Case-matched comparison of early and long-term outcomes of everted cervical vein and saphenous vein carotid patch angioplasty.

OBJECTIVES: To compare outcomes after carotid endarterectomy (CEA) with saphenous vein patch closure (SV), with cervical vein (external jugular and common facial) patch closure (CV). DESIGN: A total of 322 cases of CEA was achieved consecutively by using venous patch angioplasty. Propensity scores were calculated followed by a one-to-one basis case-matching. MATERIALS: This resulted into 90 SV and 90 CV matched cases. METHODS: The primary endpoint was the incidence of ipsilateral stroke and transient ischaemic attack at any time during follow-up. RESULTS: Ten-year freedom from stroke was 94.1% ± 3.5% for the SV group and 90.5% ± 4.2% for the CV group (log rank P = 0.230). Ten-year freedom from ipsilateral neurological events (stroke and transient ischaemic attack) was 93.5% ± 3.3% for SV group and 92.4% ± 3.0% for the CV group (log rank P = 0.403). Ten-year freedom from ≥75% stenosis/occlusion was 93.1 ± 4.8% for the SV group and 89.9 ± 6.0% for the CV group (log rank P = 0.481). CONCLUSIONS: CV is a good alternative to SV patching, particularly when the SV needs to be preserved for further use or is unsuitable.

Risk factors and treatment of stroke at the time of recurrence.

The profile of recurrent ischemic strokes has not been much investigated. The aim of this study was to evaluate how the therapeutic strategies recommended for secondary prevention after an ischemic stroke are implemented in the real world of clinical practice. All patients admitted for a recurrent ischemic stroke or TIA were prospectively registered. The etiology was determined according to the TOAST classification. The risk factors and cardiovascular treatment at the time of the recurrence were recorded. A total of 168 patients were evaluated. Most of the patients (61%) recurred after 1 year. The recurrent stroke was not associated with a particular etiological subtype. The most frequent risk factor was hypertension (79%), followed by hypercholesterolemia (43%), smoking (25%), and diabetes (22%). Most of the patients had more than 1 risk factor (84%). Hypertension was not satisfactorily controlled in 38% of patients, hypercholesterolemia in 42%, and diabetes in 59%. A significant minority of patients (15%) were not taking any antithrombotic agent despite a history of stroke or TIA. Only 34% of the cases with a known atrial fibrillation were on anticoagulant therapy and the International Normalized Ratio was < 2.0 in 71% of them. In conclusion, stroke prevention needs to be improved by better implementation of therapeutic strategies in clinical practice. The patients should also be better informed about target values as well as the importance of physical activity and smoking cessation.

The Belgian experience with intravenous thrombolysis for acute ischemic stroke.

PURPOSE: We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - International Stroke Thrombolysis Register (SITS-ISTR). This prospective observational register evaluates the safety and efficacy of intravenous thrombolysis with rtPA (recombinant tissue Plasminogen Activator) for ischemic stroke in routine clinical practice. METHODS: We compared the baseline characteristics, treatment delay, rate of symptomatic intracerebral hemorrhage and functional outcome at 90 days after treatment between patients enrolled in centres in Belgium and the non-Belgian SITS-registry population. We performed a multivariate analysis to adjust for differences in demographic and baseline characteristics. RESULTS: 743 patients were enrolled in 42 centers in Belgium between December 2002 and December 2007. These patients were older, had more severe stroke were more frequently female and more frequently had hyperlipidemia and atrial fibrillation. The median stroke onset-to-treatment delay was 140 min vs. 145 min. More patients died and were disabled 3 months after the stroke. A slight, non-significant, increase of symptomatic intracerebral hemorrhage (SICH) as per SITS protocol was observed (2.4 vs. 1.6%, p = 0.15). After adjustment for differences in baseline characteristics, functional independence (mRS < or = 2) at 3 months (OR 0.95, 95% CI 0.86-1.05, p = 0.31) was not different from non-Belgian patients, nor was the rate of SICH. However mortality at 3 months in Belgian patients was slightly higher (OR 1.15, 95% CI 1.02-1.29, p = 0.02). CONCLUSION: Intravenous thrombolysis for ischemic stroke is safe and effective in the routine clinical use in Belgium. The higher mortality we observed is not related to a higher rate of SICH.

Organisation of inhospital acute stroke care and minimum criteria for stroke care units. Recommendations of the Belgian Stroke Council.

There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.

Caecum and ascending colon herniated in the lesser sac through the Winslow's hiatus. A case report.

Herniation of the caecum and the ascending colon in the lesser sac through the Winslow's hiatus is an uncommon cause of intestinal occlusion. The clinical presentation can be acute or chronic. The diagnosis often remains unclear before surgical operation, even with the assistance of abdominal CT, providing an image of a digestive structure in the lesser sac and the presence of mesentery between the portal triad and the vena cava. The treatment consists of reducing the internal hernia, which could be considered under laparoscopy.

Family history of hypertension is not an independent genetic factor predisposing to ischemic stroke subtypes.

OBJECTIVES: The effect of family history of hypertension (FHx(HT)), as a genetic factor predisposing to some ischemic stroke subtypes and independently of hypertension as risk factor, has never been studied. METHODS: A positive FHx(HT) was searched in 472 patients (312 men, 160 women; mean [S.D.] age, 67.9 [11.4] years) consecutively admitted for a first-ever ischemic stroke (348) or transient ischemic attack (TIA) (124) due to small vessel disease (SVD, 180), large vessel disease (156), or cardioembolism (136). In this population and in three age bands, the genetically transmitted vascular risk factors, age, gender and the ischemic stroke subtypes were compared between those with and without a positive FHx(HT). RESULTS: None of the risk factors was associated with a positive FHx(HT), except for hypertension in the whole population (68.9% vs. 48.7%; p=0.001) and in the <65 year-old patients (72.5% vs. 39.5%; p<0.001). Regarding the stroke subtypes, a positive FHx(HT) was only associated with SVD in the subgroup of <65 year-old patients (odd ratios (OR), 2.07; 95% confidence interval (CI), 1.01 to 4.25; p=0.045). However, this finding disappeared in a logistic regression analysis, which only retained hypertension as independently associated with SVD. CONCLUSIONS: FHx(HT) is not an independent genetic factor predisposing to some aetiological stroke subtypes.

Atopic myelitis: a clinical, biological, radiological and histopathological diagnosis.

We describe a young patient with an unusual intramedullary lesion filled with eosinophils. The 21-year-old man developed chronic myelitis without optic neuritis or signs of systemic or infectious disease. A spinal biopsy was conducted because of the progressive extension and pseudo-tumoural aspect of the lesion. Histopathological analysis of the biopsy specimen revealed a severe inflammatory process with macrophages and numerous eosinophils. The eosinophil count in the blood and cerebrospinal fluid (CSF) were normal. Clinical, laboratory and radiological data did not correspond with the usual causes of eosinophilic myelitis. Abnormal mite antigen-specific IgE levels and features similar to Japanese cases of atopic myelitis suggested an allergic origin. Despite normal total IgE levels, this case may be the second case of atopic myelitis reported in a Caucasian patient. Striking differences with the first reported case are the absence of a typical history of atopy and normal total IgE levels. This case highlights that atopic myelitis should be considered in myelopathy occurring in Caucasian patients even in the absence of hyperIgEaemia.

Segmental spinal myoclonus and syringomyelia: A case report.

We report the case of a 75-year-old woman who developed involuntary jerks of the abdominal musculature. They occurred spontaneously or triggered by a forced inspiration or attempts to rise from the supine position. Electromyography (EMG) recorded abnormal bursts of muscle activity in the abdominal, thoracic paraspinal, and intercostal muscles up to the 3rd intercostal space. The bursts were bilateral, arrythmic and synchronous in all muscles. Magnetic resonance imaging (MRI) of the spine revealed a syringomyelic cavity between the T3 and T10 levels. The topological correlation between the EMG muscle activities and the MRI findings was consistent with spinal myoclonus arising from the thoracic spinal cord. The synchronous bursts in muscles depending from few adjacent spinal segments suggested the diagnosis of segmental spinal myoclonus (SSM). There are few reports of SSM related to syringomyelia in the literature.

Pseudomyxoma peritonei: review on a cluster of peritoneal mucinous diseases.

Pseudomyxoma peritonei is an uncommon condition characterized by abundant extracellular mucinous material and peritoneal tumoural implants. A ruptured appendiceal mucinous adenoma seems to be the most common origin, but low grade ovarian malignancies are often associated. Peritoneal gelatinous diseases must be subdivided into disseminated peritoneal adenomucinosis, peritoneal mucinous carcinomatosis and intermediate cases. These entities have significantly different prognosis. Debulking surgery is the most common treatment but some are in favour of an ultra radical surgery with hyperthermic intra-peritoneal chemotherapy, with some encouraging results.

Technetium-99m HM-PAO single photon emission computed tomography imaging in transient global amnesia.

Five right-handed patients with pure transient global amnesia were evaluated with technetium-99m hexamethylpropyleneamine oxime single photon emission computed tomography after the amnesic attack. Independent of the interval between the procedure and the amnesic episode, single photon emission computed tomography demonstrated a decreased cerebral blood flow in the left temporal lobe in one patient and in the left parietotemporal region in three patients, with a more marked reduction in the temporal lobe. The remaining three patients were normal. A control single photon emission computed tomographic study was carried out in one patient 3 months after the amnesic attack and showed a left-sided persistent temporal hypoperfusion. These findings suggest that in some patients, transient global amnesia can be due to a vascular mechanism requiring strong investigations for vascular risk factors and appropriate treatment. During a follow-up period of 12 to 32 months, none of the patients with regional hypoperfusion suffered cerebrovascular events, suggesting that single photon emission computed tomography has no predictive value for further stroke.

Cerebral blood flow and perfusion reserve capacity in hemodynamic carotid transient ischemic attacks due to innominate artery stenosis.

Ischemia in the carotid artery territory due to atherosclerotic stenosis of the innominate artery is rare. We report a case in which transcranial Doppler ultrasonography (TCD) and SPECT with acetazolamide challenge proved the hemodynamic mechanism. The patient presented with three hypotensive TIAs in the right middle cerebral artery territory. Angiography showed a tight innominate artery stenosis and subclavian steal but no coexistent carotid or vertebrobasilar lesion. SPECT showed disturbed regional blood flow in the middle cerebral artery territory along with an exhausted perfusion reserve capacity. After angioplasty, flow velocities were normal and the perfusion reserve was restored. SPECT should be used to select patients at risk susceptible to benefit from angioplasty.

Subacute sensory neuronopathy associated with Sjögren's sicca syndrome.

Sensory subacute neuropathies associated with sicca syndrome without any systemic involvement have been reported rarely. A sixth case is described with what appears to be the first report of muscle and nerve biopsy findings. The histological studies revealed axonal degeneration without vasculitis in the sural nerve, and a slight denervation process and a discrete myositis in the gastrocnemius muscle, reflecting a subtle systemic disorder. The clinical course of a long-standing subacute sensory neuropathy, the biopsy-documented axonal degeneration, and the neurophysiological findings suggest involvement of the dorsal root ganglia.

HMPAO single-photon emission computed tomography in posterior circulation infarcts.

The sensitivity of single-photon emission computed tomography (SPECT) in evaluating posterior circulation infarcts compared with that of computed tomography (CT) or magnetic resonance imaging (MRI) remains unknown. In a hospital-based population, the authors studied SPECT, CT, and MRI in 35 consecutive patients presenting with acute infarction clinically localized in the thalamus (7), posterior cerebral artery (PCA) territory (15), brainstem (19), and cerebellum (3). Multiple infarcts were noted in 8 patients. Overall, the SPECT sensitivity was lower than that of MRI (21% vs 93%, p = 0.004) and CT (42% vs 65%, p = 0.046). The SPECT and CT sensitivities were not significantly different (67% vs 73%) for PCA infarcts. Performed within 24 hours, SPECT showed a relevant hypoperfusion in all PCA infarcts. For brainstem infarcts, CT (33%, p = 0.074) and MRI (91%, p = 0.004) were more sensitive than SPECT, which showed no hemispheric hypoperfusion. The sensitivity of the three imaging techniques was 100% for large cerebellar infarcts. For the small group of thalamic infarcts, the SPECT, CT, and MRI sensitivities were 14, 71, and 100%, respectively. Thus, SPECT compared to CT and MRI is not helpful in the subacute phase to localize PCA and cerebellar infarcts and is of limited value for thalamic infarcts. In the first hours, the absence of cerebral hypoperfusion in brainstem infarcts may help to differentiate them from hemispheric infarcts usually associated with profound hypoperfusion.

Abdominal wall weakness and lumboabdominal pain revealing neuroborreliosis: a report of three cases.

The authors report three cases of thoracic radiculoneuropathy disclosing neuroborreliosis. All three patients had low back and abdominal pain and two had marked abdominal wall paresis. EMG confirmed a motor involvement of the lower thoracic roots and CSF analysis revealed a lymphocytic meningitis in all three cases. Antibodies against Borrelia burgdorferi were present in both the serum and the CSF. A favourable outcome was obtained in all three patients with appropriate antibiotherapy. The differential diagnosis of this misleading presentation is discussed.

Intravenous rtPA thrombolysis in acute ischemic stroke.

Early intravenous thrombolysis within the first three hours has been considered in the United States as the first proven treatment in acute ischemic stroke. However, not all patients will respond to this therapy which is also associated with a risk of symptomatic, including fatal, intracranial hemorrhage. This overview addresses the issue of efficacy and safety of intravenous alteplase (tPA) in acute cerebral ischemia. The rationale for thrombolytic therapy and its limits are described. The controlled studies show that intravenous tPA is effective and safe when given under restrictive conditions within 3 hours after stroke onset, but the data for a larger therapeutic window between 3 and 6 hours remain controversial. The expected functional improvement and the risk of intracranial hemorrhage greatly depend on selective clinical and imaging criteria. For this purpose, MRI, using the diffusion- and perfusion-weighted sequences combined with MR- angiography, should be preferred to CT scan in the next future. Applicability of tPA thrombolysis in current neurological practice in Belgium is discussed. Before its generalization, this therapy should be restricted to specialized stroke centers and all treated patients should be recorded in a central data bank to guarantee continued surveillance.

[Vascular headache, thrombopenia and serotonin metabolism]. / Céphalées vasculaires, thrombopénie et métabolisme de la sérotonine.

The role of platelet serotonin in migraine remains a subject of controversy. However, the frequency of association of migraine with antibody-mediated thrombocytopenia would suggest that platelet dysfunction or impaired serotonin metabolism might play a role in migrainous attack. We report three new cases, two involving chronic idiopathic thrombocytopenia and one lupus. The observation of high levels of anti-platelet antibodies in close correlation with the occurrence of attacks suggests that the Serotonin Releasing Factor (SRF) could be concerned. This was suspected previously on the basis of in vitro studies. The hypothesis that other forms of migraine might be linked to an immunopathological process involving other immunoglobulins is proposed (Acta neurol. belg., 1988, 88, 290-296).

[Palpebral asymmetry and Graves' ophthalmopathy]. / Asymétrie palpébrale et ophtalmopathie de Graves.

The authors report one case of Graves' ophthalmopathy with a palpebral asymmetry, which was characterized by a left ptosis and a right palpebral retraction. In connection with Graves' disease, many ocular signs were described, including exophthalmos, ophthalmoplegia, palpebral retraction and visual loss, but unilateral ptosis was rarely reported. The orbital CT-scanning demonstrated the bilateral enlargement of the extraocular muscles, due to the infiltrative process met in Graves' disease. The ptosis and the palpebral retraction were suspected to be related to the extension of this infiltrative process in the levator palpebrae.

Lipids in ischemic stroke subtypes.

In secondary prevention, reduction of the risk of recurrent ischemic stroke might be expected with statins if a correlation can be established between hyperlipidemia and ischemic stroke or some specific ischemic stroke/TIA subtypes. However, such correlation remains controversial, and more particularly with the etiologic stroke/TIA subtypes. Few studies have evaluated the plasma lipid profile in different ischemic stroke subtypes, and notably in lacunar infarctions and cardioembolic strokes. The objectives of this case-control study was to determine (1) which cholesterol fractions is associated with large vessel disease (LVD), small vessel disease (SVD), and cardioembolic disease (CED); (2) whether hypertriglyceridemia is related more to any particular stroke subtype; and (3) whether the lipid profile is different between LVD and SVD which are both responsible for atherothrombotic cerebral ischemia. From a cohort of 485 patients, were selected 240 consecutive cases with ischemic stroke (n = 182) or transient ischemic attack (n = 58) due to a single etiology. The levels of total cholesterol (total-C), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), and triglycerides (TG) were measured in 61 patients with LVD, in 65 with SVD, and in 114 with CED, and compared with age- and sex-matched control subjects. Additional analysis was performed to compare the lipid profile between LVD and SVD after adjustment for other risk factors. Compared to controls, the total-C level was significantly higher in patients with SVD (p = 0.005) and LVD (p = 0.018). A significant increase in the LDL-C level (p < 0.004) and a significant decrease in the HDL-C level (p = 0.001) were only observed in the LVD patients. The three stroke subtypes showed higher TG levels than the controls (CED, p = 0.037; SVD, p < 0.001; LVD, p = 0.014). The plasma lipid profile was similar in the SVD and LVD subtypes except for HDL-C, which was significantly lower in LVD than in SVD (p = 0.047). Logistic regression adjusted for confounders showed that decreased HDL-C (p = 0.020), and smoking (p = 0.019) were significant discriminative factors for LVD vs. SVD. In conclusion, this controlled study shows that hypertriglyceridemia is commonly found in patients with ischemic cerebrovascular disease whatever the etiologic subtype, whereas hypercholesterolemia is related more to SVD and LVD. In addition to hypertension and diabetes, hypercholesterolemia may also be involved in the etiology of SVD and differs from LVD by a lower decrease in HDL-C.