Biomedical subjects
Publications and source records attributed to M Rousseaux.
Two personal cases and a review of the literature permit to distinguish by anatomical, clinical and paraclinical aspects : neurilemmoma of the jugular foramen (type III), neurilemmoma of the bulbar spinal (type I), and of the medullary spinal (type II). This classification permits to choice surgical approach.
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A dorsal spinal cord compression by exuberant arthropathy and osteophytes of the articular processes occurred in a 61 years old patient with syringomyelia. The clinical symptoms were related to postero lateral cord involvement and rapidly appeared after syringo-peritoneal shunting. C.T. scan precisely displayed the pathological process and the cord compression. Surgery enabled a definite amelioration of secondary sensory deficits. It was to our knowledge the first description of such an involvement of articular processes in syringomyelia.
Ten cases of arachnoid cysts of the ponto-cerebellar angle are presented. In most cases, local arachnoiditis is disclosed during surgery, directing the discussion toward acquired pathology, and perhaps toward local infection. The clinical symptoms are dominated by the cochleo-vestibular deficit, but the involvement of the V and the VII cranial nerves is inconstant and discreet. At the present time, C.T. scan allows a rapid diagnosis but the prognosis must be reserved, in account to the possibility of a local post operatory arachnoiditis .
A case of a medial and caudal infarction of the midbrain in a 56 years old woman is reported. The clinical syndrome included a rapidly recovering sleepiness, an ophthalmoplegia related to damage to the caudal part of the oculomotor nuclear complex, a slow extrapyramidal dysarthria and a severe ataxia. The latter was characterized by the prevalent involvement of posture control, resulting from an axial hypotonia and the lack of balance reflexes. The CT scan showed a low density area in the central part of the midbrain. Electrophysiological investigations were carried out to study the impairment of the sensory and auditory tracts in the brainstem. In spite of the gravity of initial signs, recovery was good and the patient led a normal life 8 months later.
A 25-year-old man developed marked weakness of the upper limbs and shoulder girdle over a period of 6 months. On examination there was amyotrophy, fasciculations and areflexia of the upper limbs with increased lower limb reflexes. Sensation and CSF were normal. CT scan showed a thickened cord with a central medullary cavity of triangular shape with a ventral base. Myelobulbography showed a type I Arnold-Chiari malformation. Spinal angiography was normal. Isotopic studies showed early ventricular reflux. Although infusion tests gave negative results a ventriculoperitoneal shunt was performed and the condition stabilized. Follow-up examination 4 years later confirmed the absence of sensory disorders and nervous arthropathies. The mechanism of production of cervical cord lesions during hydromyelia may be related to hydrocephalus, with fluid absorption across the ependymal walls, or to venous stasis determined by the Arnold-Chiari malformation. The ventral extension of the central cord cavity accounted for the isolated atypical lesion of the anterior horns.
Two cases of cerebellar haemorrhage with hydrocephalus are presented which were successfully treated with isolated ventricular drainage. Both occurred in high risk patients, 77 and 68 years old. The first observation confirms the value of this operative procedure when the volume of the haemorrhage is relatively restricted, whatever may be the importance of the neurologic symptoms and brainstem disfunction. But the second observation also shows the risk of misappreciating the causative lesion (here a single metastasis). The importance of an extended C.T. follow up must be underlined.
With reference to three cases the main features of subdural empyema are recalled. These collected suppurations are often secondary to frontal or maxillary sinusitis due to a streptococcus. Clinical features are those of meningo-encephalitis but signs of cortical damage are more prevalent. Many cases of subdural empyema which would have been unrecognized by conventional procedures are now diagnosed by CT scan. CT scan has also improved monitoring; thus, two of the three patients could be given medical treatment alone. The authors believe that non-surgical treatment would ensure recovery in many cases of subdural empyema. Surgery should be restricted to patients with severe intracranial hypertension or persistence of a large mass after several weeks of antibiotic treatment. Non-surgical treatment may improve prognosis.
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The analysis of 8 cases of rheumatoid arthritis involving the cervical spine and resulting in neurological complications leads the authors to change their therapeutic approach. After a study of etiopathological aspects they advocate wider indications of surgical treatment. Clinical and radiological criteria are defined and operative risks are described.
Two cases of cervico-occipital malformation revealed by syncopes are reported. The first patient has an Arnold-Chiari type I malformation and the second has a basilar impression. The paroxysmal clinical manifestations are triggered by head-turning or exertion. In the second case Doppler vertebral artery recordings show circulatory arrest during a moderate turning motion of the head. A vascular mechanism may explain the occurrence of paroxysmal symptoms in cervico-occipital malformations.
A number of hypotheses and much discussion surround the subject of intracranial arachnoid cysts (ICACs). Based on the observation of 7 cases of ICACs which were asymptomatic until aggravated by head injuries, the aetiopathological relationship between head injury and ICAC is discussed. Trauma is not the only origin of ICACs, but even a slight head injury is capable of provoking the rapid decompensation of a previously dormant ICAC.
The case of a 29 years old woman with bilateral ischemic lesions in superior temporal and temporo-parietal areas is presented. An important speech reduction evolving toward muteness is associated to cortical deafness and behavior perturbations. The study of symbolic functions shows the partial respect of occipital activities and connexions between visual system and areas supporting graphism and manual praxia. The mechanisms of cortical deafness and secondary muteness is discussed, with reference to the previous descriptions.
3 communicating diverticula and 3 arachnoid symptomatic cyst in intradural situation are presented. In two cases, this pathology is slowly developing, in patients with Von Recklinghausen neurofibromatosis. A congenital malformative process may be evoked. In two other cases, myelography and surgery favor a frank or discreet arachnoïditis. Those establishments show the diversity of mechanisms underlying intradural arachnoïd cysts. They are in most cases in a postero medullary and dorsal situation, but cervical as well as lumbar position are possible. One must insist on the frequency and importance of local and cordonal pain, accompanying in most cases sensory and motor deficits in inferior limbs. A rapid revelation or decompensation is most rare. Prognosis must be reserved, as post operative arachnoïditis and relapse are not rare.
Therapy in 19 consecutive cases of cerebral abscess was limited to medical treatment whenever possible, using high doses of a combination of several antibiotics. Long-term follow up by serial computed tomography was performed. Antibiotic treatment alone was effective in 8 patients with multiple hemispheric abscesses of metastatic origin, though one patient seen late with three large abscesses die on the 4th day. In 8 cases with single abscesses, medical treatment alone was effective: 5 had lesions less than 4 cm in diameter; in 2 cases with lesions 4 to 5 cm in diameter, additional abscess puncture was carried out. One patient required early excision of an occipital abscess, and 2 cases of pontocerebellar angle abscesses were also treated surgically. Antibiotic therapy alone was effective in 1 patient with a large brain stem abscess. Treatment of cerebral abscess has largely changed since the availability of computed tomography, with a progressively more important place being accorded to antibiotic therapy alone. The stage of the abscess does not appear to be a decisive factor in the choice of treatment, medical therapy appearing to provide a definitive cure with a minimum of sequelae in the majority of cases. Abscess puncture may be an adjunct to antibiotic therapy in large abscesses with clinical signs.
Extradural spinal hematomas observed in 9 cases over a period of 11 years developed in the absence of blood coagulation disorders in 3 cases, during anticoagulant therapy in 5 cases, and during the course of a megaloblastic anemia in one patient. The presence of marked associated myelomalacia was confirmed at postmortem in one case. Etiopathogenic factors remain obscure, particularly in spontaneously developing forms, and careful histologic examination of all clots is necessary to determine possible vascular malformations at the origin of the hematoma.
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Between 1964 and 1980, 17 patients operated upon for cerebral metastasis as initial presentation of bronchial cancer underwent excision of the thoracic tumour 24 to 131 days later. One patient died post-operatively of acute pneumopathy. Nine patients showed signs of recurrent cerebral malignancy after a 55 to 904 days' delay. Increase in life expectancy and regression of neurological symptoms justify this bifocal surgical strategy. Using cerebral and thoracic radiotherapy as well as chemotherapy as supplementary measures seems rational and likely to improve the present results.