[Contribution of magnetic resonance imaging in sclerotic combined degeneration of the spinal cord due to vitamin B12 deficiency]. / Intérêt de l'imagerie par résonance magnétique dans la sclérose combinée de la moelle par carence en vitamine B12.

Subacute combined degeneration (SCD) of the spinal cord is known to present histopathologically degenerative lesions in the spinal cord, but few studies on the neuroradiological findings have so far been reported. We present the interest of initial and follow-up MR findings in three cases of SCD. In the three cases, a causal event precipitated the onset of neurological symptoms: general anesthesia for the first and the third one and folic acid treatment for the second one. Clinical evolution was favorable after specific treatment with nearly total recovery. The initial MR study disclosed lesions predominantly involving the posterior columns of the spinal cord: high intensity on T2 weighted image was seen in the initial MR study and disappeared three months after treatment in correlation with good recovery, but with a delay. The recognition of this MR pattern suggests that MRI may be used in conjunction with clinical assessment to confirm the diagnosis and to monitor the efficacity of treatment in SCD.

Epilepsy in patients with multiple sclerosis: radiological-clinical correlations.

PURPOSE: To determine potential mechanisms of epilepsy in patients with multiple sclerosis (MS). METHODS: Among 402 patients with clinically and radiologically defined MS, including de novo cases, presenting to the Neurology Service, University Hospital of Dijon, we identified 17 with epileptic seizures (4.25%). Among them, the percentage with partial seizures (50%) was greater than that in the reference population. RESULTS: In most of the patients with MS, plaques were localized in the frontal region, associated with frontal and callosal atrophy, a frontal syndrome, and severe disability status (as assessed by a standard scale). Magnetic resonance imaging (MRI) showed numerous subcortical plaques. Seizures generally were well controlled with antiepileptic drugs (AEDs). CONCLUSIONS: Our data suggest that the subcortical plaques of MS underlie seizure activity in patients with MS and epilepsy.

Incidence of transient ischemic attacks in Dijon, France. A 5-year community-based study.

The aim of this study was to determine the incidence of first-ever TIA and the distribution of risk factors in those patients with TIA in Dijon. We performed a prospective population-based study in Dijon City with 135,000 inhabitants, from 1990 to 1994, using several case-collection sources. Over a 5-year period, we recorded 258 cases of first-ever TIA, giving a crude annual incidence rate of 38.68/100,000 for men and 32.70/100,000 for women. The mean age of first-ever TIA was higher in women (71.75 years) than in men (70.35 years). A CT scan was performed in 97% of the cases and silent lacunes were discovered in 17% of cases. In our 5-year study in Dijon of first-ever TIA, we found incidence rates similar to those of previous population-based studies. Our results also support the hypothesis that risk factors for TIA are similar to those for stroke.

Clinical patterns of acute stroke among the three health-care systems in France.

Data from 959 consecutive patients registered with the Dijon Stroke Registry were used to compare the characteristics of the patients who were admitted to the public hospital within the first days after their first stroke with those admitted to the private hospitals or who remained at home. Seven hundred and one patients (73%) were admitted to the public hospital, 185 (19%) were admitted to private hospitals and 73 (8%) remained in the community. The results show that the clinical patterns of the stroke are quite different among the three health-care systems. The clinical patterns of stroke managed in the public hospital are characterized by: a younger age (63-years-old vs, 77 and 76-years-old), earlier coma (29% vs 2.8 and 1.5%), more severe deficit (71% vs 15 and 5%), more hemorrhagic mechanism (23 vs 4.5% and 1.7%), more associated ischemic heart disease (31% vs 18 and 15%), more cardiac arrhythmia (38% vs 11 and 8%), higher case fatality rate (39% vs 8 and 2%). Therefore, we have identified three clinical patterns among the three health-care facilities. These three clinical patterns are quite different on the point of view of the clinical severity, and the associated co-morbidities. The socio-economic status is not a criteria in the choice of the health-care facility. This observed distribution is not the consequence of a voluntary policy. Copyright 1998 Lippincott Williams & Wilkins

[Agenesis of the corpus callosum: modes of manifestation in adults]. / Agénésie du corps calleux: les modes de révélation chez l'adulte.

Agenesis of corpus callosum is an uncommon brain malformation that is usually detected in childhood. In adult, focal epileptic seizure is the most frequent manifestation. Otherwise, asymptomatic patients can be detected by cerebral imagery with specific criteria. Neither developmental disability nor interhemispheric transfer dysfunction are observed in those patients. Minor facial abnormalities can be found. Agenesis of corpus callosum in adult is usually paucisymptomatic. The prognosis depends on cerebral associated malformations which are involved in epilepsy and cognitive disturbances.

Unilateral lenticular infarcts: radiological and clinical syndromes, aetiology, and prognosis.

OBJECTIVES: To analyse the clinical features induced by lenticular infarction found in 20 patients, and to analyse the radiological and clinical correlations. METHODS: Eight women and 12 men, mean age 73 years, were included in this study, which was carried out from 1 January 1994 to 30 November 1996. They were characterised by the onset of a lenticular infarction, shown by CT and MRI. A complete neurological and neurocognitive examination, and photon emission computed tomography (SPECT), were performed in all the patients and there was a long clinical follow up. RESULTS: Two distinct clinical syndromes were identified corresponding to the two anatomical areas of the lenticular nucleus: behavioural and cognitive disorders were associated with infarcts within the globus pallidus, whereas both motor disorders (dystonia) and cognitive disorders were associated with infarcts within the putamen. Outcome was excellent in all the patients for motor function, but slight cognitive disorders, problems with short term memory, and dysphasia persisted for several months. The size of the lesion did not explain these symptoms. By contrast, the slight reduction in cerebral blood flow found in the adjacent frontotemporal area may explain them by a deafferentation or a diaschisis phenomenon. CONCLUSION: It is possible to identify the clinical symptoms of a single lesion in the pallidus nucleus and in the putaminal nucleus, in which behavioural, cognitive, and movements disorders are important. After an acute and spectacular onset, outcome is in general excellent. A disease of the small arteries must be involved.

Stroke in children under 16 years of age. Clinical and etiological difference with adults.

OBJECTIVES: The aim of this study was to re-evaluate the clinical features of stroke in children, their outcome and the place of the different mechanisms, in the light of CT-scan and magnetic resonance imaging. METHODS: A 10-year review of the Dijon Childhood Neurology Clinic experience (1985-1995) identified 54 patients with arterial stroke. Diagnosis was established by CT-scan and angiography and by magnetic resonance imaging from 1987. When an hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following tests were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocystine in the plasma and the urine, an electrocardiogram, a Holter procedure and a cardiac echography. RESULTS: During the 11 full calendar years of this study, we observed 54 stroke patients. There were 31 cases of ischemic stroke, representing some 57% of the total, as well as 23 cases of hemorrhagic stroke, representing 43% of the total. Of the 31 cases with ischemic stroke, 4 had no known predisposing condition, 6 occurred in children with pre-existing heart disease, 2 had moya-moya disease, 2 had leukemia, 2 had a carotid dissection, 1 had an hemolytic-uremic syndrome, and 14 were observed in patients with other associated conditions, such as infections (7 cases) or slight cranial trauma (7 cases). On CT-scan, a basal ganglia infarction was identified in 14 cases. Among the 23 hemorrhagic strokes, 9 were due to arteriovenous malformations, 2 to arterial aneurysm and 5 to cavernomas. Two cases occurred in hemophilia, 2 in idiopathic thrombocytopenic purpura, and 2 after throat infections. One case had no etiologic factor. Clinical course was marked by a low mortality rate even in hemorrhagic stroke, long-lasting seizures, and hemidystonia. CONCLUSION: This neuro-imaging survey focused on the real place of hemorrhage and basal ganglia infarctions in children under 16 years of age, compared to adulthood. Follow-up demonstrated good or complete resolution of neurological deficits despite the frequent late hemidystonia and late epilepsy.

Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial.

OBJECTIVE: To compare the occurrence rate of nosocomial maxillary sinusitis and pneumonia in patients who have undergone nasotracheal vs. orotracheal intubation. DESIGN: Randomized, clinical trial. SETTING: General adult intensive care unit (ICU) in a nonteaching public hospital. PATIENTS: A total of 300 (209 male, 91 female) patients were included. The mean age was 59 +/- 17 (SD) yrs. The simplified acute physiologic score was 14 +/- 6. Reasons for admission to the ICU were: coma (n = 78), pneumonia (n = 46), infection (n = 35), surgery (n = 34), multiple trauma (n = 20), head trauma (n = 12), other (n = 75). Among the 300 patients, 149 were randomized into the nasotracheal group and 151 into the orotracheal group. No statistical difference was found between initial characteristics of the two groups. INTERVENTIONS: Patients were randomized between nasal and oral endotracheal intubation. Gastric intubation was performed via the same route as endotracheal intubation. Sinus computed tomography (CT) scans were performed every 7 days or earlier in case of fever and/or purulent nasal discharge. Criteria for nosocomial sinusitis were as follows: fever of > 38 degrees C, radiographic (sinusal air-fluid level or opacification on CT scan) signs and presence of purulent aspirate from the involved sinus puncture with 10(3) colony-forming units (cfu)/mL. Diagnosis of pneumonia was based on classical criteria and a protected brush specimen with 10(3) cfu/mL. MEASUREMENTS AND MAIN RESULTS: Radiographic evidence of sinusitis was observed in 78 patients, 45 from the nasal group and 33 from the oral group (p = .08, log-rank test). Among these patients, 54 fulfilled the sinusitis criteria stated above, 29 in the nasal group and 25 in the oral group (p = .75, log-rank test). Nosocomial pneumonia was observed in 26 patients, 17 in the nasal group and 9 in the oral group (p = .11, log-rank test). A multivariable analysis considering sinusitis as a time-dependent factor has suggested that sinusitis increased the risk of nosocomial pneumonia by a factor of 3.8. Nosocomial septicemia was observed in 33 patients, 22 episodes in the nasal group and 13 episodes in the oral group (p = .11, log-rank test). Overall mortality rate was 37% in the nasal group vs. 41% in the oral group (p = .37, log-rank test). Episodes of atelectasis and accidental extubations, and doses of sedative drugs and antibiotics were not different between the two groups. Length of mechanical ventilation did not differ between the two intubation groups. The mean length of stay in the ICU was 11 +/- 15 days in the nasal group vs. 9.5 +/- 11 days in the oral group (p = .27, Student's t-test). CONCLUSIONS: In patients undergoing prolonged mechanical ventilation, there was no statistically significant difference in the occurrence rate of nosocomial sinusitis or pneumonia between patients undergoing tracheal intubation via the nasal vs. oral route. A trend (p = 0.008) suggests less sinusitis in the orotracheal group.

[Diffusion of amikacin into the sinuses in patients with nosocomial sinusitis. Administration of a single dose per day]. / Diffusion de l'amikacine dans les sinus chez les malades ayant une sinusite nosocomiale. Administration en dose unique journalière.

Twenty mechanically ventilated patients with nosocomial sinusitis were treated with amikacin 15 mg/kg administered either once a day (group 1 patients) or twice a day (group 2 patients). Amikacin was assayed in serum and in the liquid drained from the sinuses 8 times over a 24 hours' period (group 1) or 7 times over a 12 hours' period (group 2). The amikacin concentration peak was 10.9 mg/l in group 1 and 5.1 mg/l in group 2. It is concluded that amikacin can be used to treat patients with nosocomial sinusitis. High amikacin concentrations are reached with the once a day dosage.