Estimated number of eligible patients for mechanical thrombectomy based on NIHSS and population-based Brest stroke registry.

BACKGROUND: Since 2015, mechanical thrombectomy (MT) is indicated as a treatment for patients with large vessel occlusion (LVO) at the acute phase of ischemic stroke. However, the number of stroke patients eligible for MT is poorly known. OBJECTIVE: The objective of our study was to estimate the number of patients eligible for thrombectomy within the first 24hours of an ischemic stroke, based on the clinical National Institute of Health Stroke Scale (NIHSS). METHOD: Our study concerned all ischemic strokes which occurred between January 2013 and December 2016 recorded in the population-based Brest Stroke Registry (BSR). Based on positive predictive value and negative predictive value from articles evaluating the performance of a defined NIHSS threshold to identify LVO, we first estimated the frequency of patients with LVO and then the frequency of patients eligible for MT depending on pre-stroke modified Rankin score (mRS). Our results were extrapolated to regions of metropolitan France. Two scenarios were considered: one called "stringent criteria" with mRS ≤1 and one called "real-life" criteria with mRS ≤2. RESULT: We analyzed data from 2,025 ischemic strokes with symptom onset ≤24hours. No statistical difference between patient characteristics according to the time of hospital admission (≤6H vs. 6-24H) was observed. Based on NIHSS scores, between 23.90% and 44.20% of ischemic strokes admitted within the first six hours had LVO clinical characteristics. Among them, 14.53% to 26.87% met the ``stringent eligibility'' criteria for MT and 16.9 to 31.25% for ``real-life'' criteria. Eligible patients represented 6.32% to 11.70% of all ischemic strokes, irrespective of admission time. In France, 75 to 162 persons per million inhabitants per year were eligible for endovascular therapy, depending on including criteria. Based on activity levels recorded by the French Neuroradiology Society (SFNR) in 2018, the estimated needed increase in MT showed a heterogeneous pattern region-by-region, with the greatest need in Brittany, Pays de la Loire, and Corsica. CONCLUSION: Based on NIHSS, our study provides coherent information concerning the estimated number of MT procedures to be performed in France: 4,877 to 10,494 ischemic strokes would be eligible each year in metropolitan France compared to the 6,596 thrombectomy procedures actually performed in 2018. Depending on the region, an estimated 10-20% to 90-100% increase in MT activity would be necessary to meet patient needs. These data suggest that there is still room for improvement in thrombectomy activity, particularly in certain regions of France, to allow equal access to MT to the entire French population.

High completeness of the brest stroke registry evidenced by analysis of sources and capture-recapture method.

BACKGROUND: Population-based stroke registries are necessary to evaluate the precise burden of stroke. The methodology used in the Brest Stroke Registry and an estimation of its completeness are described. METHODS: 'Hot pursuit' as well as 'cold pursuit' were used, and five sources of identification were included: emergency wards, brain imaging, practitioners, death certificates and hospital-based electronic research. Ascertainment for each case was certified by a neurologist. Inclusion criteria were: (1) age >15 years; (2) a stroke defined by WHO criteria or all neurological deficits lasting at least 1 h. Completeness was estimated using capture-recapture method. RESULTS: For 2008, 2009 and 2010, 851, 898, 823 patients were collected, respectively. The number of sources of identification per patient was as follows: one source: 30.8, 24.1 and 18.7%; two sources: 54.5, 42.9 and 31.0%; three sources: 13.4, 30.1 and 46%; four sources: 1.3, 3.0 and 3.8%. Capture-recapture analysis showed data completeness over 90%. Standardized cumulative first-ever stroke incidence using a world standard population was 87 in 2008, 87 in 2009 and 84 in 2010. CONCLUSIONS: Case ascertainment by a neurologist, numerous sources, as well as 'hot' and 'cold' pursuit can provide a reliably large data set suitable for further epidemiological studies.

Cryptogenic mechanism in ischaemic stroke patients is a predictor of 5-year survival: A population-based study.

INTRODUCTION: The present study sought to identify factors affecting mortality beyond 28 days in ischaemic stroke patients with whatever ischaemic mechanism. PATIENTS AND METHODS: A prospective population-based registry was set up in Brest County, Brittany, France. Demographic data, clinical presentation, vascular risk factors and mortality were collected from January 2008 to December 2012. At "home without help" was used as a surrogate marker for low Rankin (0-1) at discharge from the hospital. IS was classified on the TOAST classification. Overall mortality was calculated using the Kaplan-Meier method. Multivariate analysis of mortality beyond 28 days was implemented, using a Cox model, on significant risk factors identified on univariate analysis. RESULTS: About 3024 IS cases were followed up beyond 28 days. Overall mortality beyond 28 days was 38.49% at 60 months. On multivariate analysis, age (10 years: HR = 1.84; [1.66-2.02]), coronary artery disease (HR = 1.28; [1.05-1.56]), cardiac arrhythmia (HR = 1.36; [1.11-1.67]), peripheral artery disease (HR = 1.66 [1.29-2.13]) and incomplete assessment (HR = 1.39; [1.12-1.74]) were associated with higher mortality risk, whereas female gender (HR = 0.80; [0.68-0.94]), high Glasgow Coma Scale score (GCS > 12) (HR = 0.58; [0.45-0.76]), lacunar syndrome (HR = 0.82; [0.68-0.99], being 'at home without help' (HR = 0.50; [0.41-0.59]) and negative assessment (HR = 0.75; [0.58-0.97], compared to cardioembolism) were associated with better survival probability. DISCUSSION: Initial clinical status, prior cardiovascular diseases and age was associated with more risk of death: an increment of 10 years almost doubled mortality. Women had more survival probability than men, controlling for age. Ischaemic stroke mechanisms were predictors of late 5-year mortality. CONCLUSION: Patients with negative assessment, i.e. representing truly cryptogenic ischaemic stroke, had the best survival probability probably due to fewer atherosclerotic markers.

High incidence of neurologic complications following rapid correction of severe hyponatremia in polydipsic patients.

BACKGROUND: Patients with self-induced water intoxication usually tolerate a large, rapid increase in plasma sodium without developing osmotically induced central pontine myelinolysis. However, we have previously reported a case of clinically suspected pontine myelinolysis in a patient with self-induced water intoxication. The purpose of our study was to investigate if a subgroup of these patients may also be vulnerable to neurologic complications of hyponatremia therapy. METHOD: Over a 10-year period, we identified retrospectively 12 polydipsic patients having a total of 24 episodes of symptomatic hyponatremia with plasma sodium < or = 115 mmol/L. The mode of treatment, the kinetics of correction, and the neurologic outcome were recorded. The presence of alcoholism was noted. RESULTS: Seven patients recovered uneventfully from 19 episodes of symptomatic hyponatremia. Five patients had delayed neurologic complications. Late therapy and/or respiratory arrest might have been associated with the complications for 2 patients. The other 3 patients experienced clinical features of central pontine myelinolysis leading to death in 1. Patients with neurologic complications had a higher maximal 24-hour increase in plasma sodium concentration (21.8 +/- 3.9 vs. 15.5 +/- 5.1 mmol/L, p < .02), and a higher incidence of both overcorrection to hypernatremia and chronic alcoholism, often associated with poor nutrition. All 5 patients became water intoxicated at home, and 2 patients with pontine dysfunction had subacute rather than acute hyponatremia. CONCLUSION: A large rapid increase in plasma sodium may also be detrimental in patients with self-induced water intoxication when they are alcoholic, malnourished, and have nonacute hyponatremia.

[Lesion of the deep branch of the ulnar nerve caused by fracture of the hook of the hamate]. / Atteinte de la branche profonde du cubital par fracture de l'os crochu.

We present a case of lesion of the deep branch of ulnar nerve at the wrist caused by fracture of the hook of the hamate. According to Wu's classification (1985) based on clinical and electromyographic findings and the clinicoanatomic correlations, our case corresponds to type IV of this classification with a pure motor ulnar neuropathy with sparing of hypothenar muscles. Improvement was observed after surgery.

[Chemotherapy with cisplatin and 5-fluorouracil in inoperable brain metastases of bronchopulmonary cancers]. / Chimiothérapie par cisplatine et 5-fluorouracile dans les métastases cérébrales inopérables des cancers bronchopulmonaires.

Chemotherapy is not a common treatment for cerebral metastases. The authors report results of combination chemotherapy with cisplatin (CDDP) and fluorouracil (5-FU). Sixteen men (age range 31-73 years) with brain metastases were treated with CDDP 20 mg/m2/day in continuous infusion for 5 days (d 1-5) and 5-FU 1 g/m2/day in continuous infusion for 4 days (d 1-4), and the treatment schedule repeated every 3 weeks. A brain computerized tomography after 2, 4 and 6 cycles was performed to assess efficacy. It was considered that complete response was achieved if no lesion was found on the CT scan, and partial response if at least half of the total volume had decreased. After 2 cycles, the response rate was therefore 8/16 (50%). Treatment toxicity was very mild with only 1 case of severe but reversible myelotoxicity (grade III). It is concluded that chemotherapy combination with CDDP and 5-FU is a useful treatment for brain metastasis of lung carcinoma.

[A case of mitochondrial myopathy in a family with oculo-pharyngeal myopathy]. / Un cas de myopathie mitochondriale dans une famille de myopathie oculo-pharyngée.

We report the case of a patient with mitochondrial lesions, an old woman belonging by her father and mother to a big family with oculopharyngeal muscular dystrophy. Four patients of this family have typical intranuclear tubulo-filamentous inclusions.

[Idiopathic medullary decompression sickness: myth or reality?]. / Accident de décompression médullaire "inexpliqué": mythe ou réalité?

Severe decompression sickness occurs unfrequently, with, generally an identifying cause (error in decompression protocols, promoting factors.). We report a case of severe spinal cord damage; onset after a common dive, neither deep nor long, without any promoting factor, absence of responsiveness to recompression, three hours post-dive, importance of MRI signal abnormalities, make us to point out the confounding variability of onset and evolution of such illness.

[Hemichorea and striatal infarction]. / Hémichorée et infarctus striatal.

We present two cases of hemichorea associated with an arterial ischaemic stroke in the controlateral striatum and we reviewed 28 similar cases in the literature. The pathogenesis of this movement disorder involves the gabaergic and enkephalinergic neurons of the striatal matrice which mainly projects on the external globus pallidus. A destruction of the striatal neurons of the indirect striato-thalamo-cortical ways may reduce their inhibitory out flow on normal inhibited thalamic and cortical structures and then create abnormal choreiform movements. The scarcity of this phenomenon can be explained by: 1) the repartition of the enkephalinergic local circuit neurons which represent but one third of the motor striatal neuronal population; 2) the type of vascularisation which often involves larger territories in the striatum and the globus pallidus or the anterior limb of the internal capsule. These abnormal movements are often transient because of the regulation of accessory striato-nigro-striatal, cortico-striato-nigro-thalamo-cortical and cortico-luysin circuits. More over, because these hypotheses and after having reviewed all such cases in literature, choreic movements to pure thalamic involvement are to be questioned.

[Sunct syndrome: case report and literature review]. / Sunct syndrome. Un cas.

The case of a woman with short neuralgiform paroxysmal attacks located in orbital-periorbital area and associated with autonomic features of ten years duration is reported. This headache syndrome is compared with trigeminal neuralgia involving the first branch of the nerve. Duration, intensity, spreading of the pain and presence of accompanying ipsilateral vasomotor phenomena may be of help in the differential diagnosis. According to the latest reports, sex distribution which passed from 17 men/2 women to 18/6 and effect of the carbamazepine on pain would not appear to have an effect. Nevertheless other reports are needed to distinguish these two clinical syndromes and to develop an etiological and pathogenesis hypothesis.

[Cerebral ischemic arterial accidents in young adults. 40 cases]. / Accidents artériels ischémiques cérébraux de l'adulte jeune. 40 cas.

We observed 40 patients aged from 15 to 40 years who suffered either a transient ischemic attack or an arterial ischemic stroke. All patients were clinically and physically examined, i.e. chest-X rays, electrocardiograms, biological tests and C.T. scan or magnetic resonance imaging that confirmed the diagnosis of ischemic cerebral infarction. Most patients underwent echocardiography and angiography. The time span between the onset of the ischemic event and angiography was recorded. A few of them had CSF analysis and determinations of antithrombin III, protein C and protein S. The etiology was confirmed in 15 patients (5 cardioembolic diseases, 7 vasculopathies, 3 coagulopathies). Twenty three had well-known vascular risk factors, but also an increase in serum fibrinogen concentration, which might have been associated with specific predisposing factors: oral contraceptives, patent foramen ovale, migraine, craniocervical trauma, acute alcohol intoxication and infectious diseases. No cause was found in 2 patients. We suggest a practical approach and highlight the value of angiography when performed early in the course of the illness to enhance the percentage of positive diagnosis. About 45 p. 100 of the patients followed-up (mean duration: 3 years) were unable to resume normal professional activity.

[Acute polyradiculoneuritis and Lyme disease]. / Polyradiculonévrite aiguë et maladie de Lyme.

A thirty-three-year-old patient developed polyradiculoneuritis with several post-therapeutic relapses despite excellent response to treatment by intravenous polyvalent gammaglobulin. After the second relapse, positive titres for Borrelia burgdorferi were found in serum and C.S.F. We gave her intravenous antibiotic and clinical signs and electrophysiological data improved. Our report and the literature can distinguish two clinical and electrophysiological presentations of neurological peripheral involvement in Lyme disease: meningoradiculoneuritis with axonal involvement and polyradiculoneuritis with demyelinization.

[Inoperable brain metastases from bronchogenic cancers. Value of combined chemotherapy with cisplatin and 5 fluorouracil]. / Les métastases cérébrales inopérables des cancers bronchiques. Intérêt d'une chimiothérapie associant cisplatine et 5 fluoro-uracile.

We report the results of a combined of chemotherapy with CDDP and 5 FU repeated every 3 weeks in sixteen men (age range 31-73 years) with brain metastases. CT was performed after 2, 4 and 6 cycles to assess efficiency. Response was considered complete when no lesion was found on the CT scan and partial when the lesion shrunk to least half its the total volume. After two cycles, the response rate was 8/16 (50%). Treatment toxicity was mild with only one case of severe but reversible myelotoxicity (grade III). CDDP and 5 FU combined chemotherapy can be a useful treatment for brain metastasis of lung carcinoma.

[New therapeutic prospects in Alzheimer disease]. / Nouvelles perspectives thérapeutiques dans la maladie d'Alzheimer.

The approval for marketing of tacrine (Cognex), an acetylcholinesterase inhibitor, allowed physicians and the general people to attract attention to a degenerative disease, which prevalence dramatically increases every year. This drug is hopeful. Meanwhile, we must keep in mind that it has only a symptomatic effect. Its hepatotoxicity requires regular biological tests. Many medications are actually in earlier stages of development along with various etiological approaches.

[Marchiafava-Bignami disease. 3 cases with favorable prognosis]. / La maladie de Marchiafava-Bignami. Trois observations d'évolution favorable.

INTRODUCTION: Marchiafava-Bignami disease is a complication of chronic alcoholism, with acute or subacute demyelination of the corpus callosum. Although subacute and benign forms of the disease have been described since the development of CT scan and MRI, it has usually a poor prognosis. EXEGESIS: We report three cases of Marchiafava-Bignami disease with favorable outcome. One of the patient was comatose upon hospital admission. Interhemispheric dysconnection syndrome was evidenced in two patients. CT scan and MRI showed lesions extending to the callosal white matter in these patients. CONCLUSION: Potential existence of Marchiafava-Bignami disease should be investigated in patients presenting with chronic alcoholism and mental confusion. However, accompanying coma and white matter demyelination should not necessarily be considered of poor prognosis. Clinical evaluation of interhemispheric dysconnection is of value in patients presenting with chronic alcoholism and mental confusion.

Natalizumab and drug holiday in clinical practice: an observational study in very active relapsing remitting multiple sclerosis patients.

BACKGROUND: In order to reduce the risk of progressive multifocal leucoencephalopathy when using natalizumab for more than 12 months, a 6-month drug holiday has been discussed. However, the consequences on short term disease activity have been poorly assessed. OBJECTIVE: The aim of this study was to assess clinical and radiological disease activity within 6 months after stopping natalizumab in very active relapsing remitting Multiple Sclerosis (RRMS) patients. METHODS: In 8 hospitals from Western France, we retrospectively collected clinical and MRI data from consecutive RRMS patients treated with natalizumab for at least 6 months, and who stopped the drug for various reasons except therapeutic failure. Patients didn't receive any other disease modifying treatment after discontinuing natalizumab. RESULTS: A total of 27 patients with very active RRMS before natalizumab start (mean annualized relapse rate of 2.3, MRI activity in 21 of 27 patients) were studied. Within 6 months after discontinuing natalizumab, 18 patients (67%) experienced clinical relapse and 3 additional patients had radiological activity, without clinical relapse. Four patients (15%) experienced a rebound activity, with severe relapse and 20 or more gadolinium enhancing lesions on MRI. CONCLUSION: Such observational data didn't support the concept of drug holiday when using natalizumab in very active RRMS.

Plaque density on CT, a potential marker of ischemic stroke.

The authors sought to determine in a retrospective analysis whether carotid plaque soft TD on CT is associated with recent ischemic neurologic events. Among 141 patients (99 asymptomatic), 106 plaques with more than 50% stenosis were selected for density measurements. They found an odds ratio for neurologic events associated with a 10-point decrease in density of 1.54 (p = 0.002), showing an association between plaque density and neurologic events.