Internal border zone injury predicts the functional outcome of acute MCA stroke patients.

BACKGROUND AND PURPOSE: Classification of deep (D), superficial (S) MCA territories and their junctional vascular area (the internal border zone, IBZ) can help to identify patients most likely to benefit from aggressive reperfusion therapy after stroke. We tested the prognostic value of an IBZ injury compared to DWI-ASPECTS and infarct volume. MATERIALS AND METHODS: DW lesions of 168 patients with acute (4.2±6.5 h) MCA strokes were retrospectively examined and manually delineated. Patients with haemorrhagic transformation or other neurological diseases were excluded. Clinical data were recorded within 24 h following symptom onset and 48 h for patients who benefited from reperfusion therapy. The occurrence of an IBZ injury was determined using a standardized stereotaxic atlas. Performance to predict a good outcome (mRS<3 at 3 months) was estimated through ROC curves for DWI-ASPECTS≤6, lesion volume≥100 mL and IBZ injury. Logistic regression models were performed to estimate independent outcomes for infarct volume and IBZ injury. RESULTS: Infarcts involving the IBZ were larger (94.9±98.8 mL vs. 30.2±31.3 mL), had higher NIHSS (13.8±7.2 vs. 7.2±5.7), more frequent MCA occlusions (64.9% vs. 28.3%), and worse outcomes (mRS 3.0±1.8 vs. 1.9±1.7), and were less responsive to IVtPA (34±47% vs. 55±48% of NIHSS improvement). The area under the ROC curves was comparable between the occurrence of IBZ injury (0.651), ASPECTS≤6 (0.657) and volume≥100 mL (0.629). Logistic regression analyses showed an independent effect of an IBZ injury, especially for superficial MCA strokes and for patients who benefited from reperfusion therapy. CONCLUSION: An IBZ injury is an early and independent marker of stroke severity, functional prognosis and treatment responsiveness.

[Systematic analysis of evaluations of Objective Structured Clinical Exam (OSCE) multiple circuits: Explanatory variables and inter-rater correlations]. / Analyse systématique des évaluations de circuits multiples d'examen clinique objectif structuré (ECOS) : variables explicatives et corrélations inter-évaluateurs.

INTRODUCTION: Objective Structured Clinical Examinations (OSCEs) assess professional performance in a simulated environment. Following their integration into the reform of the 2nd cycle of medical studies (R2C), this pedagogical modality was implemented in France. This study investigates the variability of students' OSCE scores, as well as their inter-rater reproducibility. METHODS: This single-center retrospective study covered several sessions of evaluative OSCE circuits conducted between January 2022 and June 2023. Variables collected were: baseline situation family, competency domain, presence of a standardized participant for stations; gender and professional status for evaluators; scores (global, clinical and communication skills), number of previously completed OSCE circuits and faculty scores for students. RESULTS: The variability of the overall score was explained mainly (79.7%, CI95% [77.4; 82.0]) by the station factor. The student factor and the circuit factor explained 7.5% [12.9; 20.2] and<0.01% [2.10-13; 2.10-9] respectively. The inter-rater intra-class correlation coefficient was 87.2% [86.4; 87.9] for the global score. Station characteristics (starting situation, domain) and evaluator characteristics (gender, status) were significantly associated with score variations. CONCLUSION: This first study on the variability of OSCE circuit scores in France shows good reproducibility with influence of station characteristics. In order to standardize circuits, variability linked to the domain competency should be considered as well.

Spinal Arachnoid Web: A didactic report of two cases with clinical, radiological, surgical and pathological correlations.

BACKGROUND: Arachnoid web (AW) is a rare but probably underestimated cause of spinal cord injury that is complex to diagnose due to subtle MRI findings and similarities to other better-known diseases such as arachnoid cyst (AC) or transdural spinal cord herniation (TSCH). Increased recognition of AW is mandatory since delay in diagnosis can lead to potentially serious neurological sequelae. CASE PRESENTATIONS: We report two additional cases of AW for didactic purposes, with special emphasis on the distinctive MRI and intraoperative findings. Both patients presented with progressively worsening neurological symptoms, including proprioceptive ataxia, motor weakness, numbness and neuropathic pain. The diagnosis of AW was suspected on the basis of specific MRI criteria, especially the so-called "scalpel sign". Formal confirmation of the diagnosis was obtained in two patients that were managed surgically. Postoperative follow-up demonstrated significant functional recovery. DISCUSSION: There is a need for better recognition of AW by the medical community. Careful analysis of MRI semiology is crucial for the distinction between AW, AC and TSCH. Prompt and accurate diagnosis is mandatory to conserve functional prognosis, since appropriate surgical treatment with AW resection is curative, halting or even resolving the neurological symptoms.

[Pneumomediastinum, a rare complication secondary to a minor maxillary fracture]. / Le pneumomédiastin, une complication rare d'une fracture mineure du maxillaire.

OBSERVATION: A pneumomediastinum was discovered fortuitously on a CT scan prescribed to a patient for facial and cranial trauma. Emphysema was attributed secondarily to an anterolateral maxillary wall fracture. The evolution was favorable after simple clinical and radiological surveillance. DISCUSSION: The observation of a pneumomediastinum should first be related to a tracheal or esophageal wound with a severe prognosis. Endoscopy under general anesthesia was not necessary for our patient thanks to CT scan with 3D reconstruction. There is no consensus for systematic antibioprophylaxis.

EEG analysis in anti-NMDA receptor encephalitis: Description of typical patterns.

OBJECTIVE: To describe different electroencephalogram (EEG) patterns and epileptic features in patients with anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE), their timeline in the course of the disease, their correlation with clinical data and outcome. METHODS: We retrospectively analyzed EEG recordings between November 2007 and June 2016 in 24 consecutive patients. RESULTS: Three EEG patterns were described: Excessive Beta Activity range 14-20 Hz (EBA) in 71% of patients, Extreme Delta Brush (EDB) in 58% and Generalized Rhythmic Delta Activity (GRDA) in 50%. They followed a chronological organization in the course of the disease: EBA appeared first, followed by EDB and then GRDA, as the median time of appearance for EBA, EDB and GRDA was respectively 10, 16.5 and 21.5 days. The presence of GRDA was strongly associated with concomitant abnormal movements (p < 0.001). CONCLUSION: This study focuses on EEG and epileptic abnormalities in anti-NMDARE. Beyond EDB that were already reported (Schmitt et al., 2012), GRDA seems to be a very frequent pattern. Its rhythmic aspect should not be misinterpreted as seizure or status epilepticus, to avoid antiepileptic treatments intensification. SIGNIFICANCE: This study comforts the importance of EEG in anti-NMDARE, with a better description of EEG abnormalities for a better treatment management.

Atypical permanent neurological sequelae after an acute intoxication with lithium and aripiprazole.

OBJECTIVES: The aim of the present case report was to describe atypical neurological sequelae after a lithium and aripiprazole co-intoxication in a suicide attempt. METHODS: We report the case of a 31-year-old patient with bipolar disorder who developed, after lithium and aripiprazole massive ingestion, a severe pseudobulbar dysarthria and motor disorders suggestive of basal ganglia micro lesions. We review literature on neurological sequelae due to acute lithium intoxications. RESULTS: Acute lithium intoxication can cause permanent neurological sequelae, the most frequent clinical feature being a permanent cerebellar syndrome. Moreover, the widely-prescribed combination of lithium with antipsychotics increases the neurotoxicity in lithium intoxications. In this case, both atypical neurological syndrome and normal paraclinical investigations lead first to misdiagnose the lithium neurological damages. CONCLUSIONS: This case illustrates that acute lithium intoxications can result in serious and potentially permanent neurological deficits, which remain difficult to diagnose. Imaging abnormalities are not constant, and neurological presentation can be atypical.

A single session of repetitive transcranial magnetic stimulation of the prefrontal cortex reduces cue-induced craving in patients with gambling disorder.

BACKGROUND: Gambling disorder (GD) is common and disabling addictive disorder. In patients with substance use disorders, the application of repetitive transcranial magnetic stimulation (rTMS) over the dorsolateral prefrontal cortex (DLPFC) offers promise to alleviate craving. We hypothesized that applying real compared to sham rTMS over the left DLPFC would reduce gambling craving in patients with GD. METHODS: In a randomized sham-controlled crossover design, 22 treatment-seeking patients with GD received real or sham treatment with high frequency rTMS over the left DLPFC followed a week later by the other type of treatment. Before and after each rTMS session, participants rated their gambling craving (from 0 to 100) before and after viewing a gambling video used as a cue. We used the Yale-Brown Obsessive Compulsive Scale adapted for Pathological Gambling to assess gambling behavior before and 7 days after each rTMS session. RESULTS: As compared to sham (mean +0.74; standard deviation±3.03), real rTMS significantly decreased cue-induced craving (-2.12±3.39; F(1,19)=4.87; P=0.04; partial η2=0.05; 95% CI: 0.00-0.21). No significant effect of rTMS was observed on gambling behavior. CONCLUSIONS: Patients with GD reported decreased cue-induced craving following a single session of high frequency rTMS applied over the left DLPFC. Further large randomized controlled studies are needed to determine the usefulness of rTMS in GD.

[Oxytocin and maternal stress during the post-partum period]. / Ocytocine et stress de la mère au cours de la lactation en post-partum. L'ocytocine est-elle impliquée dans la confiance en soi de la mère allaitante? Revue de la littérature.

Oxytocin is required for lactation by promoting milk expulsion. Oxytocin has also been reported to exert a positive role in social attachment. The postpartum period has been shown to be crucial for maternal behavior initiation, and required self-trust reinforcement. However, this period is also remarkable for the high risk exposure of either psychic or physical stress. A negative impact on young mother is suspected, both in the short, medium or long term, which can even be deleterious for child-mother relationships. During lactation in female rats and sheep, oxytocin production has been proved to decrease stress-induced hormonal changes and later consequences. In human beings, only the first hour after breast-feeding seems to protect against physical or psychic stress. Oxytocin improves the stress-induced response by reducing the ACTH and cortisol secretion thus representing a potential therapeutic pathway in post-partum pathologies such as depression. Thus, this review of recent literature about oxytocin and stress during post-partum period, leads to the assumption that oxytocin, at the moment of installation of breastfeeding, acts not only on the physiological condition, but also on the psychic condition of the mother.

Presurgical Assessment of the Sensorimotor Cortex Using Resting-State fMRI.

BACKGROUND AND PURPOSE: The functional characterization of the motor cortex is an important issue in the presurgical evaluation of brain lesions. fMRI noninvasively identifies motor areas while patients are asked to move different body parts. This task-based approach has some drawbacks in clinical settings: long scanning times and exclusion of patients with severe functional or neurologic disabilities and children. Resting-state fMRI can avoid these difficulties because patients do not perform any goal-directed tasks. MATERIALS AND METHODS: Nineteen patients with diverse brain pathologies were prospectively evaluated by using task-based and resting-state fMRI to localize sensorimotor function. Independent component analyses were performed to generate spatial independent components reflecting functional brain networks or noise. Three radiologists identified the motor components and 3 portions of the motor cortex corresponding to the hand, foot, and face representations. Selected motor independent components were compared with task-based fMRI activation maps resulting from movements of the corresponding body parts. RESULTS: The motor cortex was successfully and consistently identified by using resting-state fMRI by the 3 radiologists for all patients. When they subdivided the motor cortex into 3 segments, the sensitivities of resting-state and task-based fMRI were comparable. Moreover, we report a good spatial correspondence with the task-based fMRI activity estimates. CONCLUSIONS: Resting-state fMRI can reliably image sensorimotor function in a clinical preoperative routine. It is a promising opportunity for presurgical localization of sensorimotor function and has the potential to benefit a large number of patients affected by a wide range of pathologies.

A new tool for evaluating energy expenditure: the "QAPSE" development and validation.

The objective of this study was to design and validate a working tool for the objective evaluation of daily energy expenditure (DEE) by means of a simple, noninvasive method: the QAPSE (Saint-Etienne Physical Activity Questionnaire), a questionnaire about physical activity (PA) over a period of 7 d (168 h). This eight-page questionnaire is designed to provide a complete picture of the subject's habitual PA without any restriction concerning the activities investigated, nor any specialization in relation to health components. It investigates the five areas of PA during daily life: work or way of keeping occupied, leisure activity (sports and nonsports activities), housework, basic everyday activity, moving about from place to place. Assessment of physical activity was conducted in 115 healthy volunteer subjects of both sexes aged 20-88. The values of mean habitual daily energy expenditure (MHDEE) obtained varied between 6,510 and 24,331 kJ.d-1. The MHDEE were in agreement with the data reported in the literature for various groups differing in respect to level of activity, sex, and age. The study demonstrated the reproducibility of the QAPSE (r = 0.997; N = 20; P < 0.0001). Its validity was tested in a comparative study between MHDEE and caloric intake (r = 0.576; N = 20; P < 0.01).

[Outcome of endoscopically assisted surgical treatment of mandibular condyle fractures: a retrospective study of 22 patients]. / Résultats du traitement chirurgical assisté par endoscopie des fractures du condyle mandibulaire: étude rétrospective sur 22 patients.

INTRODUCTION: The condylar region is a frequent localization of mandibular fractures; there are various types of management. Mini-invasive endoscopic surgery is an alternative to open reduction. We had as goal to evaluate the outcome of this technique. MATERIAL AND METHODS: We performed a monocentric retrospective study of patients consecutively operated for a condylar fracture (type II to V in the Spiessl and Schroll classification) with intraoral route and endoscopic assistance, during 30 months. We assessed the functional and radiological outcomes, and the complications. RESULTS: Twenty-two patients (25 fractures) were included. Seventeen patients (19 fractures) could be followed (mean follow-up: 16.7 months). The mean values were: interincisal opening, 45mm (±8.4); protrusion, 8.3mm (±1.9); ipsilateral excursion of the jaw: 8.6mm (±2); contralateral excursion: 8.7mm (±4). Three routes were used combined with a preauricular approach. The fracture reduction was good for 10 of the 19 fractures and poor for 3. The complications were: 3 cases of infection, 1 case of fixation failure with good consolidation; for combined approaches: 2 cases of temporary facial palsy and 2 cases of Frey syndrome. DISCUSSION: Endoscopic assistance for the surgical management of the fracture of mandibular condyle is a reliable technique, with a good functional outcome, and a low rate of specific complications, especially for facial nerve lesion or esthetic outcome.

Isolated primary central nervous system lymphoma arising from the optic chiasm.

A 58-year-old previously healthy woman rapidly developed progressive bilateral visual loss. Magnetic resonance imaging revealed a bulging appearance of the optic chiasm, with homogeneous enhancement after gadolinium administration, which suggested an optic glioma or inflammatory disease. In the absence of (para)clinical clues for a specific diagnosis despite extensive investigation, a biopsy of one optic nerve was performed, resulting in a diagnosis of non-Hodgkin B-cell lymphoma. There was no evidence of any other ocular or systemic involvement, therefore the conclusion was that this immunocompetent patient had a primary central nervous system lymphoma isolated in the anterior visual pathway. Treatment included two cycles of polychemotherapy (rituximab, methotrexate, carmustine, etoposide, methylprednisolone), followed by autologous peripheral blood stem cell transplantation and rituximab plus cytarabine consolidation therapy. Subsequently, the patient exhibited significant improvement in vision, and was still disease-free at the 1-year follow-up examination. The aim of the present paper was to provide well-documented clinical, radiological, and intraoperative features of isolated primary malignant lymphoma arising from the anterior visual pathway. A better recognition of this rare pathological entity is necessary for clinicians who may encounter similar presentations, as prompt management is crucial for both a visual and vital prognosis.

The new haematology analyzer DxH 800: an evaluation of the analytical performances and leucocyte flags, comparison with the LH 755.

INTRODUCTION: The analytical performance and the abnormality messages on differential (flags) of the new analyzer Beckman Coulter DxH 800 were compared with those of the LH 755. METHODS: First, we evaluated the accuracy of the results of the DxH 800, in comparison with the LH 755, in 125 samples without alarm using unflagged sample results on both analyzers. Second, flagged samples on the LH 755 but not flagged by the DxH 800 were evaluated by flow cytometry for accuracy of the DxH 800 results. Finally, we evaluated the sensitivity and specificity of abnormality messages on differential given by the analyzers, in comparison with manual blood smears. RESULTS: The correlation coefficients (R) for complete blood count parameters and differential demonstrated that the DxH 800 results were similar to that of LH 755. Excellent correlation coefficients between DxH 800 and flow cytometry results were found for white blood cell count (R = 0.985, n = 31), platelet count (R = 0.976, n = 51) and nucleated red blood cells (R = 0.966, n = 37). The overall performance showed an increased sensitivity (0.892) and specificity (0.864) of the flags on DxH 800 when compared to the LH 755 (0.846 and 0.733, respectively). CONCLUSION: The DxH 800 provides reliable results and increases laboratory efficiency by reducing working time and costs associated with the optical validation of the results.

[Intracranial spread of a melanoma of the face: the trigeminal pathway]. / Extension intracrânienne d'un mélanome de la face: la voie trigéminale.

INTRODUCTION: The intracranial evolution of cutaneous melanoma is usually due to metastases. Neurotropic invasion mainly concerns the trigeminal and the facial nerves. The melanoma is a rare entity among neurotropic tumors. OBSERVATION: A patient presented with a desmoplastic melanoma of the lower lid, complicated by a perineural extension to the cavernous sinus and the mandibular nerve via the maxillary nerve. DISCUSSION: This neurotropic evolution should be carefully monitored when close to a nerve. Extensive surgical excision including peripheral nerves in the vicinity of such tumors is recommended. MRI should be performed when a motor or sensitive disorder appears in the course of a desmoplastic melanoma.

Nutritional status and physical fitness of elderly sportsmen.

The nutritional status of elderly sportsmen has not been reported on, neither has the nutritional balance nor the precise relationship between nutritional status and physical fitness been detailed for this population. Thus, group of 18 sportsmen [age 63 (SD 4.5) years] was monitored by weighing their food during a 6-day period. Macro nutrient, mineral and vitamin content was derived from tables. Daily energy expenditure (DEE) and sport activity (DSA) were quantified over a 7-day period using a questionnaire. Physical fitness was assessed by maximal oxygen uptake (VO2max) measurements. The DEE was 11429 (SD 1890) kJ x day(-1). The DSA corresponded to 38% of DEE and VO2max to 35.9 (SD 6.1) ml x min(-1) x kg(-1). When compared with French recommended dietary allowances (RDA) intakes were higher for energy (+ 24%), macro nutrients, and most minerals and vitamins. Despite high energy intakes, some subjects had mineral and vitamin deficits. Energy intakes were significantly related to intakes of magnesium, phosphorus, iron, vitamins B2, B6, C and to VO2max, but not to age. Stepwise regressions indicated that vitamin C intake was the only determinant to have a relationship with VO2max. Thus, most elderly sportsmen had higher nutritional status than RDA, although some had mineral and vitamin deficits. It is therefore suggested that elderly sportsmen should be encouraged to consume food with higher mineral and vitamin contents.