The efficacy of multimodal treatment for symptomatic vertebral hemangiomas: A report of 27 cases and a review of the literature

INTRODUCTION: Vertebral hemangiomas (VH) represent the most common primary bone tumor of the spine and are rarely symptomatic. Currently, there is no consensus for treatment and many therapeutic options are available, alone or in combination including cementoplasty, sclerotherapy, surgery, embolization and/or radiotherapy. OBJECTIVE: To evaluate the clinical and radiological outcome of a multimodal management for symptomatic VH. METHODS: A consecutive prospective and retrospective multicenter study was conducted to review cases of symptomatic VHs between 2005 and 2015. Clinical and radiological aspects, treatment modalities and complications were evaluated preoperatively; postoperatively and at last follow-up. We also reviewed the literature of studies concerning case series of VH, published after 1990 and involving more than 10 patients. RESULTS: Twenty-seven VHs were included in our series (mean age at diagnosis: 47.9 years), out of which 26 were symptomatic. Ten presented with neurologic deficit (37%). An epidural extension was noted in 13 patients (48%). Eleven patients (41%) underwent multimodal treatments. In the multimodal group, eradication was observed in 6 patients (54%), stable residue in 5 cases (46%) with no recurrence versus 3 eradication (23%), 9 stable residue (69%) and no recurrence in the monomodal group, (P>0.05). The literature comprised 14 studies including 458 patients. Only 4 studies were focused on multimodal treatments. CONCLUSION: Based on this study, the multimodal management of symptomatic VHs appeared safe and effective. Finally, we propose an algorithm for symptomatic VHS management based on the severity of epidural extension and fracture risk.Les auteurs n'ont aucun support financier à déclare

Successful Treatment with Dabrafenib/Trametinib of a Malignantly Transformed and Metastasized BRAF V600E Mutant Pleiomorphic Xanthoastrocytoma: A Case Report and Review of the Literature

Introduction: Pleiomorphic xanthoastrocytoma (PXA) is considered a low-grade glioma with a favorable prognosis following surgical resection. We present a case report of a BRAFV600E mutant malignantly transformed and disseminated PXA that was successfully treated with BRAF-/MEK-targeted therapy (dabrafenib/trametinib). Case Presentation: At the age of 16 years, our patient underwent an initial subtotal resection of a right occipital PXA. Six months later, a reintervention for an asymptomatic tumor recurrence was performed and complete resection was achieved. The patient has been followed up by MRI for 14 years without arguments for recurrence but was lost to follow-up thereafter. At 38 years of age, he presented with a symptomatic local recurrence with extra-cerebral soft tissue extension, for which a third surgical resection was performed. Anatomopathological examination reported a grade 3 anaplastic PXA (aPXA); molecular analysis detected a BRAFV600E mutation. Three months later, before the initiation of radiotherapy, a local tumor recurrence was diagnosed, for which he underwent a fourth surgical resection. Radiotherapy was performed following the surgical debulking. One month after completion of radiotherapy, disease progression was documented including multiple sites of extracranial metastases (skeletal, lung, cervical lymph node, and subcutaneous metastases). Systemic treatment with a combination of BRAF-/MEK-inhibitors (dabrafenib/trametinib) was initiated and resulted in a rapid and deep tumor response (partial response according to RECISTv1.1) and absence of BRAFV600E mutant ctDNA in plasma at 6 weeks after treatment initiation. A near-complete metabolic remission was documented on [18F]FDG-PET/CT 3 months after starting systemic therapy. Conclusion: We present a rare case of malignant transformation and systemic dissemination of a BRAFV600E mutant PXA, occurring 20 years after the initial diagnosis. This case highlights the importance of long-term follow-up of patients diagnosed with these rare central nervous system tumors that initially are considered benign and also illustrates that BRAF/MEK inhibition can be an effective therapy for BRAFV600E mutated PXA, underscoring the importance of performing molecular genetic profiling of these tumors

How I do it: anterior interhemispheric approach to tuberculum sellae meningiomas.

Tuberculum sellae meningiomas are deep-seated tumors difficult to access, located in close relation with important neurovascular structures. While the transsphenoidal approach is linked to specific complications, the different reported transcranial approaches are associated with advantages and drawbacks due to the respective angle of attack, with some areas adequately exposed and others partially hidden. We report the technical aspects of the anterior interhemispheric approach we practice. This approach has the advantage of providing full control over all the vasculo-nervous structures involved and of allowing access to the medial aspect of both optic canals tangentially to the dorsum sellae

Surgical treatment of a syringomyelia associated with an idiopathic arachnoid malformation disclosed by preoperative MRI.

BACKGROUND: We describe the very rare condition of an idiopathic spinal arachnoid malformation associated with syringomyelia (SM) and depicted on preoperative magnetic resonance imaging (MRI) whose features were confirmed at surgery. CASE DESCRIPTION: A 34-year-old female suffered from progressive gait impairment because of lower limb palsy and sensory disturbances. MRI demonstrated a bulging membrane at the T6 level that was transversely stretched between the dorsal aspect of the spinal cord and the posterior dura mater. At this level, the spinal cord appeared atrophic and pushed anteriorly against the dura with enlargement of the posterior subarachnoid spaces (SAS) and focal collapse of an associated panmedullar SM. Surgery consisted in releasing the arachnoid malformation and opening the inferior segment of the syringomyelic cavity. Pathological examination revealed a fibro-sclerotic tissue with cellular areas of meningo-endothelial cells. Postoperative neurological status progressively improved but slightly. Three-months and 1 year postoperatively, MRI showed the collapse of the whole SM and restoration of cerebrospinal fluid (CSF) flow at the treated T6 level. CONCLUSION: Spinal arachnoid malformations associated with SM are very rare and have never been described up to now on MRI. Surgical removal of the causative malformation allows spinal cord decompression and prevents the recurrence of the SM by restoring normal CSF circulation

Olfactory Groove Meningiomas: Comprehensive assessment between the different microsurgical transcranial approaches and the Endoscopic Endonasal Approaches, systematic review and metanalysis on behalf of the EANS skull base section

[EN] Currently, debate continues regarding the best approach for OGM surgery, and the question remains if there is one approach in particular which can be tailored to these lesions. The goal of the present investigation is, to compare and assess if there are significant differences between the different MTCAs, MITCAs and EEAs, and we set out to weigh and compare clinical and surgical outcomes among the different surgical groups

Surgical clipping of very small unruptured intracranial aneurysms: a multicenter international study.

BACKGROUND: Treatment of very small unruptured intracranial aneurysms (VSUIAs, defined as #3 mm) can be indicated in selected circumstances. The feasibility and outcomes of endovascular therapy for VSUIAs have been recently published; however, the efficacy and complication rate of surgical clipping has not been reported in any large series to date. OBJECTIVE: We conducted a multicenter study to examine surgical outcomes for VSUIAs. METHODS: All consecutive patients undergoing surgery for a VSUIA in 4 neurosurgical centers between October 2001 and December 2012 were retrospectively analyzed. RESULTS: In the study, 183 patients (128 women, mean age 51.3 years) were treated with 190 procedures for a total of 228 aneurysms. Most were anterior circulation aneurysms (n = 215). The majority were directly clipped (n = 222, 97.4%), with coagulation or wrapping in the remainder. After 1 reoperation for incomplete clipping, postoperative imaging of 225 aneurysms confirmed complete occlusion in 221 (98.2%), 1 neck remnant (0.44%), and 3 partial occlusions (1.3%). Mortality was 0%. Early postoperative neurological deficit developed in 12 patients (6.6%); posterior circulation location was a significant risk factor for early neurological deficit (P , .001). Middle cerebral artery aneurysms had the lowest rate of postoperative deficits at 1.5% (P = .023). After the initial 30-day perioperative period, all deficits related to treatment of posterior circulation aneurysms recovered; overall neurological morbidity decreased to 2.7% with no mortality. CONCLUSION: VSUIA clipping is highly effective and is associated with a low morbidity rate. For VSUIAs selected for treatment, our data support surgical clipping as the modality of choice

1968, entre libération et libéralisation

Les auteurs analysent ici les processus complexes et multiples de libéralisation manifestés dans différents domaines lors de la seconde moitié des années soixante ainsi que leur rôle éventuel dans la dérégulation affirmée ouvertement après 1984. Quelle place les évènements de 1968 et leurs résultats, tels qu'inscrits dans la loi, dans des décrets ou simplement dans les pratiques, occupent-ils dans ce qui constitue un retournement ? Marquent-ils la fin d'un cycle ouvert par la séquence 1936-1946 et dont les bornes ne coïncideraient pas avec celles des Trente Glorieuses ? Sont-ils annonciateurs d'une séquence nouvelle et, dans cette hypothèse, laquelle ? Ouvrent-ils plus largement à l'appréhension de temporalités autres ? Les réponses apportées ici suggèrent une chronologie inédite, où mai 1968 s'impose comme le moment d'une grande bifurcation

Apport de la sûreté de fonctionnement à l'analyse spatialisée du risque inondation

International audienceThe urban technical systems are subjected to major stakes, such as climatic and territorial issues, which affect their functioning. These stakes can make the technical systems vulnerable to natural hazards. But, the traditional methodologies used for vulnerability analyses are hazard-oriented. They are focused on the hazard as a physical process and on the direct damages to the system. This approach is found to be unsuitable for analyzing systems with a high level of complexity, interconnectedness and linkages with other urban technical systems, and with many and varied failures processes. This paper analyzes the vulnerability of guided transport systems facing flood risk. This research focuses on an innovative approach of risks analysis that associates safety and dependability methods with methods from geomatics. The geographical information allows this combination between these two very different types of methods. The chosen approach is system-oriented in order to elaborate a methodology for characterizing any direct and indirect damages to the system. The global goal is to highlight the contribution of this innovative approach for the urban risk management, and so improve the resilience of cities facing of flood risks.Les systèmes techniques urbains sont soumis à des enjeux importants, notamment cli-matiques et territoriaux, qui affectent leur fonctionnement. Ces enjeux rendent alors les systèmes techniques vulnérables aux aléas naturels. Or, les méthodologies usuellement mobilisées pour l'analyse de la vulnérabilité restent essentiellement aléa-centrées, c'est-à-dire qu'elles se focalisent sur l'aléa en tant que phénomène physique et sur les dommages directs qu'il provoque sur le système. Cette approche semble peu ou pas indiquée lorsque le système étudié est caractérisé par une importante complexité, par une forte interconnexion avec d'autres systèmes techniques et par des dynamiques de défaillances multiples et simultanées. Dans cet article, nous nous intéressons à l'analyse de la vulnérabilité des systèmes de transport guidé face au risque d'inondation. Cette recherche porte sur une approche innovante d'analyse des risques qui associe à la fois des méthodes issues de la sûreté de fonctionnement et des méthodes issues de la géomatique à l'aide de l'information géographique. L'approche est volontairement système-centrée pour concevoir une méthodologie apte à caractériser les atteintes directes et indirectes au système. L'enjeu global est de mettre en exergue l'apport d'une telle méthode pour la gestion des risques urbains, en contribuant ainsi à la résilience globale des villes face à des risques d'inondation

Endovascular treatment of proximal anterior cerebral artery aneurysms.

INTRODUCTION: Aneurysms of the proximal segment of the anterior cerebral artery (A1A) are rare and challenging to treat. No information is available regarding their management by endovascular approach. The aim of this study was to report our experience with endovascular treatment (EVT) of A1As. PATIENTS AND METHODS: A retrospective review of our prospectively maintained database identified all A1As treated in our institution. The clinical charts, procedural data, and angiographic results were reviewed. RESULTS: From April 2004 to August 2008, eight patients were identified and presented with an unruptured A1A. All aneurysms but one were <3 mm in diameter and two aneurysms had a perforator at the neck. Surgery was performed in two patients with an aneurysm <2 mm. Six patients were treated by selective embolization including five patients with balloon-assisted coiling (BAC) and/or via a retrograde approach from the contralateral side through the anterior communicating artery. These adjunctive techniques were used to safely catheterize the sac or to protect a branch at the neck. All patients showed an excellent clinical outcome. A complete aneurysm occlusion was obtained in all but one patient. Follow-up imaging in four patients showed stable results. CONCLUSION: EVT of A1As is feasible and associated with good clinical and anatomical results. Because of their location, small size, and close relationship with perforators, EVT frequently requires the use of BAC and/or a retrograde approach. Our results suggest that EVT is an alternative therapeutic option to surgical clipping if the aneurysm size is compatible with selective embolization.Clinical TrialJournal Articleinfo:eu-repo/semantics/publishe