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Brain arteriovenous malformation (BAVM) is defined as abnormal communication between cerebral of arteries and veins, without capillaries. Clinically, it may involve intracranial hemorrhage or seizures. Complete spontaneous resolution, known as BAVM disappearance, has been reported in rare cases.We retrospectively collated all cases of BAVM in Lille University Hospital, from 2005 to 2018, and identified all cases of spontaneous BAVM disappearance on angiography (nidus and early venous drainage).There were 4 cases of spontaneous BAVM disappearance, in 3573 patients: i.e., prevalence of 0.1%. Sex ratio was 2:2; ages ranged from 14 to 46 years; nidus size was generally small (20mm); 3 of the 4 patients had superficial venous drainage. Revelation of BAVM was by hemorrhage in 3 cases and by seizure in 1. There were no cases of recanalization at 1 year's follow-up.Spontaneous BAVM disappearance is rare. Associated factors may include small nidus, superficial venous drainage and hemorrhage.

WHO grade II progestin-related meningiomas have been reported in recent series but we found no previous study describing their long-term outcome. Our study aimed to evaluate patients operated on for high-grade intracranial meningioma and who underwent long-term exposure to high dose of cyproterone acetate, nomegestrol acetate, and chlormadinone acetate. Our study retrospectively included 9 patients with high-grade progestin-related intracranial meningioma between December 2006 and September 2021. In each patient, clinico-radiological follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. The mean progestative exposure was 11.4 years. Edema existence or absence of cleft sign on MRI were the key factors for surgical indication. All patients underwent surgery. Adjuvant radiotherapy was indicated in 1 patient, and Gamma Knife radiosurgery was proposed in 2 other patients for a second location of meningioma. Six patients harbored a grade II chordoid meningioma subtype with 100% PR expression and 3 patients a grade II atypical meningioma subtype with lower PR expression. The mean follow-up was 8.1 years and none of the 9 patients presented with a recurrence. Patients with grade II progestin-related meningiomas have less tumor recurrence after surgery than patients with sporadic grade II meningiomas, especially after progestin withdrawal. The presence/appearance of peri-meningioma edema and the absence of cleft sign before volumetric change should suggest the existence of an underlying WHO grade II meningiomas. In these cases, surgical resection may immediately be considered and adjuvant radiotherapy should be reserved for proven recurrence cases.

OBJECTIVE/BACKGROUND: The need for revascularization of the distal posterior cerebral artery (PCA) in the treatment of PCA aneurysms is a contentious issue. Approaches to the PCA, such as the subtemporal route, carry significant perioperative risk. This risk at times outweighs the risk of ischemia associated with endovascular PCA sacrifice. This paper describes the use of an extreme lateral supracerebellar infratentorial (ELSCIT) approach as an alternative technique for distal PCA revascularization. METHODS: Between 2016 and 2019, 3 patients underwent a PCA bypass via the ELSCIT approach for the treatment of a PCA aneurysm. In all cases, an end-to-side anastomosis to the P2-or P3-segment of the PCA was made, with the occipital artery as a donor. Bypass procedures were followed by endovascular parent artery occlusion, without ischemic complications. RESULTS: In all 3 cases, the ELSCIT approach offered a broad enough surgical corridor to perform an occipital artery-to-PCA bypass. One patient suffered a cerebrospinal fluid leak that was surgically treated. Patients' clinical conditions were stable on follow-up (mean follow-up of 34 months). All 3 aneurysms remained occluded, and no ischemia was detected on magnetic resonance imaging. CONCLUSIONS: The ELSCIT approach offers an alternative route to the distal PCA for extracranial-to-intracranial bypass with seemingly low perioperative morbidity and good surgical access to the PCA.

Background and Purpose: Infarct volumes predict malignant infarcts in patients undergoing decompressive hemicraniectomy (DH) for large middle cerebral artery territory infarcts. The aim of the study was to determine the optimal magnetic resonance imaging infarct volume threshold that predicts a catastrophic outcome at 1 year (modified Rankin Scale score of 5 or death). Methods: We included consecutive patients who underwent DH for large middle cerebral artery infarcts. We analyzed infarct volumes before DH with semi-automated methods on b1000 diffusion-weighted imaging sequences and apparent diffusion coefficient maps. We studied infarct volume thresholds for prediction of catastrophic outcomes, and analyzed sensitivity, specificity, and the area under the curve, a value ≥0.70 indicating an acceptable prediction. Results: Of 173 patients (109 men, 63%; median age 53 years), 42 (24.3%) had catastrophic outcomes. Magnetic resonance imaging b1000 diffusion-weighted imaging and apparent diffusion coefficient infarct volumes were associated to the occurrence of 1-year catastrophic outcome (adjusted odds ratio, 9.17 [95% CI, 2.00–42.04] and odds ratio, 4.18 [95% CI, 1.33–13.19], respectively, per 1 log increase). The optimal volume cutoff of were 211 mL on b1000 diffusion-weighted imaging and 181 mL on apparent diffusion coefficient maps. The 2 methods showed similar sensitivities and specificities and overlapping area under the curve of 0.64 (95% CI, 0.54–0.74). Conclusions: In patients with large middle cerebral artery infarcts, optimal magnetic resonance imaging infarct volume thresholds showed poor accuracy and low specificity to predict 1-year catastrophic outcome, with different b1000 diffusion-weighted imaging and apparent diffusion coefficient thresholds. In the setting of DH, optimal infarct volumes alone should not be used to deny DH, irrespectively of the method used.

Abdominal pseudocysts are common complications of ventriculoperitoneal shunt (VPS). We report the case of a 37-year-old woman treated by VPS for congenital obstructive hydrocephalus, who presented shunt dysfunction related to a voluminous abdominal cyst initially diagnosed as cerebrospinal fluid pseudocyst. The cyst was drained and the VPS was removed after endoscopic third ventriculocisternostomy (ETV). A few months later, a large new abdominal cyst appeared and was operated on. Diagnosis was rectified as massive ovarian mucinous cystadenoma. In any intra-abdominal cyst, differential diagnoses need considering to avoid mis-diagnosis in shunted patients, especially if the cyst is very large. The etiology of the hydrocephalus should also be investigated in case of shunt dysfunction. Even in case of longstanding shunt, ETV can be an alternative to shunt revision surgery in obstructive hydrocephalus, enabling VPS withdrawal and treatment of the hydrocephalus.

Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty.The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377.Patients with MCA aneurysms can be optimally managed within a care trial protocol.

The relationship between meningioma and progestins has not been elucidated. Meningioma regression after acetate cyproterone (CA) withdrawal has been reported. Our purpose was to evaluate the meningioma evolution after withdrawal of progestins in patients who underwent long-term exposure to CA, nomegestrol acetate (NA), chlormadinone acetate (ChlA)., info:eu-repo/semantics/published

Introduction: High grade progestin related meningiomas have been reported in recent series but we found no previous study describing their long-term outcome. Our study aimed to evaluate patients operated on for high grade intracranial meningioma and who underwent long term exposure to high dose of cyproterone acetate, nomegestrol acetate and chlormadinone acetate.Methods: Our study retrospectively included 9 patients with high grade progestin related intracranial meningioma between December 2006 and December 2020. In each patient, clinico-radiological follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. Results: The mean progestative exposure was 11.4 years. Edema existence or absence of cleft sign on MRI were the key factors for surgical indication. All patients underwent surgery. Ajduvant radiotherapy was indicated in 1 patient, and Gamma Knife Radiosurgery was proposed in 2 other patients for a second location of mengioma. 6 patients harbored a grade II chordoïd meningioma subtype with 100% PR expression and 3 patients a grade II atypical meningioma subtype with lower PR expression. The mean follow-up was 7.1 years and none of the 9 patients presented with a recurrence.Conclusion: Patients with Grade II progestin related meningiomas have less tumor recurrence after surgery than patients with sporadic high grade meningomas, especially after progestin withdrawal. The presence/ appearance of peri-meningioma edema and the absence of cleft sign before volumetric change should suggest the existence of an underlying high grade meningioma. In these cases, surgical resection may immediately be considered and adjuvant radiotherapy should be reserved for proven recurrence cases.

OBJECTIVE To determine whether cervical vestibular evoked myogenic potentials (cVEMPs) are predictive of hearing preservation in patients undergoing vestibular schwannoma removal through middle fossa craniotomy approach. STUDY DESIGN Retrospective case study. SETTING Tertiary referral center. PATIENTS Eighteen patients who underwent a middle fossa craniotomy for vestibular schwannoma (stage I or II of Koos classification) with attempted hearing preservation from January 2008 to February 2016 were retrospectively reviewed. INTERVENTION Pre-surgical cVEMPs test, videonystagmography (caloric test), and magnetic resonance imaging (MRI) as well as a pre- and post-surgical audiometry test. MAIN OUTCOME MEASURES cVEMPs parameters including amplitude asymmetry ratio (AR), P13, and N23 latencies and peak-to-peak amplitude between P13 and N23 waves were calculated. Hearing data were classified according to the AAO-HNS hearing classes. The nerve of origin of the tumor was specified during surgery and the largest tumor diameter was measure on MRI axial plane on T2-CISS weighed images. RESULTS Preoperative amplitude asymmetry ratio was lower (n = 15, Mann-Whitney U test, p

BACKGROUND AND PURPOSE Decompressive hemicraniectomy (DH) reduces mortality of large middle cerebral artery (MCA) territory infarcts. Survivors are at high risk of poststroke seizures (PSSs). This study aims to describe the incidence of PSSs, to identify associated factors, and to assess their impact on long-term outcomes. METHODS We included consecutive patients who underwent DH for large MCA infarcts from May 2005 to December 2019 at Lille University Hospital. Patients were followed up at 3 months, 1 year, and 3 years. We analysed (i) the incidence and associated factors of early onset PSSs (EPSSs) with logistic regression models; (ii) the incidence and associated factors of late onset PSSs (LPSSs) in survivors at 7 days with a univariate Cox proportional hazard regression model for interval-censored data; and (iii) the impact of PSSs (EPSSs and LPSSs) on mortality with univariate and multivariate Cox proportional hazard regression models and modified Rankin Scale at 1 and 3 years, with univariate and adjusted multivariate ordinal logistic regression analyses. RESULTS Of 248 patients (150 men, 60.5%; mean age = 50.4 ± 9.6 years), 106 (42.7%) presented PSSs (six inaugural seizures, 22 EPSSs, 78 LPSSs) during follow-up. The PSS cumulative incidence was 12.3% at 7 days, 24.9% at 3 months, 49.8% at 1 years, and 54.8% at 3 years. No predictor was significantly associated with either EPSSs or LPSSs. PSSs did not significantly impact mortality and long-term functional outcome. CONCLUSIONS The incidence of PSSs after DH is high, reaching more than 50% 3 years after stroke, but PSSs did not influence long-term mortality or functional outcome.

Fronto-temporo-insular (FTI) gliomas continue to represent a surgical challenge despite numerous technical advances. Some authors advocate for surgery in awake condition even for non-dominant hemisphere FTI, due to risk of sociocognitive impairment. Here, we report outcomes in a series of patients operated using intraoperative magnetic resonance imaging (IoMRI) guided surgery under general anesthesia, using no cortical or subcortical mapping. We evaluated the extent of resection, functional and neuropsychological outcomes after IoMRI guided surgery under general anesthesia of FTI gliomas located in the non-dominant hemisphere. Twenty patients underwent FTI glioma resection using IoMRI in asleep condition. Seventeen tumors were de novo, three were recurrences. Tumor WHO grades were II:12, III:4, IV:4. Patients were evaluated before and after microsurgical resection, clinically, neuropsychologically (i.e., social cognition) and by volumetric MR measures (T1G+ for enhancing tumors, FLAIR for non-enhancing). Fourteen (70%) patients benefited from a second IoMRI. The median age was 33.5 years (range 24–56). Seizure was the inaugural symptom in 71% of patients. The median preoperative volume was 64.5 cm3 (min 9.9, max 211). Fourteen (70%) patients underwent two IoMRI. The final median EOR was 92% (range 69–100). The median postoperative residual tumor volume (RTV) was 4.3 cm3 (range 0–38.2). A vast majority of residual tumors were located in the posterior part of the insula. Early postoperative clinical events (during hospital stay) were three transient left hemiparesis (which lasted less than 48 h) and one prolonged left brachio-facial hemiparesis. Sixty percent of patients were free of any symptom at discharge. The median Karnofsky Performance Score was of 90 both at discharge and at 3 months. No significant neuropsychological impairment was reported, excepting empathy distinction in less than 40% of patients. After surgery, 45% of patients could go back to work. In our experience and using IoMRI as an adjunct, microsurgical resection of non-dominant FTI gliomas under general anesthesia is safe. Final median EOR was 92%, with a vast majority of residual tumors located in the posterior insular part. Patients experienced minor neurological and neuropsychological morbidity. Moreover, neuropsychological evaluation reported a high preservation of sociocognitive abilities. Solely empathy seemed to be impaired in some patients.

BACKGROUNDMeningiomas are the most commonly encountered nonglial primary intracranial tumors. The authors report on the usefulness of intraoperative magnetic resonance imaging (iMRI) during microsurgical resection of meningiomas located close to eloquent areas or dural sinuses and on the feasibility of further radiation therapy.OBSERVATIONSSix patients benefited from this approach. The mean follow-up period after surgery was 3.3 (median 3.2, range 2.1–4.6) years. Five patients had no postoperative neurological deficit, of whom two with preoperative motor deficit completely recovered. One patient with preoperative left inferior limb deficit partially recovered. The mean interval between surgery and radiation therapy was 15.8 (median 16.9, range 1.4–40.5) months. Additional radiation therapy was required in five cases after surgery. The mean preoperative tumor volume was 38.7 (median 27.5, range 8.6–75.6) mL. The mean postoperative tumor volume was 1.2 (median 0.8, range 0–4.3) mL. At the last follow-up, all tumors were controlled.LESSONSThe use of iMRI was particularly helpful to (1) decide on additional tumor resection according to iMRI findings during the surgical procedure; (2) evaluate the residual tumor volume at the end of the surgery; and (3) judge the need for further radiation and, in particular, the feasibility of single-fraction radiosurgery.

The management of non-hemorrhagic arteriovenous malformations (AVMs) remains a subject of debate, even more since the ARUBA trial. Here, we report the obliteration rate, the risk of hemorrhage and the functional outcomes after Gamma Knife radiosurgery (GKRS) as first-line treatment for non-hemorrhagic AVMs treated before the ARUBA publication, in a reference university center with multimodal AVM treatments available. We retrospectively analyzed data from a continuous series of 172 patients harboring unruptured AVMs treated by GKRS as first-line treatment in our Lille University Hospital, France, between April 2004 and December 2013. The primary outcome was obliteration rate. Secondary outcomes were the hemorrhage rate, the modified Rankin Scale (mRS), morbidity and epilepsy control at last follow-up. The minimal follow-up period was of 3 years. Median age at presentation was 40 years (IQR 28; 51). Median follow-up was 8.8 years (IQR 6.8; 11.3). Median target volume was 1.9 cm3 (IQR 0.8–3.3 cm3), median Spetzler-Martin grade: 2 (IQR 1–2), median Pollock-Flickinger score: 1.07 (IQR 0.82–2.94), median Virginia score: 1 (IQR 1–2). Median treatment dose was 24 Gy at 50% isodose line. Twenty-three patients underwent a second GKRS after a median time of 58 months after first GKRS. The overall obliteration rate was of 76%, based primarily on cerebral angiography and/or rarely only upon MRI. Hemorrhage during the post-treatment follow-up was reported in 18 (10%) patients (annual risk of 1.1%). Transient post-GKRS morbidity was reported in 14 cases (8%) and persistent neurological deficit in 8 (4.6%) of patients. At last follow-up, 86% of patients had a mRS ≤ 1. Concerning patients with pretherapeutic epilepsy, 84.6% of them were seizure-free at last follow-up. GKRS as first-line therapeutic option for unruptured cerebral AVMs achieves high obliteration rates (76%) while maintaining a high-level patient’s autonomy. All hemorrhagic events occurred during the first 4 years after the initial GKRS. In cases with epilepsy, there was 84.6% seizure free at last follow-up. Permanent morbidity was reported in only 4.6%.

Objective There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. Methods Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. Results There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02–0.19) for clipping and 13/48 (27%; 95% CI, 0.17–0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09–0.33) cases, and 8/33 (24%; 95% CI, 0.13–0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60–0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22–0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54–0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36–0.70) patients with RA allocated coiling. Conclusions Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.

International audience; Purpose: Our study aimed to evaluate potential risk factors for the development of FDICA after suprasellar tumor resection.Materials and method: After reviewing all cases of pediatric patients who benefited from a suprasellar lesion resection in our two medical institutions, we found 6 patients with a FDICA. Surgical approach strategy (pterional or subfrontal approaches) was noted. Postoperative cranial MRI was performed in each patient 3 months after surgery and every year. When a FDICA occurred, MRI was performed 6 months after the diagnosis and 1 year later to detect any progression.Results: There were 6 males with a mean age at treatment of 11 years (6 to 15). Pterional approach was performed in these 6 patients. At the 2 institutions, we have done at least 50 pterional craniotomies for suprasellar lesion resection. No FDICA was reported after subfrontal approach in 27 consecutive pediatric patients operated on from a craniopharyngioma. The delay between the surgery and the diagnosis of the FDICA was 9 months (3 to 17 months). No symptoms related to the FDICA were recorded. The mean maximal diameter of the aneurysm was 14 mm (10 to 21). ICA bifurcation was involved in 2 cases. Asymptomatic FDICA progression was noted in 2 cases but no treatment was proposed.Conclusion: The pathogenesis of FDICA is unclear, and might involve arterial wall necrosis caused by postoperative arachnoid fibrosis which might be worsened by the pterional approach.

Background. - The patency of cranial bypasses must be carefully evaluated during and after the micro surgical procedure. Although, several imaging techniques are used to evaluate the patency of bypasses, their findings are sometimes difficult to interpret. Purpose. - The goal of this study was to assess the consistency of different diagnostic modalities for evaluating intracranial bypass patency. Patients and method. - This prospective study included 19 consecutive patients treated with EC-IC or IC-IC bypass for MoyaMoya disease (MMD) or complex/giant aneurysms between June 2016 and June 2018. In the early postoperative period (

Introduction Neurofibromatosis type 2 is characterized by the presence of bilateral vestibular schwannomas. However, other nervous system tumors may also occur. Therefore, the management of NF2 patients is complex and requires a multidisciplinary discussion in a specialized center. Materials and methods All recent articles concerning tumors other than vestibular schwannoma in NF2 disease were reviewed, using PubMed databases. Results Intracranial meningiomas occur in 50% of NF2 patients, and are often multiple. Surgery remains the main treatment and should be performed in cases of growing tumors. The role of antiangiogenic therapy is currently under evaluation and the role of radiosurgery still remains to be defined in NF2 disease. Spinal tumors occur in about half of NF2 patients. Surgery should be discussed when radiological tumor progression is demonstrated, even if spinal tumors are asymptomatic, in order to preserve neurological function and good quality of life. As regards lower cranial nerve schwannomas, radiosurgery appears to be a more appropriate treatment for growing tumor with a small volume in order to avoid post-operative complications, especially swallowing disorders. Facial nerve schwannomas may appear, on MRI, like vestibular schwannomas. The diagnosis should be suspected when the facial palsy is an early symptom during cerebello-pontine tumor progression. Trigeminal schwannomas are frequent in NF2 disease and fortunately they are often asymptomatic. Among major neurofibromatosis types, peripheral nerve sheath schwannomas are only present in patients with NF2 disease and schwannomatosis. Surgical resection is required when the cutaneous schwannomas is painful or when tumor progression is observed and causes symptoms. Conclusion Tumors other than vestibular schwannoma are also associated with a poor prognosis in NF2 patients. Surgery remains the main treatment in most cases. Each treatment decision in NF2 disease requires a complete evaluation of all cranial and spinal locations of the disease in order to establish surgical priorities and strategies.

Background Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. Methods This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744 ) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. Results The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio = 4.29; P = 0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. Conclusion Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Objective We aimed to evaluate the outcome of patients who underwent salvage microsurgery for vestibular schwannoma (VS) that failed primary Gammaknife radiosurgery (GKS). Patients and Methods Among the 1098 patients who received GKS for the treatment of VS in our center between January 2004 and December 2012, the follow-up was organized in our institution for 290 patients who lived in our recruitment area. Tumor progression was noted in 23 patients. A salvage microsurgical resection was performed in 11 patients, who were included in our study. Grading of facial function was done according to the House & Brackman scale. Results The mean age at diagnosis was 50.2 years (19–68 years) and the mean follow-up was 9.4 years (4–13 years). The mean dose was 11.8 Gy (11–12 Gy) and the mean volume was 922 mm3 (208–2500 mm3). The mean period between GKS and diagnosis of tumor progression was 32 months (18–72 months). Concerning salvage microsurgery, complete resection was obtained in 8 patients. Small residual tumor on the facial nerve was deliberately left in 3 patients and no tumor progression was noted with a mean follow-up of 26 months. At last follow-up, facial nerve function was grade 1 in 4 patients, grade 2 in 3 patients, grade 3 in 1 patient and grade 4 in 3 patients. Conclusion Salvage surgery of recurrent vestibular schwannoma after failed initial GKS remains a good treatment. However, facial nerve preservation is more challenging in this case and small tumor remnant could be sometimes deliberately left.

Background and purposeFlow diverters are increasingly used for the treatment of intracranial aneurysms. Evaluation of the first devices available for clinical use showed high efficacy of this treatment although safety results were worse compared with coiling or balloon-assisted coiling. The Safety and Efficacy Analysis of FRED Embolic Device in Aneurysm Treatment (SAFE) trial is a single-arm, multicenter, prospective study conducted to precisely analyze the safety and efficacy of the FRED and FRED Jr devices.MethodsUnruptured and recanalized aneurysms located in the anterior circulation treated with FRED and FRED Jr were prospectively included. Adverse events were independently evaluated by a Clinical Event Committee with a vascular neurosurgeon and an interventional neuroradiologist. Primary safety outcome measures were morbidity and mortality rates at 6 months after treatment.ResultsA total of 103 patients/aneurysms were included in 13 interventional neuroradiology (INR) centers. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 71 (68.9%), cavernous ICA in 15 (14.6%), anterior cerebral artery or anterior communicating artery in nine (8.7%), and middle cerebral artery in eight (7.8%). Aneurysms were small (ConclusionsAneurysm treatment with the FRED device is safe with low mortality (1.0%) and morbidity (2.0%).Clinical trial registrationNCT02921698.

Resume Objectif Les tumeurs gliales intramedullaires de l’adulte sont des tumeurs rares representant moins de 4 % de l’ensemble des tumeurs du systeme nerveux central. L’etude retrospective que nous rapportons, avait pour objectifs d’etudier l’histoire naturelle et les modes de prise en charge de ces tumeurs. Materiel et methodes Elle a concerne 332 patients : 72 % d’ependymomes, dont 94 % de bas grade, 24 % d’astrocytomes, dont 29 % de haut grade, 2,4 % de gliomes mixtes et 1,7 % d’oligodendrogliomes. Resultats L’âge au diagnostic etait de 42,4 ans pour les ependymomes avec une forte predominance masculine, 39,6 ans pour les astrocytomes. La douleur representait le symptome revelateur le plus frequent. Une biopsie chirurgicale, seule, etait effectuee dans pres de 20 % des astrocytomes, alors que plus de 80 % des ependymomes beneficiaient d’une exerese. Les traitements adjuvants, radiotherapie et chimiotherapie, etaient reserves aux tumeurs malignes, surtout quand il s’agissait d’ependymomes. Le taux de survie a 5 ans etait de 76,8 % pour les astrocytomes et de 94,5 % pour les ependymomes. Conclusion L’histologie, le score fonctionnel preoperatoire, le grade, sont des facteurs pronostiques retrouves dans cette serie. Si pour les ependymomes la prise en charge chirurgicale essentiellement est bien codifiee, la question d’une sous-utilisation des traitements adjuvants pour les astrocytomes est posee.

Aim The authors report the results of a multicenter retrospective series with a long-term follow-up and the analysis of clinical, radiological, surgical data as well as the complementary treatments in patients with intramedullary astrocytomas (IA). Materials and methods We performed a retrospective analysis of all the patients with IA operated on between 1984 and 2011 at 7 French centers (Kremlin-Bicetre, Lille, Lyon, Marseille, Montpellier, Nice, and Nimes). The minimum follow-up was 12 months. The clinical evaluation was based on the McCormick scale (MCS) results from the pre- and postoperative period. Results Data from 95 patients with a pathologically confirmed diagnosis of IA were considered: 54 patients were treated at the Neurosurgical Department of Kremlin-Bicetre Hospital, 8 were treated at Lille and 33 were treated in the south region of France. The epidemiological analysis was performed on the whole cohort of patients while follow-up considerations were made solely on the 54 patients managed at Kremlin-Bicetre Hospital to obtain homogeneous data. The average age at diagnosis was 35.6 years without significant gender difference (47 % men for 53 % women). The age at first clinical manifestation was 33.7 years. The average duration of the symptoms before the diagnosis was 22.9 months. Neuropathic pain was the principal revealing symptom (76 % of cases). The localization of IA was thoracic in 40 %, purely cervical in 28.4 %. Complete removal was achieved in 29.5 % of cases when considering the whole cohort and in 38 % of cases treated at Bicetre Hospital. The histological distribution recorded was: grade 1 in 35 %; grade 2 in 35 %; grade 3 in 22 % and grade 4 in 8 %. During the early postoperative period (3 months) a worsening of functional capacity was observed with an increase in the frequencies of ranks 3 and 4 of MCS in 18.4 %. At 5 years follow-up, the frequencies of ranks 1 and 2 were increased. The application of a Cox model for the determination of the relative risk of death for IA grade 1 and 2 (66 patients) showed a probability of survival at 5 years of 78.6 % (CI 95 %: 68.6 %–87.6 %). Survival at 10 years is to 76.8 % (CI 95 %: 62.3 %–84.2 %). Conclusion Surgery is indicated if the patient is symptomatic or the tumor increases in size. A radical excision remains the mainstay of treatment, while searching to preserve the motor function. A total resection was however only possible in 38 % of cases. A regular postoperative follow-up is compulsory and the adjuvant treatment is based on chemotherapy and radiotherapy according to the histological type.

BackgroundDecompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct.MethodsWe conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4–6) in 30-day survivors.ResultsOf 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume.ConclusionIn patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients’ characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.

International audience; BACKGROUNDHearing response following an osteodural decompression of the internal auditory canal (IAC) is controversial.OBJECTIVETo evaluate the course of auditory brainstem responses (ABRs) and the early hearing response during the first year following IAC decompression for small to medium-sized vestibular schwannomas occurring in neurofibromatosis type 2 (NF2).METHODSRetrospective chart review of middle fossa craniotomy for IAC osteodural decompression in NF2-related vestibular schwannomas.RESULTSTwelve NF2 patients were operated on from 2011 to 2016 for IAC decompression. All had NF2 according to the Manchester criteria. All had a progressive change of their ABRs documented from the diagnosis of NF2 over a mean period of 6.25 [0.36;10.9] yr. Treatment was proposed to stop hearing progression based on the speech discrimination scores (SDSs; n = 4) or for hearing maintenance (n = 8). In patients with prior hearing progression, hearing responses were observed in 3 of the 4 patients during the first year. One patient kept on progressing. In the hearing maintenance group, the SDSs remained stable. SDSs improved from 85% [20-100] to 92.5% [60-100] on average (n = 12) and from 55% [20-80] to 77.5% [50-100] in the hearing progression group (n = 4). ABRs improved in 4 patients following decompression.CONCLUSIONIAC decompression allows early objective hearing responses in select patients. We suggest that the procedure should be offered to patients with hearing progression based on their SDSs and/or associated progressive increases in their wave III and V latencies on ABRs.

Objectives. - To evaluate the effectiveness of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in improving cerebrovascular reserve (CVR) in Moyamoya syndrome. Patients and methods. - This prospective study included 10 consecutive patients treated for Moyamoya syndrome by STA-MCA bypass in our institution between June 2016 and January 2018. Perfusion MRI, transcranial Doppler and 99 m Tc-HMPAO SPECT with acetazolamide challenge were performed before and after treatment to evaluate perfusion and cerebrovascular reserve. STA-MCA bypass was indicated for patients with history of ischemic or hemorrhagic stroke and when CVR was diminished on both transcranial Doppler and 99 m Tc-HMPAO SPECT with acetazolamide challenge or brain perfusion was deteriorated on MRI. Results. - Bypass anastomosis was patent in all patients at end of surgery. One patient presented partial postoperative sensorimotor deficit related to an ischemic lesion in the frontal cortical area. One patient presented regressive chronic subdural hematoma without neurological deficit. Three months after treatment, CVR was significantly improved in 8 patients and unchanged in 2, probably related to low flow. Further follow-up found CVR deterioration in 1 patient, with anastomosis occlusion at 1 year. Conclusion. - Our data suggest that improvement in cerebral perfusion and CVR depends on flow in the STA-MCA anastomosis in patients with Moyamoya syndrome. Systematic long-term follow-up of anastomosis flow, brain perfusion and CVR improves quantification of the benefit of STA-MCA anastomosis in terms of disease progression. (C) 2019 Elsevier Masson SAS. All rights reserved.

BackgroundHigh-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms.Materials and methodThis prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm.ResultsThe mean age at treatment was 55years (range 34 to 67). The mean time of microsurgical procedure was 11h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient.ConclusionIn this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.

High-field intraoperative MRI (IoMRI) is part of the neurosurgical armamentarium to improve the extent of glioma resection (EOR). To report our oncological and functional outcomes using IoMRI for neuronavigated glioma surgery. In this prospective monocentric study, we reported 100 consecutive adult patients operated on for glioma using IoMRI with neuronavigation, under general anesthesia without intraoperative stimulation, from July 2014 to April 2017. The volumetric evaluation was based on the FLAIR hypersignal for non-enhancing tumors after Gadolinium infusion and on the T1 hypersignal after Gadolinium infusion for enhancing tumors. We evaluated the surgical workflow, the EOR and the clinical outcomes (using Karnofsky performance score (KPS)). Sixty-nine patients underwent one IoMRI, and 31 from two IoMRI controls. At first IoMRI, the median tumor residue was higher in the FLAIR group than in the T1G+ group whereas no more difference was reported after the second IoMRI between the 2 groups (p = 0.56). Additional resection was performed 6 times more frequently in the FLAIR group (OR = 5.7, CI (1.9–17)). The median EOR was 100% (IQR, 93.6–100) whatever the tumor type (first surgery or recurrence) and location. Higher residues were reported only in the insula area (p = 0.004). The median KPS was 90 (IQR, 80–100) at discharge, 3, 6 and 12 months after surgery, with no statistical difference between low- and high-grade gliomas (p = 0.34). IoMRI neuronavigated surgery provided maximal EOR whatever the type of glioma and location. IoMRI was all the more useful for non- or minimally enhancing tumors. The step by step surgical resection, introducing the concept of “staged volume” surgery, ensured a high security for the surgeon and low permanent morbidity for the patients.

Introduction L’hemicrâniectomie decompressive (HD) reduit la mortalite des infarctus cerebraux etendus du territoire de l’artere cerebrale moyenne (ACM). Les survivants presentent un risque eleve de crises epileptiques post-accident vasculaire cerebral. Objectifs Decrire l’incidence des crises epileptiques post-AVC, identifier les facteurs associes et leur impact sur le pronostic a long terme. Patients et methodes Il s’agit d’une etude retrospective de l’incidence et facteurs associes aux crises precoces et tardives chez les survivants a 7 jours, de l’impact des crises sur la mortalite et le score de RANKIN modifie a un an et a 3 ans chez des patients ayant presente un infarctus etendu du territoire de l’ACM traite par une hemicrâniectomie decompressive, et prospectivement inclus de mai 2005 a decembre 2019 au CHU de Lille. Resultats Des 248 patients inclus, 106 (42,7 %) ont presente des crises (6 crises inaugurales, 22 crises precoces, 78 crises tardives) durant le suivi. L’incidence cumulative des crises etait de 12,3 % a 7 jour, 24,9 % a 3 mois, 49,8 % a 1 an et 54,8 % a 3 ans. Aucun predicteur n’etait significativement associe aux crises, precoces ou tardives et ces dernieres n’ont pas eu d’impact sur la mortalite ou le pronostic fonctionnel a long terme. Discussion Cette etude fournit une quantification du risque de crise a long terme. Un patient sur deux a presente une crise durant les trois annees de suivi. Elle n’a pas pu identifier les facteurs de risque individuel, n’ayant pas identifie de facteurs associes aux crises. Elle fournit une information sur le risque pronostique, tant vital que fonctionnel, associe aux crises epileptiques. Conclusion L’incidence des crises epileptiques apres un infarctus etendu de l’ACM traite par DH est eleve (50 % apres 3 ans), sans influencer la mortalite ou le pronostic fonctionnel a long terme.

Resume L’hydrocephalie chronique de l’adulte se caracterise par une triade clinique associant des troubles de la marche, une deterioration neuro-cognitive et une incontinence urinaire. Les signes apparaissent de facon insidieuse chez un patient de plus de 40 ans. Le diagnostic radiologique est fait sur une IRM cerebrale qui retrouve un elargissement ventriculaire, des anomalies de la repartition du liquide cerebro-spinal (LCS) des espaces sous-arachnoidiens (elargissement des scissures laterales mais rarefaction du LCS au vertex) et un flux du LCS aqueducal augmente ; en cas d’hydrocephalie obstructive sur une stenose decompensee de l’aqueduc, ce flux est nul et le plancher du troisieme ventricule est abaisse. Des tests complementaires (PL depletive d’au moins 40 mL de LCS ou un test de perfusion) permettent de confirmer l’indication chirurgicale a une derivation ventriculo-peritoneale (en cas d’hydrocephalie communicante) ou a une ventriculo-cisternostomie (en cas d’hydrocephalie obstructive). Une amelioration clinique est retrouvee chez 80 % des patients si l’indication chirurgicale est bien posee, faisant de cette pathologie une des seules causes de demence curable.

Internal variation among spheno-orbital meningiomas (SOM) is surgically challenging. Optic canal invasion management is discussed. This retrospective study includes 70 patients with SOM who underwent surgery between 1995 and 2012. Preoperative ophthalmological, neurological and aesthetic clinical signs were collected. All patients benefitted from repeated tomography and magnetic resonance imaging (MRI). The surgical team consisted of a neurosurgeon and a plastic surgeon. In the majority of cases, resection was followed by bone reconstruction using an autologous iliac crest graft. The extent of resection was evaluated on the dural and osseous sides. Early clinical outcomes, long-term follow-up, recurrence and adjuvant therapies were reported. The mean age was 52 years old, and 91 % of the patients were women. Initial symptoms primarily included proptosis (65 %), decreased visual acuity (39 %) and soft tissue tumefaction (16 %). We classified 40 cases as the internal variety when considering the inner third of the greater wing of the sphenoid, optic canal, anterior clinoid process or cavernous sinus. The remaining cases were described as the external variety. The complete resection rates for the internal and external varieties were 12 % and 61 %, respectively (P

Objectives/Hypothesis To determine the long-term growth rate of vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2) patients based on volumetric measurements. Study Design Retrospective review. Methods We retrospectively reviewed magnetic resonance imaging (MRI) scans acquired from patients with NF2 from 1999 to 2013. Patients with an annual radiologic follow-up over at least 3 consecutive years were included. Volumetric VS growth was prospectively measured using a three-dimensional imaging workstation and through manual contouring of the lesion. Time to tumor progression was assessed according to the Response Evaluation in Neurofibromatosis and Schwannomatosis Tumor Measurement Group. Results Eighteen patients presenting with a total of 26 VSs were included. The mean age at diagnosis was 26.1 years (range, 7 to 49 years). One hundred five MRI scans were analyzed during a median radiological follow-up of 5.6 years (range, 3 to 12 years). The annual volume and diameter growth rates were respectively 218.3 mm3/yr (range, −10 to 1,250 mm3/yr) and 0.9 mm/yr (range, −0.5 to 4.5 mm/yr). Time to tumor progression was 3 years (median survival). There was a weak correlation between volumetric and linear measurements (P < .0001, linear regression, n = 26, r2 = 0.58). Among the 26 VSs, 76.9% (20/26) showed progression (VS growth more than 20%), 19.2% were stable, and 3.9% (1/26) exhibited shrinkage (spontaneous regression of more than 20% of the initial volume). Conclusions This study helps to assess the long-term growth profile of VS in a population of NF2 patients with untreated VS. These data could help to better acknowledge VS natural growth history. Level of Evidence 4 Laryngoscope, 2016

Introduction Management of vertebral artery-posterior inferior cerebellar artery convergence (VA-PICA) saccular aneurysms requires a specialized neurovascular team. The objective is to preserve the functional outcome while performing a complete and reliable long-term exclusion of the aneurysm. Objective The aim of our study was to evaluate the outcome of patients with VA-PICA saccular aneurysms after treatment. Materials and methods This was a retrospective series of 21 consecutive patients with a VA-PICA saccular aneurysm treated between 2000 and 2012 at our institution. Treatment option (endovascular or microsurgical) was decided for each patient following a multidisciplinary discussion. Results Twenty-one patients were treated for a VA-PICA saccular aneurysm including 16 for a ruptured aneurysm and 5 for an asymptomatic aneurysm. Among all patients, 11 underwent endovascular treatment and 10 had microsurgical treatment. Our results showed a major aneurysm recurrence after endovascular treatment in 3 patients that required a further endovascular treatment in 2 cases. These 3 major recurrences occurred after treatment of a ruptured aneurysm when the initial angiography demonstrated the origin of the PICA at the neck of the aneurysm. After microsurgery, angiography showed a remnant neck in 2 patients including 1 treated by further endovascular procedure. Conclusion VA-PICA aneurysms are rare and require multidisciplinary management. Microsurgical treatment should be discussed when the PICA originates from the aneurysmal neck, particularly in patients with a ruptured small aneurysm, in order to obtain a reliable and long-term exclusion of the aneurysm.

Due to their anatomical characteristics and the complexity of the procedures required to obtain their complete occlusion, the treatment of giant intracranial aneurysms is a real challenge. Direct reconstructive strategies, whether by interventional neuroradiology (coils, stents) or microsurgical (clipping) means, are not always applicable and, in patients that would not tolerate parent or collateral artery sacrifice, the adjunction of a revascularization procedure using a bypass technique might be necessary. Cerebral arterial bypasses can be classified according to their function (3 types: flow replacement, flow reversal or protective), the branching mode of the graft used (3 types: pedicled, interpositional or in situ), the sites of anastomosis (2 types: extracranial-intracranial or intracranial-intracranial) and the class of flow they are supposed to provide (3 types: low-, intermediate- or high-flow). In this article, the authors review the different aspects in the management of patients with a giant intracranial aneurysm using a bypass: preoperative work-up, types of bypass and indications, surgical techniques and results.

Giant intracranial aneurysms are defined as greater than 25mm in diameter. They share the same surgical challenges and strategies as so-called complex aneurysms, sometimes smaller in size but presenting with similar complex anatomy. The surgical difficulties arise from the size of the sack, the presence of intraluminal thrombus, the thickness of the arterial wall, and the complexity of arterial branching on the neck. Preoperative imaging gathers complementary information from magnetic resonance imaging, computed tomographic angiography, and rotational catheter-based angiography with three-dimensional reconstruction including balloon-test occlusion. The therapeutic decision-making needs a multidisciplinary approach including endovascular, neurosurgical and anesthesiological expertises. The microsurgical treatment needs a step-by-step preoperative planning with anticipation of possible pitfalls and alternative strategies. Classical principles of aneurysm surgery have to be tailored to face the difficulties arising from the size of the sack and from the arterial wall calcifications.

Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management.This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P0.25 in the univariate analysis (P0.05).A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P0.002), the endovascular treatment (P0.005), and the absence of neurological deterioration (P0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion.The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.

Purpose Flow diversion is 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 in a real life setting. 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 and anatomical results were independently evaluated. Results From July 2014 to July 2016, 103 patients with 103 aneurysms were included. Aneurysm location was supraclinoid ICA in 71 patients (68.9%), cavernous ICA in 15 patients (14.6%), ACA in 9 patients (8.7%), and MCA in 8 patients (7.8%). Seventy-one aneurysms (68.9%) were small ( Conclusion SAFE study shows very good safety and good mid-term efficacy of FRED and FRED Jr in aneurysm treatment. Disclosures L. Pierot: 2; C; Microvention. J. Gauvrit: None. J. Lejeune: None. A. Derelle: None. E. Chabert: None.

International audience; Background: High-field intraoperative MRI (IoMRI) is a useful tool to improve the extent of glioma resection (EOR).Objective: To compare the interest of 1.5T IoMRI in glioma surgery between enhancing and non-enhancing tumors, based on volumetric analysis.Methods: A prospective single-center study included consecutive adult patients undergoing glioma surgery with IoMRI. Volumetric evaluation was based on FLAIR hypersignal after gadolinium injection in non-enhancing tumors and T1 hypersignal after gadolinium injection in enhancing tumors. Endpoints comprised: residual tumor volume (RTV), EOR, workflow and clinical outcome on Karnofsky performance score (KPS).Results: Fifty-three surgeries were performed from July 2014 to January 2016. Thirty-four patients underwent one IoMRI, and 19 two IoMRIs. In non-enhancing tumors, intraoperative RTV on 1st IoMRI T2/FLAIR was higher than in enhancing tumors on T1 sequences (7.25cm3 vs. 0.74cm3, respectively; P=0.008), whereas the RTV on 2nd IoMRIs and final RTV were no longer significantly different. After IoMRI, 72% of patients underwent additional resection. In non-enhancing tumors, EOR increased from 77.3% on 1st IoMRI to 97.4% on last MRI (P

In the case of ventriculomegaly in the elderly, it is often difficult to differentiate between communicating chronic hydrocephalus (CCH) and brain atrophy. The aim of this study is to describe the MRI criteria of CCH, defined by a symptomatic patient with ventriculomegaly and that improved after shunt placement.Magnetic resonance imaging was prospectively evaluated in 90 patients with ventriculomegaly. Patients were classified into three groups: patients without clinical signs of CCH (control, n = 47), patients with CCH treated by shunt placement with clinical improvement (responders, n = 36), and patients with CCH treated using a shunt without clinical improvement (nonresponders, n = 7). MRI parameters of the two groups of interest (responders vs. controls) were compared.Compared with controls, Evans' index (p = 0.029), ventricular area (p0.01), and volume (p = 0.0001) were higher in the responders. In this group, the callosal angle was smaller (p ≤ 0.0001) and the aqueductal stroke volume (SVa) of CSF was higher (p ≤ 0.0001) than in controls. On the ROC curves, the optimal cut-off values for differentiating between responders and controls were a ventricular area33.5 cmOn suspicion of CCH, a large ventricular area, a small callosal angle, and an increased aqueductal stroke volume are important MRI arguments that can be associated with the clinical evaluation and dynamic testing of CSF to confirm the indication for a shunt.

16th International Conference on Intracranial Pressure and Neuromonitoring (ICP), Cambridge, MA, JUN 28-JUL 02, 2016; International audience; Objective: In the case of ventriculomegaly in the elderly, it is often difficult to differentiate between communicating chronic hydrocephalus (CCH) and brain atrophy. The aim of this study is to describe the MRI criteria of CCH, defined by a symptomatic patient with ventriculomegaly and that improved after shunt placement. Materials and methods: Magnetic resonance imaging was prospectively evaluated in 90 patients with ventriculomegaly. Patients were classified into three groups: patients without clinical signs of CCH (control, n = 47), patients with CCH treated by shunt placement with clinical improvement (responders, n = 36), and patients with CCH treated using a shunt without clinical improvement (nonresponders, n = 7). MRI parameters of the two groups of interest (responders vs. controls) were compared. Results: Compared with controls, Evans' index (p = 0.029), ventricular area (p < 0.01), and volume (p = 0.0001) were higher in the responders. In this group, the callosal angle was smaller (p = 0.0001) and the aqueductal stroke volume (SVa) of CSF was higher (p = 0.0001) than in controls. On the ROC curves, the optimal cut-off values for differentiating between responders and controls were a ventricular area >33.5 cm(2), a callosal angle 136.5 mu L/R-R. In multivariate analysis, responders remained associated with SVa and callosal angle, with a c-statistic of 0.90 (95%CI, 0.83-0.98). Conclusion: On suspicion of CCH, a large ventricular area, a small callosal angle, and an increased aqueductal stroke volume are important MRI arguments that can be associated with the clinical evaluation and dynamic testing of CSF to confirm the indication for a shunt.

Background Multiple myeloma spinal involvement can lead to bone fractures and neurologic impairment that can severely alter quality of life. The role of surgery is controversial, given its high morbidity, and the lack of evidence. We hereby aim to evaluate efficacy and safety of surgery in the management of symptomatic spinal lesions in patients with multiple myeloma. Methods We included all patients operated on for a myeloma-related spinal lesion in our institution between 2007 and 2015. Demographic, clinical, and surgical data were collected as well as hematologic profiles. We retrospectively assessed the surgical success of the procedures, if at 3 months the patient fulfilled the following 4 criteria: pain relief, ability to walk, spinal stability, and no relevant morbidity. Results Thirty-six men and 19 women, with a median age of 62 years, were included. Seventeen patients underwent an emergency intervention, whereas 38 patients underwent elective surgery. At 3 months, 88.2% and 96.1%, respectively, of patients experienced pain relief and were able to walk. Spinal stability was considered satisfactory for 94.1% of patients. We reported 8 major complications in 8 patients. Altogether, 34 patients (61.8%) fulfilled all criteria for surgical success. An International Staging System score of 1 and the absence of previous chemotherapy were significantly associated with surgical success. Conclusions Management of myeloma-related spine lesions requires a multidisciplinary approach. Surgery rapidly provides both decompression and stabilization. Using a strict patient-specific evaluation, we reported rewarding functional results, with acceptable morbidity. Surgery for multiple myeloma vertebral lesions seems to be a valuable option for carefully selected patients.

Resume L’hemorragie sous-arachnoidienne (HSA) non traumatique presente une incidence annuelle de 9 pour 100 000 habitants. Il s’agit d’un evenement rare mais grave, avec une mortalite estimee a 40 % dans les 48 premieres heures. Dans 85 % des cas, elle est liee a la rupture d’un anevrisme intracrânien. A la phase precoce, dans les 24 premieres heures, le scanner cerebral associe a un angioscanner du polygone de Willis est l’examen recommande pour le diagnostic positif d’HSA et pour le diagnostic etiologique, a la recherche d’un anevrisme intracrânien. L’IRM cerebrale peut etre proposee si l’etat clinique du patient le permet. La sequence FLAIR est plus sensible que le scanner pour demontrer l’hemorragie sous-arachnoidienne. Elle presente une sensibilite plus elevee pour le diagnostic etiologique des hemorragies sulcales. Une ponction lombaire doit etre realisee si ces examens sont normaux et la suspicion clinique elevee.

High-grade gliomas represent a widely heterogeneous group of tumors, the most frequent of which is glioblastoma multiforme. Its annual incidence has risen over the last decades, particularly amongst elderly people. The actual standards of care allow for a 15-month median survival rate for WHO grade IV gliomas. As recurrence occurs in more than 85% of patients at the surgical margins, the initial resection extent is a cornerstone of disease control. Fluorescence guided resection (FGR) aims at increasing complete resections and, thus, local control. This technique uses 5-aminolevulinic acid (5-ALA), a natural intermediate substance in the heme-porphyrin biosynthesis pathway, and a protoporphyrin IX (PpIX) precursor. PpIX is fluorescent under blue light exposure. Recent studies reported a significant increase in complete resections using FGR, which were associated with prolonged progression free survival, fewer reinterventions, and delayed neurological deterioration. Here, we depict the principles of this surgical technique, its actual outcomes, and future developments.

We report an additional case of a ruptured basilar trunk perforator aneurysm, for which an endovascular treatment was initially planned, but aborted due to the spontaneous regression of the aneurysm. Thus, a conservative management consisting on a close follow-up was decided that confirmed the favorable radiological outcome. Spontaneous regression of such aneurysm should be well-known by neurosurgeons and neuroradiologists in order to prevent the potential iatrogenic effects of the related treatment modalities.