[Cardiac surgery without transfusion in 2005]. / Chirurgie cardiaque sans transfusion en 2005. A propos d'une série de 200 témoins de Jehovah opérés.

PURPOSE: Between January 1991 and October 2003, 200 Jehovah Witnesses adult patients underwent elective cardiac surgery. To asses the impact on continuing progress of blood saving protocols and the increasing operative risk of patients proposed to surgery, we have re-assessed our results in this specific population. METHODOLOGY: Files of the first 100 patients operated upon between 1991 and 1998 were reviewed, and compared to the following 100 ones treated between 1998 to today. All patients were scored using the Euroscore model. RESULTS: In the latest series, patients are older (68 vs 51) and 13% underwent an iterative procedure, although there was none in the first series. Three deaths occurred after one month at the beginning of our experience, only one in the latest series. Operative risk factors had distinctly deteriorated, with more redux, and ejection fraction lower than 35%. Major progress to maintain morbi-mortality stability were multifactorial: preoperative erythropoietin in order to reach an haemoglobin minimal value of 14 g/dL, Cornell University protocol, mini-ECC, warm blood cardioplegia, ultra-early extubation. CONCLUSION: Cardiac surgery without transfusion can be realised with an equivalent risk to that of classical surgery, despite an operative risk aggravation, due to the association of recent conservative techniques.

[Apraxia and autotopoagnosia without aphasia or agraphia with compulsive language activity in right hemispheric lesion]. / Apraxie et autotopoagnosie sans aphasie ni agraphie, mais avec activité compulsive de langage, au cours d'une lésion hémisphérique droite.

A 75 year-old woman was admitted with a left hemiplegia resulting from an infarct in the right middle artery's territory. Her manual preference was ambiguous from early childhood. She presented with severe bilateral apraxia, autotopoagnosia, finger agnosia, and left spatial neglect. There was, however, no aphasia nor agraphia. When the patient attempted to perform gestures on order, she compulsively produced oral or written language. In this very unusual case, dominance for gesture and dominance for language were strictly independent, each ensured by one hemisphere. The patient's performances in gestual activities, especially dissociation between automatic and voluntary movements, and compulsive linguistic productions, are discussed in relation to this functional lateralization. We suggest that the propositional nature of the responses required in test conditions could activate either voluntary language in the left cerebral hemisphere, or voluntary gestures in the right. A competition between the two hemispheres could explain the patient's linguistic apraxic or behavior in response to orders. Autotopoagnosia, an uncommon symptom, could interfere with apraxia, but is not directly responsible.

[Dissociated preservation of written expression in aphasia with recurrent utterances]. / Préservation dissociée de l'expression écrite dans une aphasie à stéréotypes.

In a female patient, aphasia with recurrent utterances resulted from a double lesion of the left hemisphere, located in the base of the third frontal gyrus and the upper temporal gyri. Predominant in the fluent oral expression was a repeated neologism of which the patient was unaware. The written expression, efficient for lexical entities, was devoid of syntax and had the features of phonological agraphia. Both orally and in written words comprehension was satisfactory but syntactic comprehension was deficient. The stereotyped verbal behaviour could be due to dysfunction of the phonemic programmer. Rupture of the audi-phonatory loop, confirmed by degradation of the verbal working, memory, made this dysfunction worse and accounted for the anosognosia. The participation of the right hemisphere and of the preserved left hemispheric structures in the persistence of various language activities are discussed.

[Graphomania. Compulsive graphic activity as a manifestation of fronto-callosal glioma]. / La graphomanie. Activité graphique compulsive Manifestation d'un gliome fronto-calleux.

The presenting symptomatology in a case of fronto-callosal glioma were affective indifference, severe disorders of attention and dynamic aphasia with marked reduction in spoken expression. Spontaneous and induced writing were abundant and incoercible. Their meticulous production and formal correction contrasted with its semantic incoherence. This behavior is comparable with that of the compulsive activity that may result from pallidal lesions or bilateral frontal lesions. The term graphomania is proposed to distinguish this behavior from echographia and hypergraphism.

[Right neglect with hemiasomatognosia, mental confusion, apraxia and agraphia without aphasia]. / Négligence droite avec hémiasomatognosie, confusion mentale, apraxie et agraphie sans aphasie.

A 74 year-old woman was admitted with a right hemiplegia resulting from a left infarct that had totally destroyed the territory supplied by the middle and anterior cerebral arteries. The patient presented with anosognosia and hemiasomatognosia and negligence of the right half-field. She was aprosodic, not aphasic, and there was a severe apraxia and total agraphia. These neuropsychological disorders are discussed in relation to the contradictory data relative to the manual lateralization of the patient. Findings in this case of a "crossed apraxia" show that management of language and of the propositional gestures are not necessarily ensured by the same hemisphere. It also appears that manual preference may be a poor clue for interpretation in terms of functional lateralization.