Protocole de prise en charge neurochirurgicale des acouphènes invalidants : à propos de trois cas

Tinnitus is a public health issue in France. Around 1 % of the population is affected and 30,000 people are handicapped in their daily life. The treatments available for disabling tinnitus have until now been disappointing. We report our experience on the treatment of these patients in neurosurgery.

Patient and methods

Between 2006 and 2008, transcranial magnetic stimulation (rTMS) was performed following several supraliminal and subliminal protocols in 16 patients whose mean age was 47 years (range, 35-71). All patients underwent anatomical and functional MRI of the auditory cortex before and 18 h after rTMS, to straddle the primary and secondary auditory cortices. All patients underwent audiometric testing by an ENT physician.

Results

Nine patients responded with rTMS. After these investigations, two quadrapolar electrodes (Resume^®), connected to a stimulating device implanted under the skin (Synergy^®, from Medtronic), were extradurally implanted in three patients. The electrodes were placed between the primary and secondary auditory cortices. The mean follow-up was 25 months and significant improvement was found in these patients.

Conclusion

The feasibility of cortical stimulation in symptomatic treatment of tinnitus was demonstrated by this preparatory work. The intermediate- and long-term therapeutic effects remain to be evaluated.     

Traitement chirurgical des granulomes éosinophiles solitaires de la voûte du crâne. À propos de deux cas

Langerhans cell histiocytosis is a systemic disease resulting from the oligoclonal proliferation of Langerhans cells, occurring most commonly in children and young adults. The focal form of the disease, also known as eosinophilic granuloma, most frequently involves the calvaria. We present two cases of calvarial eosinophilic granulomas that were surgically removed. These tumors are reputed to have an excellent prognosis, even if local recurrences and systemic dissemination can occur during the follow-up. The authors discuss the pathogenesis and the evolutive profile but also the therapeutic management of solitary eosinophilic granuloma of the calvaria.     

Le traitement chirurgical des accidents vasculaires ischémiques du cervelet : à propos de cinq cas

Background and purpose

Surgical management of cerebellar infarction remains controversial. What surgical procedure should be performed when a patient presents neurological deterioration? When is the right moment to operate? Different treatments were proposed including decompressive suboccipital craniotomy, external ventricular drainage, or endoscopic third ventriculostomy.

Methods

We retrospectively reviewed five cases of cerebellar infarction treated with suboccipital craniotomy, excision of necrotic tissue, and duraplasty within a period of six months.

Results

The five patients were evaluated with regard to presenting symptoms, Glasgow Coma Scale (GCS) before surgery, timing of surgery, computed tomographic scans and magnetic resonance imaging (MRI), neurological improvement, and outcome within a follow-up period of one year. Four patients made a good recovery, one patient died three days after surgery without neurological improvement.

Conclusion

These results suggest that decompressive suboccipital craniotomy may be an effective solution for good recovery if the patient is operated early, at the moment of the neurological deterioration.     

Prise en charge anesthésique des patients porteurs de myotonie de Steinert : à propos de deux cas cliniques

Steinert disease, the most common myopathy in adults, is a challenge for anaesthesiologists and critical care physicians during the perioperative time. The risk of myotonic crisis, malign hyperthermia and the increased sensitivity to anaesthetic drugs shouldn’t be forgotten. On contrary, Steinert disease is rarely revealed in the postoperative period. It should be evoked in case of postoperative pulmonary complications such as difficult weaning with neurological symptoms like hypotonia or muscular weakness.     

Embrochage en L de Vives des fractures du col du cinquième métacarpien (À propos de 24 cas)

Fractures of the neck of the fifth metacarpal (boxer's fracture) represent 20% of all fractures of the hand and are frequently observed in male patients, involve the dominant hand, and very often follow a direct blow or punch. We present a retrospective study of 24 fractures of the neck of the fifth metacarpal, treated by “L” pinning as described by Vives, between January 2004 and January 2008. All the patients were men with a mean age of 30 years (range 18 to 50). The mechanism of injury was dominated by fist strike (18 cases). Surgical treatment was performed in cases of fractures with a mean palmar tilt of 37° (range 30° to 60°). Pinning with a Vives procedure consisted of inserting two pins in an “L” configuration; the first a centromedullary pin measuring 20 mm, the second a transverse one through the fourth metacarpal bone controlling rotation and measuring 12 mm. Surgery was performed under loco-regional anaesthesia in 75% of cases, and under general anaesthesia in 25% of cases. No immobilization was recommended. Physiotherapy was performed in all cases. Fracture consolidation was obtained in all cases, and the pins were removed in the 6th week following surgery. This technique of osteosynthesis allowed us to obtain good clinical and radiological results according to the criteria of Frere with a mean follow up of 24 months.     

Sidérose superficielle secondaire du système nerveux central : à propos de trois cas et revue de la littérature

Background

Superficial siderosis (SS) is an under-recognized entity. It is due to repeated microhemorrhages in the subarachnoid spaces resulting in a deposit of hemosiderin at the surface of the central nervous system and/or the cranial nerves. The origin of microhemorrhages remains unknown in almost one third of cases and therefore no treatment can be recommended. Through a literature review and new observations, our goal is to detail the outcome of patients with a recognized etiology of SS and treated surgically.

Methods

Series of three cases and review of the literature.

Results

We present three patients with symptomatic SS for whom the origin of microhemorrhages was found. The first two patients complained of longstanding ataxia and neurosensory deafness while the third patient presented with urinary retention, vertigo, diplopia and facial paresis. Neuroradiological explorations revealed a left temporoparietal cavernoma, a fronto-orbital arterio-venous malformation and a cauda equina myxopapillary ependymoma respectively. Surgical resection of the source of hemorrhage was performed in all cases. All outcomes were good with improvement of their SS-related symptoms. These cases are discussed and the current literature is reviewed.

Conclusion

It is important to recognize SS since the treatment of the bleeding source may prevent further deterioration and may even in some cases improve the clinical condition.     

Pneumencéphalie après ventilation non invasive en postopératoire de neurochirurgie par voie trans-sphénoïdale : à propos de deux cas

The early use of continuous positive airway pressure ventilation has been shown to be effective and is recommended for patients with obstructive sleep apnea. The complications of continuous positive airway pressure ventilation are not well described. We report two cases of pneumocephalus following the use of continuous positive airway pressure ventilation after transsphenoidal surgery. One patient had an obstructive sleep apnea and the other suffered acute respiratory failure. In both cases, pneumocephalus caused major morbidity and required specific treatment and prolonged considerably hospital stay. Based on these observations we believe new precautions in the use of noninvasive continuous positive airway pressure ventilation should be recommended.     

Lésions étagées contiguës du rachis cervical inférieur lors d’un traumatisme en flexion de diagnostic retardé : à propos d’un cas

The authors report a case of bilateral C4-C5 facet fracture dislocation associated with a severe sprain underlying C5-C6, which had occurred during an traffic accident. The diagnosis of severe sprain was raised on the 55th day. The injury mechanism is studied. Contiguous multilevel injuries of the lower cervical spine should be suspected in case of high-energy trauma. MRI can provide an exhaustif diagnosis of possible multilevel injuries. After fixation of the obvious lesion, intraoperative dynamic fluoroscopy must be performed to demonstrate any instability in another area.