Biomedical subjects
Publications and source records attributed to L Milandre.
A 63-year old diabetic man presented with left Weber's syndrome and meningitic syndrome. CSF examination showed moderate lymphocytic pleocytosis and elevated proteins with normal glucose content and sterile culture. Blood cultures yielded Listeria monocytogenes and the patient received ampicillin. While his neurological condition had partially improved, he died of heart failure. Several mesencephalic abscesses were found at autopsy.
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Infarcts in the territory of cerebellar arteries, often involving both brainstem and cerebellum, have been well recognized in recent pathological and clinicoradiological studies. To evaluate the situation of pure cerebellar infarcts (PCI) we studied 30 consecutive cases of symptomatic PCI (22 men and 8 women, mean age 58 +/- 17 years) admitted over a 5-year period and selected on the basis of brain computed tomography completed by magnetic resonance in 20 cases and angiography in 15 cases. PCIs accounted for 53 percent of cerebellar infarcts, 10 percent of vertebrobasilar infarcts and 3.2 percent of all cerebral infarcts. The arterial territories involved were the superior cerebellar artery (SCA) in 13 cases (alone in 8 cases), the anterior inferior cerebellar artery in 2 cases, the posterior inferior cerebellar artery (PICA) in 17 cases (alone in 13 cases) and border areas in 5 cases (associated with SCA or PICA). The symptoms were the same in the arterial territories involved (SCA versus PICA), except for dysmetria and vestibular syndrome which were more frequent respectively in SCA territory infarction (P < 0.001) and in PICA territory infarction (P < 0.01). Certain or presumed causes were cardiogenic embolism (23 percent), atherosclerosis (43 percent) and other identified causes, such as oral contraceptives or temporal arteritis (10 percent). They remained undetermined in 24 percent of the cases. Although most patients were severely disabled in the acute stage (Barthel index < 60 in 21 cases), 90 percent recovered subsequently (Barthel index about 100 and 0-2 score on modified Rankin scale). Our findings indicate that symptomatic PCIs are rare; their main causes (cardioembolism and atherosclerosis) do not differ in frequency from those of all cerebral infarcts collected in stroke registries and their functional prognosis is good in almost all cases.
The clinical and MRI features were correlated in five cases of infarction in the territory of the anterior inferior cerebellar artery. The lateral portion of the pons area was affected in four cases, the middle cerebellar peduncle in two, and the cerebellar hemisphere in three. The lesion was restricted to the cerebellar hemisphere in one patient. In no case did the clinical features conform to the classical description.
Seventy-eight patients with post-stroke seizures were studied retrospectively to determine the clinical, EEG and CT features of these seizures and their prognosis. There were 57 cerebral infarctions and 21 hemorrhages. Twenty-eight (36%) initial seizures occurred within one month after the stroke (0-24 hours in 19 cases) and were classified as early-onset seizures. Fifty (64%) initial seizures occurred more than 3 months after the stroke (3-12 months in 33 cases) and were classified as late-onset seizures. Compared with a population of 1938 strokes admitted during the same period, the proportion of patients with alcohol abuse, infarction in the anterior cerebral artery territory, watershed infarcts and lobar haemorrhages was significantly greater in our series. The proportion did not vary with the nature of the stroke (infarction or hemorrhage), except for early onset seizures in which the proportion of hemorrhages was significantly greater. Nor did it vary with the cause of hemispheric infarctions (cardioembolism or atherothrombosis or others). Ninety-five percent of the lesions affected the cerebral cortex or the subcortical white matter or both. Of all 78 initial seizures, 64% were partial motor (simple or secondarily generalized); 32% were primarily generalized, and 4% were partial not motor; status epilepticus was seen in 14% of the cases. An initial EEG, performed in 76 patients was normal in 7. Among the remaining 69 patients EEG showed focal or diffuse slowing down in 63% and epileptic features in 37% (including 10 cases of PLEDs). Early post-seizure EEG and repeated recordings significantly increased the specificity of EEG.(ABSTRACT TRUNCATED AT 250 WORDS)
A 17 year-old man with a one-year history of Crohn's disease presented with superior sagittal sinus thrombosis in spite of an apparent remission of the inflammatory bowel disease. Under treatment, the neurological disorders rapidly improved. Hematological studies showed mild thrombocytosis, spontaneous platelet aggregation, and an increase of the fibrinogen level, plasmatic viscosity and red blood cells aggregability. Mild hypofibrinolysis and antiphospholipid antibodies were also noted. Nine fully documented cases of cerebral venous thrombosis associated with an inflammatory bowel disease are reviewed. The possible prothrombotic role of thrombocytosis and other hematological disorders is discussed.
Two cases of Claude's syndrome due to a mesencephalic infarction in the territory of the interpedoncular fossa arteries are reported. The first case had pupillary sparing while ptosis was lacking in the second case. Partial impairment of the oculomotor nerve suggests an intra-axial fascicular organization. However, the precise intra-axial pattern of the nerve is unknown in humans.
Nine cases (seven men and two women, mean age 64.5 years) of classical lacunar syndromes due to intracerebral hemorrhage are reported. Three patients presented with pure motor hemiparesis (two putaminal hematomas with proportional weakness and one cortical hemorrhage with brachio-crural hemiparesis). Four patients presented with sensorimotor stroke due to thalamo-capsular hemorrhage. The last two patients had thalamic hemorrhage causing ataxic hemiparesis or dysarthria-clumsy hand syndrome. Four subjects had arterial hypertension, one was diabetic, and two were treated with anti-vitamin K. Abrupt onset was noted in all instances. Only one patient experienced moderate inaugural headaches. Good recovery occurred in all cases. Lacunar syndromes are a very uncommon presentation of intracerebral bleeding. Hemorrhages are yet the second etiology of such syndromes. Distinguishing hemorrhage from infarction is not clinically possible and needs early unenhanced CT scan.
Within the last four years, we have observed five patients with epidemiological, clinical, and serological features that were consistent with Q fever meningoencephalitis. Attempts to isolate Coxiella burnetii from the cerebrospinal fluid of two patients were unsuccessful. Neurological features ranged from coma, general seizures, confusion, to palsy and meningitis. All patients were febrile. These patients were neuroradiologicaly investigated. Since 1984, four other cases have been reported in the literature. Antibiotics with good penetration into the cerebrospinal fluid, such as new quinolones, may be useful for treatment of confirmed cases. Q fever should be considered as a possible etiology of meningitis in endemic areas, and diagnosis should be confirmed by serology.
Symptomatic dolichoectasia of the vertebrobasilar system was found in 23 patients (16 males and 7 females, mean age: 62 years) during a 13-year period. Arterial hypertension was noted in 20 cases and associated aortic ectasia in 4. The malformation was identified in all patients on CT completed by angiography in 19, MRI in 7. Autopsy was performed in 5 cases. Fourteen subjects (group 1) presented with a vascular event (ischemic in 13) affecting the brainstem and/or cerebellum. Nine other patients (group 2) had a chronic symptomatology resulting from compression of the cranial nerves, central nervous system and/or CSF pathway. Two patients died of stroke within the first month (rupture of the ectasia in one and occlusion in the other one). The 21 survivors were followed for a mean period of 45.3 months. Eight patients had a stroke, with a significantly higher incidence in group 1 than in group 2 (p less than 0.05). Ten patients (5 in each group) developed progressive dementia possibly resulting from multiple cerebral infarction, hypertensive leucoencephalopathy, and/or hydrocephalus. Twelve patients died during the follow-up (4 of stroke, 6 of profound mental and motor deterioration, one from ruptured ectatic aorta, and the last one of unrecognized cause). The actuarial survival rate was 60% after 3 years of follow-up. Except for the incidence of stroke, inaugural manifestations (stroke vs nervous compression) did not seem to influence the long-term prognosis.
Three HIV seropositive patients presented with cerebral toxoplasmosis which was treated by anti-infectious agents. After partial improvement, they developed hemichorea related to striatal infectious lesions. In AIDS patients with cerebral toxoplasmosis, autopsy series have reported a high incidence of basal ganglia abscesses, explaining the occurrence of involuntary movements such as hemichorea.
In 3 hypertensive patients, aged 57 to 66, profound behavioral and personality changes occurred rather abruptly, characterized by total loss of spontaneous activity and initiative, apathetic behavior, passivity, lack of drive and motivation, loss of interest for any of previous occupations and hobbies, and total flatness of affect. Neurological examination was normal or only showed mild extra-pyramidal signs. Neuropsychological evaluation was only remarkable for mild intellectual impairment suggestive of frontal lobe dysfunction. None of the 3 patients fulfilled criteria for dementia or severe depression. This neurobehavioral syndrome has been coined "athymhormic syndrome" (Habib & Poncet, 1988), a term emphasizing the specific defect in drive ("horme") and affect ("thumos"). Electrical and clinical heart examination was unremarkable. Blood pressure was always found within normal limits during hospitalization, including 24-hour monitoring in one case. However, all patients were known as hypertensive in the past, with repeated bouts of high blood pressure (up to 270 mmHg systolic in one case). X-ray CT-scan was usually normal or showed non-specific white matter changes (so-called "leukoaraiosis"). In all 3 cases, a brain MRI scan showed multiple small infarcts mainly involving deep subcortical structures (caudate nuclei and/or adjacent periventricular white matter) of both hemispheres, consistent with the definition of lacunes.(ABSTRACT TRUNCATED AT 250 WORDS)
A young women presented with chronic headaches associated with a cyst of the right lateral ventricle. The diagnosis of intraventricular so-called "arachnoid" cyst was supported by CT scan, MRI and stereotactic puncture. MRI was of great value for demonstrating that the cyst was located within the lateral ventricule, that it was delineated by a thin wall adherent to the choroid plexus and that the cyst content was CSF-like.
Two fatal cases of deep cerebral venous system thrombosis are reported in adults. The first case looked like a diencephalic tumor or encephalitis but the diagnosis was made antemortem by means of cerebral angiography. Autopsy found bilateral infarction of basal ganglia. The second patient presented with a hemorrhagic infarction of right thalamus and basal ganglia. Deep cerebral venous occlusion was diagnosed at autopsy. In spite of a few cases of survival, the thrombosis of the galenic system remains often fatal. The pathological changes and indications for anticoagulation are discussed.
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A 59-year-old hypertensive patient presented with transient global amnesia without neurological signs or symptoms. During the following 3 years, he experienced several attacks of vertebrobasilar insufficiency and a cerebellar infarction. CT scan and MRI found a partially thrombosed dolichoectatic basilar artery but no significant lesion within the limbic system. These data suggest transient global amnesia was due to a transient ischemia in the basilar artery distribution.
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The authors report on a series of 100 patients, who underwent an ischemic cerebrovascular accident (CVA) (8 transient attacks, 15 minor CVAs and 77 completed strokes) which revealed internal carotid artery occlusion (unilateral in 93 cases and bilateral in 7), proven by ultrasonography and/or angiography. The computerized tomography scan was normal in 8 cases. The middle cerebral artery territory was involved in 84 patients (isolated or associated (25 patients) with another site), whereas an isolated watershed infarction was the only lesion in the other 8 patients. Twenty-two patients died during the acute phase. Among the 68 survivors followed for a long time, 28 were severely incapacitated. The occlusions were not atherosclerotic in 18 cases (8 spontaneous dissections, 5 cardiogenic emboli, 3 radiation-induced arteries, 2 multiple causes). Eighty-two patients had atherosclerotic thromboses (67 men and 15 women, mean age 63.1 +/- 12.7 years). Among them, 24 had previously experienced minor ischemic strokes. In this group, the two year survival rate was 63 p. 100. Patients with non-fatal atherosclerotic thromboses were followed for an average of 22.2 months, during which time 28.2 p. 100 experienced another stroke.