✓ A 36-year-old woman with an uneventful medical history was admitted to the emergency department following an initial generalized seizure. Neuroimaging workup disclosed a homogeneous mass at the vertex, which first was diagnosed as vertex meningioma. Anticonvulsant drug therapy was administered and the patient was discharged. Two months later the patient was examined in our neurosurgery department for additional therapeutic recommendations. A repeated neuroimaging examination showed considerable regression of the lesion. The findings on magnetic resonance imaging were consistent with those of a regressing extradural hematoma (EDH). A complete blood-coagulation study displayed no evidence of abnormality. Thorough questioning of the patient revealed no history of pericranial infection or head trauma occurring within the last 2 years. The final diagnosis was spontaneously occurring vertex EDH. In this report the authors describe the clinical and neuroimaging features of the case as well as the management strategy, and discuss etiological aspects within the context of a careful review of the literature.
Case report and review of the literature
Henry Dufour, Philippe Métellus, Luis Manera, Stéphane Fuentes, Laurent Do and François Grisoli
Stéphane Fuentes, Olivier Levrier, Philippe Metellus, Henry Dufour, Jean Marc Fuentes and François Grisoli
Jean Régis, Philippe Metellus, Motohiro Hayashi, Philippe Roussel, Anne Donnet and Françoise Bille-Turc
Stereotactic radiosurgery is an alternative to conventional surgery for the treatment of trigeminal neuralgia. The authors conducted a prospective evaluation of the safety and efficacy of this method in a large series of patients.
A total of 100 patients presenting with trigeminal neuralgia were treated and followed up for a minimum of 12 months. The mean age was 68.2 years; 54 patients were male, and 46 were female. Seven had a history of multiple sclerosis, and 42 had already received conventional surgical treatment for trigeminal neuralgia. The intervention consisted of gamma knife surgery to the retrogasserian cisternal portion of the fifth cranial nerve. The median dose used at the maximum was 85 Gy (range 70–90 Gy). The number and intensity of pain attacks were recorded by the patient from 3 months before radiosurgery to a minimum of 12 months after treatment. Before and a minimum of 12 months after treatment, the patient completed a quality-of-life questionnaire. Neurological examination and quantitative sensory testing to evaluate sensory perception were performed by an independent neurologist over this same time period.
At the last visit 83 of 100 patients were reported to be pain free. Fifty-eight of these 83 patients had stopped taking medication during the study. All quality-of-life parameters were improved (p < 0.001). Six patients reported facial paresthesia, and four patients reported hypesthesia. These symptoms were classified as mild. None of the complications reported for other techniques were observed.
Radiosurgery is a safe and effective alternative treatment for trigeminal neuralgia and is associated with a particularly low rate of hypesthesia.
Philippe Metellus, Wesley Hsu, Siddharth Kharkar, Sumit Kapoor, William Scott and Daniele Rigamonti
The authors report their experience using preoperative chest radiography and intraoperative ultrasonography for percutaneous positioning of the distal end of the catheter when placing ventriculoatrial (VA) shunts in patients with hydrocephalus. The distal portion of VA shunt catheters were percutaneously placed into the internal jugular vein with the aid of intraoperative ultrasonography in 14 consecutive adults. In all cases, the technique was easy, there were no postoperative complications, and postoperative chest radiography demonstrated good positioning of the distal catheter tip. One patient presented with a shunt infection and needed a shunt replacement. The authors therefore conclude that percutaneous placement of a VA shunt under preoperative radiographic guidance and ultrasonographic monitoring is a safe, effective, and reliable technique that is simple to learn.
Stéphane Fuentes, Sergueï Malikov, Benjamin Blondel, Philippe Métellus, Henry Dufour and François Grisoli
The cervicothoracic junction is always a difficult area to approach. When operating on this specific area (for tumor or trauma), the aim is generally to decompress and stabilize the spine. The authors describe an improved median sternotomy method for reaching the anterior aspect of the spine down to T-5.
Seven patients with a mean age of 40 years (range 17–68 years) were included in this study. The vertebral lesion was due to trauma in 4 cases and tumor in the other 3. A single vertebral body was involved in 2 cases, 2 in 3 cases, and 3 in 2 cases. The vertebra most often involved was T-3 (6 cases), although T-4 was involved in 2 cases, T-5 in 2 cases, and T-1 and T-2 in 1 case each. All patients underwent the same preoperative workup: CT scanning, MR imaging, and CT angiography of the aortic arch.
The median sternotomy made it possible to effectively decompress and stabilize the spinal cord. An anterior screw plate was used in 5 cases. The plate extended from T-2 to T-5 in 3 cases, from T-2 to T-4 in 2 cases, and from C-7 to T-4 in 1 case. The mean duration of surgery was 195 minutes (range 180–240 minutes). No neurological deterioration occurred. The mean hospital stay was 8 days (range 6–15 days). In 2 cases (28.6%), recurrent left nerve palsy was observed postoperatively; the palsy was transient in both of these cases, and full recovery occurred within 3 months. The mean follow-up among this series of patients was 29 months (range 22–38 months).
The median sternotomy provided a good means of reaching the upper thoracic spine (T2–5) and cervicothoracic junction. It enables surgeons to decompress the spinal cord and stabilize the spine.
Jean Régis, Philippe Metellus, Henry Dufour, Pierre-Hughes Roche, Xavier Muracciole, William Pellet, Francois Grisoli and Jean-Claude Peragut
Object. This study was directed to evaluate the potential role of gamma knife surgery (GKS) in the treatment of secondary trigeminal neuralgia (TN). The authors have identified three anatomicoclinical types of secondary TN requiring different radiosurgical approaches.
Methods. Pain control was retrospectively analyzed in a population of patients harboring tumors of the middle or posterior fossa that involved the trigeminal nerve pathway. This series included 53 patients (39 women and 14 men) treated using GKS between July 1992 and June 1997. The median follow-up period was 55 months. Treatment strategies differed according to lesion type, topography, and size, as well as visibility of the fifth cranial nerve in the prepontine cistern. Three different treatment groups were established. When the primary goal was treatment of the lesion (Group IV, 46 patients) we obtained pain cessation in 79.5% of cases. In some patients in whom GKS was not indicated for treatment of the lesion, TN was treated by targeting the fifth nerve directly in the prepontine cistern if visible (Group II, three patients) or in the part of the lesion including this nerve if the nerve root could not be identified (Group III, four patients). No deaths and no radiosurgically induced adverse effects were observed, but in two cases there was slight hypesthesia (Group IV). The neuropathic component of the facial pain appeared to be poorly sensitive to radiosurgery. At the last follow-up examination, six patients (13.3%) exhibited recurrent pain, which was complete in four cases (8.8%) and partial in two (4.4%).
Conclusions. The results of GKS regarding facial pain control are very similar to those achieved by microsurgery according to series published in the literature. Nevertheless, the low rate of morbidity and the greater comfort afforded the patient render GKS safer and thus more attractive.
Olivier Levrier, Philippe Métellus, Stephane Fuentes, Luis Manera, Henry Dufour, Anne Donnet, François Grisoli, Jean-Michel Bartoli and Nadine Girard
The goal of this study was to evaluate the clinical and angiography results in 10 patients with transverse–sigmoid dural arteriovenous fistulas (DAVFs) treated using sinus angioplasty and dural sinus stent insertion.
Between 2001 and 2003, 10 consecutive patients (six men and four women, age range 54–79 years) who had presented with transverse and/or sigmoid sinus DAVFs with or without sinus thrombosis underwent self-expanding stent placement and balloon angioplasty. Eight fistulas involved the transverse sinus, three the sigmoid sinus, and one the torcular and occipital sinuses. According to the Djindjian-Merland grading system, there were two Type I, five Type IIa, one Type IIb, and two Type IV DAVFs. The mean clinical follow-up period was 21.1 months. At the last follow-up examination, seven patients were asymptomatic and three were dramatically improved. The mean angiography follow-up period was 7.5 months for the available population: four patients had complete DAVF occlusion, four had significant flow reduction, and two who experienced clinical improvement refused conventional angiography control studies. Delayed computerized tomography angiography scans were obtained to evaluate stent permeability in nine of the 10 patients. Stent permeability was demonstrated in eight of the nine patients with available control studies at a mean follow up of 20.8 months. There were two transient neurological deficits but no severe and permanent complications.
In this series, sinus stent insertion resulted in a cure or significant clinical improvement in all patients harboring a DAVF, with no severe or permanent complication. Stent placement for transverse and/or sigmoid sinus DAVFs is a promising technique whose viability should be confirmed in larger series with longer follow-up periods.