[Persistent psychotic disorder following bilateral mesencephalo-thalamic ischaemia: case report]. / Trouble psychotique persistant après ischémie mésencéphalo-thalamique bilatérale: à propos d'un cas clinique.

A 38-year old male patient with no history of psychiatric illness developed a progressive psychotic disorder after bilateral (predominantly left) mesencephalo-thalamic cerebral ischaemia. The reason of the emergency hospitalization was the sudden onset of a confusional state, culminating in a fluctuating comatose status. The neurological examination found mild right hemiparesia, praxic disorders and reactive left mydriasis with paresia of the downward vertical stare, leading to the hospitalisation in the neurology department for suspicion of a cerebral vascular ischaemic accident. The psychiatric symptoms started with acoustic-verbal hallucinations, poorly structured paranoid delusions, progressively developed over two weeks, followed by behavioural disorders with psychomotor agitation and heteroaggressivity. The patient was transferred to the psychiatric department, because of the heteroaggressive risk and lack of morbid consciousness, in spite of recovering from the confusional status. An intensive psychiatric management was proposed, combining a psychotherapeutic approach with 4 mg of risperidone and adjustable doses of benzodiazepine according to the psychomotor agitation. During the next days, there was a net recovery of the behavioural disorders, in spite of the persistence of the ideas of persecution. All the neurological symptoms also decreased. An anomaly of the polygon of Willis was found on a cerebral arteriography (the posterior cerebral arteries had a foetal origin, dependent on carotidal axes and not on the vertebro-basilar system). The main emboligen risk factor was the presence of a permeable foramen ovale, discovered during a transoesophageal echography. The patient underwent a surgical correction of the permeable foramen ovale. The psychiatric hospitalization for three months was continued by ambulatory follow-up. The initial positive symptoms (delusions, acoustic-verbal hallucinations) progressively diminished while negative symptoms became predominant after few months. One year after the first hospitalization the patient presented a second psychotic decompensation, with delusions of persecution, jealousy and behavioural disorders with heteroaggressivity, that required an emergency psychiatric hospitalization. The wife of the patient decided to divorce, because she was "frightened by the threats of death" from her husband. A neurological assessment during the second hospitalization in psychiatry did not find new ischaemic lesions after the cardiac surgery for the permeable foramen ovale, nor relevant changes in cerebral perfusion. The final diagnosis after the psychiatric follow-up of 14 months was: psychotic disorder with delusional ideas, due to cerebral ischaemia (DSM IV). There are relatively few data in the literature regarding persistent psychotic disorders in the context of ischaemic mesencephalo-thalamic lesions. However, several authors support the hypothesis of a possible disconnection of the thalamic nuclei, the frontal lobes and limbic system as a risk factor or a triggering factor for psychotic disorders in cerebral ischaemia. Observations concerning the occurrence of psychotic disorders following cerebral--especially localised--ischaemia may help to better understand the neuro-physiological mechanisms triggering or accompanying the psychiatric symptomatology. The role of functional cerebral imagery in the detection of possible structural lesions related to clinical observations must be emphasised. The slow progression (over a year) to psychotic disorder with predominantly negative symptoms emphasized the importance for long-term prospective studies. Isolated clinical observations arouse the interest for a specific scale for psychotic disorders occurring after cerebral ischaemia, similar to existing specific scale for post-ischaemic depressive disorders. The necessity of systematic psychiatric examination and re-evaluations in thalamic cerebral ischaemia is to be highlighted, both for the differential diagnosis and for the early psychiatric care.

[Prospective epidemiological study on cutaneous melanomas in the Vendée area]. / Etude épidémiologique prospective des mélanomes cutanés en Vendée.

INTRODUCTION: The aim of this prospective study was to evaluate the incidence of melanoma in the Vendée area, coastal region of Eastern France, in 1997. PATIENTS AND METHODS: The 16 dermatologists in the Vendée area in 1997, grouped together in a local association, completed a sheet for each patient in whom a new melanoma had been diagnosed. During the same period, the hospital and private pathologists of the Vendée and surrounding areas reported their new cases of melanoma in patients residing at least six months of the year in the area. The data concerning the local population was supplied by the INSEE (French national institute of economic and statistical information) and the CPAM (French health authority) supplied data on the practitioners' activity. The raw and standardized incidence was calculated by the epidemiologist and the statistician of the local Vendée Cancer registry. RESULTS: One hundred fifteen new melanomas were diagnosed in Vendée in 1997, 97 by a dermatologist and 18 declared by a pathologist. There were 36 in situ and 79 invasive melanomas discovered in 68 women and 47 men (sex ratio: 1.46). The standardized rate of incidence according to the world model was of 98/100,000 for women and 7.8/100,000 for men. The frequency curve revealed two peaks: the first at 40-50 years of age and the second at 70-75. The mean Breslow index of the 79 invasive cancers was of 1.62 mm (range: 0.10-12.5 mm). The only statistically significant difference between the melanomas of the men and the women concerned the topography; there were more melanomas on the trunk in men and more melanomas on the lower limbs in the women. Forty-seven Dubreuilh melanomas were reported: 28 in situ and 19 invasive. DISCUSSION: This prospective study determined the incidence of melanoma in Vendée in 1997. The figures have been compared with those of the Vendée cancer registry, founded in April 1997, and with those of various published studies. The comparison was difficult because of the difference in study methodology. The only figures obtained in the same conditions are those of the cancer registry and we compared them with those of the Haut-Rhin, area of Eastern France: the incidence was similar for the women in the two areas and greater for the men in the Haut-Rhin with regard to the invasive melanomas. Conversely, 44 in situ melanomas were declared in the Haut-Rhin over a 3 year period versus 37 in Vendée over a period of 1 year. The increase in the incidence of melanoma in Vendée in the years to come should permit the evaluation of the impact of the various preventive campaigns.

[Prospective clinical study on new cutaneous melanomas in the Vendée area]. / Etude clinique prospective des nouveaux mélanomes en Vendée.

INTRODUCTION: In parallel to an epidemiological study on the new cases of melanoma reported in the Vendée area in 1997, private dermatologists conducted a clinical analysis of the characteristics of melanomas (including Dubreuilh's melanoma) and of the population concerned. PATIENTS AND METHODS: For each patient in whom a melanoma had been diagnosed, the dermatologists completed a standardized sheet that included the identification, phototype (comparing the distribution with that of the local population, studied in all the consultants during a randomly selected week), the personal and family history of melanoma, the existence of severe sunburn and exposure to artificial ultra-violet rays, the screening method, the time lapse before treatment, the impact of information campaigns, the number of nevi, atypical or not, and the characteristics of the tumor. The exeresis method and the histological characteristics (type, Clark's score and Breslow's index) were also noted. RESULTS: In 1997, the 16 local dermatologists diagnosed 97 melanomas in 55 women and 42 men with a mean age of 64 years. There was no statistically significant difference between the melanomas of the men and those of the women, other than their localization. Photoype II was significantly more frequent in the population exhibiting a melanoma. Sun exposure was moderate or intensive for three thirds of the patients. Past history of severe sunburn was twofold more frequent in the patients exhibiting a melanoma on the trunk. The association of many nevi was noted in a little more than half of the patients, and with atypical nevi in 5.2 p.cent. The elements that alerted the patients were recorded. The time lapse before diagnosis was calculated in months for nodular and in years for superficial melanomas. Clark's score and Breslow's index are presented in a table. DISCUSSION: Our study underlines several interesting features: the fairly high mean age on discovery, a high rate of invasive melanomas, and patients less well informed than in the Ile de France area. These results should open the debate on the best way to educate the population concerned so as to reduce the incidence of this malignant tumor.