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The topographical neuroanatomy of the human spinal cord (SC) is currently based on the adjacent vertebrae. This morphometric study sought to develop a dataset allowing for statistical analysis of human SC segment characteristics. Overall, 32 human SCs were dissected (18 female and 14 male donors), and individual SC segments were identified. Anterior and posterior lengths, thicknesses and widths were measured by two examiners. Statistical analyses included t-tests, as well as intraclass and Pearson's correlation coefficients. The SC length was significantly shorter in females than males. The cranial (C4) and caudal (T1/T2) limits of the cervical enlargement, along with its maximal width (C6-C7), were identified by combining widths and thicknesses of the segments. The thoracic region, T2 to T12, could be identified using segments widths and thicknesses values. The length of the lumbosacral region, from segments L2 to S5, was particularly stable, independently of SC length and sex. The lumbar enlargement was characterized by a thickness increase between the segments L2 and S1 which reached its maximum at the level of L3, L4, and L5, whereas the width was not significantly increased. From the S2 to S5 segments, width and thickness were equal, with both decreasing of 1 mm per segment. The morphometrical analysis of 32 human SCs provided a dataset allowing for statistical analysis of segmental measures with significant results. A combined approach mostly using widths and thicknesses provided landmarks of potential interest for the localization of SC segments in a clinical MRI setting.

Transient tumor swelling is a well-known phenomenon following radiotherapy for vestibular schwannomas (VS). We analyzed the long-term volumetric changes of VS after LINAC radiosurgery, in order to determine a time interval during which a true tumor progression can be distinguished from a pseudoprogression. Among 63 patients with VS treated by one fraction or fractionated radiotherapy, we selected 52 of them who had a minimal follow-up of 5 years. Maximal axial diameter and three-dimensional tumor volume were measured on each MRI scan. Volume changes were interpreted using different error margins ranging from 10 to 20%. Patients were categorized according to the tumor evolution pattern over time. Median follow-up was 83 months. One tumor (1.9%) remained stable and 26.9% had continuous shrinkage. Applying an error margin of 13%, a transient tumor enlargement was observed in 63.5% of patients, with a first peak at 6-12 months and a late peak at 3-4 years. A true progression was suspected in 4 (7.7%) patients, tumor regrowth starting after the 3rd or 4th year post-treatment. Only one patient required salvage radiotherapy. Transient swelling of VS following radiotherapy is generally an early phenomenon but may occur late. In the first 5 years, a true tumor progression cannot be differentiated from a pseudoprogression. A significant tumor expansion observed on 3 sequential MRI scans after the 3rd year may be suggestive of treatment failure. Long-term follow-up is therefore mandatory and no decision of salvage treatment should be made until the 6th year.

Glioblastoma (GBM) is the most common and aggressive primary brain tumor. Despite recent advances in therapy modalities, the overall survival of GBM patients remains poor. GBM diagnosis relies on neuroimaging techniques. However, confirmation via histopathological and molecular analysis is necessary. Given the intrinsic limitations of such techniques, liquid biopsy (mainly via blood samples) emerged as a non-invasive and easy-to-implement alternative that could aid in both the diagnosis and the follow-up of GBM patients. Cancer cells release tumoral content into the bloodstream, such as circulating tumor DNA, circulating microRNAs, circulating tumor cells,extracellular vesicles, or circulating nucleosomes: all these could serve as a marker of GBM. In this narrative review, we discuss the current knowledge, the advantages, and the disadvantages of each circulating biomarker so far proposed.

Traumatic spinal cord injury (SCI) is a neurologic condition characterized by long-term motor and sensory neurologic deficits as a consequence of an external physical impact damaging the spinal cord. Anatomic MRI is considered the gold-standard diagnostic tool to obtain structural information for the prognosis of acute SCI; however, it lacks functional objective information to assess SCI progression and recovery. In this study, we explored the use of synaptic vesicle glycoprotein 2A (SV2A) PET imaging to detect spinal cord lesions noninvasively after SCI. Mice ( = 7) and rats ( = 8) subjected to unilateral moderate cervical (C5) contusion were euthanized 1 wk after SCI for histologic and autoradiographic (H-labeled (4)-1-[(3-methylpyridin-4-yl)methyl]-4-(3,4,5-trifluorophenyl)pyrrolidin-2-one [UCB-J]) investigation of SV2A levels. Longitudinal C-UCB-J PET/CT imaging was performed in sham ( = 7) and SCI rats ( = 8) 1 wk and 6 wk after SCI. Animals also underwent an F-FDG PET scan during the latter time point. Postmortem tissue SV2A analysis to corroborate in vivo PET findings was performed 6 wk after SCI. A significant SV2A loss (ranging from -70.3% to -87.3%; < 0.0001) was measured at the epicenter of the impact in vitro in both mouse and rat contusion SCI models. Longitudinal C-UCB-J PET imaging detected SV2A loss in SCI rats (-49.0% ± 8.1% at 1 wk and -52.0% ± 12.9% at 6 wk after SCI), with no change observed in sham rats. In contrast, F-FDG PET imaging measured only subtle hypometabolism (-17.6% ± 14.7%). Finally, postmortem H-UCB-J autoradiography correlated with the in vivo SV2A PET findings ( = 0.92, < 0.0001). C-UCB-J PET/CT imaging is a noninvasive marker for SV2A loss after SCI. Collectively, these findings indicate that SV2A PET may provide an objective measure of SCI and thus represent a valuable tool to evaluate novel therapeutics. Clinical assessment of SCI with SV2A PET imaging is highly recommended.

Glioblastoma multiforme (GBM) is the most aggressive primary brain tumor with a malignant prognosis. GBM is characterized by high cellular heterogeneity and its progression relies on the interaction with the central nervous system, which ensures the immune-escape and tumor promotion. This interplay induces metabolic, (epi)-genetic and molecular rewiring in both domains. In the present study, we aim to characterize the time-related changes in the GBM landscape, using a syngeneic mouse model of primary GBM. GL261 glioma cells were injected in the right striatum of immuno-competent C57Bl/6 mice and animals were sacrificed after 7, 14, and 21 days (7D, 14D, 21D). The tumor development was assessed through 3D tomographic imaging and brains were processed for immunohistochemistry, immunofluorescence, and western blotting. A human transcriptomic database was inquired to support the translational value of the experimental data. Our results showed the dynamic of the tumor progression, being established as a bulk at 14D and surrounded by a dense scar of reactive astrocytes. The GBM growth was paralleled by the impairment in the microglial/macrophagic recruitment and antigen-presenting functions, while the invasive phase was characterized by changes in the extracellular matrix, as shown by the analysis of tenascin C and metalloproteinase-9. The present study emphasizes the role of the molecular changes in the microenvironment during the GBM progression, fostering the development of novel multi-targeted, time-dependent therapies in an experimental model similar to the human disease.

This study intended to establish international recommendations for the management of spastic equinovarus foot deformity. Delphi method SETTING: International study PARTICIPANTS: 24 international experts in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopaedic surgeons, neurosurgeons, and plastic surgeons) INTERVENTIONS: Experts answered three rounds of questions related to important aspects of diagnosis, assessment and treatment of spastic equinovarus foot deformity. A consensus was established when at least 80% of experts agreed on a statement RESULTS: : A total of 52 items reached consensus. Experts recommend assessing impact of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity and evaluate the activity of antagonist muscles. Motor nerve blocks, two-dimensional video analysis and radiological exams are often required to complement a clinical exam. The treatment of equinovarus foot depends on the correctability of the deformity, but also the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between doctors and the patient, which will define personalized attainable goals before surgery. The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and non-specialists to diagnoses and assess the deformity and direct patients to a network of experts, in order to optimize patient functional recovery and improve their autonomy.

Tuberculum sellae meningiomas are deep-seated tumors difficult to access, located in close relation with important neurovascular structures. While the transsphenoidal approach is linked to specific complications, the different reported transcranial approaches are associated with advantages and drawbacks due to the respective angle of attack, with some areas adequately exposed and others partially hidden. We report the technical aspects of the anterior interhemispheric approach we practice. This approach has the advantage of providing full control over all the vasculo-nervous structures involved and of allowing access to the medial aspect of both optic canals tangentially to the dorsum sellae.

The ultimate goal of stereotactic radiotherapy (SRT) of brain metastases (BM) is to avoid or postpone whole brain radiotherapy (WBRT). A nomogram based on multi-institutional data was developed by Gorovets, et al. to estimate the 6 and 12-months WBRT-free survival (WFS). The aim of the current retrospective study was to validate the nomogram in a cohort of postoperative BM patients treated with adjuvant SRT. We reviewed the data of 68 patients treated between 2008-2017 with postoperative SRT for BM. The primary endpoint was the WFS. The receiver operating characteristic curve and area under the curve (AUC) were calculated for both 6- and 12-months time points. After a median follow-up of 64 months, the 1-year cumulative incidence of local and distant brain relapse rates were 15% [95% CI=8-26%] and 34% [95% CI=24-48%], respectively. At recurrence, repeated SRT or salvage WBRT were applied in 33% and 57% cases, respectively. The WFS rates at 6 and 12 months were 88% [95% CI=81-97%] and 67% [95% CI=56-81%], respectively. Using the Gorovets nomogram, the 6 months rates were overestimated while they were accurate at 12 months. AUC values were 0.47 and 0.62 for the 6- and 12-months respectively. Overall, Harrell's concordance index was 0.54. This nomogram-predicted well the 12 months WFS but its discriminative power was quite low. This underlines the limits of this kind of predictive tool and leads us to consider the use of big data analysis in the future.

Literature regarding cases of pregnant patients with hereditary spastic paraparesis (Strumpell-Lorrain disease) and those treated by intrathecal baclofen therapy is sparse. There are currently no specific guidelines to manage pregnancy and delivery in these patients. A 42-year-old woman presented to our clinic with hereditary spastic paraparesis and was treated with intrathecal baclofen for spasticity. She conceived twice and delivered successfully by caesarean section under subarachnoid anaesthesia. The two pregnancies had favourable outcomes with no increase in spasticity and no problems encountered with the intrathecal device. In this report, we discuss the evolution of both pregnancies and the anaesthetic management for deliveries in the presence of an intrathecal catheter.

Many closed-form analytical models have been proposed to relate the diffusion-weighted magnetic resonance imaging (DW-MRI) signal to microstructural features of white matter tissues. These models generally make assumptions about the tissue and the diffusion processes which often depart from the biophysical reality, limiting their reliability and interpretability in practice. Monte Carlo simulations of the random walk of water molecules are widely recognized to provide near groundtruth for DW-MRI signals. However, they have mostly been limited to the validation of simpler models rather than used for the estimation of microstructural properties. This work proposes a general framework which leverages Monte Carlo simulations for the estimation of physically interpretable microstructural parameters, both in single and in crossing fascicles of axons. Monte Carlo simulations of DW-MRI signals, or fingerprints, are pre-computed for a large collection of microstructural configurations. At every voxel, the microstructural parameters are estimated by optimizing a sparse combination of these fingerprints. Extensive synthetic experiments showed that our approach achieves accurate and robust estimates in the presence of noise and uncertainties over fixed or input parameters. In an in vivo rat model of spinal cord injury, our approach provided microstructural parameters that showed better correspondence with histology than five closed-form models of the diffusion signal: MMWMD, NODDI, DIAMOND, WMTI and MAPL. On whole-brain in vivo data from the human connectome project (HCP), our method exhibited spatial distributions of apparent axonal radius and axonal density indices in keeping with ex vivo studies. This work paves the way for microstructure fingerprinting with Monte Carlo simulations used directly at the modeling stage and not only as a validation tool.

INTRODUCTION : Meningiomas are the most frequent primary intracranial tumors and are generally considered benign, although they may harbor an aggressive clinical behavior [1]. While genetic criteria were introduced in the updated 2016 WHO classification for gliomas, stratification of meningiomas remains based on pure histological aspect [2]. Chordoid meningioma (CM), which represents only 1% of meningiomas, is a rare subtype characterized by cords of eosinophilic cells in an abundant myxoïd matrix with a chordoma-like appearance. It is classified as grade WHO 2 due to a high rate of early recurrence. In the last decade, genetic alterations of meningiomas were extensively studied. Monosomy 22 and inactivating mutations of neurofibromin 2 gene (NF2) are the most frequently encountered [3]. More recently, mutations in TERT promoter, TRAF7, AKT1, KLF4, SMO, and PIK3CA were detected by next-generation sequencing [4,5]. A DNA methylation-based classification was also proposed [6]. [...]

To discuss the effectiveness, indications, limitations and side effects of botulinum toxin type A and selective neurotomy for treating focal spastic muscle overactivity to help clinicians choose the most appropriate treatment. Expert opinion based on scientific evidence and personal experience RESULTS: Botulinum toxin type A can decrease muscle tone in different types of spastic muscle overactivity, which allows for treating a large variety of spastic patterns with several etiologies. The toxin effect is sometimes insufficient to improve functional outcome and is transient, thereby requiring repeated injections. Selective neurotomy is a permanent surgical treatment of the reflex component of the spastic muscle overactivity (spasticity) that is effective for spastic equinovarus foot. The neurotomy provides a greater and more constant reduction in spasticity. However, the long-lasting effect on the non-reflex muscle overactivity, especially dystonia, is doubted. The effectiveness, clinical indications, advantages, side effects and limitations of both techniques are discussed. Botulinum toxin type A has the highest level of evidence and the largest range of indications. However, the botulinum toxin effect is reversible and seems less effective, which supports a permanent surgical treatment such as selective neurotomy, especially for the spastic foot. Further research is needed to compare the effect of botulinum toxin type A and selective neurotomy for the different types of spastic muscle overactivity and clinical patterns.

Background: An enhanced and rapid recovery after surgery has become the new challenge to reduce postoperative complications and length of hospital stay. This retrospective study evaluated the benefits provided by the new sufentanil sublingual tablet system (SSTS) compared to patient controlled analgesia (PCA) with intravenous (IV) morphine in the specific context of spinal lumbar neurosurgery. Method: We selected 80 patients undergoing 1-2 levels lumbar laminectomy and/or discectomy to evaluate the SSTS. A second group was retrospectively constituted with 80 patients having benefited from the same surgery with IV morphine PCA during the period just preceding the SSTS test period. All patients received similar intraoperative multimodal analgesia. In post anesthesia care unit, piritramide (SSTS group) or morphine (IV PCA group) was titrated intravenously to insure a pain score below 4/10 before PCA initiation. The acute pain service evaluated on Day 1 and Day 2 the pain intensity (visual analogic score at rest and during mobilization) and opioid related side effects. Results were compared using Mann-Whitney-Wilcoxon test, p<0.05 was considered significant. Any comments of the health care personal were collected during the SSTS test. Results: The mean uptake after 48 hours was 34.99 mg IV morphine and 18.60 sufentanil tablets. Except for Day 1 at rest, pain intensity evaluations were significantly different between both groups, in favor of the IV PCA. There was no significant difference in side effects between groups. Valuable technical and practical comments were collected from patients and nurses, and were discussed. Conclusion: Despite a significant difference in postoperative pain scores, we demonstrated the overall satisfaction of the patients and the health care personal for the innovative system but some questions and problems were highlighted and would benefit from technical improvements, administrative refinements and further dedicated studies.

Dear Sir, Parkinsonism secondary to an arachnoid cyst appears to be very rare. We report the case of a 75-year-old woman who developed progressive gait and cognitive slowing during the preceding year. More recently, she complained of postural instability. Neurological examination revealed mild postural and action tremors of the upper limbs, along with moderate bilateral akinesia that was predominant on the left side, as well as slight rigidity of the left arm. Her face was hypomimic. Her gait was slow with short steps and no arm swing. Postural reflexes were severely reduced (Hoehn and Yahr score 3). [...]

Although brain tumours have been documented and recorded since the nineteenth century, 2016 marked 90 years since Percival Bailey and Harvey Cushing coined the term "glioblastoma multiforme". Since that time, although extensive developments in diagnosis and treatment have been made, relatively little improvement on prognosis has been achieved. The resilience of GBM thus makes treating this tumour one of the biggest challenges currently faced by neuro-oncology. Aggressive and robust development, coupled with difficulties of complete resection, drug delivery and therapeutic resistance to treatment are some of the main issues that this nemesis presents today. Current treatments are far from satisfactory with poor prognosis, and focus on palliative management rather than curative intervention. However, therapeutic research leading to developments in novel treatment stratagems show promise in combating this disease. Here we present a review on GBM, looking at the history and advances which have shaped neurosurgery over the last century that cumulate to the present day management of GBM, while also exploring future perspectives in treatment options that could lead to new treatments on the road to a cure.

OBJECTIVE: To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke. RESULTS: Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae - Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol-alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined. CONCLUSION: Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.

Une galactorrhée assoctee à une masse sellaire offre un large diagnostic différentiel. Nous présentons l'histoire d'une patiente avec un diagnostic iconographique de macroadénome hypophysaire invasif, associé à une galactorrhée et à une légère hyperprolactinémie . La dissociation entre la grande taille de la tumeur et la faible hyperprolactinémie, la normalisation rapide du taux de prolactine sous cabergoline sans réduction du volume tumoral, poussent à mener la réflexion plus loin que le diagnostic de prolactinome. Malgré l'absence de signe clinique caractéristique d'hypercorticisme, une cortisolurie et un test de freinage normaux,le diagnostic de tumeur corticotrope «silencieuse» est suspecté en préopératoire sur base de taux légèrement élevés d'ACTH contrastant avec des cortisolémies normales.

OBJECTIVE: The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults. METHODS: In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy. RESULTS: The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy. CONCLUSION: This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy.

Cholangiocarcinomas are rare tumors, and metastasis to the intramedullary spinal cord is also rare. To the best of our knowledge, this is the first case of simultaneous cholangiocarcinoma and intramedullary spinal cord metastasis to be described in the medical literature.

Objectives: To retrospectively identify morphological and physiological post-operative magnetic resonance imaging (MRI) characteristics predictive of glioblastoma recurrences after gross total resection (gross-TR). Methods: Resection margins of 24 glioblastoma were analysed immediately post-operatively (MRI ≤ 2 h) and early post-operatively (24 h ≤ MRI ≤ 48 h), and subdivided into areas with and without subtle contrast enhancement previously considered non-specific. On follow-up MRI, tumour regrowth areas were subdivided according to recurrence extent (focally/extended) and delay (≤6 and ≥12 months). Co-registration of pre-operative, immediately post-operative and early post-operative MRI with the first follow-up MRI demonstrating recurrence authorised their morphological (contrast enhancements) and physiological (rCBV) characterisation. Results: Morphologically, on immediately post-operative MRI, micro-nodular and frayed enhancements correlate significantly with early recurrences (≤6 months). After gross-TR the absence of these enhancements is associated with a significant increase in progression-free survival (61 vs 15 weeks respectively) and overall survival (125 vs 51 weeks respectively). Physiologically, areas with a future focal recurrence have a trend toward higher rCBV than other areas. Conclusion: Immediately post-operative topography of micro-nodular and frayed enhancements is suggestive of recurrence location and delay. Absence of such enhancements is associated with a fourfold increase in progression-free survival and a 2.5-fold increase in overall survival. Key Points: • Immediately post-operative MRI reveals contrast enhancement after glioblastoma gross total resection. • Immediately post-operative micro-nodular and frayed enhancement correlate with early recurrence. • Absence of micro-nodular/frayed enhancement is associated with 61 weeks' progression-free survival. • Absence of micro-nodular/frayed enhancement is associated with 125 weeks' overall su

BACKGROUND: . Selective neurotomy is a permanent treatment of focal spasticity, and its effectiveness in treating spastic equinovarus of the foot (SEF) was previously suggested by a few nonrandomized and uncontrolled case-series studies. OBJECTIVES: . This study is the first assessor-blinded, randomized, controlled trial evaluating the effects of this treatment. METHODS: . Sixteen chronic stroke patients presenting with SEF were randomized into 2 groups: 8 patients underwent a tibial neurotomy and the remaining 8 received botulinum toxin (BTX) injections. The soleus was treated in all patients, and the tibialis posterior and flexor hallucis longus were treated in about half of patients. The primary outcome was the quantitative measurement of ankle stiffness (L-path), an objective measurement directly related to spasticity. Participants were assessed by a blind assessor before their intervention and at 2 and 6 months after treatment. Evaluations were based on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). RESULTS: . Compared with BTX, tibial neurotomy induced a higher reduction in ankle stiffness. Both treatments induced a comparable improvement of ankle kinematics during gait, whereas neither induced muscle weakening. Activity, participation, and quality of life were not significantly modified in either group. CONCLUSIONS: . This study demonstrates that the tibial nerve neurotomy is an effective treatment of SEF, reducing the impairments observed in chronic stroke patients. Future studies should be conducted to confirm the long-term efficacy based on the ICF domains.

An 18-year-old man presenting with speech and behaviour disorders was found to suffer from Cushing's syndrome. Ectopic ACTH secretion was initially suspected on the basis of very high cortisoluria and ACTH concentrations, severe hypokalemia, a lung hypermetabolic lesion and a normal pituitary on conventional magnetic resonance imaging (MRI). After lung surgery, this lesion proved to be chronic necrotising aspergilloosis (CNA). Diagnostic reevaluation by bilateral inferior petrosal sinus sampling disclosed a right-sided petrosal sinus gradient consistent with Cushing's disease (CD). A new high resolution thin-section MRI demonstrated a 5 mm pituitary adenoma, which could be removed successfully. Thus, a lung mass associated with several clues in favour of ectopic ACTH secretion may hide a diagnosis of CD. Such a mass can be CNA, an opportunistic infection favoured by immunosuppression, which to our knowledge, is the first case reported in CD.

The wide use of sophisticated imaging techniques has led to the discovery of asymptomatic pituitary lesions, which are called 'incidentalomas'. Their global prevalence averages 10% whereas that of macroadenomas (> 10 mm) is less than 1%. The most frequently encountered lesions are non-functioning adenomas followed by Rathke's cleft cysts. Physiological pituitary hypertrophy is also frequent in young women. Silent functioning adenomas especially prolactinomas can be found among incidentalomas. Hypopituitarism appears to be more frequent in larger lesions but can occur in microadenomas (< 10 mm). The incidence of tumour growth is higher in macroadenomas and solid lesions in comparison with microadenomas and cystic lesions. The baseline evaluation should include in all patients a complete history and physical examination, a screening for hormone hypersecretion and hypopituitarism and a visual field examination if the lesion abuts the optic nerves or chiasm. If there is hormone hypersecretion, an appropriate treatment is indicated (dopamine agonists for prolactinomas and surgery for tumours producing GH, ACTH or TSH). If there is hypopituitarism, adequate hormone replacement therapy is required. According to recent guidelines, the indications for surgery of non-functioning incidentalomas include a visual field deficit, other visual abnormalities such as ophtalmoplegia or a lesion abutting the optic nerves or chiasm on magnetic resonance imaging (MRI). Regarding the follow-up of incidentalomas not meeting the criteria for surgery, the following tests should be performed: MRI at 1 year for micro- incidentalomas, at 6 months for macro-incidentalomas and then less frequently if unchanged in size, visual field examination for lesions enlarging to abut or compress the optic nerves or chiasm (6 months and yearly) and endocrine testing for macro-incidentalomas (6 months and yearly). Nowadays, data are insufficient to suggest the routine use of medical therapy in non-functioning

OBJECTIVE: To evaluate the quality of information available on the Internet to patients with a cervical pathology undergoing elective cervical spine surgery. METHODS: Six key words ("cervical discectomy," "cervical foraminotomy," "cervical fusion," "cervical disc replacement," "cervical arthroplasty," "cervical artificial disc") were entered into two different search engines (Google, Yahoo!). For each key word, the first 50 websites were evaluated for accessibility, comprehensibility, and website quality using the DISCERN tool, transparency and honesty criteria, and an accuracy and exhaustivity scale. RESULTS: Of 5,098,500 evaluable websites, 600 were visited; 97 (16%) of these websites were evaluated for quality and comprehensiveness. Overall, 3% of sites obtained an excellent global quality score, 7% obtained a good score, 25% obtained an above average score, 15% obtained an average score, 37% obtained a poor score, and 13% obtained a very poor score. High-quality websites were affiliated with a professional society (P = 0.021), had bibliographical references (P = 0.030), and had a recent update within 6 months (r = 0.277, P < 0.001). No correlation between global quality score and other variables was observed. CONCLUSIONS: This study shows that the search for medical information on the Internet is time-consuming and often disappointing. The Internet is a potentially misleading source of information. Surgeons and professional societies must use the Internet as an ally in providing optimal information to patients.

OBJECTIVE: Spastic equinovarus foot is a major cause of disability for neurorehabilitation patients, impairing their daily activities, social participation and general quality of life. Selective tibial nerve neurotomy is a neurosurgical treatment for focal spasticity, whose acceptance as treatment for spastic equinovarus foot remains controversial. We performed a systematic review of the literature to assess the efficacy of tibial nerve neurotomy as a treatment for adult patients presenting with spastic equinovarus foot. METHODS: We queried PubMed, Science Direct, Trip Database and PEDro databases with the following keywords: "equinus deformity" OR "muscle spasticity" AND "neurotomy." RESULTS: We selected a total of 11 non-randomized and uncontrolled studies, suggesting that neurotomy could be an efficient treatment to reduce impairments in spastic equinovarus foot patients. DISCUSSION: Our conclusions are based primarily on case series studies. The effects of tibial nerve neurotomy had not been compared with a reference treatment through a randomized controlled trial, which would be necessary to increase the level of scientific evidence. Moreover, further studies using quantitative, validated and objective assessment tools are required to evaluate the efficacy of tibial nerve neurotomy accurately based on the International Classification of Functioning, Disability and Health from the World Health Organization.

SUMMARY: We assessed feasibility, safety, and timing of an original intraoperative MR procedure in 3 cases of resection of spinal cord glioma by using a clinical 3T MR system connected to an adjacent operating room in a design being coined "twin" or "dual" MR-operating room suite.

OBJECTIVE: A twin neurosurgical magnetic resonance imaging (MRI) suite with 3-T intraoperative MRI (iMRI) was developed to be available to neurosurgeons for iMRI and for independent use by radiologists. METHODS: The suite was designed with one area dedicated to neurosurgery and the other to performing MRI under surgical conditions (sterility and anesthesia). The operating table is motorized, enabling transfer of the patient into the MRI system. These two areas can function independently, allowing the MRI area to be used for nonsurgical cases. We report the findings from the first 21 patients to undergo scheduled neurosurgery with iMRI in this suite (average age, 51 +/- 24 yr; intracranial tumor, 18 patients; epilepsy surgery, 3 patients). RESULTS: Twenty-six iMRI examinations were performed, 3 immediately before surgical incision, 9 during surgery (operative field partially closed), and 14 immediately postsurgery (operative field fully closed but patient still anesthetized and draped). Minor technical dysfunctions prolonged 10 iMRI procedures; however, no serious iMRI-related incidents occurred. Twenty-three iMRI examinations took an average of 78 +/- 20 minutes to perform. In three patients, iMRI led to further tumor resection because removable residual tumor was identified. Complete tumor resection was achieved in 15 of the 18 cases. CONCLUSION: The layout of the new complex allows open access to the 3-T iMRI system except when it is in use under surgical conditions. Three patients benefited from the iMRI examination to achieve total resection. No permanent complications were observed. Therefore, the 3-T iMRI is feasible and appears to be a safe tool for intraoperative surgical planning and assessment.

OBJECTIVE: To assess the long-term efficacy of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients. DESIGN: Intervention study (before-after trial) with an observational design and 2-year follow-up. SETTING: Spasticity group in a university hospital. PARTICIPANTS: Hemiplegic patients (N=30) with spastic equinovarus foot. INTERVENTION: A selective neurotomy was performed at the level of the motor nerve branches of the tibial nerve. MAIN OUTCOME MEASURES: Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion, gait parameters (6 min walking test), and gait kinematics (video assessment) were assessed before and at 2 months, 1 year, and 2 years after selective tibial neurotomy. RESULTS: Compared with preoperative values, there was a statistically significant decrease in triceps surae spasticity, an increase in gait speed, and a reduction in equinus and varus in swing and stance phases at 2 months postoperatively. This improvement persisted at 1 and 2 years after selective tibial neurotomy. Selective tibial neurotomy does not induce permanent triceps muscle weakness or triceps surae-Achilles' tendon complex shortening. CONCLUSION: This study confirms the long-lasting beneficial effect of selective tibial neurotomy on spasticity, gait speed, and equinovarus deformity in the treatment of spastic equinovarus foot in hemiplegic patients.

Objectif - Internet est devenu le premier média par lequel les patients s'informent. Le type et la qualité de l'information médicale disponible en langue française demeurent mal connus notamment dans le domaine de la neuro-oncologie. L'objectif de cette étude est d'évaluer la qualité des sites visités et leur caractère compréhensible. Méthode - Six mots clefs « glioblastome », « méningiome », « métastase cérébrale », « neurinome de l'acoustique », « adénome à prolactine » et « lymphome primitif cérébral » ont été soumis à deux moteurs de recherche. Les cinquante premiers sites Internet correspondant à chaque mot clé ont été évalués avec l'outil DISCERN puis vérifiés par deux neuro-oncologues. Résultats - Sur 612 sites, 110 (18 %) présentent une information exploitable par le patient avec un score moyen de qualité obtenu par l'outil DISCERN de 32 qui est considéré comme « pauvre ». Selon notre classification, 1,8 % des sites sont « Excellent », 11,8 % « Bon », 24,5 % « Assez bon », 15,4 % « Moyen », 32,7 % « Pauvre » et 13,6 % « Très pauvre ». Dans 52 à 55 %, ces sites sont considérés comme compréhensibles par le grand public. L'ordre de classement d'un site dans les moteurs de recherche, son affiliation, sa cible ou son type de financement ne sont pas des gages de qualité. Seul un auteur identifié médecin, l'existence de références bibliographiques et une date récente de mise à jour sont en faveur d'un site de qualité. Discussion et conclusion - Ce travail confirme que la quête d'information médicale sur Internet est longue et généralement décevante. L'information que l'on y trouve est souvent incomplète et peut être sujette à des conflits d'intérêt. La création, dans l'espace francophone, de sites Internet de qualité sur les tumeurs cérébrales répondrait à un besoin croissant des patients. De même, l'existence d'un portail de neuro-oncologie orientant vers des sites compréhensibles et approuvés par une instance professionnelle offrirait aux patients un gain de temp

Spastic equinovarus foot (SEF) is a major cause of disability in stroke patients. Treatments are multimodal and include rehabilitation, orthosis, botulinum toxin injections, alcohol and phenol nerve blocks, functional neurosurgery (neurotomy and intrathecal baclofen) and orthopedic surgery (tendon transfer or lengthening). Precise knowledge of the cause of the equinovarus deformity (muscle spasticity, shortening, and/or weakness) with clinical examination, diagnostic nerve blocks with anesthetics, and gait analysis may help to determine the most appropriate treatment for each patient. This article summarizes current approaches to the assessment and treatment of SEF. In contrast with the number of treatments available, there are a lack of comparative studies to guide therapeutic decisions, which actually depend more on personal experience than on scientific guidelines.

OBJECTIVE: To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot. DESIGN: Before-after trial with a 2-yr follow-up. Three hemiplegic patients with spastic equinovarus foot were treated with a selective peripheral neurotomy of the tibial motor nerve branches (soleus, lateral and medial gastrocnemius and tibialis posterior nerves). Evaluation included clinical assessment of spasticity (Ashworth scale), maximal Hoffmann reflex (H(max))/compound muscle action potential (M(max)) ratio measurement, gait analysis, and muscle stiffness evaluation performed before and 2 mos, 1 yr, and 2 yrs after the neurotomy. RESULTS: Spasticity, muscle stiffness, and H(max)/M(max) ratio decreased after neurotomy. The kinematic (ankle dorsal flexion and knee recurvatum) and kinetic variables (maximum ankle muscle moment and external work) of the gait were permanently improved after neurotomy. Interestingly, kinetic variables seemed to gradually improve with time after the neurotomy. CONCLUSION: Tibial neurotomy is an effective and durable treatment for spastic equinovarus foot.

We describe a young patient with an unusual intramedullary lesion filled with eosinophils. The 21-year-old man developed chronic myelitis without optic neuritis or signs of systemic or infectious disease. A spinal biopsy was conducted because of the progressive extension and pseudo-tumoural aspect of the lesion. Histopathological analysis of the biopsy specimen revealed a severe inflammatory process with macrophages and numerous eosinophils. The eosinophil count in the blood and cerebrospinal fluid (CSF) were normal. Clinical, laboratory and radiological data did not correspond with the usual causes of eosinophilic myelitis. Abnormal mite antigen-specific IgE levels and features similar to Japanese cases of atopic myelitis suggested an allergic origin. Despite normal total IgE levels, this case may be the second case of atopic myelitis reported in a Caucasian patient. Striking differences with the first reported case are the absence of a typical history of atopy and normal total IgE levels. This case highlights that atopic myelitis should be considered in myelopathy occurring in Caucasian patients even in the absence of hyperIgEaemia.

Tumour metastasis to the anterior pituitary-hypothalamic area is rare. We present a patient who had severe headache, bitemporal quadrant hemianopsia and an expanding mass in the sella turcica as revealed by MRI. Partial resection via a transsphenoidal approach was performed and postoperative radiation therapy was initiated. Immunohistochemical investigation identified the tumour as a metastatic small cell carcinoma whose primary site remained undetected for more than 12 months despite repeated oncological evaluations. We reviewed the literature on metastatic disease of the pituitary gland.

OBJECTIVES: To establish the feasibility of the paraseptal approach to the sella and to demonstrate the superiority of the endoscopic over the microscopic vision during pituitary surgery. STUDY DESIGN: Prospective monocentric study. METHODS: Nine consecutive patients with a pituitary tumour were operated since November 2002. The surgical procedure consisted of a paraseptal approach of the sella with use of a rigid endoscope. Pre- and postoperative (3 months after surgery) symptoms, Magnetic Resonance Imaging (MRI) findings, endocrine and ophthalmic assessment, and intraoperative findings were recorded. RESULTS: One patient presented a CSF leak with a successful peroperative repair. Regarding symptom resolution, headache disappeared during the early postoperative period in case of pituitary apoplexy. All cases of preoperative hemianopsia and diplopia but one improved significantly. Two patients recovered preoperative deficient hormonal functions and six patients did not require substitution therapy any more. No nasal packing was needed except in one case. Considering the healing course, the mucosa repair inside the sphenoid sinus was quicker with Surgicel removal at week 4. Postoperative MRI demonstrated a residual parasellar nodule in 3 out of 6 cases of macroadenoma. Only one required radiation therapy. These results are commented through comparison with the transseptal approach and with surgery exclusively using the microscope. CONCLUSIONS: The paraseptal transsphenoidal approach to the sella turcica using the telescope is at least as effective as the conventional transseptal approach using the operating microscope only. It provides a wide access to the pituitary fossa and an optimal vision of the critical areas. The absence of postoperative nasal packing improves significantly the comfort of the patient during the first postoperative hours.

Diagnostic tibial nerve block with anesthetics is a common and safe procedure for the management of the spastic equinovarus foot. Side effects have been rarely reported. We present the case of a hemiplegic patient with a spastic equinovarus foot who presented with an avulsion fracture of the calcaneum at the insertion of the Achilles tendon consecutive to a diagnostic tibial nerve block with anesthetic agents. Although rare, such a complication should be considered when the Achilles tendon is shortened and when the patient is suspected of bone osteoporosis or dystrophy.

Deltombe T, De Wispelaere J-F, Gustin T, Jamart J, Hanson P. Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot. Arch Phys Med Rehabil 2004;85:54-8. Objective: To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot. Design: Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs. Setting: Spasticity group at a university hospital. Participants: Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot. Intervention: Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics. Main Outcome Measures: Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks. Results: The mean coordinates +/- standard deviation for the soleus motor branch were 10 +/- 5mm (vertical), 17 +/- 9mm (horizontal), and 30 +/- 4mm (deep); for the tibialis posterior motor branch they were 45 +/- 6mm (vertical), 17 +/- 8mm (horizontal), and 47 +/- 4mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit. Conclusion: Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.