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In an attempt to improve the primary treatment of malignant gliomas we used a concomitant 6-week course of chemoradiotherapy with 5 fluorouracil (5 FU) and hydroxyurea (HU) in 24 adults with anaplastic astrocytoma (AA) (7 cases) or glioblastomas (GLB) (17 cases). This patient population was characterised by a poor prognostic profile; 50% of cases had biopsic or subtotal surgery and 70% had GLB. Patients received 2 Gy/day 18 MV photons with 300 mg/m2 of 5 FU in continuous infusion and 500 mg x 4/day per os of HU, five days per week during 6 weeks. Treatment was poorly tolerated in terms of toxicity and implied heavy logistics (hospitalization, central venous access) worsening the quality of life which is already bad in malignant gliomas. Unfortunately we did not improve median survival which does not exceed 26 weeks with 7 long survivors (> 49 weeks). This pilot study does not offer any benefits over current standard approaches. Aggressive locoregional approaches such as this should perhaps be attempted in patients with a better profile.

The therapeutic problems raised by recurrences are different from those which apply to the initial malignant glioma. Firstly, the histological diagnosis is known (by excision or biopsy) and secondly the clinical period which has elapsed before the recurrence represents a factor in the assessment of progression and/or malignancy. The management of treatment must take into account various parameters of an anatomical and clinical nature, but although those relating the various forms of treatment used already. Although the methods used are the same: surgery, radiotherapy, chemotherapy, the strategy will differ according to indications of final recourse or reoperation will be discussed after initial surgery followed by radiotherapy, irradiation in those cases in which radiotherapy has not already been used and chemotherapy, Corticosteroids are also widely employed. Whilst such palliative treatment has the merit of ensuring prolongation of survival, the principal aims must be concerned with the quality and conditions of this survival.

Numerous factors remain unknown as far as the mechanism of induction of cerebral metastases is concerned. Where as of cancer give metastases more readily than others, especially cerebral metastases, the neoplastic embolus can be either eliminated or remain in place in a state of quiescence. What is the role played by the blood brain barrier from a pathophysiological point of view? Is there a mechanism which prevents central nervous system metastases? What is the importance of individual variation? We attempted to induce cerebral metastases in VX2 carcinoma carrying rabbits to look for an approach to these problems and to create an experimental model of cerebral metastase. The VX2 carcinoma is easily transplantable and its biological characteristics are well known. The VX2 tumor is implanted in the thigh of the rabbits and is used in the experimentation starting two weeks following the take of the graft; the tumor is surgically resected and a solution containing approximatively 50,000 tumor cells for 0,1 ml is prepared. This solution is inoculated via the carotid artery to the same rabbit or to another rabbit of the same breed either or intrathecal way into the brain. Death occurred 6 to 20 days later and was followed by a complete pathological survey. The results were the following: --The inoculation via the carotid artery, even with very highly concentrated solution was never followed by any recognizable brain metastasis. --The inoculation intrathecaly produced only extraparenchymatous metastases where as the direct intracerebral inoculation was followed by the occurence of intracerebral metastases.

The authors have been using routinely since February 1983 a french 80W. CO2 Laser unit. They discuss the advantages and limits of this technic in the light of the first 26 intracranial and intraspinal operations carried on with it. The main and wellknown qualities of CO2 Laser are: the easiness of the hemostasis of the tumor and of the surgical cavity; and the absence of traction on the same tissue. The coupling of CO2 Laser with the operating microscope appeared very useful and made safer deep tumor excision, particularly that of the posterior fossa such as neurinomas and meningiomas. It was also quite efficient for intra-orbital tumors. The maniability of the hand piece was increased by the use of oblique mirror (45 degrees and 60 degrees) fixed at its extremity. The incision of skin, subcutaneous and muscular layers was not simplified by CO2 Laser; indeed this apparatus increased the operatory duration and was responsible of a healing time extension.

The authors have been using real time echography in neurosurgical procedures since 1981: either for detection of a small sub-cortical tumor during a surgical operation, either for biopsy-guidance, or for puncturing a cavity (abscess, cyst or hematoma). The imaging is performed with a CGR SONEL 100 apparatus and two different frequency transducer elements: 3.5 MHz and 5 MHz. 56 patients underwent this technique; 22 times the lesion was hypoechoic: abscess give homogeneous, round hypoechoic image, often surrounded by a fine hyperechoic line; intracerebral hematoma produces an hypoechoic image after a 10 to 15 days evolution: compared to an abscess it then has a more hyperechoic irregular wave-like limit; tumoral-cyst echogenicity is very low; it can even be anechoic. If a stereotaxic structure exists, indication of real time echography must be limited to such stereotaxy contraindications: threatening intracranial hypertension, suppurated lesion, fragile patient. The technique has its limit: that is the small volume of the target-lesion (inferior to 10 mm); advantages must be emphasized: light procedure, satisfying confidence when considering the probe progression, sometimes better information than that of a CT-Scan examination especially for tumoral and cystic lesions.

Fronto ethmoidal osteoma are rare slow growth benign tumors. Exceptional ophthalmological and neurological complications can occur. The authors report a case of 32 years old man with eye compression by a giant frontal sinus osteoma. This lesion was responsible for a vertical diplopia and moderate proptosis. Plain skull X-Ray show a well defined opacity filling the whole left frontal sinus and C.T. scan delimited precisely orbital extension. Neurosurgical exposure enabled a complete extraction of the tumor and satisfying recovery. The authors have compared this case to those described in literature and insist on the importance of the pre-operative C.T. scan.

This study comprises 14 patients with metastatic involvement of the cranium treated between 1957 and 1979. Anatomical and radiological aspects and the clinical manifestations of these metastatic lesions are analyzed. These lesions are not a definite clinical entity, and they have specific therapeutic problems. Treatment consisted of surgical excision and radiotherapy. The surgical results are presented and discussed.

The authors have studied 600 cases of spinal metastasis causing a neurological syndrome. The most significant statistical data are reviewed. The cases are examined according to clinical characteristics, type of primary tumor, site of lesion, and survival. Each of these factors influenced the choice and results of treatment. As a general rule, combined treatment (surgery and radiotherapy) was used. Preliminary surgery was performed as an emergency, designed to halt progression of the neurological syndrome and to prevent its more serious manifestations. The technique and usefulness of surgery are discussed for different situations and the short-term results of treatment are related to the various factors involved.

Arachnoid cysts of the quadrigeminal region are rare. We report two new cases. The first is a 29-year-old woman, who had a recurrence five years after sub-total removal of the cyst wall. Initially it was communicating and was treated by a ventriculo-atrial shunt; later it became noncommunicating and direct drainage of the cyst cavity was required. The second was a 25-year-old female, successfully treated by wide removal of the cyst wall thus creating a large communication with the subarachnoid space. Diagnosis of these lesions, as regards either morphological or functional features, nowadays rests largely on CT. Choices about treatment are extremely difficult. The most radical one, namely, complete removal of the capsule, is not without risks and disadvantages. More prudent methods, such as partial removal of the capsule and/or drainage of the cyst and the ventricles, seem on the whole to be preferable, but careful pre- and post-operative evaluation of CSF dynamics are essential for a satisfactory and long-lasting outcome.

A histological study of lymphocytic infiltration has been undertaken following removal at operation of one hundred human gliomas. This study has been completed with eight cases of tumour recurrence, six attempted autologous grafts, twenty one post-mortems and fourteen explorations of delayed hypersensitivity reactions. About half of the glioma specimens showed lymphocytic infiltration and no reaction was present in the other. Within this series of glioblastomas a correlation existed between the presence of infiltrating lymphocytes and the duration both of pre and post operative tumour evolution. The rejection of autologous grafts seemed to depend directly on the presence of lymphocytic infiltrations associated with the primary tumour. The retarded hypersensitivity reactions obtained after intradermic inoculations of cellular lyophilizates did not seem to be directly related either to the phenomenon of autologous graft rejection or to the presence of lymphocytic infiltrations. The results suggest that there is a complex system represented by two antigenic groups of transplantation type and sensitization type.

One case of trigeminal neuralgia and operative giant basilar aneurism is reported. This feature is quite rare, this case however emphasizes the importance of further investigations before surgery, especially if a direct approach is considered.

The authors report on a case of symptomatic Rathke's Cleft Cyst (RCC). The only clinical feature was headache. The cystic fluid was aspirated through a trans-sphenoidal approach. The postoperative course was uneventful. The rarity of symptomatic RCC (70 cases described in the literature; 30 operated patients) makes necessary the comparison of all data quoted in the different publications so as to define an appropriate attitude to treatment. It thus seems that the surgical procedure should be limited to an aspiration of the cyst contents through a trans-sphenoidal approach; such a procedure is more reliable than a craniotomy to avoid leakage of the cystic fluid into the subarachnoid space and possible postoperative aseptic meningitis. Some authors discussed the possibility of postoperative radiotherapy although only six patients developed recurrence of their clinical features several years after operation and also the efficacy of such a procedure has not been proved.

Concentrated irradiation (two series of 1,800 rads in 2 sessions and 3 days) separated by a rest period of 3 to 4 weeks has been used to treat 214 adult patients with brain tumors between 1965 and 1972. These included 108 glioblastomas, 18 astrocytomas and 88 brain metastases from different origins. Early side effects are moderate or inexistent provided synthetic ACTH or corticoid steroids have been given several days before irradiation. Survival is related, at least, in the first 2 groups of primary tumor to local failure. For brain metastases, death could be related to others reasons. In spite of the fact that comparison is made with a previous series of 121 cases it seems that this type of irradiation gives the same survival rates. Moreover it has specific advantages as reducing duration of hospitalization and the number of treatment sessions.

The authors report 40 personal cases of infratentorial hemangioblastomas and review 36 series from the literature for a total number of 1023 patients. The clinical, pathological, and surgical features of these tumors are discussed, with particular consideration of localizations outside the nervous system, multicentric tumors, recurrences, and long-term results. Although hemangioblastomas are benign tumors, their high growth potential makes their long-term development unpredictable in some cases.

One hundred and fifty patients admitted consecutively to the same neurosurgical service in Paris were reviewed retrospectively. There is no definite difference between intracranial tumors in mental patients and those encountered in a normal population in terms of: frequency, anatomic localisation and histological distribution. All the patients had been referred previously to psychiatric hospitals for: confusional states, disturbed behaviour or pseudo-depression in 60% of the cases. Neurological localizing signs were present in 83% of the cases; EEG was abnormal in 96% of the patients recorded during their stay in psychiatric wards. Diagnosis of brain tumors in mental patients appears feasible if not always simple; it is based upon elementary neurological examination and routine investigations. In a near future, isotopic scan and CT scan should become a great help to reduce excessive diagnostic delays in order to improve the prognosis which remains poor.

Three cell lines derived in our laboratory from human malignant gliomas (SA 130, SA 132, SA 134) were injected subcutaneously into pathogen-free nude thymus less mice. These three cell lines gave origine to malignant tumors which, as original tumors, were positive for the glial fibrillary acidic protein (GFAP) revealed by immunoperoxidase method.

Among 120 cases of cerebral metastases, 62 primary sites were found. The diagnosis of the primary site was confirmed: --after the first investigations in 48 cases (in 90% of cases by anamnestic inquiry, clinical examination or chest X ray); --by the evolution of the disease in 5 cases; --by autopsy in 9 cases. The most frequent primary sites were lung (45%), digestive tract (17.7%), melanoma (8%) and ovary (6.5%). Among the identified cases, 25 received treatment for their primary cancer, but only 4 had a surgical resection. There was no significant difference in mean survival between the 2 groups (defined as primary site known or unknown); over all mean survival was 8 months. The early discovery of cerebral metastases suggests the advanced state of the disease. Therefore, investigations which cause the patient to suffer do not seem justified merely for research purposes.

Unlabelled: During the period January 1975-October 1987, we performed stereotactic ventriculocisternostomy (V.C.S.) on 23 patients (13 M., 10 F.; age: 11-73 years, m: 33). Sometimes used as an isolated therapeutic procedure, V.C.S. may also follow stereotactic biopsies using Talairach's methodology. Serial stereotactic biopsies were performed in 15 out of 23 patients showing 11 tumoral lesion, two arachnoïdal cysts and two cryptic vascular malformations. Eight patients presented with an isolated aqueductal stenosis. Among the 12 non tumoral patients, seven had very large triventricular hydrocephalus (6 with a retroclival dilatation of the third ventricle) and 5 showed significant dilatation. Of the 11 tumoral patients, 7 had significant ventricular dilatation (1 with a protrusion of the floor of the third ventricle) and 4 with modest dilation. V.C.S. is done by creating an opening (diameter: 5-6 mm) in the floor of third ventricle with a fine forceps introduced through a tubular guide (diameter: 2.45 mm). The percutaneous double oblique transfrontal trajectory (drill-hole: 2.5 mm of diameter) passing through the foramina of Monro, avoids superficial and deep vessels visualised on the previous Stereoscopic Tele-Angiographic and Ventriculographic study. A systematic verification of the V.C.S. patency is made intraoperatively by injection of iodine contrast medium into the third ventricle., Results: (non tumoral patients: 12) (m follow-up: 4 years): two patients needed a ventricular shunt after 3 and 1 months respectively, the first one because of an associated communicant hydrocephalus, the second because of a post-operative meningeal infection. Long-term clinical and CT-Scan follow-up showed that complete resolution (7 cases) or partial (2 cases) improvement of symptoms and signs was not accompanied by normalization of ventricular size, even though the dilatation was significantly reduced in 8 cases and to a lesser extent in 2., Results: (tumoral patients: 11) (m follow-up: 3 years). Hydrocephalus was reduced in 6 cases and remained unchanged in 5. Two patients needed a ventricular shunt 2 years after the V.C.S.: 1 patient, because of a tumoral recurrence involving the region of the fenestration, the second patient because of adhesive arachnoiditis following reoperation for suspicion of recurrence, though this was found to be granulomatous inflammation. Two patients died as a result of their tumors at 2 and 6 years., Conclusion: Stereotactic V.C.S. is the treatment of choice for triventricular obstructive hydrocephalus even when there is no retroclival dilatation of the floor of the third ventricle.

The metatarsal intercapital space is located in the forefoot, between two metatarsal heads and above the transverse inter-metatarsal ligament. The 2nd space is the narrowest, the 1st is the widest and the 3rd is the most mobile. It contains a connective tissue bursa which facilitates the sliding of the metatarsal heads. The existence of this bursa was confirmed in two cases of rheumatoid arthritis (at operation). As the bursa hypertrophies, it gradually extends beyond its normal site towards the dorsal or plantar region of the foot. The metatarsal intercapital space, like the metatarso-phalangeal joint, warrants thorough clinical investigation.

On the basis of studies utilizing antibody to GFAP (glial fibrillary acidic protein) in the indirect immunofluorescent and immunoperoxydase methods we report the presence of GFAP in 5 astrocytomas, 1 ependymoma and 1 medulloblastoma. The GFAP was evidenced on cryostat sections of frozen material and in short-term tissue culture. Five others tumors including 1 oligodendrocytoma, 1 choroid-plexus papilloma, 1 meningioma and 2 secondary sarcomas were negative. Possible applications of antibodies to GFAP for localization and therapy of brains tumors were considered.

Computerized tomography is usually adequate to explore supratentorial lesions of the skull and brain. However, it is often inadequate for a detailed analysis of lesions of the base of the skull and their anatomical rapports. Opacification of the subarachnoid spaces by means of a contrast medium (computerized cisternography) has proved extremely useful in such cases. The contrast media utilized are tri-iodized, water-soluble compounds which are well tolerated. The technique and anatomical data of the method are described, and its applications in different fields of tumoral and non-tumoral pathology are discussed.

A retrospective study is reported of 120 consecutive cases of patients presenting with brain metastases as the primary sign of their malignancy. Primary site was found in 62 patients (53 while alive and 9 at postmortem examination) and remained unknown in 58. Lung was the most frequent primary site (45% of known sites), and digestive malignancies were surprisingly the second most frequent primary site (19% of known sites), whereas breast was found in less than 5%. When primary site was disclosed, in 85% it was after history, clinical exam, chest x-ray, and pathologic findings. Survival was almost identical in both known and unknown primary sites: 54% versus 44% at 6 months, 20% versus 16% at 1 year, and 6% versus 5% at 2 years. It was concluded that extensive evaluations to identify primary sites do not appear to be rational in patients presenting with brain metastases.

The authors have been using CO2-laser radiation routinely for more than 2 years. After having recalled the basic thermal properties of this beam, they present their experience. The goal of this work is to point out the particular benefit of CO2-laser cautery to perform tumoral haemostasis. The technical data of this CO2-laser haemostasis are detailed for 3 main indications: In cases of a precise origin of the haemorrhage, the coagulation of small intratumoural vessel necessitates a low output power: 2-4 watts in continued emission; 10-15 watts in the pulsed mode. The beam must be defocussed so as to be as large as the aimed vessel. A micro-manipulatotor is necessary for deeply located tumours. Basal meningiomas, neurinomas, giant adenomas are the best indications. If a diffuse bleeding is encountered in the operative cavity the output must be a little higher: 3-8 watts in continuous mode or 15-30 watts in the pulsed mode; first the cavity is swept with a defocussed CO2-laser ray; then the few larger vessels which have not been cauterized are coagulated one by one either by laser or by bipolar coagulation. The insertion zone of a meningioma can be efficiently coagulated by CO2-laser: a 150-200 watts output in the pulsed mode is necessary if the attachment is dural, a 300-400 watts pulsed output in the case of bony infiltration.

The authors describe two cases of giant intradiploic epidermoid cysts of the cranial vault in which there was massive intracranial extension causing signs of neurological involvement. The very slow growth and the benign histological nature of these tumors explain their long preoperative evolution and the mild neurological signs in some cases. Roentgenographic and computerized tomography findings permit a correct diagnosis. Complete removal of these cysts and their capsules can be easily accomplished, despite their large size. Total removal of these cysts is associated with a very good long-term prognosis.

Intracranial localizations of Hodgkin's disease (HD) are uncommon. We report on 2 patients with HD who presented with an intracranial relapse. We discuss 1) the pathogenesis of those rare recurrences; 2) the therapeutic strategy.

Twenty cases of carcinomatous meningitis in adults, treated in the Gustave Roussy Institute between 1970 and 1980, are reviewed. In fourteen cases meningitis was secondary to breast cancer. Initial inflammation was present in 90% of the mammary tumors. Clinical features as well as biochemical and cytological findings in cerebrospinal fluid are described. The various therapeutic regimens using radiotherapy and intrathecal chemotherapy are analyzed in terms of survival and compared with other published studies. The most significant point is the necessity for early diagnosis which improves survival. However, prognosis for this metastatic disease is always very poor.

Since 1965, 118 glioblastoma and 18 malignant astrocytomas of the adult have been treated by concentrated irradiation after a more or less complete surgical excision of the tumor. Three types of irradiation have been used; at present 3 600 rads whole brain irradiation are delivered in 2 series of 1 800 rads over 3 days 20 to 30 spaced a part. All patients receive ACTH and the tolerance has been excellent. The results of this rapid palliative therapy are quite comparable to those of more classical irradiation. Because of the very short survival of these patients, it would appear advantageous to treat them in as short a time interval as possible.

From 1961 to 1982, 20 adults (greater than 16 years of age) were treated with radiation therapy following surgery for medulloblastoma. All patients received neuro-axis irradiation. Five patients received adjuvant chemotherapy. A 5- and 10-year survival rate of 78 and 55%, respectively, were achieved. Treatment failures were mainly a result of local recurrences, but also of metastases. One patient died of acute myeloid leukemia. One patient developed paraplegia. The survival rate was better in males (2 deaths out of 14) than in females (5 deaths out of 6). All the survivors are free of deficit or sequelae, except the patient with paraplegia.

The particular thermal properties of CO2 laser make it an useful instrument for neurological surgery. Necrosis and carbonization zones, as well as its thermal diffusion in the nervous tissue are dramatically less important with a CO2-laser unit than with other lasers (Nd-Yag or Argon) and moreover with the electrical mono--or bipolar coagulator. That is why the authors chosed this instrumentation for achieving a good hemostasis. It was particularly useful during removal of intracranial tumors situated close to the functional structures of the basis of the brain and the brainstem. The authors present their experience with the french CO2-laser unit Ercelas 80 (Robert et Carrière Biomedical) that they have been using routinely since 1983 in 60 neurosurgical procedures. They present the technical standards necessary to perform such an hemostasis either with the hand-piece or using the micromanipulator. In all cases the output power must be much lower for hemostasis than for tumoral cutting or vaporization. Depending on the type of tumor, radiation power should vary from 2 to 10 watts if a linear emission is used, and from 10 to 30 watts in case of pulsed emission. On the other hand, CO2-laser beam must be unfocussed so as to avoid cutting the vessels less than 0.5 mm in diameter before coagulating them properly.