Damien Bresson

Decompressive Craniectomy and Early Cranioplasty for the Management of Severe Head Injury: A Prospective Multicenter Study on 147 Patients

OBJECTIVE In emergency care of patients with severe blunt head injury, uncontrollable high intracranial pressure is one of major causes of morbidity and mortality. The purpose of this study was to evaluate the efficacy of aggressive surgical treatment in managing uncontrollable elevated intracranial pressure coupled with early skull reconstruction. METHODS This was a prospective study on a series of 147 consecutive patients, managed according to the same protocol by five different neurosurgical units, for severe head injuries (Glasgow coma scale score ≤8/15 and high intracranial pressure >25 mm Hg) during a five-year period. All patients received a wide decompressive craniectomy and duroplasty in the acute phase, and a cranioplasty was also performed within 12 weeks (median 6 weeks, range 4-12 weeks). RESULTS The emergency decompressive surgery was performed within 28 hours (median 16 hours, range 6-28 hours) after sustaining the head injury. The median preoperative Glasgow coma scale score was 6/15 (range 3-8/15). At a mean follow-up of 26 months (range 14-74 months) 14 patients were lost to long-term follow-up, leaving only 133 patients available for the study. The outcome was favorable in 89 (67%, Glasgow outcome score 4 or 5), it was not favorable in 25 (19%, Glasgow outcome score 2 and 3), and 19 patients (14%) died. A younger age (<50 years) and earlier operation (within 9 hours from trauma) had a significant effect on positive outcomes (P < 0.0001 and P < 0.03, respectively). CONCLUSIONS A prompt aggressive surgery, including a wide decompressive craniectomy coupled with early cranioplasty, could be an effective treatment method to improve the outcome after a severe closed head injury reducing, perhaps, many of the complications related to decompressive craniectomy.

Antithrombotic Therapy and Bleeding Risk in a Prospective Cohort Study of Patients With Cerebral Cavernous Malformations

Background and Purpose— Cerebral cavernous malformations (CCMs) are one of the most frequently diagnosed vascular malformations of the brain and constitute a potential source of intracranial hemorrhage. In CCM patients suffering ischemic stroke or heart disease, the use of anticoagulants or antiplatelet therapy is generally avoided by fear of hemorrhagic complications, but no systematic studies exist to support this hypothesis. Methods— We prospectively followed-up consecutive patients with a diagnosis of one or more CCMs in a prospective database since 2008. Retrospective data collection was used for patients with a diagnostic event or imaging studies done before first assessment. Symptomatic hemorrhage and other focal neurological events during prospective follow-up were defined according to the current guidelines of the Angioma Alliance Scientific Advisory board. Results— A total of 87 patients were prospectively enrolled in our cohort [50 women (57%), mean age 44.8 years (SD ± 17.6), mean follow-up 3.9 years], harboring a total of 738 CCMs. Fifty-five patients (63%) had a single CCM, and 32 patients (37%) had multiple CCMs. Longitudinal follow-up included 16 (18%) patients receiving long-term antithrombotic therapy by antiplatelet treatment (n=11) or oral anticoagulants (n=5). During 5536 lesion-years of observation, none of the patients under antithrombotic therapy experienced CCM hemorrhage on follow-up. Conclusions— Our observational data suggest that long-term antithrombotic treatment by antiplatelet drugs or warfarin does not increase the frequency of CCM-related hemorrhage. Patients harboring single or multiple CCMs suffering ischemic stroke or heart disease should not be withheld antithrombotic therapy.

Efficacy and Safety of Adjuvant Proton Therapy Combined With Surgery for Chondrosarcoma of the Skull Base: A Retrospective, Population-Based Study

PURPOSE Chondrosarcoma is a rare malignant tumor of the cartilage affecting young adults. Surgery, followed by charged-particle irradiation, is considered the reference standard for the treatment of patients with grade I to II skull base chondrosarcoma. The present study was conducted to assess the effect of the quality of surgery and radiation therapy parameters on local control (LC) and overall survival (OS). METHODS AND MATERIALS From 1996 to 2013, 159 patients (median age 40 years, range 12-83) were treated with either protons alone or a combination of protons and photons. The median total dose delivered was 70.2 Gy (relative biologic effectiveness [RBE]; range 67-71). Debulking and biopsy were performed in 133 and 13 patients, respectively. RESULTS With a median follow-up of 77 months (range 2-214), 5 tumors relapsed based on the initial gross tumor volume. The 5- and 10-year LC rates were 96.4% and 93.5%, respectively, and the 5- and 10-year OS rates were 94.9% and 87%, respectively. A total of 16 patients died (13 of intercurrent disease, 3 of disease progression). On multivariate analysis, age <40 years and primary disease status were independent favorable prognostic factors for progression-free survival and OS, and local tumor control was an independent favorable predictor of OS. In contrast, the extent of surgery, dosimetric parameters, and adjacent organs at risk were not prognostic factors for LC or OS. CONCLUSIONS Systematic high-dose postoperative proton therapy for skull base chondrosarcoma can achieve a high LC rate with a low toxicity profile. Maximal safe surgery, followed by high-dose conformal proton therapy, is therefore recommended.

Prognostic and Therapeutic Markers in Chordomas: A Study of 287 Tumors

Chordomas are slow-growing malignant neoplasms. Determination of histopathologic prognostic factors using a large cohort study has been limited by their low incidence. In this retrospective study, we investigated the clinical, histopathologic, and immunohistochemical prognostic factors in 287 chordomas from 111 patients assessed by central pathologic review. Expression patterns of a variety of markers, including vascular endothelial growth factor (VEGF), mTOR pathway, c-kit, HER2, epidermal growth factor receptor (EGFR) and STAT3, and KRAS, BRAF, EGFR, and PIK3CA mutations were analyzed. On univariate analysis, the results confirm surgery as the best treatment, as judged by patient progression-free survival (PFS) and overall survival (OS). Proton therapy, the presence of a dedifferentiated component, mitotic figures, and Ki67 and p53 labeling indices correlated with PFS. Necrosis and apoptosis correlated with OS. Based on these findings, we propose a histopathologic grading system that correlates with PFS and OS. On multivariate analysis, extent of resection, tumor grade, and proton therapy were independent prognostic factors of PFS; extent of resection, tumor location, and grade were independent prognostic factors of OS. Based on the expression of EGFR, pSTAT3, VEGF, and mTOR pathway proteins, (in 85.9%, 79.1%, 85.7%, and 46% of chordomas, respectively), and 2 new mutations in the PIK3CA gene, we also provide evidence for potential therapeutic targets.

Juvenile Nasopharyngeal Angiofibroma Does the External Approach Still Make Sense

Objective The aim of this study was to review recent management of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. Study Design Case series with chart review. Setting The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisière, Paris, France). Subjects and Methods All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecutive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). Results Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and complications were similar. Recurrences (ie, residual disease growing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P > .05). Conclusion Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indications for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor.

One-year outcome after neurosurgery for intracranial tumor in elderly patients.

Background The number of elderly patients proposed for brain tumor removal is increasing. Only few data on long-term functional prognosis after intracranial surgery are available. Materials and Methods Prospective, observational study of all patients greater than 70 year of age operated for intracranial tumors. Two scales for health status evaluation were used: Karnofsky Performance Scale (KPS) and Activities of Daily Living (ADL) score. Data were expressed as medians (first to third quartiles). The primary endpoint was the probability to remain nondependant (ADL>3 and KPS≥70%) after 1 year. Results Between 2003 and 2007, 90 patients were included: 46 (51.1%) meningioma, 17 (18.9%) high-grade glioma, and 11 (12.2%) metastasis. At hospital admission, age was 73.50 years (71.25-76.00), American Society of Anesthesiology score 2 (2 to 3), KPS 80% (70–90), ADL 5.5 (4.5 to 6.0). Two patients died during the first 28 days, 3 others during the first year. Both KPS and ADL decreased after 1 year: KPS 80% (70 to 90; mean: 80%) at hospital admission versus 80% (60 to 90) at 1 year (mean: 70%), P=0.003; ADL 5.5 (4.5 to 6.0) at hospital admission versus 5.0 (3.25 to 5.50) at 1 year, P=0.001. In multivariate analysis, 2 preoperative parameters were associated with autonomy at 1 year: the ADL at hospital admission and meningioma as histologic type. Conclusions In this series of elderly patients, intracranial tumor surgery was associated with low 1-year mortality. Meningioma was associated with a better postoperative functional outcome. Preoperative ADL score was a predictive of functional evolution 1 year after the surgery.

Subarachnoid hemorrhage induces an early and reversible cardiac injury associated with catecholamine release: one-week follow-up study

IntroductionThe occurrence of cardiac dysfunction is common after subarachnoid hemorrhage (SAH) and was hypothesized to be related to the release of endogenous catecholamines. The aim of this prospective study was to evaluate the relationship between endogenous catecholamine and cardiac dysfunction at the onset and during the first week after SAH.MethodsForty consecutive patients admitted for acute SAH without known heart disease were included. Catecholamine plasma concentrations and transthoracic echocardiography (TTE) were documented on admission, on day 1 (D1), and day 7 (D7).ResultsAt baseline, 24 patients had a World Federation of Neurosurgical Societies score (WFNS) of one or two; the remaining 16 had a WFNS between three and five. Twenty patients showed signs of cardiac dysfunction on admission, including six with left ventricle (LV) systolodiastolic dysfunction and 14 with pure LV diastolic dysfunction. On admission, norepinephrine, epinephrine, dopamine, B-type Natriuretic Peptide (BNP) and Troponin Ic (cTnI) plasmatic levels were higher in patients with the higher WFNS score and in patients with altered cardiac function (all P <0.05). Among patients with cardiac injury, heart function was restored within one week in 13 patients, while seven showed persistent LV diastolic dysfunction (P = 0.002). Plasma BNP, cTnI, and catecholamine levels exerted a decrease towards normal values between D1 and D7.ConclusionOur findings show that cardiac dysfunction seen early after SAH was associated with both a rapid and sustained endogenous catecholamine release and WFNS score. SAH-induced cardiac dysfunction was regressive over the first week and paralleled the normalization of catecholamine concentration.

Anterolateral approach without fixation for resection of an intradural schwannoma of the cervical spinal canal: technical note.

OBJECTIVE Although an anterolateral approach is an ideal approach to the anterior part of the cervical spinal canal, it is not often used because of various technical difficulties. This article presents the case of a patient with an intradural schwannoma ventrolateral to the spinal cord and describes the technique, anterolateral surgery without fixation, that was used to remove it. CASE PRESENTATION A 71-year-old man presented with neck pain and easy fatigability of the legs. Magnetic resonance imaging showed an intradural tumor ventrolateral to the spinal cord at the C3 level. The diagnosis was a schwannoma. TECHNIQUE A right anterolateral approach was selected for the resection. In the dissection between the sternocleidomastoid muscle and the internal jugular vein, the accessory nerve was retracted with the fat tissue. At C3, the prevertebral aponeurosis was laterally retracted to protect the sympathetic chain. The C3 transverse process was rongeured, and the vertebral artery was shifted laterally with the venous plexus. The C2-C3 uncovertebral joint and the right third of the C3 body were removed (partial corpectomy). The tumor was easily found in the dural sac and was totally removed. The surgical wound was closed in a watertight fashion. No fixation was necessary. The symptoms improved after the operation. DISCUSSION The anterolateral approach is one of the best approaches for resecting ventrally located intradural lesions because it allows minimally invasive surgery. Control and protection of the accessory nerve, sympathetic chain, and vertebral artery are the keys to success.

Surgical management of spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas are the most common type of spinal arteriovenous malformations. Treatment options consist of microsurgical exclusion and/or endovascular embolization. We retrospectively identified all patients who benefited from surgical treatment at our tertiary center between January 2001 and December 2008. Clinical and imaging data were collected from patient files, including pre- and post-operative formal neurological examination, complete spine MRI and spinal digital subtraction angiography. Of our 30 patients, 25 were men and five were women with a median age of 62 years (range 24-76). The average delay between symptom onset and clinical diagnosis was 27 months (range 1-90). Complete cure of the fistula was obtained in all patients in a single surgical session with no procedural complications and no surgical morbidity. After a mean follow-up period of 32 months (range 14-128), 25 patients (83%) had improved, four were stable and one worsened. Despite recent advances in endovascular techniques and materials, there is a subgroup of patients for which surgery remains the best treatment option. Careful patient selection, a multidisciplinary approach and standardized surgical techniques can lead to excellent results with virtually no complications.

Primary malignant rhabdoid tumour of the brain in adults

Malignant rhabdoid tumour (MRT) was described for the first time in the kidney, and is rarely reported in the brain. Most rhabdoid tumours affect infants and young children and there have been only isolated adult patients reported. The optimal treatment for this very aggressive tumour has not yet been established. We describe the clinical and pathological features of a rare primary malignant rhabdoid tumour of the brain in a 27-year-old pregnant female. The literature is reviewed briefly and the role of the INI1 gene in adult MRTs and the also possible interactions between MRTs and pregnancy are discussed.