No abstract

Of the cerebral vascular lesions that can be treated with intravascular detachable balloon techniques, carotid-cavernous sinus fistulas and vertebro-vertebral fistulas have the best results. The great advantage of this technique is that the cerebral blood flow can usually be preserved after the occlusion of the fistula. The authors report 17 postraumatic carotid-cavernous sinus fistulas successfully treated with preservation of the carotid blood flow in 12 cases. None of the patients died, and the morbidity was limited to one case of third nerve palsy. The treatment of aneurysms by this method is, however, much more difficult and dangerous. Of 14 cases treated, seven good results were obtained. Two patients died and two had a poor outcome. The embolization of certain brain angiomas with calibrated-leak balloons using bucrylate promises to be important in the future.

The decision to operate on a patient older than 70 years for an intracranial meningioma is always difficult. Therefore a series of meningiomas treated surgically in 30 cases older than 70 years has been reconsidered and studied according to the following parameters: Karnofsky's rating scale, physiological status of the patient (A.S.A. criteria), perifocal oedema and mass effect. The locations of the meningiomas were: convexity 13, parasagittal 6, falx 2, pterion (sphenoid ridge) 5, orbito-cranial 3, jugum sphenoidale 1, tentorium (occipital) 1. Postoperative survival at day 30 shows a mortality rate of 23% which increases to 37% at day 90 including causes like decubitus ulcers and 3 cases of fatal pulmonary embolism. In a comparable series of 31 cases from 60 to 70 years, mortality rate was only 16% at day 90. Two parameters seem essential for quantifying surgical risk: clinical status, oedema and mass effect, evaluated by CT scan. The best conditions seem combined when Karnofsky rating scale is higher than or equal to 50 with no or only limited perifocal hypodensity and without mass effect. Although meningiomas may remain dormant for many years or can be kept under control medically for some time, their development is unpredictable. We think therefore that a reasonable surgical risk can be taken on patients with good physical status and favourable parameters at the time of diagnosis, particularly if the meningioma is located at the convexity where the risk of recurrence is minimal. On the other hand, patients with unfavourable parameters are not recommended for surgery.

No abstract

NPH can be reversible after cerebrospinal fluid (CSF) diversion. In the past no reliable criteria could be defined to predict the successful outcome of CSF shunting. Several authors demonstrated an increased cerebral blood flow after lumbar puncture in patients with NPH, indicating an underlying impairment of cerebral circulation autoregulation. 123I-AMP brain tomoscintigraphy was applied to 23 individuals with NPH before and after CSF drainage. Of these 23 patients, 10 underwent surgical shunting. The frontal and parietal hypoactive cortical pattern was present in NPH but not pathognomonic. Under stimulation of CSF pressure lowering, seven patients with improved outcome after shunting demonstrated an increase of cerebral perfusion in these areas, whereas a decrease of activity was found in three patients whose clinical status was unchanged after CSF diversion. This tomoscintigraphic test may be an interesting additional criterion for surgical admission.