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Christian Raftopoulos, Philippe David, Serge Allard, Brigitte Ickx, and Danielle Balériaux

✓ This report describes an unusual cephalocele originating in the temporobasal region and protruding through the sphenopetral area into the oral cavity. A rapid and nonaggressive endoscopic procedure was performed. The relationship between this type of cephalocele, spontaneous anteroinferior temporal encephaloceles, and nasopharyngeal brain heterotopia is discussed.

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Denis Dufrane, Christophe Marchal, Olivier Cornu, Christian Raftopoulos, and Christian Delloye

Object. Allogenic human fascia lata used in neurosurgery as a dura mater substitute can be associated with the risk of virus and bacterium transmission and with a delay in its incorporation due to immunological and inflammatory reactions. The authors review their preliminary experience with a chemically and physically processed fascia lata graft.

Methods. Grafts that had been treated with solvent detergents, freeze-dried for conservation, and gamma irradiated (25,000 Gy) for sterilization were placed into 17 patients during neurosurgical procedures performed to treat brain tumors, cerebral malformations, trigeminal neuralgia, and posttraumatic lesions. The handling properties of the material, surgical wound features, and hematological parameters were evaluated. The average follow-up period was 23.8 ± 2.2 months (mean ± standard deviation). The handling properties and biocompatibility of these human dural substitutes were highly satisfactory and no major complications were observed. Postoperative computerized tomography or magnetic resonance images obtained in 13 patients revealed no abnormal findings at the site of fascia lata implantation. In one patient who underwent a second surgery performed 12 months after the initial operation, this dural substitute was found to have been recolonized by host fibroblastic cells and replaced by autologous collagenous tissue.

Conclusions. Human fascia lata that has been rendered safe by applying physical and chemical treatment is a fully biocompatible alternative to the dural graft materials currently available.

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Guus Koerts, Vincent Vanthuyne, Maxime Delavallee, Herbert Rooijakkers, and Christian Raftopoulos

Spinal dural arteriovenous fistulas are rare lesions with an annual incidence of 1 per 100,000 population. In patients with this disease, an abnormal vascular dural shunt exists between a dural branch of a segmental artery and a subdural radicular vein that drains the perimedullary venous system, leading to venous hypertension and secondary congestive myelopathy. Generally, patients present with progressive paraparesis, urinary disturbances, and gait ataxia. In this report the authors describe a 61-year-old woman with a spinal dural arteriovenous fistula who developed an acute paraplegia after a nontraumatic lumbar puncture. The possible underlying mechanisms and treatment options are discussed.

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Christian Raftopoulos, Pierre Mathurin, Dutcho Boscherini, Rudolf F. Billa, Michel Van Boven, and Philippe Hantson

Object. The aim of this study was to evaluate prospectively the results of treating cerebral aneurysms with coil embolization (CE) or with surgical clipping when CE was considered the first option.

Methods. Whenever an aneurysm was to be treated, CE was first considered by our neurovascular team. Surgical clipping was reserved for cases excluded from CE or cases in which CE failed. The study consisted of 103 consecutive patients with 132 aneurysms, of which 127 were treated. Coil embolization was performed using Guglielmi detachable coils, and surgery was performed using Zeppelin clips. Three groups were defined: Group A consisted of 64 aneurysms that were treated by CE (neck/sac ratio < 1:3); Group B, 63 aneurysms that were surgically clipped; and Group C, 12 aneurysms that failed to be satisfactorily (≥ 95%) embolized and were subsequently clipped. The percentages of residual aneurysm were 31.2% in Group A, 1.6% in Group B, and 0% in Group C. The percentages of patients with poor Glasgow Outcome Scale (GOS) scores (GOS Scores 1–3) were 13.3% in Group A, 6.1% in Group B, and 8.3% in Group C. The percentages of poor outcome (GOS Scores 1–3) in patients with good clinical status before treatment were 10.7% in Group A, 0% in Group B, and 8.3% in Group C.

Conclusions. Even with preselection, CE remains associated with a significant number of treatment failures and poor outcomes, even in patients with good preoperative clinical status. Surgical clipping can offer better results than CE, even for more complex aneurysms of the anterior circulation, especially for those involving the middle cerebral artery cases. However, because CE can be effective and causes less stress and invasiveness for the patient, it should be considered first in aneurysms strictly selected by a neurovascular team.

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Marco Cenzato, Davide Colistra, Giorgia Iacopino, Christian Raftopoulos, Ulrich Sure, Marcos Tatagiba, Robert F. Spetzler, Alexander N. Konovalov, Andriy Smolanka, Volodymir Smolanka, Roberto Stefini, Carlo Bortolotti, Paolo Ferroli, Giampietro Pinna, Angelo Franzini, Philipp Dammann, Georgios Naros, Davide Boeris, Paolo Mantovani, Domenico Lizio, Mariangela Piano, and Enrica Fava


In this paper, the authors aimed to illustrate how Holmes tremor (HT) can occur as a delayed complication after brainstem cavernoma resection despite strict adherence to the safe entry zones (SEZs).


After operating on 2 patients with brainstem cavernoma at the Great Metropolitan Hospital Niguarda in Milan and noticing a similar pathological pattern postoperatively, the authors asked 10 different neurosurgery centers around the world to identify similar cases, and a total of 20 were gathered from among 1274 cases of brainstem cavernomas. They evaluated the tremor, cavernoma location, surgical approach, and SEZ for every case. For the 2 cases at their center, they also performed electromyographic and accelerometric recordings of the tremor and evaluated the post-operative tractographic representation of the neuronal pathways involved in the tremorigenesis. After gathering data on all 1274 brainstem cavernomas, they performed a statistical analysis to determine if the location of the cavernoma is a potential predicting factor for the onset of HT.


From the analysis of all 20 cases with HT, it emerged that this highly debilitating tremor can occur as a delayed complication in patients whose postoperative clinical course has been excellent and in whom surgical access has strictly adhered to the SEZs. Three of the patients were subsequently effectively treated with deep brain stimulation (DBS), which resulted in complete or almost complete tremor regression. From the statistical analysis of all 1274 brainstem cavernomas, it was determined that a cavernoma location in the midbrain was significantly associated with the onset of HT (p < 0.0005).


Despite strict adherence to SEZs, the use of intraoperative neurophysiological monitoring, and the immediate success of a resective surgery, HT, a severe neurological disorder, can occur as a delayed complication after resection of brainstem cavernomas. A cavernoma location in the midbrain is a significant predictive factor for the onset of HT. Further anatomical and neurophysiological studies will be necessary to find clues to prevent this complication.