Changes in left ventricular ejection fraction during REM sleep and exercise in chronic obstructive pulmonary disease and sleep apnoea syndrome.

Nine patients, 4 with chronic obstructive pulmonary disease (COPD) and 5 with obstructive sleep apnoea syndrome (OSAS) were monitored during sleep, rest and exercise. Left ventricular ejection fraction (LVEF) was investigated using gated equilibrium 99mtechnetium ventricular scintigraphy during rapid eye movement (REM) sleep, during exercise, and during wakeful rest. Control wakeful rest periods used for comparison with a study state (either REM sleep or exercise) were always selected during the same circadian segment as that state. Myocardial stress thallium-201 scintigraphy was performed during, and 4 h after, exercise, and results were compared to a daytime rest period. Several patients had myocardial hypoperfusion despite a normal electrocardiographic (ECG) treadmill test. During REM sleep, all patients exhibited a significant change in LVEF (greater than 5%) compared to wakefulness. During exercise, 5 subjects increased their LVEF normally (greater than 5%) and 4 (1 COPD, 3 OSAS) decreased it. All patients had a similar change (increase or decrease) during REM and at maximal exercise. Our results suggest that REM sleep in COPD and in OSAS can produce a myocardial stress as great as that produced by exercise. We conclude that REM sleep, like exercise, is a state in which morbidity may become higher and that it may account for mortality in COPD and OSAS patients with compromised myocardial circulation.

Effects of passive tactile and auditory stimuli on left visual neglect.

Patients with left-sided visual neglect fail to copy the left part of drawings or the drawings on the left side of a sheet of paper. Our aim was to study the variations in copying drawings induced by passive stimulation in patients with left-sided visual neglect. No stimulation at all, tactile unilateral and bilateral, binaural auditory verbal, and nonverbal stimuli were randomly applied to 14 patients with right-hemisphere strokes. Only nonverbal stimuli decreased the neglect. As nonverbal stimuli mainly activate the right hemisphere, the decrease in neglect suggests right-hemispheric hypoactivity at rest in these patients. The absence of modification of neglect during verbal stimulation suggests a bilateral hemispheric activation and the persistence of interhemispheric imbalance. Our results showed that auditory pathways take part in the network involved with neglect. Passive nonverbal auditory stimuli may be of interest in the rehabilitation of patients with left visual neglect.

Prospective study of lacunar infarction using magnetic resonance imaging.

Using computed tomography and magnetic resonance imaging, we prospectively studied 100 patients hospitalized with a lacunar infarct. Our aim was to evaluate the capabilities of magnetic resonance imaging in the detection and delineation of lacunes in a project of clinicotopographic correlations. Seventy-nine patients had a classic lacunar syndrome; 35 had pure motor stroke, 26 had ataxic hemiparesis, seven had sensorimotor stroke, and 11 had pure sensory stroke. A miscellaneous group of 21 patients had less typical lacunar syndromes, primarily with brainstem signs and symptoms. Among a total of 153 lacunes, magnetic resonance imaging detected at least one lacune appropriate to the symptoms in 89 patients. In 16 patients at least two lesions correlated with the clinical features, and precise clinicotopographic correlations were possible in 68 patients. Magnetic resonance imaging was more effective when it was performed a few days after the stroke. Lesions causing different types of lacunar syndromes had significantly different volumes, suggesting that the size of the lesion may influence clinical features. Magnetic resonance imaging may be the imaging technique of choice in the study of lacunar syndromes.

[Subcutaneous administration of apomorphine in motor fluctuations in Parkinson's disease]. / Administration sous-cutanée d'apomorphine dans les fluctuations motrices de la maladie de Parkinson.

Apomorphine, a dopaminergic agonist was given over a period of 12 months to 14 parkinsonian patients suffering from severe L-dopa induced on-off effects. Nine patients (mean age: 52 years; mean age at onset of the disease: 37 years), were treated by continuous infusion with a portable minipump, and 5 others by multiple injections with a penject. The mean duration of daily off periods was reduced by two thirds in all patients. The motor fluctuation intensity was only diminished in the 9 patients treated by continuous infusion. These patients received a mean apomorphine daily dose of 93 mg and L-dopa dosage was reduced by 53 p. 100. Red fibrous subcutaneous nodules occurred at the injection sites in all patients treated by infusion. This study confirms the effectiveness of subcutaneous apomorphine administration in the treatment of severe motor fluctuations.

[Parkinson's disease and parkinsonian syndromes]. / Maladie de Parkinson: et syndromes parkinsoniens.

The parkinsonian syndrome rests on the clinical tripod: akinesia, rigidity, tremor. Akinesia is the key symptom, broadly defined as a difficulty in initiating and performing movements in proportion to their complexity (sophisticated, simultaneous movements) and their duration (repetitive movements). The most frequent cause of the syndrome is Parkinson's disease. Although this diagnosis needs to be confirmed in pathological terms by the loss of neurons and the presence of Lewy's bodies in the substantia nigra, some clinical data enable it to be envisaged with a minimum of errors; these are pure parkinsonian triad, good response to dopatherapy and asymmetrical symptoms. The other causes of parkinsonian syndrome are usually related to the administration of neuroleptic drugs and to degenerative diseases with lesions that are more diffuse than those of Parkinson's disease. In Steele-Richardson-Olzewski disease a parkinsonian syndrome is associated with supranuclear ophthalmoplegia. Multiple systematized atrophy presents under three different clinical aspects: a parkinsonian syndrome without tremor and resistant to L-dopa, suggesting atrophy of the strionigral tract; a parkinsonian syndrome associated with a cerebellar syndrome, suggesting olivo-cerebellar-pontine atrophy, and Shy-Drager disease which includes primary dysautonomy and other neurological syndromes.

Encephalopathy, deafness and blindness in young women: a distinct retinocochleocerebral arteriolopathy?

Three young women (aged 18 years, 19 years and 19 years) who developed progressive neuropsychic and neurologic disturbances with hearing loss and multifocal retinal artery branch occlusions are reported. This retinocochleocerebral syndrome has been reported previously only in 12 young North American women. Its pathogenesis is unknown, but an atypical viral infection of the vessel walls has been suggested. Abnormalities of T lymphocytes subsets in blood in one of the patients suggested an immunological dysfunction, but all other tests, including immunological reactions on brain and skin biopsies, were negative or non-specific. Steroids and immunosuppressive agents have been advocated on an empirical basis, but the second patient showed a substantial recovery without any therapy and the third gradually deteriorated despite azathioprine, cyclophosphamide, prednisone and plasma exchanges. This retinocochleocerebral syndrome probably corresponds to an arteriolopathy of unknown nature.

[Treatment of Parkinson tremor by chronic stimulation of the ventral intermediate nucleus of the thalamus]. / Traitement du tremblement parkinsonien par stimulation chronique du noyau ventral intermédaire du thalamus.

Stereotactic ventral intermediate nucleus (Vim) thalamotomy may improve drug resistant severe parkinsonian tremor. However, tremor may recur and bilateral thalamotomy is known to induce unacceptable side effects in a proportion of patients. A high frequency (130 Hz) chronic Vim stimulation was performed in 4 parkinsonian patients, 2 of them having previously undergone a thalamotomy on the other side. Tremor was suppressed in all patients at the price of slight paresthesias. This improvement has been lasting from 2 to 14 months. Beneficial and adverse effects were suppressed at once each time the stimulation was stopped. These preliminary results are encouraging but a longer delay and more patients are obviously needed.

[Chronic spinal amyotrophy involving the upper limbs in young adults (O'Sullivan and McLeod syndrome). MRI study of the cervical spinal cord]. / Amyotrophie spinale chronique des membres supérieurs de l'adulte jeune (syndrome de O'Sullivan et McLeod). Etude en IRM de la moelle cervicale.

In 5 cases of sporadic spinal muscular atrophy in young adults the muscular atrophy was localized in the hands and forearms. Age at onset ranged from 7 to 20 years. The duration of the disease was less than 5 years in 3 patients and more than 15 years in 2. Electromyography showed neurogenic anomalies in all wasted muscles, denervation potentials being also present in the proximal muscles of the upper limbs and distal muscles of the lower limbs in 2 patients. Motor nerve conduction velocity and sensory nerve action potentials were normal. Advantages of a topographic classification of the distal form of chronic spinal muscular atrophy are discussed. Spinal cord MRI was performed in 4 patients with a 0.5 Tesla superconducting magnet using surface coils, using a T1-weighted spin-echo technique (ET 26 ms; RT 500 ms) and a T2-weighted spin-echo technique (ET 90, 180 ms; 2,000 ms). With the T1 technique, axial MRI sections 7 to 9 mm thick of spinal cord showed a normal image between C1 and C4, and a flattened image between C5 and T1. This was considered as a possible spinal cord segmental atrophy.

[Alzheimer's disease and Parkinson's disease: neuropsychological differentiation]. / Maladie d'Alzheimer et maladie de Parkinson. Difféferenciation neuropsychologique.

54 patients with idiopathic Parkinson's disease (PD), 26 patients with Alzheimer's disease (AD) and 18 control subjects, all over 55, have performed neuropsychological tests, evaluating global intellectual function (Rosen's cognitive scale, WAIS digit symbol, WAIS similitude and WMS logical memory tests) and visuospatial functions (Rey lacunar pictures, Poppelreuter and Benton line orientation tests). AD group results were distinctly different from those of the PD and the control groups (p less than 0.001). In the PD group, only the Rosen's scale total score and the visuospatial tests were slightly altered (p less than 0.05). In a PD subgroup with a normal Rosen's scale result, the Benton line orientation test was different from controls (p less than 0.05). In another PD subgroup with Rosen's scale score comparable to a midly impaired AD subgroup, all the neuropsychological tests were abnormal. Only the WAIS digit symbol test, altered in this PD subgroup, was different comparing these 2 subgroups (p less than 0.05). With regard to the PD total group, the neuropsychological perturbed PD subgroup was older, had a longer duration of disease, a higher depression's score, less tremor and a worse equilibrium. These results might reflect a neuropsychological defect heterogeneity among PD patients, related to various pathophysiological hypothesis which are discussed in this paper.

[Magnetic resonance imaging in horizontal oculomotor paralysis caused by infarction]. / L'imagerie par résonance magnétique dans les paralysies de l'oculomotricité horizontale par infarctus.

Four patients with focal brainstem ischemic strokes and various types of horizontal oculomotor disturbances have been studied clinically and radiologically. One had a six nerve palsy, one a unilateral internuclear ophthalmoplegia, one a Fisher's one-and-a-half syndrome, and one a paramedian pontine reticular formation syndrome with a sixth nerve palsy. In all patients a C.T. Scan and a Magnetic Resonance Imaging (MRI) were obtained. The MRI study was performed on a CGR Magniscan 5000 with a superconducting magnet of 0.5 Tesla. In all patients a hypersignal in T2 weighted images was shown and corresponded to the brainstem infarct. MRI allowed accurate delineation of the lesion and clinico-radiologic correlations in three patients. But the low specificity of MRI does not permit to distinguish edema from necrosis, gliosis or demyelination in a region with a pathological MRI signal. In one patient this low specificity and perhaps partial volume effects decreased the accuracy of the clinico-topographic correlation.

[Magnetic resonance imaging and laterobulbar infarction]. / Imagerie par résonance magnétique et infarctus latérobulbaire.

Six patients with a clinical diagnosis of lateral medullary infarction have been studied by CT scan and Magnetic Resonance Imaging (MRI). The MRI study was performed on a CGR Magniscan 5000 with a superconducting magnet of 5 Tesla. In all patients T2 weighted images (TR = 2000, TE 60, 120) in joined section of 9 or 6 mm thickness were obtained in the axial plane. Three patients were also studied in T1 weighted sequences (TR = 500, TE = 28). A lateral medullary infarct was shown in 5 patients. MRI findings were consistent with a hemorrhagic infarct in one case. Occlusion of a vertebral artery was suggested in 2 cases and was confirmed by angiography. In 3 cases, an associated ipsilateral cerebellar infarct was demonstrated. The CT scan had only shown bleeding in the medulla oblongata in the hemorrhagic infarction case, and a cerebellar infarction in another case. Some clinical manifestations are discussed with regard to the results of MRI. MRI appears as the best current method to improve clinico-topographic correlations in medullary infarcts.

[Spontaneous dissecting aneurysm of the internal carotid artery. Magnetic resonance imaging]. / Anévrisme disséquant spontané de l'artère carotide interne. Imagerie par résonance magnétique.

A man underwent Magnetic Resonance Imaging (MRI) of the left carotid artery 11 days after a spontaneous dissection of this vessel. T1 weighed images were obtained in the frontal and axial planes. There was a hyperintense lesion expanding the arterial wall due to the hematoma. The image of the lumen was narrowed. These findings corresponded to the angiographic abnormalities. In this case MRI was able to diagnose specifically and non invasively carotid artery dissections. Its sensitivity remains to be evaluated.

Clinical and biochemical effects of gamma-vinyl Gaba in tardive dyskinesia.

Clinical and biochemical effects of Gamma-vinyl-Gaba (GVG) have been evaluated in a blind video-controlled study in 10 psychiatric patients (mean age 71 yr) with tardive dyskinesia. CSF free and total Gaba and homocarnosine concentrations increased from three to five fold with GVG treatment. Despite the GVG-induced biological effects on Gaba metabolism, GVG did not consistently improve tardive dyskinesia. Psychomotor side-effects occurred in older patients, who only tolerated GVG dosages of 2-4 g/day.

[Ataxic hemiparesis caused by a thalamic lacuna]. / Hémiparésie ataxique par lacune thalamique.

A 64 year old man was admitted for an ataxic hemiparesis. Magnetic resonance imaging (MRI) suggested a lacunar infarct. The lesion was located in the postero-lateral part of the contralateral thalamus, sparing the internal capsule.

[Tactile and visual neglect. Preliminary study of 4 patients]. / Négligence tactile et visuelle. Etude préléminaire de quatre patients.

A battery of tactile tests for the study of unilateral neglect is presented with the purpose of comparing the tactile modality to the visual modality. This was applied in 4 patients with right hemisphere lesions. In 3 patients, there was evidence of neglect in both modalities with qualitatively identical anomalies. The function of spatial manipulation involved in the tasks is stressed. In the cases where both modalities were involved a supramodal hemispatial disturbance is assumed.

[Magnetic resonance imaging in multiple sclerosis. Sensitivity and correlation with the clinical picture]. / L'imagerie par résonance magnétique dans la sclérose en plaques. Sensibilité et corrélations avec la clinique.

The aim of imaging the brain in Multiple Sclerosis (MS) is to prove the dissemination of lesions, so critical for the diagnosis and so difficult to ascertain clinically. Our study included 21 patients with clinically definite (12) and probable (9) MS. A 21 patients underwent a neurological standard examination, a double-dose delayed CT scan and a Magnetic Resonance Imaging with a superconducting 0.5 Tesla magnet. Jointed slices were performed with a T2-weighted Spin-Echo sequence (TE 60, 120; TR 2000 msec). MRI detected 640 lesions in 20 patients while CT scan detected only 24 lesions in 9 patients. Technical limiting factors are discussed. Abnormalities in MRI were high-intense spots, blotches and streaks, located predominantly in the periventricular area. Capping lesions were common around the ventricular horns. "Plaques" were visualized in the posterior fossa. For each patient, the total surface of the lesions was calculated and was found to be related with the presence of lesions and with the cortical atrophy on CT scan. A correlation between the surface of lesions calculated by MRI and the disability scale was found especially in the group of patients with clinically proven cerebral lesions, while patients with predominantly spinal forms had a significantly lower surface of lesions. This finding could yield a new quantitative evaluation of the MS pathologic process which could be used to assess therapeutic efficacy.

[Left anterior choroidal artery syndrome with language disorders and constructional apraxia]. / Syndrome de l'artère choroidienne antérieure gauche avec troubles du langage et apraxie constructive.

The infarction in the territory of the anterior choroidal artery may induce a sensory motor impairment and neuropsychological symptoms close to those observed in some thalamic lesions. In a right handed man with a left sided infarction, language disturbances and constructional apraxia were observed. Cerebral blood flow measurements were performed 4 days after the stroke with the 133Xenon inhalation method. A decrease of mean hemispheric values was observed on both sides but more so on the left hemisphere, in the left frontoparietal regions. 98 days after the stroke language and constructional apraxia have partially improved. We have drawn a parallel between blood flow variations and neuropsychological signs. The cortical deafferentation caused by the interruption of the thalamo-cortical projections may explain the focalized decrease in cerebral blood flow values in the left hemisphere.