D. Le Gars

Fracture de l'odontoïde chez le sujet de plus de 70 ans: morbidité, handicap et place du traitement chirurgical. À propos d'une série de 27 patients

BACKGROUND AND PURPOSE Odontoid process fractures of the axis are frequent in elderly patients. However, the impact in terms of handicap and morbidity in this particular population are unknown. The role of surgical treatment remains controversial. METHODS We present a retrospective series of patients aged 70 years or older with odontoid fractures treated in our department between 1998 and 2006. Two cohorts were defined (surgery versus conservative) and compared. Morbidity, handicap, and radiographic fusion were analyzed. RESULTS Twenty-seven patients were treated. The mean age was 80.67 years. Five patients died early during hospitalization. Fractures were type II in 66.7% of the cases and type III in 33.3%. Orthopedic treatment was chosen in 44.4% of the cases. A non-union at the fracture site was found in 33% of the cases and morbidity in 41.7% of the cases was found after a 1-year follow-up. Surgery was performed in 40.7% of the cases. There was 18% non-union and no morbidity after 1-year of follow-up. Morbidity was statistically lower in the surgery group (p=0.037), particularly in cases of type II fracture (p=0.0063); no statistically significant difference was found for non-union at the fracture site (p=0.64) except for type II fractures (p=0.028). CONCLUSIONS Odontoid fractures in the elderly are a very frequent problem. Immediate mortality is still high but appears correlated to associated lesions. Todays treatments must preserve autonomy for these patients. For elderly patients, the treatment must be chosen in relation to the fracture analysis. In our opinion, surgical management is the treatment of choice for unstable fractures (type II). Conservative management is indicated for stable fractures.

Anévrisme termino-vertébral sur fenestration de l’artère basilaire

Resume Nous rapportons un cas d’anevrisme sacculaire sur une fenestration de l’artere basilaire, survenu chez une femme de 47 ans hospitalisee pour hemorragie meningee peri-mesencephalique. Les anomalies de la media de la tunique arterielle au niveau des bifurcations expliquent l’association entre les anevrismes vertebro-basilaires et les fenestrations de l’artere basilaire. L’arteriographie cerebrale a mis en evidence un anevrisme en situation termino-vertebrale a orientation ventrale. Le traitement a consiste en une embolisation. Ce cas clinique nous permet de revoir la morphogenese de l’artere basilaire, les anomalies parietales interessant les fenestrations, et de discuter les deux prises en charges therapeutiques envisageables.

Melanocytic schwannomas. Report of three cases.

OBJECTIVE AND IMPORTANCE Melanocytic tumors are rare. The literature reports less than 40 cases and suggests that they behave aggressively, can recur and progress to malignancy. CLINICAL PRESENTATION We report three patients with melanocytic schwannomas located in the cervical spine, in the thoracic spine and in the lumbar spine. In the two first cases, these symptoms were a spinal cord compression whereas the last patient presented symptoms of cruralgy. IMAGING MRI always showed an extramedullary intradural tumor arising from the root destroying the intervertebral foramen. INTERVENTION The patients underwent laminectomy and the excision was complete. Immunohistochemical stains were positive to S100 and HMB45 antibodies. The evolution was unfavourable for two patients with local recurrence and leptomeningeal metastasis. CONCLUSION These three cases demonstrate that melanocytic schwannomas have a guarded prognosis because of their metastatic potential, especially for young people.

Imagerie de l’hydrodynamique cérébrale dans les hémorragies méningées

Resume Description et objectifs de l’etude Les oscillations de liquide cerebro-spinal (LCS) sont synchronisees avec le flux sanguin cerebral et sont impliquees dans le controle de la variation de la pression intracrânienne. Le but de cette etude est d’explorer les alterations possibles de la dynamique des flux de LCS lors des hemorragies meningees (HM). Methodes Onze patients avec HM confirmee au scanner cerebral ont beneficie d’une IRM qui comprenait des sequences morphologiques et des sequences dynamiques de flux pour la quantification des flux de LCS et des flux arteriels. Les oscillations de LCS etaient enregistrees au niveau de l’aqueduc du mesencephale et des espaces sous-arachnoidiens en C2-C3 (ESA), ou une sequence vasculaire etait egalement realisee afin de quantifier les flux arteriels. Les resultats obtenus etaient compares a ceux de 44 sujets temoins, et une difference de plus de deux deviations standards permettait de definir un flux de LCS hypo- ou hyperdynamique. La dilatation du systeme ventriculaire etait appreciee par deux radiologues et un neurochirurgien. Resultats Un patient a ete exclu pour defaut de mesure. L’etude du LCS ventriculaire montre que seulement 4 patients presentaient un flux normal, 1 patient un flux hypodynamique et 5 patients des flux hyperdynamiques. En ce qui concerne le LCS extra-ventriculaire, 5 patients presentaient un flux normal et 5 patients un flux hyperdynamique. Les 2 patients qui ont developpe une dilatation ventriculaire avaient tous les deux des flux ventriculaires hyperdynamiques avec un flux de LCS cervical normal. Conclusion Nous avons montre qu’il existe des alterations de la dynamique des flux de LCS lors des HM, ce qui laisse supposer que le saignement entraine une augmentation du volume intracrânien et une reduction de la compliance cerebrale avec une augmentation de la pression intracrânienne. L’augmentation des oscillations intra-ventriculaires pourrait favoriser la dilatation ventriculaire.

Non-traumatic pseudocyst of Glisson capsule complicating a ventriculoperitoneal shunt

BACKGROUND Cerebrospinal fluid pseudocysts in the peritoneal cavity following ventriculoperitoneal shunt are relatively uncommon. In these complications, perforation of solid organs is unusual. CASE DESCRIPTION A case of subcapsular hepatic pseudocyst is described. A 48-year-old man treated by ventriculoperitoneal shunt presented with abdominal pain. Laboratory examinations revealed hepatic cytolysis. The CT-scan of the abdomen demonstrated a small ovoid non-enhanced cystic collection in the subcapsular area of hepatic segment V. Percutaneous hepatic fine-needle aspiration of the cyst guided by abdominal ultrasonography showed no abnormal findings. Peritoneal reimplantation at a different site was performed. The clinicopathological features of this entity are described and treatments are discussed. CONCLUSION Reinsertion of the catheter at a different abdominal site is effective in non-infections cases. In contrast, a temporary external drainage with adequate antibiotic treatment followed by shunt reinsertion is necessary to treat a documented infection of CSF collections.

Les ruptures anévrismales intracrâniennes per-embolisation

Resume Objectif Nous rapportons notre experience sur la rupture d’anevrismes intracrâniens lors de l’embolisation. La frequence, les etiologies, la prise en charge therapeutique et le devenir des patients sont etudies. Methodes Ce travail retrospectif a permis de retrouver 6 cas de rupture per-embolisation sur 314 anevrismes cerebraux rompus embolises. Les donnees cliniques des patients, leur prise en charge et leur devenir sont exposes et compares a une revue de la litterature. Resultats Six patients ont presente une rupture per-embolisation de facon sporadique. Le taux de prevalence etait de 1,9 %. Sur ces 6 patients, il y avait 4 femmes et 2 hommes. L’âge moyen etait de 68 ans (extremes : 43-74 ans). 4 anevrismes etaient localises sur la circulation anterieure et 2 sur la circulation posterieure. La rupture est survenue dans un cas par perforation du micro-catheter, et lors de la deposition des coils dans les 5 autres cas. Il s’agissait du premier coil pour trois patients et du troisieme et dernier coil dans 2 cas. Des modifications des parametres dynamiques etaient enregistrees 1 fois sur 6. Lors du suivi, le Glasgow Outcome Scale etait de 1 pour 3 patients et 3 pour un patient. Le taux de mortalite etait de 33 % et celui de morbidite de 16,7 %. Conclusion La perforation anevrismale lors de l’embolisation reste une complication rare (1,8 a 4,4 %). Des qu’elle est reconnue, l’embolisation doit dans la mesure du possible etre completee rapidement et l’heparinotherapie doit etre levee.

Should we fear cement leakage during kyphoplasty in percutaneous traumatic spine surgery? A single experience with 76 consecutive cases

OBJECTIVE Although kyphoplasty is widely used to repair osteoporotic and pathologic vertebral fractures, balloon kyphoplasty and vertebral body stenting are new treatment options in cases of traumatic spinal injury. To our knowledge, there are no literature data on the incidence of cement leakage whereas these two percutaneous techniques are commonly used to repair non-pathologic fractures. The aim of this study was to evaluate and compare the clinical characteristics and the incidence of cement leakage associated with balloon kyphoplasty and vertebral body stenting in the percutaneous treatment of traumatic spinal injury. METHODS A series of 76 consecutive kyphoplasties (50 with vertebral body stenting and 26 balloon kyphoplasties) were retrospectively reviewed. Preoperative and postoperative computed tomography scans were analyzed in order to detect cement leakage and grade it as minor, moderate or major. RESULTS The overall leakage rate was 50%. None of the leakages gave rise to clinical symptoms. Although balloon kyphoplasty and vertebral body stenting did not differ in terms of the leakage rate, the latter technique was associated with a lower leakage volume. The Magerl type, fracture level and use of concomitant osteosynthesis did not appear to significantly influence the leakage rate. CONCLUSION Vertebral body stenting can reduce the amount of cement leakage due to a better cohesion of the bone fragments after kyphosis correction and maintenance.

Tension pneumocephalus and rhinorrhea revealing spontaneous cerebrospinal fluid fistula of the anterior cranial base

Spontaneous cerebrospinal fluid fistulas (CSFFs) of the anterior skull base are extremely rare. We report a case of spontaneous CSFF of the ethmoid cribriform plate presenting with rhinorrhea and tension pneumocephalus. We discuss the physiopathology, the radiological management, and the treatment of spontaneous CSF fistulas related to the anterior skull base. A 58-year-old woman was admitted to our institution for headaches with clear rhinorrhea persisting over several days. Antecedents were unremarkable. An episode of epistaxis three days before was reported. Clinical examination showed clear rhinorrhea, headaches, and anosmia. The CT scan showed voluminous epidural and subdural pneumocephalus with mass effect on both frontal and temporal lobes. A high-resolution CT scan with bone reconstruction showed a 2-mm bony defect of the cribriform plate. Surgery consisted of epidural frontal anterior skull base repair. Postsurgery follow-up was uneventful. At one year, the patient was asymptomatic apart from the persistence of anosmia. Spontaneous CSF fistulas are uncommon and can be associated with tension pneumocephalus. The physiopathology remains unclear. Their treatment by complete exclusion of the fistula is necessary because of the lethal risk of pneumococcus meningitis.

Dilatations géantes des espaces de Virchow-Robin

INTRODUCTION Virchow-Robin spaces are very well-known anatomical and radiological entities. However, the observation of giant cystic widening of Virchow-Robin spaces is anecdotic. We report herein the case of a patient presenting with giant cystic widening of Virchow-Robin spaces located in both cerebral hemispheres. OBSERVATION A 26-year-old female presented with numbness of left arm and then, of both arms. CT scan showed many hypodensities located in the two hemispheres. Neurologic examination was normal. MR imaging allowed the diagnosis of giant cystic widening Virchow-Robin spaces in T2, T2*, T1 gadolinium and Flair weighted images. Neuropsychological investigations were normal. CONCLUSION Giant cystic widening of Virchow-Robin spaces are extremely rare entities. MR imaging helps the diagnosis. Only extreme dilatation of Virchow-Robin perivascular spaces close to ventricular system must be watched and treated in case of an obstructive hydrocephalus risk. When located in cerebral hemispheres, these dilatations are mostly asymptomatic and must not be confused with a cystic tumoral disease.

Embryologie et anatomie fondamentale du ventricule latéral

The lateral ventricles are the C-shaped cavities of the telencephalon. Embryology of theses cavities is recalled as well as the immediate relationship of the frontal horn, the body, the atrium and the temporal and occipital horns.