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Objectifs : Évaluer la technologie MOSFET en comparaison avec la technologie des films radiochromiques pour déterminer la dose cutanée maximale reçue par le patient au niveau du cuir chevelu lors d’embolisations vasculaires intra crâniennes. Sensibiliser les opérateurs à l’importance de la dose reçue par les patients avec la visualisation en temps réel de cette valeur que permet la technologie MOSFET. Matériel et méthode : Six patients traités pour un anévrysme intracrânien ont fait l’objet de 24 mesures comparatives de dose par film radiochromique et avec la technologie MOSFET. Résultats : Les dosimètres MOSFET mesuraient la dose ponctuelle au cuir chevelu du patient en temps réel et avec un niveau de précision suffisant, compte tenu du besoin (dose inférieure de 9 % à celle lue par les films dans 54 % des cas et supérieure de 12 % dans 45 % des cas). Néanmoins, il s’agissait de valeurs localisées au point de mesure de chaque dosimètre MOSFET, alors que les films radiochromiques permettaient d’accéder à une cartographie dosimétrique prenant en compte les recoupes et chevauchements des champs d’exposition. Conclusion : La dosimétrie MOSFET, actuellement plus onéreuse, nous apparaissait donc plus indiquée pour des mesures de dose ciblées (e.g. cristallin) ou sur des champs de dose uniforme que pour une recherche systématique de la dose cutanée maximale lors d’embolisations vasculaires intracrâniennes, pour laquelle nous persisterons à utiliser les films radiochromiques.

We report the case of an 85-year-old patient, referred by her ophthalmologist for neuro-ophthalmologic consultation at the Clermont-Ferrand University Medical Center, for conjunctival hyperemia and ocular hypertension in the left eye for 12 months. The patient's only past medical history was treated, controlled arterial hypertension and there was no mention of falling or head trauma. MRI (magnetic resonance imaging) and angiography identified a type D carotid-cavernous fistula. Intravenous embolization was performed under general anesthesia by retrograde selective catheterization facial vein and ophthalmic vein and placement of coils into the cavernous sinus, resulting in regression of physical and functional signs immediately after the procedure. This case illustrates the symptoms of spontaneous carotid-cavernous fistula and immediate efficacy of embolization. We report the epidemiology, characteristics and various presentations of the condition.

We report the case of a single-eyed patient with acute occlusion of the central retinal artery on her functional eye. The patient was a 72-year-old women with high cardiovascular risk, bilateral severe myopia, and amblyopia in her right eye. The occlusion affected the left eye so treatment consisting of local intra-arterial fibrinolysis was initiated by administration of alteplase and sodic heparin in the left ophthalmic artery. The result was successful restoration of initial visual acuity after 1 month, which was stable at the 9-month-follow-up.

Interventional radiology:Transoral approach to C2 Purpose: Toassess the value of a direct transoral approach to C2 for interventionalprocedures. Materials and methods: A transoral approachto C2 was used in 4 patients (9-64 year old) with lyticlesion of the C2 vertebra and/or base of the odontoid overa 10 year period. Three patients underwent biopsy and 1 patientunderwent vertebroplasty using biplane fluoroscopy. All procedureswere performed under general anesthesia using a 13G needle directlyintroduced in the C2 vertebra through the posterior pharyngeal wall. Results: Noneof the patients reported ill-effects from the procedure. Needleplacement was satisfactory in all patients, without technical difficulty.No technical complication was noted. Specifically, no infectiouscomplication occurred. Conclusion: Our results indicatethat a direct transoral approach to C2 is safe for biopsy or vertebroplasty.

Economic and societal constraints require to take into account the economic dimension and medical performance of hospital departments. We carried out a self-assessment study, which we thought could be useful to share with the neurosurgical community.Care and research activities were assessed from 2009 to 2013. We used institutional and assessment-body parameters in order to describe activities and perform a financial evaluation. It was a retrospective descriptive study based on the guidelines of the DHOS/O4 circular No. 2007/390 of October 29, 2007.The average annual, analytic income statement was +1.39 millions euros, for 63 beds with a 92% occupancy rate, including 6.7 full-time equivalent neurosurgeons (and assistants), for 2553 patients and 1975 surgeries. The average mortality rate was 2.74%. The annual mean length of stay was 6.82 days. Per year, on average 15.6% of patients were admitted in emergency and 76.9% returned home. The annual, act-related-pricing and publication-related incomes represented 77% and 0.6%, respectively of the total funding. Difficulties to find downstream beds for the most severe patients induced 1401 "waiting days" in 2012.Medico-economic analysis of a neurosurgery department at a university hospital was useful in order to take into account the care, teaching and research activities, as well as its related financial value.

We report the case of an 85-year-old patient, referred by her ophthalmologist for neuro-ophthalmologic consultation at the Clermont-Ferrand University Medical Center, for conjunctival hyperemia and ocular hypertension in the left eye for 12 months. The patient's only past medical history was treated, controlled arterial hypertension and there was no mention of falling or head trauma. MRI (magnetic resonance imaging) and angiography identified a type D carotid-cavernous fistula. Intravenous embolization was performed under general anesthesia by retrograde selective catheterization facial vein and ophthalmic vein and placement of coils into the cavernous sinus, resulting in regression of physical and functional signs immediately after the procedure. This case illustrates the symptoms of spontaneous carotid-cavernous fistula and immediate efficacy of embolization. We report the epidemiology, characteristics and various presentations of the condition.

Purpose Flow diversion is now a well-established endovascular technique for the treatment of intracranial aneurysms. FRED and FRED Jr are dual-layer, self-expanding nickel titanium flow-diverters. SAFE is a prospective, multicenter study conducted in 14 French and Belgian centers to evaluate the safety and efficacy of these devices. Materials and methods Only aneurysms located in the anterior circulation were included. The primary efficacy endpoint is the rate of complete aneurysm occlusion at 6 months without associated stenosis of the parent vessel. The primary safety endpoint is the rate of morbidity (mRS > 2) and mortality at 6 months. Adverse events as well as anatomical results will be independently evaluated. According to the endpoints, the target population is 85 patients, now extended to 95/100. Results Inclusions started in July 2014. End of February 2016, 92 patients with 92 aneurysms were included. The expectation is to have inclusions completed end of April 2016. Most patients were females (80/92, 87.0%). All but one patient were mRS 0 or 1 before the treatment. Among the 92 aneurysms, 22 (23.9%) were aneurysm remnant after a previous treatment and the 70 others (76.1%) were unruptured. Aneurysm locations were internal carotid artery (n = 83, 90.2%), anterior communicating artery (n = 6, 6.5%), and middle cerebral artery (n = 3, 3.3%). Aneurysm size was 24 mm in 3 aneurysms (3.3%). Neck size was or = 4 mm in 67/91 aneurysms (73.6%). Placement of the flow diverter was achieved in all cases. Intra-operative events were reported in 7/92 patients (7.6%), including technical problems (n = 3), thromboembolic events (n = 3), and others (n = 1). Postoperative events, morbidity, and mortality are also analyzed. Preliminary anatomical results (at 6 months) are presented. Conclusion SAFE is an ongoing GCP (Good Clinical Practice) study aiming to evaluate safety and efficacy of FRED flow diverter in aneurysm treatment. Inclusions are close from completion. As of now, the safety of the FRED as evaluated by the CEC seems to be in line with published results for Flow Diversion technique. Disclosures L. Pierot: 2; C; Microvention. J. Gauvrit: 2; C; Microvention. J. Lejeune: 2; C; Microvention. A. Derelle: 2; C; Microvention. J. Gabrillargues: 2; C; Microvention.

Finite element modelling of the human lumbar vertebral column employs data-processing procedures for study of the linear and nonlinear elasticity of materials such as are currently used in mechanics or in civil engineering. Thanks to developments in computer science, requiring a close collaboration between doctors and engineers, we put forward in this preliminary study a linear computerised model of the lumbar column comprising 4824 meshes and 6813 nodes. By reducing the simplificatory hypotheses and integrating new parameters, this model as developed is capable of important clinical applications in surgery and ergonomics.

Deep brain stimulation (DBS) is an effective treatment of movement disorders and psychiatric diseases. However, this surgery is still time consuming and associated with complications, among which we aimed to identify non-stimulo-induced adverse effects. Hence, we retrospectively systematically analyzed patients operated on, at our institution, using magnetic resonance imaging (MRI) direct anatomic mapping.One hundred and seventy-five patients (184 surgeries) were performed between 1994 and 2008, for Parkinson's disease, essential tremor, dystonia and obsessive compulsive disorder. Primary anatomic targets were the subthalamic region, the intern pallidum and the thalamus. Final electrode positioning was adjusted according to intraoperative neuron recordings and acute stimulation tests. All surgically related adverse effects were collected. Life threatening or new non-planed surgery was considered as severe adverse effects.Adverse effects occurred 10 times (5.4%) during MRI acquisition, 24 times (13%) with five serious (2.7%) including one1 death (0.5%) during electrodes implantation and 17 times (9.2%) with four serious (2.2%) during neuropacemaker implantation. Electrodes were repositioned in six cases (five patients, n=3.4%).DBS efficiency is recognized however the significant incidence of adverse effects should prompt us to improve the procedures.

Rhabdomyosarcoma is an extremely virulent rare tumor whose early diagnosis considerably improves survival and visual prognosis. We report the case of a 2-year-old child with levator palpebrae superioris muscle rhabdomyosarcoma revealed by a sudden and isolated blepharoptosis. Initially, clinical and imaging investigations did not show any abnormality but a painful tumor with some hematoma quickly developed, so the investigations were repeated. The CT-scan showed an extra-conal tumor that had developed at the superior part of the orbit. Histology confirmed the diagnosis of embryonic rhabdomyosarcoma. Because of its results, treatment consisting of chemotherapy associating ifosfamide, vincristine, actinomycin and orbital radiotherapy of 40 Gy with a local addition of 10 Gy were administrated with successful results after a 3-year-follow-up.

We report the case of a single-eyed patient with acute occlusion of the central retinal artery on her functional eye. The patient was a 72-year-old women with high cardiovascular risk, bilateral severe myopia, and amblyopia in her right eye. The occlusion affected the left eye so treatment consisting of local intra-arterial fibrinolysis was initiated by administration of alteplase and sodic heparin in the left ophthalmic artery. The result was successful restoration of initial visual acuity after 1 month, which was stable at the 9-month-follow-up.

To assess the value of a direct transoral approach to C2 for interventional procedures.A transoral approach to C2 was used in 4 patients (9-64 year old) with lytic lesion of the C2 vertebra and/or base of the odontoid over a 10 year period. Three patients underwent biopsy and 1 patient underwent vertebroplasty using biplane fluoroscopy. All procedures were performed under general anesthesia using a 13G needle directly introduced in the C2 vertebra through the posterior pharyngeal wall.None of the patients reported ill-effects from the procedure. Needle placement was satisfactory in all patients, without technical difficulty. No technical complication was noted. Specifically, no infectious complication occurred.Our results indicate that a direct transoral approach to C2 is safe for biopsy or vertebroplasty.

MRI is the best radiological technique to explore cavernomas, vascular malformations affecting the entire central nervous system. The presence of blood degradation products produces a specific aspect which enables excellent contrast resolution. Certain diagnosis can be established with MRI which can also be used to follow growth and modifications, particularly in familial forms. In the emergency setting, the first exam is often a CT-scan for patients presenting acute neurological sign(s) and/or with a clinical suspicion of hemorrhagic stroke. Angiography is generally not contributive because cavernomas are occult vascular malformations. Nevertheless, this exam is often necessary when an associated vascular abnormality is suspected, particularly a developmental venous abnormality.

To demonstrate the technical feasibility, safety and results of intracranial aneurysm treatment by coils of 0.018-inch diameter wire (GDC 18) for ruptured and non-ruptured intracranial aneurysms.From a commune database from five neuroradiological centers, we analysed endovascular technique with Gugliemi Detachable Coils (GDC) 18, complications of technique, acute angiographic occlusion results and long-term angiographic follow-up. Sixty-six percent of aneurysms were ruptured. The mean size of treated aneurysms was 13.7 mm.Overall feasibility of coil 18 treatments was 95%. Acute angiographic results in 110 aneurysms demonstrated total occlusion in 63 aneurysms (57.2%), subtotal occlusion in 37 cases (33.6%), and incomplete occlusion in 10 cases (9%). A second treatment was performed in 15 cases; follow-up demonstrated 60 (61%) total occlusions, 32 (33%) subtotal occlusion and 5 (5%) incomplete. Five patients were lost to follow-up, and 8 patients had died. Stability of occlusion with these coils was 61%.Coiling of intracranial aneurysms, ruptured or non-ruptured, using coils with a wire diameter of 0.018-inch is safe, with no more complications than standard coils. Remodelling technique is possible. This type of coils must be considered for treatment of large aneurysms.

To report a case of adenoid cystic carcinoma of the external auditory canal with petrous involvement.A 50-year-old woman was referred to our department for the management of a necrotizing external otitis. Computed tomography and biopsy revealed an adenoid cystic carcinoma of the external auditory canal.The patient was treated by complete surgical excision. A radiation therapy completed the treatment. Follow-up time was 19 months without evidence of recurrence. Adenoid cystic carcinoma of the external auditory canal is a rare tumor. It's a special type of carcinoma developing from the ceruminous glands. Histogenesis is difficult and unsettled. The most important survival factor is removal of the tumor with histologically free margins.Lack of specific clinical and radiological signs makes the diagnostic challenging. The adenoid cystic carcinoma is a rare neoplasm of the external auditory canal. An initial aggressive wide "en bloc" surgical resection is mandatory.

The purpose of the study was to report two cases of cervical and para-pharyngeal bone tumors.Patients were two 29 and 67-year-old men. Presentation of the lesions included respectively a right cervical mass and a left para-pharyngeal mass. Clinical features and radiological, anatomopathological and therapeutic characteristics of the tumors were retrospectively studied.A cervical approach was made in both cases. Tumor biopsies revealed a vertebral aneurismal cyst and a corporeo-pedicular chordoma respectively.Vertebral bone tumors with cervical expression are very uncommon entities. Diagnosis could be systematically evoked in patients with a cervical or para-pharyngeal tumor presenting vertebral lysis.

The purpose of this work was to evaluate the diagnostic strategy and outcome of patients treated for tympanic paraganglioma.Nine patients presented with tympanic paraganglioma were treated in our unit from 1996 to 2003. There were eight women and one man, mean age 65 years. Surgery was performed in all nine patients. This retrospective analysis focused on revealing signs, diagnostic tools, surgical procedure for tumor resection, and short-, mid-, and long-term functional outcome.The surgical procedure was well tolerated by all patients. There were no cases of postoperative mastoiditis. None of the patients experienced postoperative dizziness. Total tumor removal was achieved in seven patients. In one patient, incomplete tumor resection was decided in order to preserve facial motion. All patients but one were relieved from their tinnitus in the early postoperative period. In four patients, preoperative hearing levels were worsened by the surgical procedure, essentially through an alteration of preoperative conductive hearing loss.MRI is highly contributive to the diagnosis of tympanic paraganglioma, which should be evoked in patients with pulsatile tinnitus. Diagnosis should be established as early as possible to lower the postoperative morbidity. While surgery can provide cure and relieve tinnitus, there is a high risk of auditory deterioration.

Metastatic carcinoma involving the middle ear space is a rare entity that is little described in the literature. The number of cases seems to be increasing. It is usually recognized that palliative treatment as the most reasonable treatment for this tumors.A 59-year-old female patient presented with a history of a metastatic carcinoma involving the middle ear space and mastoid. This metastase occurred one year late in the course of a bladder cancer. Presentation of the lesion included otorrhea and facial palsy complicated by headache and bilateral visual loss in relation with lateral sinus thrombophlebitis and intracranial hypertension. Diffuses metastases in the skeletal system were demonstrated by pretreatment investigations. Treatment was only palliative chemotherapy. Outcome was fatal two months after onset of symptoms.This case illustrates the clinical and pathological features of this tumor and the pitfalls of diagnosis and treatment. We will discuss the current accepted management and the difference after diagnosis modalities for this type of metastatic tumor.

Two cases of internal carotid artery aneurysm arising within the petrous bone are described, bringing up to 56 the number of such cases reported to date in the medical literature scanned through Medline. The first case presented as a moderately bleeding tumor of the petrous apex, while the second was revealed by a massive otorrhage. In both cases a pulsatile nasopharyngeal mass was associated with otorrhage. The treatment required in both cases the aneurysm to be embolized in extreme emergency. One patient suffered transient hemiplegia and aphasia that completely recovered, while the second eventually died, although the carotid occlusion had been well tolerated in the first two weeks that followed this procedure. From their own experience and a literature review, we can emphasize the need for arterial extra-intracranial bypass before an aneurysm embolization be proposed, since the neurological issue following internal carotid occlusion cannot be predicted.

A perfect knowledge of the anatomy of the vestibuloacusticofacial pedicle is required to preserve hearing and facial functions during cerebellopontine angle surgery for vestibular schwannoma. A clarification of the anatomy of this pedicle, in particular of its blood supply, is presented here, based on a review of the available literature, as well as on the author's data issued from anatomical dissections on latex-injected fresh specimens, and from radiological images of the cerebellopontine angle. The blood supply to the vestibuloacusticofacial bundle arises from the meatal loop of the anterior inferior cerebellar artery most often exhibited at the porus of the internal acoustical meatus. The labyrinthine artery is particularly exposed to injury between the cochlear and facial nerves. In addition, dissection in between these two nerves is likely to sever vessels directed to these nerves even though the labyrinthine artery is not interrupted. Thus, aside from a direct injury to the labyrinth, auditory function can be impaired through two distinct ischemic lesion types. Although the facial nerve is supplied through three main arterial systems (from the labyrinthine, the middle meningeal, and the stylomastoid arteries), its labyrinthine portion is more likely to suffer from ischemic damage as it is only supplied by meatal arteries. A refinement of our anatomical knowledge of the vestibuloacusticofacial pedicle, from a functional point of view, could arise from laser Doppler measurements of labyrinthine and facial blood flow during surgery, in an attempt to improve our functional preservation rate during therapeutic procedures for vestibular schwannoma.

Intraoperative fluoroscopy imaging during coronaroplasty or transjugular intrahepatic portosystemic shunt may induce chronic radiodermatitis. Temporary hair loss is a peculiar form of radiodermatitis following endovascular surgery of the cerebral arteries.Six patients (2 women, 4 men, age range: 27-47 years old) were seen for a solitary plaque of alopecia. In all of the cases, the plaque had appeared two weeks after a neuroradiologically guided embolization procedure. No other skin lesions were seen. Alopecia spontaneously and completely regressed within three to four months. However, it reappeared after a subsequent embolization (one case) but not after arteriographies (five cases).Five similar cases have been reported in the literature. Transient alopecia often occurs after neurologically guided endovascular surgery of the cerebral arteries. This side-effect is well known by neurosurgeons and thus, these patients are rarely referred to a dermatologist. Two differential diagnoses must be evoqued: alopecia aerata and anticonvulsant - induced alopecia. The role played as cofactor by carbamazepine which is a photosensitivant drug, is discussed.

The meaning of facial nerve enhancement by gadolinium-enhanced magnetic resonanca imaging (MRI) in Bell's palsy is very discussed. Aim of our study was to define the radiological data in facial Bell's palsy and to correlate them with clinical data.34 patients with facial Bell's palsy were studied prospectively. Each patient had two gadolinium-enhanced MRI. The first MRI was realized during the first ten days. The second MRI was realized three months later. Two patients with facial nerve enhancement localized on the third portion was not clinically normalized at 3 months. Facial nerve enhancement and his precise location was noted.Facial nerve enhancement was noted in 71,5% on first MRI and in 30% on second MRI. Gadolinium-enhancement was predominantly noted on the Fundus. No patients with facial nerve enhancement persisting at three months was clinically normalized at one month.Facial nerve enhancement localized on the fundus and/or on the third portion, persisting at three months, could be consider as a negative landmark of fast clinical facial recuperation.

Background:Typical presentation of spontaneous internal carotid artery (ICA) dissection is an ipsilateral pain in neck and face with Horner's syndrome and contralateral deficits. Although rare, lower cranial nerve palsy have been reported in association with an ipsilateral spontaneous ICA dissection.Case studies:We report three new cases of ICA dissection with lower cranial nerve palsies.Results:The first symtom to appear was headache in all three patients. Examination disclosed a Horner's syndrome in two cases (1 and 2), an isolated XIIth nerve palsy in two patients (case 1 and 3) and IX, X, and XIIth nerve palsies (case 2) revealing an ipsilateral carotid dissection, confirmed by MRI and angiography. In all cases, prognosis was good after a few weeks.Conclusion:These cases, analysed with those in the literature, led us to discuss two possible mechanisms: direct compression of cranial nerves by a subadventitial haematoma in the parapharyngeal space or ischemic palsy by compression of the ascending pharyngeal artery.

Percutaneous balloon occlusion of a large hypertensive idiopathic renal arteriovenous fistula is reported. A lumbar thrill was noted in a 52-year-old hypertensive woman. Intravenous digital substraction angiography identified the lesion. After arteriographic assessment a percutaneous embolisation was performed with a releasable balloon positioned on a coaxial micro-catheter. Immediate post-procedural angiographic control demonstrated complete occlusion with a small segmental area of renal hypoperfusion. The lumbar thrill disappeared. Normalisation of the blood pressure was noted two days later and confirmed eight months later. Persistent occlusion of the fistula was angiographically confirmed, whereas the area of renal hypoperfusion had partially decreased. Releasable balloon percutaneous embolisation appears to be a safe alternative to surgery in the treatment of large renal arteriovenous fistulas.