Intravenous thrombolytic therapy for acute anterior ischemic stroke: Experience at the French Military Teaching Hospital in Toulon from 2003 to 2014.

INTRODUCTION: Intravenous thrombolysis with rt-PA is the key treatment for acute ischemic stroke (IS), and has largely been developed at the Military Teaching Hospital in Toulon since 2003. This report is of the results of our practices compared with those in the literature, as well as our attempts to identify factors predictive of a favorable outcome after thrombolysis. METHODS: All patients treated with rt-PA for IS in the carotid territory between 2003 and 2014 were prospectively included. Disability was assessed at 3 months by modified Rankin Scale (m-RS) scores; outcome was considered unfavorable if the m-RS score was >2. Multivariate analyses were also performed to identify parameters correlating with poor and favorable outcomes. RESULTS: Of the 289 patients prospectively enrolled in the study [mean initial National Institutes of Health Stroke Scale (NIHSS) score: 14.3], 52.5% had an m-RS score >2 at 3 months of follow-up. Three independent predictive factors for poor functional outcomes at the 3-month follow-up were identified: NIHSS score>12 on admission (P=0.048); NIHSS score>8 at discharge (P<0.001); and early neurological worsening within the first 24h (P=0.015). Early neurological improvement within 24h of rt-PA infusion was significantly associated with recanalization of the stroke-related occluded cerebral artery (P<0.001, r=0.37). CONCLUSION: After 12 years of practice, our stroke unit has produced results similar to those of the major clinical studies in terms of safety and efficacy. High NIHSS scores on admission and a lack of neurological improvement during the first 24h of thrombolysis due to failure of early recanalization were identified as independent predictive factors of poor functional outcomes.

[Intravenous thrombolysis with rt-PA in stroke: experience of the French military hospital of Toulon from September 2003 to June 2009]. / Expérience de la thrombolyse intraveineuse des infarctus cérébraux à l'hôpital d'instruction des armées Sainte-Anne de Toulon de septembre 2003 à juin 2009.

INTRODUCTION: Since 2003, intravenous thrombolysis with rt-PA for stroke victims has been largely developed in the military hospital of Toulon. We report the results of our practice and compare them with the literature. We also sought to identify predictive factors of favorable outcome after thrombolysis. METHODS: All patients treated with rt-PA for a stroke in the carotid territory between September 2003 and June 2009 were prospectively included. Disability was assessed at 3 months with the modified Rankin Scale (m-RS); outcome was considered unfavorable if m-RS score was above 2. Multivariate analysis was then performed to identify parameters correlating with poor and favorable outcome at 3 months follow-up. RESULTS: One hundred and one patients were included in this study (mean initial National Institute of Health Stroke Scale [NIHSS]: 15.2). 53.4% had a Rankin score higher than 2 at 3 months follow-up. The absence of diabetes mellitus, low NIHSS score on admission, short time from stroke onset to treatment, and prior statin use were identified as independent predictive factors of favorable functional outcome. CONCLUSIONS: After 6 years of activity, our stroke unit has results that appear similar to those of the French and international trials in terms of safety and efficacy. Efficacy of rt-PA in our series is poor for strokes caused by large-vessel atherothrombotic changes and cervical artery dissection due to high incidence of internal carotid thrombosis in these cases. Our studies also suggest that prior statin use may be an independent predictive factor of favorable outcome after thrombolysis.

[Benign intracranial hypertension and chronic hypervitaminosis A]. / Hypertension intracrânienne bénigne et hypervitaminose A chronique.

We report a case of benign intracranial hypertension due to chronic A-hypervitaminosis and a review of literature with 30 cases in adults and adolescents. The most prominent clinical features are: predominance of young women with normal weight and cured for acne; benign intracranial hypertension without other symptoms in half of cases; wide difference of daily doses and time of continuous intake. Prognosis for vitamin A intoxication is good, when intake of vitamin is discontinued. We reviewed five cases of benign intracranial hypertension due to retinoic acid. The mechanism of vitamin A neurotoxicity is still unknown.

[Pheochromocytoma revealed by cerebral hematomas. Significance of the abolition of a cutaneous abdominal reflex ipsilateral to the adrenal tumor]. / Hématomes intra-cérébraux révélant un phéochromocytome. Abolition d'un réflexe cutané abdominal ipsilatéral à la tumeur surrénalienne.

Cerebro-vascular complications of pheochromocytoma are now rare. The case reported here is a 47-year-old woman who presented with two cerebral hematomas and a pheochromocytoma. Abolition of a cutaneous abdominal reflex abolition can help the clinician to locate the adrenal tumor side.

[Mitochondrial encephalopathies with late disclosure and predominant involvement of central nervous system]. / Encéphalopathies mitochondriales à révélation tardive avec atteinte prédominante du système nerveux central.

We report three cases of mitochondrial encephalomyopathy affecting predominantly the central nervous system; two patients had the MELAS syndrome and one had "ophthalmoplegia plus". Histoenzymatic analysis of muscle biopsy and biochemical studies of muscle mitochondria demonstrated myopathy associated with partial deficiency of complex I of the electron transfer chain in three cases, complex IV in two cases and complex III in one case. Molecular analysis of mtDNA in the first case did not revealed any abnormality. Coenzyme Q10 therapy improved exercise tolerance but not the central nervous signs.

[Meningoradiculitis revealing an occult medulloblastoma-PNET in an adult]. / Méningo-radiculite révélant un médulloblastome-PNET occulte de l'adulte.

Neoplastic meningitis as the presentation of occult primitive neuroectodermal tumor (PNET) is occasionally described in children. We report the case of an 64 year old-man who presented a meningo-radiculopathy with progressive injury of the cauda equina and then the ocular motor nerves, revealing an occult medulloblastoma-PNET.

[Pharmaco-epidemiological study on the prophylactic treatment of migraine. National inquiry on attitude to prescription practices by primary care physicians and neurologists in Franceø]. / Etude pharmaco-épidémiologique sur le traitement de fond de la migraine.

A pharmacoepidemiological survey was conducted in order to understand the pattern of migraine prophylactic drug utilization by French physicians. Neurologists and primary care physicians completed a phone-mail-phone questionnaire which inquired about migraine prophylactic treatment. French neurologists and PCP made the same use of migraine prophylaxis in terms of indication, time interval between treatment onset and evaluation, and duration. The two most commonly chosen migraine prophylactic agents were dihydroergotamine and beta-blockers. This study also showed the importance of considering quality of life to evaluate efficacy of migraine prophylaxis.

[Hypothyroid hypertrophic myopathy in adults related to chronic lymphocytic thyroiditis. A case]. / Myopathie hypothyroïdienne hypertrophique de l'adulte liée à une thyroïdite lymphocytaire chronique. Une observation.

The authors report a case of hypothyroid hypertrophic myopathy which reveal chronic lymphocytic thyroiditis. This entity est uncommon, can be the most important sign of hypothyroidism and cure after the institution of thyroid hormone replacement therapy. The E. M. G. is usually myopathic and serum muscle markers (myoglobin and enzymes) increased. Pathologic studies of muscle show caracteritic but non specific and inconstant abnormalities. Hypothyroid myopathy could be caused by a mitochondrial oxidative phosphorylation deficiency or changes in muscle contractile properties (both in fibre type proportion and in the properties of the muscle contractile proteins).

[Meningoencephalitis after vaccination against yellow fever with the 17 D strain: 2 cases]. / Méningo-encéphalite après vaccination anti-amarile par la souche 17 D: deux observations.

The authors report two cases of meningoencephalitis consecutive to immunization with the 17 D yellow fever virus in adults. This complication is exceptional; the rare cases previously reported usually occurred in children. The meningoencephalitis had no particular clinical features; it was more severe in our second case but nevertheless followed a favourable course, as usually described in the literature. The pathogenesis of these central nervous system reactions is unclear. In our two cases the vaccine seems to have acted synergistically with another neurotropic virus (adenovirus in the first case, unknown virus in the second) which was either pre-existing and latent or occurring de novo.

[Cytomegalovirus myeloradiculitis in pregnancy]. / Myéloradiculite à cytomégalovirus au cours d'une grossesse.

INTRODUCTION: Cytomegalovirus neurological complications are frequent in immunocompromised patients specially in HIV positive patient. In immunocompetent patient these complications are infrequent. EXEGESIS: We describe a case of cytomegalovirus myeloradiculitis during pregnancy in a 25-year-old woman, HIV negative. The evolution was favorable with foscarnet therapy. CONCLUSION: A spinal complication during cytomegalovirus infection in immunocompetent patient should lead to a therapy with a specific antiviral to reduce neurologic involvement.

[Homozygotic C5 deficiency disclosed by purulent Neisseria meningitidis meningitis]. / Déficit homozygote en C5 révélé par une méningite purulente à Neisseria meningitidis.

The complement system functions to protect the individual against infectious agents. Deficiencies of the late-acting complement proteins C5-C8 are associated with an increased susceptibility to Neisseria infection. This paper describes a deficiency in C5 in a Caucasoid family from the north of France that was revealed by the occurrence of a N. meningitidis meningitis in the homozygous C5-deficient propositus.

[Marchiafava-Bignani disease of good prognosis. Two cases]. / Maladie de Marchiafava-Bignami d'évolution favorable. Deux observations.

BACKGROUND: Marchiafava-Bignami disease or corpus callosum necrosis, is an uncommon complication of chronic alcoholism. Prognosis is severe. CASE REPORTS: Two young adults with chronic alcoholism who developed Marchiafava-Bignami disease initially improved clinically. DISCUSSION: Diagnosis has been facilitated with MRI. An MRI exploration should be performed in chronic alcoholic patients presenting chronic encephalopathy with dementia, dysarthria, hypertonia, and ataxia, or acute encephalopathy with confusion, dumbness, seizures, and hypertonia. Necrosis of the corpus callosum gives the diagnosis of Marchiafava-Bignami disease.

[Blue nevus of the scalp associated with a meningeal melanocytoma]. / Naevus bleu en plaque du cuir chevelu associé à un mélanocytome méningé.

INTRODUCTION: Headache opposite to a blue nevus of the scalp can reveal intra cranial melanotic lesions. CASE REPORT: A 25-year-old man caucasian was admitted to hospital for a first generalized tonic-clonic seizure. For six months, he has had episodic frontal-temporal right headache opposite to a blue pigmentary cutaneous congenital lesion in frontal territory (histology confirmed benign blue nevus). Neurologic examination noted a right congenital hereditary ophtalmoplegia. Cerebral MRI showed a right rolandic tumor with diffuse leptomeninge infiltration. This patient was operated of a meningeal melanocytoma with leptomeninges melanosis. DISCUSSION: The apparition of headache related to a blue nevus must lead to realize a cerebral MRI to look for a neuroectodermic hamartoma: melanotic tumor (in particular melanoma), or leptomeninges melanosis with high potential of degeneration. Meningeal melanocytoma is a rare benign spinal or intra cranial melanotic tumor.

[Fibrinolysis and acute stroke in maritime search and rescue medical evacuation]. / Thrombolyse et accident vasculaire cérébral, à propos d'un cas de secours en mer.

Medical management of a female passenger with acute stroke aboard a cruise ship at the sea allowed a fast evacuation towards a stroke unit by an helicopter staffed with an emergency medical doctor. Fibrinolysis begun in a short delay after magnetic resonance imaging.

The paradox of negative exercise stress ECG/positive thallium scintigram. Ischemic ST-segment counterpoise as the underlying mechanism.

A 62-year-old woman with exertional angina underwent an exercise thallium-201 stress test. She exercised for 4 minutes on the treadmill using a modified Bruce protocol, reaching 94% of her predicted maximal heart rate, and stopped because of chest pain and fatigue. No ST-segment depression was detected at peak exercise or in the recovery period. In contrast, the thallium-201 myocardial single-photon emission computed tomography images in the short-axis, vertical long-axis, and horizontal long-axis views revealed severe myocardial ischemia involving the anterior, septal, posteroinferior, and posterolateral planes of the heart. Coronary arteriography showed severe stenosis of the left anterior descending and right coronary arteries. The information from the exercise electrocardiogram (ECG), thallium-201 myocardial scintigraphy, and a coronary angiogram suggested that the false negative ECG response was due to ischemic ST-segment counterpoise (i.e., cancellation of ischemic ST-segment vectors, generated by equally extensive and severe ischemia involving myocardial planes opposite each other.