[Management of adult refractory convulsive status epilepticus in the intensive care unit]. / Prise en charge des états de mal épileptiques convulsifs réfractaires en réanimation.

Patients with convulsive status epilepticus in whom first line treatment is not rapidly effective, or with a persistent delay in recovering consciousness must be admitted in an ICU even if assisted, mechanical ventilation is not performed. Continuous EEG monitoring performed in close collaboration with a neurophysiologist/epileptologist is mandatory to detect and treat subtle status epilepticus and to exclude post-anoxic encephalopathy. A number of drugs and anaesthetic agents have been proposed to control refractory status epilepticus. Midazolam and/or propofol have been recently recommended before performing general barbiturate anaesthesia. However, this approach is not rigorously assessed, because patients and series are heterogeneous, and controlled studies are difficult to design. Prognosis is closely related to the quality of initial management, to the development of subtle status epilepticus and, above all, to aetiology.

Ischemic stroke and active migraine.

OBJECTIVE: To determine the characteristics of acute ischemic stroke (IS) in patients with active migraine in a prospective stroke registry. METHODS: The authors studied the characteristics of patients admitted to a population-based primary-care center with IS and active migraine. The diagnosis of previous migraine was made based on replies to International Headache Society-based questions. Patients with migraine were divided into two age groups, one below 45 years of age and one 45 years or older, and compared by univariate and multivariate analysis with age-matched control subjects with IS, but without migraine. RESULTS: Of the 3,502 patients with acute IS, 130 (3.7%) had active migraine; 66 of these were younger than 45 years and 64 were 45 years or older (15.8% and 2.1% of the total for the corresponding age group). The proportion of women was significantly higher in both groups of patients with migraine (74% and 63% in the younger and older groups) than in control subjects. In young migraineurs, the posterior circulation involvement and the presence of patent foramen ovale were characteristic. In the younger migraine group, nine patients developed IS during a typical attack of migraine with aura, and 15 during migraine attack without aura in the absence of any other determined cause. In the older group, surprisingly, absence of vascular risk factors (previous hypertension, ischemic heart disease, and cigarette smoking) was characteristic. CONCLUSIONS: Migraine is frequent in young patients with IS and infrequent in older patients with IS. Patients with IS and migraine are mainly women with stroke features that are age dependent.

[The value of MRI for the diagnosis of meningeal hemorrhage during vasospasm]. / Intérêt de l'IRM pour le diagnostic d'hémorragie méningée en période de spasme.

Retrospectively, subarachnoidal hemorrhage can be misdiagnosed when the acute event did not bring the patient to medical attention, when clinical history is unclear and the CT scan is normal. Moreover, days after subarachnoid hemorrhage, cerebral vasospasm can result in neurological deficits that are indistinguishable from that produced by other causes of stroke. We report our experience with two patients who presented with symptoms of ischemia due to an arterial vasospasm that followed unrecognized rupture of an intracranial aneurysm. In both cases, CT scan failed to detect subarachnoid hemorrhage while MR detected the presence of signal changes in the subarachnoidal spaces associated with an ischemic stroke in one case. Neurological symptoms resolved completely after aneurysm treatment. MR can be a critical for the diagnosis of stroke secondary to vasospasm in order to prescribe an adapted treatment, avoid anticoagulant or thrombolytic therapy, and rapidly exclude the recently ruptured aneurysm to protect the patient from the risk of rebleeding.

The filaria Litomosoides galizai in mites; microfilarial distribution in the host and regulation of the transmission.

The mites, Bdellonyssus bacoti, are engorged on rodents having 800 to 60,000 microfilarie/10 mm3 blood. Quantitation of L. galizai larval development shows that an additional blood meal improves development and that high microfilaremiae do not result in a proportional increase in the number of infective larvae. The first important stage of transmission regulation occurs during ingestion of microfilariae: the numbers of ingested microfilariae are lower than expected in cases of high microfilaremia. This phenomenon cannot be ascribed to the mite vector that engorges a constant blood meal whatever the level of microfilaremia. Contrarily, one finds that microfilarial density in the small peripheral blood vessels (blood drawn from incision of the dorsal skin) increases less than in large blood vessels (retro-orbital sinus). A similar observation was reported by Dickerson et al. (1989) working with Wuchereria bancrofti. We assume that in both cases, the high microfilaremiae cause the small blood vessles accessible to the vector to become saturated with parasites. Although regulation during engorging is not the sole factor to monitor the infection in B. bacoti (another one operates during larval development of L. galizai), demonstrating its existence seems to us fundamental: it points out the concept that sub-ingestion, as well as over-ingestion, shows the inequalities of microfilarial densities in the host which seem to be dependent on mechanical factors such as the diameter of blood vessles and the size of microfilariae.