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Resume Le diagnostic precoce d’hemorragie meningee permet d’en ameliorer une mortalite et une morbidite importantes. L’objectif de cet article est de determiner les causes des retards diagnostiques. Nous avons repris tous les dossiers des hemorragies meningees hospitalisees dans le service de Neurochirurgie entre 2002 et 2003 en selectionnant les cas de retard diagnostique et nous avons trouve un taux de 16 %, qui est conforme aux donnees de la litterature. Dans tous les cas il s’agissait d’hemorragies meningees pauci-symptomatiques dont diagnostic doit etre systematiquement envisage devant une cephalee brutale ou d’intensite inhabituelle qui est le seul signe constant d’hemorragie meningee. Il faut insister sur l’absence de raideur meningee dans deux tiers des cas car elle est a l’origine de la plupart des erreurs diagnostiques. La cephalee en coup de tonnerre (« thunder clap headhache ») qui peut avoir exactement la meme semiologie est le principal diagnostic differentiel. Mais ce diagnostic ne peut etre retenu qu’apres scanner cerebral en urgence et ponction lombaire normaux.

Brain abscesses and empyemas are severe infections with lethal outcomes in the case of inappropriate treatment. The files of 34 patients with brain abscesses, and nine with intracranial empyemas treated over eight years (1990-1997) were analyzed retrospectively. Cases were evaluated for treatment and compared with data from the literature. Patients with brain abscess underwent either aspiration of the lesion through a burr hole (79.5% of the cases), or craniotomy and excision (8.8% of the cases); 11.7% were treated only with antibiotics. The operative mortality was 2.9% and the outcome was satisfactory in 85% of patients. These results are in agreement with data from the literature. Prognosis is strongly related to the initial clinical status. Current methods of treatment include surgical aspiration of large abscesses with a mass effect, and are usually associated with a poor clinical status. Excision is suggested whenever aspiration procedures have failed, or in the presence of foreign material or fungal abscess. Medical treatment is indicated for small and deeply located abscesses in patients with satisfactory clinical states. Empyemas in our series were treated with burr hole and pus aspiration. The mortality rate was 11%, and 62.5% of the patients made a good recovery. In agreement with other reported studies, the method of treating subdural empyema is much less significant than an aggressive early drainage of the infection. Although brain abscesses and empyema remain a significant neurosurgical concern, aggressive treatment can result in an excellent outcome in the majority of patients.

Infarction in the territory of the posterior spinal arteries is uncommon, giving rise to a softening of variable extend in the peripheral arterial system. In the reported case, the lesion was restricted to a posterior column and produced a syndrome of crural ataxic hemiparesis.

Cervical spondylotic myelopathy is usually a chronic and progressive disease. In a few cases, however, dramatic tetraplegia sometimes occurs after even minor injury.We report seven patients (6 males, 1 female, aged from 41 to 63), who suffered from acute myelopathy after an injury.In 5 cases, the injury revealed the cervical spondylotic myelopathy. A hyperextension of the cervical spine was found in 5 cases. The injury was severe in only one case, but there was no bony abnormalities, except arthrosis. The most common cause was a fall. In contrast, severe tetraplegia was found in 4 cases. Spontaneous, but incomplete, recuperation occurred in 4 patients. In all 7 cases, CT scan and MRI showed congenital cervical stenosis associated with cervical spondylosis. The level of disco-osteophytic changes was mainly in C4, C5, C6. On T2-weighted spin-echo image, an increased signal intensity was present in the cord of 3 patients, but was not correlated with the severity of the symptoms, nor with improvement. Surgical treatment was performed in 6 cases: 3 laminectomies, 3 anterior or antero-lateral approaches. Improvement after operative decompression was observed in all but one case, even when the motor or sensory deficit persists for more than one year. Motricity of the inferior limbs improved better than the other deficits, perhaps because of the location of non-reversible lesions in the spinal gray matter.The acute medullary syndrome of cervical spondylotic myelopathy is serious and can cause major handicaps. This complication justifies a preventive surgical attitude when medullar signs are moderate, and cervical imagery shows a spondylotic compression of the cord with congenital stenosis.

Six patients with neurological complications in Rendu-Osler-Weber disease were reviewed. There were 4 patients (3 int the same family) with a brain abscess, one patient with a brain abscess and a spinal cord subarachnoid hemorrhage, one patient with a recurrent intracerebral hemorrhage due to a vascular malformation. The infectious complications are related to the presence of pulmonary arterio-venous fistula, which should be treated, whenever diagnosed. Because of the potentially severe outcome of these neurological complications of the Rendu-Osler-Weber disease, screening of the patient's relatives is highly recommended.

Pituitary apoplexy results from necrosis or haemorrhage of a pituitary adenoma. This rare complication occurs in 2 to 10% of operated adenomas. The acute form results from massive intrapituitary bleeding leading to violent headache, meningeal signs, impaired conscience and ophthalmology signs, basically bilateral blindness. Associated signs are frequent including paralysis of the oculomotor nerves, epilepsy seizure, hemiplegia. Diabetes insipidis is exceptional. In less acute forms, the sudden nature of the headache and ophthalmology signs can suggest diagnosis. Standard X-ray reveals destruction of the sella turcica. Computed tomography shows either a haematoma or a cystic cavity in the pituitary gland which must be perfectly described together with the integrity of the bone structures due to the risk of lysis. Magnetic resonance imaging is an essential technique which can be used to describe the volume and suprasellar extension of the tumour, its texture, possible compression of adjacent structures and determine the age of the haemorrhage. This imaging technique can also isolate rare optochiasmatic apoplexia requiring intracranial evacuation. Emergency surgery is mandatory for most all authors. Rhinal-septal decompression is usually used, but the intracranial route may be preferred for very large suprasellar tumours. Medical treatment alone may be successful for small prolactin adenomas. Outcome depends on the time lapse to decompression. Optic nerve recovery is usually possible if the delay is less than 7 days. Cranial nerve recovery is less dependent on the time interval. In all cases hormone substitution is required.

Seventeen patients with subdural empyema were treated from 1985 to 1993. These included 13 males and 4 females with 11 patients aged between 12 and 30 years old. Sinusitis was found to be the primary source of infection in 16 cases. The clinical presentation was classic and the preoperative diagnosis was established on the first CT in 12 cases. In the remaining cases a second or third CT was necessary to demonstrate the empyema, 24 to 48 hours later. Surgical management was first made by burr holes with a small craniectomy in 15 cases. A large craniotomy was performed in 2 patients. Soft catheter drainage was carried out in 6 cases, 9 patients received surgical treatment once (3) or twice (6). Two patients, operated on while in a coma (stage IV of Bannister scale) died and one patient survived with severe disability (operated at stage III). The others (14) made a good recovery (6 in grade A and 8 in grade B of Mauser). These results were compared with those in the literature and we concluded that the mean factor of prognosis is the level of consciousness at the time of initial treatment. In most of the cases, burr holes or a small craniotomy, carried out on the basis of CT or MRI data, are the easiest and most effective method of surgical treatment.

We describe the case of a woman, who presents a spontaneous rhinorrhea. The metrizamid computerized tomographic cisternography proves the precise anatomic location of the dural osseous defect, in the left sphenoidal sinus. Transsphenoidal approach terminated the leakage in a single procedure, without shunt.

Using latex injections we have studied the anastomoses between the ophthalmic artery (a. ophthalmica) and the branches of the external carotid (a. carotis exerna) in the orbital region (regio orbitalis). We have limited this report to the macroscopic anastomoses which have a functional supply and which are accessible to examination by the Doppler technique. After examination of 60 specimen pairs it is clear that most anastomoses were inconstant. We have thus recorded their frequency: for the facial artery (a. facialis) the frequency of anastomoses was 60%, for the superficial temporal artery (a. temporalis superficialis) it was 33%, for the infraorbital artery (a. infraorbitalis) anastomoses were present in 37%. We have furthermore studied the association between the different anastomoses to establish whether their relationship to one another was organized or simply random. We found that the anastomoses between the branches of the opthalmic artery and those of the external carotid artery were much more frequent on the right side. Finally, we have compared our anatomical results with those of a series of Doppler examinations designed to detect reversal of the circulation at the level of different anastomoses of the ophthalmic artery in subjects who presented with unilateral thrombosis of the internal carotid artery (a. carotis interna). This study revealed a good correlation between the anatomical findings and those observed on Doppler examination. There are however differences which can be explained by the small number of subjects examined, by the calibre of the vessels and also by the fact that in certain subjects, the circle of Willis (circulus arteriosus cerebri) was particularly well-developed. In such circumstances the anastomoses were not clinically functional and there was no reversal of blood flow within them.

Rupture of the dura mater during lumbar laminectomy may result in destruction of the herniated sacral and lumbar nerve roots. This can be avoided by a simple but immediate surgical procedure, details of which are presented here.

We have performed micro-anastomoses by continuous suture technic: --circular suture of an aorta with 9/0 and with 10/0 Vicryl three (90% permeability); --next we performed an aortic-iliac bypass thanks to a carotid graft (70% permeability). The verification was carried out by injection of the complete arterial system with solidifying agent, and we obtained an arterial fitting after corrosion by the mean of hydrochloric acid.

Pharmacokinetics and biodistribution of 99m Technetium (99mTc) labelled heparin were studies to assess its value as a tracer of heparin kinetics in comparison with unlabelled heparin. In vitro, the stability and labelling efficiency (98%) of the labelled drug were excellent and elution was minimal. In vivo, after I.V. infusion of the drug, there was no difference in the same animal between anticoagulant activity measurements and radioactive countings, both displaying a plasmatic biexponential pattern (T1 = 2.9 minutes, T2 = 76 minutes). Biodistribution studies showed primarily liver, spleen and kidney accumulation, with no thyroid uptake. The advantages of this technetium labelling may therefore be used for the heparin drug in various experimental and pathological situations even in humans.

Following demonstration of a method of assay of circulation heparin by measurement of radioactivity after labelling with 99 m technetium, the technique was used to study effects of arterial microsuture on metabolism of heparin injected postoperatively. Results of a study involving rat aorta showed that local binding was maximum during the first half-hour and that abnormal consumption of heparin continued during the 6 hours following operation. These finding suggest that a risk of thrombosis probably persists throughout this postoperative period.

The introduction of vascular micro-surgical techniques has allowed to treat cerebral ischemia, through extra-intra-cranial anastomosis, when the causative arterial lesions have a surgically unfavorable location. Thirty patients underwent brain revascularization through extra-intra-cranial micro-anastomosis between the superficial temporal artery (branch of the external carotid artery) and a cortical branch of the middle cerebral artery. Twenty five patients had definite sensitive and motor deficits. Five patients, on the other hand, underwent preventive surgery because of transient cerebral ischemia. In our series, the global rate of the microanastomosis patency is 78%. When the anastomosis is patent, 85% of the cases with motor deficits are cured or improved. The results are even more favorable in case of transient cerebral ischemia, for the anastomosis in such cases was always patent. None of these later patients had ischemia attacks with a one-year follow-up.

In 21 autopsy specimens, we performed latex injection, and studied the rate and the diameter of the anastomosis between the ophthalmic artery and the facial artery: we find 26 cases in 42 face-sides, 60 %; which can supply rapidly a circulatory insufficiency. The anastomosis which go to the ophthalmic artery from the others branches of the external carotid are less frequent.

The use of a floating graft is proposed in order to attempt resolution of surgical problems raised by distal internal carotid artery lesions located high in the neck. Surgical treatment is essential, but vascular suture is impossible below the petrosa and ligature of internal carotid artery is often the only solution. The floating graft, which is fixed proximally only and is allowed to float in the circulation, allows exclusion of the lesion and maintenance of the carotid vascular axis. Preliminary experimental studies in the rat have provided satisfactory results and research should be continued in larger animals prior to possible clinical use.

Following an anatomical study of the lateral suboccipital region, the authors have devised an approach to the third segment of the vertebral artery, from C2 to the foramen magnum, which enabled them to treat an arteriovenous fistula in C1 while preserving the vertebral artery. The different operative stages and anatomical features are described. The simplicity and safety of this approach should encourage surgeons to use it.

40 temporo-sylvian anastomoses were controlled using Doppler ultrasonic examination. The results are compared to post-operative arteriograms. The Doppler examination has proved to be highly accurate when compared to contrast arteriography in the survey of extra-intracranial anastomosis. This non invasive procedure can easily be repeated. However the size of the revascularized area cannot be estimated. The simultaneous isotopic studies of regional cerebral blood flow could provide a means of quantifying the results of the anastomoses.

Pharmacokinetics of technetium 99m (99mTc) labelled heparin was studied after I.V. infusion (70 IU/kg) in normal rats and in a group of animals just after aortic longitudinal incision and suture. Anticoagulant activity measurements and radioactivity were compared on the same plasma samples. The pharmacokinetic decay of 99mTc-heparin followed a bi-exponential pattern. Half-lives (T1, T2) were significantly shortened after surgery using both techniques. Liver accumulation of labelled heparin was decreased in "sutured" rats and a high uptake of 99mTc-heparin was found on the operated area of the aorta.

Description of an arterio-venous fistula of the suboccipital V3 portion of the vertebral artery in a male of 48. The first clinical manifestation of the fistula was a bruit following an injury, which had produced i.a. a mandibular fracture. For various reasons, the authors are of opinion that the fistula was rather congenital than traumatic. The technique of a paramedian surgical approach of the lesion is described. The authors think that this is a valuable procedure in the treatment of vertebral arterio-venous fistulas in the region between C2 and the foramen magnum.