Neurosurgical manpower in France.
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Cross-Cultural Comparison↗
Biomedical subjects
F Cohadon
Publications and source records attributed to F Cohadon.
EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium.
Guidelines for the management of severe head injury in adults as evolved by the European Brain Injury Consortium are presented and discussed. The importance of preventing and treating secondary insults is emphasized and the principles on which treatment is based are reviewed. Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted. The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.
Adult↗
Guidelines for treatment of head injury in adults. Opinions of a group of neurosurgeons.
There are a number of parallel activities world wide to devise guidelines for the treatment of head injuries. A Group of neurosurgeons from various European countries worked on guidelines during three informal meetings, which may serve as a base for discussion of national or local protocols. Three levels of certainty were distinguished: Measures that must be taken which such a high degree of certainty, that they have not seriously been challenged-principles. Measures, that should be taken, as there is reasonable evidence in the literature about its efficacy-recommendations and measures that may be taken, but proof of its efficacy is lacking-optional measures. Protocols based on these guidelines are felt to help young neurosurgeons in training, define neurosurgical needs for other specialities and enhance the general efficacy of care for the head injured patient including multiple injuries.
Adult↗
Pathological laughing as a symptom of a tentorial edge tumour.
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Adult↗
Primary Langerhans' cell histiocytosis of the central nervous system with fatal outcome. Case report.
An unusual case of primary parenchymal Langerhans' cell histiocytosis of the central nervous system is reported. The definitive diagnosis was obtained by ultrastructural detection of Birbeck granules and by immunohistochemical evidence of CD1a expression. Despite complete surgical resection, there was an early recurrence with multiple central nervous system metastases leading to a fatal outcome.
Adult↗
Low-grade astrocytomas: prognosis factors and elements of management.
BACKGROUND: The literature provides information concerning prognosis of low-grade astrocytomas, but the series are quite heterogeneous in terms of clinical material, neuropathological evaluation, and statistical methods of analysis. Therapeutical indications are poorly defined. The last World Health Organization (WHO) histological classification provided a very precise definition of low-grade gliomas. METHODS: Taking into account a recent study of our own and literature data, management guidelines of these tumors were proposed. RESULTS: Grade I (pilocytic and subependymal giant cell astrocytomas) are surgically curable lesions. No adjuvant treatment is mandatory. Management of grade II astrocytomas is less clear-cut. Conservative management is probably possible in young patients without functional threat. The role of surgery on duration of survival has been properly established in very few series and was negative in many others. The role of radiotherapy has been demonstrated in a few subgroups of patients. In our study of ordinary astrocytomas, considering decades of age at diagnosis, survival curve analysis established three prognostic classes of age (before 50, between 50 and 60, and after 60 years of age). Based on our results and on recently published data, a branch decisional approach was proposed for management of grade II astrocytomas. Other grade II gliomas exhibit more favorable prognoses but could be managed in the same manner. CONCLUSIONS: Ordinary grade II astrocytomas constitute a paradigm of difficult differential management. Further pertinent information on these tumors could come from the field of tumor biology, or be provided by very large and homogeneous groups of patients.
Astrocytoma↗
Isolations of intestinal spirochaetes from the blood of human patients.
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Aged↗
Lymphoplasmacyte-rich meningioma in a child. Case report.
A rare case of lymphoplasmacyte-rich meningioma observed in a young girl is reported. The first clinical manifestations of the disease were seizures. Neuroradiological images favored the existence of a meningioma. Abnormalities in the patient's blood chemistry, principally including hypergammaglobulinemia and inflammatory syndrome, were associated with the disease. The tumor was histologically confirmed as meningioma with massive infiltrates of type B lymphocytes. The pathophysiology of the conspicuous lymphoplasmacyte infiltrates, responsible for peripheral blood abnormalities, has remained poorly understood. Alternative diagnostic hypotheses of masses that mimic this type of meningioma are discussed.
Brain Neoplasms↗
[Supra-tentorial low-grade astrocytomas in adults. Prognostic factors and therapeutic indications. Apropos of a series of 141 patients].
An abundant literature provides informations upon the prognosis of supratentorial low grade (grade II) astrocytomas, but the series are quite heterogeneous in terms of clinical material, neuropathological evaluation and statistical methods of analysis. So, outcome, prognostic factors and therapeutical indications are poorly defined. A retrospective study of 141 adults patients suffering ordinary low grade astrocytoma diagnosed in our unit between 1978 and 1988 was conducted. A follow up of 5 years or more, since neuropathological diagnosis, was mandatory for inclusion. Endpoint of statistical analysis was duration of survival. Results were expressed after uni and multivariates analysis. Clinical and morphological features of our series were comparable to those previously reported in the literature. Median survival time was 52 months. Considering age at diagnosis, survival curve analysis showed highly significant differences (p < 0.0001) and established three prognostic classes of age (before 50, between 50 and 60, and after 60 years of age). Comparisons of survival curves showed significant statistical differences (p < 0.0001) according to pretreatment functional status. Analysis of a clinical condition using a functional scale is more powerful, from a statistical point of view, than an individual analysis of each constituting parameters. In this series a good correlation was found between functional status and age at diagnosis. Neurological deficit was more correlated to age than to tumor location. Multivariate analysis, using the Cox model, defined some parameters acting independently on duration of survival: fronto-parietal location (p < 0.0001), pretherapeutical functional status (p < 0.001), age at diagnosis (p = 0.001), deepseated or multicentric tumor, mass effect (p < 0.01), frontal location (p < 0.02), total surgical removal (p < 0.05). Non significant parameters were: radiotherapy, time before diagnosis, age of onset, sex, contrast enhancement on CT scan. Our results are in agreement with previously reported data confirmed literature data concerning prognostic factors characteristics of the host (age), characteristics of the tumor (location) and expressing the influence of the tumor on the host (functional status). Our series documented prognostic clinical forms of these tumors (function of age, of performance status, and of tumor location). Our results confirm the relative inefficacy of therapeutic weapons, considering the population as a whole, on duration of survival. Based on our results and on recently published data, a decision tree analysis was proposed for management of grade II astrocytomas.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Brain protection.
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Acid-Base Equilibrium↗
Images and icons.
Modern images have became essential to our daily work because they provide high quality representations which, with admittedly some difficulties and pitfalls, allow detection and diagnosis of lesions and moreover inspire and guide every step of surgery. This place and value of the image as the main source of technical information required for the patient's management is straightforward and raises no major epistemological problem. However our use of images easily escapes critical thinking. Images may impose their own power and rationality. Medical images are powerful for the patient and for the doctor because they contain an unlimited source of explanation for the disease, they make disease and functional complaints, comprehensible. They are important for the surgeons because they offer an unique and irreplaceable guide to the lesions, they make it visible, they give shape and in fact reality to what in the patient, belongs to surgery. This power of medical images is irrefutable because, rather than mere representations, they are analogical reflexions of the real body with its real lesions, there is an ontological continuity between image and reality. For these and some other reasons we are tempted to give to images a consideration which should be due only to the patient himself. This temptation is idolatrous in nature. Under a number of different aspects this temptation pervades the entire field of medicine and might ultimately narrow our vision of patients, our vision of man.
Brain Diseases↗
[Training of surgeons for laboratory research].
A degree in surgical research has been set up in 1986 in France. It includes a one-year full time work in a research laboratory, and seminars (one to three days long, each). General surgical research objectives are gathered in a first seminar. Then, candidates select one among four optional subjects: biomaterials-artificial organs, transplantation, oncology, and neurosciences. Two prerequisites are necessary in order to register. The first is to write a research project according to standardized rules, and the second is to attend two seminars, one dealing with scientific communication and the other with methodology in clinical research. A nation-wide valid Academic degree is delivered to candidates who pass an oral presentation of their research report and who attended all seminars according to the optional subject that they selected. From 1986 to 1993, 434 students attended the formation. They came from different regions of France, proving the nation-wide characteristic of the degree, and some from foreign countries. Seminars were held in different French University towns. An increasing number of students become Ph.D.
Education, Medical, Graduate↗
[Stereotaxic biopsies of pineal tumors. Comments on their risk and implication apropos of 370 cases].
370 stereotactic biopsies of pineal region tumors, from 15 neurosurgical centers in France have been reviewed with the goal to evaluate the mortality/morbidity rates and diagnostic yield of this procedure. The impact of neuroradiological means of localisation, the probe trajectory, the type of biopsy instrument, the time of shunting are discussed in order to maximize the diagnostic yield and minimize the mortality/morbidity rates. Stereotactic biopsy contribution, as compared to other diagnostic methods, in pineal region tumors was evaluated. The mortality rate was 1.3 % (5 patients of 370), 3 patients suffered severe neurological complication. In relation to the large number of patients in this study, we can assess that the mortality rate of stereotactic biopsy in this region doesn't significantly exceed that of stereotactic brain tumor biopsies in general.
Adolescent↗
[Post-traumatic vegetative states].
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Brain Injuries↗
[Deep cerebral stimulation in patients with post-traumatic vegetative state. 25 cases].
In 25 cases of post traumatic vegetative state persisting 3 months after the initial injury, deep brain stimulation (DBS) has been used with the aim to activate the cortex and the hope to produce some degree of functional recovery. Electrodes were stereotaxically implanted in the centrum medianum-parafascicularis complex. Bipolar stimulation was provided daily from 8 a.m. to 8 p.m. In 12 cases no changes occurred in the clinical features and overall behaviour. DBS was given up after 2 months. All these patients with a follow-up of 1 to 10 years, remained in a permanent vegetative state, 4 of them eventually deceased. In 13 cases, following 1 to 3 weeks of DBS a definite improvement was obtained with recovery of some degree of consciousness and interpersonal relationship. However all these patients, with 1 to 12 years follow-up remained severely disabled. 2 of them deceased from intercurrent causes. The practical meaning of these clinical results are questioned. We consider that the absence of response to DBS is an important argument to predict the irreversibility of post traumatic vegetative state. It is not certain that DBS is directly responsible for positive changes observed, some degree of long-term spontaneous recovery being already documented in such patients. However it seems likely that DBS accelerates recovery and possibly improves the final level of performances.
Brain Injuries↗
[Electrophysiological development under thalamic stimulation of post-traumatic persistent vegetative states. Apropos of 25 cases].
We have studied the electrophysiological evolution, with the aid of long-term, quantitative E.E.G. (Holter method) and sensory evoked potentials (visual, auditory and somatosensory) on 25 severe traumatic head injury patients (initial Glasgow scale--between 3 and 5) aged from 5 to 42 years having evolved towards a persistent vegetative state and being object of a protocol of thalamic stimulation. Electrophysiological exploration was practised before placement of the stimulation, then at 2 weeks, 1 month, 2 months and finally 3 months after. The electrophysiological parameters appear to have no predictive value on the clinical evolution after stimulation. However, changes such as long-term quantitative EEG as well as evoked potentials mostly precede clinical progress when present. Cortical evoked potentials are the first to change significantly (J15) followed by long-term quantitative EEG and brain stem evoked potentials (J30); the latter improving more completely. Also the consideration of the chronobiological aspects of the recordings of the long term EEG allow the proposal of "waking targeted" stimulations at the most favorable moments of the nyctohemeral period.
Adolescent↗
A longitudinal assessment of seizure outcome and overall benefit from 100 cortectomies for epilepsy.
Results of 100 cortical resections for 76 temporal, 23 frontal and one parietal lobe epilepsies were studied in terms of seizure relief and overall benefit. A non-homogenous Markov chain model was used to take into account both the intravariability of post-surgical outcome and the differences in duration of follow-up in a group of patients consecutively operated. The seizure free (SF) state was defined as no seizure in the previous five months at first follow up visit and none in the preceding 12 months at subsequent annual visits. For the whole of the population the SF probability was 82%, 66%, 61%, and 62% at six months, one year, two and five years respectively. A better outcome was found for temporal lobe epilepsy (SF probability: 68% at the fifth postoperative year) than for frontal lobe epilepsy (SF probability: 42% at the fifth postoperative year) with a statistically significant difference. Pre- and postoperative interictal signs and symptoms were classified according to their clinical significance: (a) mild handicap--symptoms recognisable but no interference with usual life, and (b) moderate or severe handicap--interference with some or all daily activities. The interictal state was considered more impaired after surgery than before in two situations: (a) either symptoms, absent before surgery, appeared in the postoperative period involving a moderate or severe handicap, or (b) symptoms present before surgery and answerable for a mild or moderate handicap that increased to involve a moderate or severe handicap respectively in the postoperative period. Surgery was considered a major benefit when two conditions were fulfilled-namely, a SF state and no deterioration of the interictal stage when compared with the preoperative period. The probability of obtaining such a benefit was 58%, 51%, 48% and 56% at six months, one year, two and five years respectively. The results suggest that surgery is an effective treatment for more than 50% of long lasting medically intractable epilepsies.
Adolescent↗