[Improvement in swallowing difficulties treated by subcutaneous apomorphine infusion after deep brain stimulation in Parkinson's disease]. / Amélioration des troubles de la déglutition par l'apomorphine en perfusion sous cutanée au décours de la mise en place d'électrodes de stimulation cérébrale profonde, dans la maladie de Parkinson.

In Parkinson's patients, swallowing difficulties may result in inhalation pneumonia, with a potentially serious prognosis. They may be revealed by withdrawal of L-dopa, especially after deep brain stimulation surgery. The following two cases illustrate the usefulness of apomorphine.

Relationship between sleep apnoea syndrome, snoring and headaches.

There is still a controversy regarding the relationship between sleep apnoea syndrome and headaches, especially morning headaches. Our objectives were: (i) to compare the prevalence and the clinical data of headaches in sleep apnoea syndrome (SAS) and control (snorers) groups defined by polysomnographic recording; (ii) to analyse the clinical improvement of headaches with appropriate treatment; and (iii) to correlate headaches with mood disorders, and nocturnal respiratory and architectural sleep parameters in order to understand the underlying pathophysiological mechanisms. This is a prospective study of 324 consecutive patients referred to our sleep centre for snoring. Of these, 312 patients who underwent sleep polysomnography were finally included. Patients and controls were interviewed about their medical past, headache history and clinical characteristics, their daytime sleepiness (Epworth's sleepiness scale) and their mood disorders (Zerssen's scale). Follow-up of patients with headaches (SAS and control groups), treated or not, was also assessed. According to our definition of SAS, patients were dissociated in SAS (n=164) and snorers (n=148). Fifty-three SAS patients had headaches, of whom 58.5% (n=30) suffered from morning headaches. However, there was no statistical difference between the two groups concerning the prevalence and the clinical characteristics of headaches. In addition, headaches and morning headaches were not correlated with nocturnal respiratory and architectural sleep parameters, nor with excessive daytime sleepiness, but were strongly correlated with mood disorders. In 36 SAS patients, headaches improved under treatment, but this was not statistically different from what was found among untreated snorers. Headaches and morning headaches are common in patients with SAS but may be considered as a non-specific symptom. The underlying mechanisms are not fully elucidated but depression could play an important role. Despite this absence of specificity, the treatment of SAS, especially nasal continuous positive airway pressure, leads to an improvement in headaches in several cases.

[Hallucinations, delusions, and nocturnal events in 152 Parkinson's patients: a regional survey]. / Hallucinations, idées délirantes, événements nocturnes chez 152 patients atteints de maladie de Parkinson. Enquête régionale.

Parkinson's disease cannot be reduced to its motor symptoms. Psychological and behavioral disorders often accompany its development. Our study was conducted in June 1999 among 36 neurologists practicing in hospital or private clinic settings in the Poitou-Charentes area. Neurologists were requested to record hallucinations, delusions and nocturnal events observed in Parkinson's patients. A total of 152 reports were collected from 17 physicians. Fifty-three percent of the patients attended hospital clinics and 47p.100; were seen at the physician's office. Hallucinations were recorded in 23.1p.100; of the patients. The risk of hallucination symptoms was higher among patients seen at hospital clinics and who had more advanced disease. Only 7.2p.100; of the patients reported delusions, most often of a persecution type. Nocturnal events affected 49.3p.100; of the patients. The appearance of such symptoms was highly related to Hoehn and Yahr stage and was more frequent in hospital patients. Hallucinations, delusions, and nocturnal events affect patients with advanced Parkinson's disease, associated with long-term L-dopa treatment. Eighty-three percent of the patients had such symptoms and most of them used L-dopa. This long-term treatment is linked to these three symptoms. Hallucinations were increasingly reported for patients with increasing long-term medication with dopaminergic agonists. Nocturnal events, for patients on L-dopa, were associated with advanced disease, long-term treatment with L-dopa, and hospitalization. Psychic and behavioral disorders appear frequently in Parkinson's disease patients and are inter-related. Physicians should be aware of the relationship with treatment to avoid aggravation.

[Aphasic hypergraphy in the course of a bilateral hemispheric glioblastoma]. / Hypergraphie aphasique dans l'évolution d'un glioblastome bi-hémisphèrique.

A 68-year old patient, suffering from a left temporal and right frontal multifocal glioblastoma, initially presented Wernicke's aphasia with abnormal behavior. After a stereotaxic biopsy of his right frontal lesion, the patient developed an activity of ceaseless writing associated with mutism. This hypergraphic behavior was accompanied with a production of numerous aphasic paragraphics contrasting with the mutism. Such association could evoke the rise of a suppressive activity of the right hemisphere on graphic functions linguistically organized by the left hemisphere.

[The recording of cognitive evoked potentials during and after transient global amnesia: report of three cases]. / Enregistrement des potentiels évoqués cognitifs au cours et au décours de l'ictus amnésique: quatre cas.

It is of interest to record event-related potentials in the course of transient global amnesia (TGA) because the hippocampus and diencephalon, generally considered to be the sites of the dysfunction responsible for the amnesic episodes are also considered as two possible generators of the P300 wave. However, the only four cases reported so far in the literature showed an intact auditive P300 in three cases and an intact auditive P300 with reduction of visual P300 in one case. Here are reported four new cases. The P300 wave was readily identifiable in all four cases, without any amplitude reduction, thus suggesting that the condition did not entail inactivation or functional depression of P300 generators. Concerning P300 latency, in one case it was delayed but became normal after the ictus. In the second case, the latency, although within normal limits, shortened after the ictus. In the third and the fourth cases, the latency, initially within normal limits, remained unchanged. These apparently disparate results should be analysed in the light of the results of isotope measurement of cerebral blood flow during the amnesia, which are also inconsistent but most frequently indicate bilateral temporal or thalamic flow reduction. It remains to be determined in the future whether the stability or change in the P300 will make it possible to predict the brain region involved in transient global amnesia, which could perhaps vary from one patient to another.

[Bilateral medial medullary infarction]. / Infarctus bulbaire médian bilatéral.

We report a case of a 42-year old man with a bilateral medial medullary stroke (MMS) with favorable outcome. First described by Spiller in 1908, the MMS accounts for less than 0,5% of all cerebral infarcts. It may be unilateral or more rarely bilateral, and may often be the consequence of the atherosclerosis. The clinical features of MMS classically associate contralateral hemiparesis and lemniscal hypoesthesia accompanied by ipsilateral lingual palsy and sometimes oculomotor disturbances (upbeat nystagmus). With the advent of magnetic resonance imaging, some restricted or unusual clinical manifestations can be attributed to this localization. The benign form of MMS seems much more common than MMS with poor prognosis.

[Cerebral ischemic disorders in the young subject. Etiologic diagnostic approach to ischemic disorders]. / Accidents ischémiques cérébraux du sujet jeune. Démarche étiologique en cas d'accidents ischémiques.

EXHAUSTIVE WORK-UP: Initial explorations include standard laboratory tests, electrocardiogram, ultrasound exam of the cervical vessels, and transthoracic echocardiogram. If the initial work-up is normal, a transesophageal echocardiogram and/or an angiogram (arteriography, magnetic resonance angiography or spiral CT) can be helpful in addition to further immunology and hemostasis explorations. TRANSESOPHAGEAL ECHOCARDIOGRAM: This is a cardinal exam for the etiological work-up in young subjects having suffered a cerebral ischemic event. It can detect anomalies involving the left atrium and auricle, the interventricular septum or the aortic arch missed on standard echocardiography. CONVENTIONAL ARTERIOGRAPHY: There is a trend to replace conventional arteriography with less invasive techniques such as magnetic resonance angiography or spiral CT. When coupled with an ultrasound exploration of the cervical and intracranial vessels, the contribution of these new techniques is similar to that of conventional arteriography, particularly in patients with arterial disease.

[Papillary fibroelastoma. A rare etiology of strokes in young patients]. / Fibroélastome papillaire. Une étiologie rare des accidents vasculaires cérébraux du sujet jeune.

BACKGROUND: The papillary fibroelastomas are cardiac lesions, which typically occur on the cardiac valves, but rarely on the endocardium. The incidence of these benign primitive tumors varies from 0.002 to 0.33% and increases with advancing age. METHODS: We report two cases of stroke, one in a 31-year-old man and the other in a 48-year-old woman, both admitted to the same stroke center. RESULTS: The diagnostic studies were normal in these two patients, except for the echocardiography. The first showed an echogenic mass on the mitral valve on transthoracic echocardiography (TTE), confirmed by the transesophageal echocardiography (TEE). The second demonstrated a mass on the sigmoid aortic valve on TEE, but the TTE was normal. For these two patients, a surgical excision was carried out and pathologic examination concluded to a papillary fibroelastoma. After surgery, no recurrence was observed. CONCLUSIONS: The papillary fibroelastomas are usually asymptomatic and easily detected by TEE. However, it can be revealed by stroke, myocardial infarction and lower limbs ischemia. These cardiac tumors should be surgically removed, since their complete excision remains the only means of avoiding a recurrence of embolism.

Recurrent intracerebral hemorrhage.

Between 1984 and 1994, of the 375 patients admitted to our department for intracerebral hemorrhage (ICH), 24 (6.4%) had a recurrent ICH. There were 15 women and nine men and the mean age of the patients was 64.7 +/- 9.4 years (range 49-81) at the first bleeding episode and 68.7 +/- 7.5 years (range 57-83) at the second. The mean interval between the two bleeding episodes was 47.5 +/- 30.5 months (range 3 months to 14.8 years). Nine patients presented with more than one recurrence of ICH. Seventy-one percent of the patients were hypertensive. The site of the first hemorrhage was lobar in 17 patients, ganglionic (putamen, thalamus, or caudate nucleus) in six patients, and subdural in one. The recurrent hemorrhage occurred at a different location from the previous ICH. The most common pattern of recurrence was "lobar-lobar" (14 patients) and more rarely "ganglionic-ganglionic" (five patients), which was always observed in hypertensive patients. The outcome after the recurrent hemorrhage was usually poor, with severe cognitive impairment. By comparison with 81 patients followed up to 24 months (47.9 +/- 22.2 months) with isolated ICH without recurrence, only lobar hematoma and a younger age were risk factors for recurrences whereas sex and previous hypertension were not. The mechanisms of recurrence of ICH were multiple (hypertension, cerebral amyloid angiopathy). Control of blood pressure after the first hemorrhage may prevent ICH recurrences.