Endoscopy of pineal region tumours has been developed since the year 2000 either via a transventricular or extracerebral approach. The initial purpose of applying neuroendoscopy in the management of pineal region tumours was to resolve the obstructive hydrocephalus, and identify the pathological characteristics of the tumour. Based on this approach, a piecemeal resection of the tumour can be performed. The approaches, derived from the microsurgical pathway using an endoscope to expose the operative field, have been proposed either via an infratentorial supracerebellar approach or posterior transtentorial interhemispheric approach. Neuroendoscopic procedures can be considered as a therapeutic alternative to the microsurgical approach when CSF markers are negative. This procedure is considered mini-invasive for the approach along the surgical corridor access but extensive and in depth at the interface between the tumour and the surrounding neurological parenchyma. The limitations and complications are related to the type of procedure (mono- or bimanual) as well as the tumoral characteristics. Different approaches are presented in detail in order to avoid the occurrence of any surgical complications.L’endoscopie des tumeurs de la région pinéale est proposée depuis les années 2000, que ce soit par voie transventriculaire ou extracérébrale. Au départ, l’objectif était de résoudre l’hydrocéphalie obstructive par perforation du plancher du 3e ventricule. Utilisant cet accès pour réaliser des biopsies, la possibilité de résection tumorale a été rapidement proposée par cette voie transventriculaire. Les approches extracérébrales, dérivées des voies microchirurgicales supracérébelleuses ou transtentorielles permettent de travailler selon une dissection bimanuelle comparable à celle réalisée sous microscope opératoire. Ces procédures considérées comme mini-invasives le sont uniquement pour l’approche réduisant à son strict minimum les dissections tissulaires mais en profondeur, la largeur du champ opératoire en fait une procédure extensive à haut risque fonctionnel pour les structures environnantes. La difficulté opératoire est liée à la procédure selon l’usage de procédure mono- ou bimanuelle mais aussi aux caractéristiques de la tumeur en termes de vascularisation, de consistance, de taille et de risque de dissémination liquidienne de cellules tumorales. Le futur serait un système hybride entre le microscope opératoire et l’endoscopie.

Results of a close prospective follow-up of patients treated for a high grade glioma with or without biodegradable Carmustine wafers but receiving treatment according to Stupp schedule. From May 2007 to June 2008, 65 patients were operated on for a high grade glioma with (28 patients) or without implantation of Gliadel (37 patients). Overall patients received radiotherapy with concomitant temozolomide following or not by 5-day monthly schedule of adjuvant témozolomide. Median of follow-up was 11 months. The two groups were comparable. For overall patients, the median of relapse-free survival was 11 months. Six- and 12-month relapse free survival rates were respectively 80% and 49%. In monovariate analysis, there was no difference of relapse-free survival between patients who received Gliadel and those did not, median relapse free survival and 1-year relapse free survival rates were respectively, 12.9 and 11.7 months and 50.2% and 44% (p = 0.98). However, significant difference of relapse-free survival were shown for pathologic grade (p = 0.0025), age (p = 0.0066) and MGMT methylation status (p = 0.02). In multivariate analysis, only methylated MGMT was a favorable relapse free-survival (p = 0.04, RR: 2.7 CI [1-6.7]). Median of overall survival was not reached. For overall patients, 6- and 12-months overall survival rates were respectively, 92% and 76% (p = 0.12). In monovariate analysis, there was no difference of overall survival between patients who received Gliadel® and those did not, 1-year overall survival rates were respectively, 91.6% and 76.2%, medians of overall survival were not reached for both groups. However, difference of overall survival were shown for irradiation dose (p = 0.014), MGMT methylation status (p = 0.02) and age (p = 0.048). In multivariate analysis, unmethylated MGMT and irradiation dose lower than 60 Gy were unfavorable prognostic factor of overall survival, respectively p = 0.006, RR: 9.8 CI [1.8-51] and p = 0.001, RR: 8,4 CI [2.3-33]. We did not observe difference of peritumor edema volume between the both groups. With Carmustine median GTV plus edema was 84 [27-229] and without Carmustine, it was 68 [10-362], (p = non significant). We observed four cases of thrombopenia, all in the Carmustine Wafers group. Adding Gliadel® before a Stupp schedule for patient with high grade glioma did not decrease survivals.

In spite of having been the object of considerable attention, the histopathological grading of oligodendrogliomas is still controversial. The determination of reliable biomarkers capable of improving the malignancy grading remains an essential step in working toward better therapeutic management of patients. Therefore the metabolome of 34 human brain biopsies, histopathologically classified as low‐grade (LGO, N = 10) and high‐grade (HGO, N = 24) oligodendrogliomas, was studied using high‐resolution magic angle spinning nuclear magnetic resonance spectroscopy (HRMAS NMR) and multivariate statistical analysis. The classification model obtained afforded a clear distinction between LGOs and HGOs and provided some useful insights into the different metabolic pathways that underlie malignancy grading. The analysis of the most discriminant metabolites in the model revealed the presence of tumoral hypoxia in HGOs. The statistical model was then used to study biopsy samples that were classified as intermediate oligodendrogliomas ( N = 6) and glioblastomas (GBMs) ( N = 30) by histopathology. The results revealed a gradient of tumoral hypoxia increasing in the following direction: LGOs, intermediate oligodendrogliomas, HGOs, and GBMs. Moreover upon analysis of the clinical evolution of the patients, the metabolic classification seems to provide a closer correlation with the actual patient evolution than the histopathological analysis. Magn Reson Med 59:959–965, 2008. © 2008 Wiley‐Liss, Inc.

INTRODUCTION:Acute myelitis accounts for 4 to 5 percent of all cases of neuroborreliosis. In the literature, simultaneous spinal MRI and cerebrospinal fluid (CSF) investigations are presented for only 8 cases. We describe here 3 cases of acute Lyme myelitis.METHOD:In a cohort of 45 patients with neuroborreliosis, diagnosed between January 1998 and January 2005, 3 had acute myelitis. Clinical, biological and radiological data were studied.CASE REPORTS:The three patients had motor, sensorial and sphincter involvement. Extra-spinal involvement, such as fever and headache for one, facial nerve palsy for the second and subarachnoid hemorrhage for the third, was also noted. Pleocytosis varied from 10 to 520 white cells per mm3. Lyme serology was positive in CSF for all. Intrathecal anti-Borrelia antibody index was positive or intermediate for all three patients. Spinal cord MRI revealed a large hyperintense zone involving more than 3 vertebral segments. Myelitis was central, posterior or transverse in the axial plane. The clinical course was favorable after a three-week course of appropriate antibiotics.CONCLUSION:These 3 cases and the others from the literature show the diversity of the clinical and radiological features of acute myelitis: transverse, central or posterior myelitis. Thus, Lyme serology in CSF in indicated for patients presenting acute myelitis, particularly in endemic areas.

Introduction. Acute myelitis accounts for 4 to 5 percent of all cases of neuroborreliosis. In the literature, simultaneous spinal MRI and cerebrospinal fluid (CSF) investigations are presented for only 8 cases. We describe here 3 cases of acute Lyme myelitis. Method. In a cohort of 45 patients with neuroborreliosis, diagnosed between January 1998 and January 2005, 3 had acute myelitis. Clinical, biological and radiological data were studied. Case reports. The three patients had motor, sensorial and sphincter involvement. Extra-spinal involvement, such as fever and headache for one, facial nerve palsy for the second and subarachnoid hemorrhage for the third, was also noted. Pleocytosis varied from 10 to 520 white cells per mm(3). Lyme serology was positive in CSF for all. Intrathecal anti-Borrelia antibody index was positive or intermediate for all three patients. Spinal cord MRI revealed a large hyperintense zone involving more than 3 vertebral segments. Myelitis was central, posterior or transverse in the axial plane. The clinical course was favorable after a three-week course of appropriate antibiotics. Conclusion. These 3 cases and the others from the literature show the diversity of the clinical and radiological features of acute myelitis: transverse, central or posterior myelitis. Thus, Lyme serology in CSF in indicated for patients presenting acute myelitis, particularly in endemic areas.

Evaluer les résultats de la prise en charge des hémangio-mes vertébraux agressifs par vertébroplastie, sclérothérapie et chirurgie, en discutant la place de chaque technique et des combinaisons thérapeutiques. De novembre 1991 à décembre 2006, 31 hémangiomes vertébraux agressifs, responsables de douleurs ont été traités chez 30 patients. Des symptômes neurologiques étaient présents chez 8 patients (4 radiculalgies, 4 déficits moteurs). Une verté-broplastie seule a été réalisée pour 22 hémangiomes limités au corps vertébral ou avec extension paravertébrale minime. La vertébroplastie a été combinée à une sclérothérapie (n = 6), à une embolisation artérielle et une laminectomie réglée (n = 2), ou à une laminectomie réglée seule (n = 1) en cas de large extension paravertébrale ou épi-durale. L’évolution des douleurs, des symptômes neurologiques, de l’effet de masse en IRM, ainsi que la stabilité vertébrale ont été évaluées. Toutes les procédures étaient techniquement réalisables. Un syndrome de la queue de cheval nécessitant une laminectomie en urgence a constitué la seule complication sévère après sclérothérapie. Cinq fuites mineures de ciment sont restées asymptomatiques. Une deuxième session a été nécessaire chez 5 patients (2 vertébroplasties, 3 sclérothérapies) pour compléter le traitement de l’hémangiome. La résolution des douleurs a été obtenue chez 28 patients. La régression des symptômes neurologiques a été systématique. Il n’y a pas eu de tassement vertébral secondaire. La vertébroplastie est le principal traitement de l’hémangiome agressif et permet la consolidation vertébrale. La sclérothérapie lui est associée en cas d’extension paravertébrale ou épi-durale, afin d’assurer l’oblitération complète de la tumeur et éviter la récidive. La laminectomie est réalisée en cas d’aggravation des symptômes neurologiques.

Les myélites aiguës de Lyme représentent 4 % des neuroborrélioses. Seuls 8 cas ayant fait l'objet d'une étude du liquide céphalorachidien et d'une IRM médullaire ont été décrits dans la littérature. Décrire 3 nouveaux cas de myélite aiguë de Lyme. Dans une série de 45 patients atteints de neuroborréliose diagnostiquée en 8 ans entre le premier janvier 1997 et le 31 décembre 2004, 3 avaient un tableau de myélite aiguë. Nous en avons analysé les caractéristiques cliniques, biologiques et radiologiques. Ces 3 patients avaient tous une atteinte sensitivo-motrice, sphinctérienne et extra-médullaire : fièvre et céphalées ou paralysie faciale périphérique ou hémorragie méningée. La pléiocytose était constante. La sérologie de Lyme était positive dans le LCR pour les 3 cas. L'index de synthèse intrathécale anti-Borrelia était positif ou intermédiaire. L'IRM médullaire retrouvait un hypersignal (transverse, postérieur ou central) de plus de 3 métamères de hauteur. L'évolution sous antibiothérapie était favorable. Ces 3 cas ainsi que les autres décrits dans la littérature attestent de l'extension sur plus de 3 métamères des myélites aiguës de Lyme. Il existe par ailleurs une diversité des tableaux clinico-radiologiques de myélite aiguë de Lyme : myélite transverse, postérieure ou centrale. Une sérologie de Lyme dans le liquide céphalorachidien doit être systématiquement pratiquée dans les myélites aiguës étendues, en particulier en zone d'endémie.

BACKGROUND:Memory for the past has been much less explored than anterograde memory in temporal lobe epilepsy. No data are available about the course after surgical treatment. Moreover, case-reports showing isolated memory deficit for publics events with preserved autobiographical memory are notorious for their paucity.METHODS:We report the case of a patient with a left hippocampal lesion associated with intractable temporal lobe epilepsy. Comprehensive neuropsychological assessments were carried out before and after temporal lobectomy, stressing particularly memory for the past by means of standardised and tailor-made tests.RESULTS:The patient exhibited preserved memory for autobiographical events and facts but impaired scores on several public event tests, in the context of preserved general abilities. Furthermore, we found an accelerated forgetting rate for verbal and non verbal material.CONCLUSION:Our findings suggest that the patient's impaired long-term consolidation might have contributed to the impaired performance on public event memory tests. We discuss the specific features of new events processing that may contribute to its increased vulnerability relative to autobiographical memory, in the event of accelerated forgetting.

Objective. - To assess the predictive value of MRI vertebral end-plate changes (Modic) on clinical outcome of surgically treated lumbar single-level degenerative disc disease (DDD).Methods. - A cohort of 60 patients was included. Patient groups were similar in respect of age, gender and clinical presentation, allowing comparisons. Patient age ranged from 30 to 72 years (mean: 45.8 years). All patients suffered severe chronic low back pain for more than 6 months, with single-level symptomatic DDD. All patients experienced segmental instrumented interbody (n=22) or posterolateral (n=38) fusion. Clinical outcome was assessed by using a visual analog scale (VAS) and the functional disability scale of the Japanese Orthopaedic Association (JOA) for lumbar spine. The number of patients for each Modic group was as follows: Modic type 0, n=15; Modic type I, n=22; Modic type II, n=14; and Modic type IIII, n=9. Fusion rates were similar for each Modic group of patients. Mean follow-up was 14 months.Results. - The pre-operative mean VAS improved by 53.5% (from 8.2 +/- 2. 0 to 3.8 +/- 1.9, p<0.05) and the pre-operative mean JOA score by 58% (from 5.5 +/- 2.1 to 11.0 +/- 2.4, p < 0.05). Patients harboring Modic type 1 changes improved much better than others (p<0.05). Conversely, clinical outcome of patients presenting with Modic type II lesions was poor.Conclusion. - This study confirms instrumented fusion as an effective treatment in symptomatic lumbar DDD. Preoperative combination of low back pain of discal origin and severe DDD with Modic type I lesion on MRI may lead to excellent results after fusion in a large proportion of patients. Conversely, arthrodesis for patients harboring Modic type II abnormalities implicates smaller benefit of doubtful clinical significance.

Persistent traumatic peroneal nerve palsy, following nerve surgery failure, is usually treated by tendon transfer or more recently by tibial nerve transfer. However, when there is destruction of the tibial anterior muscle, an isolated nerve transfer is not possible. In this article, we present the key steps and surgical tips for the Ninkovic procedure including transposition of the neurotized lateral gastrocnemius muscle with the aim of restoring active voluntary dorsiflexion.The transposition of the lateral head of the gastrocnemius muscle to the tendons of the anterior tibial muscle group, with simultaneous transposition of the intact proximal end of the deep peroneal nerve to the tibial nerve of the gastrocnemius muscle by microsurgical neurorrhaphy is performed in one stage. It includes 10 key steps which are described in this article. Since 1994, three clinical series have highlighted the advantages of this technique. Functional and subjective results are discussed. We review the indications and limitations of the technique.Early clinical results after neurotized lateral gastrocnemius muscle transfer appear excellent; however, they still need to be compared with conventional tendon transfer procedures. Clinical studies are likely to be conducted in this area largely due to the frequency of persistant peroneal nerve palsy and the limitations of functional options in cases of longstanding peripheral nerve palsy, anterior tibial muscle atrophy or destruction.La paralysie post-traumatique persistante du nerf fibulaire après échec de la chirurgie nerveuse est habituellement traitée par transfert tendineux et, plus récemment, par transfert du nerf tibial. Cependant, en cas d’atrophie du muscle tibial antérieur, un transfert nerveux isolé n’est pas possible. Dans cet article, nous présentons les étapes-clés de la technique de Ninkovic, incluant la neurotisation et le transfert du muscle gastrocnemius latéral dans le but de restaurer la flexion dorsale active du pied.La neurotisation et le transfert du muscle gastrocnemius latéral sont effectués en une étape. Cette technique chirurgicale comprend 10 étapes-clés qui sont décrites dans cet article. Depuis 1994, trois séries cliniques ont mis en évidence les avantages de cette technique. Les résultats fonctionnels et subjectifs sont discutés. Nous revenons sur les indications et les limites de cette technique chirurgicale.Les premiers résultats cliniques après neurotisation et transfert du muscle gastrocnemius latéral paraissent prometteurs. Ils doivent encore être comparés avec les procédures de transfert tendineux classiques. Les études cliniques sont susceptibles de se développer en raison de la fréquence des paralysies du nerf fibulaire et des limites fonctionnelles en cas de paralysie fibulaire persistante, atrophie du muscle tibial antérieur ou destruction de ce dernier.

Background. Memory for the past has been much less explored than anterograde memory in temporal lobe epilepsy. No data are available about the course after surgical treatment. Moreover, case-reports showing isolated memory deficit for publics events with preserved autobiographical memory are notorious for their paucity. Methods. We report the case of a patient with a left hippocampal lesion associated with intractable temporal lobe epilepsy. Comprehensive neuropsychological assessments were carried out before and after temporal lobectomy, stressing particularly memory for the past by means of standardised and tailor-made tests. Results. The patient exhibited preserved memory for autobiographical events and facts but impaired scores on several public event tests, in the context of preserved general abilities. Furthermore, we found an accelerated forgetting rate for verbal and non verbal material. Conclusion. Our findings suggest that the patient's impaired long-term consolidation might have contributed to the impaired performance on public event memory tests. We discuss the specific features of new events processing that may contribute to its increased vulnerability relative to autobiographical memory, in the event of accelerated forgetting.

Cerebral venous thrombosis is a rare complication of intracranial hypotension. We describe 3 cases in which this phenomenon occurred, as a result of a lumbar puncture or due to a spontaneous cerebrospinal fluid leak. We emphasize the importance of early detection of the intracranial hypotension syndrome, the most common clinical manifestation being orthostatic headache. It is not an innocent condition as it is associated with other potential complications such as subdural hygroma/hematoma, cranial nerve palsies, cerebellar tonsillar descent, and even brainstem manifestations. Any change in the typical features of the syndrome should lead to further investigation. Repeat cerebral imaging is important in that situation, including ruling out cerebral venous thrombosis.

We describe a rare case of parietal intradiploic encephalocele in a 51-year-old woman with no history of head trauma. The patient presented with a 1-month history of left hemiparesthesia. A hard indolent scalp lesion was palpable on examination in the right parietal area. Skull x-rays and cranial computed tomography examination demonstrated a lytic lesion that was consistent with a malignant osteolytic skull lesion. Magnetic resonance imaging of the head revealed an intradiploic cyst that included a round tissue mass contiguous with the parietal cortex. Surgery confirmed the diagnosis of encephalocele and the patient underwent surgical resection of the herniated brain, duraplasty, and cranioplasty. The presenting hemiparesthesia persisted at the 6-month follow-up. Encephaloceles of the cranial vault are a rare complication of skull fractures and rarely occur in adults. These lesions can be difficult to distinguish from congenital encephaloceles in patients with no history of head trauma. The pathogenesis, clinical and radiological nuances and the role of surgery are discussed.

Highly selective memory impairment for public events was demonstrated in a patient (JR), who suffered from temporal lobe epilepsy (TLE). We successfully trained JR's memory for a set of news events and discuss, on those bases, the characteristics of news events processing that may have contributed to its increased vulnerability relative to autobiographical memory (AbM).

Introduction. Systemic maternal-fetal Candida albicans infections are uncommon diseases with a poor outcome. An associated cerebro-meningeal infection increases morbidity. We present a case of neuromeningeal candidiasis following systemic neonatal infection in a premature infant. Management and therapeutic difficulties are outlined. Observation. The patient was a male infant born preterm at 30 weeks gestation. During his first week of life, he developed a systemic infection with an associated symptomatic hydrocephalus. Systemic candidaisis with neuromeningeal complication was diagnosed five weeks later. Despite treatment including cerebrospinal fluid (CSF) shunting and antimycotic medications (flucytosin and amphotericin 8), the candidal infection did not resolve. Infectious and mechanical complications of the CSF drainage were treated by several surgical interventions during the following months. At 10 months of life, there was clinical and laboratory evidence of active persistent neuromeningeal candidaisis. Finally, candidal infection was eradicated with intravenous administration of fluconazole. After five year follow-up, the intellectual and psychological status of the patient was quite satisfactory, and no neurological deficits were found on clinical examination. Discussion. Management of neuromeningeal candidaisis in premature infants is a challenging task particularly because of delayed diagnosis. Candida infection should routinely be suspected in cases of systemic infection with neurological impairment in premature infants. Fluconazole may constitue an efficient therapeutic option.