[Creation of a regional stroke network in Tours hospital (France): consequences for stroke care and thrombolysis]. / Création d'une filière neuro-vasculaire régionale: évaluation de la prise en charge à 18 mois.

INTRODUCTION: Our university hospital serves a population of 300 000 inhabitants. Stroke is the leading cause of admission in our department of neurology. In June 2003, when the Emergency Department (ED) was closed in our institution, was created an acute stroke network (ASN), comprising 2 beds of direct admission and thrombolysis in the intensive care unit, and 4 beds dedicated to stroke care in the department of neurology, in which standardized stroke care protocols were implemented. OBJECTIVE: The aim of this study was to evaluate changes in stroke care related to the creation of the ASN in terms of delays of arrival, imaging, use of intravenous (IV) thrombolysis, and outcome of patients. We conducted a prospective study during 18 months to evaluate characteristics of patients admitted with suspected stroke or transient ischemic attack (TIA) in the newly created ASN and to assess conditions of treatment with IV thrombolysis in terms of safety and efficacy. We also compared the outcome data before and after the creation of the ASN. METHODS: For each patient admitted in our hospital for suspected stroke or TIA, were prospectively collected clinical and outcome data (age, mode of transport, delay of arrival after the onset of symptoms (OS), treatment with IV thrombolysis, outcome and discharge). This study was conducted in the ED during six months in 2002, and in the ASN during 18 months, for all patients admitted for stroke. RESULTS: Three hundred and sixty four patients were admitted in the ASN. Emergency medical services (EMS) were used in half of cases for transport, and median delay of admission after the OS was 2h and 52 min. Median delay of imaging was 1 h and 45 min. Seventeen patients (8.5 p. 100 of ischemic stroke patients) were treated with IV thrombolysis, with an initial good outcome in 9 patients, 7 with a dramatic recovery). The main reason for therapeutic abstention for untreated patients admitted in the first 3 hours was a mild deficit with a NIHSS<6. Compared with the previous management in the ED, patients in the ASN were younger, had more severe neurological symptoms, the EMS transport was the main mode of transport (versus used in 17 p. 100 of cases in 2002), and the delay of admission was significantly lower: 2 h 52 versus 5 h 10 (p<0.02). After adjustment on the main predictive factors, only patients with hemorrhagic strokes had a better outcome after the creation of the ASN. CONCLUSIONS: Creation of an ASN was associated with a significant decrease of admission and imaging delays, due to a strong collaboration with EMS, and with a better outcome for hemorrhagic stroke patients. Treatment with intravenous thrombolysis in the first 3 hours could be used widely and was efficient and safe. However, the creation of dedicated stroke units for all stroke patients remains necessary to improve quality of care and outcome.

Comparative study of atrial vulnerability in patients with unexplained ischemic stroke or lone atrial paroxysmal fibrillation.

Strokes have a high prevalence, with a high rate of recurrence, and about 30-40% remain of unknown cause. Some patients might have asymptomatic paroxysmal atrial fibrillation (AF) which remains the main cause of embolic events. A latent atrial arrhythmogenic substrate may induce recurrent arrhythmias, including functional abnormalities such as nonuniform refractoriness and/or anatomic abnormalities such as atrial septum aneurysm (ASA) and patent foramen ovale (PFO). In 175 patients divided into three groups (Group I: 103 patients with unexplained ischemic stroke, Group II: 48 patients with paroxysmal AF and Group III or control group: 24 patients explored for another cause), such an atrial arrhythmogenic substrate was assessed by electrophysiological study. Groups I and II had a similar high rate of inducible atrial arrhythmias compared to control group III where no arrhythmia was induced. An induced atrial arrhythmia was observed in more than 50% of patients of Group I and in more than 70% of patients of Group II without any significant difference according to age. However, in 26 young patients of Group I who had a transesophageal echocardiography, both a high rate (46%) of ASA and/or PFO and a frequent latent atrial vulnerability (LAV) were observed, compared to older patients where an atrial septum abnormality was observed in only 21% of cases. Thus, among patients with stroke of unknown cause, a high percentage of them might have asymptomatic atrial paroxysmal arrhythmia. The predictive value of the electrophysiological study for spontaneous arrhythmias and recurrence of stroke remains to be demonstrated.

Sleep and brain lesions: a critical review of the literature and additional new cases.

We present a comprehensive review of sleep studies performed in patients with brain lesions complemented by 16 additional personal selected cases and by discussion of the corresponding animal data. The reader is cautioned about the risk of establishing an erroneous correlation between abnormal sleep and a given disorder due to the important inter and intra variability of sleep parameters among individuals. Salient points are stressed: the high frequency of post-stroke sleep breathing disorders is becoming increasingly recognised and may, in the near future, change the way this condition is managed. Meso-diencephalic bilateral infarcts induce a variable degree of damage to both waking and non-REM sleep networks producing and abnormal waking and sometimes a stage 1 hypersomnia reduced by modafinil or bromocriptine, which can be considered as a syndrome of cathecholaminergic deficiency. Central pontine lesions induce REM and non-REM sleep insomnia with bilateral lateral gaze paralysis. Bulbar stroke leads to frequent sleep breathing disorders. Polysomnography can help define the extent of involvement of various degenerative diseases. Fragmented sleep in Parkinson's disease may be preceded by REM sleep behavioural disorders. Multiple system atrophies are characterised by important sleep disorganization. Sleep waking disorganization and a specific ocular REM pattern are often seen in supra-nuclear ophtalmoplegia. In Alzheimer patients, sleep perturbations parallel the mental deterioration and are possibly related to cholinergic deficiency. Fronto-temporal dementia may be associated with an important decrease in REM sleep. Few narcoleptic syndromes are reported to be associated with a tumour of the third ventricle or a multiple sclerosis or to follow a brain trauma; all these cases raise the question whether this is a simple coincidence, a revelation of a latent narcolepsy or, as in non-DR16/DQ5 patients, a genuine symptomatic narcolepsy. Trypanosomiasis and the abnormal prion protein precociously after sleep patterns. Polysomnography is a precious tool for evaluating brain function provided it is realised under optimal conditions in stable patients and interpreted with caution. Several unpublished cases are presented: one case of pseudohypersomnia due to a bilateral thalamic infarct and corrected by modafinil, four probable late-onset autosomal recessive cerebellar ataxias without sleep pattern anomalies, six cases of fronto-temporal dementia with strong reduction in total sleep time and REMS percentage on the first polysomnographic night, one case of periodic hypersomnia associated with a Rathke's cleft cyst and four cases of suspected symptomatic narcolepsy with a DR16-DQ5 haplotype, three of which were post-traumatic without MRI anomalies, and one associated with multiple sclerosis exhibiting pontine hyper signals on MRI.

[Cerebral achromatopsia without prosopagnosia, alexia, object agnosia]. / Achromatopsie cérébrale sans prosopagnosie ni alexie ni agnosie des objets.

A 62-year-old woman was admitted for a disorder of color vision. This cerebral achromatopsia was isolated, without prosopagnosia, alexia, object agnosia. MRI showed bilateral temporo-occipital infarcts, including lingual and fusiform gyrus. Neuropsychological examination and topographic hypotheses are discussed.

A double-blind, placebo-controlled, enriched population study of tacrine in patients with Alzheimer's disease.

The efficacy of tacrine in the treatment of patients with probable Alzheimer's disease (AD) was evaluated in a double-blind, placebo-controlled, enriched population multicenter study in France. A total of 280 patients entered the dose titration phase of the study. The assessment of potential benefit of tacrine ("best dose") was based on demonstrating improvement on the Alzheimer's Disease Assessment Scale (ADAS) total score versus a blinded placebo. One hundred and thirty of 242 (54%) patients achieved a "best dose" and were eligible for the double-blind, parallel group (pivotal) phase. Primary efficacy measures were ADAS-Cognitive and Clinical Global Impression of Change; secondary efficacy measures of cognition and activities of daily living were also included. Results indicated that tacrine-treated patients showed improved functioning based on the ADAS-Cognitive in comparison to placebo-treated patients. Transaminase elevations above the upper limit of normal occurred in 32% of patients, were more frequent in women than in men, demonstrated a delayed onset, and returned to normal limits for all patients following discontinuation of treatment The results from this study are supportive of the efficacy of tacrine in the treatment of AD as demonstrated in a study of similar design conducted in the US and studies using different designs.

[The influence of sleep on abnormal waking movements]. / Influence du sommeil sur les mouvements anormaux de la veille.

Sleep decreases considerably the abnormal movements seen during waking in the degenerative extra-pyramidal diseases. However, the electrophysiologic recordings reveal that muscular contractions are not completely abolished. This decrease parallels the reduction of the waking system which act likely as a non-specific system of amplification. One can notice that sleep modifies the characteristics of the parkinsonian tremor and that some palatal myoclonias persist during sleep.

[Gougerot-Sjögren syndrome. Central neurological involvement with recurrent development]. / Syndrome de Gougerot-Sjögren primitif. Atteinte neurologique centrale évoluant par poussées.

A 64-year-old woman was repeatedly hospitalized for various recurrent clinical signs of central nervous system involvement. The diagnosis of primary Sjögren's syndrome was established 3 years 6 months after the onset of the disease. Sicca symptoms, as well as inflammatory biological abnormalities were absent. Moreover, both lacrymal and salivary gland secretions were affected. A high level of antinuclear antibodies to SSA and SSB was associated with inflammatory lesions in minor salivary glands biopsy samples consistent with the diagnosis of Sjögren's syndrome.

Two mesencephalic lacunar infarcts presenting as Claude's syndrome and pure motor hemiparesis.

Two exceptional cases of mesencephalic lacunar infarcts located both in the anterior vascular territory are reported. In patient 1, the infarct selectively involved the red nucleus, thus resulting in a Claude's syndrome. In patient 2, the lesion was limited to the external 2/3 of the cerebral peduncle, and was responsible for a pure motor hemiplegia (PMH). CT scan easily demonstrated the lesion in both cases. Claude's syndrome is very unusual, and PMH has only been reported once before in a mesencephalic infarct. The reasons why these lesions are so uncommon are discussed.

Stroke risk in patients with carotid stenosis.

In 242 neurologically symptomless patients with at least one non-occlusive carotid stenosis on ultrasonography (continuous wave doppler and echotomography-B mode imaging) 171 carotids showed 0-50% stenosis, 150 showed 50-75% stenosis, and 78 showed more than 75% stenosis. The mean follow-up was 29.4 months, with stroke and death as end points. Of the 56 deaths 2 were causally linked to a stroke (crude annual mortality index 9.57%). Of the 10 strokes 7 were judged to be infarctions in carotid territory. 7 out of 20 patients with transient ischaemic attacks (TIA) had ischaemic symptoms definitely related to carotid territory. The crude annual indices of specific stroke or TIA were 0.45% for nonstenotic carotid, 0.23% for 0-50% stenosis, 2.48% for 50-75% stenosis, and 1.71% for 75-99% stenosis. Stenoses of greater than 50% were associated with more ischaemic events than were lesser degrees of narrowing (p less than 0.01).

[Atheroma: which carotids should be surgically treated?]. / Athérome: quelles carotides opérer?

Atheroma of the carotid bifurcation can be held responsible for 15% of the 150 000 cases of cerebrovascular attack recorded annually in France. Most of these are caused by an embolus detached from the thrombus formed around the atheromatous lesions. The natural history of asymptomatic carotid stenosis is imperfectly known because the patients are very heterogeneous. However, published series suggest that the risk of ischaemic complication in cases with more than 50% stenosis is about 0.7% per annum. No medical treatment has been tested against this disease. On the other hand, several uncontrolled studies have highlighted the therapeutic value of endarterectomy. The tendency towards surgery may become more widespread as non-invasive detection by ultrasounds is increasingly used. A randomized therapeutic trial is required to determine the value of this operation and the maximum tolerable morbidity rate. In the case of transient ischaemic attacks, a joint study on extracranial arterial occlusion has demonstrated the value of successful endarterectomy and shown that the maximum tolerable morbidity from surgery is 3%. Slightly higher figures are probably acceptable for cases with tight stenosis. Such an approach cannot determine whether endarterectomy would be of value in completed stroke, because the pathological conditions involved are extremely variable. Reasoning by analogy with transient ischaemic attacks, it would seem that tight or ulcerated stenoses could benefit from the operation some time after a regressive stroke. Ultrasonic techniques and intravenous angiography have made examination of the cervical arteries considerably easier. The risk of wounding the left carotid artery should be carefully weighed. Preoperative cardiac assessment is necessary in view of the high incidence of heart disease in the follow-up of these patients. Thus, natural history data set high standards for surgical performance and less risk for pre-operative investigations.

[Outcome of intracranial meningioma in adults. Retrospective study of a medicosurgical series of 161 meningiomas]. / Devenir des méningiomes intracrâniens chez l'adulte. Etude rétrospective d'une série médico-chirurgicale de 161 méningiomes.

The authors report the retrospective study of a medico-surgical series of 161 patients with intracranial meningiomas, diagnosed over a period of 9 years, with a follow-up period varying from 18 months to 9 years. Out of 185 cases studied, 24 were excluded because information or perspective were inadequate. Of the 161 cases retained, 133 (82.6%) were given surgical treatment and 28 (17.4%) were given conservative treatment because the clinical state was poor or the location was deemed inoperable. The sex ratio was 3 women to 1 man. The average age was 58 years. The most frequent locations were the convexity (27.9%) and the sphenoid ridge (24.7%). Among the clinical signs, apart from the usual general seizures or pyramidal signs should be noted the importance of psychological disorders. The operative mortality rate was 14.3% with a very high peak in the sixth decade, reaching 27%, while it was only 9% in the seventh decade and 13% in those over seventy. The internal sphenoid ridge location had a mortality rate of 31.5%, which is significantly higher than for all the other locations. Quality of survival was identical for all age groups. Complications were mainly seizures, functional deficits and psychological disorders. Recurrences were relatively few (10%), but insufficient lapse of time and the presence of only one malignant meningioma explain the lowness of this figure. The use of scanner was not determinant in our series, neither on the earliness of diagnosis, nor on prognosis, comparison of figures before and since scanning showing no significant differences.

Disseminated aspergillosis in a patient with bronchiectasis. A 15-month clinical and immunological follow-up.

We report a case of disseminated aspergillosis involving both lung and brain in an adult female patient affected with bronchiectasis. Immunological follow-up was conducted before the clinical diagnosis and during the illness and revealed an excessively high helper-inducer/cytotoxic-suppressor (T4/T8) ratio. Peripheral granulocyte function was normal. A progressive reduction of lung and brain localizations was obtained with antifungal therapy and Imuthiol, an immunopotentiator which regulates the ratio of T-cell subsets. T4/T8 ratio returned to average values. The patient is alive 12 months after the diagnosis.