[Pain management in severe subarachnoid haemorrhage].
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Analgesics↗
Biomedical subjects
H Dufour
Publications and source records attributed to H Dufour.
[Endovascular treatment of benign intracranial hypertension by stent placement in the transverse sinus. Therapeutic and pathophysiological considerations illustrated by a case report].
We report a case of benign intracranial hypertension in a 31-year-old man treated by endovascular stent placement in the right transverse sinus. The patient presented with a typical benign intracranial hypertension syndrome. Ophthalmologic findings showed bilateral papilledema with a 7/10 loss visual acuity loss in the right eye and 2/10 in the left eye. At lumbar puncture, cerebrospinal fluid (CSF) pressure was 40 mmHg. Magnetic resonance imaging (MRI) showed slit ventricles and dilatation of optic nerve sheaths. optiques. After failure of medical treatment, the patient was referred to our neurosurgical department for therapeutic decision. Direct retrograde cerebral venography showed predominant cerebral venous drainage via the right transverse sinus which exhibited stenosis in its proximal third. Mamometry revealed a 25 mmHg pressure gradient across the point of stenosis. Due to possible venogenic benign intracranial hypertension, endovascular stent placement was proposed and accepted by the patient. At 3 months follow-up, the patient was symptoms free, papilledema had disappeared and visual acuity was 10/10 on both eyes. CSF pressure on lumbar puncture was 11 mmHg. The pathophysiological aspects and therapeutic management of this pathology illustrated by this are discussed along with a careful and exhaustive review of the literature.
Adult↗
[Endoscopic treatment of a voluminous benign symptomatic cyst of the pineal region responsible for an obstructive hydrocephalus].
Asymptomatic non neoplastic cysts of the pineal region are common incidental findings in adults. On the contrary, voluminous and symptomatic cysts of the pineal region are rare and their management are not well defined. We present the case of a 32-year-old woman suffering who suffered from mild intracranial hypertension, gait disturbance and vertigo for one year. The neuroradiological workup showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. An endoscopic etiological treatment was decided. The operation consisted in a marsupialization of the cyst in the third ventricle with a stereotactic guidance system. A frozen section of the cyst wall failed to show tumoral cells. Immediate postoperative course was uneventful. Intracranial hypertension symptoms resolved in 24 hours. Clinical examination and neuropsychological testing were normal at two years postoperatively. The two years follow-up cerebral MRI demonstrated a remnant cystic cavity without mass effect and the patency of the aqueduct of Sylvius. Endoscopic treatment of symptomatic pineal cysts constitutes an interesting therapeutic alternative in the management of this pathology.
Adult↗
[Transsacral approach to lumbosacral extraforaminal disc herniations].
INTRODUCTION: The lateral approach is classically used for surgical treatment of extraforminal disc herniations (EDH). However, its use at the level of the L5-S1 space can require more or less extensive resection of the facet joint. This study reports our experience in the treatment of L5-S1 EDH using the transsacral approach described by Muller and Reulen in 1998. MATERIAL AND METHODS: From February 2002 to October 2004, 12 patients presenting EDH at the L5-S1 level underwent treatment using the transsacral approach. There were 8 men and 4 women. Mean age was 55 years (range: 36 to 75 years). All patients presented lumbalgia and L5radiculalgia. Only one patient had dysesthesia. Five patients presented motor deficits and 3 presented sensory deficits. Surgical treatment was proposed after failure of medical treatment and two L5 corticoids infiltrations. RESULTS: All patients were re-examined two months after the procedure. Mean follow-up was 15 months. Complete resolution of radiculalgia with no paresthesia was achieved in all patients. Patients presenting preoperative motor deficit recovered fully after treatment. All patients resumed normal activity. CONCLUSION: The transsacral approach is a valid alternative to the lateral approach for treatment of L5-S1 EDH. The amount of operative exposure achieved using this technique is sufficient to avoid joint injury that can result in chronic postoperative lumbalgia. Another advantage is that excision of the protruding disc fragment can be achieved without mobilization of the nerve root or dorsal root ganglion, thus avoiding postoperative dysesthesia.
Adult↗
Depressed skull fracture overlying the superior sagittal sinus causing benign intracranial hypertension. Description of two cases and review of the literature.
The purpose of this report is to describe successful surgical treatment of benign intracranial hypertension (BIH) in two patients presenting with depressed skull fractures over the superior sagittal sinus (SSS). The first case involved a 22-year-old patient who presented with depressed skull fracture overlying the posterior third of the SSS. Symptoms of BIH developed within 48 h. The second case involved a 33-year-old patient who presented with depressed skull fracture overlying the junction between the middle and posterior thirds of the SSS. Symptoms of BIH developed 1 month after. Although this patient presented with bilateral papilloedema, the less straightforward nature of his BIH symptoms prompted us to undertake further neuroradiological assessment by angiography with retrograde venous catheterization. A high-pressure gradient was found between venous flow upstream and downstream from the compressed zone. Both patients underwent surgical decompression in the lateral decubital position. Continuous monitoring of intracranial pressure was begun upon induction of general anaesthesia. High preoperative pressure declined immediately after elevation of the depressed zone. Bleeding was not a problem at any time during the procedure. Follow-up MRI and angio-MRI demonstrated total restoration of SSS patency. Benign intracranial hypertension is an uncommon complication of depressed skull fracture. Retrograde venous catheterization with pressure measurement can be a useful diagnostic adjunct. Surgical treatment is indicated in symptomatic patients. Based on the two cases reported, we now propose MRI venography in all patients presenting with symptoms of BIH and arteriography with retrograde venous catheterization when venous sinus stenosis exists.
Adult↗
Efficacy of chimeric molecules directed towards multiple somatostatin and dopamine receptors on inhibition of GH and prolactin secretion from GH-secreting pituitary adenomas classified as partially responsive to somatostatin analog therapy.
OBJECTIVE: This study compared the potency of a somatostatin receptor (sstr)2-sstr5 analog, BIM-23244, of an sstr2-dopamine D2 receptor (sstr2-DAD2) molecule, BIM-23A387 and of new somatostatin-dopamine chimeric molecules with differing, enhanced affinities for sstr2, sstr5 and DAD2, BIM-23A758, BIM-23A760 and BIM-23A761, to suppress GH and prolactin (PRL) from 18 human GH adenomas that are partially responsive to octreotide or lanreotide. MATERIALS AND METHODS: The sstr2, sstr5 and DAD2 mRNA levels were determined by RT-PCR. The effect of drugs was tested in cell cultures at various concentrations. RESULTS: In all tumors, the sstr2, sstr5 and DAD2 mRNA levels were coexpressed (mean levels+/-s.e.m. 0.4+/-0.1, 5.3+/-1.9 and 2.0+/-0.4 copy/copy beta-glucuronidase). In 13 tumors, the maximal suppression of GH secretion produced by BIM-23A387 (30+/-3%) and BIM-23244 (28+/-3%) was greater than that produced by octreotide (23+/-3%). In six out of 13 tumors, BIM-23A758, BIM-23A760 and BIM- 23A761 produced greater maximal suppression of GH secretion than octreotide (33+/-5, 38+/-2 and 41+/-2 vs 24+/-2%). Their EC(50) values were 10, 2 and 4 pmol/l. BIM-23A761 was more effective than BIM-23A387 in GH suppression (41+/-2 vs 32+/-4%). The new chimeric molecules produced maximal PRL suppression greater than octreotide (62+/-8 to 74+/-5 vs 46+/-11%). CONCLUSIONS: Novel dopamine-somatostatin chimeric molecules with differing, enhanced activity at sstr2, sstr5 and DAD2, consistently produced significatly greater suppression of GH and PRL than either octreotide or single-receptor-interacting ligands in tumors from patients classified as only partially responsive to octreotide therapy. The higher efficacy of the chimeric compounds was, at least partially, linked to their high affinity for sstr2 (IC50 1-10 pmol/l). The other mechanisms by which such molecules produce an enhanced inhibition of GH remain to be elucidated.
Acromegaly↗
BIM-23A760, a chimeric molecule directed towards somatostatin and dopamine receptors, vs universal somatostatin receptors ligands in GH-secreting pituitary adenomas partial responders to octreotide.
We report the comparative efficacy of a somatostatin receptor 1 and 5 subtypes (SSTR2 and SSTR5), and dopamine D2 (DAD2) compound, BIM-23A760, in suppressing GH secretion, in cell culture from human GH-secreting tumors, from patients partially responsive to long-term treatments with octreotide or lanreotide. In 18 tumors tested, the SSTR2, SSTR5, and DAD2 mRNAs were coexpressed. The SSTR2-selective analog, BIM-23197, the SSTR5-selective analog, BIM-23268, and the dopamine (DA) analog, BIM-53097, produced a mean maximal suppression of GH secretion (24 +/- 3, 20 +/- 3, and 20 +/- 3%, respectively) that was similar to that obtained with octreotide (23 +/- 3%). Nevertheless, based on individual responses, 60% of the tumors were mostly sensitive to the SSTR2 analog while 19 and 21% of the tumors were mainly responsive to the SSTR5 analog and to the DA analog, respectively. Among a series of new chimeric compounds that bind the SSTR2, SSTR5, and DAD2 receptors with variable affinities, BIM-23A760 produced greater maximal suppression of GH secretion than octreotide (38 +/- 2 vs 24 +/- 2%; p<0.03). The EC50 for BIM-23A760 was 2 pmol/l. In the presence of sulpride, the dose response inhibition of GH secretion by the trihybrid molecule, BIM-23A760, was partially reversed. The trihybrid produced also a maximal suppression of PRL greater than octreotide (74 +/- 5 vs 46 +/- 11%). When SSTRs pan inhibitors such as BIM-23A779 (binding affinity for SSTR1, SSTR2, SSTR3, SSTR5, respectively: 2.5, 0.3, 0.6, 0.6 nmol/l) or SOM230 were tested for their suppressive effects on GH secretion, they were less potent than the previous dopastatin hybrid molecule. After a brief exposure to a SSTR2-selective analog, BIM-23197, or to a DA analog, BIM-53097, the maximal GH suppression was achieved during 12 h. Under exposure to BIM-23A760, in the same conditions, maximal suppression of GH secretion lasted for 24 h. Such a longer biological effect, yet not explained, probably participates in the higher efficacy of BIM-23A760. The higher efficacy of BIM-23A760 is, at least partially, linked to its high affinity for the SSTR2 receptor subtype (IC50: 3 pmol/l). As compared to the dopastatin compound, the lower efficacy of the universal somatostatin ligands in the inhibition of GH secretion of GH-secreting tumors argues for the use of drugs targeted, according to specific receptors expression and functionality which may vary among the various classes of tumors.
Acromegaly↗
Differential patterns of cognitive impairment in patients with aqueductal stenosis and normal pressure hydrocephalus.
METHODS: We report a preoperative neuropsychological evaluation for ten adult patients with aqueductal stenosis, and compare the results of this group with a normal pressure hydrocephalus group. FINDINGS: For executive functions, aqueductal stenosis patients failed on isolated tests and results were heterogeneous; the normal pressure hydrocephalus group was more impaired, except for tasks which required memory processing. Memory deficits in aqueductal stenosis group are qualitatively dissimilar and more homogeneous and severe, despite the younger age, than in the normal pressure hydrocephalus group. INTERPRETATION: These findings indicate that neuropsychological deficits of patients with aqueductal stenosis are linked with fornix damage and frontal dysfunction. In the normal pressure hydrocephalus group, deficits could be linked with a prefrontal lobe disconnection.
Adult↗
[Hydroxyurea treatment for unresectable meningioma].
BACKGROUND: Management of unresectable progressive meningioma remains controversial and constitutes a major challenge since therapeutic options including chemotherapy and hormone modulation are limited. Recent data have suggested that hydroxyurea treatment may have an antitumoral effect. The purpose of this prospective phase II study was to evaluate the efficacy of hydroxyurea treatment for unresectable progressive meningioma. METHODS: From 1997 to 1999, consecutive patients presenting unresectable meningioma with clinically and/or neuroradiologically documented progression were considered for entry into this protocol. Previous radiotherapy was not a mandatory inclusion criteria. Treatment consisted of continuous oral administration of hydroxyurea at a dose of 20 mg/kg per day. Follow-up assessment included physical examination, computed tomography (CT), and magnetic resonance imaging (MRI) performed every three months, as well as regular blood testing. The primary endpoint was documentation of objective response by MRI or CT. RESULTS: The intent-to-treat population was 43 patients with at least 18 months follow-up. Median age was 60.4 years. Twenty-eight patients had undergone surgery following initial diagnosis. The meningioma was located in the skull base in 67% of patients. Histology was benign in 18 and atypical in 10. The eligible population included 36 patients with documented progressive disease at the time of inclusion; with progression documented clinically in 29 (67.5%) and/or radiologically in 20 (46%). In 7 patients, clinical or radiological progression could not be confirmed. The intent-to-treat analysis at median 26 months follow-up revealed objective response to hydroxyurea in only 3 patients (7%) including one on the basis of improvement in visual symptoms and two on MRI analysis. Progressive disease was observed clinically or radiologically in 26 patients (60.5%). Of the eligible population (n=36), 2 achieved an objective response and 13 (36%) exhibited stabilization under hydroxyurea therapy, while 21 (58%) progressed under treatment. Overall tolerance was good but anemia (grade I-II) and asthenia (grade I-II) were observed in 28% and 23.5% respectively. Treatment was discontinued in 3 patients because of chronic skin toxicity in one and anemia and asthenia in two. CONCLUSION: Hydroxyurea treatment is of marginal efficacy for meningioma and must not be considered as an alternative if radiotherapy or surgery is feasible. New efficient medical treatments are still required for progressive meningiomas.
Adult↗
[Retro-odontoid synovial cyst with Forestier's disease].
STUDY DESIGN: We report one case of 66-year-old man with Forestier disease and spinal cord compression by retro-odontoid synovial cyst. OBJECTIVES AND METHODS: Although retro-odontoid synovial cysts remain rare, an increasing number have been reported in the literature. Affecting adults in the sixth decade of life, retro-odontoid synovial cysts produce slowly progressive upper spinal cord symptoms. Diagnosis can be achieved by means of magnetic resonance imaging (MRI). Association with Forestier's disease has been reported in only one previous study. Cyst probably develop as a result of enhanced mechanical stress on the only remaining mobile joint. In the literature treatment of retro-odontoid mass associated with Forestier has usually involved occipito-cervical fusion with transoral decompression. RESULTS: In this report we describe a patient treated by the posterolateral route with good short- and mid-term clinical and radiological outcome. CONCLUSIONS: In comparison of transoral route, the advantages of the posterolatral route are shorter hospitalization and lower morbidity especially in elderly patients with operative risk factors.
Aged↗
[Traumatic spondylolisthesis of the axis: arguments in favor of surgical management after analysis of 8 patients].
BACKGROUND AND PURPOSE: The purpose of this report is to assess the efficacy of primary surgical stabilization in the management of traumatic C2 spondylolisthesis. MATERIAL AND METHODS: Eight patients including 5 men and 3 women (mean age, 44 years) were treated surgically for traumatic spondylolisthesis of the axis. Three patients presented permanent neurological deficit. The indication for operative treatment included fracture instability and association with either neurological deficit or multiple trauma. External immobilization was attempted and failed in two patients. In all cases the procedure was performed by the anterior route and consisted of surgical fixation with C2/C3 discectomy, intersomatic graft placement, and bone fusion. RESULTS: Using the Effendi and Levine classification, fractures were classified as type I in 2 cases, type II in 3, type IIa in 2, and type III in 1. The two patients with severe tetraparesis presented spinal cord contusion at the C2/C3 disk level. Postoperative radiography demonstrated C2/C3 fusion in all patients. No surgical complications were observed. The average hospital stay was 4.5 days. CONCLUSION: Surgical stabilization by C2-C3 fusion via the anterior route is effective for management of all types of traumatic C2 spondylolisthesis. It achieves immediate stability. We recommend its use as a primary intervention not only for unstable lesions but also for lesions associated with neurological deficits or multiple trauma. A major benefit is to facilitate nursing care and patient rehabilitation.
Adult↗
[A retrospective study of 32 lumbar synovial cysts. Clinical aspect and surgical management].
We report a retrospective analysis of a series of 32 cases of lumbar synovial cysts. Clinically, two populations were identified: patients who presented radicular pain mimicking the clinical diagnosis of disk herniation (group I) and patients who presented neurogenic claudication consistent with a diagnosis of lumbar spinal stenosis (group II). The radiological work-up consisted in standard X-rays and CT-scan for all patients. MRI (magnetic resonance imaging) was performed in 14 patients. All the patients were operated on. The surgical technique consisted in foraminotomy for patients in group I and more or less extensive laminectomy for patients in group II. Functional outcome was marked by a significant improvement in 96.9% of the patients and those who presented a motor deficit recovered in 83% of the cases. Based on the findings in this series, we discuss the clinical aspects and the therapeutic management of this pathological entity.
Adult↗
[Intracranial aneurysm revealed by panhypopituitarism. Considerations on therapeutic management based on a case report and review of the literature].
We report a case of an unruptured intracranial aneurysm in paraclinoidal location which was a unmasked by severe panhypopituitarism. An ipsilateral internal carotid artery (ICA) clamp test was performed in the pretreatment stage. The test was well tolerated and the aneurysm could be embolized with GDC (Guglielmi detachable coils) without necessitating an occlusion of the ICA. The postoperative course was uneventful and the patient was discharged after 48 hours. At one year, cerebral angiograms confirmed complete obliteration of the aneurysm. Therapeutic management of this rare entity is discussed along with a careful and exhaustive review of the literature.
Adult↗
[Therapeutic strategies in somatotroph adenomas with extrasellar extension: role of the medical approach, a consensus study of the French Acromegaly Registry].
UNLABELLED: From the first 198 patient files included into the French Acromegaly Registry, we analyzed 68 patients harboring a somatotroph adenoma with extrasellar extension, after exclusion of those treated by stereotactic or conventional radiotherapy. In these patients (including 37 women), aged 21-77 yr. (45.7 +/- 13.3), GH concentrations ranged from 2-260 microg/L (38.6 +/- 44.3), and IGF I from 86-967% of age-matched upper limit of normal (303 +/- 164). Maximal diameter of the adenoma at MRI was 11-36.5 mm (20.4 +/- 6.5), with cavernous sinus involvement in 68% of cases. Three subgroups were defined: 20 patients treated by long-acting somatostatin analogs only (group M), for a mean duration of 3 yr. (extremes 1-7 yr.), 48 patients initially treated by transsphenoidal surgery (group C), of whom 21 were secondarily treated by long-acting somatostatin analogs (group CM) for a mean duration of 1.2 yr. (extremes 0.2-2 yr.). All 3 groups were not statistically different in terms of tumor mass and initial levels of GH and IGF-1. Patients from group M were significantly older than those of the other groups (p<0.05). RESULTS: 46% of patients from group C after surgery vs. 45% of patients from group M had a mean GH below 2.5 microg/L. Biochemical remission (GH<2.5 microg/L and normal IGF1 normal) was obtained in 31% of cases in group C, vs. 25% in group M. In this group, a decrease of the largest tumor diameter was observed in 10 patients (71.5%), ranging from 10-25% in 7 (50%) and exceeded 50% in 3 (21.5%). In group CM, the biochemical remission rate (42%) and final GH or IGF1 values were not significantly different from group M. In conclusion, these data suggest that surgery or long-acting somatostatin analogs have a comparable efficacy in terms of remission rates in somatotroph macroadenomas with extrasellar extensions.
Acromegaly↗
Distribution and functionality of the somatostatin receptor subtypes in acromegaly.
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Acromegaly↗
Pituicytomas, a mis-diagnosed benign tumor of the neurohypophysis: report of three cases.
Pituicytoma is a rare benign primary tumor of the neurohypophysis, occurring in the sellar and suprasellar spaces. We report here three new cases with immunohistochemical and electron microscopic study. Particular attention was paid to the expression of some cell adhesion molecules. These tumors were characterized by bundles of elongated cells strongly immunoreactive to anti-vimentin, S-100 protein, neural cell adhesion molecule and neuron-specific enolase antibodies. Glial fibrillary acidic protein (GFAP) was not recorded. It expressed the very late antigen alpha2 (VLAalpha2), but not VLAalpha5, and lacked epithelial markers expression (epithelial membrane antigen, E-cadherin), and specific neuronal markers (synaptophysin, chromogranin, neurofilament). Staining for pituitary hormones was negative. At the ultrastructural level, tumor/blood vessel basal lamina and cytoplasmic intermediate filaments were observed but desmosome or pericellular basal lamina were lacking. In one case few secretory granules were recorded. Differential diagnoses include granular cell tumors, pilocytic astrocytomas and spindle cell tumors such as solitary fibrous tumors, fibroblastic meningiomas and schwannomas. However, the unique pattern of antigenic expression and ultrastructural features of pituicytomas distinguish this rare tumor. As a subpopulation of pituicytes (which are distinctive glial cells of the neurophypophysis), some pituicytomas do not expressed GFAP. This suggests that pituicytomas presumably arise from pituicytes at various stages of their differentiation.
Astrocytoma↗
[Metastatic meningioma to the first thoracic vertebral body. A case report and review of the literature].
This report describes a case of metastatic meningioma involving the first thoracic vertebral body in a 63-year-old woman. The patient was treated surgically 10 years earlier for a benign meningioma of the right parietal vault. Local recurrence was diagnosed in 1992. Despite the gamma-knife radiosurgery, recurrence required surgical treatment in 1999. Histological findings were compatible with atypical meningioma (grade II WHO). One year later, the patient presented left C8 cervicobrachial neuralgia. Investigation led to discovery of a D1 tumor that was a metastasis of the atypical intracranial meningioma. A resection of the vertebral T1 body with C7-T2 osteosynthesis was performed with an excellent recovery and no postoperative complication.
Brachial Plexus Neuritis↗
[Dissemination of melanoma cells after anterior surgery of the cervical spine].
We describe a previously unreported complication after anterior surgery of the cervical spine for melanoma. Ten days after the surgical procedure, a 51-year-old man presented a huge cystic cervical metastasis along the surgical route. The pathophysiology and the surgical risk of the procedure are discussed.
Cervical Vertebrae↗