V. Gilard

Cervical spine fractures in patients with ankylosing spondylitis: Importance of early management

INTRODUCTION Ankylosing spondylitis (AS) affects 0.5% of the population. Alteration of the biomechanical properties of the spine related to AS explains the high prevalence of traumatic vertebral fractures and risk of instability. At admission, 65% of patients present neurological signs. There are no reported studies regarding secondary neurological deterioration. The aim of this study was to evaluate the rate of secondary neurological deterioration before surgical treatment of spine fracture in a context of AS. METHODS This retrospective cases series consisted of patients admitted for traumatic cervical spine fractures or luxation in a context of AS between June 2007 and December 2012. Clinical status was evaluated using Frankel classification at time of trauma, at admission to the neurosurgery ward, as well as before and after surgery. Delay between trauma and admission, and between admission and surgery was recorded. Causes of morbidity, mortality and surgical management were discussed. RESULTS During the study period, seven patients were admitted for traumatic cervical spine fracture or luxation. All patients were autonomous before trauma. Between trauma and transfer to neurosurgery ward, the status of four patients worsened. Mean delay between trauma and admission was 12.9 days (range 1 to 60 days). Between admission to neurosurgery ward and surgical treatment, two more patients worsened and only two patients remained autonomous. Mean delay between admission and surgery was 15.7h (range 2 to 24h). Neurological deterioration was due to both deterioration during transfer despite immobilization with a rigid cervical collar and failure of X-ray to reveal any fractures, in two and three cases respectively. After surgery, clinical status remained unchanged in two patients, four patients improved, and one patient worsened. Two patients died from respiratory failure a few days after surgery due to neurological deterioration. Five patients had a delayed diagnosis (>24h). CONCLUSION Cervical spine fracture in AS is a serious condition with high instability. Our series emphasizes the necessity of early surgical treatment because of risk of secondary neurological deterioration in cases of delayed treatment. CT scan must be the gold standard for exploration of these patients.

Small versus large catheters for ventriculostomy in the management of intraventricular hemorrhage.

OBJECTIVE Intraventricular hemorrhage (IVH) often requires the insertion of an external ventricular drain (EVD), but blood clots could occlude the catheters. Large EVD catheters may help to reduce the risk of catheter occlusion. Here, we compared small catheters with large catheters for ventriculostomy in patients suffering from IVH. METHODS We conducted a retrospective cohort study. Patients were included if they had IVH requiring EVD insertion. We then compared baseline characteristics and outcomes of patients treated with large catheters with patients treated with small catheters. RESULTS Between 2011 and 2015, 227 IVH patients were admitted to our 2 hospitals. Among the patients, 28 were treated in first intention with large catheters, and 46 controls were identified. Insertion of large catheter decreased the risk of temporary and permanent catheter occlusion without impact on the occurrence of intracerebral hemorrhage (ICH) related to catheter insertion. There was 38.5% more catheter-related infections in the small catheter group when compared with the large catheter group, but this result was not significant. There was no impact on functional outcomes. Surprisingly, the rate of death was higher in the large catheter group. CONCLUSIONS In patients suffering from IVH, the use of large catheters for EVD reduced the risk of catheter occlusion without increasing the risk of ICH related to catheter insertion. The risk of catheter-related infection may subsequently be decreased by using large catheters. A prospective randomized trial would be necessary to seek out any benefits that large catheters may provide for the risk of death and functional outcome.

Headache changes prior to aneurysmal rupture: A symptom of unruptured aneurysm?

BACKGROUND AND OBJECTIVES The symptomatic status of unruptured aneurysms has to be looked for. The objective of this retrospective case-control study was to identify the headache semiologic characteristics of symptomatic aneurysms during the 3 months prior to patient admission. PATIENTS AND METHODS The case cohort was composed of 40 consecutive patients admitted for the treatment of a ruptured intracranial aneurysm (IA) and able to answer a standardized questionnaire by the same neurologist. This cohort was matched with a control cohort of 40 patients operated on for a degenerative lumbar pathology. This questionnaire, using the criteria for headache characteristics according to the International Headache Society (IHS) enabled us to classify headaches during the previous 3 months prior to the rupture (study period) and during the year prior to the period studied (reference period) in both cohorts. Headache status was considered as unstable if there were modifications of semiologic headache characteristics, thunderclap headaches or de novo headaches, or on the contrary stable. RESULTS During the status period, chronic headaches were reported by 31 patients (77.5%) in the studied cohort and 35 (87.5%) in the control cohort. During the study period, the cephalagia status was stable in 19 patients (47.5%) versus 35 patients (87.5%) in the control cohort (P<0.001). Modifications of chronic headaches were present in 11 patients (35.5%) in the studied cohort versus 4 patients (11.4%) in the control cohort (P=0.04). Thunderclap headaches were present in 7 patients (17.5%) in the studied cohort but none in the control cohort (P=0.006). DISCUSSION Modifications of headaches semiologic characteristics during the 3 previous months were significantly more frequent in the studied cohort. This modification could be a sign of IA instability.

Dysgeusia following ventral intermediate nucleus deep brain stimulation for essential tremor

e. A, Coronal view of a fusion betw e; B the same in axial view; C, Loca medial nucleus (VPM) of the thalam tion of the references to colour in th sia following unilateral surgery and dysarthria with cerexia [1] in case of bilateral implantation. We reported the observation of a 52 year-old man who complained of disabling dysgeusia following bilateral VIM-DBS for essential tremor. We first proceeded to left VIM implantation under stereotactic conditions. No complication was observed and right side tremor reduced from more than 90%. Two months later, the same surgical procedure was performed for the controlateral side with the same outcome. The patient was stimulated bilaterally at contact 0 of the definitive electrode (model 3789, MedtronicR) with the following parameters (130 Hz, 60 ms, 2.3 V right and left). The stereotactic coordinates for the contact 0 were for each

Cervical pedicular agenesis: Case report and a review of the literature

Cervical pedicular agenesis, an unusual disorder, is a rare clinical and radiological finding, which can lead to misdiagnosis, moreover in a traumatic situation. The authors report the case of a young woman with a C3 right congenital absence of the cervical pedicle. A systematic review of literature found more than 70 reported cases. In patients with congenital agenesis of the cervical pedicle, the two most common levels of this congenital absence are C6 and C5. The three radiological findings were: the false appearance of an enlarged ipsilateral neural foramen due to the absent pedicle; a dysplastic, dorsally displaced ipsilateral articular pillar and lamina; and a dysplastic ipsilateral transverse process. These pedicle ageneses are a stable congenital anomaly.

Effects of melatonin in the treatment of asthenia in aneurysmal subarachnoid hemorrhage

BACKGROUND AND OBJECTIVES Survivors of aneurysmal subarachnoid hemorrhage (aSAH) commonly experience sleep disorders resulting in asthenia. The objective of this prospective study was to determine, in a cohort of patients with treated ruptured intracranial aneurysm (IA), the proportion of asthenia at 2months, in a cohort of patients treated with melatonin and in a control cohort. PATIENTS AND METHODS Twenty consecutive patients admitted for the treatment of ruptured IA and able to answer a standardized questionnaire were included in the study. After evaluation for fatigue at discharge, we divided our population into 2 cohorts of 10 patients: the first cohort was treated with melatonin for a period of 2months; the second cohort had no specific treatment for fatigue. The primary endpoint was the proportion of asthenia at 2months in both groups. Confounding factors, such as depression, autonomy and apathy were evaluated at the same time. RESULTS At discharge, there was no significant difference observed between both groups in terms of mean age and initial clinical status (WFNS, Rankin Scale and Fatigue Severity Scale). At 2months, the mean FSS score in the control group was of 4.7±1.0 versus 3.8±0.9 in the melatonin group (P=0.03). The mean MADRS score in the control group was of 1.1±1.45 versus 2.7±2.5 in the melatonin group (P=0.10). The mean LARS score in the control group was of -32.5±1.7 versus -31.7±1.9 in the melatonin group (P=0.24). DISCUSSION In a prospective evaluation of post-aSAH fatigue, we suggest that melatonin could decrease fatigue. There is no significant impact on depression and apathy. Further studies would be necessary to improve our comprehension of fatigue physiopathology in a context of aSAH.

Coincidental vascular anomalies at the foramen magnum: Dural arteriovenous fistula and high flow aneurysm on perimedullary fistula

We report the case of a 59-year-old woman admitted for a sudden headache due to a subarachnoid haemorrhage. On CT scan, the clots predominated into the posterior fossa without high-density in the sylvian or interhemispheric fissures. The vertebral angiography revealed a dural arteriovenous fistula at the foramen magnum associated to an aneurysm of the cervical anterior spinal artery. Due to the high rebleeding risk of a dural shunt, we proposed curative treatment using microsurgical interruption of the intradural draining vein. On the postoperative angiography at 15-day follow-up, the 2 malformations were corrected and the outcome at 6 months was excellent. Based on the literature, we assess this exceptional association and suggest its possible management.

Sudden paraplegia due to spontaneous bleeding in a thoracic epidural angiolipoma and literature review

BACKGROUND Spinal angiolipomas are rare epidural tumours that are usually revealed by chronic symptoms of medullar irritation. We report a case of acute paraplegia caused by spontaneous bleeding revealing a thoracic angiolipoma. CASE DESCRIPTION A 17-year-old male patient with no previous medical history was admitted for acute onset of paraplegia with bladder retention and loss of sensation in the lower limbs, preceded by dorsal pain during the three previous days. MRI showed an enhanced T1-weighted image of a T7-T12 epidural lesion. The T1-weighted isosignal and the T2-weighted hyposignal suggested haemorrhagic complications. Due to a mass effect on the spinal cord, an emergency laminectomy was performed. Histopathological examination of the lesion revealed an angiolipoma with spontaneous bleeding. Clinical outcome was favourable after two months. CONCLUSION This case is one of the first to be reported, although the clinical presentation is similar to that of other rare reported cases of paraplegia due to spinal compression by tumoural bleeding.

Intraventricular hemorrhage related to AVM rupture: Description, outcomes and impact of intraventricular fibrinolysis

OBJECTIVES Arteriovenous malformation (AVM) rupture could lead to intraventricular hemorrhage (IVH), a particularly severe form of intracranial bleeding. The epidemiology, presentation, management and outcomes of IVH related to AVM rupture have not been clearly addressed yet. The aim of the present study was to investigate the characteristics of IVH related to AVM rupture, with particular attention paid to functional outcomes and to the impact of intraventricular fibrinolysis (IVF). PATIENTS AND METHODS Between 2011 and 2015, all patients suffering from IVH admitted in two tertiary neurosurgical centers were included in a prospective register. Patient with IVH related to AVM rupture were identified (n=29) and their data retrospectively collected. Particular attention was paid on patients who received IVF. We also compared them to 29 apparied aneurysmal IVH. RESULTS IVH related to AVM rupture often occurred in young patients. In most cases, intracerebral hemorrhage was associated to IVH. 17% of the patients died, and functional outcome at 6 months was similar to those with aneurysmal IVH. Interestingly, 5 patients received IVF and none experienced any rebleeding. CONCLUSION IVH related to AVM rupture is a severe form of hemorrhagic stroke, with a poor neurologic prognosis. IVF seems to be safe and may be considered in this particular form of IVH.

Untreated unruptured aneurysm: Natural history at long-term

BACKGROUND AND OBJECTIVES Although the diagnosis of unruptured intracranial aneurysm (IA) has become more frequent, its natural history and management still remain controversial. A better comprehension of its evolution could optimize our therapeutic strategies. The aim of our study was to evaluate, in a cohort of patients with untreated unruptured IA based on the proposition of multidisciplinary staff meetings, the proportion of bleeding, death and cardiovascular events during a long-term prospective follow-up. PATIENTS AND METHODS This longitudinal study concerned a series of patients with unruptured IA collected over a period of 8 years (2006-2014) identified from a prospectively collected database including all patients with unruptured IA discussed during multidisciplinary staff meetings in the neurosurgery department at Rouen University Hospital. Clinical endpoints were the rupture rate, incidence of death or occurrence of noticeable pathological event defined by any event leading to death, admission to the intensive care unit or challenging the vital prognosis. RESULTS After a mean follow-up delay of 46.9±18.7 months, the IA remained stable in 73 patients (98.6%) out of 74. The rate of rupture per aneurysm year of follow-up was 0.3%, the rate of cardiovascular events was 2.1% and the death rate was 2.8% per year of follow-up. DISCUSSION In this study, we emphasize the important incidence of adverse events in these patients, which has to be taken into account before proposing a prophylactic IA exclusion. The low incidence of IA rupture confirmed the decision of conservative treatment made during a multidisciplinary staff meeting.