Neurochirurgie
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Review
[Role of radiosurgery in the management of intracranial cavernomas. Review of the literature].
From a review of the literature dealing with radiosurgery of cavernous malformations, we have analyzed its impact on hemorrhagic risk, epilepsy, histological modifications, morbidity and potential indications of treatment. Radiosurgery could significantly reduce the hemorrhagic risk, in a selected population with a high risk of hemorrhage, after an interval of about 2 years, but cannot provide protection against rebleeding. As for epilepsy related to the lesion, a significant reduction of seizures has been observed in certain cases, with better control in case of recent evolution and simple seizures linked to the site of the vascular malformation. ⋯ Radiosurgery can be proposed for non-surgical lesions with a high risk of hemorrhage, nevertheless the superiority of the technique over conservative treatment has to be proven. Without long-term prospective studies, the efficiency of RS for cavernomas remains questionable and subject to debate. New imaging methods proving the obstruction of the cavernous malformation are needed.
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Intramedullary cavernomas are rare, but with routinely use of MRI detection has improved, raising the problem of choosing the adequate management approach: conservative or surgical. Cavernomas are vascular malformations, but, as hemangioblastomas they appear as vascular tumors of the spinal cord. They can be durably asymptomatic. ⋯ The lesion is often superficial, covered by the pia-mater, visible immediately after opening the dura, the approach is direct; but in few cases the cavernoma is deep seated in the spinal cord and not visible, the approach is through the midline. It is recommended to perform a complete "en bloc" resection. A yearly MRI control is necessary to search possible "de novo" cases.
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The aim of this review is to summarize our knowledge about Dandy-Walker malformation (DWM) and introduce recent notions about its prognosis. DWM is a malformation associating hypoplasia of the vermis, pseudocystic fourth ventricle, upward displacement of the tentorium, torcular and lateral sinuses and anterio-posterior enlargement of the posterior fossa. It is frequently associated with genetic anomalies, brain malformations (anomalies of gyration, grey matter heterotopias, meningoceles, corpus callosum agenesis...) or systemic malformations (heart, orthopedic, intestinal, urogenital and facial anomalies). ⋯ A cerebellar vermis with three groups of lobes and two main fissures, as identified on MRI T2 sagittal views, not only has the greatest chance to not be associated with other malformation but also to have a favorable neurocognitive outcome. On the contrary, a deeply dysgenetic vermis with only two or one recognizable lobes is not only constantly associated with other brain malformation but also with poor prognosis. This is a recent advance that may be important for those involved in prenatal counselling.
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Review Case Reports
[Surgical management of cervical radiculopathy in Forestier's disease. Case report and review].
Forestier's disease now called DISH (diffuse idiopathic skeletal hyperostosis) is a non inflammatory enthesopathy ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Radiology performed for minor trauma or to explore a stiff neck provides the diagnosis. The main differential diagnosis is ankylosing spondylitis presenting an inflammatory profile as well as previously existing alterations of the sacroiliac joint. ⋯ Surgery in DISH is mainly indicated for dysphagia and rarely after cervical trauma. Of note are associated lesions such as OPLL (ossification of the posterior longitudinal ligament) or synovial cysts responsible for the exceptional and severe myelopathy presentation. The neurosurgical community should become better aware of Forestier's disease.
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Significant progress in prognosis after brain injury has been achieved over the last 20 years. Knowledge of post-traumatic brain hypersensitivity to ischemic events is critical for management. Therefore, all recommended emergency treatments (intubation, oxygenation, prevention of hypotension) focus on situations where oxygen delivery to the brain is compromised (peripheral hypoxia or hypotension but also compressible cerebral hematoma). ⋯ After controlling peripheral hemodynamics and hemostasis, multimodal monitoring (intracranial pressure, transcranial Doppler, SvjO(2)) is necessary to achieve cerebral hemodynamic equilibrium. Management during the first hours after trauma is important for outcome in patients with traumatic brain injury. A well-organized medical referral system with close collaboration between specialists will be able to control this socially accepted silent epidemic.