[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Some observational and experimental studies have suggested a short-term relationship between air pollutants and ischaemic stroke; however, the results conflict. AIMS: The objective of this study was to investigate the association between particulate matter less than 2·5 and 10 microns in aerodynamic diameter, nitrogen dioxide, sulphur dioxide and ozone, and short-term risk of ischaemic stroke in Lyon, France. METHODS: The AVC69 study was a multicenter cohort study in which all consecutive adult patients admitted to one of the emergency or neurological departments of the Rhône area for suspicion of stroke were included during a seven-month period. Only patients with ischaemic stroke living within the study area, composed of Lyon and 18 neighbouring communities with homogenous air pollutants exposure, formed the basis of our study. We adopted a time-stratified case-crossover design to analyse the short-term effect (up to two-days) of air pollutants on ischaemic stroke incidence. Models were adjusted for temperature, variation of atmospheric pressure, minimal relative humidity, influenza epidemics, pollen count, and holidays. Stratified analyses by gender and class age were performed. Different lag times were analysed. RESULTS: 376 patients were included. Mean age was 76·6 years (±13·7). 53·7% were women. No association was observed between air pollutants and short-term risk of ischaemic stroke after adjustment for main confounding factors. Results remained unchanged whatever the gender or age. CONCLUSIONS: These results suggest a lack of association between air pollutant exposure and short-term risk of ischaemic stroke in a French urban area.
International Journal of Stroke 02/2012; · 4.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Internal carotid artery (ICA) dissection with tandem internal carotid and middle cerebral artery occlusion may carry a poor prognosis even if intravenous recombinant-tissular plasminogen activator is administered. A better outcome may be expected with the combination of intravenous thrombolysis and endovascular methods (stenting and thromboaspiration). This procedure was performed in 3 patients who had concurrent ICA dissection and intracerebral occlusion. Endovascular treatment was feasible and safe. All our patients had a good clinical outcome. This potential effective approach may need further validation.
European Neurology 03/2010; 63(4):211-4. · 1.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are a few reports of moyamoya disease (MMD) in the European Caucasian adult population. We present the clinical manifestations, the neuroradiological aspects, the treatment, and the outcome after surgical revascularization of four French patients with MMD.
We identified four adults (age >18 years; three women and one man) with MMD who underwent digital subtraction catheter angiography at our institution from 1997 through 2006. The median age at symptom onset was 35 years (range, 22 to 41 years). The initial clinical presentation was intracerebral hemorrhage in three patients and ischemic stroke in one patient.
Three patients underwent bilateral surgical revascularization and one patient underwent unilateral surgical revascularization. All patients underwent the same surgical revascularization procedure (encephalo-duro-arterio-myo-synangiosis). The mean (+/-SD) period of follow-up after diagnosis of MMD was 6 years and 9 months (+/-3 years and 5 months). No patient experienced any recurrent hemorrhagic or ischemic stroke. No perioperative stroke occurred. No patient was severely disabled or unable to walk. Three patients out of four were employed.
Our data suggest safety and a potential benefit of surgical revascularization (indirect bypass surgery) in European adult patients with symptomatic MMD. Further long-term prospective multicenter studies are needed. The establishment of a registry would be useful in order to accumulate data in large numbers of European patients with this uncommon disease.
Journal of the neurological sciences 10/2009; 288(1-2):92-5. · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Melatonin's neuroprotective action has been demonstrated in experimental models of brain ischaemia. The relationship between stroke and melatonin levels has been based on scarce and small sample size studies. In addition, the changes have not been correlated with the age of patients. We compared levels of nocturnal urinary melatonin and its metabolite, 6-sulfatoxymelatonin (aMT6S) in a large series of acute ischaemic stroke patients and healthy volunteers. Consecutive ischaemic stroke patients with a first episode of anterior circulation stroke were recruited. Urine samples were collected in 127 patients on day 1 poststroke and in a control population including 216 healthy volunteers, from 20:00 to 08:00 hr. Melatonin and aMT6S were measured by radioimmunoassay. Differences in melatonin and aMT6S levels between ischaemic stroke patients and healthy volunteers were assessed by gender and age categories, using the Student's t-test. Melatonin excretion was decreased in stroke patients compared with healthy volunteers (74.1 +/- 13.9 versus 211.9 +/- 31.0 ng/hr; P = 0.0004), whereas aMT6S level was not significantly reduced (6371 +/- 1028 versus 4469 +/- 508 ng/hr; P = 0.10). Conversely, the stratification by age showed a significant reduction of both melatonin and aMT6S levels among ischaemic stroke patients over 70 yr (P = 0.001 and P = 0.03 respectively). The impact of melatonin at the acute stage of stroke on clinical severity and lesion size needs further assessment, as melatonin may have potential neuroprotective effects.
Journal of Pineal Research 05/2009; 46(3):349-52. · 7.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tuberothalamic artery infarction (TTAI) results mainly in a myriad of neuropsychological symptoms such as memory impairment, euphoria, apathy, verbal perseverations, constructional apraxia and lack of spontaneity. Language disturbances, acalculia, buccofacial and limb apraxia occur prominently after left TTAI while visual spatial processing deficits and hemispatial neglect occur prominently after the right one. Some cases of TTAI causing Horner's syndrome in addition of these wide-ranging neurobehavioral symptoms have been reported. Here, we report a case of TTAI with an ipsilateral ptosis as main clinical manifestation. This finding suggests that a Horner's syndrome can be the main feature of TTAI when neuropsychological manifestations are inconspicuous.
[Show abstract][Hide abstract] ABSTRACT: The benefit of recanalization in basilar artery occlusion (BAO) has been established. The baseline extent of brain stem damage may also influence the outcome. We investigated whether a baseline diffusion-weighted imaging (DWI) score may provide additional prognostic value in BAO.
We analyzed baseline clinical and DWI parameters in consecutive patients treated with endovascular procedures for acute BAO. Brain stem DWI lesions were assessed by using a semiquantitative score based on arterial territory segmentation. Outcome at 3 months was dichotomized according to the modified Rankin Scale (mRS) as favorable (mRS, 0-2) or unfavorable (mRS, 3-6). Spearman rank correlation tests assessed the correlation between DWI and clinical variables. Univariate and multivariate logistic regression analyses were used to identify clinical and MR imaging predictors of outcome.
Twenty-nine patients were included. The brain stem DWI score (median, 3; range, 0-14) was correlated with the baseline National Institutes of Health Stroke Scale (NIHSS) score and the presence and length of coma (r = 0.67, 0.49, and 0.53, respectively; P < .01). Recanalization was achieved in 76%. A higher baseline NIHSS score (P = .02) and brain stem DWI score (P = .03), a lower Glasgow Coma Scale score (P = .04), and the presence of coma (P = .05) were associated with poor outcome in univariate analysis. Multivariate analysis showed that the brain stem DWI score was the only independent baseline predictor for clinical outcome (P = .026).
Baseline brain stem DWI lesion score is an independent marker of outcome in BAO.
American Journal of Neuroradiology 09/2008; 30(1):194-8. · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recurrent cerebral venous thrombosis (CVT), as a manifestation of paraneoplastic angiitis and revealing of nodular lymphocyte predominant Hodgkin's disease (NLPHD), is an extremely rare condition. We herein report a 55-year-old man who developed recurrent CVT despite efficacious anticoagulant therapy and subsequent stenting of the superior longitudinal sinus. Progressive neurological deterioration ensued and a body scan revealed axillary lymph nodes. Pathological analysis led to a diagnosis of NLPHD. Conventional angiography showed CVT and multiple arterial narrowings. A paraneoplastic primary cerebral angiitis with prominent venous structure involvement was suspected. Immunotherapy using rituximab and steroids provided a dramatic recovery. This case of CVT due to paraneoplastic cerebral angiitis is a rare condition and represents a new, very rare manifestation of nodular lymphocyte predominant Hodgkin's disease.
Journal of Neuro-Oncology 06/2008; 89(2):195-8. · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intracranial angioplasty stenting may be an efficient therapy in patients with intracranial atherosclerotic symptomatic vertebrobasilar artery stenosis unresponsive to optimal medical therapy. We present our experience in this setting. RESULTS: The study included 12 cases (8 men, 4 women), with an age range of 43-78 years (mean 62.6 years). Intracranial stenosis that resulted in qualifying stroke or transient ischemic attack involved the vertebral artery (n = 4), lower basilar artery (n = 1) and mid basilar artery (n = 5). Tandem stenosis included the intracranial vertebral artery and basilar artery (n = 1) and both intracranial vertebral arteries (n = 1). The degree of stenosis ranged between 70 and 90% in the basilar and vertebral arteries. Angioplasty + stenting was performed in all lesions. A successful procedure resulting in 30% of residual stenosis was found in 14 vessels. A periprocedural adverse event occurred in 1 case and was related to a brain hemorrhage. The mean patient follow-up was 15 +/- 3 months; 10 patients remained symptom free. All patients underwent a percutaneous endovascular balloon angioplasty and stent placement. CONCLUSIONS: This study supports the safety and the potential efficiency of stent-assisted angioplasty in patients resistant to optimal prevention. Randomized larger prospective trials are needed to confirm the benefit of this approach.
European Neurology 01/2008; 60(3):127-31. · 1.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The intensity of the inflammatory response may be related to the volume of acute infarction. Ultra-small superparamagnetic particles of iron oxide (USPIO) may enable assessment of neuroinflammation. We aimed to assess whether the intensity of the inflammatory response might be related to the subacute ischemic lesion volume.
We enrolled patients who presented with acute anterior circulation stroke. MRI was performed at day 0, day 6, and day 9. The MRI protocol included T1-weighted imaging, gradient-echo T2*-weighted imaging, diffusion-weighted imaging, perfusion-weighted imaging and MR angiography. Blood-brain barrier disruption was defined as post-gadolinium enhancement on T1-weighted images. USPIO was administered after day 6 MRI. USPIO enhancement ratios were defined as the ratio between USPIO-related signal volume on day 9 T1-weighted imaging (respectively T2*-weighted imaging) and day 6 diffusion-weighted imaging infarct volume. The relationship between day 6 infarct volume and the enhancement ratio was assessed using Pearson and Spearman correlation tests.
The protocol was completed in 10 patients. Signal alterations after USPIO injection was observed in 9/10 patients on day 9 T1-weighted imaging and in 5/10 patients on day 9 T2*-weighted imaging. USPIO-related MRI enhancement was heterogeneous. Lesion volume on day 6 diffusion-weighted imaging had no impact on USPIO enhancement at day 9 according to the Pearson correlation test (P=0.39) or Spearman test (P=0.25). There was no relationship between blood-brain barrier disruption and USPIO enhancement.
USPIO MRI enhancement is heterogeneous and not clearly related to subacute lesion volume.
[Show abstract][Hide abstract] ABSTRACT: Introduction
La vascularisation des noyaux antérieur, ventro-latéral antérieur et ventro-latéral intermédiaire du thalamus est principalement assurée par l’artère tubéro-thalamique qui est une branche de l’artère communicante postérieure.
Nous rapportons le cas d’une patiente de 74 ans, hypertendue, dyslipidémique, porteuse d’une valvulopathie mitrale, sous traitement médicamenteux, admise dans notre service pour un ptosis gauche d’installation brutale et une désorientation temporo-spatiale.
L’examen neurologique était normal hormis ce ptosis isolé, sans myosis ni autre anomalie de paires crâniennes associée. Il n’y avait ni ophtalmoplégie, ni paralysie faciale, ni déficit sensitivo-moteur des 4 membres, ni syndrome cérébello-vestibulaire, pas plus que de syndrome méningé, de trouble de vigilance ou de mouvements anormaux.
L’IRM avec ARM montra un infarctus aigu et unique de la partie antéro-latérale du thalamus gauche, correspondant au territoire de l’artère tubéro-thalamique. Il n’y avait pas d’argument pour une dissection, une sténose artérielle ou une malformation vasculaire.
La radio pulmonaire était normale.
Le test à la Néosynéphrine a permis d’obtenir une correction transitoire du ptosis confirmant qu’il s’agissait bien d’un syndrome de Claude Bernard Horner (CBH) partiel.
Un bilan neuropsychologique réalisé à J10 a trouvé une perturbation modérée des capacités mnésiques et du langage.
L’infarctus tubéro-thalamique se manifeste classiquement par une sémiologie frontale : apathie, euphorie, troubles attentionnels, persévérations etc. avec des signes de latéralisation selon l’hémisphère touché : aphasie, amnésie, troubles visuo-spatiaux, héminégligence, associés de manière inconstante à une hémiparésie et/ou hémihypoesthésie d’évolution en général régressive. Quelques rares cas comportant un CBH sont rapportés dans la littérature.
Un syndrome de CBH peut être satellite d’un infarctus de l’artère tubéro-thalamique. Cette présentation clinique est certes rare mais doit être évoquée devant tout CBH d’installation brutale chez un sujet à risque vasculaire.
[Show abstract][Hide abstract] ABSTRACT: Whether aggressive treatment or no treatment is the optimal management for low-grade gliomas is controversial. However, symptomatic low-grade gliomas require prompt therapeutic intervention because of neurological impairment, uncontrolled seizures, and deterioration of life quality.
We report the long-term follow-up, 71 months, of seven patients treated by procarbazine, lomustine and vincristine (PCV) therapy for a symptomatic low-grade oligodendrogliomatous tumor. The mean age at diagnosis was 47 years, the mean time from first symptoms to initiation of PCV therapy was 62 months (range 15-147).
All patients initially responded favorably, with improvement of the neurological symptoms and radiological response. Chemotherapy was clinically well tolerated, the main side effect being low hematological toxicity. During the follow-up, no progression was observed in two patients. For the five remaining patients, the time to progression after the PCV induction was 56+/-12 months (range 38 to 73). Four of these patients showed favorable response to a second line of treatment.
PCV therapy is an interesting therapeutic option for progressively symptomatic low-grade gliomas, even in cases with large tumoral volume. This treatment, of moderate toxicity, improves the quality of life and can result in long-term tumor stabilization.
[Show abstract][Hide abstract] ABSTRACT: Sinus venosus defect is a rare cardiac abnormality, provoking an interatrial shunting outside the interatrial septum. Echographic diagnosis is difficult and may require examination by a specialized cardiologist.
We report the case of a young woman who presented with repeated episodes of hemiparesis.
Surgical correction of sinus venosus defect led to disappearance of neurological symptoms.
[Show abstract][Hide abstract] ABSTRACT: Glioma is seldom diagnosed during pregnancy. In this situation management presents difficult problems for both neuro-oncologists and obstetricians. We report four cases and discuss the management of this unusual situation.
The first patient was admitted to hospital at 29 weeks' gestation because of a generalized seizure and a right hemiparesis. MRI showed a left fronto-insular lesion. A stereotactic biopsy was obtained and revealed an anaplastic oligodendroglioma. With corticosteroids the patient remained stable until cesarean delivery at 36 weeks. In post-partum additional treatment with chemotherapy was started. The second patient was hospitalized at 26 weeks' gestation because of cranial hypertension, right hemiparesis and aphasia. MRI showed an important left fronto-parietal lesion. Partial resection was performed at 28 weeks. Histology revealed a glioblastoma multiforme. With corticosteroids the patient remained stable until cesarean delivery at 33 weeks. In post-partum additional treatment with radiotherapy and chemotherapy was started. The third patient was admitted to the hospital at 12 weeks' gestation because of cranial hypertension. MRI showed a left frontal lesion. A subtotal resection was done at 13 weeks. Histology revealed a glioblastoma multiforme. Two weeks after surgery the patient's neurological condition worsened and in agreement with the patient a therapeutic abortion was decided. Afterwards additional treatment with radiotherapy and chemotherapy was started. The last patient received combined treatment with radiotherapy and chemotherapy for local recurrence of a mesencephalic high-grade glioma. A posteriori it was discovered that the patient was at 4 months' gestation during this treatment. Cesarean delivery was done at 36 weeks. The child was normal at birth and is still in good health 5 years later.
The management of gliomas diagnosed during pregnancy should not be different from the standard management of gliomas in young non-pregnant adults. Pregnant women because of their young age can have a long survival. Their pregnancy should not prevent them from receiving the best treatment for their glioma. Treatment will depend upon clinico-radiological presentation, histology, gestational age and the patient's desires. Generally speaking, surgical resection of high-grade gliomas should not be delayed during pregnancy. Progress in anesthesia and neurosurgery have greatly reduced the risks for the foetus. After delivery, if the delay between surgery and delivery is too long it is possible to begin cerebral radiotherapy during pregnancy. After the first trimester of gestation this treatment can be given without any important risks for the child.
[Show abstract][Hide abstract] ABSTRACT: Brain hemorrhage after ischemic stroke is a serious complication of treatment; however, its pathology is poorly understood. A classification based on brain imaging may help to better understand and avoid causal factors.
Review of the results of controlled randomized trials and the available literature.
Hemorrhagic infarctions have no impact on clinical outcome and are probably not associated with the thrombolytic itself and the type of reperfusion strategy. They are associated with the extent of ischemic damage and most probably to an ischemic vasculopathy. Parenchymal hematomas are often clinically relevant. Their incidence is affected by the thrombolytic itself, the type, and probably the time point of reperfusion strategy. The loss of hemostatic control seems important in their pathogenesis. Extraischemic hematomas (remote from the infarct), unique or multiple, suggest pre-existing brain pathology, especially cerebral amyloid angiopathy.
The radiological description of 3 different types of brain hemorrhage is useful to better understand the specific pathology and the impact on clinical outcome. It may help to avoid clinically relevant brain hemorrhages.