Christian Raftopoulos

Prospective analysis by computed tomography and long-term outcome of 23 adult patients with chronic idiopathic hydrocephalus

From 1986 to 1989, 23 adult patients (average age, 70 yr) with idiopathic chronic hydrocephalus received shunts with medium-pressure Pudenz-Schulte valves for suspected normal pressure hydrocephalus. Prospective clinical and computed tomographic monitoring was continued for at least 5 years. We observed the formation of a hypodense subdural collection in each of 10 patients (43%). Those collections that occurred early, i.e., within the first 9 postoperative days, evolved differently from those that occurred late; only early hypodense collections became subdural hematomas (three cases). In one case, a subdural hematoma was already present 9 days after surgery, so that four patients (17%) presented a subdural hematoma within the first 2 postoperative months. Our long-term follow-up revealed three patients (13%) with hypodense subdural collections, which appeared more than 2 months after surgery. None of the collection evolved into a subdural hematoma. Thirteen patients (57%) died between 9 and 68 months (average, 20 mo) after surgery, most often of an ischemic stroke. During the 1st postoperative year, there was improvement in the condition of 22 patients (96%) who had received a ventricular shunt; 21 of these patients (91%) remained improved until death or for at least 5 years.

Factors predicting relapse of nonfunctioning pituitary macroadenomas after neurosurgery: a study of 142 patients

CONTEXT Adequate postoperative management of nonfunctioning pituitary macroadenomas (NFMAs) remains a challenge for the clinician. OBJECTIVE To identify predictive factors of NFMA relapse after initial surgery. PATIENTS AND METHODS This retrospective study included 142 patients operated for an NFMA in two academic centers (CHU Bicêtre in France and UCL St Luc in Belgium). The rate of tumor relapse, defined as recurrence after total surgical resection or regrowth of a surgical remnant, as well as predictive factors was analyzed. RESULTS During a mean follow-up of 6.9 years, 10 out of 42 patients (24%) who had complete macroscopic resection of their tumor had recurrence, and 47 out of 100 patients (47%) with a surgical remnant experienced regrowth. The overall relapse rates were 25, 43, and 61% at 5, 10, and 15 years respectively. Invasion of the cavernous sinus, absence of immediate radiotherapy after the first neurosurgery, and immunohistochemical features of the tumor (mainly positive immunostaining for several hormones or for hormones other than gonadotropins) were independent risk factors for tumor relapse. Incomplete excision was only associated with relapse when invasion was withdrawn from the analysis, suggesting that these two factors are closely linked. CONCLUSION NFMAs frequently recur/regrow after initial surgery, particularly when tumor is invasive, precluding complete removal. Immunohistochemical features such as positive immunostaining for several hormones or for hormones other than gonadotropins could help to predict undesirable outcomes.

Propofol infusion syndrome associated with short-term large-dose infusion during surgical anesthesia in an adult

In this case report we describe a case of propofol infusion syndrome in an adult after a short-term infusion of large-dose propofol during a neurosurgical procedure. Large-dose propofol (9 mg.kg(-1).h(-1)) was given for only 3 h during surgery and was followed by a small-dose infusion (2.3 mg.kg(-1).h(-1)) for 20 h postoperatively. The patient had also received large doses of methylprednisolone. He developed a marked lactic acidosis with mild biological signs of renal impairment and rhabdomyolysis but no cardiocirculatory failure. There were no other evident causes of lactic acidosis as documented by laboratory data. We believe this is the first report of reversible lactic acidosis associated with a short duration of large-dose propofol anesthesia.

Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms.

OBJECTIVERecent reports in the literature have described a significant discrepancy in adverse outcomes between coil embolization (CE; 10%) and surgical clipping (SC; 25%) for the management of unruptured intracranial aneurysms (UIA). This discrepancy led us to analyze our experience. METHODSIn 1996, we designed a prospective study of patients with UIA in which CE was considered the treatment of choice and was performed if the interventional neuroradiologists deemed the aneurysm’s fundus-to-neck ratio accessible for CE. SC was performed only if complete CE was unlikely to be achieved or in patients in whom CE already had failed. RESULTSCE was performed in 38 patients with at least one UIA (41 UIAs, 83% in the anterior circulation). SC was performed in 39 patients with at least one UIA unsuitable for CE (59 UIAs, including 6 after failed CE, 96.5% in the anterior circulation). For CE, the total obliteration rate was 56.1%, the subtotal was 14.6%, and CE failed in 29.3%. There were transient complications in 10% of the cases and permanent complications in 7.5%. Of the 12 failed CE procedures, 7 (58%) were performed for middle cerebral artery aneurysms. For SC, the total obliteration rate was 93.2%, the subtotal was 1.7%, and SC failed (wrapping) in 5.1%. There were transient complications in 16.3% of the patients and permanent complications in 1.7%. The success rate for CE was similar to that for SC only when CE was used for aneurysms with a fundus-to-neck ratio of at least 2.5. CONCLUSIONSC can produce better results than CE in patients with UIA of the anterior circulation. CE as a first-line treatment should be reserved for patients with UIAs with a fundus-to-neck ratio of 2.5 or greater.

NEUROSERPIN MUTATION CAUSES ELECTRICAL STATUS EPILEPTICUS OF SLOW-WAVE SLEEP

Conformational diseases result from cellular dysfunctions induced by aberrant aggregation of proteins. They are caused either by excess of secretion of a normal protein, or more frequently, by mutation in a protein, as in prion diseases. Recently, one of them, familial encephalopathy with neuroserpin inclusion bodies (FENIB, OMIM #604218), an autosomal dominant dementia, was recognized. It is caused by mutations in PI12 (proteinase inhibitor 12, SERPINI1 or neuroserpin, OMIM #602445), a neuron-specific serine proteinase inhibitor (serpin).1,2 Neuroserpin was first identified in culture medium of chicken axons, then in human neurons.3 It plays roles in synapses and vessel permeability, and is known to be associated with learning, memory, and behavior. It belongs to the serpin super-family, members of which display at least 30% amino acid sequence homology with their archetype, alpha-1-antitrypsin. Mutated neuroserpin progressively polymerizes in neuronal endoplasmic reticulum, inducing cognitive impairment and sometimes myoclonic epilepsy. Neuropathology is characterized by neuronal intra-cytoplasmic rounded inclusions, homogeneously pale to intensely pink with eosin, and PAS positive after diastase treatment (Collins bodies). Four different mutations have been described in six families affected by FENIB: two in exon 2 (S49P and S52R) and two in exon 9 (H338R and G392E). Known mutations in serpins are localized in the mobile regions of the molecule (exon 2 and 9). They result in proteins …

Diffusion-weighted MRI postoperative assessment of an epidermoid tumour in the cerebellopontine angle.

Abstract Cerebellopontine angle epidermoid tumour generally has a typical appearance with conventional MRI sequences. The lesion is irregular in shape and gives slightly higher signal than cerebrospinal fluid on T1- and T2-weighted images, with a characteristic marbled inner pattern on T1-weighted images. Diffusion-weighted imaging (DWI) can be useful for the diagnosis of an atypical epidermoid tumour. Our case report illustrates the usefulness of DWI for postoperative assessment of residual foci of tumour. The specific appearance of an epidermoid tumour is illustrated, with emphasis on apparent diffusion coefficient (ADC) measurements.

Outcomes of transsphenoidal surgery in prolactinomas: improvement of hormonal control in dopamine agonist-resistant patients

CONTEXT Few studies have recently re-examined the efficacy of neurosurgery in prolactinoma patients operated for various indications. OBJECTIVE To analyze outcomes of patients with a prolactinoma treated by transsphenoidal surgery, to identify factors associated with remission and relapse, and to evaluate if surgical debulking allows for better hormonal control in patients with preoperative resistance to dopamine agonists (DAs). PATIENTS AND METHODS This was a retrospective review of patients with a benign prolactinoma followed preoperatively and postoperatively in our department and treated by transsphenoidal surgery (n=63; 45 women; mean age: 31 ± 14 years). RESULTS Postoperative remission was obtained in 63% of microprolactinomas, 60% of noninvasive macroprolactinomas, and none of the invasive macroprolactinomas. Better remission rate was independently predicted by lower diagnostic prolactin (PRL) levels and by the lack of abnormal postoperative residual tissue (P<0.05). A recurrence of hyperprolactinemia was observed in 34% of patients after a median follow-up period of 36 (7-164) months. In patients with preoperative DA resistance treated again after surgery, there was a significant reduction in PRL levels postoperatively (26 (6-687) ng/ml) vs preoperatively (70 (22-1514) ng/ml; P<0.01) under a lower DA dose, and about half of the patients had PRL normalization. CONCLUSIONS Recurrence of hyperprolactinemia is observed in one-third of prolactinoma patients after surgical remission and may occur as late as 13 years after surgery. Resistance to DA can be considered as a good surgical indication, as partial tumor resection allows for better hormonal control with a lower dose of DAs.

STEREOTACTIC VENTRICULOPERITONEAL SHUNTING FOR REFRACTORY IDIOPATHIC INTRACRANIAL HYPERTENSION

OBJECTIVERecent reports have shown promising short- to medium-term results in patients with refractory idiopathic intracranial hypertension (IIH) treated using the stereotactic ventriculoperitoneal shunting (SVPS) technique. However, the long-term clinical efficacy of this technique remains questionable. This report provides the long-term results of SVPS in treating refractory IIH patients. METHODSWe reviewed the medical charts of nine consecutive patients (mean age, 26.4 yr; range, 4–63 yr) treated using either a frame-based or frameless SVPS technique for IIH. RESULTSThe mean postoperative follow-up period was 44.3 months (range, 6–110 mo). Before shunting procedures were performed, each patient presented with intractable headache, and five patients (55.6%) had mild to moderate visual deficits. The last follow-up assessment showed that after shunting was performed, eight patients (89%) were headache-free. Only one patient had recurrent headache; however, this patients pain was much less frequent and severe than before the shunting procedure was completed and was concomitant with recent weight increase. Visual deficits were resolved in three patients and remained stable in two who already had optic nerve atrophy before shunting was completed. Twelve SVPS procedures were performed on our patients. Nine shunt revisions were needed in six patients because of infection (n = 5, including two revisions in one patient), valve dysfunction (n = 2), distal obstruction (n = 1), and ventricular catheter malpositioning (n = 1). No patient had proximal catheter obstruction. CONCLUSIONGiven the favorable long-term outcome of the SVPS technique for refractory IIH, we are encouraged to apply this procedure on our patients. More invasive approaches should be reserved for patients who have SVPS failure.

Intraoperative magnetic resonance imaging at 3-T using a dual independent operating room-magnetic resonance imaging suite: development, feasibility, safety, and preliminary experience.

OBJECTIVEA twin neurosurgical magnetic resonance imaging (MRI) suite with 3-T intraoperative MRI (iMRI) was developed to be available to neurosurgeons for iMRI and for independent use by radiologists. METHODSThe suite was designed with one area dedicated to neurosurgery and the other to performing MRI under surgical conditions (sterility and anesthesia). The operating table is motorized, enabling transfer of the patient into the MRI system. These two areas can function independently, allowing the MRI area to be used for nonsurgical cases. We report the findings from the first 21 patients to undergo scheduled neurosurgery with iMRI in this suite (average age, 51 ± 24 yr; intracranial tumor, 18 patients; epilepsy surgery, 3 patients). RESULTSTwenty-six iMRI examinations were performed, 3 immediately before surgical incision, 9 during surgery (operative field partially closed), and 14 immediately postsurgery (operative field fully closed but patient still anesthetized and draped). Minor technical dysfunctions prolonged 10 iMRI procedures; however, no serious iMRI-related incidents occurred. Twenty-three iMRI examinations took an average of 78 ± 20 minutes to perform. In three patients, iMRI led to further tumor resection because removable residual tumor was identified. Complete tumor resection was achieved in 15 of the 18 cases. CONCLUSIONThe layout of the new complex allows open access to the 3-T iMRI system except when it is in use under surgical conditions. Three patients benefited from the iMRI examination to achieve total resection. No permanent complications were observed. Therefore, the 3-T iMRI is feasible and appears to be a safe tool for intraoperative surgical planning and assessment.

Hydrosyringomyelia-Chiari I complex. Prospective evaluation of a modified foramen magnum decompression procedure: preliminary results.

A modified foramen magnum decompression procedure, designed to respect the subarachnoid spaces as much as possible, was prospectively evaluated in eight consecutive patients with a progressive clinical syndrome related to hydrosyringomyelia-Chiari I complex. This evaluation included quantitative clinical and magnetic resonance follow-up of at least 1 year in the first six patients and 6 months for the last two. Magnetic resonance scans at 6 months or more confirmed a persistent reduction of the hydrosyringomyelic cavity in all cases, which was associated with obvious subjective improvement. All patients have maintained this improvement. The operative technique and methods of clinical and radiological follow-up are discussed.