Recanalisation des anévrysmes intracrâniens traités par chirurgie ou embolisation (analyse d une série consécutive d anévrysmes non rompus)

ILa rupture d un anévrysme intracrânien est rare mais très grave, ce qui inciterait à le traiter avant tout accident. Ce traitement préventif sous-entend son innocuité et son efficacité au long cours, d où le problème de la recanalisation. Nous avons analysé rétrospectivement 179 anévrysmes non rompus sacciformes chez 150 patients traités à la Pitié-Salpêtrière entre 2004 et 2009. 115 anévrysmes ont été traités par embolisation, 64 par chirurgie. Nous avons analysé les données morphologiques angiographiques immédiates et à long terme, identifié les facteurs impliqués dans la recanalisation et comparé nos résultats pour chaque groupe. Dans le groupe d anévrysmes opérés, le taux d exclusion totale était de 84,6 % et stable pour la totalité des anévrysmes contrôlés à long terme sur un suivi moyen de 3,5 ans ; 2 anévrysmes incomplètement clippés se sont recanalisés. Aucun n a été retraité.Dans le groupe d anévrysmes traités par embolisation, l exclusion totale était obtenue pour 91,3% des anévrysmes, et stable sur un suivi moyen de 4 ans pour 52% de ceux qui avaient été contrôlés. Le taux de recanalisation était de 50% dont 67% de recanalisations mineures au terme d un suivi moyen de 2 ans. 18 anévrysmes ont été retraités.Le principal facteur de risque identifié est le rapport diamètre/collet.Aucun anévrysme n a saigné après le traitement. Les recanalisations concernent les deux options thérapeutiques mais la chirurgie semble apporter une meilleure protection sur le long terme, particulièrement quand l exclusion est complète. Il est donc très important de vérifier la qualité du geste en postopératoire immédiat.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Same Diagnosis but Different Story! A Tale of Two Primary Lymphomas of the Calvaria

We present 2 cases of isolated tumour of the calvaria that underwent a different management but, unexpectedly, the same very rare diagnosis of primary diffuse large B-cell lymphoma of the cranial vault. Unfortunately, the outcome was the opposite due to numerous factors. We discuss herein the radiological diagnosis and surgical options in the light of the literature

An analysis of heart donation after circulatory determination of death

Heart donation after circulatory determination of death (DCDD) has provoked ethical debate focused primarily on whether heart DCDD donors are dead when death is declared and when organs are procured. We rigorously analyse whether four heart DCDD programmes (Cape Town, Denver, Australia, Cambridge) respect the dead donor rule (DDR), according to six criteria of death: irreversible cessation of all bodily cells function (or organs), irreversible cessation of heart function, irreversible cessation of circulation, permanent cessation of circulation, irreversible cessation of brain function and permanent cessation of brain function. Only death criteria based on permanency are compatible with the DDR under two conditions: (1) a minimum stand-off period of 5 min to ensure that autoresuscitation is impossible and that all brain functions have been lost and (2) no medical intervention is undertaken that might resume bodily or brain circulation. By our analysis, only the Australia heart DCDD programme using a stand-off period of 5 min respects the DDR when the criteria of death are based on permanency

Combined Nasoseptal and Inferior Turbinate Flap for Reconstruction of Large Skull Base Defect After Expanded Endonasal Approach: Operative Technique

International audienceBACKROUND:Increasing indications for endoscopic endonasal approaches have led neurosurgeons to develop new reconstruction techniques for larger skull base defects. Vascularized grafts have been a great adjunction to reduce the rate of cerebrospinal fluid leak and can also be used to cover exposed critical structures such as the internal carotid artery. The nasoseptal flap and the inferior or middle turbinate flap are thus widely used in endoscopic skull base surgery, but may be insufficient for very large defects.OBJECTIVE:To present a new mucosal flap used to cover large skull base defects in which the mucosa of the inferior turbinate, inferior meatus, nasal floor, and nasal septum is harvested in 1 piece keeping both vascular pedicles intact (inferior turbinate and septal arteries).METHODS:We describe a surgical technique to harvest a combined inferior turbinate-nasoseptal flap.RESULTS:Technical pearls and surgical pitfalls are described through 2 clinical cases in which the nasoseptal mucosa was partially damaged during a previous surgery, rendering the nasoseptal flap insufficient by itself. The flap is harvested thanks to 2 mucosal cuts: a first circular cut around the choanal arch and the junction between the hard and the soft palate, and a second one combining classical cuts of the nasoseptal flap and the inferior turbinate flap.CONCLUSION:The inferior turbinate-nasoseptal flap can be a useful alternative in patients whose septal mucosa was partially damaged and/or with very large postoperative skull base defects

Surgery and protontherapy in Grade I and II skull base chondrosarcoma: A comparative retrospective study.

OBJECTIVE:Skull base chondrosarcoma is a rare tumour usually treated by surgery and proton therapy. However, as mortality rate is very low and treatment complications are frequent, a less aggressive therapeutic strategy could be considered. The objective of this study was to compare the results of surgery only vs surgery and adjuvant proton therapy, in terms of survival and treatment adverse effects, based on a retrospective series. METHODS:Monocentric retrospective study at a tertiary care centre. All patients treated for a skull base grade I and II chondrosarcoma were included. We collected data concerning surgical and proton therapy treatment and up-to-date follow-up, including Common Terminology Criteria for Adverse Events (CTCAE) scores. RESULTS:47 patients (23M/24F) were operated on between 2002 and 2015; mean age at diagnosis was 47 years-old (10-85). Petroclival and anterior skull base locations were found in 34 and 13 patients, respectively. Gross total resection was achieved in 17 cases (36%) and partial in 30 (64%). Adjuvant proton therapy (mean total dose 70 GyRBE,1.8 GyRBE/day) was administered in 23 cases. Overall mean follow-up was 91 months (7-182). Of the patients treated by surgery only, 8 (34%) experienced residual tumour progression (mean delay 51 months) and 5 received second-line proton therapy. Adjuvant proton therapy was associated with a significantly lower rate of relapse (11%; p = 0.01). There was no significant difference in 10-year disease specific survival between patients initially treated with or without adjuvant proton therapy (100% vs 89.8%, p = 0.14). Difference in high-grade toxicity was not statistically significant between patients in both groups (25% (7) vs 11% (5), p = 0.10). The most frequent adverse effect of proton therapy was sensorineural hearing loss (39%). CONCLUSION:Long-term disease specific survival was not significantly lower in patients without adjuvant proton therapy, but they experienced less adverse effects. We believe a surgery only strategy could be discussed, delaying as much as possible proton therapy in cases of relapse. Further prospective studies are needed to validate this more conservative strategy in skull base chondrosarcoma

Preoperative Resectability Estimates of Nonenhancing Glioma by Neurosurgeons and a Resection Probability Map

International audienceBACKGROUND:Preoperative interpretation of resectability of diffuse nonenhancing glioma is primarily based on individual surgical expertise.OBJECTIVE:To compare the accuracy and precision between observed resections and preoperative estimates of neurosurgeons and a resection probability map (RPM). We hypothesize that the RPM estimates is as good as senior neurosurgeons.METHODS:A total of 234 consecutive patients were included from 2 centers, who had resective surgery with functional mapping between 2006 and 2012 for a supra-tentorial nonenhancing glioma. Extent of resection (EOR) and residual tumor volume (RTV) were segmented and an RPM was constructed in standard brain space. Three junior and three senior neurosurgeons estimated EOR and RTV, blinded for postoperative results. We determined the agreement between the estimates and calculated the diagnostic accuracy of the neurosurgeons and the RPM to predict the observed resections.RESULTS:Preoperative estimates of resection results by junior and senior neurosurgeons were significantly biased towards overestimation of EOR (4.2% and 11.2%) and underestimation of RTV (4.3 and 9.0 mL), whereas estimates of the RPM were unbiased (-2.6% and -.2 mL, respectively). The limits of agreement were wide for neurosurgeons and for the RPM. The RPM was significantly more accurate in identifying patients in whom an EOR >40% was observed than neurosurgeons.CONCLUSION:Neurosurgeons estimate preoperative resectability before surgery of a nonenhancing glioma rather accurate-with a small bias-and imprecise-with wide limits of agreement. An RPM provides unbiased resectability estimates, which can be useful for surgical decision-making, planning, and education

Preoperative Resectability Estimates of Nonenhancing Glioma by Neurosurgeons and a Resection Probability Map

BACKGROUND: Preoperative interpretation of resectability of diffuse nonenhancing glioma is primarily based on individual surgical expertise. OBJECTIVE: To compare the accuracy and precision between observed resections and preoperative estimates of neurosurgeons and a resection probability map (RPM). We hypothesize that the RPM estimates is as good as senior neurosurgeons. METHODS: A total of 234 consecutive patients were included from 2 centers, who had resective surgery with functional mapping between 2006 and 2012 for a supra-tentorial nonenhancing glioma. Extent of resection (EOR) and residual tumor volume (RTV) were segmented and an RPM was constructed in standard brain space. Three junior and three senior neurosurgeons estimated EOR and RTV, blinded for postoperative results. We determined the agreement between the estimates and calculated the diagnostic accuracy of the neurosurgeons and the RPM to predict the observed resections. RESULTS: Preoperative estimates of resection results by junior and senior neurosurgeons were significantly biased towards overestimation of EOR (4.2% and 11.2%) and underestimation of RTV (4.3 and 9.0 mL), whereas estimates of the RPM were unbiased (-2.6% and -.2 mL, respectively). The limits of agreement were wide for neurosurgeons and for the RPM. The RPM was significantly more accurate in identifying patients in whom an EOR >40% was observed than neurosurgeons. CONCLUSION: Neurosurgeons estimate preoperative resectability before surgery of a nonenhancing glioma rather accurate-with a small bias-and imprecise-with wide limits of agreement. An RPM provides unbiased resectability estimates, which can be useful for surgical decision-making, planning, and education

Clinical, pathologic, and imaging characteristics of pituitary null cell adenomas as defined according to the 2017 World Health Organization criteria: a case series from two pituitary centers.

PURPOSE: The 2017 World Health Organization classification of pituitary tumors redefined pituitary null cell adenomas (NCAs) by restricting this diagnostic category to pituitary tumors that are negative for pituitary transcription factors and adenohypophyseal hormones. The clinical behavior of this redefined entity has not been widely studied, and this is a major shortcoming of the classification. This study evaluated the imaging and clinical features of NCAs from two pituitary centers and compared them with those of gonadotroph adenomas (GAs). METHODS: Imaging, pathologic, and clinical characteristics of NCAs and GAs were retrospectively reviewed. Tumor immunohistochemistry was performed to confirm absence of adenohypophyseal hormones and pituitary transcription factor expression. RESULTS: Thirty-one NCAs were compared with 38 GAs. NCAs were more likely to invade the cavernous sinus (15/31 [48%] vs. 5/38 [13%], P = .003) and had a higher proliferative index (i.e., MIB-1 \u3e 3%, 11/31 [35%] vs. 5/38 [13%], P = .04). Gross total resection was less likely in the NCA group (19/31 [61%] vs. 33/38 [87], P = .02). Progression-free survival was worse in the NCA cohort (5-year progression-free survival, 0.70 vs. 1.00; P = .011, by log-rank test). CONCLUSIONS: Compared with GAs, NCAs are more invasive at the time of presentation and have a more aggressive clinical course. This study provides evidence that NCAs represent a distinct clinicopathologic entity with behavior that differs adversely from that of GAs. This may inform clinical decision-making, including frequency of postoperative tumor surveillance and timing of adjunctive treatments