Microsurgical neurovascular anastomosis: The example of superficial temporal artery to middle cerebral artery bypass. Technical principles

AbstractThe superficial temporal artery to the middle cerebral artery (STA-MCA) bypass is a good example of cerebrovascular anastomosis. In this article, we describe the different stages of the procedure: patient installation, superficial temporal artery harvesting, recipient artery exposure, microsurgical anastomosis, and closure of the craniotomy. When meticulously performed, with the observance of important details at each stage, this technique offers a high rate of technical success (patency>90%) with a very low morbi-mortality (respectively 3% and 1%). Some anesthetic parameters have to be considered to insure perioperative technical and clinical success. STA-MCA bypass is a very useful technique for the management of complex or giant aneurysms where surgical treatment sometimes requires the sacrifice and revascularization of a main arterial trunk. It is also a valuable option for the treatment of chronic and symptomatic hemispheric hypoperfusion (Moyamoya disease, carotid or middle cerebral artery occlusion)

Delamination technique together with longitudinal incisions for treatment of Chiari I/syringomyelia complex: a prospective clinical study

<p>Abstract</p> <p>Background</p> <p>Treatment modalities in Chiari malformation type 1(CMI) accompanied by syringomyelia have not yet been standardized. Pathologies such as a small posterior fossa and thickened dura mater have been discussed previously. Various techniques have been explored to enlarge the foramen magnum and to expand the dura. The aim of this clinical study was to explore a new technique of excision of the external dura accompanied by widening the cisterna magna and making longitudinal incisions in the internal dura, without disturbing the arachnoid.</p> <p>Methods</p> <p>Ten patients with CMI and syringomyelia, operated between 2004 and 2006, formed this prospective series. All cases underwent foramen magnum decompression of 3 × 3 cm area with C1–C2 (partial) laminectomy, resection of foramen magnum fibrous band, excision of external dura, delamination and widening of internal dura with longitudinal incisions.</p> <p>Results</p> <p>Patients were aged between 25 and 58 years and occipital headache was the most common complaint. The mean duration of preoperative symptoms was 4 years and the follow-up time was 25 months. Clinical progression was halted for all patients; eight patients completely recovered and two reported no change. In one patient, there was a transient cerebrospinal fluid (CSF) fistula that was treated with tissue adhesive. While syringomyelia persisted radiologically with radiological stability in five patients; for three patients the syringomyelic cavity decreased in size, and for the remaining two it regressed completely.</p> <p>Conclusion</p> <p>Removal of the fibrous band and the outer dural layer, at level of foramen magnum, together with the incision of inner dural layer appears to be good technique in adult CMI patients. The advantages are short operation time, no need for duraplasty, sufficient posterior fossa decompression, absence of CSF fistulas as a result of extra arachnoidal surgery, and short duration of hospitalization. Hence this surgical technique has advantages compared to other techniques.</p

La formation des psychiatres en France

Guyotat J. La formation des psychiatres en France. In: Raison présente, n°83, 3e trimestre 1987. Le besoin de psychiatrie. pp. 69-81

Is fluorescence-guided surgery with 5-ala in eloquent areas for malignant gliomas a reasonable and useful technique?

Introduction. – High-grade gliomas surgery in eloquent areas must achieve two pivotal aims: oncological efficacy and preservation of unimpaired neurological functions or improvement of impaired neurological functions. Here, we evaluated the safety and the usefulness of 5-ALA fluorescence-guided surgery in eloquent areas. Material and methods. – Single center, retrospective and consecutive series of adult patients operated on for a supratentorial glioblastoma between November 2012 and November 2015. Results. – Fifty-one patients with a glioblastoma located within an eloquent area were included: 24 patients operated on with 5-ALA (5-ALA group), and 27 patients operated on under white light (con- trol group). Preoperative motor and language deficits were similar in the 5-ALA group (50%, 37.5%) as in the control group (59.3%, 55.6%) (P=0.510; P=0.200). Three-month postoperative motor and lan- guage deficits rates were similar in the 5-ALA group (12.5%, 12.5%) as in the control group (29.6%, 14.8%) (P = 0.180; P = 0.990). The extent of resection did not significantly vary between groups (P = 0.280). The overall survival did not significantly vary between groups (P = 0.080) but the progression-free survival was significantly higher in the 5-ALA group than in the control group (P = 0.020). The 12-month progression- free survival was significantly higher in 5-ALA group (60%) than in control group (21%; P = 0.006). In multivariate analysis, the 5-ALA was an independent prognostic factor associated with progression-free survival (P = 0.030). Conclusion. – 5-ALA fluorescence-guided surgery for glioblastoma located in eloquent areas is effective to improve progression-free survival. To preserve functional outcomes, it requires the routine use of intraoperative functional mapping to respect functional boundaries

Is normal pressure hydrocephalus a valid concept in 2002? A reappraisal in five questions and proposal for a new designation of the syndrome as "chronic hydrocephalus"

The authors question the current validity of the traditional concept of normal pressure hydrocephalus (NPH) as it was described by Adams and Hakim in 1965. The classic features of the disease are addressed. It is concluded that most of the historical statements made three decades ago need to be revised. Especially, the term "normal pressure" hydrocephalus probably does not match the actual manometric profile of patients with NPH. Similarly, the terms"curable"and "reversible" dementia are inadequate to designate the mental alterations of NPH. That NPH is non-specific to the adult population is also stressed, since it may be not uncommonly encountered in paediatrics, especially in an implanted shunt malfunction. The term "chronic hydrocephalus" without reference to cerebrospinal fluid pressure and to the age of the patient is proposed instead of NPH, which seems out of step with current knowledge of the pressure profile and with the diagnosis and decision making context in patients with so called NPH