Abad Cherif El Asri

Cavernous hemangioma of the skull: 3 case reports

BACKGROUND Intraosseous cavernous hemangiomas of the bone are uncommon tumors, accounting for 0.7% to 1% of all bone neoplasms. The vertebral column is most often affected, followed by the skull. Calvarial cavernous hemangioma is rare, comprising about 0.2% of all benign neoplasms of the skull. CASES REPORTS We describe 3 patients with calvarial hemangiomas that were localized frontally (2 cases) and parietally. The diameter ranged from 2 to 3 cm. They presented with slowly growing mass, hard to pressure, with freely mobile skin above the cavernoma sites. Cranial CT scan showed osteolytic lesion with erosion of the tabula externa. Magnetic resonance imaging performed in one patient showed hypointense lesion on T1-weighted image and hyperintense on T2-weighted image. Resection and postoperative course were uneventful. Pathological examination revealed a cavernous hemangioma of the diploe. CONCLUSION Skull cavernous hemangiomas are rare benign tumors. The preferred treatment is complete tumor removal with normal bony margins. Sometimes, the classic radiographic appearances are not evident. Consequently, the diagnosis is most often made during surgical resection.

Posterior epidural migration of lumbar disk fragments: report of two cases and review of the literature

BACKGROUND Posterior epidural migration of an extruded disk fragment is rare, and posterior migration of the free fragments causing cauda equina syndrome is exceptionally rare. The disk fragment must transgress through numerous anatomical restraints including the nerve roots in such cases. METHODS Two cases of migration of the sequestrated disk into the posterior epidural space are presented. The first patient complained, over the course of 1 month, of paresthesias and weakness of the lower limbs, with urinary retention. However, in the other case, there was steppage gait and strength score of 3/5 on dorsiflexion of left foot, without bladder or bowel disturbance. RESULTS Lumbar CT scan with sagittal reconstruction showed a posterior epidural mass, which was isodense to the disk. The preoperative differential diagnosis included epidural abscess, hematoma, and neoplasm. An urgent decompressive lumbar laminectomy was performed. At surgery, the lesion proved to be a massive extruded disk fragment. CONCLUSION Diagnosis of posterior epidural migration of the sequestrated disks may be difficult. It may present with subtle clinical features. Magnetic resonance images may mimic those of other more common posterior epidural lesions. Early surgery should be the first choice to prevent severe neurologic deficits.

Factors Influencing the Prognosis in Intracranial Dural Arteriovenous Fistulas with Perimedullary Drainage

OBJECTIVE Intracranial dural arteriovenous fistulas with perimedullary venous drainage (IDAVFPD) are classified as type V dural arteriovenous fistulas. Publications are limited to single case reports and small case series. We conducted a systematic review of the literature for patients with IDAVFPD. The aim of this study is to identify the predictive factors of poor prognosis in patients with IDAVFPD. METHODS We present the case of a 48-year-old man who underwent surgical interruption of IDAVFPD. A complete MEDLINE search was then undertaken for all articles reporting outcomes data for IDAVFPD. According to the results we have divided the patient population into two groups: I, those patients who showed improvement after treatment, and II: those patients who did not show improvement. We conducted a comparative statistical analysis of the epidemiologic, clinical, radiologic, and therapeutic parameters between the two groups. RESULTS A total of 37 articles comprising with 58 cases were included for analysis with an average follow-up of 12 months. There were 36 patients in group I and 22 in group II. The average age was 57.8 years in group I and 54.3 years in group II (P=0.32). Onset of symptoms was acute or subacute in 57% of patients in group I, and in 50% of patients in group II (P=0.62). Bulbar signs were present in 28% of cases in group I and in 36% of cases in group II (P=0.49). Hyperintensity of the brainstem on T2-weighted sequence magnetic resonance imaging was more common in patients in group II (78%) compared with patients in group I (45%) (P=0.012). Patients who underwent surgical procedure have shown good outcomes compared to patients treated with endovascular approach (P=0.039). CONCLUSIONS The poor outcomes were correlated to the presence of brainstem signal abnormalities on magnetic resonance imaging, whereas the prognosis does not depend on age, sex, clinical presentation, or anatomic characteristics of the fistula.

Chondrosarcome mésenchymateux sphéno-orbitaire : À propos d'un cas

Mesenchymal chondrosarcoma is a highly malignant and extremely rare tumor of the orbit: only 18 cases have been reported to date. We report a case of spheno-orbital mesenchymal chondrosarcoma in a 36-year-old woman presented with a 4-month history of progressive left exophthalmia and temporal mass. A CT-scan of the orbit and MRI showed a spheno-orbital mass, with temporal fossa extension, fed by the internal maxillary artery visible on cerebral angiography. Surgery via a transcranial, left frontotemporozygomatic approach after selective embolization enabled subtotal removal. Definitive histologic examination revealed mesenchymal chondrosarcoma. Postoperatively, exophthalmia spectacularly regressed. We report our clinical findings and present a review of the literature.Le chondrosarcome mesenchymateux spheno-orbitaire est une tumeur extremement rare a haute malignite. Seuls 18 cas ont ete rapportes a ce jour. Nous rapportons le cas d’un chondrosarcome mesenchymateux spheno-orbitaire chez une patiente âgee de 36 ans ayant presente une exophtalmie gauche avec une tumefaction temporale gauche evoluant depuis 4 mois. La tomodensitometrie de l’orbite et l’IRM encephalique montraient un processus spheno-orbitaire avec une extension vers la fosse temporale. Ce processus etait alimente essentiellement par l’artere maxillaire interne a l’arteriographie cerebrale. Un abord chirurgical par voie fronto-temporo-zygomatique gauche avec une depose du rebord orbitaire lateral apres embolisation selective de la tumeur permit une exerese subtotale de la tumeur. L’examen histologique conclut a un chondrosarcome mesenchymateux. L’evolution fut favorable avec une reduction spectaculaire de l’exophtalmie gauche.

Treatment of postoperative cerebellar mutism with fluoxetine

Dear Editor: This 13-year-old boy presented with a 4-month history of progressive headaches, vertigo, and blurred vision. At the initial presentation, he showed minor cerebellar ataxia with bilateral papillary edema. There were no further neurological deficits. The cranial MRI scan revealed a vermian fourth ventricular space-occupying lesion consistent with a medulloblastoma causing obstructive hydrocephalus. He had a right ventriculoperitoneal shunt with a medium-pressure valve inserted. The postoperative course was uneventful. One month later, a suboccipital median craniectomy approach was performed (in prone position) to remove the tumor. The histological examination revealed a medulloblastoma. The patient was asymptomatic for the first 2 days. However, on the third postoperative day, he developed significant reduced spontaneous speech and voluntary activity, concentration deficits, and drooling. These symptoms were in agreement with the diagnosis of cerebellar mutism. Laboratory examination revealed no abnormalities related to these symptoms. The postoperative CT scan demonstrated some edema without residual tumor, infarction, or bleeding in the primary site. Despite administration of corticosteroids with speech therapy, the symptoms worsened gradually. On the third postoperative week, the patient was started on 20 mg of fluoxetine at bedtime (for 9 weeks). Three to 4 days later, the patient’s mutism slowly resolved and disappeared completely about 4 weeks after starting fluoxetine, although some ataxia persisted in a mild form. There is no specific treatment that facilitated recovery from cerebellar mutism, although speech therapy, corticosteroids, and dopamine agonist bromocriptine and zolpidem are sporadically reported in the literature [1, 2, 5, 6]. On the other hand, fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class that is approved for the treatment of major depression (including pediatric depression), obsessivecompulsive disorder (in both adult and pediatric populations), bulimia nervosa, and panic disorder [7]. Since 1994, there have been a number of favorable reports on the use of fluoxetine in akinetic mutism [3, 4]. But to our knowledge, this drug has never been used on postoperative cerebellar mutism. The administration of fluoxetine in our patient coincided with improvement in symptoms, after a period of worsening before administration of this drug. The mechanism by which fluoxetine might ameliorate speech inhibition is unknown. Our children had no evidence of depressive disorders. So, as suggested by Dummit et al., the positive treatment effects cannot be attributed to an antidepressant effect of fluoxetine [4]. On the basis of our case report, we suggest that fluoxetine therapy may be efficacious in patients who manifest mutism after posterior fossa surgery.

Arachnoiditis ossificans of the cauda equina

Abstract A case of post-traumatic arachnoiditis ossificans of the cauda equina is reported. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equine compression. The pathophysiology and therapeutic strategy of this rare entity are still controversial.

Multiple lytic lesions of the spine: a rare diagnosis of eosinophilic granuloma in an adult: a case report

Eosinophilic granuloma (EG) is a rare benign osteolytic lesion observed rarely in adults, with only some 18 cases of spinal location reported in the literature. We present an unusual variant of EG in a 23-year-old man with radiological features of multiple spinal lytic lesions which was evocated of metastatic processes. A surgically transpedicular biopsy of the thoracic collapsed vertebrae with posterior stabilization was made. Histological examination of the tissue showed features of eosinophilic granuloma. The clinical and radiological findings of EG present dilemmas of both diagnosis and treatment. The etiology is unclear and the therapeutic approach is still controversial.

Hypocalcemic seizure in adult: rare cause of lumbar fracture.

Bone fractures in epileptic patients may be associated with rauma either induced directly by a seizure or resulting from a fall or ther accident resulting from the seizure [1]. Muscular contractions enerated during a seizure can lead to a variety of musculoskeletal njuries as fractures and dislocations of the shoulder, femur, and cetabulum [2]. A seizure-induced fracture of the spine is a rare linical entity with only few reported cases in the medical literature o date [1,3]. Although rare, it is extremely crucial to recognize this mergent fracture because it predisposes the patient to irreversible eurological injury [4].

Dynamic CT scan of the craniovertebral junction: a role in the management of os odontoideum

Os odontoideum is an uncommon abnormality of the cranio-vertebral junction (CVJ) that exists as a separate ossicle apart from a hypoplastic dens. Its genesis and natural history have been debated, and its proper treatment remains uncertain. A 48-year-old woman complained of persistent upper neck pain and paraesthesia of her left side. Magnetic resonance imaging of the CVJ demonstrated an os odontoideum. Dynamic computed tomography scan of the CVJ showed a reduction of the space available for the spinal cord to 50% from extended to flexed position. The patient underwent posterior spinal fusion of C1-C2 using a sublaminar titanium hook and rods fixed in moderate extension. We discuss the usefulness of the dynamic computed tomography (CT) scan in the evaluation of atlantoaxial motion and the management of this pathology.

Rare Cause of Pituitary Insufficiency: Chronic Hypophyseal Abscess

A previously healthy 61-year-old man was admitted to our department with an 18-month history of progressive headache associated with a visual loss and physical asthenia. No fever was obvious, nor were there signs of infection. Clinical examination revealed bitemporal hemianopsia without neurological deficit. Cerebral magnetic resonance imaging (MRI) showed a mass of the sellar and suprasellar area measuring 2.8 ¥ 2.1 ¥ 1.9 cm with a peripheral enhancement and compressing the optic chiasm. The process was heterogeneous with a central hyperintense area on T1and T2-weighted images (Figure A). No mucoperiosteal thickening was noted in the sphenoid sinus. Laboratory examination revealed a panhypopituitarism with deficiencies of steroid, thyroid, gonadal, and somatotropic axes. The patient received hydrocortisone and thyroxine replacement therapy. Hypophyseal MRI, performed 8 months later, demonstrated no change in the size and the appearance of the pituitary process. The patient was operated on through a transsphenoidal approach revealing after the removal of the floor of the sella, a thickened dura mater under tension. A dural incision resulted in an egress of a significant amount of a whitish-yellow purulent material under pressure (Figure B). After a complete evacuation and irrigation, a normal pituitary gland parenchyma was observed. Pathological examination of the capsule was suggestive of a wall of an abscess with a mixture of inflammatory cells including neutrophils and lymphocytes. There was also no evidence of pituitary adenoma. A broad-spectrum antibiotic therapy (third-generation cephalosporin) was initiated during surgery and continued 3 weeks postoperatively. The culture of the sellar contents revealed no microorganism, and the staining for acid-fast bacilli were negative. The patient remained asymptomatic at the 6-month control, and no sign of recurrence was seen on the follow-up MRI. The patient was, however, still continuing the hormonal replacement therapy.