibromas as in our case are rare and maybe asymptomatic for a long time. It is crucial to screen the entire spinal axis to detect all neurofibromas. Symptomatic cases justify surgical treatment but the decision for surgery and the surgical approach is quite complex because neurofibromas occupy a large spinal and extraspinal regions.

A 33-year-old previously healthy man was admitted with a craniofacial trauma sustained in a road traffic accident. No post-traumatic seizures were documented. On physical examination, large wound was observed in the frontal region on the right side. He was comatose, and his consciousness level was 6 on the Glasgow Coma Scale. The right pupil was dilated but responsive to light. The axial slices of the cerebral computed tomography-scan (CT-scan) revealed a distorted right cerebral hemisphere with effacement of the basal cisterns, which was compressed by an extraaxial haematoma located in the right frontoparietal region. This haematoma was found to have two different components: the first (anterior) was epidural and the second (posterior) was subdural. Both haematomas were evacuated through a right frontoparietal craniotomy. Postoperatively, CT-scan showed no evidence of residual haematoma. The patient has been in good health throughout the 3-month follow-up since the accident. Classic CT-scan appearance of intracranial epidural haematoma (EDH) is high density biconvex shape adjacent to the skull and usually confined to small segment of calvaria. On the contrary, acute subdural haematoma (ASDH) appear more diffuse, less uniform, usually concave over brain surface and often less dense (from mixing with cerebrospinal fluid) than EDH. But when combined, these two different surgical entities are not easy to distinguish on CT-scan. The Yin-yang-shaped image seen in our patient is formed by an anterior biconvex shape and a posterior concave shape, the combination of adjacent epidural and acute subdural haematoma. The radiologic features of our presentation are interesting and might be useful to distinguish both adjacent EDH and ASDH.

Clay-shoveler's fracture is an avulsion fracture of one or more spinous processes of the lower cervical and/or upper thoracic vertebra. The site of fracture is most commonly C6, C7 or T1 but it occurs rarely at multiple levels. More often the mechanism is a combination of direct impact and hyperflexion of the neck. It concerns healthy individuals with no history of prior disease. These injuries are known to be stable but painful at the cervicothoracic site without neurological symptoms. In most patients, immobilization of the neck with a cervical collar and restriction of physical activity for 1 to 2 months frequently result in pain relief. This 29-year-old woman was admitted following a road traffic accident. She had severe neck and posterior thoracic pain with radiation to the bilateral shoulder regions. Physical examination revealed tenderness over the posterior cervicothoracic spine without neurological deficit. Computed Tomography (CT) scan of the spine revealed isolated fractures of the spinous processes interesting eleven adjacent levels from C6 to T9 spinal vertebrae without any other traumatic bony lesions. Conservative treatment was administered (analgesic therapy and muscle relaxant) and immobilization was maintained for 6 weeks followed by a good outcome.

A 4-year-old girl was admitted complaining of recurrent swelling, facial wound discharge and pain in the left cheek for 4 months with difficulty to open her month completely. Her parents report that after a fall, six months later, she presented a small facial laceration that had spontaneously healed. No particular symptom had developed during 2 months. After that time, the facial wound discharge appeared episodically and a facial abscess was suspected and treated with antibiotics by two physicians without improvement. Plain facial radiography revealed a metallic foreign body in the left cheek without osteolysis. No abscess collection was identified by ultrasonography examination. The patient had a mild leukocytosis, while C-reactive protein and sedimentation rates were normal. An approximately 5 x 10 mm metallic fragment that was surrounded by granulation tissue was palpated and extracted surgically and the patient discharged without complications. A retained foreign body in the check after an apparently minor facial injury is an extremely rare event. The present case report reveals the diagnostic and therapeutic challenges and stresses the importance of high degree of suspicion to diagnose retained facial foreign bodies, especially in children, and the need for early surgical exploration, to avoid chronic and potentially life threatening infectious complications.

Pediatric intramedullary schwannoma without neurofibromatosis is extremely rare with only five cases reported so far. We present this rare finding in an 10-year-old boy who presented with a sudden onset of weakness in the lower limbs. An intraoperative diagnosis of schwannoma enabled us to carry out a total excision of the tumor, which resulted in near complete recovery at 10 months follow-up. Although rare, this diagnosis should be considered when a child presents with a solitary intramedullary tumor since its total resection can be achieved improving surgical outcome.