Spheno-Orbital Meningiomas

Spheno-orbital meningiomas are mainly defined as primary en plaque tumors of the lesser and greater sphenoid wings, invading the underlying bone and adjacent anatomical structures. The patients, mostly women in their fifties, generally present with a progressive, unilateral, and nonpulsatile proptosis, often associated with cosmetic deformity and optic nerve damage. Surgical resection is currently the gold standard of treatment in case of optic neuropathy, significant symptoms, or radiological progression. The surgical strategy should take into account the morphology of the tumor, its epicenter at the level of the sphenoid wing, and the invasion of adjacent anatomical structures. Surgery stabilizes or improves visual function and oculomotricity in most cases but it is rare that the proptosis recovers completely. Gross total resection is hard to achieve considering the complex anatomy of the spheno-orbital region and the risk of inducing cranial nerve deficits. Rare cases of WHO grade II or III meningiomas warrant adjuvant radiotherapy. Tumor residues after subtotal resections of WHO grade I meningiomas are first radiologically monitored and then treated by stereotactic radiosurgery in case of progression

Traitement des schwannomes vestibulaires de gros volume (Koos IV) : les stratégies conservatrices

Thèse présentée sous la forme d'une "Thèse Article "Background: The major burden of the surgical removal of large and giant vestibular schwannomas (VS) is related to the potential risk of postoperative FN palsy responsible of severe functional and social handicap for the patients. The “Functional Sparing Surgery” policy consists in performing an optimal tumor resection while reducing the risk for the FN, underlying the possibility of leaving a minor remnant of tumor. Objective: To assess long term clinical and radiological outcomes in patients harboring large vestibular schwannomas (VS) operated with a facial nerve-sparing technique.Methods: Single center retrospective cohort study about 169 consecutive large VS, defined as KOOS Grade IV, operated between January 2003 and May 2015. The postoperative volume of the tumor residue was assessed by a thin slides MRI six months after surgery and checked sequentially. After resection, patients were allocated to a wait & re-scan (W&reS) or an upfront Gamma-Knife Surgery (GKS) policy.Results: At last follow-up examination, among the 145 patients without preoperative facial nerve palsy, facial nerve function was good (House-Brackmann (HB) Grades I or II) in 84% and moderate (HB Grade III) in 15% of patients. Only 1 (1%) patient presented poor FN function (HB Grade IV). Eleven percent of patients underwent gross total (GTR), 59% near total, 21% subtotal, and 9% partial resection. In the 143 non-GTR patients, the overall median volume of tumor residue was .39cc. Sixty six of them had been allocated to a W&reS policy and 77 underwent upfront GKS. Overall tumor control was achieved in 83% of cases with a mean follow-up of 62 months. Among the 27 cases of regrowth, 16 underwent salvage GKS and one required salvage surgery, which corresponds to a failure rate of 11% in the overall population. Among the non-GTR patients, the 1-, 5- and 7-year PFS were 95%, 82% & 76% respectively in the W&reS, and 99%, 81% & 78% in the GKS group (p=0.57). Conclusion: Our analysis of a large group of operated VS indicates that functional nerve-sparing resection provides satisfactory facial nerve preservation. Considering the low probability of regrowth of small remnants in the long term, W&reS seems reasonable. GKS is a legitimate option as a salvage treatment.Introduction : l’exérèse micro-chirurgicale reste le traitement de référence des volumineux schwannomes vestibulaires (SV) Koos IV. La chirurgie conservatrice, « functional sparing surgery » des anglo-saxons, consiste à réaliser une exérèse tumorale optimale en ayant pour priorité de préserver le nerf facial, avec pour corollaire l’éventualité de laisser un résidu tumoral en cas de dissection difficile, afin minimiser les risques de paralysie faciale périphérique (PFP).Objectif : évaluer les résultats fonctionnels et le contrôle tumoral à long terme de patients opérés de SV Koos IV selon ce protocole.Méthode : étude de cohorte rétrospective mono-centrique portant sur 169 patients consécutifs porteurs de SV Koos IV, opérés entre Janvier 2003 et Mai 2015. Le volume tumoral résiduel postopératoire était mesuré sur des IRM séquences T1 en coupes fines après injection de Gadolinium six mois après la chirurgie, et contrôlé de manière séquentielle. Après l’exérèse micro-chirurgicale, les patients bénéficiaient d’une surveillance du résidu « Wait & re-Scan policy » (W&reS) ou d’un traitement complémentaire par radiochirurgie Gamma-Knife (GKS) pro-active. Résultats : Parmi les 145 patients ne présentant pas d’atteinte faciale préopératoire, 122 (84%) présentaient une fonction faciale normale (Grades I et II de House-Brackmann) à la dernière consultation, tandis que 22 patients (15%) avaient une PFP modérée (Grade III). Un patient seulement (<1%) gardait une PFP sévère (Grade IV). Onze pour cent des patients avaient bénéficié d’une résection complète dite Gross Total Resection (GTR), 59% quasi-totale, 21% sous-totale, et 9% une résection partielle. Le volume résiduel médian était de 0.39cc dans la population des 143 patients présentant un résidu tumoral. Soixante-six d’entre eux avaient été inclus dans le groupe W&reS (volume moyen 0,387cc) et 77 avaient été traités par GKS de manière pro-active (volume moyen 0,831cc). Le contrôle tumoral de la population globale était de 83% avec un suivi moyen de 62 mois. Chez les patients porteurs d’un résidu tumoral, les survies sans progression à 1-, 5- et 7-ans étaient respectivement de 95%, 82% & 76% dans le groupe W&reS, et de 99%, 81% & 78% dans le groupe GKS (p=0.57). Parmi les 27 cas de croissance du résidu, 17 avaient été retraités (taux d’échec global de 11%), 16 par GKS et un chirurgicalement.Conclusion : notre étude portant sur un large effectif de patients opérés de SV Koos IV montre que la résection optimale programmée permet d’obtenir des résultats satisfaisants sur la fonction faciale. En considérant la faible probabilité de croissance des petits résidus à long terme, la surveillance armée semble raisonnable. La radiochirurgie Gamma-Knife est une option thérapeutique légitime devant un échec de contrôle tumoral

How I do it: the combined petrosectomy

BACKGROUND: Petroclival and ventral brain stem tumors require a complex approach. METHOD: The combined petrosectomy is an epidural transtentorial-transpetrosal otoneurosurgical approach to achieve a retrolabyrinthine presigmoidal approach and an anterior petrosectomy in one single procedure. The different steps of this approach are described and illustrated by figures and a video. The indications and limitations of the technique are presented. CONCLUSION: The combined petrosectomy offers multiple corridors to the petroclival region and ventral brainstem while preserving the intrapetrous neurotological structures. Meticulous stepwise bony resection optimizing the dural opening and preservation of veins contributes to reducing the risk inherent to this technique

Haemophilus influenzae Meningitis Direct Diagnosis by Metagenomic Next-Generation Sequencing: A Case Report

International audienceCurrent routine real-time PCR methods used for the point-of-care diagnosis of infectious meningitis do not allow for one-shot genotyping of the pathogen, as in the case of deadly Haemophilus influenzae meningitis. Real-time PCR diagnosed H. influenzae meningitis in a 22-year-old male patient, during his hospitalisation following a more than six-metre fall. Using an Oxford Nanopore Technologies real-time sequencing run in parallel to real-time PCR, we detected the H. influenzae genome directly from the cerebrospinal fluid sample in six hours. Furthermore, BLAST analysis of the sequence encoding for a partial DUF417 domain-containing protein diagnosed a non-b serotype, non-typeable H.influenzae belonging to lineage H. influenzae 22.1-21. The Oxford Nanopore metagenomic next-generation sequencing approach could be considered for the point-of-care diagnosis of infectious meningitis, by direct identification of pathogenic genomes and their genotypes/serotypes

Robot-assisted multi-level anterior lumbar interbody fusion: an anatomical study.

Place: AustriaBACKGROUND: Minimally invasive surgical approaches still provide limited exposure. Access to the L2-L5 intervertebral discs during a single procedure is challenging and often requires repositioning of the patient and adopting an alternative approach. OBJECTIVES: Investigate the windows to the L2-L5 intervertebral discs to assess the dimensions of the interbody implants suitable for the procedure and evaluate the feasibility of multi-level lumbar intervertebral disc surgery in robot-assisted surgery (RAS) METHODS: Sixteen fresh-frozen cadaveric specimens underwent a retroperitoneal approach to access the L2-L5 intervertebral discs. The L2-L3 to L4-L5 windows were defined as the distance between the left lateral border of the aorta (or nearest common iliac vessel) and the medial border of the psoas, measured in a static state and after gentle medial retraction of the vascular structures. Two living porcine specimens and one cadaveric specimen underwent da Vinci robot-assisted transperitoneal approach to expose the L2-L3 to L4-L5 intervertebral discs and perform multi-level discectomy and interbody implant placement. RESULTS: The L2-L3 to L4-L5 intervertebral disc windows significantly increased from a static to a retracted state (p \textless 0.05). The mean L2-L3, L3-L4, and L4-L5 windows measured respectively 20.1, 21.6, and 19.6 mm in the static state, and 27.2, 30.9, and 30.3 mm after gentle vascular retraction. The intervertebral windows from L2-L3 to L4-L5 were successfully exposed through an anterior transperitoneal approach with the da Vinci robot on the cadaveric and living porcine specimens, and interbody implants were inserted. CONCLUSION: RAS appears to be feasible for a mini-invasive multi-level lumbar intervertebral disc surgery. The RAS procedure, longer and more expensive than conventional MIS approaches, should be reserved for elective patients

Ipsilateral vs controlateral approach in tuberculum sellae meningiomas surgery: a retrospective comparative study

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Spinal Fractures during Touristic Motorboat Sea Cruises: An Underestimated and Avoidable Phenomenon

Purpose: Each summer, many vacationers enjoy the Mediterranean Sea shores. Among the recreational nautical activities, motorboat cruise is a popular choice that leads to a significant number of thoracolumbar spine fractures at our clinic. This phenomenon seems to be underreported, and its injury mechanism remains unclear. Here, we aim to describe the fracture pattern and propose a possible mechanism of injury. Methods: We retrospectively reviewed the clinical, radiological, and contextual parameters of all motorboat-related spinal fracture cases during a 14-year period (2006–2020) in three French neurosurgical level I centers bordering the Mediterranean Sea. Fractures were classified according to the AOSpine thoracolumbar classification system. Results: A total of 79 patients presented 90 fractures altogether. Women presented more commonly than men (61/18). Most of the lesions occurred at the thoracolumbar transition region between T10 and L2 (88.9% of the levels fractured). Compression A type fractures were seen in all cases (100%). Only one case of posterior spinal element injury was observed. The occurrence of neurological deficit was rare (7.6%). The most commonly encountered context was a patient sitting at the boat’s bow, without anticipating the trauma, when the ship’s bow suddenly elevated while crossing another wave, resulting in a “deck-slap” mechanism hitting and propelling the patient in the air. Conclusions: Thoracolumbar compression fractures are a frequent finding in nautical tourism. Passengers seated at the boat’s bow are the typical victims. Some specific biomechanical patterns are involved with the boat’s deck suddenly elevating across the waves. More data with biomechanical studies are necessary to understand the phenomenon. Prevention and safety recommendations should be given before motorboat use to fight against these avoidable fractures