Epilepsie insulaire (du concept électro-clinique à la cortectomie insulaire)

Introduction : La responsabilité du lobe insulaire dans l'épilepsie partielle pharmaco-résistante a longtemps été ignorée du fait de sa topographie singu lière. La stéréo-électroencéphalographie (SEEG) offre la possibilité d'explorer le cortex insulaire, permet de mieux comprendre son rôle dans les foncti ons cérébrales, et de caractériser électro-cliniquement les crises d'épilepsie du lobe insulaire. Cependant la cortectomie insulaire est peu pratiquée en raison des risques fonctionnels importants que suppose l'abord chirurgical de cette région. Objectif: Ce travail a été entrepris afin d'évaluer l'acuité des corrélations anatomo-électrocliniques permise par la SEEG. Lorsque la zone épileptogène a été localisée au niveau de l' insula, nous avons proposé de réaliser la cortectomie insulaire et d'évaluer son efficacité épileptologique. Patients et méthode : 7 patients souffrant d'épilepsie pharmaco-résistante, éligibles au programme d'évaluation pré-chirurgicale dans l'unité d'épileptologie du CHU de Grenoble, ont fait l'objet d' investigations permettant de conclure à une épilepsie du lobe insulaire. 6 patients ont bénéficié de SEEG pour déterminer la zone épileptogène, parmi lesquels 4 pat ients ava ient une IRM pré-opératoire normale. Le septième patient présentait une lésion d'allure tumorale de l'insula postérieur droit et une symptomatologie typique autorisant l'abstention de SEEG: Les 7 patients ont bénéficié d' une cortectomie insulaire par voie trans-operculaire. Résultats: Les investigations par SEEG ont permis de déterminer une zone épileptogène insulaire dans tous les cas. Après la cortectomie, 6 patients sur 7 sont libres de crises (Engell) avec un recul moyen de 32.4 mois (5-60), et le dernier a une diminution importante de la fréquence des crises (Engel IlI a). L'analyse histologique retrouvait une dysplasie corticale focale dans 5 cas, un cas de gliose cicatricielle, et un cas de gangliogliome. 6 patients ont eu un déficit neurologique mineur transitoire. Le dernier n'a eu aucun déficit. Conclusion: La SEEG permet de réa liser avec une grande fiabilité les corrélations anatomoélectrocliniques amenant au diagnostic d'épilepsie insulaire. La cortectomie insulaire a permis de guérir 6 patients sur 7 sans complicati ons. Ces résultats suggèrent que la SEEG doit être réalisée plus systématiquement lorsque l'on soupçonne une épilepsie d'origine insulaire, et la cortectomie doit légitimement faire partie de l'arsenal thérapeutique dans un but curatifMONTPELLIER-BU Médecine UPM (341722108) / SudocMONTPELLIER-BU Médecine (341722104) / SudocSudocFranceF

Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography

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Herpes Simplex Encephalitis Shortly After Surgery for a Secondary Glioblastoma: A Case Report and Review of the Literature

International audienceBackground: Herpes simplex encephalitis (HSE) and glioblastoma multiforme (GBM) co-occurrence has been described in few cases presenting immunocompromised status related to chemotherapy or chemoradiotherapy. Focal encephalitis over surgical edge of resection occurring shortly after GBM resection is rarely reported, and such infection has never been reported in low-grade glioma with secondary malignant transformation (i.e., secondary GBM). Here, we report a case of HSE misdiagnosed in the early postoperative course following a secondary GBM resection. We also provide a review of the literature about HSE occurring after glioma surgery. Case description: We report a case of an acute HSE with a fatal outcome occurring shortly after surgery for a secondary GBM. The patient presented with hyperthermia 12 days after the surgery and was treated with empirical antibiotics. She later suffered from seizure and neurologic deterioration, leading to death despite delayed antiviral administration. Magnetic resonance imaging revealed considerable fluid-attenuated inversion-recovery signal progression at the edge of the surgical resection and polymerase chain reaction amplification of herpes simplex virus (HSV) 1 DNA was positive. Conclusions: Clinicians should be aware of the existing co-occurrence between HSV infections and GBM during the postoperative course. Cerebrospinal fluid analysis with HSV polymerase chain reaction testing should be promptly undertaken, and some keys clinical elements should justify early empirical treatment, including acyclovir administration. The significant prognostic implication of HSE complicating GBM must raise the attention of neurosurgeon and neuro-oncologist about this entity

Stable Isotope Labeling by Amino acid in Vivo (SILAV): a new method to explore protein metabolism

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Surgeon's and patient's radiation exposure during percutaneous thoraco-lumbar pedicle screw fixation: A prospective multicenter study of 100 cases

International audienceHypothesis: Percutaneous pedicle screw fixations (PPSF) are increasingly used in spine surgery, minimizing morbidity through less muscle breakdown but at the cost of intraoperative fluoroscopic guidance that generates high radiation exposure. Few studies have been conducted to measure them accurately. Material and methods: The objective of our study is to quantify, during a PPSF carried out in different experimented centers respecting current radiation protection recommendations, this irradiation at the level of the surgeon and the patient. We have prospectively included 100 FPVP procedures for which we have collected radiation doses from the main operator. For each procedure, the doses of whole-body radiation, lens and extremities were measured. Results: Our results show a mean whole body, extremity and lens exposure dose per procedure reaching 1.7 ± 2.8 Sv, 204.7 ± 260.9 Sv and 30.5 ± 25.9 Sv, respectively. According to these values, the exposure of the surgeon's extremities and lens will exceed the annual limit allowed by the International Commission on Radiological Protection (ICRP) after 2440 and 4840 procedures respectively. Conclusion: Recent European guidelines will reduce the maximum annual exposure dose from 150 to 20 mSv. The number of surgical procedures to not reach the eye threshold, according to our results, should not exceed 645 procedures per year. Pending the democratization of neuronavigation systems, the use of conventional fluoroscopy exposes the eyes in the first place. Therefore they must be protected by leaded glasses. Level of proof: IV, case series

Corticosteroids as an Adjuvant Treatment to Surgery in Chronic Subdural Hematomas: A Multi-Center Double-Blind Randomized Placebo-Controlled Trial

International audienceChronic subdural hematoma (CSDH) is a common condition necessitating surgery; however, recurrence occurs in 15–25% of cases despite surgical management. The HEMACORT trial was a prospective randomized, double-blind, placebo-controlled, multi-centric study (NCT01380028). The aim of this trial was to determine the effect of corticosteroids as an adjuvant treatment to surgery on CSDH recurrence at 6 months. After surgery, participants were assigned by block-randomization to receive either placebo or oral prednisone at a dose of 1 mg/kg/day followed by weekly stepwise tapering in steps of 10 mg/day. The primary outcome was CSDH recurrence, defined by the need for reoperation and/or radiological progression of CSDH. Secondary outcomes were one-year death, radiological changes, safety, neurological status, and quality of life. The trial was discontinued at midpoint of expected inclusions: 78 participants received prednisone and 77 received placebo controls. In an intention-to-treat analysis, CSDH clinicoradiological recurrence was not different between prednisone and placebo groups (21.8% vs. 35.1%, respectively; hazard ratio 0.56; 95% confidence interval 0.30–1.02; p = 0.06), although post hoc analyses concluded to statistical significance (p = 0.02). Earlier radiological resolution was observed after prednisone administration, but reoperation rates (reaching 5.8% overall) and functional outcomes were not different at 6 months. Among adverse events, sleep disorders occurred more often in the prednisone group (26.1% vs. 9.1%, p = 0.02). The HEMACORT trial data suggest that prednisone, as an adjuvant treatment to surgery, may reduce early radiological recurrence of CSDH, although clinical benefits are unclear. In view of these findings, the authors suggest that shorter treatment duration should be assessed for safety and efficacy in future trials