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We present a vascular anatomical study of the arteries and veins of the sylvian fissure and insula.A good knowledge of the sylvian fissure, the insula, and their vascular relationship would seem mandatory before performing surgery in this area, whatever the type of surgery (aneurysms, arteriovenous malformations, insular tumors).We start with the sylvian fissure and insula morphology, followed by the MCA description and its perforators, with special attention paid to the insular perforators. We demonstrate that the long insular perforators penetrating in the superior part of the posterior short gyrus and long gyri vascularize, respectively, the corticonuclear and corticospinal fasciculi. We particularly insist too on three anatomical constants regarding the vascularization of the insula, already described in the literature: The superior periinsular sulcus is the only sulcus on the lateral surface of the brain without an artery along its axis; the superior branch of the MCA supplies the anterior insular pole and both the anterior and middle short gyri in 100 % of cases; in at least 90 % of cases, the artery that supplied the central insular sulcus continued on to become the central artery.We end with the anatomical study of the veins and cisterns.

Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET.A retrospective study was carried out on 176 adult patients surgically treated for CET in our two departments from 1994 to 2010. We reviewed pre- and postoperative symptoms, magnetic resonance imaging aspects, surgical findings, outcome including operative neurological morbidity, local recurrence rate and operative mortality, and incidence of rare CET.Seventeen percent (30 patients) of CETs operated on were neither schwannomas nor benign ependymomas. Half of these cases were benign tumours, with paragangliomas being the most common. Two patients were in poorer clinical condition after surgery, one patient experienced a local recurrence, and one died following surgery, from the progress of his disease (Von Hippel-Lindau disease). The other half were malignant tumours, with metastases being the most common. One third of the patients were worsened by surgery, and the mortality rate was 1/3 at 8 months (1-27 months).Roughly one in six CET were neither schwannomas nor benign ependymomas. This study demonstrated the efficiency of surgery for rare benign CET with a low local recurrence rate. Surgical treatment of rare malignant CET led to a high rate of increased postoperative neurological deficit in patients with a reduced life expectancy.

I tumori spinali e intrarachidei sono suscettibili di causare una morbilita neurologica importante. Questi tumori si rivelano, il piu delle volte, con un dolore vertebrale, vero e proprio sintomo cardine che puo associarsi a un deficit motorio e/o sensitivo di comparsa progressiva o subacuta e associato a disturbi vescicosfinterici. La risonanza magnetica e l’esame chiave nella valutazione di questi tumori che possono essere vertebrali ossei, epidurali o intradurali o strettamente intramidollari. Essa permette uno studio anatomico preciso del rachide, del suo contenuto e delle parti molli circostanti. La TC conserva la sua utilita per lo studio dei tumori a componente ossea. Le neoplasie vertebrali ed epidurali sono essenzialmente delle metastasi, il cui programma terapeutico e molto progredito nei tempi recenti. Se possibile, e proposta in prima intenzione una chirurgia circonferenziale con stabilizzazione, seguita da una radioterapia e/o dalla chemioterapia. I meningiomi e gli schwannomi sono i tumori intradurali ed extramidollari piu frequenti. Essi sono, generalmente, benigni, e il loro trattamento e essenzialmente chirurgico, con un’exeresi spesso completa. I tumori intramidollari sono molto rari e sono rappresentati soprattutto dagli astrocitomi e dagli ependimomi, la cui rimozione chirurgica e piu difficile pur restando il solo trattamento efficace.

One hundred brains (first injected in cerebral arteries and veins with latex neoprene or India ink and studied under optic magnification) illustrate this anatomic chapter concerning the microsurgical anatomy of the cisternal segment, the neurovascular relationships, and the blood supply of the IIIrd to the XIIth cranial nerves.

Metastatic spreading is a rare complication of meningioma. We report a subcutaneous metastasis from an atypical meningioma of the tentorium. A 69-year-old man presented with a meningioma of the tentorium. The tumor was totally resected. The histological diagnosis was atypical meningioma. The tumor recurred two years later and was irradiated. Despite irradiation, the tumor progressed and was resected three years later. Five months following the second surgery, an isolated subcutaneous mass developed at the skin incision and was resected. The histological examination of the subcutaneous tumor showed histological features of atypical meningioma. Surgery of atypical meningioma carries the risk of iatrogenic metastasis, despite previous irradiation.

The aim of this report is to illustrate the successful surgical management of five patients with suprasellar retrochiasmatic and diencephalo-mesencephalic tumours, using a trans-amygdala extension of the trans-temporal/trans-choroidal fissure approach. The procedure is described for five surgically treated patients with such lesions that includes three retrochiasmatic craniopharyngiomas, one hypothalamic hamartoma, and one pilocytic astrocytoma in the left crus cerebri. The management procedure included computed tomography scan (CT scan) and magnetic resonance imaging (MRI). The trans-temporal/trans-choroidal fissure approach enabled us to perform total tumour resection in four patients and a subtotal resection in one. Some technical aspects and pitfalls of the procedure are discussed. This method creates optimum conditions for a radical excision of various suprasellar retrochiasmatic and diencephalo-mesencephalic tumours without mortality and only minimum morbidity. However, no single surgical approach can provide access to the entire variety of tumours located in the suprasellar retrochiasmatic and diencephalo-mesencepalic region. Surgical approaches must be tailored to the site, type of lesion, and its extensions. This method is only another surgical option. Its successful use requires a familiarity with the anatomy of these regions and an understanding of its specificity for a radical excision of some selected tumours, as well as its limitations to access others types of lesions. Although, it seems effective, this approach needs to be evaluated by further experience, owing to the small number of patients reported in this series.

This study of 25 brains at the pontomedullary junction defined the different possible origins of the perforating arteries and lateral spinal arteries in relation to the posterior inferior cerebellar arteries (PICAs). - If the PICA emerges from the common trunk of the AICA-PICA coming from the basilar artery, it never gives perforating arteries or a lateral spinal artery on the lateral surface of the brain stem but supplies blood to a part of the ipsilateral cerebellar hemisphere. - If the PICA arises extradurally at C1, it never gives perforating arteries for the lateral surface of the brain stem, but it gives pial branches for the posterior surface of the medulla oblongata and is always the origin of the lateral spinal artery. - If the PICA emerges in the intradural vertebral artery, it is the source of the perforating arteries for the lateral surface of the brain stem and of the blood supply of the ipsilateral cerebellum.

Background For several years, the sessions of continuing medical education organized within the framework of the Societe francaise de neurochirurgie have been recorded on the “campus de neurochirurgie” website, accessible in a form called in “videostreaming” which structures the training session. Purpose Using modern educational methods, how can we transform the scientific productions of our meetings into effective tools for on-line continuing education? Methods The article describes the experience gained while creating self-assessment tools starting from the teaching material transmitted by the person in charge of a continuing medical education session, selected and an example for demonstration. Results We present the various written tools for self-assessment: multiple-choice test and script concordance test (SC). These SC were based partly on a clinical case with various test formats: units of diagnosis, investigation and therapeutics. In connection with the example chosen, we propose a model for constructing on-line continuing medical education sessions, which could be used by persons in charge of such training sessions in neurosurgery and in other specialties. Conclusions With the availability of on-line self-assessment tests round-tables videostreaming, this teaching method can be used to fulfil mandatory continuing medical education requirements.

There is few published series dealing on the long-term outcome of the adult-onset craniopharyngiomas. We report the long term clinical, tomodensitometric and MRI data outcome of 35 (23 woman and 12 men) consecutive adult-onset cured for craniopharyngiomas between 1983 and 2002, and followed-up in Rennes University Hospital. The operation was performed via frontopterional approach in 59% and transphenoidal approach in 41% of cases. Their age at the time of diagnosis was 44.7+/-15.1 years (21-74). The average postoperation follow-up was 7.4+/-7.0 years (0.1-19.1). Recurrence of tumour occurred in 8 patients (25.8%) and a tumor progression in 1 case. The delay of recurrence after initial surgery was 4.1+/-1.3 years (1.4-6.3). Two patients had 5 and 6 years treatment by growth hormone (GH), without tumor recurrence. The observed increase of weight after the surgical cure of craniopharyngiomas concerned 22 patients (63%). The average weight gain was 17.5+/-14.7 kg (1.5-58). In 7 cases (20%) neuropsychological disorders were noted, of which 2 with lost of professional activity. Three patients died. In conclusion the craniopharyngiomas recurrence is frequent and can appear in very prolonged deadlines after the initial surgery.

✓ The concept of hemorrhage in a preexisting syringomyelic cavity was first described by Gowers in 1904. Since its first description only 13 cases have been reported. The aims of this report are to describe a new case, bring this entity to wider attention, and summarize the existing literature on the subject. This 36-year-old woman presented with progressive gait disturbance and unsteadiness. Physical examination revealed incomplete quadriparesis, predominantly on the left side, and hypesthesia below C-7. Magnetic resonance imaging revealed hematomyelia characterized by a heterogeneous hyperintense signal within the central cervical cord. A liquefied well-limited hematoma was evacuated. The postoperative course was uneventful; a near-complete recovery was observed at the 7-year follow-up examination. Most cases of intrasyringal hemorrhage (ISH) have occurred in syringomyelic cavities associated with scoliosis or Chiari malformation Type I. Although there is no specific clinical picture associated with this entity, it can be characterized by three neurological forms: 1) sudden onset or rapid development of signs and symptoms, 2) acute worsening of symptoms that may improve but leaving greater neurological dysfunction than before the previous episode, and 3) ISH may initiate progressive deterioration in a patient with known syringomyelia. Intrasyringal bleeding is most probably caused by a sudden dilation of the syringomyelic cavity, which may provoke rupture of the intrasyringal vessels by an acute distension of the accompanying strands. Magnetic resonance imaging is the most accurate diagnostic modality, and recognition of ISH can lead to early, safe, and efficient surgical treatment.

Resume Du fait de la presence de mouvements anormaux, certains patients infirmes moteurs cerebraux (IMC) sont exposes aux complications degeneratives du rachis cervical. Nous rapportons les cas de cinq patients ayant presente une myelopathie cervicarthrosique avec un niveau plus eleve que dans la population normale. Quatre d'entre eux ont beneficie d'une decompression chirurgicale. L'existence d'un syndrome depressif associe peut amener a un retard diagnostique compte tenu d'un examen neurologique de base qui est deja pathologique. L'examen par resonance magnetique nucleaire est probablement le plus pertinent sur le plan diagnostic, avec une realisation qui est rendue difficile du fait de l'existence des mouvements anormaux. Sur le plan therapeutique la chirurgie donne les meilleurs resultats. Conclusion. – La myelopathie cervicarthrosique doit etre discutee systematiquement chez les patients IMC qui presentent une aggravation sur le plan fonctionnel. La chirurgie est le traitement de reference dans ce contexte.

We herein report five cases of cerebral palsy athetosic patients with spondyloid cervical myelopathy. Four of them underwent decompressive surgery. The level of cervicarthrosis differs from a control population with a more frequent osteoarthritis on the lower cervical spine. The diagnosis of spondylotic cervical myelopathy is frequently overlooked because of the insidious progression of neurologic disorders and of the pre-existent neurological handicap. Depressive syndrome is often evoked in such a situation, and thus responsible for a delay of diagnosis. The presence of an hypersignal in T2 MRI sequences is still controversial. For some authors it is an indication for surgery, which is the treatment with the best functional results. Conclusion. – Cervical spondylotic myelopathy must be evoked in patients with athetoid cerebral palsy who complain about a decrease of their functional ability.

Liposarcoma is a malignant tumor of soft tissue. The thoracic spine is an unusual location, even for metastasis, and to our knowledge, no case of primary pleomorphic liposarcoma of the vertebral body has been reported until now. A female patient presented with paraplegia. She had a previous medical history of mental depression, and complained of dorsal pain for three months following a road accident. Magnetic Resonance Imaging (MRI) revealed a collapse of T7-T8, and the diagnosis of plasmocytoma was made. She was treated with decompressive laminectomy and posterior instrumentation. Histological examination revealed a pleomorphic liposarcoma. She received a course of radiotherapy. At 13 months follow-up she developed pulmonary metastases and rib involvement. The spine is an unusual location for pleomorphic liposarcoma, even as metastasis. The differential diagnoses of this rare entity are discussed, as well as the criteria for diagnosing primary spinal liposarcoma. Although rare, our case demonstrates that liposarcoma should be considered in the differential diagnosis of spinal tumors.

Capillary haemangiomas (CHs) are the most common soft tissue tumours of infancy. It is generally believed that the primary defect in CHs is intrinsic to endothelial cells, but their pathogenesis is yet poorly understood. The relatively low oxygen environment, in which the human foeto-placental unit develops, during the first trimester, is necessary to induce vasculo-angiogenesis via embryonic endothelial cells proliferation, since these cells are sensitive to hypoxia and acidosis. In newborn infants with haemangioma, persistent embryonic primitive endothelial cells trapped in the intimae underneath the developing vessels, and representing "leader" endothelial cells, can stabilise the labile vascular endothelial growth factor mRNA (VEGF mRNA), produce other angiogenic factors, degrade the underlying basement membrane and invade into the stroma of the neighbouring tissue. With bearing down, the transition from intra- to extra-uterine life is accompanied by more or less pronounced hypoxia. Consequently, in babies with haemangioma, hypoxia can act as a switch to activate these "leader" endothelial cells and thereby initiate a cascade of reactions leading to CH proliferation. As they are regulated by embryonic cells, the haemangioma growth mechanisms pursue the pathway of embryonic angiogenesis and it will stop at the end of the embryonic endothelial cell cycle. Addressing this mechanism in vivo has partly been done (the angiogenic peptide bFGF varies with haemangioma growth). Thus, early treatment seems necessary in infants with haemangioma, before the endothelial cells achieve their proliferative stage. The use of an antibody to interfere with VEGF receptors provides a particular attractive strategy.

Spinal schwannomas and meningiomas are mostly benign, intra-dural extramedullary tumours. We retrospectively reviewed the Magnetic Resonance Imaging (MRI) examinations of 52 spinal schwannomas and meningiomas operated on at our institution since 1998. The series included 28 schwannomas and 24 meningiomas. We compared MRI features of schwannomas and meningiomas and evaluated statistical features that would allow differentiation. Tumours with extraspinal extension were excluded. Concerning the cranio-caudal distribution, half of the cervical tumours were schwannomas, 72% of thoracic lesions were meningiomas and all lumbar tumours were schwannomas. Meningiomas were significantly located at the upper and mid thoracic levels and schwannomas in the lumbar area. On T1-weighted images, MRI signal intensity and heterogeneity were not statistically different between meningiomas and schwannomas. On T2-weighted images, the signal intensity appeared significantly hyperintense and heterogeneous for schwannomas. After Gd-DTPA, we observed a significant difference between meningiomas and schwannomas, the enhancement being intense and heterogeneous in cases of schwannomas, and moderate and homogeneous in cases of meningiomas. The last significant qualitative item was the "dural tail sign", a dural enhancement or thickening near the tumour. It was found in only 16 cases of meningiomas. A simple diagnostic test was built for schwannomas by processing a multiple agreement analysis with the 6 significant items: cranio-caudal location, T2 signal intensity, T2 signal heterogeneity, Gd-DTPA enhancement intensity and heterogeneity, and the "dural tail sign". This test allowed diagnosis of schwannomas with a sensitivity of 96.4%, a specificity of 83.3%, a positive predictive value of 87.1%, and a negative predictive value of 95.7%. In conclusion, we consider that a diagnosis of schwannoma should be made when a spinal intradural extramedullary tumour shows hyperintensity on T2W images or intense enhancement without dural tail sign; otherwise meningioma is more probable.

Spinal meningiomas are usually benign, slow-growing tumours and are commonly associated with good patient outcome following surgery. However, the existence of a severe preoperative neurological deficit has been considered to be a possible predictor of poor functional outcome after surgery. We retrospectively reviewed data from 33 patients with 35 spinal meningiomas treated in our institution over the past 17 years and exhibiting severe preoperative deficits before surgery. Among them, 20 suffered from paraparesis and 13 were paraplegic. The mean follow-up duration was 70.7 months (range 12–183 months). By the 1-year follow-up, all patients had improved in comparison with their preoperative neurological status, and 60% of them had totally recovered. It can be concluded from this study, that, in the vast majority of cases, patients harbouring spinal meningioma with severe preoperative deficits can expect a good outcome.

Study design Thirty consecutive patients over 70 years of age who were operated on for spinal meningiomas are presented to assess surgical criteria and postoperative outcome. Objectives To assess the outcome of surgically treated spinal meningiomas in patients in their eighth or ninth decade of life and to analyze the possible role of some prognostic factors. Summary of background data The ageing of the population in the industrial nations has led to increased findings of benign spinal tumors, namely meningiomas, in the elderly. These slow-growing tumors may prevent these patients from leading an autonomous life. Little is known about the outcome of spinal meningioma surgery in patients of 70 years or older because the number of these patients, although increasing, is still small. Methods Thirty consecutive patients over 70 years of age (mean age, 77.1 years) were operated on for spinal meningiomas between 1986 and 2001. The preoperative neurologic status of the patients was graded with the Solero score, and the general health conditions were staged according to the American Society of Anesthesiology classification. Total tumor removal was achieved in 27 patients. The follow-up period ranged from 17 to 173 months (mean, 62.7 months). Results There was no operative mortality, and morbidity was not significant. Although not significant, neurologic outcome was better in patients with a low preoperative Solero score than those with a high one (P = 0.06). Clinical outcome was not influenced by the duration of symptoms before surgery or preoperative American Society of Anesthesiology classification. No recurrence was observed during the follow-up period. Conclusions Neurologic outcome following surgery was favorable in the vast majority of patients, with no mortality or significant morbidity. Surgery is the only treatment in elderly patients with symptomatic spinal meningiomas, even those with a poor preoperative neurologic condition, whenever there is an acceptable risk from an anesthesiological point of view.

Among cases of embryonic carotid-basilar anastomosis which may persist after birth, persistent trigeminal artery is the most common. It has been associated with a wide variety of intracranial abnormalities. We are unaware of any other reported association with cavernoma. We report a young woman who experienced seizures following spontaneous abortion. A CT scan disclosed a right frontal hematoma. MRI revealed a cavernoma associated with a persistent trigeminal artery. The cavernoma was removed through a frontal approach. The aim of the present case is to report another type of lesion fortuitously associated with a persistent trigeminal artery.

Resume Les complications neurologiques survenant apres manipulation du rachis lombaire sont rares. Lorsqu’elles surviennent, elles sont le plus souvent dues a une hernie discale ou au deplacement de structures osseuses. Nous rapportons le cas d’un patient qui a presente une paraplegie quelques heures apres une manipulation du rachis lombaire. L’imagerie par resonance magnetique rachidienne etait en faveur d’une ischemie de la moelle spinale caudale et ne montrait pas de fragment discal ou de compression d’origine osseuse. Les auteurs suggerent de considerer l’ischemie medullaire comme une complication possible apres une manipulation lombaire.

Objective and importance Spinal cord injury is a rare complication of neurosurgery performed with the patient in the sitting position. Previous reports showed that the level of injury is usually located at or near the C5 segmental spinal level, and the term midcervical quadriplegia has been proposed. Extensive spinal cord and lower brainstem infarction also can occur after posterior fossa surgery performed with the patient in the sitting position. Clinical presentation We describe a 45-year-old woman who was operated on in the sitting position because of a fourth ventricular pilocytic astrocytoma. After surgery, the patient experienced quadriplegia. Intervention T2-weighted magnetic resonance imaging scans revealed a long, hyperintense area within the cervicothoracic spinal cord that was extended to the lower pons and was consistent with infarction. There was no evidence of previous spine disease. The patient died 6 weeks later of respiratory failure. Conclusion We speculate that alteration of spinal cord blood flow by stretching of the cervical spinal cord and spinal epidural venous engorgement might have caused this devastating complication.

Epithelioid hemangioendothelioma (EHE) is an uncommon vascular neoplasm. Its intracranial occurrence is rare, and the literature review revealed only 23 cases (14 adults and 9 children). To our knowledge, this is the first case of EHE arising in the infundibular-hypothalamic region. A 53-year-old man presented with headaches and loss of libido. Magnetic resonance imaging revealed a supra-sellar mass, which homogeneously absorbed the contrast agent. A trans-sphenoidal craniotomy and a biopsy were performed. Adjuvant radiotherapy was administered due to intolerance to interferon. Epithelioid hemangioendothelioma is a hemorrhagic tumor. Total resection is mandatory where possible, otherwise radiotherapy seems necessary. The prognosis of intracranial location has not yet been well defined, despite the favorable outcome noted in the majority of cases.

The authors report a case of a huge colloid cyst of the septum pellucidum with acute worsening. A 42-year-old man was admitted for unexplained lethargy. A brain CT scan disclosed a huge intra-ventricular lesion. He experienced a sudden deterioration with coma, and was managed with bilateral ventricular external shunting. Total removal was performed a few days later using a right frontal trans-ventricular approach. The discussion focuses on colloid cyst potential to mimic other intracranial lesions, rendering accurate diagnosis difficult and leading to possibly inappropriate management in similar cases.

BACKGROUND Patients with nevoid basal cell carcinoma syndrome (NBCCS) are believed to be predisposed to develop early-onset neoplasms including medulloblastomas (MB). The desmoplastic subtype of MB is associated most commonly with NBCCS. The goals of this study were to demonstrate the relation between desmoplastic MB and NBCCS and to evaluate the concomitant diagnosis of NBCCS and MB. METHODS The medical records of 76 consecutive children who received surgical treatment for MB between 1970 and 2000 were studied. A review of the literature was performed based on the National Library of Medicine database and bibliographies of selected articles were scanned. RESULTS The authors reported three patients with NBCCS who received surgical treatment for an MB during infancy. The literature review identified 33 patients with NBCCS who were treated for MB at a mean age of 28 months. The desmoplastic subtype was the only histopathologic subtype of MB reported in the NBCCS population. Although patients with NBCCS are predisposed to develop multiple basal cell carcinomas and intracranial tumors in the field of irradiation, the prognosis for syndromic MBs was much better compared with the prognosis for sporadic MBs. CONCLUSIONS Patients with NBCCS have an increased risk for other malignancies, especially radiation-induced neoplasms. Early diagnosis of this syndrome is important for the selection of appropriate adjuvant treatment and family genetic counseling. The authors did not advocate the use of radiotherapy as an adjuvant treatment in desmoplastic MB diagnosed in children younger than 5 years of age. They suggested that the desmoplastic subtype of MB in children younger than 2 years of age is a major diagnostic criterion for the diagnosis of NBCCS. Cancer 2003;98:618–24. © 2003 American Cancer Society. DOI 10.1002/cncr.11537

Study design The clinical data, magnetic resonance imaging, intraoperative findings, and functional outcome were reviewed for three patients under anticoagulant therapy who experienced acute nontraumatic spinal subdural hematoma. Objectives To draw attention to this rare complication of anticoagulant therapy and to assess the magnetic resonance findings and clinical outcome of patients with spinal subdural hematoma after surgical evacuation. Summary of background data Among intraspinal hematomas, spinal subdural hematomas are by far the least common. Magnetic resonance findings have been demonstrated in only a few cases of spinal subdural hematomas. The timing of the operation and the anatomic location of the hematoma essentially determine the functional outcome. Methods Three case reports of spinal subdural hematomas in patients receiving anticoagulant therapy are presented. Particular interest was given to the clinical and magnetic resonance data, the intraoperative findings, and the functional outcome. Results The three patients each had a complete preoperative neurologic deficit. Sagittal T1- and T2-weighted magnetic resonance images of the spine proved to have high sensitivity for defining the type of bleeding and delineating the craniocaudal extension of the hematoma. Surgical evacuation was performed within 26 hours after the onset of symptoms. Intraoperative findings showed the hematoma to be confined between the dura and the arachnoid in two patients, and to be associated with rupture into the subarachnoid space in one patient. Postoperative recovery was incomplete in two patients, and did not improve in the remaining patient. Conclusions Spinal subdural hematoma must be considered in patients under anticoagulant therapy with spontaneous signs of acute spinal cord or cauda equina compression. Magnetic resonance imaging with sagittal T1- and T2-weighted images were adequate and reliable for diagnosis of spinal subdural hematoma. On the basis of previous studies and the authors' intraoperative findings, spinal subdural hematomas could be viewed as spinal dural border hematomas. The level of preoperative neurologic deficit seemed to be critical for recovery despite prompt surgical evacuation.

The anatomy of the radial tunnel was studied on twenty-five elbow preparations. We noted five different elements that could affect the deep branch of the radial nerve in the radial tunnel and cause an entrapment syndrome : a capsule-tendon-aponeurotic complex on the anterior aspect of both the humeroradial joint and the radial head, the vascular arcade formed by the radial recurrent a. and its branches, the arcade formed by the medial edge of extensor carpi radialis brevis muscle, and the superior and inferior arcades of the superficial layer of the supinator muscle. These results are compared with recent anatomical and clinical data, and the relevance of a surgical approach between the extensor carpi radialis brevis and longus muscles is discussed.

Intramedullary abscesses of the spinal cord are uncommon. Most of them occur in association with heart, pulmonary or urogenital infections. We report two cases of intramedullary spinal cord abscesses secondary to congenital dermal sinus. Only 14 cases of such an association have previously been reported. In our cases, dermal sinus was associated with an epidermoid tumour. The clinical presentation, pathogenesis, magnetic resonance imaging findings, surgical management and outcome are discussed.

BACKGROUND Anterior screw fixation is the best treatment for odontoid fractures when the fracture line is horizontal or oblique downward and backward, as it preserves atlantoaxial mobility, especially axial rotation. Some details regarding patient positioning and operative technique need to be stressed to obtain the best results and avoid complications. METHODS Between 1989 and 1997, we treated 17 cases of odontoid fracture by anterior screw fixation. Only two patients presented with motor neurologic deficit. Fracture line was horizontal in 3 cases and oblique downward and backward in 14 cases. RESULTS Adequate reduction and fixation was obtained in all cases except one, where posterior displacement of the screw occurred without neurologic complications. Functional result was satisfactory in all cases except two, where we noted significant limitation of cervical rotation. CONCLUSION Successful anterior screw fixation gives the best anatomical and functional results for odontoid fractures. Correct installation is very important for operative success.

International audience; BACKGROUND: Haemangioblastomas are benign vascular tumours that may appear sporadically or in von Hippel-Lindau disease. Despite their higher incidence, sporadic haemangioblastomas have been less studied than syndromic ones. In this article, we evaluate the specific features, outcome and quality of life of patients with intracranial sporadic haemangioblastomas (ISHs) operated on in our institution. METHODS: Between 1998 and 2010, 38 patients harbouring 38 ISHs were operated on in our department. Their clinical, biological, radiological and surgical features were retrospectively reviewed. All patients were contacted for a quality-of-life (QOL) survey assessed by the Short Form 36 questionnaire (SF36). The mean duration of follow-up was 40 months (13-108 months). RESULTS: ISH represented 0.9 % of primary intracranial neoplasms treated in our centre during this period. Patients comprised 23 men and 15 women with a mean age of 47 years. None had polycythaemia. Cerebellar locations accounted for 79 % of ISHs, and brainstem ISH with involvement of the floor of the fourth ventricle represented 11 % of ISHs. At last follow-up, two patients harbouring solid medulla oblongata haemangioblastoma had died following severe bulbar syndrome and five patients had died of unrelated causes. One patient had multiple surgeries for three recurrences. Tumoral control was achieved in all cases at last follow-up. Results of the SF-36 questionnaire were as follows: median physical functioning score 100 (range 0-100), median physical problems score 100 (range 0-100), median bodily pain score 100 (range 45-100), median social functioning score 100 (range 25-100), median general mental health score 84 (range 40-92), median emotional problems score 100 (range 0-100), median vitality score 70 (range 35-80) and median general health perceptions score 70 (range 35-100). Mean QOL scores were similar to the general healthy population. CONCLUSION: Surgery of ISH provides good QOL and tumoral control except for those located in the medulla oblongata. We recommend considering a careful multimodal therapeutic approach, including radiosurgery for these specific locations.

In this study, the authors present the results of 50 dissections of the anterior choroidal a. in man. Fifty cerebral hemispheres were prepared with the classic techniques of preservation and vascular injection. An ectopic origin was observed in 4% of cases. The intracisternal segment of the anterior choroidal a. forms a neurovascular bundle with the optic tract and basal v. Most of its intraparenchymatous branches arise from the cisternal segment, while branches supplying the optic tract, lateral geniculate body and thalamus arise from the intraplexual segment. Constant anastomoses exist with the vertebrobasilar system, specially the postero-lateral choroidal and posterior cerebral aa. We discuss the importance of an adequate knowledge of the anatomy of the anterior choroidal a. and its relations in the surgical approach to arterial aneurysms and arteriovenous malformations of the region.

STUDY DESIGN This is a case report of a young patient who experienced an acute epidural compression of cauda equina revealing Stage IV Hodgkin's disease. OBJECTIVES To draw attention to this rare presentation of Hodgkin's disease, and to assess the role of surgery in acute cauda equina compression in a context of a chemosensitive disease. SUMMARY OF BACKGROUND DATA Lymphomatous tissue in Hodgkin's disease may involve the spine usually in the setting of advanced disease. Initial manifestation of Hodgkin's disease in the spine is rare. The management of this rare presentation may be conservative, but surgery provides the most rapid way of neurologic tissue decompression. METHODS The case of a 14-year-old patient who experienced an acute epidural compression of cauda equina revealing Stage IV Hodgkin's disease is presented. RESULTS The patient complained of an increased lower back pain of 1-month duration before he developed lower limbs numbness, loss of perineal sensation, and urinary retention. Sagittal and axial T2-weighted magnetic resonance images of the lumbar spine revealed tumoral invasion of the epidural space compressing the cauda equina. Emergency surgical decompression was performed. In fine, Stage IV Hodgkin's disease revealed by acute epidural cauda equina compression was diagnosed. The patient recovered normal neurologic functions in a few days and then underwent chemotherapy and radiotherapy. CONCLUSION Although a rare situation, Hodgkin's disease may involve the spinal epidural space at presentation. The management is complex, but surgery provides the most rapid means of diagnosis and neurologic tissue decompression in severely affected patients.

International audience; CONTEXT: Craniopharyngiomas are often associated with an unfavorable prognosis, but data on their long-term consequences are sparse. OBJECTIVE: The aim of the study was to identify markers of recurrence and factors associated with compromised social rehabilitation and altered quality of life in a large cohort of patients with either childhood-onset (CO) or adult-onset craniopharyngioma. METHODS: Retrospective analysis was performed for 171 patients treated for craniopharyngioma in two academic centers in France between 1972 and 2009. For each subject, data were collected concerning clinical presentation, imaging features, visual sequelae, endocrine and metabolic impact, treatment modalities (surgery, radiotherapy), recurrence-free survival rate, and social insertion, as well as answers to the WHO-QOL BREF questionnaire. RESULTS: A total of 65 CO and 106 adult-onset patients were reviewed. If CO was diagnosed before the age of 10 yr, this was associated with a higher incidence of obesity, blindness, and panhypopituitarism, and only 40.7% of subjects had adequate work or school attendance compared to 72.4% of patients with later disease onset. Initial symptoms of intracranial hypertension (SIHT), pterional surgery, and multiple surgery were associated with obesity and poorer social insertion. No determinant of quality of life was identified. In the subgroup of patients treated in the 1990s and later, the progression rate was 59.4% in patients with residual tumor on magnetic resonance imaging compared with a 19.8% recurrence rate in the group with apparently complete resection. Recurrence/progression correlates significantly with male gender, early onset (before 10 yr), and SIHT, but only SIHT at presentation remained a significant predictor with multivariate analysis. CONCLUSIONS: Craniopharyngioma continues to be associated with severe outcomes. Higher morbidity rates are found in patients with early-onset disease (before 10 yr), initial SIHT, or in whom pterional surgery was required. Markers of recurrence are difficult to identify, with SIHT being the most powerful predictor.

International audience; PURPOSE: Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians. METHODS: Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability. RESULTS: There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients. CONCLUSIONS: Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.

International audience; This article describes a two-year surveillance of neurosurgical site infections and an outbreak of infections in deep brain stimulation (DBS) cases. From April to December 2008, six patients had a DBS surgical site infection (SSI). Audits of hygiene practices, infection control of the healthcare environment, and preoperative antimicrobial prophylaxis characteristics were carried out. The results of surgical audits showed that skin preparation and antimicrobial prophylaxis were not being performed adequately. In 2008, the general SSI rate was 1.8% (27 SSIs/1471 patients). Length of preoperative stay was significantly longer among infected patients (2.7 ± 2.9 months) compared with uninfected patients (2.2 ± 4.6 months) (P=0.01). Based on these results, skin preparation and antimicrobial prophylaxis were reviewed with the neurosurgery team. In 2009, the general SSI rate was reduced to 1.1% (16 SSI in 1410 patients), a reduction from 2008 (P=0.12). Although the overall incidence of SSI in 2008 (1.8%) was within the range of published data, this surveillance of SSIs permitted identification of site operative infected patients surgically treated for DBS. A set of actions was then taken to reduce SSI risk. This work demonstrates how an active surveillance programme can successfully change clinical care practice.

Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5–24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5–T6 and T9–T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients’ condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.

International audience; The subthalamic nucleus (STN) has become an effective target of deep-brain stimulation (DBS) in severely disabled patients with advanced Parkinson's disease (PD). Clinical studies have reported DBS-induced adverse effects on cognitive functions, mood, emotion and behavior. STN DBS seems to interfere with the limbic functions of the basal ganglia, but the limbic effects of STN DBS are controversial. We measured prospectively resting regional cerebral metabolism (rCMb) with 18-fluorodeoxyglucose and PET, and resting regional cerebral blood flow (rCBF) with HMPAO and SPECT in six patients with Parkinson's disease. We compared PET and SPECT 1 month before and 3 months after STN DBS. On cerebral MRI, 13 regions of interest (ROI) were manually delineated slice by slice in frontal and limbic lobes. We obtained mean rCBF and rCMb values for each ROI and the whole brain. We normalized rCBF and rCMB values to ones for the whole brain volume, which we compared before and following STN DBS. No significant difference emerged in the SPECT analysis. PET analysis revealed a significant decrease in rCMb following STN DBS in the superior frontal gyri and left and right dorsolateral prefrontal cortex (p < 0.05). A non-significant decrease in rCMb in the left anterior cingulate gyrus appeared following STN DBS (p = 0.075). Our prospective SPECT and PET study revealed significantly decreased glucose metabolism of the two superior frontal gyri without any attendant perfusion changes following STN DBS. These results suggest that STN DBS may change medial prefrontal function and therefore the integration of limbic information, either by disrupting emotional processes within the STN, or by hampering the normal function of a limbic circuit.

Olfactory ensheathing cell tumour (OECT) and olfactory groove schwannoma (OGS) are among the rarest intracranial tumour types that develop within anterior cranial fossa. These tumours share several similarities, including radiological and histological aspects, and only immunohistochemical staining can differentiate between them. We report a case of OECT occurring in a 28-year-old woman with a history of complex partial seizures, emotional lability and anosmia. Radiological features showed a predominantly left subfrontal extra-axial mass. Total excision of the tumour, connected to the cribriform plate and contiguous to the left olfactory bulb, was performed. Histological examination suggested an atypical schwannoma; however, immunohistochemical staining was strongly positive for S-100 protein but negative for both epithelial membrane antigen (EMA) and CD 57 (Leu-7). The final diagnosis was olfactory ensheathing cell tumour. We describe the third case of OECT and emphasize the important role of immunohistochemical staining in diagnosis: awareness of this entity, and use of immunohistochemistry help to distinguish it from OGS.

L'echec du traitement medical d'un syndrome douloureux evoquant un syndrome du tunnel radial justifie l'exploration chirurgicale du tunnel radial a la recherche de structures de compression avec la BPNR, en gardant a l'esprit tous les sites possibles de conflit. L'abord entre les mm. court et long extenseur radiaux du carpe permet alors une approche directe et rapide aux deux structures les plus frequemment en cause : l'arcade du CERC et l'arcade superieure du chef superficiel du m. supinateur. Cet abord est aussi approprie pour l'exploration de l'ensemble du tunnel radial en restant a distance des multiples branches nerveuses collaterales pour les mm. brachioradial et LERC. La difficulte reside alors dans le reperage de la branche collaterale unique pour le CERC, particulierement lorsqu'elle nait de la BPNR a proximite de la zone exploree.

Any variations in the origin of the ophthalmic a. are uncommon and well-explained by the comparative anatomy and human embryology. A unique case is reported of an ophthalmic a. arising from the middle meningeal a. associated with an occlusion of the central retinal a. Embryologic variations which can give such an unusual origin are discussed. Although this association may be fortuitous, we consider that an unusual origin of the ophthalmic a. could be a further factor for an occlusion of the central retinal a.

The authors document a rapid development, within 3 weeks, of hydromyelia in a 12 year-old boy. The boy was admitted to a local hospital because of drowsiness and persistent severe neck pain. Neurological examination disclosed a lethargic boy with no neurological deficit other than Parinaud’s sign. During his transfer to our department, he presented a cardio-respiratory arrest with coma and bilateral mydriasis. External ventricular drain and craniocervical decompression achieved excellent clinical and neuroradiological outcomes. The development of hydromyelia in this case is caused by obstruction to the natural cerebrospinal fluid pathway at the craniocervical junction and the cardio-respiratory arrest is provoked by a brain stem compression against the clivus and odontoid process. This report illustrates that hydromyelia may complicate acute obstructive hydrocephalus due to acquired Chiari malformation.

Syringomyelia is frequently associated with Chiari malformation or one of many otherpathological conditions. Its co-occurrence with medulloblastoma is rare, and to our knowledge, only 4 patients have been reported, although some reports have documented on syringomyelia associated with intracranial processes or intramedullary tumor. The authors describe an unusual case of asymptomatic thoracic syringomyelia complicated by an intrasyringal hemorrhage in a child with medulloblastoma. This report illustrates that, although unusual, syringomyelia is a potential complication in the natural history of medulloblastoma, and the authors consider the possible pathogenesis of syrinx enlargement.

Up to now, extra-dural haematomas (EDH) in elderly patients have been known for their poor prognosis and few studies have focused on the particularity of EDH in the elderly. Most clinical studies relating to EDH have generally focused on its occurrence in children and the middle-aged, grouping people of over 50 and 60 years together as the elderly. The purpose of this paper is to present a series of EDH cases in the elderly.500 EDH patients (of all ages) were admitted to our Department from January 1990 to December 2003 and this is a retrospective study of 14 of those patients who were aged 70 years and over.The study consists of 8 women and 6 men with an average age of 74 years. A high incidence of disease predisposes elderly to falls, which are the most frequent cause of head trauma. The elderly are less likely to manifest signs or symptoms of increased intracranial pressure due to cerebral atrophy, and almost all haematomas occurred in the parietal area. Post-operative results were satisfactory and only one death was recorded.This study shows that the elderly, presenting EDH after a fall, have a better prognosis than is often feared.

Capillary haemangioma of the central nervous system is extremely rare. Histologically proven cases developed in the dura mater and choroid plexus, or were typically intracranial extensions of an extra-cranial lesion.This report details a case that developed in the anterior choroidal artery of a newborn infant and manifested as a lethal intra-cerebral haemorrhage. Pathological criteria for the diagnosis of vascular malformations should be carefully investigated and the differential diagnoses of the present case are discussed.Intracranial haemangioma presents a diagnostic challenge and the treatment of deep lesions remains problematic.

Although some complications have been reported when using endoscopic techniques, epidural hematoma (EDH) has rarely been caused. The authors report a case of EDH complicating a concomitant endoscopic biopsy procedure with ventricular shunt placement in a young, 14-year-old boy harboring a third ventricle tumor with a hydrocephalus. Few cases have been reported; however, the authors warn that there is a risk that EDH may develop following an endoscopic procedure and shunt placement.