Purpose. - The management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.Methods. - All pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).Results. - n = 27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n = 8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n = 7 had headache, n = 4 had ataxia, and n = 2 had impaired level of consciousness. In the unruptured group N (n = 19), n = 7 patients had headache, n = 6 patients had focal neurological deficit, n = 4 patients had tin-nitus, n = 3 (had ataxia, and one presented with seizure. n = 24 patients were treated by endovascular therapy (EVT), n = 2 patients were treated by microsurgery (MS) and n = 1 patient was managed with a combined approach. Re-treatment was necessary in n = 6 patients. n = 24 patients showed total exclusion at last FU. n = 2 patients died during the first 30 days; n = 1 patient died during FU.Conclusions. - While EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.(c) 2022 Elsevier Masson SAS. All rights reserved.

Background. - Neurosurgical teams are exposed to various stressors: complexity of surgical procedures, environment, time pressure and interruptions contribute to increasing the perceived workload. Objective. - This study aimed to evaluate the impact of interruptions and surgical complexity on neurosurgical team workload. Methods. - A prospective observational study was conducted on thirty surgical procedures of graduated complexity recorded in our Department of Neurosurgery. A scale was created and used by neurosurgeons to evaluate the perceived complexity of the surgical procedure. Interruptions and severity of interruptions were noted. The workloads of the neurosurgeon, surgical assistant, scrub nurse and circulating nurse were measured on the Surgery Task Load Index (SURG-TLX) at the end of the procedure. Results. - A mean 24.6 interruptions per hour were recorded. The mean interference level of the interruptions was 3.5/7. Mean surgical complexity was 4.3/10. Mean sterile team workload was 43.4/100. The multiple linear regression model showed that sterile team workload increased with surgical complexity (beta = 6.692, P= .0002) but decreased in spite of increases in the number of interruptions per hour (beta = -0.855, P= .027). Neurosurgeon and surgical assistant workload increased with surgical complexity (beta = 11.53, P< 0.0001 and beta = 7.42, P= 0.0007, respectively). Scrub nurse workload decreased in spite of increases in the number of interruptions per hour (beta =-1.11, P= .026). Conclusion. - Our study suggests positive effects of some interruptions during elective neurosurgical procedures with strong team familiarity. (C) 2020 Elsevier Masson SAS. All rights reserved.

BACKGROUND:Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS:This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS:The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION:Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Aneurysmal subarachnoid hemorrhage (SAH) is a sudden event responsible of significant morbidity and mortality. Several studies suggest a role of climate in SAH occurrence. The aim of this study is to determine the impact of climate parameters and moon cycle on SAH occurrence in Brittany. All adult patients hospitalized for SAH, between 2011 and 2012, were included. The meteorological variables, changes in these variables, the moon phase and the tidal coefficient were compared between days with and without SAH. The minimum temperature was significantly lower on days with SAH (7.7°C vs 8.3°C, p = 0,039) and temperature drop between two days was significantly higher for days with SAH (8.6°C vs 7 , 9°C, p = 0,0095). If the temperature dropped to 8°C or more between 2 days, the SAH risk increased by 35%. There was no effect of other variables. Low temperatures and the temperature drop are associated with SAH occurrence.

Background. - Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). Methods. - From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n = 20) or to MS (n = 21). The objectives were to determine the proportion of patients with modified Rankin Scale score <= 2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. Results. - At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P = 0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. Conclusion. - In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL. (C) 2018 Elsevier Masson SAS. All rights reserved.

Le but de cette étude était d’évaluer le taux de fusion osseuse chez des patients traités par arthrodèse antérieure cervicale avec cage intersomatique de type polyétheréthercétone (PEEK) remplie d’un substitut osseux synthétique dans les traumatismes aigus du rachis cervical. Vingt-neuf patients (âge moyen : 49 ans) avec une lésion mono-segmentaire instable du rachis cervical ont été inclus. Nous avons évalué le taux de fusion osseuse et le délai de fusion pour chaque patient à 1 an. Dans les cas de déplacements secondaires, nous avons analysé leurs causes et leur prise en charge chirurgicale. Le taux de fusion était de 86,2 %. Le délai moyen de fusion était de 7,2 mois. Cette fusion a été observée pour 4 patients à 3 mois, pour 14 à 6 mois et pour 7 à 1 an. Quatre patients ont eu un déplacement secondaire dans les 3 premiers mois. L’arthrodèse par cage de type PEEK remplie d’un greffon osseux synthétique semble être une alternative intéressante au greffon osseux de crête iliaque.

PURPOSE:The dorsolateral prefrontal cortex (DLPFC) is a cortical area involved in higher cognitive functions, and at the center of the pathophysiology of mental disorders such as depression and schizophrenia. Considering these major roles and the development of deep brain stimulation, the object of this study was to assess the patterns of connectivity of the DLPFC with its main subcortical relay, the thalamus, with the help of probabilistic tractography. METHODS:We used T1-weighted imaging and diffusion data from 18 subjects from the Human Connectome Project. The DLPFC and the thalamic nuclear groups were defined using the combination of atlases, sulcogyral anatomy and cytoarchitectonic data. Probabilistic tractography was performed from the DLPFC to the thalamus. The patterns of connectivity were assessed using two indexes: (1) a connectivity index (CI) which evaluate the strength of connection (2) an asymmetry index (AI) which explores the inter-hemispheric variability. RESULTS:The analysis of CI showed significant connections between the DLPFC and the dorsomedial nuclei (p < 0.05), the anterior nuclear groups (p < 0.05) and the right centromedian nucleus (p < 0.05). No link was found between handedness and AI (p > 0.05). Most of subjects (15/18) had a right predominance of the thalamo cortical connections of the DLPFC. CONCLUSIONS:Probabilistic tractography appears as a valuable non-invasive tool for the exploration of the thalamocortical connections between the dorsolateral prefrontal cortex and thalamic nuclei. It allowed to show different inter-hemispheric patterns of connectivity, and highlighted the centromedian nucleus as a key subcortical relay of executive functions.

In a controlled before-and-after study in a single centre, it was aimed to determine whether identification of Staphylococcus aureus nasal carriers followed by nasal mupirocin ointment and chlorhexidine soap reduced surgical site infections (SSIs) among 182 patients undergoing deep brain stimulation. In all, 119 patients were included in the control group and 63 in the screening group. There was a significant SSI decrease from 10.9% to 1.6% between the two groups (P < 0.04; relative risk: 0.13; 95% confidence interval: 0.003-0.922). There were eight SSIs involving S. aureus in the control group, none in the screening group. No specific risk factors for SSI were identified. (C) 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

The aims of this multicentre retrospective study were to identify prognostic or therapeutic factors impacting on overall survival in patients with gliosarcoma. The analysis included all patients treated for gliosarcoma between 1998 and 2014 in seven French academic centres. Seventy-five patients with a median age of 60 years (range from 23 to 79 years) were treated with a combination of surgery (n = 66), radiotherapy (adjuvant for 64 patients and exclusive for 8 patients) and temozolomide based chemotherapy (n = 58). Median follow-up was 12 months (range from 2 to 71 months). Two-year overall survival (OS) and disease free survival rates were 12 % (95 % CI 4–20 %) and 2 % (95 % CI 0–6 %), respectively. The median OS was 13 months. Treatment at recurrence consisted of chemotherapy (n = 38) (bevazicumab for 18 patients, repeat temozolomide for 10 patients), salvage surgery (n = 8) and radiochemotherapy (n = 1). In univariate analysis, younger age, higher total dose of radiotherapy, longer time to recurrence and treatment at recurrence significantly increased OS. In multivariate analysis, high total dose of radiotherapy (HR = 0.97, p = 0.007) and treatment at recurrence (HR = 0.28, p < 0.001) were favourable prognostic factors of OS. Radiotherapy at a minimum dose of 54 Gy and salvage treatment increased OS of gliosarcoma. Unlike glioblastoma, in our analysis, TMZ based chemotherapy was not associated with an improvement in OS compared to patients who received radiation therapy only.

Purpose or Objective: Surgery represents the treatment of choice for meningiomas.However, complete resection is often not possible, and recurrence is common.Radiation therapy (RT) can be prescribed as an alternative treatment to surgery for low-grade meningiomas, or in the recurrent/adjuvant setting.Differentiation between normal tissue, i.e. meninges, post-operative changes and residual viable tumor can be difficult using MR and CT imaging alone.We evaluated the impact of 68Ga-Dotatoc-PET imaging on treatment planning including potential benefit in terms of outcome. Material and Methods:We analyzed 15 patients with WHO I meningiomas of different localizations.All patients were treated with fractionated stereotactic radiotherapy (FSRT) with a total dose of 54 Gy and a single dose of 1.8 Gy.An advanced radiation oncologist delineated gross tumor volume (GTV) independently once based on diagnostic CT and MRI only (GTV_MR/CT), and a second time complemented by data of diagnostic 68Ga-Dotatoc-PET (GTV_PET).For image fusion and target definition BrainLab iPlan RT® software (Munich, Germany) was used.The intersection and union volumes of both GTVs (GTV_inter, GTV_union), were calculated. Results:In 11 of 15 patients (73%) the additional data gained by 68Ga-Dotatoc-PET led to a lager GTV.In four patients (27%) GTV_PET was smaller than GTV_MR/CT.The mean intersection of both GTVs was 58.6%.Hence, 41.4% of the GTV_PET was contributed only due to information from 68Ga-Dotatoc-PET.About 22.6% of the GTV_MR/CT was not delineated in the GTV_PET volume because no increased tracer enhancement could be detected in these parts.Our first analyses of overall and progression free survival showed no significance in patients with a 68Ga-Dotatoc-PET for tumor delineation during treatment planning.Conclusion: 68Ga-Dotatoc-PET improves the detection of residual or recurrent tumor cells especially in patients with meningioma of the skull base and the sphenoorbital region.In addition it helps to spare normal tissue in patients with large tissue defects after operation.However, the interobserver variability must be taken into account.The data will now be correlated with OS and further analyzed concerning the standard uptake values (SUV) of the PET-images to assess if a threshold value can be recommended for meningioma detection and delineation.

PURPOSE:The aim of this study was to assess the interbody fusion rate for patients treated by anterior cervical interbody fusion (ACIF) using polyetheretherketone (PEEK) cages filled with synthetic bone graft in acute cervical spine injury. MATERIALS AND METHODS:Twenty-nine patients (mean age: 49 years) with monosegmental instability due to cervical spine injury were followed. We assessed the rate of and time to interbody fusion at 1-year follow-up. In case of secondary displacement, we analysed its causes and surgical management. RESULTS:The rate of fusion was 86.2%. The mean time to fusion was 7.2 months. Interbody fusion was observed at 3 months in 4 patients, at 6 months in 14 and at 1 year in 7. Four patients had secondary displacement within 3 months. CONCLUSION:ACIF with a PEEK cage filled with synthetic bone graft seems to be an alternative to iliac crest bone graft with no morbidity related to the harvest site.

RADIOLOGIE ET IMAGERIE MEDICALE : Musculosquelettique - Neurologique - Maxillofaciale - 31-658-B-10

PURPOSE:This study proposes a framework coming from cognitive engineering, which makes it possible to define what information content has to be displayed or emphasised from medical imaging, for assisting clinicians according to their level of expertise in the domain.METHOD:We designed a rating scale to assess visualisation systems in image-guided neurosurgery with respect to the depiction of the neurosurgical work domain. This rating scale was based on a neurosurgical work domain analysis. This scale has been used to evaluate visualisation modes among neurosurgeons, residents and engineers. We asked five neurosurgeons, ten medical residents and ten engineers to rate two visualisation modes from the same data (2D MR image vs. 3D computerised image). With this method, the amount of abstract and concrete work domain information displayed by each visualisation mode can be measured.RESULTS:A global difference in quantities of perceived information between both images was observed. Surgeons and medical residents perceived significantly more information than engineers for both images. Unlike surgeons, however, the amount of information perceived by residents and engineers significantly decreased as information abstraction increased.CONCLUSIONS:We demonstrated the possibility of measuring the amount of work domain information displayed by different visualisation modes of medical imaging according to different user profiles. Engineers in charge of the design of medical image-guided surgical systems did not perceive the same set of information as surgeons or even medical residents. This framework can constitute a user-oriented approach to evaluate the amount of perceived information from image-guided surgical systems and support their design from a cognitive engineering point of view.

Postoperative hematoma is a rare and dangerous complication of cervical spine surgery. The aim of this study was to investigate the incidence and related factors of postoperative hematoma, and to report on 15 cases at our institution over a 6-year period.Fifteen cases of postoperative hematoma were retrospectively identified. We investigated their neurological outcomes, characteristics, and surgical data, and identified risk factors associated with postoperative (PO) hematoma. Patients with hematoma were compared to those with no hematoma, in order to identify risk factors.Retropharyngeal hematomas developed in seven cases and epidural hematomas in eight. The total incidence of postoperative hematoma was 1.2%: 0.5% retropharyngeal hematomas and 0.6% spinal epidural hematomas. At time of onset, the severity of paralysis was assessed as grade B in one case, grade C in six cases, and grade D in eight cases. Risk factors for PO hematoma were: (1) presence of ossification of the posterior longitudinal ligament (OPLL) (P < 0.001); (2) longer operative duration (P = 0.048); (3) greater number of surgical levels (P = 0.02); and (4) higher body mass index (BMI; P = 0.035). There was no significant difference in modified Japan Orthopedic Association scores between the hematoma group and non-hematoma group (P > 0.05).Precise preoperative preparation and systematic evaluation are central to successful management of PO hematoma after anterior cervical surgery. Risk factors for PO hematoma include multilevel decompression, OPLL, higher BMI, and longer operation time.

Purpose Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians. Methods Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability. Results There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients. Conclusions Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.

Objective: Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines. Methods: Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors. Results: In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks. Conclusion: This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

INTRODUCTION:Using an anonymous questionnaire, this study aimed to assess hopes and perceptions of second-year medical school students faced to gross anatomy dissections and to appreciate the status of dissection within the others anatomical teaching tools.MATERIALS AND METHODS:The questionnaire was distributed among 210 second-year medical students during gross anatomy dissections. The first part of the questionnaire aimed to assess perceptions of students before dissections while the second part aimed to position dissection in their anatomical teaching cursus.RESULTS:Within the 210 students participating to the study, 70 (45%) had not seen a dead human body before the laboratory cession. The main stressful factors were technical difficulties encountered during dissection more than embarrassment in front of the cadaver. The level of stress was significantly higher in female students. Hand, neck and gluteal regions were the most stressful regions reported by students. Students considered that gross anatomy dissection was a key ritual experience crucial for their formation that should not be only proposed to senior practitioners.CONCLUSION:This study illustrates the invariable interest of medical students for gross anatomy laboratory cessions that permit a first technical experience, faced to the death.