H. Cebula

Tumeur à cellules géantes de C2 colonisée par un kyste anévrismal. À propos d’un cas

Giant cell tumor is colonized by aneurismal bone cyst in only 15% of cases and cervical localisation accounts for less than 1% of giant cell tumors. We are reporting a rare case of a C2 hypervascularized giant cell tumor colonized by an aneurismal bone cyst treated with an effective preoperative Onyx embolization followed by a full tumor resection. The patient experienced a moderate cervical spine injury 2 months prior admission followed by a progressive stiff neck and cervicalgia. CT and MRI identified a lytic lesion of the body and lateral masses of the C2 with encasement of both vertebral arteries. The angiography showed a hypervascularization of the lesion from the vertebral and external carotid arteries as well as a thrombosis of the V3 segment of the right vertebral artery at the C1 level. A posterior occipito-C3/C4 fixation and a tumor biopsy were performed. Histopathological examination concluded to a giant cell tumor colonized by an aneurismal bone cyst. Three weeks later, the patient developed a right upper extremity deficit. The MRI showed an increased C1-C2 stenosis and an increase of the hypervascularization. Three sessions of embolization by the onyx were performed. During surgery a near total tumor devascularisation was observed and a complete resection of the tumor was achieved through an anterolateral approach. Reconstruction consisted of a cementoplasty of the C2 body and odontoïd process with an anterior C3-prosthesis plate. The postoperative course was uneventful.

Risk of Deep vein thrombosis in neurosurgery: State of the art on prophylaxis protocols and best clinical practices

OBJECTIVE To analytically discuss some protocols in Deep vein thrombosis (DVT)/pulmonary Embolism (PE) prophylaxis currently use in Neurosurgical Departments around the world. DATA SOURCES Analysis of the prophylaxis protocols in the English literature: An analytical and narrative review of literature concerning DVT prophylaxis protocols in Neurosurgery have been conducted by a PubMed search (back to 1978). DATA EXTRACTION 80 abstracts were reviewed, and 74 articles were extracted. DATA ANALYSIS The majority of DVT seems to develop within the first week after a neurosurgical procedure, and a linear correlation between the duration of surgery and DVT occurrence has been highlighted. The incidence of DVT seems greater for cranial (7.7%) than spinal procedures (1.5%). Although intermittent pneumatic compression (IPC) devices provided adequate reduction of DVT/PE in some cranial and combined cranial/spinal series, low-dose subcutaneous unfractionated heparin (UFH) or low molecular-weight heparin (LMWH) further reduced the incidence, not always of DVT, but of PE. Nevertheless, low-dose heparin-based prophylaxis in cranial and spinal series risks minor and major postoperative haemorrhages: 2-4% in cranial series, 3.4% minor and 3.4% major haemorrhages in combined cranial/spinal series, and a 0.7% incidence of major/minor haemorrhages in spinal series. CONCLUSION This analysis showed that currently most of the articles are represented by case series and case reports. As long as clear guidelines will not be defined and universally applied to this diverse group of patients, any prophylaxis for DVT and PE should be tailored to the individual patient with cautious assessment of benefits versus risks.

Subarachnoidal migration of intraocular silicone oil.

Dear Editor, Silicone has been used as an intraocular endotamponade for the repair of complex retinal detachments (RD) [2] associated with proliferative vitreoretinopathy, giant retinal tear, proliferative diabetic retinopathy, trauma, or cytomegalovirus infection for almost 40 years. Evidence of cerebral abnormalities discovered on magnetic resonance imaging (MRI) in patients with history of intraocular silicone oil use is growing [3, 4]. Cases of silicone migration into the chambers of the eye, the periorbital space, and into the cerebral ventricles trough the subarachnoidal space around the optic nerve were punctually reported. In this letter, we describe imaging findings of silicone migration into both the posterior chamber of the eye and the subarachnoidal space (including intra-ventricular spread) after intraocular injection in two patients treated for complex retinal detachment. The first patient was treated three times for idiopathic rhegmatogenous RD and the second one time for a RD secondary to uveitis, by silicone injection into the vitreous cavity. Standard injection technique included intraocular injection of a mean of 9 ml of silicon oil in a time ranging from 50 to 240 s, depending on the type and viscosity of the silicone utilized. Both patients were asymptomatic and underwent MRI for different purposes not related to the history of ocular surgery: the first for suspicion of stroke and the second for headache. By consequence, the delay in between the silicone injection and its brain migration was unknown and difficult to estimate considering also that such an occurrence is very rare. In addition, computed tomography (CT) was performed in the first patient. In both patients, silicone spreading from the eye into the subarachnoid space following optic nerve and chiasm was nicely seen on imaging. Silicon has the same signal inside the eye, around the optic nerve, and within the brain on the CT scan and MRI (Fig. 1a–f). No previous imagery was found. In the first patient, a CT scanner showed silicone as a hyperdense, non-enhancing material within the anterior chamber of the right eye and along the right optic nerve following the optic chiasm (Fig. 1a, b, c). Silicone spreading was even more nicely shown on MRI as a hyperintense material within the posterior chamber and along the optical nerve (Fig. 1c). In the second patient, hyperintense material corresponding to silicone could be tracked on MRI from the posterior chamber of the left eye along the optic chiasm up to the subarachnoid space within the left ventricle (Fig. 1d, e, f). An additional MRI of the spine (not shown) was realized but no silicone was found. The two patients were followed up in our department and were finally treated conservatively, as they remained asymptomatic. Notably, there was no visual impairment due to silicone spread along the optic nerve or chiasm. This migration was possibly eased by elevated intraocular pressure or by the presence of congenital anatomical abnormalities allowing the passage from the vitreous space into the subarachnoidal space. Fangtian * H. Cebula helene.cebula@hotmail.fr

Spinal adhesive arachnoiditis following the rupture of an Adamkiewicz aneurysm: Literature review and a case illustration

BACKGROUND The rupture of an isolated spinal aneurysm is an exceptional occurrence. It might be responsible for a spinal subarachnoid haemorrhage (SSAH) that in rare cases can be complicated by arachnoiditis. Among the former the adhesive type is the most severe leading to the formation of a cyst and/or a syrinx. PATIENTS AND METHODS The literature review was performed via a PubMed search using the following keywords. Adhesive arachnoiditis; spinal subarachnoid haemorrhage; spinal arachnoiditis; spinal arachnoid cyst; arachnoid cyst .Thesearch yielded 24 articles. Given the fact that only a few studies had been reported on the subject, we decided to include all studies regarding adhesive arachnoiditis after SAH leading to a descriptive literature review. Furthermore, a case illustration of a 57 year old man harbouring this type of rare pathology is described. RESULTS Twenty-four case reports were found regarding spinal adhesive arachnoiditis (SAA) following SSAH. Posterior cerebral circulation bleeding (66.7%) most often occurred followed by spinal (9.1%) and anterior cerebral circulation (9.1%) respectively. The mean time between the haemorrhage and the SAA onset was 10 months. A higher predominance of symptomatic thoracic SAA was found. Including the present case, 80% of patients had a laminectomy, 72% had a micro adhesiolysis, and 56% a shunt placement. Cervical and upper thoracic involvement appeared to have a better outcome. CONCLUSION Although most authors suggested surgical treatment, the long-term outcome remains unclear. Early stage diagnosis and management of this rare and disabling pathology may lead to a better outcome. Larger co-operative studies remain essential to obtain a better understanding of such a rare and complex disease.

Endonasal Endoscopic Odontoidectomy in Ventral Diseases of the Craniocervical Junction: Results of a Multicenter Experience

BACKGROUND Over the past decades, supported by preliminary anatomic and clinical studies exploring its feasibility and safety, experience has increased of the use of the endoscopic endonasal approach (EEA) to ventral diseases at the craniocervical junction (CCJ). METHODS A multicenter study was carried out over a 4-year period of 14 patients managed by EEA odontoidectomy for CCJ diseases causing irreducible atlantoaxial dislocation. The surgical setup included an IGS system based on computed tomography and magnetic resonance images fusion, and 0° and 30° angled endoscopes with dedicated endoscopic tools. RESULTS Nine men and 5 women, with a mean age of 60.7 years, were included. The mean follow-up was 28.5 months; 9 patients had basilar impression, whereas 5 had a degenerative pannus. The quality of anterior decompression was excellent in all cases; nonetheless, a posterior stabilization was deemed necessary in 13 patients, and no external orthosis was used during the postoperative course. No tracheostomy or gastrostomy was required after surgery; no deaths, no new neurologic deficits/complications, and no postoperative cerebrospinal fluid leak were recorded. At follow-up, the neurologic status assessed with Frankel grade did not deteriorate in any of the patients but improved in 13 of them; and no new listhesis was shown on neuroradiologic follow-up. CONCLUSIONS The results show that EEA provides a direct surgical corridor to the CCJ, allowing an adequate decompression as with the more invasive transoral route. Morbidity is less than with a transoral approach, resulting in higher patient comfort and faster recovery.

The usefulness of fibrin glue as a support in the dissection of malignant cystic brain tumors

BACKGROUND If the complete microsurgical resection of a brain tumor is a logical oncologic goal, the surgical strategy for the cystic component remains controversial secondary to the risk of morbidity. The objective of this study was to analyze the interest of using fibrin glue in the resection of malignant cystic brain tumors (MCBT). METHODS Seven patients (median: 60-years-old (range [52-72]/sex ratio M/F: 2.5) were analyzed prospectively in the Neurosurgery Department at Strasbourg University Hospital, from October 2014 to November 2016. The surgical technique consisted of injecting fibrin glue into the tumor cyst after partial drainage. After the solidification of the glue, the cysts walls were removal by following the dissection plan around the fibrin glue. The primary objective was to evaluate the quality of surgical resection on brain MRI scans postoperatively with the use of ITK-SNAP software for precise measurements of tumor volume. RESULTS Four metastases and 3 glial lesions were operated on with this technique. An average reduction in cystic volume of 64.6% (P=0.016) and 82.1% (P=0.016) for contrast enhancement volume were observed. If two cases (#2 and #7) were excluded, the average contrast enhancement reduction was respectively 94% and 72% for the cystic volume. In addition, there were no complications, tumor recurrence or difference between gliomas and metastases and the Karnofsky score increased by at least 10% in all patients. CONCLUSION This procedure allowed to extend the resection to the cystic component of MCBT without increasing the risk of morbidity related to injury on the underlying parenchyma.

Multimodal management of severe herpes simplex virus encephalitis: A case report and literature review

BACKGROUND Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature. CASE DESCRIPTION The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1. CONCLUSION Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.

Multidisciplinary management of an intra-sellar cavernous hemangioma: Case report and review of the literature

Extra-axial cavernous hemangiomas (ECH) are rare vascular lesions with a tendency to grow within the medial structures of the middle cranial fossa. This pathological entity lacks specific symptoms, and falls into the category of differential diagnosis of space occupying lesions in the cavernous sinus (CS) with or without sellar involvement, including those of tumoral, vascular and inflammatory nature. Of note, ECH can also be indolent, and is at times discovered incidentally during autopsy investigations. On radiological studies, ECH with sellar extension are frequently mistaken at first for pituitary adenomas. Total removal of intrasellar-CS ECH is technically demanding and burdened by remarkable morbidity and mortality rates, mostly related to the complex neuroanatomy of the CS-sellar region (i.e., peri and postoperative bleeding, and transitory or permanent nerve palsies, hormonal deficits). Consequently, only a few cases of successful total removal have been reported so far in the literature. Surgical debulking with cranial nerve decompression followed by stereotactic radiosurgery is currently considered the best alternative to total removal when the latter carries excessive perioperative risks. We present a rare case of a mainly located intrasellar ECH extending to the left CS discussing its clinical features and focusing on the most relevant aspects of the surgical management along with a review of the pertinent literature.

Letter of response: Evidence for the existence of a communication between the eye and the brain?

We have read with interest the letter to the editor: Evidence for the existence of a communication between the eye and the brain? First, we thank Wostyn et al. for their suggestions and comments. Wostyn et al. described an alternative hypothesis for the existence of a communication between the eye and the brain to explain intraocular silicone migration into the subarachnoid space [6]. This intraocular silicone migration represents a consequence of the possible continuum between the subarachnoid space surrounding the optic nerve and the subhyaloid space [2]. Terson syndrome (TS) is another possible consequence of this continuum with another direction. The TS was defined by an increase of the intracranial pressure (ICP) transmitted directly through the optic nerve sheath resulting in venous hypertension and bleeding of the retinal vessels [4]. Others speculated that the subarachnoid space is pressed directly into the orbital cavity via the optic nerve sheath. The combination of these two mechanisms seemed logical. Wostyn et al. proposed another explanation of the silicone migration by a paravascular communication between the surrounding of the retinal vascular system and the surroundings of the central vessels in the optic nerves with a possible transmission of the fluid from the vitreous cavity to the subarachnoid space. This hypothesis supports arguments for the discussion of the possible existence of the continuum [6]. Different predisposing factors need to be added to explain these two syndromes [1, 3]. The most important factors could be the increased intraocular pressure for the silicone migration into the brain or the increased intracranial pressure for the TS with a possible positive correlation between the TS and ICP [5]. This Bparavascular retino-orbital continuity^ could permit a transmission of fluid with two possible directions: from the subarachnoid space to the vitreous cavity and from the intraocular space to the subarachnoid space [6].

Familial intracranial aneurysm, the relationship of the aortic diameter

OBJECTIVES Familial predisposition appears as an identified risk factor for cerebrovascular disease. The primary objective of our study was to assess intracranial aneurysm (IA) recurrence rate in a population of familial IA. Secondary objectives were first to analyse the inheritance categorisation/pattern of these families and second to assess the correlation between the aortic diameter on MRI and the aneurysmal characteristics. PATIENTS AND METHODS Over a period of 20 years (1990-2010), 26 patients from 23 families, identified from a regional register, accepted to participate in this prospective trial in order to determine, the inheritance pattern, the screening of de novo aneurysms by CT angioscan, and the aortic mensuration by MRI. The transmission pattern was categorised into autosomal dominant inheritance, autosomal recessive and autosomal dominance with incomplete penetrance. The aortic diameter was measured: anatomic coverage in the caudo-cranial direction from the iliac arteries to the ventriculo-aortic junction. RESULTS All 26 patients [from 55.4 ± 11.2 years, sex ratio female/male: 1.36] were reviewed after a mean follow-up of 7.9 ± 6.6 years after the diagnosis of a cerebral aneurysm. The characteristics of this population were the diagnostic circumstances such as a subarachnoid hemorrhage (SAH) in 14 (53.8%), the multiple locations in 10 (38.5%) and a giant aneurysm in 4 (15.4%). Four de novo aneurysms were diagnosed in 3 patients (11.5%) after a mean follow-up of 22.3 ± 4 years, which corresponds to an annual incidence of 1.9 (95% CI 1.4-2.6%). The transmission pattern was autosomal dominant in 16 (61.5%), recessive in 3 (11.5%) and not defined in 7 (26.9%). As regards the aortic diameter, a significant decrease in the aortic diameter was observed in patients with an aneurysmal diameter superior to 10mm. CONCLUSION The rate of de novo aneurysm justifies prolonged monitoring by imaging of these patients with familial intracranial aneurysm. The narrowing of the terminal part of the aorta could be a hemodynamic factor involved into the IA development.