Non-oral continuous drug delivery based therapies and sleep dysfunction in Parkinson's disease.

Continuous drug delivery (CDD) has emerged as a feasible and pragmatic therapeutic option for dopamine replacement therapy in advanced Parkinson's disease (PD). CDD aims to mimic the physiological tonic dopamine release from striatal dopaminergic neurons and thus reduces the severity and duration of motor and non-motor fluctuations partly related to pulsatile levodopa stimulation. Non-motor symptoms and fluctuations are ubiquitous in PD and include sleep dysfunction, a problem that occurs in over 90% of PD patients across all stages, from prodromal to palliative. In this review, we discuss the currently available and in development non-oral dopaminergic CDD strategies with a focus on their efficacy in the treatment of the burdensome sleep dysfunction in PD.

Bilateral Wada test: amobarbital or propofol?

PURPOSE: The Wada test is still the gold standard procedure to predict language and memory deficits before temporal lobe epilepsy surgery. As amobarbital was no longer available, our aim was to validate propofol as an alternative. METHOD: We retrospectively studied 47 patients who underwent a bilateral intracarotid procedure, performed with amobarbital (18), or propofol (29), between 2000 and 2010 during the preoperative evaluation of temporal lobe epilepsy. RESULTS: The number of patients experiencing an adverse event (mostly transient disturbance of consciousness or benign ocular symptoms) during both injections did not differ significantly between amobarbital and propofol. Hemispheric dominance was successfully determined in 96.5% patients with propofol vs. 94.4% with amobarbital for language, and in 72.4% under propofol vs. 77.7% under amobarbital for memory with no significant difference between groups. CONCLUSION: Propofol can be used for the Wada test with an efficacy and safety comparable to amobarbital.

Migraine with aura and silent brain infarcts lack of mediation of patent foramen ovale.

BACKGROUND AND PURPOSE: Population-based studies have shown a heightened prevalence of clinically silent brain infarcts in subjects who have migraine with aura (MA). We sought to determine whether this association could be confirmed in young patients with cryptogenic ischemic stroke, and explored the role of patent foramen ovale (PFO) as a potential underlying mechanism. METHODS: Patients were selected from a registry of young patients consecutively treated for ischemic stroke in a tertiary university hospital among those without definite cause of stroke. Patients with PFO were matched for age and gender with patients with normal atrial septum. Migraine and MA were evaluated after patient selection and matching. Silent brain infarcts were independently evaluated on MRI. RESULTS: We included 100 patients [60 men; mean age (SD), 44.8 years (8.3)], 50 patients with PFO. We found silent brain infarcts in 36 patients and MA in 13 patients. MA was more frequent in patients with silent brain infarcts than in patients without silent brain infarcts (25.0% vs. 6.3%; OR, 5; 95% CI, 1.4-17.6; P = 0.01). Traditional cardiovascular risk factors were not associated with silent brain infarcts. PFO was neither associated with MA (OR, 1.7; 95% CI, 0.5-5.3) nor silent brain infarcts (OR, 0.7; 95% CI, 0.3-1.5). The association of MA with silent brain infarcts was not altered after adjustment for PFO. CONCLUSION: Findings suggest that silent brain infarcts in young patients with cryptogenic stroke is associated with MA. We found no evidence for a mediating effect of PFO on this association.

Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx.

BACKGROUND AND PURPOSE: DAVFs (dural arteriovenous fistulas) represent one of the most dangerous types of intracranial AV shunts. Most of them are cured by arterial or venous embolization, but surgery/radiosurgery can be required in case of failure. Our goal was to reconsider the endovascular treatment strategy according to the new possibilities of arterial embolization using non polymerizing liquid embolic agent. MATERIALS AND METHODS: Thirty patients were included in a prospective study during the interval between July 2003 and November 2006. Ten of these had type II, 8 had type III, and 12 had type IV fistulas. Sixteen presented with hemorrhage. Five had been treated previously with other embolic materials. RESULTS: Complete angiographic cure was obtained in 24 cases. Of these 24 cures, 20 were achieved after a single procedure. Cures were achieved in 23 of 25 patients who had not been embolized previously and in only 1 of 5 previously embolized patients. Among these 24 patients, 23 underwent a follow-up angiography, which has confirmed the complete cure. Partial occlusion was obtained in 6 patients, 2 were cured after additional surgery, and 2 underwent radiosurgery. Onyx volume injected per procedure ranged from 0.5 to 12.2 mL (mean, 2.45 mL). Rebleeding occurred in 1 completely cured patient at day 2 due to draining vein thrombosis. One patient had cranial nerve palsy that resolved. Two ethmoidal dural arteriovenous fistulas were occluded. All 10 of the patients with sinus and then CVR drainage were cured. CONCLUSION: Based on this experience, we believe that Onyx may be the treatment of choice for many patients with intracranial dural arteriovenous fistula (ICDAVF) with direct cortical venous reflux (CVR). The applicability of this new embolic agent indicates the need for reconsideration of the global treatment strategy for such fistulas.

Aspergillus fumigatus-related spondylodiscitis in a heart transplant patient successfully treated with voriconazole.

Organ transplant patients, such as heart transplant (HT) recipients, are prone to infections, among which are yeast infections. Of these, aspergillosis is usually associated with pneumopathy or facial sinusitis, and Aspergillus fumigatus is rarely responsible for osteomyelitis or spondylodiscitis. Herein we have reported a case of an 18-year-old male HT patient presenting with subacute lumbar spondylodiscitis at 6 months posttransplantation and 3 months after antirejection therapy with antithymocyte globulins. A percutaneous needle biopsy of the intervertebral disc yielded Aspergillus fumigatus. The patient had no evidence of lung aspergillosis, but did have maxillary sinusitis. He was successfully treated with voriconazole.

Delayed Medullar Syndrome after Aneurysmal Subarachnoid Haemorrhage. A Case report of Cystic Arachnoiditis!

SUMMARY: We described a case of chronic spinal cystic arachnoiditis after subarachnoid haemorrhage in a 54-year-old woman with a ruptured vertebral artery aneurysm treated by coils. At three months she complained of lumbar pain.At twelve months she presented lower limbs paresthesia then a rapidly bilateral motor deficit. MR showed a spinal arachnoiditis with two compressive cysts. Surgical decompression was inefficient and after three months spinal compression symptoms worsened and MR signs were unchanged.

[Imaging of cerebral ischemia within first hours: computed tomography (CT)]. / Imagerie de l'ischémie cérébrale dans les premières heures: scanner.

Imaging of stroke has evolved with the development of stroke units and the CE approval of intravenous thrombolysis in the first three hours after stroke onset. The goal of imaging in the acute phase of stroke is: to make the diagnosis of stroke; to rule out other diagnosis (above all hemorrhagic strokes); to precise the location of the arterial occlusion; to assess the level of hypoperfusion; to evaluate the viability and reversibility of brain lesions; to understand the origin of the stroke by evaluating cervical arteries. Constraints of imaging in the acute phase of stroke are: the need to be performed as fast as possible to not delay IV thrombolysis (time is brain); machines must be available 24 hours a day, 7 days a week as close as possible to the stroke unit. The aim of imaging are: in routine practice to evaluate the likely benefits (provided by penumbra imaging) and risks of IV thrombolysis; in term of "evidence based medicine" to better evaluate new specific stroke therapies in randomized studies (IV thrombolysis between 3 to 4 hours, use of anti GpIIbIIIa, intra-arterial mechanical or chemical thrombolysis...). Magnetic resonance imaging is considered the goal standard of stroke imaging allowing to evaluate in a "one stop shopping" the level of arterial occlusion, hypoperfusion and brain viability. However, stroke management is a regional issue and performing MR in extreme emergency is almost impossible in all stroke units outside or even within university hospitals 24 hours a day. CT-perfusion and CT angiography are therefore an accurate alternative tool for acute stroke imaging. Multislice CT is indeed available in almost all stroke units. The examination is very time-saving and clinically relevant to make the decision for IV thrombolysis.