Thierry Gustin

Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage:case report and literature review

BACKGROUND Traumatic false aneurysms of the meningeal arteries are rare. We report an unusual case of an intracerebral hematoma caused by the rupture of a traumatic aneurysm of the middle meningeal artery. CASE DESCRIPTION A 64-year-old woman suffered a massive spontaneous intracerebral fronto-temporal hemorrhage. Cerebral angiogram revealed a pseudoaneurysm of the middle meningeal artery. At operation, a skull fracture was discovered in the vicinity of the aneurysm. The patient died the day after surgery. CONCLUSION Although rare, traumatic meningeal aneurysms should be considered as a possible cause of cerebral hematoma. Because of their potential morbidity and mortality, they must be detected and treated rapidly.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot

OBJECTIVE To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot. DESIGN Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs. SETTING Spasticity group at a university hospital. PARTICIPANTS Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot. INTERVENTION Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics. MAIN OUTCOME MEASURES Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks. RESULTS The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit. CONCLUSION Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.

Selective tibial neurotomy in the treatment of spastic equinovarus foot: a 2-year follow-up of three cases.

Deltombe T, Detrembleur C, Hanson P, Gustin T: Selective tibial neurotomy in the treatment of spastic equinovarus foot: A 2-year follow-up of three cases. Am J Phys Med Rehabil 2006;85:82–88. Objective:To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot. Design:Before–after trial with a 2-yr follow-up. Three hemiplegic patients with spastic equinovarus foot were treated with a selective peripheral neurotomy of the tibial motor nerve branches (soleus, lateral and medial gastrocnemius and tibialis posterior nerves). Evaluation included clinical assessment of spasticity (Ashworth scale), maximal Hoffmann reflex (Hmax)/compound muscle action potential (Mmax) ratio measurement, gait analysis, and muscle stiffness evaluation performed before and 2 mos, 1 yr, and 2 yrs after the neurotomy. Results:Spasticity, muscle stiffness, and Hmax/Mmax ratio decreased after neurotomy. The kinematic (ankle dorsal flexion and knee recurvatum) and kinetic variables (maximum ankle muscle moment and external work) of the gait were permanently improved after neurotomy. Interestingly, kinetic variables seemed to gradually improve with time after the neurotomy. Conclusion:Tibial neurotomy is an effective and durable treatment for spastic equinovarus foot.

A Randomized Controlled Trial of Selective Neurotomy Versus Botulinum Toxin for Spastic Equinovarus Foot After Stroke

Background. Selective neurotomy is a permanent treatment of focal spasticity, and its effectiveness in treating spastic equinovarus of the foot (SEF) was previously suggested by a few nonrandomized and uncontrolled case-series studies. Objectives. This study is the first assessor-blinded, randomized, controlled trial evaluating the effects of this treatment. Methods. Sixteen chronic stroke patients presenting with SEF were randomized into 2 groups: 8 patients underwent a tibial neurotomy and the remaining 8 received botulinum toxin (BTX) injections. The soleus was treated in all patients, and the tibialis posterior and flexor hallucis longus were treated in about half of patients. The primary outcome was the quantitative measurement of ankle stiffness (L-path), an objective measurement directly related to spasticity. Participants were assessed by a blind assessor before their intervention and at 2 and 6 months after treatment. Evaluations were based on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). Results. Compared with BTX, tibial neurotomy induced a higher reduction in ankle stiffness. Both treatments induced a comparable improvement of ankle kinematics during gait, whereas neither induced muscle weakening. Activity, participation, and quality of life were not significantly modified in either group. Conclusions. This study demonstrates that the tibial nerve neurotomy is an effective treatment of SEF, reducing the impairments observed in chronic stroke patients. Future studies should be conducted to confirm the long-term efficacy based on the ICF domains.

Cervical spinal cord injury in sapho syndrome.

Cervical spinal fracture and pseudarthrosis are previously described causes of spinal cord injury (SCI) in patients with spondylarthropathy. SAPHO (Synovitis Acne Pustulosis Hyperostosis Osteitis) syndrome is a recently recognized rheumatic condition characterized by hyperostosis and arthro-osteitis of the upper anterior chest wall, spinal involvement similar to spondylarthropathies and skin manifestations including palmoplantar pustulosis and pustular psoriasis. We report the first case of SAPHO syndrome disclosed by SCI related to cervical spine ankylosis.

Unusual growth within a meningioma (leukemic infiltrate).

Intracranial meningiomas are generally slow-growing neoplasms. Symptoms depend on their critical intracranial location. The authors describe a case of rapidly enlarging meningioma that became symptomatic as a result of invasion by leukemic cells at the time of a blastic crisis in the context of chronic myeloid leukemia. Infiltration of an intracranial meningioma by cells from extracranial malignant neoplasms is a rare event. Even though central nervous system (CNS) or meningeal involvement is common in some hematologic malignancies, this is, to the best of our knowledge, the first report of invasion of an intracranial meningioma by leukemic cells.

Comparison between tibial nerve block with anaesthetics and neurotomy in hemiplegic adults with spastic equinovarus foot.

OBJECTIVE The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults. METHODS In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy. RESULTS The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy. CONCLUSION This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy.

Does fascicular neurotomy have long-lasting effects?

We read with interest the recent article by Collado et al. (1) on the recurrence of spasticity after tibial neurotomy observed in 4 cases. Although the methodology of the study is controversial (e.g. how many patients undergoing neurotomy were followed?), we agree that precise information about the longlasting effects of our treatment is essential, especially in the rehabilitation field. Most of all, we think that the term “recurrence of spasticity” is inappropriate. The term “deformity recurrence” (the exact term used by Berard in the article cited by Collado et al.) would be more appropriate, as the recurrence observed by Collado et al. is probably not related to spasticity but to pathological motor activation pattern and musculo-tendinous retraction. Several facts lead us to this conclusion. First, spasticity is usually defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex (2). Neurotomy results in a section of the afferent fibres mediating the spastic monosynaptic reflex arc, leading to reduction of spasticity and osteo-tendinous reflex and clonus disappearance. The long-lasting effect of neurotomy to reduce the monosynaptic reflex arc has been demonstrated in 3 studies by means of Hmax/Mmax ratio permanent reduction, with a mean follow-up of 5 months, 24 months and 29 months, respectively (3–5). The related functional improvement obtained after neurotomy has been confirmed in a multicentre study with a mean followup of 10 months (6). Neurotomy also results in sectioning of the efferent motor fibres, which is responsible for a transient muscle weakness. Such weakness recovers thanks to collateral re-innervation, which is correlated with the return of the Mmax amplitude (corresponding to the sum of the motor units) to baseline value 8 months after the neurotomy (5). The recovery of the voluntary (and involuntary) muscle strength explains the recurrence of the pathological motor activation pattern, which is sometimes implicated in the equinovarus deformity. This also explains the recurrence of deformity after neurotomy in the case of dystonic patterns that are not related to an increase in tonic stretch. Secondly, Collado et al. evaluated triceps spasticity with the Ashworth scale (all the patients were graded Ashworth 3 or 4). Although the Ashworth scale is commonly used in the literature, it is confounded by contracture, as increased resistance to movement is not exclusively dependent on stretch reflex activity, but is also due to increased stiffness as a result of contracture. The Tardieu scale seems more appropriate, especially to evaluate triceps spasticity (7). Moreover, all the patients had ankle dorsal flexion limitation in the pre-operative evaluation (ranging from –5° to –35°), which had worsened in the post-operative evaluation (ranging from –10° to –45°) leading to the suggestion that the triceps muscle shortening noted before the neurotomy is enhanced after it. In Berard’s article, cited by the authors, the equinovarus deformity recurrence was correlated with triceps muscle shortening, while the spasticity evaluation was not detailed. Moreover, Berard evaluated children with hemiplegia with growth potential and higher risk of muscle shortening. As a denervated muscle risks retraction, triceps muscle shortening is a relative contra-indication to neurotomy, and special attention must be paid to the rehabilitation program, with stretching and posture training of the triceps muscle. There is no doubt that Collado et al. noted equinovarus deformity recurrence after neurotomies. The recurrence can be caused by the logical recovery of a pathological motor activation pattern associated with a muscular retraction following the denervation. That is why experienced surgical teams prefer to section the motor nerve branches to the soleus muscle (which is, in most cases, responsible for the triceps clonus) and to spare the motor nerve branches to the gastrocnemius muscles which, as a bi-articular and fusiform muscle, are at higher risk of retraction (8). We have doubts as to the spasticity implication in such recurrence. If the spasticity is considered as a hyperexcitability of the stretch reflex, regarding the literature and our personal experience, neurotomy undoubtedly has long-lasting effects. We have never seen a clonus recurrence in a muscle whose nerve has been partially sectioned. The main questions are what are the frequency and causes of the equinovarus deformity sometimes recurring: a pathological motor pattern and a triceps muscle shortening (especially when the gastrocnemius nerves are treated) may explain such recurrence. Collado et al.’s observation emphasizes the need for longterm clinical follow-up after neurotomy, for a well-defined rehabilitation programme, and the need for an interdisciplinary approach (integrating physical medicine and rehabilitation specialist, neurosurgeon and orthopaedic surgeon) to select the patients.

Cystic macroprolactinoma: primary medical treatment?

We were very interested by an article published by Inder and MacFarlane in the September 2004 issue of the Internal Medicine Journal. 1 The authors suggest primary surgical management of patients suspected of having a macroprolactinoma, if magnetic resonance imaging (MRI) discloses a major cystic component with hyperintensity on T2-weighted imaging. They argue that the cystic component of the tumour is unlikely to shrink under dopamine agonists. A few months ago, we managed a very similar case, but chose primary medical treatment. A 16-year-old woman presented to a neurologist with an 18-month history of headaches. The MRI scan (Fig. 1) showed a cystic pituitary mass. Visual field assessment was normal. Endocrine evaluation revealed a secondary amenorrhoea present for 6 months and a marked hyperprolactinaemia (6555 mIU/L; normal range: 105–426). The dopamine agonist cabergoline was started at the dose of 0.5 mg twice weekly. After 2 weeks, prolactin level dropped to 516 mIU/L. After 6 weeks of treatment, prolactin level was 98 mIU/L, menstruations resumed, headaches disappeared and MRI disclosed a marked tumour shrinkage (Fig. 1). This case illustrates that a trial of dopamine agonist treatment might be proposed in patients suspected of harbouring a macroprolactinoma, even if a large cystic component is present. This appearance can reflect intratumoural haemorrhage, which is frequent in macroprolactinomas and does not preclude tumour shrinkage. 2

Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group.

OBJECTIVE To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke. RESULTS Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae - Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol-alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined. CONCLUSION Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.