Vascular cognitive impairment: Advances and trends.

The presence of vascular neurocognitive impairment (whatever the severity) is always associated with a functional impact and increased risk of dependency and institutionalization. However, vascular cognitive impairment remains underdiagnosed, and the mechanisms underlying post-stroke cognitive disorders are still poorly understood. However, the advent of new criteria and a standardized international neuropsychological battery is expected to lead to improved diagnosis and management, and the development of novel techniques (such as brain imaging and amyloid PET) should improve our understanding of the mechanisms underlying vascular cognitive impairment and help to identify potential targets for therapy.

[Supportive care, cognition and quality of life in brain metastases]. / Soins de support, cognition, qualité de vie et métastases cérébrales.

Brain metastases impact on the survival of the patients, but on their quality of life as well. The objective of the management of these patients is then double. Currently, due to medical advances, survivals tend to improve, especially for some tumor subtypes. During the course of the disease, different neurological signs and symptoms can be observed according to the location, the number and the volume of the metastase(s). Patients and caregivers are especially worried about the loss of autonomy and cognitive impairments. A permanent dialogue, during the course of the disease, is mandatory, in order to adapt the management to the objectives determined by the patients and the medical team. These objectives may vary according to the objective response rates of the disease to anticancer therapies, according to the impact of the disease and its management in daily living. Anticancer therapies and supportive care must be appreciated according to their impact on the survival, on the preservation of the functional independence and the quality of life of the patient, on their abilities to preserve the neurological status and delay the apparition of new neurological signs and symptoms, and their adverse events. Supportive care, cognition and quality of life should be regularly evaluated and adapted according to the objectives of the management of brain metastases patients. Different approaches are described in this paper.

Randomized phase II trial of irinotecan and bevacizumab as neo-adjuvant and adjuvant to temozolomide-based chemoradiation compared with temozolomide-chemoradiation for unresectable glioblastoma: final results of the TEMAVIR study from ANOCEF†.

BACKGROUND: Prognosis of unresectable glioblastoma (GB) remains poor, despite temozolomide (TMZ)-based chemoradiation. Activity of bevacizumab (BEV) and irinotecan (IRI) has been reported in recurrent disease. We evaluated BEV and IRI as neo-adjuvant and adjuvant treatment combined with TMZ-based chemoradiation for unresectable GB. PATIENTS AND METHODS: Patients with unresectable GB, age 18-70, IK ≥50 were eligible. The experimental arm (BEV/IRI) consisted of neo-adjuvant intravenous BEV, 10 mg/kg, and IRI, 125 mg/m(2), every 2 weeks for four cycles before radiotherapy (RT) (60 Gy), concomitant oral TMZ, 75 mg/m(2)/day, and BEV, 10 mg/kg every 2 weeks. Adjuvant BEV and IRI were given every 2 weeks for 6 months. The control arm consisted of concomitant oral TMZ, 75 mg/m(2)/day during RT, and 150-200 mg/m(2) for 5 days every 28 days for 6 months. The use of BEV was allowed at progression in the control arm. RESULTS: Patients (120) were included from April 2009 to January 2011. The working hypothesis was that treatment would increase the progression-free survival at 6 month (PFS-6) from 50% to 66%. The primary objective was not achieved, and only 30 out of 60 patients were alive without progression at 6 months (50.0% [IC95% (36.8; 63.1)] in the BEV/IRI arm when 37 out of 60 patients were required according to the Fleming decision rules. PFS-6 was 7.1 months in BEV/IRI versus 5.2 months in the control arm. The median overall survival was not different between the two arms (11.1 months). Main toxicities were three fatal intracranial bleedings, three bile duct or digestive perforations/infections (1 fatal), and six thrombotic episodes in the BEV/IRI arm, whereas there was one intracranial bleeding, two bile duct or digestive perforations/infections (1 fatal), and one thrombotic episode in the control arm. CONCLUSIONS: Neo-adjuvant and adjuvant BEV/IRI, combined with TMZ-radiation, is not recommended for further evaluation in the first-line treatment of unresectable GB. CLINICAL TRIAL REGISTRATION: Clinical trial registered under EUDRACT number 2008-002775-28 (NCT01022918).

[Cognitive evaluation during brain radiotherapy in adults: a simple assessment is possible]. / Évaluation cognitive lors de la radiothérapie cérébrale chez l'adulte : vers un outil simple d'évaluation.

Brain irradiation can be used for the treatment of cancers in different protocols: focal radiotherapy, whole brain radiotherapy, with or without additive dose on the tumour. Different modalities (conformational, stereotactic radiosurgery) can be used for curative or prophylactic treatment. Brain radiotherapy leads to cognitive deterioration with subcortical profile. This cognitive deterioration can be associated to radiation-induced leukoencephalopathy on brain MRI. Taking into account radiation induced cognitive troubles is becoming more important with the prolonged survival allowed by treatment improvement. Concerning low-grade gliomas, radiation-induced cognitive troubles appear about 6 years after treatment and occur earlier when the fraction dose is important. Primitive cerebral lymphoma treatment can induce cognitive troubles in 25 to 30% surviving patients. These deficits are more frequent in elderly patients, leading to radiotherapy delay in those patients. Patients treated for brain metastasis often have cognitive impairment before radiotherapy (until 66%), this pretreatment impairment is related to global survival. The use of conformational radiation therapy, particularly with hippocampal sparing is conceptually interesting but has not proved its efficiency for cognitive preservation in clinical trials yet. Stereotactic radiation therapy could be an interesting compromise between metastatic tumoral volume reduction and cognitive preservation. Taking care of radiotherapy induced cognitive troubles is a challenge. Before considering its treatment and prevention, we need to elaborate a way of detecting them using a reliable and easy way. CSCT, a computerized test whose execution needs 90 seconds, could be used before treatment and during the clinical follow-up by the patient's oncologist or radiotherapist. If the patient's performance reduces, he can be oriented to a neurologist in order to perform fuller evaluation of its cognitive capacities and be treated if necessary.

Neuropsychological assessment and cerebral vascular disease: the new standards.

Vascular cognitive impairment (VCI) includes vascular dementia (VaD), vascular mild cognitive impairment (VaMCI) and mixed dementia. In clinical practice, VCI concerns patients referred for clinical stroke or cognitive complaint. To improve the characterization of VCI and to refine its diagnostic criteria, an international group has elaborated a new standardized evaluation battery of clinical, cognitive, behavioral and neuroradiological data which now constitutes the reference battery. The adaption of the battery for French-speaking subjects is reported as well as preliminary results of the on-going validation study of the GRECOG-VASC group [Clinical Trial NCT01339195]. The diagnostic accuracy of various screening tests is reviewed and showed an overall sub-optimal sensitivity (<0.8). Thus, the general recommendation is to perform systematically a comprehensive assessment in stroke patients at risk of VCI. Furthermore,the use of a structured interview has been shown to increase the detection of dementia. In addition to the well known NINDS-AIREN criteria of VaD, criteria of VCI have been recently proposed which are based on the demonstration of a cognitive disorder by neuropsychological testing and either history of clinical stroke or presence of vascular lesion by neuroimaging suggestive of a link between cognitive impairment and vascular disease. A memory deficit is no longer required for the diagnosis of VaD as it is based on the cognitive decline concerning two or more domains that affect activities of daily living. Both VaMCI and VaD are classified as probable or possible. These new criteria have yet to be validated. Considerable uncertainties remain regarding the determinant of VCI, and especially the lesion amount inducing VCI and VaD. The interaction between lesion amount and its location is currently re-examined using recent techniques for the analysis of MRI data. The high frequency of associated Alzheimer pathology is now assessable in vivo using amyloid imaging. The first studies showed that about a third of patients with VaD due to small vessel disease or with poststroke dementia have amyloid PET imaging suggestive of AD. These new techniques will examine the interaction between vascular lesions and promotion of amyloid deposition. Although results of these on-going studies will be available in few years, these data indicate that efforts should be done in clinical practice to reduce underdiagnosis of VCI; VCI should be examined using a specific protocol which will be fully normalized soon for French-speaking patients; the sub-optimal sensitivity of screening tests prompts to use a structured interview to grade Rankin scale and to perform systematically a comprehensive assessment in stroke patients at risk of VCI; poststroke dementia occurring after 3 months poststroke may be preventable by treatment of modifiable vascular risk factors and secondary prevention of stroke recurrence according to recent recommendations.

[What's new concerning the chemobrain?]. / Qu'en-est-il du chemobrain ?

Chemobrain, a subtle cognitive decline after chemotherapy in non-cerebral cancer, remains a debated issue, which has nevertheless been widely described for more than 15 years in the international literature. This phenomenon is almost unknown in France to experts, neurologists and oncologists. Experimental evidence from animal models and from human functional imagery is reliable but contrasts with the observations made during clinical studies. Indeed, in clinical practice, the difficulty in proving the occurrence of chemobrain may be explained by a large number of methodological skews. However, considering the International Cognition and Cancer Task Force (ICCTF) guidelines, we propose a methodology applicable in daily practice and capable of improving awareness of this phenomenon.

[Susac syndrome: variable onset modes and disease courses: two case reports]. / Syndrome de SUSAC. Modes d'entrée et évolutions variables: à propos de deux cas.

INTRODUCTION: Susac syndrome is a rare microangiopathy of unknown etiology, which involves the clinical triad of encephalopathy, visual loss, and hearing loss. Several onset and progression patterns are possible. OBSERVATION: Case 1: a 43-year-old woman developed subacute encephalopathy, which had not been diagnosed and had been evolving for 2 months, as well as left sensorineural hearing loss. The fundus exam found central artery branch occlusion in the left retina. The treatment was based on corticosteroids combined with cyclophosphamide and immunoglobulins. Angiographic monitoring revealed persistent asymptomatic arterial alterations despite positive neurological progression. Case 2: a 27-year-old woman presented visual loss in the right eye after recurrent neurological episodes. The triad was completed by deafness in the right ear. Treatment with corticosteroids led to favorable neurological progression and stabilized the ophthalmologic symptoms. DISCUSSION: This syndrome preferentially affects young women. The nearly constant neurological symptoms can differ. Branch occlusions are frequently bilateral and often come with the appearance of vasculitis. Deafness is bilateral, asymmetrical, and of endocochlear origin. Brain MRI shows lesions of the corpus callosum that are distinctive of the syndrome. The disease mainly evolves in a monocyclic way, self-limited in time, and it rarely becomes chronic. Treatment, which has not been codified to date, is based on corticosteroids and, in severe cases, immunosuppressive drugs. Other therapies have not proved to be effective. CONCLUSION: The diagnosis is based on the triad of neurological, ophthalmic, and ENT damage, but sometimes it can be difficult to formulate because of the chronology of symptom onset. Neurological damage, the first manifestation, will help make therapeutic decisions.

[Guillain-Barré syndrome and anti-hepatitis A vaccination]. / Syndrome de Guillain-Barré et vaccination contre l'hépatite A.

The Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuritis. The pathophysiology remains unknown but the existence of triggering factors such as external antigens is regularly suspected. We report the case of a 30-year-old patient with a past medical history of Graves disease, who presented with GBS within the month after receiving an anti-hepatitis A vaccination. GBS rarely happens after a hepatitis A vaccination. However, the responsibility of this vaccine should be considered in the clinical presentation of an acute polyradiculoneuritis.

[Anticonvulsant hypersensitivity syndrome and lamotrigine-associated anticonvulsant hypersensitivity syndrome]. / Syndrome d'hypersensibilité aux antiépileptiques. Cas particulier de la lamotrigine.

Anticonvulsant hypersensitivity syndrome (AHS) is defined by the association of high fever, cutaneous rash and multiorgan-system abnormalities (incidence, one in 1000 to one in 10,000 exposures). Fatal complications are described in 10%. This reaction usually develops 1 to 12 weeks after initiation of an aromatic anticonvulsant. Drug rash with eosinophilia and systemic symptoms (DRESS) can be discussed as differential diagnosis. Several hypotheses have been put forward to explain the pathogenesis of AHS. These include accumulation of toxic metabolites, antibody production and viral infection. The one based on toxic metabolites has found the greatest acceptance due to the fact that it can be proven by an in vitro test, the lymphocyte toxicity assay. In vivo, skin biopsies show characteristic findings of erythema multiform or typical leucocytoclastic angitis. The patch-test is positive in 80% of the cases. Lamotrigine-associated anticonvulsant hypersensitivity syndrome (LASH) is rare and was described in 1998. We report two new cases demonstrating the two particular configurations of apparition of LASH found in the 14 cases from the review of literature (Pubmed: anticonvulsant hypersensitivity syndrome - lamotrigine): high doses of lamotrigine (or lamotrigine in very young or old patients), and lamotrigine associated with another anti-epileptic (phenobarbital or sodium valproate). We discuss the links between DRESS after lamotrigine and LASH as illustrated in a new case.

[Idiopathic intracranial hypertension as a side effect of doxycycline]. / Hypertension intracrânienne bénigne secondaire à la prise de doxycycline.

Idiopathic intracranial hypertension is a rare disorder characterized by elevated intracranial pressure without hydrocephaly or intracranial process. Its mechanism is poorly understood. Most cases of benign intracranial hypertension are presumed to be idiopathic but some of them may be related to some treatment. We report a 26-year-old female with benign intracranial hypertension due to tetracycline, revealed by headaches and gradual visual loss. Standard investigations were unremarkable and favourable outcome after therapeutic lumbar puncture confirmed the diagnosis.

[Interferon-beta retinopathy]. / Rétinopathie liée à l'interféron-beta 1a sous-cutané

INTRODUCTION: Interferon-alpha associated retinopathy is an ocular complication of hepatitis C treatment well established in the literature. But, there are far fewer reports on multiple sclerosis related interferon-beta retinopathy. CASE REPORT: A 58-year-old male while receiving subcutaneous interferon-beta 1a 44microg thrice a week since 2001 for multiple sclerosis developed blurred vision. Visual acuity remained stable throughout the course of surveillance. Cotton wool spots were found on fundus exam. The retinopathy disappeared without specific therapy 2 months after discontinuing interferon injections. The diagnosis of interferon-beta 1a retinopathy was retained due to the lack of any other etiology. CONCLUSION: An ophthalmological examination including a fundus examination to search for a retinopathy should be undertaken when new ocular symptoms develop in a multiple sclerosis patient receiving interferon. An adverse event linked to interferon can be discussed and favored if the retinopathy resolves after interferon withdrawal.

[Neurological damage of brain tumor therapy]. / Complications neurologiques des traitements des tumeurs cérébrales.

Damage to the central nervous system induced by treatment of brain tumors is common and impairs the patient quality-of-life. Neurotoxicity is induced by synergistic effects of different cytotoxic treatments such as radiotherapy and chemotherapies administered concurrently or sequentially. Recent progress in the management of brain tumors has led to new neurotoxicities. The growing concern about the neuropsychological performance of patients has disclosed another type of brain damage which has been largely neglected to date. Neurological toxicity can be acute, requiring dose adaptation or a change of drugs. But it also often occurs late and can be irreversible. To date, treatments have been ineffective. The early diagnosis of neurotoxicity is thus a major challenge. Numerous clinical studies suggest an individual sensitivity which is not only related to age or vascular status, but also to genetic predisposition that remains to be detailed. Understanding the mechanisms of personal susceptibilities would be helpful in designing more tailored treatments. In this review we address the question of adverse effects of brain radiation as well as those of chemotherapy protocols which are particularly toxic for the central nervous system that is, methotrexate, platin and aracytin.

[Spontaneous low cerebospinal fluid pressure syndrome. A case report and literature review]. / Syndrome d'hypotension spontanée du liquide cérébrospinal. Revue de la littérature à propos d'un cas.

INTRODUCTION: Spontaneous low cerebrospinal fluid pressure syndrome is a spontaneous intracranial hypotension pressure due to a cerebrospinal fluid leak without any known dural effraction. It is clinically characterised by postural headaches relieved by supine position. We report a 38-year-old patient with this syndrome and review the literature. EXEGESIS: The diagnosis is sometimes difficult in atypical presentation of the syndrome and can lead to incapacitating chronic headache and rarely to complications. Cerebral magnetic resonance imaging has dramatically improved identification, diagnosis and management of this syndrome. Treatment is mainly based on blood patch realisation. Cerebrospinal fluid leak probably due to a spontaneous defect in the dural mater is suspected to be the main mechanism of this syndrome without any history of lumbar puncture or penetrating trauma. CONCLUSION: Early diagnosis, often easy on the basis of clinical characteristics of the headache may avoid complications.

[Listeria monocytogenes abscess of the brain]. / Abcès du tronc cérébral à Listeria monocytogenes.

INTRODUCTION: Listeriosis commonly involves the central nervous system. Meningoencephalitis and rhomboencephalitis are the most frequent manifestations. Brain abscesses are rare. CASE REPORT: We report the case of a 63-year-old man treated with steroids for a long period; he was hospitalized for hemiparesis, confusion and fever. Clinical examination revealed meningeal signs, right hemiparesis and Parinaud syndrome. Initial CT scan was normal. The CSF contained 520 white cells/mm3 with predominance of polymorphonuclear neutrophils. An acute meningo- rhombencephalitis in an immunodepressed patient was suggested. The diagnosis of listeriosis was confirmed by blood cultures. Amoxicillin and gentamycin were started. The outcome on day 4 was severe with coma and tetraparesis. Brain MRI revealed a left peduncle abscess which descended deep into the brain reaching the internal capsule. The final clinical outcome involved residual right hemiparesis and left oculomotor nerve (III) palsy. CONCLUSION: Brain stem abscess is an uncommon form of listerial central nervous system infection. Listeria monocytogenes infection should be considered in patients with altered cell-mediated immunity that develop local neurologic deficits, a diagnosis which pursued rapidly with repeated blood cultures. Successful treatment requires early antibiotic therapy with ampicillin and gentamycin.

[Eulenburg's paramyotonia congenita]. / Paramyotonie congénitale d'Eulenburg.

INTRODUCTION: Paramyotonia congenita is an autosomal dominant sodium channelopathy, caused by mutations in gene coding for muscle voltage-gated sodium channel alpha subunit. CASE REPORT: We report the case of a 38-year-old man who described since childhood muscle stiffness with attacks ok weakness induced by two provocative stimuli: cold exposure and exercise. It primarily concerned eyelids and hands, occasionally limbs. Family history suggested an autosomal dominant mode of transmission. Clinical examination revealed myotonia at the thenar eminence percussion. Generalized myotonic discharges were observed on electromyography. Molecular diagnosis reported an Arg1448Cys mutation in exon 24 in gene coding for muscle voltage-gated sodium channel alpha subunit (SCN4A) in chromosome 17. CONCLUSION: Paramyotonia congenita is not evolutive. Treatment is essentially preventive. Some medications could be proposed: membrane stabilizing agents like antiarrhythmic drugs (mexiletine, tocainide), or the carbonic anhydrase inhibitor (acetazolamide). Precautions may be taken during general anaesthesia because of diaphragm myotonia risk.

[Cerebral venous thrombosis and ulcerative colitis]. / Thrombose veineuse cérébrale et rectocolite hémorragique.

INTRODUCTION: Thromboembolic events are serious complications in patients with inflammatory bowel disease. EXEGESIS: An 18-year-old patient, with a one year history of ulcerative colitis, presented with cerebral venous thrombosis during the decreasing period of corticotherapy after an active phase of the disease. Under treatment, the neurological disorder rapidly improved. No inherited thrombophilia was found. CONCLUSION: The role of acquired and inherited risks factors is discussed.

The brain of the elderly diabetic patient.

All available estimations agree that the French population is aging and that the proportion of diabetics in the elderly population is increasing. The prevalence of diabetes could be about 10% in the over 65 y population. The fact that diabetes has an effect on brain function is widely accepted, but there are very few studies providing pertinent details. Diabetes is known to affect brain function, potential consequences including cognitive decline, dementia, depression, and stroke. These complications are frequently associated, leading to poor quality-of-life with considerable social and economic impact. While the results of different studies can be contradictory, there is an overall trend towards the conclusion that diabetes, often associated with high blood pressure, contributes to cognitive decline in elderly diabetics as well as to an increased frequency and severity of cerebral vascular events. These considerations point out the importance of proper management of diabetes in the elderly population and the need for cooperative studies to determine the role of diabetes and different cardiovascular risk factors in the development of dementia, stroke, and depressive syndromes whose consequences are probably underestimated.

[Cerebral Erdheim-Chester disease]. / Maladie d'Erdheim-Chester cérébrale.

We report the case of a 26-old-year man hospitalized for first partial complex epileptic seizure. Brain MRI showed an asymptomatic pseudo-tumor lesion in the brainstem. Diabetes insipidus, hypophyseal gonadotropic deficiency and osteosclerosis of long bones strongly suggested Erdheim-Chester disease, a rare histiocytosis, confirmed after tibial biopsy. Six months later, the patient remained stable. A persistent, and even increased, enhancement with Gd-DTPA on brain MR images was noted as previously described. The review of the literature collected 64 cases, and only 7 cases of cerebral "tumor".