Phong Dam-Hieu

Retrospective study of 19 patients with intramedullary spinal cord metastasis.

OBJECT Intramedullary spinal cord metastasis (ISCM) is a rare but devastating complication of cancer. Due to both widespread MRI availability and longer survival of cancer patients, the probability of discovering an ISCM during the course of the disease has increased and raised issues regarding the management of these patients, and particularly the place of surgery. In this study, we assess predictive factors for surgical outcome and survival. PATIENTS AND METHODS We retrospectively reviewed a series of 19 patients consecutively admitted in our institution from 1993 to 2006 for ISCM, representing the second largest series published in the literature. MRI was performed on all patients. Thirteen underwent microsurgical excision of ISCM. Functional outcome was evaluated and factors influencing survival were statistically analyzed. RESULTS Median survival was statistically longer when surgery was performed (7.4 vs. 2.6 months). Preoperative neurological status, nature of primary cancer, presence of systemic and/or CNS metastases influenced survival, but differences were without statistical significance. Neurological status improved in 58% (11/19) of operated patients. CONCLUSIONS Optimal management of patients with ISCM is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Diagnosis should be made as early as possible and surgical resection should be considered as the primary treatment whenever feasible, particularly in the case of rapidly progressive neurological deficits and when a clear cleavage plane exists. Our study shows that surgery could result in both increased survival rate and significant improvement of neurological function.

Cervical cord compression due to delayed scarring around epidural electrodes used in spinal cord stimulation

The authors report on 2 cases of delayed compression of the cervical spinal cord by dense scar tissue forming around epidural electrodes implanted for spinal cord stimulation (SCS). This complication has not been previously reported. Myelopathy developed in 2 patients 5 and 16 years after the surgical placement of a cervical epidural electrode. Prior to myelopathy, both patients experienced a tolerance phenomenon. Magnetic resonance imaging in both cases showed severe compression of the spinal cord by the electrode. At surgery, thick scar tissue surrounding the electrode and compressing the posterior aspect of the cord was discovered. Both patients experienced a full recovery following the removal of both scar tissue and the electrode. Medical and paramedical staff dealing with SCS should be aware of this severe and delayed complication. In addition, the development of epidural fibrosis can explain the occurrence of tolerance.

Spontaneous resolution of arachnoid cysts: review and features of an unusual case

SummaryMost intra-cranial arachnoid cysts are quiescent and remain asymptomatic throughout life. Within the natural course of arachnoid cyst evolution, spontaneous resolution has been known to occur rarely, but its frequency is probably underestimated due to lack of systematic detection and long-term observation.We illustrate the spontaneous regression of arachnoid cysts with a patient which was conjointly diagnosed with an arachnoid cyst and a post-traumatic epidural haematoma. Cyst regression was observed 16 months later, upon examination following a second benign cranial trauma. Mechanisms underlying the resolution of the arachnoid cyst are discussed.

Bilateral Subdural Hematoma Following Implantation of Intrathecal Drug Delivery Device

Objectives:  To report a case of bilateral subacute subdural hematoma following implantation of intrathecal drug delivery device.

Management of ACTH-secreting supradiaphragmatic adenomas

Supradiaphragmatic adrenocorticotropic hormone (ACTH) secreting pituitary adenomas are exceptionally encountered (14 cases previously described) and raise issues concerning their nosology and management. If surgery is the treatment of choice, the nature of surgical approach (craniotomy, transsphenoidal approach) remains controversial. To illustrate this issue, we presented two cases of supradiaphragmatic ACTH secreting pituitary adenomas successfully excised via a subfrontal approach. Both patients were female (20 and 41 years) and had a typical Cushings syndrome. MRI revealed, in both cases, a suprasellar mass in contact with the pars tuberalis of the pituitary. In the first case, the patient underwent initially a transsphenoidal approach with negative exploration and subsequent partial hypophysectomy. One year later, the patient was operated on again via a subfrontal approach, allowing excision of a supradiaphragmatic adenoma and a complete cure of Cushings disease. In the second case, the patient underwent initially a subfrontal approach and was definitely cured. In both cases, the diaphragma sellae was found to be intact and the pituitary stalk could be preserved. Postoperative MRI demonstrated a clearly visible intact pituitary stalk in conjunction with normal aspect of the pituitary. Supradiaphragmatic pituitary adenomas are most likely adenomas of the pituitary stalk with extra-axial development. Surgery remains the treatment of choice. Should the superior approach be preferred, the transsphenoidal-transtuberculum sellae approach may represent a viable alternative when performed by a well-trained surgical team. Surgery may be difficult, and drawbacks are non negligible, particularly in elderly patients. In these cases, stereotactic radiosurgery should receive more consideration.

Venous organization in the transverse foramen: dissection, histology, and magnetic resonance imaging

OBJECT The anatomical arrangement of the venous system within the transverse foramen is controversial; there is disagreement whether the anatomy consists of a single vertebral vein or a confluence of venous plexus. Precise knowledge of this arrangement is necessary in imaging when vertebral artery dissection is suspected, as well as in surgical approaches for the cervical spine. This study aimed to better explain anatomical organization of the venous system within the transverse foramen according to the Trolard hypothesis of a transverse vertebral sinus. METHODS This was an anatomical and radiological study. For the anatomical study, 10 specimens were analyzed after vascular injection. After dissection, histological cuts were prepared. For the radiological study, a high-resolution MRI study with 2D time-of-flight segment MR venography sequences was performed on 10 healthy volunteers. RESULTS Vertebral veins are arranged in a plexiform manner within the transverse canal. This arrangement begins at the upper part of the transverse canal before the vertebral vein turns into a single vein along with the vertebral artery running from the transverse foramen of the C-6. This venous system runs somewhat ventrolaterally to the vertebral artery. In most cases, this arrangement is symmetrical and facilitates radiological readings. The anastomoses between vertebral veins and ventral longitudinal veins are uniform and arranged segmentally at each vertebra. CONCLUSIONS These findings confirm recent or previous anatomical descriptions and invalidate others. It is hard to come up with a common description of the arrangement of vertebral veins. The authors suggest providing clinicians as well as anatomists with a well-detailed description of components essential to the understanding of this organization.

Hémangioblastome « en sablier » de la huitième racine cervicale

Resume Les hemangioblastomes radiculaires cervicaux « en sablier » avec une composante a la fois extra- et intra-durale sont exceptionnellement rencontres puisqu’un seul cas a ete decrit dans la litterature. Nous rapportons une seconde observation d’un patient de 33 ans ayant une tumeur cervicale inferieure « en sablier », responsable d’une nevralgie cervico-brachiale depuis 6 mois. L’aspect en IRM evoquait un schwannome et l’angiographie du tronc thyro-bicervico-scapulaire montrait une hyper-vascularisation non specifique, si bien que le diagnostic d’hemangioblastome n’a ete precise que par l’examen histologique.L’exerese complete de cette lesion tres vascularisee peut necessiter un abord chirurgical combine (anterieur et posterieur), ainsi qu’une embolisation pre-operatoire.

Hémangiome capillaire ethmoïdal : Cas clinique et revue de la littérature

Resume Nous rapportons l’observation exceptionnelle d’un homme de 38 ans ayant un hemangiome capillaire de siege exclusivement ethmoidal, dont l’exerese complete a pu etre realisee par une double voie d’abord, haute et basse.Les hemangiomes capillaires sont des tumeurs vasculaires, benignes et rares, qui interessent surtout la peau de la tete et du cou, ainsi que les muqueuses orale et nasale. Aucune atteinte ethmoidale pure n’a ete rapportee dans la litterature. Le traitement de choix est chirurgical et doit assurer l’exerese complete de la lesion. Le pronostic est alors bon et le risque de recidive est faible.