Jean Guichard

Real-time magnetic resonance-guided laser thermal therapy for focal metastatic brain tumors.

OBJECTIVE We report the initial results of a pilot clinical trial exploring the safety and feasibility of the first real-time magnetic resonance-guided laser-induced thermal therapy of treatment-resistant focal metastatic intracranial tumors. METHODS Patients with resistant metastatic intracranial tumors who had previously undergone chemotherapy, whole-brain radiation therapy, and radiosurgery and who were recused from surgery were eligible for this trial. Under local anesthesia, a Leksell stereotactic head frame was used to insert a water-cooled interstitial fiberoptic laser applicator inside the cranium. In the bore of a magnetic resonance imaging (MRI) scanner, laser energy was delivered to heat the tumor while continuous MRI was performed. A computer workstation extracted temperature-sensitive information to display images of laser heating and computed estimates of the thermal damage zone. Posttreatment MRI scans were used to confirm the zone of thermal necrosis, and follow-up was performed at 7, 15, 30, and 90 days after treatment. RESULTS In all cases, the procedure was well tolerated without secondary effect, and patients were discharged to home within 14 hours after the procedure. Follow-up imaging showed an acute increase in apparent lesion volume followed by a gradual and steady decrease. No tumor recurrence within thermal ablation zones was noted. CONCLUSION In this ongoing trial, a total of four patients have had six metastatic tumors treated with laser thermal ablations. Magnetic resonance-guided laser-induced thermal therapy appears to provide a new, efficient treatment for recurrent focal metastatic brain disease. This therapy is a prelude to the future development of closed-head interventional MRI techniques in neurosurgery.

Perception of Verticality After Recent Cerebral Hemispheric Stroke

Background and Purpose— Perception of the subjective visual vertical (SVV) is affected by cerebral hemispheric lesions. Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances. There is still uncertainty about the possible effects of a visual field defect and of the side and site of the lesion. This study was conducted to assess SVV with the head upright or tilted and to explore its relation to a visual field defect, visuospatial neglect, and the site of lesion. Methods— Forty patients with hemiplegia after a recent hemispheric stroke (20 with left and 20 with right stroke) were studied. The site of the lesion was determined on CT scan, with special attention focused on the vestibular cortex. A neurological examination with determination of the visual field and visual neglect was conducted before SVV was tested. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. Measures were repeated with binocular and monocular vision and with the head upright or tilted to the right or left. Results— SVV was abnormally deviated in 23 of 40 patients (57%). The deviation was significantly greater among patients with a right or left hemispheric lesion than among healthy controls (−2.2° and 1.5° versus 0.2°); the same applied to the range of uncertainty (7.6° and 4.7° versus 1.9°). SVV deviation was not significantly related to the location of the lesion but was closely related to visuospatial neglect. The “E” effect observed in controls with the head tilted, ie, an SVV shift in the direction opposite to the head tilt, was not observed in hemiplegic patients with the head tilted toward the nonparetic side. Conclusions— Recent hemispheric stroke affects SVV perception, which is closely correlated to visuospatial neglect. It is suggested that the E effect might be mediated by the stretching of the somatosensory structure of the neck.

Laser thermal therapy: Real‐time MRI‐guided and computer‐controlled procedures for metastatic brain tumors

We report the final results of a pilot clinical trial exploring the safety and feasibility of real‐time magnetic resonance‐guided laser‐induced thermal therapy (MRgLITT) for treatment of resistant focal metastatic intracranial tumors.

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.

A Century of Career Education: Review and Perspectives

Although a textbook defining the principles of career education was published in Paris as early as 1957, career education did not actually develop in Europe until a quarter of a century later. Why it eventually came into its own can be explained by a number of factors, including an ideology promoting individual success, and changes in work organisation. The ends of career education practices are seldom defined: are they aimed at making workers more flexible?; are they meant to facilitate personal achievement?Although the theoretical foundations of these educational programs are often fragile and many of them have never been rigorously evaluated, those that have appear to have reached some of their educational objectives. Several factors should determine the future of career education: the evolution of the social function of school, changes in the role attributed to work in personal development, etc.

A Constructivist Approach to Ethically Grounded Vocational Development Interventions for Young People

This chapter introduces an ethical component to career education and counselling as it can be applied in constructivist approaches. A constructivist approach focuses on the individual’s life-planning and vocational interventions are aimed at helping them in this process, which will involve work and employment. The authors argue that these interventions thus need to be grounded in knowledge of the self-construction process and make their societal and ethical ends explicit. The first part of the chapter examines some European models of the way in which young people self-construct their futures. These are: (1) Huteau’s systemic model of the representative matching of self and occupations; (2) Dumora’s systemic and developmental model of the development of career decision making cognitive abilities; (3) the Van Esbroeck et al. dynamic model of career choice that represents the recurrent and diverse mini-cycles of career development activities; and (4) Guichard’s self-construction model, which centres on the self rather than the career, and where vocational counselling and education is aimed at helping individuals in their self-construction, which includes involvement in occupational activities. The second part of the chapter looks at human and social goals and outcomes of vocational interventions, and presents two career development interventions included in such a framework, the first relating to career education and the second to counselling.

Dilated Perivascular Spaces in Small-Vessel Disease: A Study in CADASIL

Background and Aim: Dilated perivascular spaces (dPVS) have previously been associated with aging and hypertension-related cerebral microangiopathy. However, their risk factors, radiological features and clinical relevance have been poorly evaluated in CADASIL (cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy), a unique model to investigate the pathophysiology of ischemic small-vessel disease. The purpose of this study was to investigate these different aspects in a large cohort of patients with this disorder. Methods: Demographic and MRI data of 344 patients from a prospective cohort study were analyzed. The severity of dPVS was evaluated separately in the anterior temporal lobes, subinsular areas, basal ganglia and white matter, using validated semiquantitative scales. Logistic and multiple linear regression models were used to determine the risk factors associated with the severity of dPVS in these different regions and their relationships with cognition, disability and the MRI markers of the disease (white matter hyperintensities (WMH) lacunar infarcts, microbleeds and brain parenchymal fraction (BPF)). Results: The severity of dPVS was found to increase with age regardless of cerebral area (p < 0.001). In contrast with dPVS in other locations, the severity of dPVS in the temporal lobes or subinsular areas was also found strongly and specifically related to the extent of WMH (p < 0.001). Conversely, no significant association was detected with lacunar volume, number of microbleeds or BPF. A high degree of dPVS in the white matter was associated with lower cognitive performances independently of age and other MRI markers of the disease including BPF (p ≤ 0.04). Conclusions: In CADASIL, the progression of the hereditary microangiopathy with aging may promote the dilation of perivascular spaces throughout the whole brain but with variable extent according to cerebral location. In temporal lobes and subinsular areas, dPVS are common MRI features and may share a similar pathogenesis with the extension of WMH during the course of the disease. dPVS may also participate in the development of cognitive decline in this model of small-vessel disease, and their large number in white matter may alert clinicians to a higher risk of cognitive decline in CADASIL.

Are somatostatin analogs therapeutic alternatives in the management of head and neck paragangliomas

Background: Although mostly benign, head and neck paragangliomas require active management because of injury to adjacent neurovascular structures. Surgery, usually preceded by embolization, allows for complete tumor removal. However, surgery carries a significant risk of iatrogenic injury, related to tumor volume. Because paragangliomas express somatostatin receptors with high density, we investigated the effect of a long‐acting somatostatin analogue (OCT‐LAR) on the size of such tumors to reduce iatrogenic injury and related the percentage of tumor shrinkage to a tracer uptake index calculated on somatostatin receptor scintigraphy (SRS).

Extensive White Matter Hyperintensities May Increase Brain Volume in Cerebral Autosomal-Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy

Background and Purpose— The extent of white matter hyperintensities (WMH) is associated with cerebral atrophy in elderly people. WMH is a radiological hallmark of cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), but their relationship with brain volume remains poorly understood. The association between WMH and brain volume was analyzed in a large population of patients with CADASIL. Methods— Demographic and MRI data of 278 patients recruited from a prospective cohort study were analyzed. Volumes of WMH and lacunar infarcts, number of cerebral microbleeds, and brain parenchymal fraction were measured. Multivariate analysis was used to study the impact of WMH on brain volume at baseline. Results— In univariate analyses, brain parenchymal fraction was negatively associated with age, male sex, and all MRI markers. Multiple regression modeling showed that brain parenchymal fraction was inversely related to age, number of cerebral microbleeds, and normalized volume of lacunar infarcts but positively related to normalized volume of WMH (P<0.001). This positive relationship was independent of the presence/absence of lacunar infarcts or of cerebral microbleeds. Subgroup analysis showed that this association was significant in subjects having normalized volume of WMH ≥6.13 or brain parenchymal fraction ≥86.37% (median values, both P⩽0.001). Conclusion— The results of the present study suggest that extensive WMH may be associated with increase of brain volume in CADASIL. In this disorder, WMH may be related not only to loss of white matter components, but also to a global increase of water content in the cerebral tissue.

Expanding the Impact of the Psychology of Working: Engaging Psychology in the Struggle for Decent Work and Human Rights

Building on new developments in the psychology of working framework (PWF) and psychology of working theory (PWT), this article proposes a rationale and research agenda for applied psychologists and career development professionals to contribute to the many challenges related to human rights and decent work. Recent and ongoing changes in the world are contributing to a significant loss of decent work, including a rise of unemployment, underemployment, and precarious work across the globe. By failing to satisfy human needs for economic survival, social connection, and self-determination, the loss of decent work undermines individual and societal well-being, particularly for marginalized groups and those without highly marketable skills. Informed by innovations in the PWF/PWT, we offer exemplary research agendas that focus on examining the psychological meaning and impact of economic and social protections, balancing caregiving work and market work, making work more just, and enhancing individual capacities for coping and adapting to changes in the world of work. These examples are intended to stimulate new ideas and initiatives for psychological research that will inform and enhance efforts pertaining to work as a human right.