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Biomedical subjects

J F Hirsch

Publications and source records attributed to J F Hirsch.

At least 19 recordsLinked to original sources
PubMed1992

Surgery of hydrocephalus: past, present and future.

The treatment of hydrocephalus, over the centuries, underwent three stages of evolution. During antiquity, middle ages and Renaissance, hydrocephalus was not understood. Medical treatment was useless; surgery was hopeless. The second stage extends from the XIXth century to the end of the first half of the XXth century. CSF circulation was now understood; surgery however, remained inefficient, but some patients survived with arrested hydrocephalus. The third stage begins in the nineteen fifties with the development of silicone shunts with a valve. Surgery transforms the prognosis of hydrocephalus, but the number of post-operative complications creates new problems. The different attempts that have been made during these past two decades to solve these problems are reviewed. They have resulted in a reduction of the mechanical and infectious complications. CSF overdrainage has been minimized. Percutaneous ventriculo-cisternostomies have in some cases replaced shunts. In the future, to improve outcome in these hydrocephalics, surgery, when indicated, should be performed as early as possible. Knowledge and prevention of the causes of hydrocephalus should be developed.

Cerebrospinal Fluid Pressure↗
PubMed1992

[Percutaneous endoscopic gastrostomy: its value in assisted alimentation in malnutrition in elderly patients. Apropos of 101 consecutive cases in patients over 70 years of age].

This is a prospective study concerning 101 percutaneous endoscopic gastrostomies (PEG) performed in patients aged from 70 to 98 (83.6). We obtained a success in 99%. Indications were stroke and its consequences in 36%, dementia in 22%, depressive syndrome in 38% (7% in the postoperative period) laryngeal or oesophageal tumors in 4%. This technique was carried out in outpatients without anesthesia but PEG must be considered to be a surgical method. Only 5% patients presented major immediate complications with three deaths (3%) due to the technique. Follow-up (30 days) demonstrated 11 other deaths. Would earlier PEG have given better results? Oral feedings (alone or both oral and PEG) were possible in 51% patients. PEG is a valuable technique of feeding assistance in the aged, offering an alternative to nasogastric tube and could be used more extensively in old patients.

Age Factors↗
PubMed1991

Cerebrospinal fluid flow dynamics in children with external ventricular drains.

Fifty-five children had 64 external ventricular drains (EVDs) placed predominantly (95%) for cerebrospinal fluid (CSF) shunt infections. In 9 children, a computer monitoring system measured the CSF output each second continuously for up to 24 hours. The monitoring was repeated daily for up to 9 days. The state of arousal of the patients was recorded simultaneously. In all children, daily EVD outputs were related to age, sex, weight, method of establishing the EVD, height of the drip chamber, time since insertion, and type of infecting organism. Computer monitoring revealed wide fluctuations in flow rate, with peak rates frequently greater than 20 ml/h and periods of flow arrest. These changes were usually associated with increased arousal, but also occurred with sleep. The mean EVD flow rate for all children was 6.3 ml/h. EVD output increased with age and weight. EVD output decreased with Gram-negative or multiple-organism infections and with elevation of the drip chamber. Resolution of the infection, sex of the patient, and method of establishing the EVD had no effect on output. These results predict that CSF production increases with brain growth in humans: that CSF production is depressed by Gram-negative and multiple-organism infections: that implanted CSF shunts with standard valves flow at equivalent rates to an EVD in the supine position; and that the CSF drainage requirements in this group are approximately equal to their EVD outputs.

Adolescent↗
PubMed1991

A new surgical approach to subcortical lesions: balloon inflation and cortical gluing. Technical note.

A cortical incision performed with inflation of a balloon to create a channel has been used in an approach to deep lesions with minimal damage to cerebral tissue. The balloon is slipped over a blunt needle and, once in place, is inflated through the needle. Postoperative sealing of the incision with fibrin glue avoids the subdural collection of cerebrospinal fluid such as is sometimes observed when the ventricle is opened during surgery.

Brain Neoplasms↗
PubMed1991

[Overdrainage in the treatment of hydrocephalus].

In infants or children, hydrocephalus is usually the consequence of an obstacle in the cerebro-spinal fluid (CSF) pathways and is most frequently treated by the insertion of a ventriculo-peritoneal shunt (rarely ventriculo-atrial). The CSF flow through such a shunt is equal to the ratio of the difference (DP) between the CSF input and output pressures over the valve resistance. When the child is in the upright position, a DP increase occurs due to the height of the hydrostatic column between the inlet and the shunt outlet. Thus if the shunt drains correctly in the prone position, it overdrains in the upright position. As the CSF flow through the shunt in standing patients is higher than the CSF secretion, the excess fluid will be taken out of the ventricles, resulting in pericerebral collections, slit ventricles or post-shunt craniostenoses. Many different techniques have been proposed to reduce overdrainage. The Orbis-Sigma shunt was designed in the "Service des Enfants-Malades" precisely for this purpose. In the upright position this shunt becomes a flow regulator and thus reduces overdrainage. Its use has decreased by 2-fold the number of mechanical complications related to overdrainage.

Cerebrospinal Fluid Shunts↗
PubMed1991

[Screening of asymptomatic pulmonary embolisms by systematic scintigraphy in apparently uncomplicated phlebitis].

To evaluate the presence of asymptomatic pulmonary emboli, a prospective study was conducted in 21 patients with radiologically confirmed phlebitis. Systematic screening by means of radioisotope perfusion lung scanning revealed 8 pulmonary emboli (38%), 6 of which were confirmed by pulmonary angiography (28% using this criterion). In 3 of these patients, the cutoff affected more than 60% of the lung. All the patients remained asymptomatic throughout the study. It is our opinion that the presence of a latent pulmonary embolus should modify the therapeutic approach. In addition to screening for asymptomatic pulmonary emboli, systematic radioisotope perfusion scanning will enable the compilation of a reference document useful in the interpretation of clinical events arising during treatment.

Adult↗
PubMed1991

[Epidural chordoma without bone involvement. A propos of a case in a child. Review of the literature].

The authors report the case of a chordoma developed exclusively in the epidural space at the L1-L2 level in a 6 year old child. The tumor was easily removed in toto. No post-operative radiotherapy was given. The diagnosis of chordoma was based on the histological characteristics of the lesion and the results of immunohistological studies which were both typical of this lesion. This observation is exceptional because of the young age of the patient, the lumbar level of the tumor and, even more, the absence of any bone involvement. The 8 previously published cases of chordoma developed along the craniospinal axis but without bone involvement are reviewed and analysed: all were subdural; 7 were intracranial (6 prepontic, 1 suprasellar): only one was intraspinal. These lesions raise the problem of their diagnosis, of their treatment and of their embryogenesis. They could develop from ectopic notochordal remnants: the "ecchondrosis physaliphura".

Child↗
PubMed1990

[Percutaneous endoscopic gastrostomy. 174 cases].

Nutritional assistance was given by percutaneous endoscopic gastrostomy to 174 patients with neurological diseases (80 cases), tumours of the ear, nose and throat (ENT) region (70 cases) or malnutrition (24 elderly people). These patients had either deglutition disorders with inhalation or severe malnutrition, or could not tolerate a nasogastric tube. The endoscopic catheter (Bioser) was installed by the pull technique under general anaesthesia (26 percent), neuroleptanalgesia (16 percent), premedication (14 percent) or without sedation (44 percent). Installation was possible in 98 percent of the cases. Twenty-nine percent of the patients were treated in an outpatient clinic. The problems encountered (21 percent) were mainly due to blockade of the flange and rupture of the thread. Transoperative accidents, such as dyspnoea, bleeding or cardiac arrest, all without sequelae, were noted in 5 percent of the cases. The catheter remained in situ for a mean period of 3.9 +/- 0.3 months (range: 0.1 to 20 months). The following complications were observed: short-term (15 percent), hyperthermia (5), local infection (6), abscess of the abdominal wall (3), meteorism (9), pneumoperitoneum (1), subocclusion (2); long-term (25 percent), inflammatory reactions (13), leakage (19), catheter displacement (8) and catheter rupture (3). Local infections were more frequent in patients with ENT tumours than in the others. Percutaneous endoscopic gastrostomy is a fast and reliable technique preferable to surgical gastrostomy. Complications are frequent (46 percent) but usually minor (42 percent). Contra-indications must be respected, and the catheter must be introduced with the utmost care.

Administration, Cutaneous↗
PubMed1990

Neurosurgery with craniotomy and CT stereotactic guidance in the treatment of intracerebral space-occupying lesions.

When intracerebral space-occupying lesions are small or located deeply within the brain parenchyma, it is sometimes difficult to localize them at surgery or to design the most direct and least hazardous surgical approach. Therefore, we have developed a method that combines conventional neurosurgical techniques with craniotomy using stereotactic guidance. We have used the Brown-Roberts-Wells (BRW) stereotactic system, which allows for computed tomography (CT) or magnetic resonance imaging (MRI) guidance and does not interfere with the absolute sterility mandatory each time a flap is created. Eleven patients were operated on using this method. The deep tumors were approached through a linear incision of the cerebral cortex. Then a needle, fixed in the right position on the arc system of the BRW, was inserted toward the surface of the lesion; the exposure was finally widened by inflation of a rubber balloon set on the stereotactic needle. This technique allows the two lips of the cortical incision to be glued at the end of the operation. Gluing with a fibrin glue avoids the postoperative subdural collections that often develop when the ventricle has been opened. Except for one case, the postoperative course was uncomplicated in these patients. No permanent postoperative neurological worsening was observed even after the removal of an intrathalamic tumor.

Brain Diseases↗
PubMed1990

Medulloblastoma in childhood: progressive intellectual deterioration.

A series of 120 medulloblastomas in children operated on between 1967 and 1987 at the Hôpital des Enfants-Malades has been reviewed in order to check whether the conclusions of our study published 10 years ago have remained valid and, in particular, to verify whether the quality of life of these patients, which had been found to be poor at the time, had improved or worsened over the years. The postoperative mortality for the whole series was 6.5%; there have been no deaths in the 35 patients operated on after 1980. The overall survival rate for the 120 children was 60% at 5 years and 53% at 10 years; for the patients who completed radiotherapy, the survival rate was 73% at 5 years and 64% at 10 years. Survival rates were surprisingly better in patients treated when under 6 years of age than in older children. They were also better in girls than in boys, and in desmoplastic compared with other medulloblastomas; however, the differences were not significant. When comparing the groups after total or subtotal resection of tumors, survival rates were not significantly different, but were lower in the small group of partial resections. Cell differentiation did not influence the prognosis. Psychological sequelae were significant and worsened over the years. Five years after treatment 58% of the children showed an IQ above 80; 5 years later this group included only 15% of the patients. These psychological sequelae were related to age at the time of radiotherapy: the younger the child, the lower the final IQ.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

Presentation and management of suprasellar arachnoid cysts. Review of 20 cases.

The clinical presentation and treatment of suprasellar arachnoid cysts remain controversial. The authors review 20 cases treated at their institution and 86 cases from the literature reported in sufficient detail for analysis. The high frequency of endocrinological disorders, which not only persist following treatment but may also develop years later despite the satisfactory decrease in volume of the cyst, are emphasized and documented. The difficulties of management are discussed, including; subfrontal approaches to these cysts; removal and/or marsupialization of the cysts, procedures that are frequently dangerous and ineffective; and ventricular shunting which often leads to a paradoxical increase in the size of the cysts. The authors emphasize the advantages of percutaneous ventriculocystostomy, which is a simple, benign, and efficacious procedure.

Adolescent↗
PubMed1990

[Treatment of suprasellar arachnoid cysts by percutaneous transfrontal ventriculocystostomy. Apropos of a series of 17 cases].

The treatment of suprasellar cysts is controversial and most often disappointing: on the one hand, subfrontal approaches to the cysts, in view of removal or fenestration, are frequently dangerous and ineffective; on the other hand, ventricular shunting frequently leads to the paradoxical increase in the size of the cyst. Because of these difficulties, the authors have treated 17 consecutive cases by the means of a percutaneous transfrontal ventriculocystostomy. In 11 cases, the cyst was perforated by a leukotome which was guided radiologically in 10 cases and by ultrasounds in 1 case. In the remaining 6 patients, the cystostomy was achieved by a monopolar coagulation under ventriculoscopic control. The results were as follows: in 3 cases, it was not possible to achieve the fenestration of the cyst with the leukotome due to the resistance of the membrane; in 1 case, the ventriculocystostomy was complicated by a poor control of the trocar progression under ultrasounds; the other 14 procedures were successful: signs of increased I.C.P. disappeared; the neurological symptoms regressed; the cysts diminished in size. However, the preoperative endocrine troubles did not decrease. The persistence of a post operative ventriculomegaly apparently did not affect the level of the intellectual development of the patients. The authors emphasize the interest of the percutaneous ventriculocystostomy, this procedure being simple, benign and efficacious. The fenestration of the cyst by coagulation appeared more suitable than by the leukotome.

Adolescent↗
PubMed1989

[Prognosis of antenatal hydrocephalus].

One hundred and eight children born with hydrocephalus were reviewed in order to evaluate their neuropsychological development. Premature children and children with spina bifida were excluded. The most frequent types of hydrocephalus were the communicating type (39 cases) and that where the condition is due to stenosis of the aqueduct of Sylvius (32 cases, not counting 6 cases of Bickers-Adams syndrome and 4 cases of toxoplasmosis); 84 per cent of the children were operated upon before the age of 3 months. The mean follow-up period was 7 years (range: 1 to 14 years). The actuarial survival rate at 10 years was 62 per cent. Among the 75 survivors, 28 per cent had an IQ of at least 80 and 50 per cent and IQ lower than 60; 29 per cent of the 52 children who reached school age had normal education. Forty-six per cent of the children showed little or no disorder of behaviour. The head circumference at birth, the size of the cerebral ventricles and the child's age at the time of surgery had no influence on the neuropsychological development. However, the prognosis seemed to be better in cases without associated malformation or infected valve, in those where the hydrocephalus was due to stenosis of the aqueduct of Sylvius (except when related to sex or toxoplasmosis) and when the first IQ evaluated at the age of about 6 months was higher than 80.

Abnormalities, Multiple↗
PubMed1989

Benign astrocytic and oligodendrocytic tumors of the cerebral hemispheres in children.

The authors review 42 consecutive cases of benign astrocytic and oligodendrocytic tumors of the cerebral hemispheres in children undergoing surgery in the pediatric service of the Hôpital des Enfants Malades between 1975 and 1987. Epilepsy was the presenting sign in 76% of the children and remained the only clinical sign at diagnosis in 62%. Partial or complex partial seizures were observed in half of the cases, but other seizure types were also frequent. Diagnosis of the tumor as the etiological agent rested upon the results of computerized tomography or magnetic resonance imaging. Postoperative mortality (5%) and morbidity (16%) rates were low. The postoperative intelligence quotient was above 80 in 71% of the patients, and 77% of the children had no major problem in school. Although only two of the 42 patients were given postoperative radiotherapy, there were no recurrences in 82% of the survivors. The actuarial probability of nonrecurrence of the tumor was 95% at 5 years. Three patients with recurrent tumor underwent further surgery and are, at the present time, recurrence-free. The incidence of epilepsy fell from 76% before surgery to 19% after removal of the tumor alone; therefore, intraoperative electrocorticography and resection of the electrically abnormal cortex at the time of the first surgical procedure do not appear necessary. It is possible that tumor removal restores a mechanism that limits the spread of seizures and, thus, the clinical manifestations of epilepsy. Benign astrocytic and oligodendrocytic tumors of the cerebral hemispheres in children should not be treated with adjuvant radiotherapy, at least initially.

Adolescent↗