Nicolas de Tribolet

EEG-Triggered Functional MRI in Patients With Pharmacoresistant Epilepsy

Functional magnetic resonance imaging (fMRI) triggered by scalp electroencephalography (EEG) recordings has become a promising new tool for noninvasive epileptic focus localization. Studies to date have shown that it can be used safely and that highly localized information can be obtained. So far, no reports using comprehensive clinical information and/or long‐term follow‐up after epilepsy surgery in a larger patient group have been given that would allow a valuable judgment of the utility of this technique. Here, the results of 11 patients with EEG‐triggered fMRI exams who also underwent presurgical evaluation of their epilepsy are given. In most patients we were able to record good quality EEG inside the magnet, allowing us to trigger fMRI acquisition by interictal discharges. The fMRI consisted of echoplanar multislice acquisition permitting a large anatomical coverage of the patients brain. In 8 of the 11 patients the exam confirmed clinical diagnosis, either by the presence (n = 7) or absence (n = 1) of focal signal enhancement. In six patients, intracranial recordings were carried out, and in five of them, the epileptogenic zone as determined by fMRI was confirmed. Limitations were encountered a) when the focus was too close to air cavities; b) if an active epileptogenic focus was absent; and c) if only reduced cooperation with respect to body movements was provided by the patient. We conclude that EEG‐triggered fMRI is a safe and powerful noninvasive tool that improves the diagnostic value of MRI by localizing the epileptic focus precisely. J. Magn. Reson. Imaging 2000;12:177–185.

Appropriateness of Indications for Surgery of Lumbar Disc Hernia and Spinal Stenosis

Study Design This prospective study examines the appropriateness of indications for surgery of herniated intervertebral disc and spinal stenosis in patients undergoing surgery in a university hospital setting. Objective To evaluate the appropriateness of surgery using explicit criteria developed by an expert panel in the United States. Summary of Background Data The use of surgery for herniated intervertebral disc and spinal stenosis varies widely within and among countries. It has been postulated that the main reason for treatment failure is poor selection of condidates for the procedure. Methods The authors prospectively evaluated appropriateness of surgical indications for herniated lumbar intervertebral disc or spinal stenosis in 328 consecutive patients undergoing the operation in two university neurosurgery departments. Outcome was measured 1 year after surgery by a standardized interview. Results Indications for surgery were considered to be appropriate or equivocal in 202 (62%) patients and inappropriate in 126 (38%). Among the 126 inappropriate procedures, 66 were so rated because of insufficient activity restriction before the procedure. One year after surgery, 74% of the patients perceived the results of the operation as good or very good. Conclusions Appropriateness as measured by the criteria established by the American panel identified a large percentage of day-to-day practice in the two surgical units as inappropriate. However, use of criteria that include new findings about lack of efficacy of bed rest probably would lower this percentage. Criteria of appropriateness of medical and surgical procedures, developed through the panel process, need to be updated regularly.

Cefuroxime Prophylaxis Is Effective in Noninstrumented Spine Surgery : A Double-Blind, Placebo-Controlled Study

Study Design. Double-blind, placebo-controlled randomized clinical trial. Objective. To assess the efficacy of 1 preoperative 1.5 g dose of cefuroxime in preventing surgical site infection after surgery for herniated disc. Summary of Background Data. Antibiotic prophylaxis was only tested in nonconclusive trials in this setting. Methods. The study was conducted in 2 university hospitals in Switzerland. Patients were assessed for occurrence of surgical site infection (defined by the criteria of the Centers for Diseases Control and Prevention), other infections, or adverse events up to 6 months after surgery. Outcome measures were compared in a univariate, per-protocol analysis. Results. Baseline characteristics were similar in patients allocated to cefuroxime (n = 613) or placebo (n = 624). Eight (1.3%) patients in the cefuroxime group and 18 patients (2.8%) in the placebo group developed a surgical site infection (P = 0.073). A diagnosis of spondylodiscitis or epidural abscess was made in 9 patients in the placebo group, but none in the cefuroxime group (P < 0.01), which corresponded to a number necessary to treat of 69 patients to prevent one of these infections. There were no significant adverse events attributed to either cefuroxime or placebo. Conclusion. A single, preoperative dose of cefuroxime significantly reduces the risk of organ-space infection, most notably spondylodiscitis, after surgery for herniated disc.

Leptomeningeal cyst in newborns due to vaccum extraction: report of two cases

Two new cases of leptomeningeal cysts subsequent to vacuum extraction are reported. Both children presented with a huge, nonpulsating, transilluminating subgaleal collection over the anterior fontanel that appeared soon after instrument delivery. Plain X-rays, computed tomography, and magnetic resonance imaging confirmed that the subgaleal collection was cerebrospinal fluid and showed the presence of a diastatic coronal suture in both cases. Treatment consisted of duraplasty with periosteal flaps and application of fibrin glue. In one case, an associated porencephalic cyst was treated with a cystoperitoneal shunt. Surgical treatment of leptomeningeal cyst due to vaccum extraction is simple and should not be postponed, despite the tendency for the extracrainal cyst to regress, because of the potential risk of continuous growth of an underlying porencephalic cyst and risk of neurological damage.

Quality of Life after Aneurysmal Subarachnoid Hemorrhage in the Elderly

With the advancing age of the population in the western countries, aneurysmal subarachnoid hemorrhage in elderly patients has become an increasingly frequent situation. As endovascular and surgical exclusion of the aneurysm diminishes the likelihood of re-bleeding but does not directly influence the patient’s recovery from the first rupture, such an aggressive attitude should probably only be offered to elderly patients with a potential of recovering with an acceptable quality of life. In these circumstances, the decision to secure the ruptured aneurysm heavily relies on understanding the factors determining which patient will recover and which one will not. To provide an insight into this difficult process, we reviewed our experience with 33 consecutive patients, aged 670 years and admitted to our hospital with a diagnosis of aneurysmal subarachnoid hemorrhage. Outcome was measured with a questionnaire assessing the patients’ quality of life between 1 and 2 years after the aneurysm rupture. The median age of these 10 males and 23 females was 76.8 years (range 70–83). Nineteen patients, all with an initial WFNS score between 1 and 3, underwent securing of the aneurysm, whereas the remaining 14 were offered conservative and supportive medical treatment (table 1). The reason for conservative treatment was either a bad initial clinical condition (WFNS 13) or significant co-morbidity. Thirty-day mortality in the whole group was 45% (15/33). Among the survivors, 53% were able to return to their previous home in a complete (modified Rankin Score – mRS – [1] 0–2) or almost complete (mRS 3) state of independence; 40% rated their quality of life as ‘same as before’, 30% as ‘mildly to moderately diminished’ and 30% as ‘severely diminished’. In the 14 patients treated conservatively, the main causes of death were the initial hemorrhage (36%) and early re-bleeding (36%). Fatal re-bleeding occurred during the first 24 h after the initial SAH in 3, in the first 36 h in 1 and after 13 days in 1 patient. Four patients (28%) survived (table 1), 2 with excellent (mRS 1) and 2 with a satisfactory quality of life (mRS 3); 2 of them were still alive at the time of this review (32 and 34 months after SAH), and 2 had died of reasons not related to the unsecured aneurysm (64 and 18 months after the SAH). Among the 19 patients with a secured aneurysm, vasospasm was by far the main cause of mortality (26%) and left all of those who Table 1. Relation between outcome, WFNS score at presentation and treatment modality

Transient crossed aphasia evidenced by functional brain imagery

Crossed aphasia refers to language deficits induced by unilateral right hemisphere injuries in right-handed people who had no previous history of brain damage. One of the intriguing questions concerning crossed aphasia is the atypical language representation in the brain. In this respect, fMRI is a valuable tool for understanding the neural basis of crossed aphasia. Here, we used neuropsychological and fMRI language tasks in a right-handed subject who presented a crossed aphasia due to a right frontal meningioma. fMRI maps from two language tasks showed bilateral patterns of activation. In the light of previous studies reporting much frequent bilateral than exclusive right hemisphere representations, we hypothesise that some crossed aphasia cases could occur in subjects with bilateral language representation.

Herald facial numbness.

Three unusual patients who developed subacute facial numbness as the heralding symptom of an expanding tumor that involved the trigeminal nerve fibers are reported. The first patient had clinical and electrophysiological evidence of an isolated mental neuropathy as a result of metastatic lesions with bone destruction from a renal cell carcinoma. The second patient had a sensorimotor trigeminal neuropathy caused by a direct compression of the semilunar ganglion by a cavernous hemangioma of Meckels cave. The last patient experienced facial numbness as the unusual presenting manifestation of a primary brainstem lymphoma. Patients 1 and 3 died a few weeks after the admission, whereas patient 2 poorly recovered. Despite the availability of new techniques for early diagnosis, this report demonstrates how difficult it can initially be to differentiate a benign trigeminal neuropathy from serious conditions and underscores the poor prognosis of fifth nerve fibers involvement by an expanding mass. Early referral with clinical and electrophysiological evaluation appears to be of crucial importance.