Jean Noël Vallée

Epistaxis revealing the rupture of a carotid aneurysm of the cavernous sinus extending into the sphenoid: treatment using an uncovered stent and coils. Review of literature

True carotid aneurysms with sphenoid extension and revealed by epistaxis are rare. A review of the literature shows the mortality risk of this pathology and the different therapeutic options. A 41-year-old female presented with a cavernous carotid aneurysm with sphenoid extension revealed by massive epistaxis. We propose a combined treatment of the affected vessel using coils and an uncovered stent. The first stage to stop the hemorrhages and occlude the aneurysm using the coil and the second stage several days later after anticoagulation using the stent to prevent revascularization. This treatment has been shown to be effective in producing immediate hemostasis and stable long-term occlusion.

Cerebral peritumoral oedema study: Does a single dynamic MR sequence assessing perfusion and permeability can help to differentiate glioblastoma from metastasis?

Our purpose was to differentiate glioblastoma from metastasis using a single dynamic MR sequence to assess perfusion and permeability parameters. 24 patients with glioblastoma or cerebral metastasis with peritumoral oedema were recruited and explored with a 3T MR unit. Post processing used DPTools software. Regions of interest were drawn around contrast enhancement to assess relative cerebral blood volume and permeability parameters. Around the contrast enhancement Glioblastoma present high rCBV with modification of the permeability, metastasis present slight modified rCBV without modification of permeability. In conclusion, peritumoral T2 hypersignal exploration associating morphological MR and functional MR parameters can help to differentiate cerebral metastasis from glioblastoma.

Controlled segmental balloon kyphoplasy: a new technique for patients with heterogeneous vertebral bone density.

Study Design. Case series. Objective. To describe a novel kyphoplasty procedure that gives uniform bone expansion in treatment of vertebra with heterogeneous bone structure. Summary of Background Data. Balloon kyphoplasty is used to treat vertebral compression fractures by restoring vertebral height and correcting kyphosis before the injection of bone cement that stabilizes the fracture. In vertebra with heterogeneous bone structure, balloon expansion may be nonuniformly as a result of this heterogeneity and could result in inadequate fracture reduction. Methods. In the first part of the procedure, the balloon remains partially in its introducer trocar to inflate only the distal segment of balloon in the stronger bone area that provides high mechanical resistance. This segmental inflation creates a cavity that will allow to initiate fracture reduction in the stronger bone area. In the second part of the procedure, the emerging segment is deflated and the balloon is advanced until it emerges completely from the introducer trocar, after which the balloon is inflated totally in the vertebral body. Seven vertebrae in 5 patients (mean age of 71.4 years) were managed with this procedure. Etiology of fractures included myeloma (2 patients, 4 vertebrae) and senile osteoporosis (3 patients, 3 vertebrae). Twenty-millimeter long kyphoplasty balloons were used in all vertebrae. Polyméthylmetacrylate bone cement was used to fill the cavities. Technical, anatomic and clinical parameters were used for evaluation of the procedure. Results. No complications occurred on balloon inflation. Mean volume of cement injected was 5.8 mL (range, 5–6 mL). Mean maximal inflation pressure was 200 PSI (range, 150–300 PSI). One (14.8%) cement leak was observed at 1 vertebra. Mean restoration of maximal lost height was 42.8% (range, 25%–52.9%). Mean reduction in local kyphosis was 4.4° (range, 0–10°). All 5 patients were pain free at 1 month post procedure. Morbidity and mortality were nil. Conclusion. The described procedure allows for uniform bone expansion and adequate fracture reduction in vertebrae with heterogeneous bone structure.

Caractérisation des perturbations du flux de LCS dans l’aqueduc du mésencéphale par IRM–CP à la phase aiguë de l’hémorragie méningée

PURPOSE Determining acute intracranial hydrodynamic changes after subarachnoid hemorrhage through an analysis of the CSF stroke volume (SV) as measured by phase-contrast MRI (PC-MRI) in the mesencephalon aqueduct. METHOD A prospective study was performed in 33 patients with subarachnoid hemorrhage. A PC-MRI imaging study was performed n the acute phase (< 48 hours). CSF flow was measured in the aqueduct. The appearance of acute hydrocephalus (HCA) was then compared with data on CSF flow, and the location of the intraventricular and perimesencephalic bleeding. RESULTS CSF analysis was performed on 27 patients, 11 of whom presented with an acute HCA. All 11 patients had an abnormal SV in the aqueduct: patients with a communicating HCA had an increased SV (n=8); and patients with a noncommunicating HCA had a nil SV (n=3). Patients with a normal SV in the aqueduct did not develop an acute HCA. Intraventricular bleeding significantly led to HCA (P=0.02), which was of the communicating type in 70% of cases. CONCLUSION Subarachnoid hemorrhage leads to intracranial CSF hydrodynamic modifications in the aqueduct in the majority of patients. CSF flow can help us to understand the mechanism of the appearance of acute HCA. Indeed, hydrocephalus occurred - of the communicating type in most cases - even in the presence of intraventricular bleeding.

Article originalCaractérisation des perturbations du flux de LCS dans l’aqueduc du mésencéphale par IRM–CP à la phase aiguë de l’hémorragie méningéeAcute CSF changes in the mesencephalon aqueduct after subarachnoid hemorrhage as measured by PC–MRI

PURPOSE Determining acute intracranial hydrodynamic changes after subarachnoid hemorrhage through an analysis of the CSF stroke volume (SV) as measured by phase-contrast MRI (PC-MRI) in the mesencephalon aqueduct. METHOD A prospective study was performed in 33 patients with subarachnoid hemorrhage. A PC-MRI imaging study was performed n the acute phase (< 48 hours). CSF flow was measured in the aqueduct. The appearance of acute hydrocephalus (HCA) was then compared with data on CSF flow, and the location of the intraventricular and perimesencephalic bleeding. RESULTS CSF analysis was performed on 27 patients, 11 of whom presented with an acute HCA. All 11 patients had an abnormal SV in the aqueduct: patients with a communicating HCA had an increased SV (n=8); and patients with a noncommunicating HCA had a nil SV (n=3). Patients with a normal SV in the aqueduct did not develop an acute HCA. Intraventricular bleeding significantly led to HCA (P=0.02), which was of the communicating type in 70% of cases. CONCLUSION Subarachnoid hemorrhage leads to intracranial CSF hydrodynamic modifications in the aqueduct in the majority of patients. CSF flow can help us to understand the mechanism of the appearance of acute HCA. Indeed, hydrocephalus occurred - of the communicating type in most cases - even in the presence of intraventricular bleeding.

Prise en charge radiologique des brèches ostéo-durales: à propos d'un cas rare de brèche ethmoïdale de nature spontanée

Une patiente de 58 ans se présentait spontanément aux urgences pour céphalées intenses évoluant depuis quelques jours dans les suites d’un épisode d’épistaxis. L’examen clinique d’entrée mettait en évidence une rhinorrhée abondante de liquide clair également d’apparition récente. L’interrogatoire ne retrouvait pas d’antécédent ORL, de chirurgie ORL ou de traumatisme crânien ou facial y compris ancien. Il n’y avait pas d’antécédents médicaux notables. Une TDM cérébrale sans injection de produit de contraste était dès lors réalisée en urgence à la recherche d’une hémorragie sous arachnoïdienne ou d’un accident vasculaire hémorragique. Elle mettait en évidence une importante pneumocéphalie diffuse visible en regard des deux lobes frontaux, des deux lobes temporaux, des citernes de la base ainsi que des espaces sous arachnoïdiens de la convexité (fig. 1a). Le système ventriculaire présentait un niveau hydro-aérique au niveau de ses deux cornes frontales (pneumocéphalie ventriculaire) (fig. 1b). Il n’existait pas d’anomalie parenchymateuse individualisable ou d’hémorragie intra ou péricérébrale. Les investigations étaient alors complétées par un examen tomodensitométrique du massif facial en coupes fines avec reconstructions multiplanaires. Celui-ci objectivait la brèche ostéo-durale mesurée à 2 mm de largeur sur les reconstructions dans le plan coronal au niveau de la lame criblée de l’ethmoïde du côté gauche