Louis-Marie Terrier

Internal carotid artery dissection after anterior cervical disc replacement: first case report and literature review of vascular complications of the approach.

We report the case of a 41-year-old woman who underwent cervical total disc replacement at C4C5 and C5C6 levels and fusion at C6C7 level through an anterior right-side approach. After anesthesia recovery, the patient presented left hemiparesia and facial palsy due to large right hemispheric stroke. Diffusion-weighted magnetic resonance imaging was performed as soon as the patient developed neurologic symptoms of stroke and revealed a right internal carotid artery dissection. Digital substraction angiography, endovascular stenting, angioplasty and thrombectomy were performed. Six months after treatment, clinical examination showed mild left-arm spasticity. To the best of our knowledge, only two cases of internal carotid artery stroke without dissection or thrombosis are reported. In conclusion, although vascular complications are rare after anterior cervical spine procedure, internal carotid artery dissection can occur. Suspected risk factors are prolonged retraction of the carotid artery and neck extension.

Natural course and prognosis of anaplastic gangliogliomas: a multicenter retrospective study of 43 cases from the French Brain Tumor Database

Background Anaplastic gangliogliomas (GGGs) are rare tumors whose natural history is poorly documented. We aimed to define their clinical and imaging features and to identify prognostic factors. Methods Consecutive cases of anaplastic GGGs in adults prospectively entered into the French Brain Tumor Database between March 2004 and April 2014 were screened. After diagnosis was confirmed by pathological review, clinical, imaging, therapeutic, and outcome data were collected retrospectively. Results Forty-three patients with anaplastic GGG (median age, 49.4 y) from 18 centers were included. Presenting symptoms were neurological deficit (37.2%), epileptic seizure (37.2%), or increased intracranial pressure (25.6%). Typical imaging findings were unifocal location (94.7%), contrast enhancement (88.1%), central necrosis (43.2%), and mass effect (47.6%). Therapeutic strategy included surgical resection (95.3%), adjuvant radiochemotherapy (48.8%), or radiotherapy alone (27.9%). Median progression-free survival (PFS) and overall survival (OS) were 8.0 and 24.7 months, respectively. Three- and 5-year tumor recurrence rates were 69% and 100%, respectively. The 5-year survival rate was 24.9%. Considering unadjusted significant prognostic factors, tumor midline crossing and frontal location were associated with shorter OS. Temporal and parietal locations were associated with longer and shorter PFS, respectively. None of these factors remained statistically significant in multivariate analysis. Conclusions We report a large series providing clinical, imaging, therapeutic, and prognostic features of adult patients treated for an intracerebral anaplastic GGG. Our results show that pathological diagnosis is difficult, that survivals are only slightly better than for glioblastomas, and that complete surgical resection followed with adjuvant chemoradiotherapy offers longer survival.

Craniovertebral Junction Transoral Approach: Predictive Factors of Complications

BACKGROUND The transoral approach provides the most direct exposure to extradural lesions of the ventral craniovertebral junction. The morbidity and mortality from this approach greatly limits its use because they are still feared and debated. Using univariable and multivariable logistic regression analyses, this study aims to identify the factors associated with short-term complications in patients undergoing the transoral approach. METHODS A consecutive cohort analysis of prospectively collected data in several neurosurgery spine departments evaluated 143 consecutive patients who had undergone craniovertebral junction transoral approach surgery. The mean age at the time of surgery was 45.1 ± 19.1 years. The study analyzed the comorbidities, the operative procedure, and postoperative morbidity and mortality. RESULTS Seventeen patients (11.9%) had a postoperative complication in the first month. In our univariable analysis: age, smoking, tumor etiology, preoperative posterior fixation, posterior bone graft, preoperative external lumbar shunt, and the transoral approach pathway were significantly associated with postoperative mortality and morbidity. In our multivariable analyses, preoperative external lumbar shunt was significantly associated with complication risks (odds ratio [OR] 6.7; 95% confidence interval [CI] 2.1-21.7, P < 0.001), whereas preoperative posterior fixation (OR 0.28; 95% CI 0.08-1.1, P < 0.04) and posterior bone graft (OR 0.14; 95% CI 0.03-0.6, P < 0.008) were significantly associated with lower complication risks. CONCLUSIONS To reduce complications, it is essential to be aware of and to manage these preoperative risk factors. In such manner, we insinuate that postoperative complications depend on the surgeons familiarity with the transoral approach.

The interperiosteodural concept applied to the jugular foramen and its compartmentalization

OBJECTIVE The dura mater is made of 2 layers: the endosteal layer (outer layer), which is firmly attached to the bone, and the meningeal layer (inner layer), which directly covers the brain and spinal cord. These 2 dural layers join together in most parts of the skull base and cranial convexity, and separate into the orbital and perisellar compartments or into the spinal epidural space to form the extradural neural axis compartment (EDNAC). The EDNAC contains fat and/or venous blood. The aim of this dissection study was to anatomically verify the concept of the EDNAC by focusing on the dural layers surrounding the jugular foramen area. METHODS The authors injected 10 cadaveric heads (20 jugular foramina) with colored latex and fixed them in formalin. The brainstem and cerebellum of 7 specimens were cautiously removed to allow a superior approach to the jugular foramen. Special attention was paid to the meningeal architecture of the jugular foramen, the petrosal inferior sinus and its venous confluence with the sigmoid sinus, and the glossopharyngeal, vagus, and accessory nerves. The 3 remaining heads were bleached with a 20% hydrogen peroxide solution. This procedure produced softening of the bone without modifying the fixed soft tissues, thus permitting coronal and axial dissections. RESULTS The EDNAC of the jugular foramen was limited by the endosteal and meningeal layers and contained venous blood. These 2 dural layers joined together at the level of the petrous and occipital bones and separated at the inferior petrosal sinus and the sigmoid sinus, and around the lower cranial nerves, to form the EDNAC. Study of the dural sheaths allowed the authors to describe an original compartmentalization of the jugular foramen in 3 parts: 2 neural compartments-glossopharyngeal and vagal-and the interperiosteodural compartment. CONCLUSIONS In this dissection study, the existence of the EDNAC concept in the jugular foramen was demonstrated, leading to the proposal of a novel 3-part compartmentalization, challenging the classical 2-part compartmentalization, of the jugular foramen.

Spinal metastases in multiple myeloma: A high-risk subgroup for ISS III patients

BACKGROUND Patients with multiple myeloma (MM) have an extremely heterogeneous prognosis. The International Staging System (ISS) is actually the most reliable staging system and chromosomal abnormalities were integrated in the Revised-ISS. We wanted to evaluate the prognostic value of spinal secondary localization in patients with MM and its impact on the ISS. METHODS Epidemiological and biological data, as well as treatment protocols and secondary localization were analyzed for 650 consecutive patients diagnosed with MM from January 2006 to January 2017. RESULTS The overall survival (OS) was dependent on the WHO performance status, ISS and Salmon and Durie stage at diagnosis. Furthermore, presence of spinal metastases at diagnosis was predictive of a worse outcome (p < 0.0001), while presence of peripheral bone metastases was not. Spinal metastases had a significant impact on OS for ISS III patients (p < 0.0001). Also, a history of bone marrow graft was associated with a better OS (p < 0.0001), while radiotherapy had no significant impact. The multivariate analysis confirmed that the spinal metastases at diagnosis determined a high-risk subgroup for ISS III patients with a very poor OS (p < 0.0001). CONCLUSIONS Spinal metastases are a negative prognostic factor for patients with MM, especially for ISS III patients, and are associated with a shorter OS. Spinal metastasis should be systemically searched for and should be included in a modified staging system to better manage these patients.

Surgical Anatomy of the Insula

The insula was for a long time considered as one of the most challenging areas of the brain. This is mainly related to its location, deep and medial to the frontoparietal, temporal, and fronto-orbital opercula. Another difficulty is the content of the lateral fossa, located between the insula and the opercula, which contains the trunks, stem, arteries, and cortical branches of the insular (M2) and opercular (M3) segments of the middle cerebral artery (MCA). Finally, the insula is surrounded by several white matter tracts and cortical structures having important functional roles, especially for language in the dominant hemisphere; the insula is indeed located between a dorsal phonological stream, centered by the arcuate fasciculus and lateral to the posterior insula, and a ventral semantic system, medial to the ventral aspect of the insula and centered by the inferior fronto-occipital fasciculus (IFOF). This chapter reviews some of these surgically relevant anatomical relationships.

Bilateral ape hand deformity

A 54-year-old man with a history of alcohol abuse (>2 bottles of wine per day for 40 years) presented with 2 years of progressive weakness in all 4 limbs. Alcoholic polyneuropathy was diagnosed on clinical grounds and gabapentin was used for alcohol withdrawal.1

The Musical Footprint of Cushing Syndrome

The Musical Footprint of Cushing Syndrome Endogenous pathologic hypercortisolism, or Cushing syndrome, is associated with poor quality of life, morbidity, and increased mortality.1 The clinical presentation of Cushing syndrome varies, in part related to the extent and duration of cortisol excess.2 When hypercortisolism is severe, its signs and symptoms are unmistakable. In particular, proximal muscle weakness; increased fat in the abdomen, torso, and face; and wide purple striae suggest marked hypercortisolism. Because of the variety in presentation, patients are often referred to a dermatologist for red facial skin, poor wound healing, andstriae.Earlydiagnosismaymitigatetheprogressionofthedisease. We present the case of a 19-year-old musician presenting with a history of weight gain of 10 kg in 2 years, muscular weaknessinlowerlimbs,skinfragility,andrepeatedecchymosis.Purple marks developed on the thorax, thighs, shoulders, and arms.3 The patient was mainly concerned about “flameshaped” abdominal striae, that according to him, appeared several months before. These wide purple striae had a very typical appearance, forming the shape of a lyre (Figure 1A), an instrument associated in the Greek mythology with Apollo, God of art, music, and poetry (Figure 1B). These signs and symptoms suggested Cushing syndrome, which was confirmed by endocrine evaluation showing a high level of 24-hour urinary free cortisol (2036 nmol/24 hours; reference range, 30-200 nmol/24 hours)4 and brain magnetic resonance imaging (MRI) exploration showing the presence of a pituitary microadenoma located inside the left pituitary wing (Figure 2A). Figure 2. Brain Magnetic Resonance Images (MRIs)