Old microbleeds are a potential risk factor for cerebral bleeding after ischemic stroke: a gradient-echo T2*-weighted brain MRI study.

BACKGROUND AND PURPOSE: T2*-weighted gradient-echo MRI is known to detect old microbleeds (MBs), considered indicative of microangiopathy. MBs might be a potential risk factor for early cerebral bleeding (CB) after ischemic stroke. Therefore, we assessed the impact of MBs on the occurrence of CB after cerebral infarction. METHODS: We included prospectively stroke patients who had documented ischemic damage. The imaging protocol involved baseline CT scan, T2*-weighted gradient-echo MRI, diffusion-weighted imaging, T2-weighted imaging, and magnetic resonance angiography and had to be performed within 24 hours after symptom onset. The assessment of CB with T2*-weighted gradient-echo sequence necessitated a focal area of signal loss either within the ischemic area revealed by diffusion-weighted imaging or remote from it. Old MBs were defined on T2*-weighted images as homogeneous rounded areas of signal loss without surrounding edema. CT scan was systematically repeated within the first week to verify CB as diagnosed by the T2* weighted sequence. RESULTS: One hundred patients (mean age, 60 +/- 13 years; range, 19 to 83 years; 58 men, 42 women) met the inclusion criteria. MBs were seen in 20 patients on T2*-weighted imaging. Multivariate logistic regression analysis revealed that age, diabetes, previous use of antithrombotic drugs, evidence of an atherothrombotic source of stroke, and lacunar infarct were significantly associated with MBs (P<0.0001). CB was diagnosed in 26 patients: at the acute stage by T2*-gradient echo sequence in 18 patients and with CT scan performed within the first week in 8 patients. Multivariate logistic regression analysis showed that baseline National Institutes of Health Stroke Scale score, diabetes, and MBs were considered significant and independent predictors of CB (P<0.001). CONCLUSIONS: Although the pathogenesis of CB after ischemic stroke is multifactorial, the increased observation of CB in patients with MBs suggests that the associated vascular vulnerability contributes to CB.

Baseline magnetic resonance imaging parameters and stroke outcome in patients treated by intravenous tissue plasminogen activator.

BACKGROUND AND PURPOSE: We designed a prospective sequential pretreatment and posttreatment MRI study to assess the relation between neuroimaging parameters and clinical outcome in patients treated with intravenous recombinant tissue-type plasminogen activator (rtPA). METHODS: Patients with symptoms of acute hemispheric ischemic stroke were recruited. The National Institutes of Health Stroke Scale (NIHSS) score was assessed at baseline and at days 1, 7, and 60, and the modified Rankin scale (mRS) at day 60, by which outcome was classified in terms of independence (mRS score 0, 1, or 2) or severe disability or death (mRS score 3 through 6), was assigned. Multimodal stroke MRI was performed at presentation and repeated at day 1. MRI procedures included magnetic resonance angiography, T2* gradient-echo sequence, echoplanar imaging, and isotropic diffusion- (DWI) and perfusion-weighted (PWI) imaging. Patients were treated with intravenous rtPA after MRI completion. RESULTS: Twenty-nine patients (16 men and 13 women; mean+/-SD age, 65+/-14 years) underwent MRI; the mean time from symptom onset to treatment was 255+/-62 minutes. Twenty-six patients had a vessel occlusion, and 15 patients experienced a partial (Thrombolysis in Myocardial Infarction [TIMI]-2) or total (TIMI-3) recanalization at day 1, whereas 11 patients had a persistent occlusion. Mean NIHSS scores at day 60 were 5.7+/-5.4 if recanalization had occurred and 14+/-2 in cases of persistent occlusion. According to the mRS, 13 patients were independent (mRS 0 through 2), whereas severe disability or death (mRS 3 through 6) was observed in 15 patients. A better outcome was observed when recanalization was achieved (r=-0.68, P=0.0002). PWI volume and time to peak (TTP) within the DWI lesion assessed before therapy were correlated with day-60 NIHSS score (PWI volume: r=0.51, P=0.006, TTP: r=0.35, P=0.07). The day-0 DWI abnormality volume was well correlated with day-60 NIHSS score (r=0.58, P=0.001). Multiple regression linear analysis showed that 2 factors mainly influenced clinical outcome: (1) recanalization, with a high correlation with NIHSS score at day 60 (P=0.0001) and (2) day-0 DWI lesion volume, which is closely associated with day-60 NIHSS score (P=0.03). CONCLUSIONS: Baseline DWI volume and recanalization are the main factors influencing clinical outcome after rtPA for ischemic stroke.

Large-artery stroke in a young patient with Crohn's disease. Role of vitamin B6 deficiency-induced hyperhomocysteinemia.

An increased incidence of ischemic stroke has been reported in patients with Crohn's disease. Cerebral infarcts are usually considered as a complication of the hypercoagulable state associated with this inflammatory bowel disease (IBD). The association between Crohn's disease, hyperhomocysteinemia and large-artery stroke of the young has rarely been reported. A 39-year-old woman, with prior medical history of Crohn's disease and hypertension, presented with an ischemic stroke of the left internal carotid artery (ICA) territory. Etiological workup disclosed bilateral high-grade ICA stenosis and atheroma of the subclavian and vertebral arteries. Exhaustive search for prothrombotic factors showed inflammation, with an increased level of fibrinogen and factor IX, and a marked hyperhomocysteinemia. Both vitamin B1 and vitamin B6 plasmatic levels were decreased. Heterozygous C677T methylene-tetrahydrofolate reductase gene mutation was present. This observation highlights the combined proatherogenic effect of vitamin B deficiency-induced hyperhomocysteinemia and inflammation leading to large-artery stroke of the young in the setting of Crohn's disease. Our case report stresses the importance of vitamin deficiency screening in patients with IBD in terms of stroke prevention.

[Anterior choroidal artery infarction revealing polyarteritis nodosa]. / Infarctus de l'artère choroïdienne antérieure révélateur d'une périartérite noueuse.

An 81-year old man presented with a sudden right ataxic hemiparesis. Brain CT scan showed a left anterior choroidal artery territory infarction. Biological signs of inflammation were present without any evidence of infection or neoplasm. The patient's clinical status deteriorated with fever, loss of weight and confusion. Muscle biopsy showed characteristic abnormalities of polyarteritis nodosa (PAN). Oral corticosteroids plus monthly pulse intravenous cyclophosphamide were started. A rapid clinical improvement was observed as well as the resolution of inflammation within one month. Twenty months later, the patient had recovered normal cognitive function and was able to carry out all usual activities. We describe the CNS complications of PAN and the therapeutic options.

[Delayed post-anoxic leukoencephalopathy]. / Leucoencéphalopathie post-anoxique d'apparition retardée.

INTRODUCTION: The onset of post-anoxic encephalopathies can be delayed after the acute hypoxic injury. CASE REPORT: We present the case of a 45-year-old woman who achieved complete recovery from an episode of hypoxia related to a suicide attempt (ingestion of benzodiazepine). Three weeks later she developed a confusional state with akinetic mutism and parkinsonism. Brain CT-scan showed bilateral hemispheric white matter hypodensities. MRI showed extensive bilateral hyperintensities on T2-weighted and Flair sequences within the hemispheric white matter and the globus pallidus. EEG showed diffuse slow activity. All investigations for leukodystrophies were negative. Brain biopsy showed normal cortex and widespread demyelination with axonal sparing in the underlying white matter. The patient experienced a partial clinical recovery. CONCLUSION: The clinical course and the results of paraclinic investigations were consistent with the diagnosis of delayed post-anoxic leukoencephalopathy.

[Intra-cavernous aneurysm of the internal carotid artery complicating sphenoid sinusitis]. / Anévrysme de la carotide interne intra-caverneuse compliquant une sinusite sphénoïdale.

INTRODUCTION: Mycotic or post-infectious aneurysm of the intra-cavernous portion of the internal carotid artery is uncommon. CASE REPORT: We report here the case of a patient who developed progressive left ophthalmoplegia, with left hemi-crania three weeks after a tooth extraction. The patient was febrile. Neuroradiological and microbiological analysis led to the diagnosis of sphenoidal and ethmoidal sinus infection with extension to the left cavernous sinus. An aneurysm of the intra-cavernous portion of the left internal carotid artery was also found. CONCLUSIONS: The risk of rupture for this kind of aneurysm is difficult to assess. Treatment always consists in prolonged and adapted antibiotic therapy. For certain patients neurosurgical or endovascular repair is necessary. We followed our patient for four Years without surgical intervention. The diameter of the aneurysm has remained stable.

[JC virus infection and lympho-plasmocytic infiltration of the central nervous system revealed by a cerebellar syndrome]. / Infection par le virus JC et infiltration lympho-plasmocytaire du système nerveux central se révélant par un syndrome cérébelleux.

We report the case of a 74 year-old woman who had been treated since 8 years for a Waldenström's disease. She also was affected by a progressive multi-focal leukoencephalopathy. The interest of this case lies in two principal features. On the one hand, the clinical and radiological signs were restricted to the cerebellum and to the brainstem, on the other hand, brain examination revealed lymphocytes and plasma cells infiltration suggestive of an associated Bing and Neel syndrome.

Hyperthyroidism and cerebral venous thrombosis.

The demonstration of an underlying prothrombotic condition in cerebral venous thrombosis (CVT) may have important practical consequences in terms of prevention. Thyrotoxicosis through a hypercoagulable state may be a predisposing factor for CVT. The authors present the cases of 4 patients who developed CVT and hyperthyroidism. At the acute stage, hyperthyroidism was associated with an increase in factor VIII (FVIII). At follow-up, FVIII level remained increased in 2 patients. Hyperthyroidism may have an impact on FVIII level. Accordingly in patients with hyperthyroidism and neurological symptoms, the diagnosis of CVT should be considered and an exhaustive coagulation screening may be appropriate.

Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator.

OBJECTIVE: To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients. METHODS: 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion. RESULTS: The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not. CONCLUSION: Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.

Intravenous r-TPA in vertebrobasilar acute infarcts.

Presented are the clinical data of 18 consecutive patients who were treated by IV recombinant tissue plasminogen activator (r-TPA) for suspected vertebrobasilar (VB) acute ischemia within 7 hours. The mean delay for treatment was 5 +/- 3.6 hours. Mean baseline NIH Stroke Scale score was 17 +/- 4. At 3 months, 10 patients were independent (modified Rankin Scale [mRS] score = 0 to 2), whereas 8 patients showed a poor outcome (mRs = 3 to 6). IV r-TPA in VB ischemia in a 7-hour window may be safe and efficient.

Cerebral venous thrombosis: clinical outcome and systematic screening of prothrombotic factors.

The authors studied 16 consecutive cases of cerebral venous thrombosis (CVT). Clinical outcome was good or excellent in 14 patients. Comprehensive hypercoagulable screening was done at least 3 months after the onset of CVT, including evaluation of genetic coagulation disorders and plasma levels of homocysteine and factor VIII. This screening was positive in 12 patients (75%). An acquired prothrombotic factor was identified in 9 of these 12 patients. Elevation of factor VIII plasma level was the most common coagulation disorder (8 patients).

The first case of new variant Creutzfeldt-Jakob disease in France: clinical data and neuropathological findings.

Clinical data and autopsy findings in a case of new variant Creutzfeldt-Jakob disease (vCJD) are reported. This case, the first histologically confirmed case described outside the United Kingdom, very much resembles the cases described by Will et al. [(1996) Lancet 347:921-925] and Zeidler et al. [(1997) Lancet 350:903-908, 908-910]. Neuropathological studies failed to reveal any conspicuous clues that could be relevant for understanding the pathophysiology of the disease. For epidemiological surveillance, neuropathologists should scrutinize suspected cases keeping in mind the possibility of vCJD.