Dominique Liguoro

Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases.

OBJECTIVE: The goal of this study was to review decision factors and overall results regarding surgical and nonsurgical management of post-traumatic facial nerve paralysis (FP). STUDY DESIGN: A retrospective study and literature review were performed. METHODS: Between 1984 and 1990, 115 cases of post-traumatic FP were handled. Patients were evaluated through clinical, audiologic, radiologic, and electromyogram assessment. Depending on examination results, patients were treated either medically or surgically through total facial nerve decompression. RESULTS: Forty-nine of the 50 medically treated patients experienced a normal or subnormal facial function recovery (grade I–II). Of the 65 (56.5%) surgically treated patients, 52 (80%) had immediate, 2 had delayed, and 11 (17%) had unknown delay-associated FP. The approaches chosen were middle fossa and transmastoid (75.3%), translabyrinthine (10.7%), or pure transmastoid according to facial nerve nonmotor branch evaluation, hearing, location of the fracture line, and the patients general condition. Lesions were predominantly found in the geniculate ganglion area (66.2%). A nerve gap was found in only 13.8% of the cases. At 2 years after surgery, 93.8% had a grade I to III recovery. None had grade V or VI. CONCLUSION: The rarity of severe nerve lesions encountered in surgically treated patients raises the question of better selection of candidates for surgery. Surgery is clearly indicated when FP is total, is of immediate onset, and is associated with a bad prognosis electromyogram pattern. In other settings, decisions are to be made based on high-resolution CT data and electromyogram results, thanks to a clinical survey and second electromyogram evaluation.

Intracranial meningioma surgery in the ninth decade of life.

OBJECTIVEThe aims of this study are to assess the surgical outcome of elderly patients aged 80 years or more, to analyze the factors influencing postoperative course, and to propose a grading system to standardize the surgical indication of intracranial meningioma in the elderly. METHODSBetween 1990 and 2005, we surgically treated 74 consecutive patients aged 80 years or more for intracranial meningiomas (47 women, 27 men; mean age, 82 yr; age range, 80–90 yr). The median follow-up period was 94 months (range, 15–147 mo). We retrospectively analyzed the factors influencing surgical outcome and retained the significant factors to form the Sex, Karnofsky Performance Scale, American Society of Anesthesiology Class, Location of Tumor, and Peritumoral Edema (SKALE) grading system. RESULTSThere was no perioperative mortality, and the 1-year mortality rate was 9.4%. Postoperative mortality was lower in women with a Karnofsky Performance Scale score of 60 or greater, an American Society of Anesthesiology Class of 1 or 2, a noncritical tumor location, and a moderate or absent peritumoral edema. Patients with a SKALE score of more than 8 had an excellent outcome, whereas those with a SKALE score of less than 8 had a poor outcome. The rate of postoperative complications was 9.4%. Large tumors, critical locations, severe peritumoral edema, and total surgical excision were associated with a higher risk of postoperative complications. CONCLUSIONSurgery of intracranial meningioma in elderly patients is feasible when the SKALE score is 8 or greater. Prospective studies are required to validate this grading system.

Morphologic and histologic study of the ligamentum flavum in the thoraco-lumbar region

The ligamentum flavum, of which there are only a few studies in the literature, has several features discussed in this work. On the macroscopic level, it has a metameric arrangement it has two layers, superficial and deep, whose fibers are oppposite, and it has close relations with the tendons of attachment of some spinal erector muscles. On the microscopic level, its structure is unique for a ligament, because of a predominance of elastic fibers, because of its intrinsic innervation at each level of the spine, and because this innervation grows poorer with increasing degeneration. The ligamentum flavum constitutes an active ligament, with an essential biomechanical role. Its injury is probably not without consequences, and therefore there are many technical problems about the surgical interlaminar approach.

Peritumoral edema and prognosis in intracranial meningioma surgery

Peritumoral brain edema (PTBE) is often associated with meningiomas. PTBE is probably implicated in the complications occurring in intracranial meningiomas. The goal of this study was to determine the exact implication of PTBE in prognosis. Thirty consecutive patients who underwent surgery for intracranial meningiomas were investigated over a 1-year period. We focused on the clinical and radiological status before and after surgery, and postoperative complications. Multiple regression analysis revealed a close correlation (p<0.05) between PTBE and symptoms, type of arterial supply, difficulty of surgical removal, and postoperative complications. PTBE is likely implicated in the morbidity of intracranial meningiomas. We suggest predictive factors for difficult surgical resection, and emphasise the importance of medical preoperative management and post-operative follow-up.

Effects of prolactin on intracellular calcium concentration and cell proliferation in human glioma cells

Prolactin (PRL) has several physiological effects on peripheral tissues and the brain. This hormone acts via its membrane receptor (PRL‐R) to induce cell differentiation or proliferation. Using reverse transcription–polymerase chain reaction (RT‐PCR) combined with Southern blot analysis, we detected PRL‐R transcripts in a human glioma cell line (U87‐MG) and in primary cultured human glioblastoma cells. These transcripts were deleted or not in their extracellular domains. We examined the effects of PRL on intracellular free Ca2+ concentration ([Ca2+]i) in these cells in order to improve our understanding of the PRL transduction mechanism, which is still poorly documented. [Ca2+]i was measured by microspectrofluorimetry using indo‐1 as the Ca2+ fluorescent probe. Spatiotemporal aspects of PRL‐induced Ca2+ signals were investigated using high‐speed fluo‐3 confocal imaging. We found that physiological concentrations (0.4–4 nM) of PRL‐stimulated Ca2+ entry and intracellular Ca2+ mobilization via a tyrosine kinase–dependent mechanism. The two types of Ca2+ responses observed were distinguishable by their kinetics: one showing a slow (type I) and the other a fast (type II) increase in [Ca2+]i. The amplitude of PRL‐induced Ca2+ increases may be sufficient to provoke several physiological responses, such as stimulating proliferation. Furthermore, PRL induced a dose‐dependent increase in [3H]thymidine incorporation levels and in cellular growth and survival, detected by the MTT method. These data indicate that PRL induced mitogenesis of human glioma cells. GLIA 38:200–214, 2002.

Intraosseous lidocaine provides effective analgesia for percutaneous vertebroplasty of osteoporotic fractures

PurposeTo assess the safety and efficacy of intraosseous lidocaine (IL), in comparison with iv nalbuphine and propacetamol (NP) for analgesia during percutaneous vertebroplasty (PV) in order to avoid general anesthesia in elderly patients.MethodsPatients (age 68 ±13 yr, weight 66 ±6 kg) undergoing PV for osteoporotic fractures were randomized prospectively into two groups: NP(n = 50)and IL(n = 50). All patients were premedicated (oral hydroxyzine I mg·kg−1) and had skin infiltration with 5 ml_ of 1% lidocaine prior to vertebral puncture. Thirty minutes before the procedure, Group NP received, in a blinded manner, SO ml_ of iv nalbuphine (0.3 mg·kg−1) and propacetamol (30 mg·kg−1) while Group IL received 50 mL of iv saline. During vertebral puncture, Groups NP and IL received, in a blinded manner, I mL·10 kg−1 of intraosseous saline and 1% lidocaine respectively. Pain was assessed during vertebral puncture and cement injection with a four-point verbal rating scale. Additionally, lidocaine plasma kinetics were obtained in I I IL patients.ResultsAnalgesic efficacy was similar in the IL and NP groups (85 vs 84%). Group NP had more side effects. Lidocaine peak recorded concentration was 2.6 ±0.1 μg·mL−1 i.e., about three times less than the reported toxic limits.ConclusionIL is as effective as the association of iv NP for analgesia in PV. However, considering that both protocols were insufficient in about 15% of cases, other modalities are needed to further improve analgesia and avoid general anesthesia during vertebroplasty.RésuméObjectifÉvaluer l’efficacité et la sécurité d’une injection intraosseuse de lidocaïne (IL) comparée à une sédation iv à base de nalbuphine et de propacétamol (NP) pour l’analgésie des vertébroplasties percutanées (VP) afin d’éviter l’anesthésie générale chez des patients âgés.MéthodeCent patients devant subir une l’P sont prospectivement randomisés en deux groupes: 30 min avant la procédure, le groupe NP reçoit en aveugle 50 mL d’un mélange iv de nalbuphine (0,3 mg·kg−1) et de propacétamol (30 mg·kg−1) tandis que le groupe IL reçoit 50 mL iv de solution salée. Tous les patients reçoivent une prémédication avec de l’hydroxyzine (I mg·kg−1) et ont une infiltration cutanée avant la ponction vertébrale avec 5 mL de lidocaine I %. Pendant la ponction vertébrale, le groupe NP reçoit à son tour une solution salée alors que le groupe IL reçoit I mL· 10 kg−1 de lidocaïne I %. La douleur est évaluée pendant l’opération par une échelle verbale à quatre degrés. Un profil cinétique de la lidocaïne plasmatique est réalisé chez les 11 premiers patients.RésultatsUne analgésie efficace est constatée dans les groupes IL et NP dans 85 et 84 % des cas respectivement. Le groupe NP présente plus d’effets secondaires. Le pic plasmatique de lidocaïne circulante est 2,6 ±0,1 μg·mL−1 soit trois fois moins que les limites toxiques.ConclusionLa lidocaïne intra-osseuse procure la même analgésie que l’association iv de NP pour les l’P. Étant donné que les deux protocoles sont insuffisants dans environ 15% des cas, d’autres associations sont nécessaires pour améliorer encore l’analgésie et éviter l’anesthésie générale.

Unique case of malignant transformation of a vestibular schwannoma after fractionated radiotherapy.

OBJECTIVE Malignant transformation of vestibular schwannoma is considered a rare clinical entity. Radiotherapy, as a treatment option for vestibular schwannoma, is regarded as a potential risk factor for secondary malignancy. Recently, radiotherapy with dose fractionation has been proposed, intended to diminish the risk of radiation-induced neuropathy. CASE PRESENTATION The aim of the present study is to report the first case, to the best of our knowledge, of malignant transformation of a residual vestibular schwannoma 19 years after fractionated radiotherapy, describing its characteristics with regard to those previously reported in the literature. CONCLUSIONS The main purpose of the present work is to state that the knowledge of the iatrogenic potential pitfalls of any technique of radiotherapy in clinical oncology is becoming a necessity. Finally, our report demonstrates that the irradiated patients must be monitored for life because a secondary malignancy may appear after a very long delay.

The posterior sacral foramina: an anatomical study.

The vascular and nervous structures and their relations with the spinal nerve roots were examined in the 2nd, 3rd and 4th posterior sacral foramina in relation to percutaneous needle insertion for neuromodulation. A foraminal branch provided by the lateral sacral artery to each foramen entered the inferior lateral quadrant of each foramen, adjacent to the nerve root medially. Facing the posterior sacral aperture and around the sacral nerves, there was no venous plexus. A venous plexus was sometimes present near the median line, and always around the proximal part of the spinal ganglion. The sacral nerve roots, especially the 3rd, had a long extradural course in the foramen, presenting a potential risk of nerve lesions during procedures involving needle insertion.

Intraorbital apocrine hidrocystoma.

A 33-year-old man reported an 18 months history of a progressive right eyelid swelling, a sensation of eye pain and headaches. He noted a visual discomfort. Physical examination showed right eyelid edema, without skin lesion. The patients acuity was unchanged from the baseline; neither exophthalmia nor deficit in the visual field was noted. Magnetic resonance image showed an intraorbital, extraconal cystic lesion. Histopathologic examination revealed apocrine hidrocystoma.

Transpetrosal approaches for meningiomas of the posterior aspect of the petrous bone: Results in 43 consecutive patients

OBJECTIVE To assess outcome following excision of meningiomas of the posterior aspect of the petrous bone through transpetrosal approaches. MATERIAL AND METHOD We carried out a retrospective case-series study in a multidisciplinary tertiary care center on all patients who underwent meningiomas removal from January 1989 to September 2005. Surgical approaches were transpetrosal: widened retrolabyrinthine, translabyrinthine, transotic and transcochlear, occasionally combined with a subtemporal transtentorial approach. Epidemiology, symptoms, preoperative evaluation, surgery, postoperative complications and facial and auditory results were analyzed using standardized grading systems. The Desgeorges and Sterkers classification was used to assess tumor size and location. RESULTS Forty women and three men underwent surgery (mean age: 56.7). Medium-sized tumors stages 2 and 3 (84%) and AM and P localization (34% and 20.4%) predominated. In 65% of cases, the tumor extended beyond the CPA. Main presenting symptoms were balance disorders (72%) and sensorineural hearing loss (53.5%). Mortality was nil. A preoperative facial nerve paresis was present in 14% of patients. Tumor removal was complete in 79.1% of cases. At 1-year post-op, 73% of patients had a normal or subnormal facial function and 55% had serviceable hearing. A cerebrospinal fluid leakage occurred in 6.9%. DISCUSSION Posteriorly attached meningiomas are less symptomatic and of better prognosis than medially inserted ones. Transpetrosal approaches are reliable for the removal for all types and sizes of such tumors, and can be easily combined in the same procedure with a subtemporal transtentorial approach to remove extensions to the clivus and tentorium. They offer low morbidity and a high proportion of facial nerve and hearing preservation.