BACKGROUND AND PURPOSE:The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH were studied as well.METHODS:Symptomatic vasospasm was defined as the association of deterioration in a patient's neurological condition between 3 and 14 days after SAH with no other explanation and an increase in mean transcranial Doppler velocities of >120 cm/s. The prognostic factors were registered on admission and during the intensive care stay.RESULTS:Symptomatic vasospasm occurred in 22.2% surgical patients compared with 17.2% endovascular treatment patients (P=0.37). Multivariate analysis revealed that the probability of occurrence of symptomatic vasospasm decreased with age >50 years (relative risk [RR], 0.47 [0.25 to 0.88]) and severe World Federation of Neurological Surgeons (WFNS) grade measured on admission (RR, 0.43 [0.20 to 0.90]) and increased with hyperglycemia occurring during the intensive care stay (RR, 1.94 [1.04 to 3.63]). No difference in risk of symptomatic vasospasm could be identified between surgical and endovascular treatment. Symptomatic vasospasm (OR, 4.73 [CI, 1. 77 to 12.6]) as well as WFNS grade of >2 (OR, 8.95 [3.46 to 23.2]), treatment complications (OR, 8.39 [3.16 to 22.3]), and secondary brain insults were associated with an increased risk of 6-month sequelae.CONCLUSIONS:Age <50 years, good neurological grade, and hyperglycemia were all associated with an increased risk of cerebral vasospasm whereas treatment was not. This provides a basis for future clinical prospective randomized trials comparing both treatments.

Two patients presenting with an intrasellar epidermoid cyst and operated on through a transsphenoidal approach, are reported. Problems regarding pathological controversies about the differential diagnosis (particularly craniopharyngiomas) are addressed. In order to establish the adequate preoperative diagnosis, the interest of MRI is discussed.

Since 1987, we have treated four patients with diaphragma sellae meningioma. Tuberculum sellae meningiomas with intrasellar extension were strictly excluded from this retrospective study. A complete tumor removal was performed in two patients. The two other patients underwent post-operative radiotherapy. According to the Kinjo's classification, the four meningiomas were classified as follows: one type A (supradiaphragmatic-prepituitary), one type B (supradiaphragmatic-retropituitary), one type C (subdiaphragmatic), one type not described in this classification characterized by sub and supradiaphragmatic extension. Based on our experience and data in the literature, the clinical and neuroradiological features of the diaphragma sellae meningiomas are reviewed. Diaphragma sellae visualization at MRI, which is not always possible, allows to localize the tumor on a supra- or infra- diaphragmatic position and to decide the optimal surgical approach. The diaphragma sellae is more visible on protonic density, or T2-weighted sequences, but can be located on T1-weighted images. Appropriate surgical approaches are the sub-fronto-pterional route for supradiaphragmatic meningiomas and the transsphenoidal approach for subdiaphragmatic meningiomas.

A 21-year old woman underwent surgery in December 1996 for the removal of a presumed tuberculum sellae meningioma. However, some radio-clinical findings were proved somewhat intriguing:the patient's age, the presence of inflammatory and febrile syndromes together with the diagnosis of aseptic meningitis associated with perilesional edema intensity (an unusual feature in such cases) made us challenge the initial neuroradiological diagnosis evoked in connection with the tumoral location and dural attachment pattern. A right sub-fronto-temporal approach allowed complete tumor resection (confirmed with a postoperative MRI) and clinical recovery of the patient. But while pathological examination suggested a chordoma, the study of immunohistochemical stains revealed a meningioma. The final diagnosis was chordoid meningioma. Our review of the literature has shown that chordoid meningiomas display several areas of physaliferous cells which give the tumor a chordoma-like aspect. However, the results of immunohistochemical studies along with the location of the tumor were not consistent with the diagnosis of chordoma. Eight cases of chordoid meningiomas are reviewed in the literature. They are described as inducing systemic symptoms, particularly anemia. They could also be linked to Castleman's syndrome according to Kepes et al. After careful evaluation, we retained the hypothesis of a cause and effect relationship between the local and generalised inflammatory syndrome and chordoid meningioma.

Since 1987, we have treated four patients with diaphragma sellae meningioma. Tuberculum sellae meningiomas with intrasellar extension were strictly excluded from this retrospective study. A complete tumor removal was performed in two patients. The two other patients underwent post-operative radiotherapy. According to the Kinjo's classification, the four meningiomas were classified as follows: one type A (supradiaphragmatic-prepituitary), one type B (supradiaphragmatic-retropituitary), one type C (subdiaphragmatic), one type not described in this classification characterized by sub and supradiaphragmatic extension.Based on our experience and data in the literature, the clinical and neuroradiological features of the diaphragma sellae meningiomas are reviewed. Diaphragma sellae visualization at MRI, which is not always possible, allows to localize the tumor on a supra- or infra-diaphragmatic position and to decide the optimal surgical approach. The diaphragma sellae is more visible on protonic density, or T2-weighted sequences, but can be located on T1-weighted images. Appropriate surgical approaches are the sub-fronto-pterional route for supradiaphragmatic meningiomas and the transsphenoidal approach for subdiaphragmatic meningiomas.

Traditionally the aneurysms of the circle of Willis have been an indication for neurosurgery. New technologies of endovascular treatment with electrically detachable coils resulted in a different therapeutical concept since four years. A series including 140 patients has been treated in our institution from 1 January 1992 to 31 December 1994, 94 of them presenting with a subarachnoid haemorrhage. Out of these 140 patients, 84 were treated with surgery, 51 with the endovascular technique, five with surgery after incomplete or unsuccessful endovascular treatment. Surgery was indicated in patients presenting early after bleeding, devoid of vasospasm, with a favourable Hunt and Hess grading and in aneurysms located in the anterior part of the circle of Willis. Endovascular treatment was indicated in patients admitted with delay, with severe vasospasm, a poor Hunt and Hess grading and in all aneurysms of the vertebrobasilar arterial network. Age was of less importance in comparison to the status of the vessels for selection of the method of treatment. Giant aneurysms are difficult to treat as surgery is faced with the size of the aneurysmal itself and endovascular technique with the width of the aneurysmal neck.

Les anévrismes du polygone de Willis relevaient traditionnellement de la chirurgie. Les technologies nouvelles de la voie endovasculaire (coils ou spires thermolargables) ont permis un concept thérapeutique différent depuis 4 ans. Cent quarante patients pris en charge pour hémorragie méningée par rupture anévrismale ont été traités du 1er janvier 1992 au 31 décembre 1994, 84 cas par chirurgie, 51 par voie endovasculaire, cinq successivement par voie endovasculaire et chirurgie. Les indications de la chirurgie étaient les malades vus tôt, sans vasospasme, avec un bon score de Hunt et Hess et les localisations sur la partie antérieure du polygone de Willis. Le traitement endovasculaire s'adressait aux patients vus tardivement, avec un vasospasme, un score de Hunt et Hess péjoratif et aux localisations sur le système vertébrobasilaire. L'âge a joué un rôle moins important que l'état vasculaire dans le choix de l'une ou l'autre de ces méthodes. Les anévrismes géants ne bénéficient pas d'un traitement idéal, la chirurgie se heurtant à la taille de l'anévrisme lui-même, le traitement endovasculaire à la taille du collet.

Traditionally the aneurysms of the circle of Willis have been an indication for neurosurgery. New technologies of endovascular treatment with electrically detachable coils resulted in a different therapeutical concept since four years, A series including 140 patients has been treated in our institution from 1 January 1992 to 31 December 1994, 94 of them presenting with a subarachnoid haemorrhage. Out of these 140 patients, 84 were treated with surgery, 51 with the endovascular technique, five with surgery after incomplete or unsuccessfull endovascular treatment. Surgery was indicated in patients presenting early after bleeding, devoid of vasospasm, with a favourable Hunt and Hess grading and in aneurysms located in the anterior part of the circle of Willis, Endovascular treatment was indicated in patients-admitted with delay, with severe vasospasm, a poor Hunt and Hess grading and in all aneurysms of the vertebrobasilar arterial network. Age was of less importance in comparison to the status of the vessels for selection of the method of treatment, Giant aneurysms are difficult to treat as surgery is faced with the size of the aneurysm itself acid endovascular technique with the width of the aneurysmal neck.

According to many ethical and humanitarian arguments, the diagnosis of "brain death" is more and more an emergency. The forensic criteria include abolition of consciousness, abolition of brain stem reflexes, abolition of spontaneous breathing joined to electrocerebral silence. However using EEG criteria of electrical silence may be unreliable because of technical artefacts or depressed electrical activity due to drug intoxication and hypothermia. Venous angiography was used in 125 cases: our experience proves reliability and efficiency of angiographic criteria for diagnosis of brain death. For organ transplant, it is better to be as fast as possible: transplanted organ will be better and it reduces the cost of a long useless intensive care. When it is necessary, we suggest to allow the choice between EEG and angiography.

According to many ethical and humanitarian arguments, the diagnosis of "brain death" is more and more an emergency. The forensic criteria include abolition of consciousness, abolition of brain stem reflexes, abolition of spontaneous breathing joined to electrocerebral silence. However using EEG criteria of electrical silence may be unreliable because of technical artefacts or depressed electrical activity due to drug intoxication and hypothermia. Venous angiography was used in 125 cases : our experience proves reliability and efficiency of angiographic criteria for diagnosis of brain death. For organ transplant, it is better to be as fast as possible : transplanted organ will be better and it reduces the cost of a long unuseful intensive care. When it is necessary, we suggest to allow the choice between EEG and angiography.

Transcranial Doppler ultrasonography (TCD) is a non invasive technique which assesses blood flow velocities in basal cerebral arteries. Specific patterns have been observed in brain death. In a continuous series of 72 patients, the TCD recordings from the intracranial internal carotid and middle cerebral arteries were compared with the results from the usual investigations for brain death, such as electroencephalogramme (EEG), and arteriography. All the patients were clinically brain dead : Glasgow score of 3, apnoea, bilateral mydriasis, loss of cortical function and cerebral reflexes. This clinical diagnosis was confirmed by and isoelectric EEG with or without angiographic circulatory arrest. Two characteristic patterns were identified : an oscillating to and fro signal, with a positive sharp systolic peak and a negative diastolic reflux; and a systolic peak without any diastolic component. The absence of signal on both sides did not allow any conclusion, except when this pattern occurred during follow-up. The oscillating pattern was seen on both sides in 60 patients (83 %), and, in 3 other patients, only on one side, always combined with a contralateral systolic peak pattern, in 3 other patients. A bilateral systolic peak pattern was identified in 7 patients (10 %). The TCD results were compared with angiography in 37 cases. TCD circulatory arrest preceded angiographic arrest by six hours in three cases. Hypotension was the main limitation to this technique. On the other hand, TCD may be used in patients treated with sedative drugs. The non invasive character of TCD, its low cost, the possibility of repeating it at the patient's bedside make TCD a very interesting diagnostic tool. The specificity and sensitivity of this technique need to be confirmed in larger serics of patients.

The LaryngoscopeVolume 102, Issue 2 p. 198-202 Article How i do it: Head and neck and plastic surgery: Endoscopic pituitary tumor surgery Roger Jankowski MD, Corresponding Author Roger Jankowski MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceDepartment of Otorhinolaryngology—Head and Neck Surgery, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54000 Nancy, FranceSearch for more papers by this authorJean Auque MD, Jean Auque MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorClaude Simon MD, Claude Simon MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorJean Claude Marchal MD, Jean Claude Marchal MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorHenry Hepner MD, Henry Hepner MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorMichel Wayoff MD, Michel Wayoff MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceSearch for more papers by this author Roger Jankowski MD, Corresponding Author Roger Jankowski MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceDepartment of Otorhinolaryngology—Head and Neck Surgery, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54000 Nancy, FranceSearch for more papers by this authorJean Auque MD, Jean Auque MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorClaude Simon MD, Claude Simon MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorJean Claude Marchal MD, Jean Claude Marchal MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorHenry Hepner MD, Henry Hepner MD Department of Neurosurgery, Central Hospital, University of Nancy, FranceSearch for more papers by this authorMichel Wayoff MD, Michel Wayoff MD Department of Otorhinolaryngology—Head and Neck Surgery, Central Hospital, University of Nancy, FranceSearch for more papers by this author First published: February 1992 https://doi.org/10.1288/00005537-199202000-00016Citations: 320AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume102, Issue2February 1992Pages 198-202 RelatedInformation

Transcranial Doppler ultrasonography (TCD) is a non invasive technique which assesses blood flow velocitics in basal cerebral arteries. Specific patterns have been observed in brain death. In a continuous series of 72 patients, the TCD recordings from the intracranial internal carotid and middle cerebral arteries were compared with the results from the usual investigations for brain death, such as electroencephalogramme (EEG), and arteriography. All the patients were clinically brain dead: Glasgow score of 3, apnoea, bilateral mydriasis, loss of cortical function and cerebral reflexes. This clinical diagnosis was confirmed by and isoelectric EEG with or without angiographic circulatory arrest. Two characteristic patterns were identified: an oscillating to and fro signal, with a positive sharp systolic peak and a negative diastolic reflux; and a systolic peak without any diastolic component. The absence of signal on both sides did not allow any conclusion, except when this pattern occurred during follow-up. The oscillating pattern was seen on both sides in 60 patients (83%), and, in 3 other patients, only on one side, always combined with a contralateral systolic peak pattern, in 3 other patients. A bilateral systolic peak pattern was identified in 7 patients (10%). The TCD results were compared with angiography in 37 cases. TCD circulatory arrest preceded angiographic arrest by six hours in three cases. Hypotension was the main limitation to this technique. n the other hand, TCD may be used in patients treated with sedative drugs. The non invasive character of TCD, its low cost, the possibility of repeating it at the patient's bedside make TCD a very interesting diagnostic tool.(ABSTRACT TRUNCATED AT 250 WORDS)