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Sophie Curey, Stéphane Derrey, Pierre Hannequin, Didier Hannequin, Pierre Fréger, Marc Muraine, Hélène Castel and François Proust

Object

The objective of this study was to evaluate the ophthalmological outcome, nonvisual morbidity, and surgical complications after tuberculum sellae meningioma (TSM) removal using a superior interhemispheric approach.

Methods

In the last decade, 20 consecutive patients with TSM underwent operations using the superior interhemispheric approach. Visual acuity, visual field, and ocular fundus examination were assessed both preoperatively and 6-months postoperatively. Nonvisual morbidity was determined at an early postoperative period and at 6 months based on assessment of the Karnofsky Performance Scale score, leakage of CSF, endocrinological status, and olfactory function, which was assessed using a visual analog scale (VAS). The potential brain injury related to the approach was assessed by MRI at 6 months. Magnetic resonance imaging was then performed yearly to detect a recurrence. The mean follow up was 56.3 ± 34 months.

Results

The primary presenting symptom for diagnosis of TSM in 20 patients (female:male ratio of 6.6:1, mean age 59.1 ± 11.1 years) was visual disturbance in 12 patients (60%), headache in 4 (20%), cognitive alteration in 1 (5%), epilepsy in 2 (10%), and accidental in 1 (5%). In a total of 40 eyes, 17 eyes in 11 patients presented with preoperative deterioration of visual acuity. Postoperatively, the visual acuity improved in 13 eyes in 8 patients (72.8%), remained unchanged in 3 eyes in 2 patients (18.2%) and deteriorated in 1 patient (9%). The nonvisual morbidity included olfactory deterioration in 7 patients (35%), and panhypopituitarism in 1 patient (5%). No patients experienced a CSF leak. The impact of olfactory deterioration on the quality of life, as estimated by a VAS score (range 0–10), was a mean of 5.7 ± 2.2 (95% CI 4.1–7.3). On the follow-up MRI, no additional lesions or recurrences were observed on the medial aspect of the frontal lobe along the surgical corridor.

Conclusions

The superior interhemispheric approach appears to be effective in resolving the problem of visual deterioration due to a TSM, without inducing surgical injury on the brain surface along the surgical corridor. Olfactory deterioration remained the challenging predominant nonvisual morbidity using this approach.

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Stéphane Derrey, Axel Lebas, Dominique Parain, Marie Gilles Baray, Christophe Marguet, Pierre Freger and François Proust

Intracranial bleeding following stereoelectroencephalography (sEEG) is rare and commonly occurs early after electrode implantation. The authors report the case of a delayed intracranial hematoma following sEEG. This 10-year-old boy was referred to the authors' department to undergo an sEEG study for intractable epilepsy, with the hypothesis of a single localized epileptic zone in the left precentral region. To perform the exploration, 14 depth electrodes were implanted under stereotactic conditions. The results of a postoperative CT scan performed routinely at the end of the surgical procedure were normal. Eight days later, following an epileptic seizure, the child's condition worsened. The neurological examination revealed a left hemiparesis, agitation, and coma due to a right subdural hematoma with intraparenchymal bleeding. Despite a surgical evacuation followed by a decompressive craniectomy, the curative treatments were stopped 1 week later due to severe diffuse ischemic lesions found on MRI studies.

This is the first observation of a delayed hematoma following an sEEG procedure. The mechanism underlying this complication remains unclear, but the rupture of a growing pseudoaneurysm caused by the electrode's implantation or the tearing of a neighboring vessel by an electrode were suspected. In consequence, physicians must remain vigilant during the entire sEEG recording period and probably also several days after electrode removal.

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François Proust, Olivier Martinaud, Emmanuel Gérardin, Stéphane Derrey, Sophie Levèque, Sandrine Bioux, Eléonore Tollard, Erick Clavier, Olivier Langlois, Olivier Godefroy, Didier Hannequin and Pierre Fréger

Object

For anterior communicating artery (ACoA) aneurysms, endovascular coil embolization constitutes a safe alternative therapeutic procedure to microsurgical clip occlusion. The authors' aim in this study was to evaluate the quality of life (QOL), cognitive function, and brain structure damage after the treatment of ruptured ACoA aneurysms in a group of patients who underwent microsurgical clipping (36 patients) compared with a reference group who underwent endovascular coiling (14 patients).

Methods

At 14 months posttreatment all patients underwent evaluations by independent observers. These observers evaluated global efficacy, executive functions using a frontal assessment battery of tests (Trail making test, Stroop tasks, dual task of Baddeley, verbal fluency, and Wisconsin Card Sorting test), behavior dysexecutive syndrome (the Inventaire du Syndrome Dysexécutif Comportemental questionnaire [ISDC]), and QOL by using the Reintegration To Normal Living Index. Brain damage was analyzed using MR imaging.

Results

In the microsurgical clipping and endovascular coiling groups, the distribution on the modified Rankin Scale (p = 0.19) and mean QOL score (85.4 vs 83.4, respectively) were similar. Moreover, the proportion of executive dysfunctions (19.4 vs 28.6%, respectively) and the mean score on the ISDC questionnaire (8.9 vs 8.5, respectively) were not significant, but verbal memory was more altered in the microsurgical clipping group (p = 0.055). Magnetic resonance imaging revealed that the incidence of local encephalomalacia and the median number of lesions per patient increased significantly in the microsurgical clipping group (p = 0.003).

Conclusions

In the 2 groups, no significant difference was observed regarding QOL, executive functions, and behavior. Despite the significant decrease in verbal memory after microsurgical clipping, the interdisciplinary approach remains a safe and useful strategy.

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Stéphane Derrey, Romain Lefaucheur, Nathalie Chastan, Emmanuel Gérardin, Didier Hannequin, Marie Desbordes and David Maltête

Object

A collision/implantation or microlesion effect is commonly described after subthalamic nucleus (STN) implantation for high-frequency stimulation, and this is presumed to reflect disruption of cells and/or fibers. Off-period dystonia, a frequent cause of disability in patients with advanced Parkinson disease, can lead to the need for surgical treatment. The authors assessed the early effect of this microlesion on off-period dystonia.

Methods

The authors assessed 30 consecutive patients with the advanced levodopa-responsive form of Parkinson disease. The patients' symptoms were Hoehn and Yahr Scale score ≥ 3, the mean duration of their disease was 11.4 ± 3.5 years, and they had undergone bilateral implantation of electrodes within the STN for high-frequency stimulation between February 2004 and December 2006. The microlesion effect was defined by the clinical improvement (Unified Parkinson's Disease Rating Scale [UPDRS] Part III score, UPDRS Part IV, item 35) assessed the morning of the 3rd day following STN implantation, after at least a 12-hour withdrawal of dopaminergic treatment and before the programmable pulse generator was switched on (off-drug/off-stimulation mode).

Results

Compared with baseline (off state), the microlesion effect improved the motor score (UPDRS Part III) by 27%. Subscores for tremor, rigidity, and bradykinesia respectively improved by 42, 37, and 25%. Nineteen patients (63%) suffered from off-period dystonia before surgery. Twelve (41%) reported complete relief of their symptoms in the immediate postoperative period and remained free of painful off-period dystonia throughout the 6-month follow-up period.

Conclusions

The author postulated that off-period dystonia alleviation may reflect both a microsubthalamotomy and micropallidotomy effect. They hypothesize, moreover, that the microlesion could play a role in the 6-month postoperative outcome.

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François Proust, Emmanuel Gérardin, Stéphane Derrey, Sophie Lesvèque, Sylvio Ramos, Olivier Langlois, Eléonore Tollard, Jacques Bénichou, Philippe Chassagne, Erick Clavier and Pierre Fréger

Object

The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context.

Methods

This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997–June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score ≤ 2) and unfavorable (mRS score > 2).

Results

Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001).

Conclusions

The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.