[Cervicogenic headaches]. / Les céphalées cervicogéniques.

Cervicogenic headaches are a relatively new nosological entity. The diagnostic criteria are still under discussion. They are rare: the diagnostic is based on anamnestic and clinical considerations. Rx investigation is mandatory. The aetiology is multifactorial. In case of cervical trauma, the relationship with the primary peripheral lesion must be carefully discussed. The actual opinion from the neurophysiological point of view is based on the hypothesis of "central hypersensitivity". This progressive dysfunction is probably modulated by genetic characteristics: the mechanism is triggered by the initial peripheral nociceptive input. In chronic situations, psychosocial factors are important. The treatment must be considered individually. It is based on a pharmacological approach and, in selected cases, includes anaesthetic block.

Heralding manifestations of basilar artery occlusion with lethal or severe stroke.

BACKGROUND: Basilar artery occlusion usually causes severe disability or death. Until the recent developments in local intra-arterial or systemic intravenous fibrinolysis, interest in early diagnosis was low because there was no satisfactory treatment. Thus there is little information about the initial phase of the disease. OBJECTIVE: To report on the early clinical features and patterns of evolution of severe symptomatic basilar artery occlusion. METHODS: 24 patients with established basilar artery occlusion (confirmed by angiography or at necropsy) were reviewed retrospectively, focusing on the early clinical aspects and time course of the disease. RESULTS: The most common initial symptoms were motor deficits (16/24, including facial palsies), articulatory speech difficulties (15/24), vertigo, nausea or vomiting (13/24), and headaches (10/24). The most frequent objective initial findings were motor deficits (22/24), facial palsies (19/24), eye movement abnormalities (15/24), lower cranial nerve deficits (15/24), altered level of consciousness (12/24), and bilateral extensor plantar responses (9/24). Onset of the disease was gradual in nearly all patients and in half the warning signs were present for up to two months before the final stage. Headaches and visual disturbances were early signs, while speech difficulties and motor deficits were late signs. Once permanent neurological deficits were present, the final illness was reached within six hours in 41%, between six and 24 hours in 32%, and in two to three days in 27%. CONCLUSIONS: All the patients reviewed presented some symptoms and signs pointing to brain stem involvement. Only 8% (2/24) had an acute course with no adequate warning signs.

Effects of proximal and distal muscles' groups contraction and mental stress on the amplitude and frequency of physiological finger tremor. An accelerometric study.

Physiological finger tremor was assessed by two-dimensional solid accelerometry in 40 healthy normal subjects at rest (R) with the hand hanging over the armrest of a chair, in posture (P) with the arm rested on the armrest but the hand extended from the wrist, and finally adding proximal muscles contraction in extension (E) with the arm extended in front of the patient, each time with and without mental stress. The mean amplitude for physiological tremor, about 30 microns, was almost doubled by hand extension and increased by 4 to 5-fold by arm extension with further increase by mental stress in each position, which gives a good estimation of the contribution of proximal and distal muscles into the amplitude of physiological tremor. There was no significant effect of age between 20 and 60 years on tremor amplitude, but mean tremor frequency decreased significantly between 40 to 60 years. Mental stress increased amplitude but decreased tremor frequency of both across all position, possibly by increasing the synchronization of motor unit firing and by modifying the gain of the motoneurones and the stretch reflex as shown by electrophysiological studies.

[Recurrent subacute encephalopathy in the framework of idiopathic hypereosinophilic syndrome]. / Subakute rekurrierende Enzephalopathie im Rahmen eines idiopathischen hypereosinophilen Syndroms.

HISTORY: An 81-year-old man, previously good health, suddenly developed confusion and rapidly progressive severe tetraparesis. INVESTIGATIONS: Peripheral blood and bone marrow revealed marked eosinophilia: allergic, parasitic, neoplastic or vasculitic causes were excluded. Magnetic resonance imaging demonstrated multiple lesions in the cortical and subcortical white matter. DIAGNOSIS, TREATMENT AND COURSE: The findings indicated idiopathic hypereosinophilic syndrome involving the central nervous system and treatment with high doses of glucocorticoids was started. After a stormy course almost complete recovery occurred. CONCLUSION: Idiopathic hypereosinophilic syndrome can rarely manifest itself a an isolated severe subacute encephalopathy.

Autologous fat injection for soft tissue augmentation in the face: a safe procedure?

Autologous fat injection for soft tissue augmentation in the face is claimed to be a safe procedure. However, there are several case reports in the literature where patients have suffered from acute visual loss and cerebral infarction following fat injections into the face. Acute visual loss after injection of various substances into the face is a well-known complication of such interventions. We report two further patients who suffered from ocular and cerebral embolism after fat injections into the face. For the intravasation of fat particles there are three preconditions: well-vascularized tissue, fragmentation of parenchyma, and, especially, a local increase in pressure in the affected tissue. Fat injections into the face lead to an acute local increase in pressure in highly vascularized tissue. We assume that fragments of fatty tissue reach ocular and cerebral arteries by reversed flow through branches of the carotid arteries after they are introduced into facial vessels. The manifestation of fat embolism appears either immediately after the fat injection or after a latency period. Fat embolism can remain subclinical and may not be recognized, or the clinical features may be misinterpreted. To minimize the risk of such a major complication, fat injections should be performed slowly, with the lowest possible force. One should avoid fat injections into pretraumatized soft tissue, for example, after rhytidectomy, because the risk of intravasation of fat particles may be higher. Metabolic disturbances such as hyperlipidemia may also contribute to the clinical manifestation of fat embolism Routine funduscopic examinations after fat injections into the face could help to provide data for future estimation of the patient's general risk.

Persistent recurrence of hypomania and prosopoaffective agnosia in a patient with right thalamic infarct.

The authors report a 63-year-old man with a history of brief isolated manic episodes who became persistently hypomanic after a small right thalamic infarct. Detailed behavioral and neuropsychologic assessment were performed 18 months after the stroke and revealed a prosopoaffective agnosia as the foremost cognitive disorder, i.e., an impairment in the identification of emotional facial expressions with preserved discrimination of facial identity. Difficulties in reasoning on humorous material and other signs of mild right hemisphere dysfunction were present, but other perceptual, frontal and abstract-reasoning cognitive functions were unimpaired. Prosopoaffective agnosia has not been reported previously in thalamic lesions or in primary or secondary mania. The authors discuss the hypothetical relationships between a right hemisphere deficit in processing emotions and relapsing of the patient's hypomanic behavior.

The alpha2-adrenoceptor agonists xylazine and guanfacine exert different central nervous system, but comparable peripheral effects in calves.

Acute pharmacodynamic effects of the alpha2-adrenoceptor agonists, xylazine and guanfacine, were investigated in nine healthy calves in an open crossover trial. Xylazine (100 microg/kg body weight intravenously (i.v.)) and guanfacine (20 microg/ kg body weight i.v.) were equi-effective in lowering heart rate by 25-30%, at 5 min. Under these conditions, xylazine induced strong sedation and increased plasma growth hormone levels, indicating central nervous system mediated actions, whereas guanfacine was not sedative and did not induce release of growth hormone. Oxygen consumption was decreased by both drugs, but respiratory exchange ratio decreased only in response to xylazine. However, in response to both drugs, plasma levels of noradrenaline, adrenaline, insulin and non esterified fatty acids decreased similarly and glucose increased comparably. These results demonstrate marked differences in the central nervous system-mediated effects of the two alpha2-adrenoceptor agonists, whereas peripheral actions are similar.

[Behavior disorders of neurological origin]. / Les troubles du comportement d'origine neurologique.

The modifications of behavior related to neurological diseases are various and important to be correctly diagnosed. The purpose of this article is to present the clinical features of main neuropsychiatric syndromes: depression, delusions, anxiety, obsessive-compulsive syndrome. The differential diagnosis is also developed. The appropriate treatment is discussed.

[Olivo-ponto-cerebellous degeneration. A study of 21 patients defined by the Quinn criteria]. / La dégénérescence olivo-ponto-cérébelleuse. Une étude de 21 patients définis selon les critères de Quinn.

21 patients with diagnosis of idiopathic OPCA were examined clinically and evaluated by MRI or CT-scan. On the basis of Quinn's criteria for MSA, patients were subdivided into those with probable MSA (48 p. cent) and those with possible MSA (52 p. cent). Median age at onset was 51.8 years. The initial clinical feature of the disease was ataxia, but the presence of multiple system involvement was clear in all cases. The combination of involvement of four different system (cerebellar, parkinsonian, pyramidal, autonomic) was the most common (28.5 p. cent), followed by the association of cerebellar and pyramidal features (24 p. cent). Autonomic symptoms were present in 48 p. cent of patients. CY-scan or MRI showed cerebellar and brainstem atrophy in 43 p. cent of cases. There was no relation with the duration of the disease or the severity of clinical features. Moreover brainstem auditory evoked response and EMG were not helpful in diagnosis.

[Sentinel headache: a premonitory symptom too often unrecognized in intracranial ruptured aneurysm]. / Céphalée sentinelle: symptôme prémonitoire trop souvent méconnu d'une rupture d'anévrisme intracrânien.

Headache is a common complaint in emergency departments, but only a small percentage of patients have a serious disease. Nevertheless, some forms of headache, such as "warning headaches", need special attention. By far the most common symptom associated with aneurysmal minor bleed (warning leak) is a sudden headache that is considered to be a warning symptom of impending aneurysmal rupture. In the presence of sudden severe headache with or without meningeal signs or nausea, subarachnoid hemorrhage should always be considered. Recognition of these warning headaches probably offers the best opportunity of reducing the otherwise serious mortality and morbidity of aneurysmal subarachnoid hemorrhage. This report describes 7 non-consecutive patients presenting warning headaches before major aneurysm rupture. Based on our experience and a review of the literature, we recommend a management algorithm for patients presenting with sudden severe headache.

[Astral and out-of-body voyages. Heautoscopy, ecstasis and experimental hallucinations of epileptic origin]. / Voyages astraux et hors du corps. Héautoscopie, extase et hallucinations expérientielles d'origine épileptique.

We report a 38 year-old patient who had temporoparietal epilepsy and unusual ictal "out of body" experiences that remained undiagnosed for more than ten years, until her admission for a motor seizure of the left hemibody. Out of body episodes were experienced as intense and ecstatic astral journeys. EEG showed a bilateral extension of epileptiform abnormalities to the parietal regions, predominantly on the right side. We discuss the various forms of heautoscopy and their putative mechanisms. We suggest that a disturbance in representing space in independent extrapersonal and personal coordinates might be as crucial as the elusive hypothesis of a body schema disorder. Combined involvement of the parietal neocortex and temporolimbic structures might allow those experiences to gain a subjective vividness which appears to be indissociable from normal conscious experiences.

Hyperkinetic movement disorders during and after acute stroke: the Lausanne Stroke Registry.

BACKGROUND AND OBJECTIVE: To study consecutive patients with acute or delayed hyperkinetic movement disorders in the Lausanne Stroke Registry. METHODS: We have identified 29 patients with acute or delayed movement disorders among 2500 patients who had their first-ever acute stroke in the Lausanne Stroke Registry. SETTING: Department of Neurology, Lausanne University Hospital. RESULTS: Our patients presented with hemichorea-hemiballism (11 patients), hemidystonia (5 patients), stereotypias (2 patients), jerky dystonic unsteady hand (3 patients), asterixis (2 patients), initial limb-shaking (2 patients), bilateral tremor (1 patients), bilateral jaw myoclonus (1 patient), hemiakathisia (1 patient) and dysarthria-dyskinetic hand (1 patient). On neuroimaging a lesion was found in 25 of the 29 cases in the territory of the middle cerebral artery (7 deep, 2 superficial and 2 complete), the posterior cerebral artery (11 patients), both middle and posterior cerebral arteries (2 patients) or the anterior cerebral artery (1 patient). The jerky dystonic unsteady hand syndrome was associated with a specific lesion, an infarct in the territory of the posterior choroidal artery. Presumed small-vessel disease was the commonest cause of stroke (15 patients). Only 3 patients had persistent movements (> 6 months). CONCLUSION: Hyperkinetic movement disorders are uncommon in acute stroke (1%), the commonest types being hemichorea-hemiballism and hemidystonia. These movement disorders are associated with stroke involving the basal ganglia and adjacent white matter in the territory of the middle or the posterior cerebral artery. The jerky dystonic unsteady hand syndrome is specifically associated with a small infarct in the territory of the posterior choroidal artery. The abnormal movements usually regress spontaneously.

Clinical and prognostic features in unilateral femoral neuropathies.

We have examined the clinical features of patients with femoral neuropathy and the factors that influence the prognosis. Of 80 consecutive patients referred for neurophysiological evaluations of proximal lower limb weakness, 32 fulfilled strict inclusion criteria and had adequate information, including estimates of axon loss (AxL) by stimulation of the bilateral femoral nerve. In 31, the Kaplan-Meier method was used to describe the time course of the outcome, while logistic regression was employed to determine the contributing factors. Excellent, satisfactory, and poor outcomes were seen in 10 (31%), 11 (34%), and 10 (31%) patients, respectively. Logistic regression analysis of seven factors demonstrated that the estimate of AxL was the only significant variable. The best prognostic factor was an estimate of AxL < or = 50%, with all patients fulfilling this criterion showing improvement with 1 year; fewer than half the patients with AxL > 50% should be expected to improve. This study clearly shows that, irrespective of the cause of femoral neuropathy, functional improvement is seen in 2 out of 3 patients within 2 years and that the estimate of AxL is the only factor influencing prognosis.