[Plasma exchanges in severe and acute inflammatory demyelinating attacks of the central nervous system]. / Échanges plasmatiques dans les maladies inflammatoires démyélinisantes aiguës sévères du système nerveux central.

BACKGROUND: They are severe inflammatory demyelinating diseases of the central nervous system, often called idiopathic inflammatory demyelinating disease (IIDD). These diseases are explosive or pseudotumoral multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), transverse myelitis and neuromyelitis optica (NMO). The usual therapeutic are intraveinous corticosteroids. Sometimes, these diseases are unresponsive to corticosteroids and it is necessary to use more incisive immunoactive treatment such as the plasma exchanges (PE). METHODS: We retrospectively reviewed the medical records of 35 patients (10 of Dijon and 25 of Lyon) corresponding to the definition of IIDD and having treated by PE after failure of corticosteroids. RESULTS: Seventy-four percent of the patients were women, the median age was 38years. Forty-three percent of the patients had MS, 31.5% NMO, 14% ADEM and 11.5% a transverse myelitis. The response of the PE was favorable in 77% of the cases (moderate or marked improvement, at 1month, 3months and more than 6months). They are well tolerated. CONCLUSIONS: Early initiation of PE seems to be a predictor of a good response.

Transient ischaemic attack mimics revealing focal subarachnoid haemorrhage.

We describe here 7 elderly patients with a transient neurological deficit due to a focal subarachnoid haemorrhage, identified from the Dijon Stroke Registry over 4 years. These 7 patients presented a clinical pattern marked by focal paraesthesia, with several stereotyped focal episodes (5 of the 7 cases), lasting less than 30 min (6 of the 7 cases), and associated with a cognitive decline (4 of the 7 cases). Headache was present in only 1 case. Neuroimaging revealed focal haemorrhage present in a cortical sulcus contralateral to the symptoms. No vascular lesions nor epileptic mechanisms nor ischemic lesions were observed. This syndrome could be explained by a spreading depression, and the focal subarachnoid haemorrhage could reflect possible cerebral amyloid angiopathy, suggested by the cognitive decline present in more than 50% of our series. Our observations suggest that focal subarachnoid haemorrhage may be diagnosed by MRI in the absence of acute headache and it may be revealed by transient focal and repetitive sensory perturbations. In medical practice, it is important to evoke this diagnosis in the elderly to avoid inappropriate treatment.

[Pregnancy and multiple sclerosis]. / Grossesse et sclérose en plaques.

Because multiple sclerosis is a disease that affects young women, the question of pregnancy frequently arises early in the management of the disease. Although the relapse rate decreases during the nine months of pregnancy, it rises significantly during the first trimester post-partum, affecting one third of patients. Pregnancy has no influence on disability progression. Patients have no particular difficulties during pregnancy, labor or delivery. No significant fetal risk has been reported. Neither breast-feeding nor epidural analgesia is deleterious. Disease-modifying treatment must be stopped before conception.

[Botulism has not disappeared]. / Le botulisme est toujours d'actualité

INTRODUCTION: Botulism is a potentially fatal infectious disease induced by a neurotoxin secreted by Clostridium botulinum, a sporulated species of obligate anaerobic bacteria. This neurotoxin inhibits the normal release of acetylcholine in the synaptic cleft, inducing presynaptic neuromuscular blockade. The diagnosis is often difficult because of the range and the lack of specificity of the symptoms. CASE: We report two cases of human botulism. The first case was easy to diagnose, with dysphagia, dysphonia, blurred vision, and xerostomia, associated with potentiation on electromyogram and B botulinum toxin in the serum. Symptoms in the second case included diplopia, blurred vision, dysphagia, dysphonia, with potentiation on electromyogram but no botulinum toxin. DISCUSSION: These two cases remind us of the necessity to keep botulism in mind when systemic atropinic symptoms are found together with generalized, progressive and extensive paralysis. The diagnosis is confirmed by electromyogram and serology. There is no specific treatment for botulism; only intensive care surveillance and symptomatic treatment improve survival.

Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial).

BACKGROUND AND PURPOSE: There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. METHODS: We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score < or =3) at 6 months' follow-up (primary outcome) between the 2 treatment groups. RESULTS: After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score < or =3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (P=0.18 and P=0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (P<0.0001). CONCLUSIONS: In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Trends in the incidence of transient ischemic attacks, premorbid risk factors and the use of preventive treatments in the population of Dijon, France from 1985 to 2004.

BACKGROUND: We describe the epidemiological trends of transient ischemic attack (TIA) in a 20-year population-based pilot study. METHODS: Trends in the incidence, risk factors and pre-TIA use of preventive treatments for TIA were observed from 1985 to 2004 according to the classic definition in the population of the city of Dijon, France (150,000 inhabitants). RESULTS: The raw and standardized incidence of TIA were stable over time. We observed a significant increase in the mean age at TIA onset in women only. The prevalence of hypercholesterolemia and diastolic blood pressure > or =90 mm Hg among patients with TIA increased significantly. This contrasts with falls in smoking and in history of previous myocardial infarction. CONCLUSION: The stability of classic TIA incidence, despite the rise in the proportion of elderly people, and the increase in the mean age at onset in women may be considered as a medical progress.

Stable stroke incidence rates but improved case-fatality in Dijon, France, from 1985 to 2004.

BACKGROUND AND PURPOSE: With the progress in stroke prevention, it is important to evaluate the epidemiological trends of strokes over a long period and from a nonselected population-based perspective. METHODS: We estimated changes in incidence, case-fatality rates, severity, risk factors and prestroke use of preventive treatments for first-ever strokes, from a continuous 20-year well-defined population-based registry, from 1985 to 2004. RESULTS: We recorded 3142 ischemic strokes, 341 primary cerebral hemorrhages and 74 subarachnoid hemorrhages. During the 20-year study, the age at first stroke onset increased by 5 years in men and 8 years in women. Comparing the 1985 to 1989 and the 2000 to 2004 periods, age- and sex-standardized incidences of first-ever strokes were stable except for lacunar strokes whose incidence significantly increased (P=0.01) and for cardioembolic stroke whose incidence significantly decreased (P=0.01). Twenty-eight-day case-fatality rates decreased significantly mainly for lacunar strokes (P=0.05) and for primary cerebral hemorrhages (P=0.03). The proportion of hypercholesterolemia and diabetes significantly increased (P<0.01). In contrast, the proportion of myocardial infarction significantly decreased (P=0.02). Prestroke antiplatelets and anticoagulants treatment significantly increased (P<0.01). CONCLUSIONS: The age- and sex-standardized incidences of first strokes in Dijon have been stable over the past 20 years and were associated with an increase in age at stroke onset, a decrease in case-fatality rates, and an increased use of antiplatelet treatments.

[Specificity of stroke in the elderly: clinical characteristics and impact on care]. / Particularités de l'accident vasculaire cérébral du sujet âgé et impact sur la prise en charge.

Stroke in the elderly differs from stroke in younger adults in several points. It represents the most frequent consequence of atherothrombotic disease associated with hypertension, diabetes and hypercholesterolemia. It is also the main complication of cardiac arrhythmia. From a clinical point of view, epileptic seizure is frequently observed at the onset, and prognosis is darkened by a high risk of dementia occurrence (20%). Management of stroke in acute phase requires intensive care, which has been shown to decrease mortality and handicap by 20% in Stroke Units. Fibrinolysis with rt-PA can be carried out till 80 years. Primary and secondary prevention are still very efficacious in old patients and decrease not only the risk of stroke, but also the risk of dementia. Moreover, influenzae vaccination has been shown to decrease the risk of stroke in the following year in subjects over 65 years.

Trends in utilization of antithrombotic therapy in patients with atrial fibrillation before stroke onset in a community-based study, from 1985 through 1997. From scientific evidence to practice.

BACKGROUND: Despite the significant beneficial effects of antithrombotic therapy in primary prevention of stroke in patients with chronic nonvalvular atrial arrhythmia, this prevention therapy is underutilized. We conducted this population-based study to determine the rates and the trends of utilization of antithrombotic therapy for stroke patients with atrial fibrillation before stroke onset, and to evaluate indirectly the impact of medical recommendations on physician practice. Our aim was not to evaluate the efficacy of such prevention therapy. METHODS: From 2,330 men and women of any age registered for a first-ever stroke from 1985 to 1997 in a community-based study, we selected 599 patients admitted for ischemic stroke or TIA, associated with prior atrial fibrillation. Previous antithrombotic treatment before stroke onset was recorded and we evaluated the ratio of stroke patients who had received antithrombotic treatment for atrial fibrillation, from 1985 through 1997. RESULTS: Our study was performed to evaluate the practice of physicians in the prevention of stroke, and not to evaluate the efficacy of the anticoagulants in the prevention of stroke. Atrial fibrillation before stroke onset was identified in 599 patients. Of these, 222 (37%) received no antithrombotic therapy, 65 (10.8%) received an anticoagulant alone, 147 (24.5%) received an antiplatelet agent alone and 10 (1.7%) received both anticoagulation and antiplatelet treatment. From 1985 to 1988, the proportion of treated atrial fibrillation before stroke was small (14.6%). This increased to 21.5% within the period 1989-1991, to 40.3% within the period 1992-1994 and then to 47.6% within the period 1995-1997. It appears that the most significant change occurred within the period 1992-1994 (14.6% of treated atrial fibrillation within the period 1985-1987 constituted to 40.3% within the period 1992-1994) (P < 0.05), with a current rate of utilization of antithrombotic therapy close to 50%. The logistic regression analysis concerning anticoagulant therapy before stroke onset as a dependent variable, found that the factors independently associated with the use of anticoagulants before stroke were the lack of arterial hypertension and a history of smoking. The factors independently associated with the use of aspirin before stroke were arterial hypertension and lower limb peripheral vascular disease. CONCLUSION: For primary prevention of stroke onset in patients with atrial fibrillation, therapeutic trials have changed medical practices although not to ideal levels because close to 50% of patients with atrial fibrillation experiencing an acute stroke or TIA received antithrombotic treatment. Therefore, clinical practice is inconsistent with the guidelines resulting from therapeutic trials. It is necessary to know the reasons for this inconsistency and to improve medical information about the cerebrovascular risk of atrial fibrillation and the efficacy of anticoagulants in stroke prevention in this condition.

[Indications for anticoagulant use in secondary prevention of strokes]. / Indications des anticoagulants en prévention secondaire des accidents vasculaires cérébraux.

THE CONTEXT: The demonstration of the efficacy of oral anticoagulants in the secondary prevention of ischemic stroke represents a major progress in medicine in the last twenty years. Efficacy in fact depends on the causes and this determines the indications. ADMITTED AND DEMONSTRATED INDICATIONS: Cardiac arrhythmia due to atrial fibrillation and the existence of mechanical prosthetic valves are the only two indications that have been demonstrated with sufficient proof. ADMITTED NON-DEMONSTRATED INDICATIONS: These are basically the dissection of cervical arteries, aortal cross atheroma, vascular cerebral accidents within the context of antiphospholipid antibody syndromes. POSSIBLE INDICATIONS: There are three: stenosis of the intra-cranial arteries, patent foramen ovale with atrial septum aneurysm and the basilar dolichoectasia trunks. NON-DEMONSTRATED SUPERIORITY: In atherosclerosis-induced cerebral ischemic accidents.

Association between diabetes and stroke subtype on survival and functional outcome 3 months after stroke: data from the European BIOMED Stroke Project.

BACKGROUND AND PURPOSE: Although diabetes is a strong risk factor for stroke, it is still unclear whether stroke subtype, severity, and prognosis are different in diabetic and nondiabetic patients. We sought to evaluate stroke features, prognosis, and functional outcome in patients with diabetes compared with patients without diabetes. METHODS: In a European Union Concerted Action involving 7 countries and 4537 patients hospitalized for a first-in-a-lifetime stroke, defined according to the Oxfordshire Community Stroke Project criteria, we collected data on demographics, risk factors, clinical presentation, and outcome. We used logistic regression to examine the relationship between diabetes and outcome at 3 months (disability, handicap, and death), controlling for risk factors, clinical presentation, and demographics. RESULTS: Overall, diabetes was present in 937 patients (21%). Diabetic patients, compared with those without diabetes, were more likely to have limb weakness (P<0.02), dysarthria (P<0.001), ischemic stroke (P<0.001), and lacunar cerebral infarction (P=0.03). At 3 months, the case fatality rates were not higher in the diabetic groups (P=0.33). Handicap (Rankin Scale) and disability (Barthel Index) were significantly higher in diabetic patients (P=0.005 and P=0.016, respectively). CONCLUSIONS: Stroke in diabetic patients has a specific clinical pattern and a poor prognosis in terms of motor function, which emphasizes the need for early diagnosis and treatment of every case of diabetes.

5-Hydroxyindolacetic acid and homovanillic acid are not involved in the cerebrospinal fluid after a seizure in patients with Delirium Tremens.

Little is known about 5-hydroxyindolacetic acid (5-HIAA) and homovanillic acid (HVA) levels in cerebrospinal fluid of patients with Delirium Tremens revealed at onset by seizures. The aim of the study is to understand the biochemical abnormalities induced by seizures in the cerebrospinal fluid of patients involved by Delirium Tremens. Nine patients 42-62 years of age, who had experienced a Delirium Tremens after alcohol withdrawal, with one or two seizures at onset, were included in this study. The lumbar puncture (and a CT scan) were performed after the last seizure. Nine patients with neither Delirium Tremens nor seizure, needing a lumbar puncture for their medical problem, were matched by sex and by age. For the measures of 5-HIAA and HVA, we systematically took the first cm3. The mean value of 5-HIAA levels were 12.70 ng ml(-1) in the group of nine patients with Delirium Tremens versus 13.45 ng ml(-1) in the control group. The mean value of HVA levels were 19.81 ng ml(-1) in the group of nine patients with Delirium Tremens versus 25.25 ng ml(-1) in the control group. The differences were not statistically significant. During a Delirium Tremens with seizure at onset, there are no statistically significant changes in 5-HIAA and HVA levels in the cerebrospinal fluid. Our work raises the question of the role of Delirium Tremens in the normalization of the levels of neuro-mediators that usually decrease soon after seizures.