Rupture d’anévrysme de l’artère cérébrale moyenne avec hématome : une série de 58 cas consécutifs

Objective: intracerebral hematomas in patients with aneurysmal subarachnoidal hemorrhage require critical therapeutic decisions. Survival, with sometimes very poor functional outcomes, depends on emergency treatment, but there is no consensus regarding the indications. Our objective was to determine prognostic factors helping initial therapeutic decisions. Methods: we retrospectively analyzed 58 consecutive patients presenting intracerebral hematomas secondary to middle cerebral artery aneurysmal subarachnoidal hemorraghe from 2008 to 2016 in La Pitié Salpétrière neurosurgery and intensive care departments, Paris. Clinical and radiological presentation, aneurysm treatment, intracranial hypertension treatments, and outcome were examined. Survival was the principal evaluation criterion, the secondary one was functional outcome assessed by Glasgow outcome scale and modified Rankin score. Results: mortality rate was 28% (16/58 patients). Death risk was associated with initial symptoms of cerebral herniation, left-sided hematoma, and intraoperative aneurysm rupture. A one year favorable functional outcome (GOS or mRS= 1 or 2) was achieved for 38% of patients (22/58). Unfavorable outcome was associated with insular location, left-sided hematoma and initial midline shift. Treatment modalities were not associated with outcome. Conclusion: because of the poor outcome, our results tend to encourage avoiding useless treatments for patients with clinically significant cerebral herniation, initial midline shift, and left-sided or insular hematomas. However these results need to be confirmed, and the benefit of performing simultaneous embolization and surgical evacuation of hematoma needs to be assessed more precisely.Introduction : l’hématome sur rupture d’anévrysme est une pathologie grave qui nécessite une prise en charge en urgence. Il n’existe pas de consensus concernant les indications et limitations de son traitement. Le but de ce travail est de guider sa prise en charge par des facteurs pronostiques validés. Matériel et Méthode : nous avons analysé rétrospectivement 58 patients victimes d’hématome par rupture d’anévrysme de l’artère cérébrale moyenne pris en charge entre 2008 et 2016. Les facteurs étudiés étaient les caractéristiques cliniques et radiologiques initiales, le traitement du sac anévrismal et de l’hypertension intracrânienne, l’évolution clinique et radiologique. Le critère de jugement principal était la survie, le critère de jugement secondaire était le résultat fonctionnel jugé selon les scores Glasgow Outcome Scale et Rankin modifié. Résultats : jugé à un an, le résultat fonctionnel était bon chez 38% des patients et mauvais chez 34%. La mortalité était de 28%. Les principaux facteurs de risque de décès étaient la gravité clinique initiale, notamment les signes d’engagement, la latéralisation gauche des lésions, la rupture per-opératoire de l’anévrysme. Les principaux facteurs de risque de mauvais résultat fonctionnel étaient la localisation insulaire, la latéralisation gauche des lésions, la déviation de la ligne médiane initiale. Conclusion : malgré les progrès de la neurochirurgie, de l’embolisation et de la réanimation, l’hématome sur rupture d’anévrysme reste une pathologie grave. Des indicateurs cliniques initiaux peuvent nous permettre d’éviter des traitements déraisonnables. Les études à venir devront évaluer le traitement par embolisation de l’anévrysme et évacuation de l’hématome quasi simultanée, notamment grâce à des salles opératoires hybrides

Rupture d’anévrysme de l’artère cérébrale moyenne avec hématome : une série de 58 cas consécutifs

Objective: intracerebral hematomas in patients with aneurysmal subarachnoidal hemorrhage require critical therapeutic decisions. Survival, with sometimes very poor functional outcomes, depends on emergency treatment, but there is no consensus regarding the indications. Our objective was to determine prognostic factors helping initial therapeutic decisions. Methods: we retrospectively analyzed 58 consecutive patients presenting intracerebral hematomas secondary to middle cerebral artery aneurysmal subarachnoidal hemorraghe from 2008 to 2016 in La Pitié Salpétrière neurosurgery and intensive care departments, Paris. Clinical and radiological presentation, aneurysm treatment, intracranial hypertension treatments, and outcome were examined. Survival was the principal evaluation criterion, the secondary one was functional outcome assessed by Glasgow outcome scale and modified Rankin score. Results: mortality rate was 28% (16/58 patients). Death risk was associated with initial symptoms of cerebral herniation, left-sided hematoma, and intraoperative aneurysm rupture. A one year favorable functional outcome (GOS or mRS= 1 or 2) was achieved for 38% of patients (22/58). Unfavorable outcome was associated with insular location, left-sided hematoma and initial midline shift. Treatment modalities were not associated with outcome. Conclusion: because of the poor outcome, our results tend to encourage avoiding useless treatments for patients with clinically significant cerebral herniation, initial midline shift, and left-sided or insular hematomas. However these results need to be confirmed, and the benefit of performing simultaneous embolization and surgical evacuation of hematoma needs to be assessed more precisely.Introduction : l’hématome sur rupture d’anévrysme est une pathologie grave qui nécessite une prise en charge en urgence. Il n’existe pas de consensus concernant les indications et limitations de son traitement. Le but de ce travail est de guider sa prise en charge par des facteurs pronostiques validés. Matériel et Méthode : nous avons analysé rétrospectivement 58 patients victimes d’hématome par rupture d’anévrysme de l’artère cérébrale moyenne pris en charge entre 2008 et 2016. Les facteurs étudiés étaient les caractéristiques cliniques et radiologiques initiales, le traitement du sac anévrismal et de l’hypertension intracrânienne, l’évolution clinique et radiologique. Le critère de jugement principal était la survie, le critère de jugement secondaire était le résultat fonctionnel jugé selon les scores Glasgow Outcome Scale et Rankin modifié. Résultats : jugé à un an, le résultat fonctionnel était bon chez 38% des patients et mauvais chez 34%. La mortalité était de 28%. Les principaux facteurs de risque de décès étaient la gravité clinique initiale, notamment les signes d’engagement, la latéralisation gauche des lésions, la rupture per-opératoire de l’anévrysme. Les principaux facteurs de risque de mauvais résultat fonctionnel étaient la localisation insulaire, la latéralisation gauche des lésions, la déviation de la ligne médiane initiale. Conclusion : malgré les progrès de la neurochirurgie, de l’embolisation et de la réanimation, l’hématome sur rupture d’anévrysme reste une pathologie grave. Des indicateurs cliniques initiaux peuvent nous permettre d’éviter des traitements déraisonnables. Les études à venir devront évaluer le traitement par embolisation de l’anévrysme et évacuation de l’hématome quasi simultanée, notamment grâce à des salles opératoires hybrides

MBCL-43 pronostic factors for overall survival after recurrence in childhood medulloblastoma

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Prognostic Clinical and Biologic Features for Overall Survival after Relapse in Childhood Medulloblastoma

International audienceDespite progress in the biology and upfront treatment of childhood medulloblastoma, relapse is almost universally fatal. No standardized treatment has so far been established for these patients. By determining which characteristics are prognostic after relapse, treatment strategies may be optimized for each of these children. We demonstrated that molecular subgroup at diagnosis is a relevant prognostic factor of outcome after relapse. Moreover, we showed that time to relapse and the use of salvage radiotherapy at relapse might have a potential impact on post-relapse survival. Our data suggest that ongoing efforts toward a better understanding of the biology, timing and type of relapse would be important to understand the determinants of tumor behavior at relapse. This could help us address more specific questions on the best surveillance strategies after completion of the treatment and the introduction of risk-stratified second-line treatment strategies

Acute surgical management of children with ruptured brain arteriovenous malformation

International audienceObjective: Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM.Methods: This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury.Results: A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently.Conclusions: HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management

Prognostic factors for survival in adult patients with recurrent glioblastoma: a decision-tree-based model

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Aberrant ERBB4-SRC Signaling as a Hallmark of Group 4 Medulloblastoma Revealed by Integrative Phosphoproteomic Profiling

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