J. Peltier

Cognitive Impairment and Dementia After Intracerebral Hemorrhage: A Cross-sectional Study of a Hospital-based Series

BACKGROUND Frequencies of cognitive impairment and dementia have not been assessed in spontaneous intracerebral hemorrhage (ICH). The objective of this study was to determine the frequencies and patterns of cognitive impairment and dementia in a cross-sectional study of consecutive patients hospitalized in a single university medical center. METHODS Of 183 consecutive patients hospitalized between 2002 and 2006, 80 survivors were contacted and 78 were included (mean time since stroke 40 months). Thirty patients were scored with the Informant Questionnaire on Cognitive Decline in the Elderly and Instrumental Activities of Daily Living in a telephone interview, and 48 underwent a comprehensive clinical and neuropsychological assessment. RESULTS Dementia was observed in 18 of 78 patients (23%; 95% confidence interval [CI] 13-32%) and cognitive impairment without dementia was seen in 37 of 48 patients (77%; 95% CI 65-89%). The cognitive disorders mainly concerned episodic memory (52%), psychomotor speed (44%), and executive function (37%), followed by language and visuoconstructive abilities. In a logistic regression analysis, Rankin score >1 at discharge and hemorrhage volume were the initial factors to be selected as a predictor of long-term dementia. CONCLUSIONS This single-center, cross-sectional study revealed that the prevalence of dementia and cognitive impairment without dementia after ICH are high and are similar to those observed in cerebral infarct. Further longitudinal, prospective studies are required to assess accurately the prevalence, mechanisms and predictors of post-ICH dementia.

Perfusion MRI as a Neurosurgical Tool for Improved Targeting in Stereotactic Tumor Biopsies

Objective: Stereotactic biopsies are subject to sampling errors (essentially due to target selection). The presence of contrast enhancement is not a reliable marker of malignancy. The goal of the present study was to determine whether perfusion-weighted imaging can improve target selection in stereotactic biopsies. Methods: We studied 21 consecutive stereotactic biopsies between June 2009 and March 2010. Perfusion-weighted magnetic resonance imaging (MRI) was integrated into our neuronavigator. Perfusion-weighted imaging was used as an adjunct to conventional MRI data for target determination. Conventional MRI alone was used to determine the trajectory. Results: We found a linear correlation between regional cerebral blood volume (rCBV) and vessel density (number of vessels per mm2; R = 0.64; p < 0.001). Perfusion-weighted imaging facilitated target determination in 11 cases (52.4%), all of which were histopathologically diagnosed as glial tumors. For glial tumors, which presented with contrast enhancement, perfusion-weighted imaging identified a more precisely delimited target in 9 cases, a different target in 1 case, and exactly the same target in 1 other case. In all cases, perfusion-selected sampling provided information on cellular features and tumor grading. rCBV was significantly associated with grading (p < 0.01), endothelial proliferation (p < 0.01), and vessel density (p < 0.01). For lesions with rCBV values ≤1, perfusion-weighted MRI did not help to determine the target but was useful for surgical management. Conclusions: For stereotactic biopsies, targeting based on perfusion-weighted imaging is a feasible method for reducing the sampling error and improving target selection in the histopathological diagnosis of tumors with high rCBVs.

Surgical anatomy and surgical approaches to the lateral ventricles

This study focuses on the surgical approaches to intraventricular tumors which have developed within the cavity of the lateral ventricle. The first section is dedicated to embryology and describes the wrapping of the telencephalic vesicles around the thalamus and the morphogenesis of basal nuclei and commissures. In the second section, the anatomy of the lateral ventricles is described, along with their arterial and venous vasculature, their relationship with the eloquent cortical areas and cortical sulci, and their relationship with white matter fascicles, especially the optic radiations. In the third part, the main surgical approaches to the frontal horn, to the ventricular atrium and to the temporal horn are detailed.

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.

Neurosarcoïdose médullaire révélatrice

Resume Les formes medullaires de la sarcoidose sont rares et il est exceptionnel qu’elles soient inaugurales. Nous rapportons le cas d’une patiente africaine de 45 ans chez laquelle un diagnostic de sclerose en plaques avait ete suggere devant la presence d’un syndrome medullaire regressif sous methylprednisolone et a rechutes. L’imagerie par resonance magnetique medullaire revela des hypersignaux etages de C3 a D1 prenant le gadolinium sur les sequences ponderees en T2 et un aspect de grosse moelle de C7 a D1. L’IRM encephalique etait sans particularite. Le scanner X thoracique montrait un syndrome interstitiel sans adenopathie (stade III). L’enzyme de conversion de l’angiotensine etait tres elevee dans le sang et dans le liquide cephalorachidien. La ponction lombaire montra une meningite lymphocytaire. Le lavage broncho-alveolaire revela une hyperlymphocytose avec un rapport CD4/CD8 tres eleve. L’evolution sous corticoides fut satisfaisante tant sur le plan clinique que biologique. Ce cas suggere que devant un syndrome medullaire il convient de penser a la neurosarcoidose, surtout si le patient est de race noire. En l’absence de lesion accessible a la biopsie, le diagnostic repose sur un faisceau d’arguments cliniques, neuroradiologiques et biologiques.

An unusual superolateral origin of ophthalmic artery: an anatomic case report.

Background and importanceIf ophthalmic artery’s (OphA) origin anomalies are frequent, the superolateral origin of the OphA was rarely described.Clinical presentationDuring an aneurysmal surgery, a superolateral origin of the left OphA was found. This variation was associated with a sylvian aneurysm. The anatomical, embryological features, the neurosurgical implications of this origin such as treatment of carotid-ophthalmic aneurysm or intra arterial retinoblastoma chemotherapy are discussed.ConclusionTo the best of our knowledge, this is a very rare operative case of both superolateral origin and initial course of OphA.

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.

Dissection of the vertebral artery complicating Jefferson fracture

Although traumatic vertebral artery dissections are commonly observed, the association with an upper cervical spine is very rare judging from the scarcity of cases reported in the literature. This report describes the case of a patient with a Jefferson fracture causing a delayed vertebral artery dissection. CT brain scan and magnetic resonance angiography showed an infarction of the cerebellum and brainstem. The patient required a shunt, was treated by a halo orthosis and was anti-coagulated with heparin. The evolution was unfavourable. This case draws attention to the fact that a displacement of the lateral masses of the atlas can cause a vertebral artery dissection. This occlusion and ischemic symptoms can be delayed. Resonance angiogram or selective angiography should be used to demonstrate vessel dissections, especially for polytraumatised patients.RésuméSi les dissections de l’artère vertébrale sont fréquentes en traumatologie, leur association dans un traumatisme du rachis cervical supérieur reste rare si l’on s’en réfère aux données de la littérature. Ce cas clinique résume l’histoire d’un patient présentant une dissection de l’artère vertébrale négligée secondaire à une fracture de Jefferson. La tomodensitométrie cérébrale et l’imagerie par résonance magnétique montraient un accident vasculaire ischémique du tronc cérébral et du cervelet. Le patient bénéficiait d’une dérivation ventriculaire externe, était traité par un halo cervical, et anticoagulé par héparinothérapie. L’évolution était défavorable. Les auteurs attirent l’attention sur le fait qu’un déplacement des masses latérales de l’atlas peut occasionner une dissection de l’artère vertébrale. Ces symptômes peuvent passer inaperçus. L’angiographie par résonance magnétique et l’artériographie sélective conventionnelle doivent être proposées pour confirmer le diagnostic, tout particulièrement chez les patients polytraumatisés.

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.