Internal border zone injury predicts the functional outcome of acute MCA stroke patients.

BACKGROUND AND PURPOSE: Classification of deep (D), superficial (S) MCA territories and their junctional vascular area (the internal border zone, IBZ) can help to identify patients most likely to benefit from aggressive reperfusion therapy after stroke. We tested the prognostic value of an IBZ injury compared to DWI-ASPECTS and infarct volume. MATERIALS AND METHODS: DW lesions of 168 patients with acute (4.2±6.5 h) MCA strokes were retrospectively examined and manually delineated. Patients with haemorrhagic transformation or other neurological diseases were excluded. Clinical data were recorded within 24 h following symptom onset and 48 h for patients who benefited from reperfusion therapy. The occurrence of an IBZ injury was determined using a standardized stereotaxic atlas. Performance to predict a good outcome (mRS<3 at 3 months) was estimated through ROC curves for DWI-ASPECTS≤6, lesion volume≥100 mL and IBZ injury. Logistic regression models were performed to estimate independent outcomes for infarct volume and IBZ injury. RESULTS: Infarcts involving the IBZ were larger (94.9±98.8 mL vs. 30.2±31.3 mL), had higher NIHSS (13.8±7.2 vs. 7.2±5.7), more frequent MCA occlusions (64.9% vs. 28.3%), and worse outcomes (mRS 3.0±1.8 vs. 1.9±1.7), and were less responsive to IVtPA (34±47% vs. 55±48% of NIHSS improvement). The area under the ROC curves was comparable between the occurrence of IBZ injury (0.651), ASPECTS≤6 (0.657) and volume≥100 mL (0.629). Logistic regression analyses showed an independent effect of an IBZ injury, especially for superficial MCA strokes and for patients who benefited from reperfusion therapy. CONCLUSION: An IBZ injury is an early and independent marker of stroke severity, functional prognosis and treatment responsiveness.

Assessment of a flow cytometry technique for studying signaling pathways in platelets: Monitoring of VASP phosphorylation in clinical samples.

A recently released kit (PerFix EXPOSE) was reported to improve the measurement of the degree of phosphorylation of proteins in leukocytes by flow cytometry. We tested its adaptation for platelets to monitor vasodilator-stimulated phosphoprotein (VASP) phosphorylation, which is the basis of a currently used test for the assessment of the pharmacological response to P2Y12 antagonists (PLT VASP/P2Y12). The PerFix EXPOSE kit was compared to the PLT VASP/P2Y12 kit by using blood samples drawn at 24 h post clopidogrel dose from 19 patients hospitalized for a non-cardio-embolic ischemic stroke and treated with clopidogrel monotherapy for at least five days in an observational study. The platelet PerFix method was based on adaptation of the volume of the sample, the centrifugation speed and the incubation temperature. Poor agreement between prevention by adenosine diphosphate (ADP) of PGE1-induced cAMP-mediated VASP phosphorylation and ADP induced aggregation assessed by Light Transmittance Aggregometry was found. We found a significant correlation between the PLT VASP/P2Y12 kit and the PerFix EXPOSE kit. The PerFix EXPOSE kit may also be helpful to monitor adverse effects of second-generation tyrosine kinase inhibitors on platelets.

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.

[Sneddon syndrome: a rare cause of vascular dementia]. / Le syndrome de Sneddon: une cause rare de démence vasculaire.

Few vascular dementias are diagnosed in memory clinic consultations. One type, a rare etiology, Sneddon syndrome, can lead patients to consult for an isolated memory complaint. We report the cases of two patients, aged 63 and 66 years, who presented frontocortical cognitive profile and behavior disorders. Seronegative Sneddon syndrome, complicated with dementia, was diagnosed in each case by noticing an association between, on MRI, an atrophy and several ischemic cerebrovascular accident aftermaths, and a livedo racemosa. Management of vascular risks factors improves the prognosis.

[Non-small cell carcinoma presenting as limbic encephalitis. Place of endobronchial ultrasound in the diagnosis]. / Encéphalite limbique paranéoplasique révélant un cancer bronchique non à petites cellules. Place de l'échographie endobronchique dans le diagnostic étiologique.

INTRODUCTION: Limbic encephalitis is a rare neurological paraneoplastic syndrome, characterized by anterograde amnesia, epilepsy and confusion. Diagnosis of the underlying cancer is essential for treatment. CASE REPORT: A 55-year-old heavy smoker was admitted on account of general physical deterioration and neurological symptoms. The diagnosis of limbic encephalitis was based on rapidly progressive symptoms, inflammatory cerebrospinal fluid, increased signal intensity in the temporal lobes on magnetic resonance imaging and the presence of anti-neuronal anti-Ma2 antibodies. The initial work-up, including positron emission tomography, did not reveal any cancer. Four months later, sub-carenal lymphadenopathy was detected. Echo-guided transbronchial and mediastinoscopic biopsies revealed bronchial adenocarcinoma (TxN2M0). Neurological and general physical deterioration followed despite radio-chemotherapy giving total control of the tumour macroscopically. The patient died two months after the end of his treatment as a result of staphylococcal septic shock. CONCLUSIONS: The neurological prognosis is poor. The search for bronchial cancer, when suspected, should include positron emission tomography, to be repeated if necessary, and sampling of the mediastinal lymph nodes using endobronchial ultrasound.

[Postpartum reversible cerebral angiopathy: an unusual cause of headache]. / Angiopathie cérébrale aiguë réversible du post-partum : une cause particulière de céphalée aiguë du post-partum.

We present the case of a 34-year-old woman who developed, in postpartum period of an uncomplicated pregnancy, a thunderclap headache with visual disturbance associated with a severe arterial hypertension. Both clinical evolution and cerebral imaging including angio-MR confirmed the diagnosis of postpartum reversible vasoconstriction syndrome. One of the leading causes of this syndrome is the use of vasoactive drugs as it was observed in the case of this patient. It is important to consider this syndrome in the differential diagnosis in patients presenting with headache in the postpartum period.

Acute psychiatric syndrome leading young patients to ICU: consider anti-NMDA-receptor antibodies.

We report on a case of anti-N-Methyl-D-Aspartate receptor antibody encephalitis, and review cases and series previously published in the literature. Anti-N-Methyl-D-Aspartate receptor antibody encephalitis usually occurs in young female patients with no past medical history, in whom an ovarian teratoma is often detected. They subacutely develop predominantly psychiatric symptoms, followed by severe neurological disorders requiring transfer to the intensive care unit and prolonged ventilatory support. Complete or substantial recovery depends on early diagnosis, removal of the teratoma and immunotherapy. Our purpose is to focus intensivists' attention on this potentially lethal disorder, which should always be considered in young women admitted to the intensive care unit with characteristic neuropsychiatric disorders.

[Atypical Lewy body disease revealed by burning mouth syndrome and a pseudo-psychiatric syndrome]. / Démence à corps de Lewy atypique révélée par une glossodynie et des troubles pseudo-psychiatriques.

INTRODUCTION: Among the degenerative diseases of the nervous system, Lewy body disease has the most psychiatric symptoms especially hallucinations, delusion and identification disorders. CASE REPORT: We report a case of Lewy body disease that started with a burning mouth syndrome for three year as the only symptom before the development of a pseudo-psychiatric syndrome (melancholy and Capgras). None of the usual cardinal criteria were present. MRI, cerebrospinal fluid, and DAT scan findings enabled the diagnosis. CONCLUSION: The dopaminergic hypothesis put forward in some cases of burning mouth syndrome might explain this symptom in Lewy body disease.