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Resume La chirurgie de l’hypophyse est realisee par voie transsphenoidale dans l’immense majorite des cas. Les methodes ont varie au fil du temps. Les voies transseptales par une incision muqueuse sous-labiale ou par une incision muqueuse nasale, sous controle microscopique, ont ete largement utilisees. L’usage de l’endoscope par voie transnasale a ete decrit dans les annees 1990. Il s’est ensuivi la conception que l’abord transseptal etait attache a l’usage du microscope et que l’abord endoscopique se faisait par la voie endonasale stricte. Nous utilisons la voie transseptale transsphenoidale, par abord muqueux nasal, integralement guidee par endoscopie, tant pour l’abord que pour l’exerese. Cette technique presente a nos yeux de nombreux avantages : abord strictement median de la selle turcique, large champ operatoire, absence de conflit d’instruments et peu complications nasales.

International audience; To report the results of a series of patients undergoing the endoscopic subperichondrial transseptal (STRAS) approach for pituitary surgery and to evaluate the efficiency and the safety of this approach. Methods: This is a single-centre retrospective study including all patients undergoing pituitary lesion resection through the STRAS approach from January 2002 to December 2017 by a multidisciplinary surgical team (ENT and neurosurgeon). Demographic data, tumour type, complication rate and pre- and post-operative visual, endocrine and tumour status were retrospectively analysed.Results: 119 patients were included in the study, 80 (67%) presenting macroadenoma, 24 (20%) microadenoma (20%) and 6 (5%) giant adenoma. 61 (51%) patients had secreting adenoma and 51 (42%) patient had non-functioning adenoma. The STRAS approach allowed a good visualization of intrasphenoidal and intrasellar anatomical landmarks in all cases and no patient needed turbinate resection. No patient died or had neurological deficit. Endocrine remission or control was achieved in 90.5% of hormone-secreting microadenomas and in 84.2% of hormone-secreting macroadenomas. Gross-total resection was achieved for 39 patients (48.8%) of the 80 macroadenomas. Nasal complication rate was very low, with no septal perforation and two epistaxis (1.7%) medically treated.Conclusion: The STRAS approach is an elegant approach to the sphenoid sinus that enables a good exposure of the intrasphenoidal anatomical landmarks with a maximal preservation of the nasal mucosa. This approach allows an intrasellar work with great comfort and safety for the surgeon using a two-hand or a four-hand technique.

International audience; Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic transseptal approach via a sublabial mucosal incision or a nasal mucosal incision has also been extensively used. An endoscopic transnasal approach was first described in the 1990's, followed by the concept of a microscopic transseptal approach and an endoscopic strictly endonasal approach. We use an entirely endoscopic transseptal transsphenoidal approach via an incision in the nasal mucosa for both access and tumour resection. This procedure has a number of advantages: strictly midline approach to the sella turcica, large operative field, no interference between instruments and a low rate of nasal complications.

Purpose The morphological and biomechanical features of the thoracic spine, together with its close proximity to the spinal cord, set it apart from other spinal segments. Management of thoracic spine injuries consists of achieving a reduction and an immediate and long-lasting stabilization of the spine while constantly protecting the central and peripheral nervous system. The aim of this study was to determine the best treatment for surgical thoracic spine fractures. Materials and methods We studied the baseline characteristics of 68 patients admitted to our neurosurgical department for one or several thoracic spine fractures between 2008 and 2010. We analysed on this group of patient the surgical management, complications and functional outcomes. We detailed the 2-years radiological outcome on 50 patients (23 months mean follow-up). Results The majority of patients underwent an extensive posterior arthrodesis bridging, on average, 5.3 vertebrae. The median time between diagnosis and surgery was 2 days and the median length of stay in hospital was 13.5 days. About 94% of hooks and 80% of pedicle screws were considered stable. Mean values of reduction and correction loss were similar (about 4.5°). We concluded to the superiority of extensive procedures and of pedicle screws fixation for the reduction and the maintenance of the correction by the end of follow-up. Functional data indicated daily discomfort and moderate pain. Conclusion A prospective study comparing the different procedures and instrumentations is needed to better define guidelines for the management of thoracic spine injuries. Level of evidence Level IV.

Background and purpose To evaluate the incidence, clinical presentation, operative techniques and long-term outcome of spinal meningiomas following surgery. Methods Fifteen patients harboring spinal meningiomas were treated between 1998 and 2005 in our department. Diagnosis was made on magnetic resonance imaging and confirmed histologically. Microsurgical resection was carried out through a posterior approach in all cases. Results Follow-up extended from 60 to 156 months (mean: 99 and median 105 months). The most common site of spinal meningiomas was the thoracic region. Tumors were strictly intradural and extramedullary in 14 patients (93%) and macroscopic resection was considered as complete in all cases. Neurological improvement was observed in 13 patients (87%). There was no operative mortality and morbidity was low (20%). No patient underwent radiotherapy and the recurrence rate is 8%. Conclusion Spinal meningiomas are benign tumors for which advances in imaging tools and microsurgical techniques have yielded better results. The goal of surgery should be the total resection, which significantly reduces the risk of recurrence with an acceptable morbidity.

Background and purpose Glioblastoma, the most common malignant primary brain tumor in adults, is usually rapidly fatal. The current care standards for newly diagnosed glioblastoma consist, when feasible, in surgical resection, radiotherapy, and chemotherapy, as described in the Stupp protocol. Despite optimal treatment, nearly all malignant gliomas recur. If the tumor is symptomatic for mass effect, repeated surgery may be proposed. Methods We retrospectively analyzed the survival of patients with histologically confirmed primary glioblastoma (WHO grade 4) who were operated in two centers between January 2004 and December 2007. All patients who underwent a second resection for recurrent glioblastoma were included. Results During this period, 320 patients were operated in the two centers, with 240 surgical resections and 80 surgical biopsies. In the surgical resection group, 8.3% (20 patients) underwent a second surgical resection for glioblastoma. The mean age was 52 years. At the end of the study, seven patients were alive. The median survival was 24 months and progression-free survival was 7.5 months. Conclusions The effect of resection of recurrent glioblastoma on survival has not been extensively studied. No randomized trials have been conducted. Our data were globally identical to other retrospective studies. Selected patients with recurrent glioblastoma may be candidates for repeated surgery when the situation appears favorable based on assessment of the individual patient's factors. Factors such medical history, neurological status, location of the tumor, and progression-free survival have been proven in retrospective studies to give better results.

This work aims to prospectively record all primary central nervous system tumors (PCNST), in France, for which histological diagnosis is available. The objectives are to create a national registry and a network to perform epidemiological studies, to implement clinical and basic research protocols, and to harmonize the healthcare of patients affected by PCNST. Following a feasibility study, including an estimate of the gross incidence of PCNST (15.8/100,000 person-years) in France, all French neuropathology and neurosurgery departments decided to participate in the program. For each patient, the neurosurgeon and the neuropathologist complete a data file containing socio-demographic, clinical, radiologic and anatomopathologic information. The Tumor Registry from Herault is authorized to compile the data files with personal identifiers. In 2.5 years, 10,093 cases of newly diagnosed PCNST have been recorded. Tumor resections were performed in 75.3%, while biopsies accounted for 24.7%. Histological diagnoses included glioma (49.6%), other neuroepithelial tumors (3.8%), meningioma (30.9%), neurinoma (8.7%), lymphoma (2.9%) and others (4.1%). Cryopreservation was reported for 2,261 PCNST specimens. Clinical and radiological aspects were also recorded. Preliminary results are encouraging and stimulating for the long-term goal of creating a National Registry and a National Network for patients affected by PCNST. To our knowledge, this is the first European databank dedicated to PCNST, with collection of clinical, radiological and histological data (including cryopreservation of the specimen). The creation of this registry and this database may have major clinical and fundamental implications.

Resume Objectif Revoir les resultats du traitement endovasculaire et le pronostic a court terme d’anevrysmes rompus traites a la phase aigue. Methode Entre 1997 et 2002, 229 patients (254 anevrysmes traites, 140 femmes, 89 hommes, âge moyen : 51 ans), presentant une hemorragie sous-arachnoidienne, ont ete traites par coils GDC® (Bost®n Scientific Neurovascular, Fremont, CA) des lors que les conditions anatomiques d’operabilite etaient reunies. Plus de 90 % des anevrysmes traites (taille moyenne : 5,8 mm) etaient localises au niveau de la circulation anterieure. Les anevrysmes de l’artere communicante anterieure (87 cas) de la face posterieure de l’artere carotide interne (65 cas) et l’artere cerebrale moyenne (49 cas) sont les localisations les plus frequentes. Resultats A la fin de la periode initiale d’hospitalisation, 14 patients (6,1 %) sont decedes. Les complications liees au traitement sont associees soit a une perforation du sac anevrysmal pour 9 patients (3,9 %), un accident thromboembolique pour 10 patients (4,3 %) responsable de deux deces (0,8 %) et de sequelles neurologiques permanentes pour 7 patients (3 %). L’analyse univariee ne montre pas de relation entre le deces et le delai du traitement, le siege de l’anevrysme ou la survenue de complications liees au geste. Les resultats du modele de regression logistique montrent que le score clinique a l’entree et la survenue d’un vasospasme sont les deux seuls facteurs predictifs independants du deces du malade. Les facteurs pronostiques predictifs du degre de sequelle, identifies par le modele de regression logistique, sont le score clinique a l’entree, l’âge, les complications liees au traitement et les complications pulmonaires. Conclusions Le traitement endovasculaire des anevrysmes rompus de la circulation anterieure, incluant les anevrysmes de l’artere cerebrale moyenne, par GDC est associe a une morbidite et une mortalite faible. Cependant, l’impact des complications techniques sur le niveau de sequelles montre que des ameliorations techniques doivent etre recherchees pour le traitement des anevrysmes rompus de petite taille et de taille moyenne.

Specify the epidemiological data on the acute spinal cord injuries and define a group of patients that could benefit from cellular transplantation therapy designed with the aim of repair and regeneration of damaged spinal cord tissues.Five years monocentric (Gui-de-Chauliac Hospital, Montpellier, France) retrospective analysis of patients suffering from spinal cord injury (SCI). Spinal cord injured-patients, defined as sensory-motor complete, underwent a clinical evaluation following American Spinal Injury Association (ASIA) and functional type 2 Spinal Cord Independence Measure (SCIM2) scorings as well as radiological evaluation through spinal cord magnetic resonance imaging (MRI).One hundred and fifty-seven medical records were reviewed and we selected and re-examined 20 patients with complete thoracic spinal cord lesion. Clinical and radiological evaluations of these patients demonstrated, in 75 % of the cases, an absence of clinical progression after a mean of 49months. Radiological abnormalities were constantly present in the initial (at the admission to hospital) and control (re-evaluation) MRI and no reliable predictive criteria of prognosis had been found.We compare our results to the literature and discuss advantages and limits of cellular transplantation strategies for these patients.

Background and purpose: Individual rupture risk assessment of intracranial aneurysms is a major issue in the clinical management of asymptomatic aneurysms. Aneurysm rupture occurs when wall tension exceeds the strength limit of the wall tissue. At present, aneurysmal wall mechanics are poorly understood and thus, risk assessment involving mechanical properties is inexistent. Aneurysm computational hemodynamics studies make the assumption of rigid walls, an arguable simplification. We therefore aim to assess mechanical properties of ruptured and unruptured intracranial aneurysms in order to provide the foundation for future patient-specific aneurysmal risk assessment. This work also challenges some of the currently held hypotheses in computational flow hemodynamics research. Methods: A specific conservation protocol was applied to aneurysmal tissues following clipping and resection in order to preserve their mechanical properties. Sixteen intracranial aneurysms (11 female, 5 male) underwent mechanical uniaxial stress tests under physiological conditions, temperature, and saline isotonic solution. These represented 11 unruptured and 5 ruptured aneurysms. Stress/strain curves were then obtained for each sample, and a fitting algorithm was applied following a 3-parameter (C(10), C(01), C(11)) Mooney-Rivlin hyperelastic model. Each aneurysm was classified according to its biomechanical properties and (un)rupture status./nResults: Tissue testing demonstrated three main tissue classes: Soft, Rigid, and Intermediate. All unruptured aneurysms presented a more Rigid tissue than ruptured or pre-ruptured aneurysms within each gender subgroup. Wall thickness was not correlated to aneurysmal status (ruptured/unruptured). An Intermediate subgroup of unruptured aneurysms with softer tissue characteristic was identified and correlated with multiple documented risk factors of rupture. Conclusion: There is a significant modification in biomechanical properties between ruptured aneurysm, presenting a soft tissue and unruptured aneurysms, presenting a rigid material. This finding strongly supports the idea that a biomechanical risk factor based assessment should be utilized in the to improve the therapeutic decision making.

This work is based on the microscopic study of 30 trochlear nerve trunks (15 heads). In 17 cases, the trunk arose from two nerve bundles, in 8 cases from one bundle, and for the other 5 nerves, three or four bundles. The mean total length of the trochlear nerve was 86 mm. The nerve may be separated into the 3 following parts: infratentorial, intracavernous, intraorbital. In all 30 cases studied, the first part of the nerve was infratentorial, thus leading us to suggest the term “infratentorial part” for this segment of the nerve. In 27 cases, contact was found with the superior cerebellar artery, in the infratentorial part. In the intracavernous part of ten nerves we found two rami tentorii and in eight cases fibers were exchanged with the ophthalmic nerve. In the orbit, 18 trochlear nerves crossed the posterior ethmoidal artery. 23 trochlear nerves ended on the medial face of the superior oblique muscle. The remaining 7 ended at the superior border of the muscle.

Glioblastoma, the most common malignant primary brain tumor in adults, is usually rapidly fatal. The current care standards for newly diagnosed glioblastoma consist, when feasible, in surgical resection, radiotherapy, and chemotherapy, as described in the Stupp protocol. Despite optimal treatment, nearly all malignant gliomas recur. If the tumor is symptomatic for mass effect, repeated surgery may be proposed.We retrospectively analyzed the survival of patients with histologically confirmed primary glioblastoma (WHO grade 4) who were operated in two centers between January 2004 and December 2007. All patients who underwent a second resection for recurrent glioblastoma were included.During this period, 320 patients were operated in the two centers, with 240 surgical resections and 80 surgical biopsies. In the surgical resection group, 8.3% (20 patients) underwent a second surgical resection for glioblastoma. The mean age was 52 years. At the end of the study, seven patients were alive. The median survival was 24 months and progression-free survival was 7.5 months.The effect of resection of recurrent glioblastoma on survival has not been extensively studied. No randomized trials have been conducted. Our data were globally identical to other retrospective studies. Selected patients with recurrent glioblastoma may be candidates for repeated surgery when the situation appears favorable based on assessment of the individual patient's factors. Factors such medical history, neurological status, location of the tumor, and progression-free survival have been proven in retrospective studies to give better results.

We prospectively reviewed the clinical results of acutely ruptured cerebral aneurysms treated with GDC over a 5 year period, in order to characterize death and dependency factors.Between 1997 and 2002, 229 patients (254 aneurysms treated, 140 females, 89 males; mean age: 51 years) with aneurysmal subarachnoid hemorrhage were treated with GDC (Boston Scientific Neurovascular, Fremont, CA) once the anatomical conditions of feasibility had been achieved. Over 90% of the aneurysms treated (mean size: 5,8 mm) were located in the anterior circulation. The anterior communicating artery complex (87 cases), the posterior aspect of the internal carotid artery (65 cases), and the middle cerebral artery (49 cases) were most commonly treated.At the end of the initial hospitalization period, 14 patients (6.1%) died. Major procedural complications were associated with perforation of the aneurysmal sac in 9 patients (3.9%), thromboembolic events in 10 patients (4.3%) which resulted in 2 deaths (0.8%) and permanent neurologic morbidity in 7 patients (3%). The univariate analysis demonstrated no correlation between death and time-to-treatment, the topography of the aneurysm, or the occurrence of treatment related complications. The results of the logistical regression model demonstrated that the clinical score upon entry, and the occurrence of delayed ischemia were the only independent factors correlated with patient death. The prognostic factors affecting the degree of sequellae identified by the logistical regression model were the clinical score upon admission, age, treatment related complications, and pulmonary complications.Endovascular treatment of ruptured anterior circulation aneurysms with GDC, including MCA aneurysms, is associated with low morbidity and allows good overall outcomes in patients with subarachnoid hemorrhage. A better understanding of dependency factors associated with endovascular coiling will foster further technical advances in order to improve the treatment of small and medium sized ruptured aneurysms.

Resume Introduction Les accidents de plongeon presentent dans 90 % des cas une lesion du rachis cervical avec de possibles atteintes de la moelle cervicale. Les victimes sont souvent jeunes, en bonne sante et meconnaissent frequemment les lieux de l’accident. Objectifs Preciser les caracteristiques epidemiologiques des accidents de plongeon dans notre region. Determiner les mecanismes lesionnels les plus frequemment retrouves. Evaluer les choix therapeutiques realises et l’evolution neurologique (score ASIA) et biomecanique (cyphose). Patients et methodes Etude retrospective de 64 patients sur une periode de dix ans (2000–2010), pris en charge pour un traumatisme du rachis cervical par plongeon. Cette cohorte comprenait un sex-ratio homme-femme de 19 et un âge median de 22 ans. Le statut neurologique etait pour 13 % des patients une tetraplegie complete au moment de la prise en charge avec 6 % des deces apres l’admission. Un traitement chirurgical etait realise dans 85 % des cas, majoritairement par voie anterieure. Les patients ont ete evalues par le score au dernier recul par l’indice de douleur et d’incapacite cervicale (INDIC) et par une tomodensitometrie du rachis cervical. Resultats Au recul median de 44,7 mois, 34 patients ont ete revus. Le statut neurologique etait inchange pour 14 patients. La sensibilite de l’IRM dans la prediction de troubles neurologiques etait de 90 %. Notre etude ne permet de conclure concernant le role pronostique de l’IRM sur la recuperation neurologique. Conclusion L’incidence des accidents de plongeon dans le sud de la France est une des plus importantes de la litterature. Dans 22 % des cas, les patients presentent des troubles neurologiques severes a l’admission (score ASIA A, B ou C) et 70 % d’entre eux n’evoluent pas. Les lesions retrouvees sont dans pres de 70 % des cas, des Burst ou Tear-drop fractures. Les consequences individuelles peuvent etre desastreuses et le retentissement socioeconomique lourd. Des programmes de prevention sont indispensables. Niveau de Preuve Niveau IV – etude retrospective.

We present a case report of a thirty-six-year-old right-handed female. She suffered with a malignant space-occupying supratentorial ischemic stroke caused by a traumatic cervical internal carotid artery dissection. She had a car accident and, initially, presented with a normal examination. In two days, she became comatose (Glasgow Coma Scale score was 5) with complete left hemiplegia, right mydriasis and required respiratory assistance despite the medical treatment. It was decided to perform a large right frontotemporoparietal bone flap with large dural plasty. Eighteen months later, with intensive rehabilitation, the results of neuropsychological testing were normal, and the Barthel Index score was 90. The indications for decompressive surgery in malignant space-occupying supratentorial ischemic stroke remains controversial. The age, general condition, neurological examination (consciousness, pupils, deficit), extent of parenchymal hypodensity and attenuated corticomedullary contrast on the brain CT, degree of midline shift, presence of uncal hernation, disparition of the visibility of the mesencephalic cisterns and third ventricle, high level of the intracranial pressure, and perhaps the results of the perfusion-and diffusion-weighted MRI, are the elements to decide (or not decide) decompressive surgery.

We propose to evaluate the effect of sacral percutaneous thermorhizotomy on cerebral palsy children. A prospective study including 29 children followed by a multidisciplinary team was conducted from 1990 to 2000. A thermal radiofrequency lesion of the first sacral root was obtained by percutaneous puncture of the posterior intervertebral foramen with evaluation by stimulation of the best motor response for the minimal threshold (0.5 volts). The efficacy of the lesion was evaluated by testing and modification of the stimulation threshold obtained (x 2). The results on spasticity was evaluated using the Held score and the functional effect on walking, and classified as "good" (9 cases), "efficacy" (6 cases) and "nil" (4 cases). Indications of the procedure are discussed during the walking acquisition period and growing period of the cerebral palsy child.

Resume Introduction Le rachis thoracique est un segment particulier de la colonne vertebrale du fait de ses particularites morphologiques et biomecaniques, et de ses rapports etroits avec l’axe neural. Les objectifs de la prise en charge des traumatismes de ce segment sont multiples : apporter une reduction, et une stabilisation immediate et perenne du rachis ; proteger le systeme nerveux central et peripherique tout en restant adapte aux contraintes biomecaniques specifiques de cette region. Patients et methodes Entre 2008 et 2010, 68 patients sont operes au CHU de Montpellier d’une ou plusieurs fractures du rachis thoracique. Nous avons etudie les caracteristiques cliniques et radiologiques initiales de cette population ainsi que les traitements effectues, les complications et les resultats fonctionnels. L’evolution radiologique apres 23 mois de suivi moyen a ete effectuee sur 50 patients. Resultats La majorite des patients sont operes par voie posterieure, avec un montage long comprenant en moyenne 5,3 vertebres. Le delai median entre le traumatisme et l’intervention est de 2 jours et la duree mediane d’hospitalisation de 13,5 jours. Sur les instrumentations realisees, pres de 94 % des crochets et 80 % des vis sont consideres stables. Les valeurs moyennes de la reduction et de perte de correction sont semblables, d’environ 4,5°. Discussion Il est retrouve une superiorite des montages posterieurs longs ainsi que des vis pediculaires pour la reduction et le maintien de la deformation au terme du suivi. Les donnees fonctionnelles rapportent a l’issue du suivi une gene quotidienne et des douleurs moderees. Conclusion Les resultats de cette etude retrospective sont superposables aux donnees de la litterature. Une etude prospective analysant les differents types de procedures et d’instrumentations permettrait de determiner des « guidelines » de prise en charge. Etude retrospective, niveau de preuve scientifique 4.

We report long-term results of posterior sacral root rhizotomies in combination with Finetech-Brindley anterior sacral root stimulators implanted intradurally in 20 spinal cord injury patients.and methods: The 14 female and 6 male patients included 14 paraplegics and 6 tetraplegics. All of them initially presented hyperactive bladder, detrusor-sphincter dyssynergia, recurrent urinary tract infection and performed (self) intermittent catheterization. Prior to implantation, an intrathecal test using bupivacaine was performed to confirm the compliances of the bladder. The main indication for implantation was persistent urinary incontinence refractory to medical therapy.After implantation the mean follow-up was 4,5 years. In all, 18 patients used the stimulator alone for bladder emptying and 18 patients were completely continent. The mean bladder capacity increased from 190 ml preoperatively to 460 ml after the operation. The mean residual urinary volume was reduced from 90 ml to 25 ml. No changes were noted by renal isotopic scanning in upper urinary tracts of patients. In 1 patient, a second extradural implant was performed.This article also include an overview of a) the different available sites where application of electrical stimulation results in a detrusor contraction, b) the benefits and disadvantages of the sacral posterior rhizotomy, c) selective stimulation techniques that allow selective detrusor activation by sacral root stimulation.Sacral anterior root stimulation combined with sacral posterior rhizotomy is a valuable method to restore bladder functions in spinal cord injured patients suffering from hyperactive bladder refractory to medical therapy.

Evolution was characterized by a progressive increase in weakness and wasting of the lower extremities. Ankle and knee reflexes were abolished. Numbness, bowel, bladder or sexual dysfunction were absent. Initial spinal MR (October 1996) showed diffuse and uniform gadolinium enhancement of the roots on T 1 sequences at levels L 1 –L 4 . No lesion was seen on T 1 sequence without contrast injection. Further MR (February 1998 and February 2003) showed an increase in the gadolinium enhancement ( fig. 1 a). Absence of a hypointense rim was noted on T 2 sequences. Surgical biopsy of the sacral spinal nerve roots was performed to exclude malignant infiltration. The surgeon noted angiomatous aspects of the roots, without evidence of hemosiderin staining at their surface. Microscopic examination showed nerve tissue presenting fibrosis and vascular lesions. Fibrosis was observed between the nerve fibers, around and in the vessel walls. Vascular lesions were composed of closely apposed dilated cavities without intervening nerve tissue ( fig. 1 b). The walls of cavities were thin, with endothelium and connective tissue. Low numbers of macrophages are seen scattered around the vessel walls. These features are characteristic of cavernous malformations. Dear Sir, The consequences of radiotherapy on the spinal cord have been well known for several years [1] . They include acute myelopathy corresponding to spinal cord infarction, mild sensory myelopathy occurring several months after irradiation, chronic progressive myelopathy and lower motor neuron syndrome. The pathogenesis of the latter is not clearly established. It could be related to loss of motor neuron cell bodies or damage to cauda equina roots [1] . We report an observation of spinal root cavernoma induced by radiotherapy.

This work is based on the microscopic study of 30 trochlear nerve trunks (15 heads). In 17 cases, the trunk arose from two nerve bundles, in 8 cases from one bundle, and for the other 5 nerves, three or four bundles. The mean total length of the trochlear nerve was 86 mm. The nerve may be separated into the 3 following parts: infratentorial, intracavernous, intraorbital. In all 30 cases studied, the first part of the nerve was infratentorial, thus leading us to suggest the term "infratentorial part" for this segment of the nerve. In 27 cases, contact was found with the superior cerebellar artery, in the infratentorial part. In the intracavernous part of ten nerves we found two rami tentorii and in eight cases fibers were exchanged with the ophthalmic nerve. In the orbit, 18 trochlear nerves crossed the posterior ethmoidal artery. 23 trochlear nerves ended on the medial face of the superior oblique muscle. The remaining 7 ended at the superior border of the muscle.

Twenty one cases of proven subarachnoid hemorrhage (S.A.H.) have been analysed in a protocol especially including transcranial doppler (T.C.D.) and 88mTc-H.M.P.A.O. single photon emission tomography (H.M.P.A.O.-S.P.E.C.T.). Seventeen patients were intraoperatively studied. All data were compared with clinical grading, computerized tomography (C.T.) and angiography. S.P.E.C.T. is a quite recent method of measuring and three-dimensional imaging of brain perfusion. It provides important information for the diagnosis of ischemic syndromes in S.A.H. Sixty-two S.P.E.C.T.-scans were performed in twenty one patients. Fifty-eight were abnormal and showed significant abnormalities of brain perfusion varying in extent and severity. In this preliminary study, we set out to validate the clinical use of H.M.P.A.O.-S.P.E.C.T. for the diagnosis of "vapospasm" comparing S.P.E.C.T. data with classical criteria. We propose a classification which allowed us to quantify the ischemic risk in an attempt to adapt the global therapeutic management to hemodynamic data. This method appears to be very sensitive and reliable in this field. It will introduce, if these first results are confirmed, important criteria for the evaluation of patients presenting with S.A.H. as far as prognosis and treatment are concerned, especially in regard to timing of surgery and institution of medical hemodynamic therapy.

We studied the modalities and delays of restructuring of consciousness in a series of 89 consecutive survival cases, ranging over a large variety of age and severity and leading to any degree of awareness and results. We used the Glasgow coma scale, the study of brain-stem reflexes, and the Glasgow outcome scale. The recovery of awareness (eye opening to pain and fronto-orbicular reflex) was obtained mainly on the 9th day, with a limited variance. Recovery of a basic responsiveness to pain was concomittant of spontaneous eye opening mainly on the 15th day. A true relationship obeying orders was noticed on the 21st day, and a verbal response ranging mainly from the 30th day (confused) to the 60th (oriented). There was not any significative correlation of the delays with other early indicators of prognosis (Initial Glasgow score, C.T. scann lesions). Relating to the used sedation the effect was significant for the delays of eye opening only, with a possible analyse of the relationship. An inter-relationship between the steps and delays, leading to define an optimum for eye opening before day 15, for a motor response localizing pain before day 21, and for the item "obey to orders" before day 30 can be define as related to G.O.S. 4 and 5. A final analysis gave 79% of positive correlation with good results. We find a correlation between the delays of restructuring of consciousness and the functional results.

We report the effects of induced ultrasonic lesions on the sciatic nerve of the rat. Using different level of intensity (5 to 35%) and time exposure (5 to 60 seconds) for each application, we study the effects by action potential recording, microphotography and histological study. The nerve remains unaltered for low intensity (5 to 10%) until a time exposure of 20 seconds. Beyond that level, a progressive severity of the lesion is documented from oedema to contusion. A safe use of the surgical ultrasonic aspiration in the vicinity of nerves and roots must have a low intensity level, reducing the risks of direct contact between nerve and sonoprobe.

Using the animal model of mesencephalic transection, Sherrington (1940) demonstrated in 1898 that decerebrate rigidity was abolished by posterior rhizotomy. The first posterior rhizotomies were attempted independently by Bennet (1889) and Abbe (1911), the procedure having been suggested to the latter by Dana. On the background of Sherrington’s work, Foerster in 1908 (Foerster 1908) applied the posterior rhizotomy procedure from L1 to S2 for the treatment of spasticity in four patients. His results in 159 patients operated on for pain or spasticity were published in 1913 (Foerster 1913).

Spasticity is one of the major component of the upper motor neuron syndrome. It may arise in patients suffering from a multitude of lesions which include the sensori-motor cortical area and its descending tracts, centers in the brain stem and their descending pathways, and the spinal cord itself (Wiesendanger 1985). Hyperexcitability of the stretch-reflex continues to be considered as the basic phenomenon causing the increase in muscle tone, in addition to the pathological proprioceptive reflexes.

For 8 cases of aneurysmal ruptures in patients between twenty two and sixty-six years old, with clinical grade I or II, without diabetes neither high blood pressure, all of them underwent before the third day, with EEG monitoring, the surgical technic requires a temporary clipping of the carrying vessel (extreme times: 2 min 30 and 16 min), with a normal mean blood pressure. mean (ASBP) The circulatory cerebral brain protection is obtained with vascular filling before the clipping time and administration of Etomidate, (0.4 mg.kg-1) as soon as the aneurysm is exposed. For etomidate the posology is. The total required dose of Etomidate was about 98 mg. In all cases this protocol well tolerated (no neurological deficit) enables a good brain protection without cardio-vascular inconveniences of high barbiturate posologies. The waking up is very quick and allows a very early neurological check-up and a return to the presurgery tensional pattern too.

La douleur chronique rebelle du blesse medullaire est diversement appreciee dans la litterature (11 a 94%). Une analyse faite sur 162 cas nous a permis de precison les particularites cliniques de survenue de la douleur, leur frequence et leur incidence sur la vie sociale. Les douleurs centrales chroniques caracterisees par leur aspect cyclique interessent, dans la majorite des cas, le territoire sous lesionnel (membres inferieurs et perinee). Elles sont frequemment constatees en cas de lesions dorsales basses et lombaires hautes (52% entre T7 et L2). Les douleurs, ont tendance a evoluer dans le temps, pour devenir invalidantes dans 25% des cas. L'incidence therapeutique reste modeste, malgre une avancee dans la comprehension des mecanismes intimes de la douleur neurologique.

ObjectiveSpecify the epidemiological data on the acute spinal cord injuries and define a group of patients that could benefit from cellular transplantation therapy designed with the aim of repair and regeneration of damaged spinal cord tissues.Material and methodsFive years monocentric (Gui-de-Chauliac Hospital, Montpellier, France) retrospective analysis of patients suffering from spinal cord injury (SCI). Spinal cord injured-patients, defined as sensory-motor complete, underwent a clinical evaluation following American Spinal Injury Association (ASIA) and functional type 2 Spinal Cord Independence Measure (SCIM2) scorings as well as radiological evaluation through spinal cord magnetic resonance imaging (MRI).ResultsOne hundred and fifty-seven medical records were reviewed and we selected and re-examined 20 patients with complete thoracic spinal cord lesion. Clinical and radiological evaluations of these patients demonstrated, in 75 % of the cases, an absence of clinical progression after a mean of 49months. Radiological abnormalities were constantly present in the initial (at the admission to hospital) and control (re-evaluation) MRI and no reliable predictive criteria of prognosis had been found.Discussion/ConclusionWe compare our results to the literature and discuss advantages and limits of cellular transplantation strategies for these patients.RésuméObjectifsConnaître les données épidémiologiques de notre région sanitaire sur les traumatismes médullaires. Au sein de cette population, sélectionner les patients susceptibles de bénéficier de thérapie cellulaire dans la moelle épinière lésée dans l’objectif de régénérer le tissu nerveux. Évaluer à distance ces patients.Patients et méthodeAnalyse rétrospective de tous les patients pris en charge pour un traumatisme vertébro-médullaire. Réévaluation clinique et radiologique des patients présentant une atteinte médullaire thoracique sensitivomotrice complète. Réévaluation réalisée par le score de l’American Spinal Injury Association (ASIA), le score fonctionnel Type 2 Spinal Cord Independence Measure (SCIM2) et contrôle radiologique par une IRM médullaire.RésultatsCent cinquante-sept dossiers de patients ont été analysés et 28 patients présentaient une lésion médullaire complète. Une évaluation clinique et radiologique réalisée chez 20 patients sur 28 (71 %) a montré l’absence d’évolution clinique dans 75 % des cas dans un délai moyen de 49 mois. Les anomalies radiologiques étaient présentes dans 100 % des cas sur l’IRM initiale et de contrôle sans qu’aucun critère fiable prédictif de bon pronostic n’est retrouvé.Discussion/conclusionNous présentons ces résultats comparativement à ceux de la littérature et nous discutons chez ces malades les stratégies de transplantation cellulaire, leurs limites actuelles et les progrès nécessaires pour obtenir des résultats.

Eleven of our own cases of tuberous sclerosis with intraventricular tumor and 34 cases from the literature are reviewed. Initial symptoms and identification of tuberous sclerosis and tumor are reviewed. Results of surgical treatment, including direct radical excision and shunting are given. On gross examination, the tumor was most often loosely connected to ependyma near the foramen of Monro, causing hydrocephalus. Giant cell subependymal astrocytoma was frequently found on microscopic examination. The glial origin of the tumor is discussed and direct surgical approach of the tumor is proposed as the best treatment of these lesions.

The authors report six cases of pharyngo-oesophageal damage associated with fractures of the cervical spine treated by osteo-synthesis via the anterior route. These complications, not previously described, may have life threatening (especially mediastinitis) and functional consequences. They discuss the relative responsibility of: the initial trauma, which should be better defined by an initial endoscopic assessment. the surgical approach, the principles of which and its dangers and preventive aspects are discussed, early or late fixation failure justifying careful surveillance of the osteosynthesis material and in certain cases its systematic removal.

Between 1981 and 1984, 44 patients underwent acoustic neurinoma removal by a posterior cranial fossa approach with an attempt to preserve hearing. Seven tumors were small (40 mm). Preoperatively, 4 patients had normal hearing, 15 had serviceable hearing, 10 had poor hearing, and 15 had no hearing. Postoperative hearing was preserved in 11 cases. Of the 19 patients with normal or serviceable hearing, 8 (42%) had serviceable hearing preserved postoperatively. Hearing preservation was achieved in 43% of the patients with small tumors, 25% of those with medium tumors, and 11% of those with large tumors. This study confirms the value of the suboccipital approach, which can be used in an attempt to preserve hearing whenever the patient has serviceable hearing preoperatively and whenever the tumor size makes it feasible.