Infarctus cérébral et myocardique après consommation de cannabis chez une femme jeune

Introduction

Cannabis is the most consumed drug in the world particularly in young adults. Few reports have suggested a causal role of cannabis in the development of cerebral or cardiovascular events. We describe the first association of myocardial infarction and stroke after heavy cannabis consumption in a 45-year-old woman.

Observation

Stroke occurred in relation with a right carotid and middle cerebral artery thrombosis after cannabis abuse. The patient was successfully treated with intravenous rt-PA. Two days after her admission, she presented a myocardial infarction due to a coronary thrombosis. Cerebral and coronary arteries were angiographically normal. Etiological tests were negative and a toxic cause in relation with cannabis consumption was concluded.

Conclusion

Cannabis can be associated with vascular events by different mechanisms. Thrombosis may occur in cerebral and/or coronary arteries. We suggest that it might be useful to search for cannabis consumption systematically in young subjects victims of stroke and myocardial infarction.     

Évolution clinique de la dépression post-accident vasculaire cérébral à Kinshasa

Objectives

To describe the evolution of the clinical profile of post-stroke depression over a period of one year and to determine factors associated with changes in post-stroke depression.

Methods

Prospective cohort study with a follow-up of 1 year including 30 consecutive eligible patients. The severity of depression was assessed with the patient health questionnaire (PHQ9).

Results

The mean age was 55.87 ± 12.67 years. Seventy percent of patients were men. The two assessments for neurological status, perceived health status and test results of attention were not statistically different. The rate of depressive symptoms was 26.67% in 2011 and 20% in 2012. Disability and apathy were significantly improved. The average for disability increased from 2.77 ± 1.19 to 2.46 ± 2.19 (P = 0.002). From 66.7% in 2011, the proportion of patients able to walk without assistance rose to 93.3% in 2012 (P = 0.03). In addition, the proportion of patients apathetic decreased from 43.3% to 13.3% (P = 0.01). Greater age, female sex, sleep disorders and post-stroke apathy remained associated with DPAVC between the two assessments, with an increase in the strength of the association for apathy.

Conclusions

The frequency of post-stroke depression is high and remains stable over time. Disability is the clinical feature that evolved more favorably. The association with apathy, present at the beginning, of the study was strengthened one year later.     

Accident vasculaire cérébral révélant une granulomatose

Introduction

Central nervous system involvement is rare in Wegener granulomatosis. Stroke is the most common event suggestive of the disease.

Comment

A 35-year-old woman, who was followed for rhinitis and mild asthma, described gradual decline of visual acuity in the right eye over two months, persistent nasal obstruction and fronto-orbital headache since a few weeks. She presented left hemiparesis due to a stroke, associated with exophthalmos and deficits of the optic nerve and abducens of the right eye. The otolaryngological examination found signs of crusty rhinitis and right nasal stenosis. The diagnosis of Wegener's granulomatosis was established on the basis of the clinical findings, radiological aspects and the presence of ANCA. The patient was treated by antiplatelet agents and high-dose corticosteroids associated with immunosuppressive drugs including cyclophosphamide in a monthly bolus.

Discussion

This case illustrates two of the three pathogenic mechanisms that may account for central nervous system involvement in Wegener granulomatosis: vasculitis, extension by contiguity of granulomatous tissue from the nasal cavity or sinuses, and in situ formation of a granuloma into the brain parenchyma or meninges.     

Infarctus cérébral récidivant révélant une maladie de Biermer

Introduction

Biermer's disease is an autoimmune disorder characterized by vitamin B12 deficiency. Ischemic stroke is an uncommon complication of Biermer's disease, possibly though hyperhomocysteinemia.

Case report

A 58-year-old male presented with recurrent ischemic stroke. Extensive investigations were normal, except for a high plasma level of homocysteine in the context of pernicious anemia which was otherwise asymptomatic.

Discussion

Hyperhomocysteinemia is a known marker, and probably a risk factor, for stroke, fostering atherosclerosis and thrombosis. It can be found among individuals suffering from homocysteinuria, but also when there is deficiency of vitamin B12 or folic acid. Vitamin B12 supplementation would reduce homocysteine concentration which in turn would reduce the risk of ischemic stroke.     

Angioplastie carotidienne bilatérale chez une patiente avec infarctus cérébral sur maladie de Horton

Introduction

Giant cell arteritis is the most frequent vasculitis and can cause stroke in about 4% of the patients. The mechanism is often hemodynamic in relation with an arterial stenosis or occlusion. Optimal treatment remains to be defined. Outcome is often poor.

Case report

We report the case of a 78-year-old patient, with giant cell arteritis who developed neurological deterioration after the onset of the corticotherapy. Brain MRI revealed bilateral stroke caused by multiple preocclusive internal carotid stenosis. The patient was treated successfully with angioplasty and stenting.

Conclusion

Endovascular treatment could constitute an interesting alternative for patients with giant cell arteritis associated with neurological deterioration after a first episode of stroke because of hemodynamic instability or at stroke recurrence. For these patients, the usual medical treatment appears to be insufficient.     

Maladie cœliaque et accidents vasculaires cérébraux ischémiques

Introduction

Neurological manifestations of celiac disease are various. An association with ischemic stroke is not common and has not been well documented. We report two cases.

Observations

The first patient had experienced several transient ischemic strokes in the past 2 years and then had an acute ischemic stroke involving the territory of the right posterior cerebral artery. Investigations revealed celiac disease with no other recognizable etiology. The clinical course was marked by persistent visual aftereffects, but no new vascular event. The second patient had been followed since 1998 for celiac disease confirmed by pathology and serology tests. She was on a gluten-free diet. The patient had an ischemic stroke involving the territory of the left middle cerebral artery. Apart from a positive serology for celiac disease and iron deficiency anemia, the etiological work-up was negative.

Discussion

The mechanisms of vascular involvement in celiac disease are controversial. The most widely incriminated factor is autoimmune central nervous system vasculitis, in which tissue transglutaminase, the main auto-antigen contributing to maintaining the integrity of endothelium tissue, plays a major role. Other mechanisms are still debated, mainly vitamin deficiency.

Conclusion

Being a potentially treatable cause of ischemic stroke, celiac disease must be considered as a potential etiology of stroke of unknown cause, particularly in young patients, and even without gastrointestinal manifestations.     

Le syndrome de vasoconstriction cérébrale réversible

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches, as well as vasoconstriction of cerebral arteries, which resolves spontaneously in one to three months. This condition has a moderate female preponderance. The mean age of onset is around 45 years. About 60% of the cases are secondary, mainly occurring during postpartum and/or after exposure to vasoactive substances. The main clinical presentation includes multiple recurrent thunderclap headaches over one to three weeks. The major complications of RCVS are localized cortical subarachnoid hemorrhages (cSAH) (20-25%) and parenchymal strokes (5-10%). Complications occur with different time courses: hemorrhages (cSAH and intracerebral hemorrhages), and posterior reversible encephalopathy syndrome are early events occurring during the first week, while ischemic events including TIAs and cerebral infarcts occur significantly later, during the second week. Diagnosis requires the demonstration of the “string and beads” aspect of cerebral arteries by a cerebral angiogram (MRA, CTA or conventional) and the demonstration of the complete or marked normalisation of arteries by a repeat angiogram performed within 12 weeks of onset. Treatment is based on nimodipine that seems to reduce thunderclap headaches within 48 h. However, nimodipine has not proven any efficacy against the hemorrhagic and ischemic complications of RCVS. Relapses are possible but rare and have not been reported yet in prospective series. It seems appropriate to advise the patients to avoid sympathomimetic and serotoninergic substances.     

Les accidents vasculaires cérébraux du nouveau-né et de l’enfant

The clinical presentation, risk factors, causes, vital or functional prognosis, and acute management options for stroke occurring in neonates and children are specific, differing from those observed in young adults. Compared with the adult population, less is known about the epidemiology of stroke in the under-18 population where the disease could become more frequent because of advances in both neonatal resuscitation techniques for cerebral disorders and neuroimaging techniques enabling the diagnosis of small lesions. Clinical features are often delayed, especially in neonates, and unlike epilepsy or dystonia of the affected limb, which are frequent complications, aphasia is rather rare. The most frequent causes of stroke at the beginning of life are cardiac embolism, for ischemic stroke, and arteriovenous malformations, for intracerebral hemorrhage. Acute management at this age is specific. This article reviews the literature on the epidemiological and clinical features, the main causes, and the acute management guidelines of stroke occurring in newborn infants and children and highlights the need for neurologists to have comprehensive knowledge of this disease.     

Aspergillose cérébrale chez le sujet immunocompétent. À propos de trois cas

Introduction

Cerebral aspergillosis is a severe disease most commonly suspected in immunocompromised patients.

Case report

We report herein three cases of cerebral aspergillosis in immunocompetent adults. Sinus involvement was noted in two cases, but there was no extracerebral involvement in the third case. Mycology samples provided the diagnosis in two cases. In the third case, cerebral imaging visualized a tumor; the patient underwent surgery and the pathology exam of the surgical specimen established the diagnosis. All patients were given antifungal treatment and achieved a good outcome.

Conclusion

Cerebral aspergillosis is highly uncommon in immunocompetent patients. In addition to immunodepression, the notion of pulmonary or ENT involvement may be suggestive. In the brain, aspergillosis mainly involves the basal nuclei and the thalamus.     

La force musculaire et son évaluation chez l’enfant infirme moteur cérébral

The muscular weakness is a determining factor in the cerebral palsy symptoms. Muscle strength should be evaluated as objectively as possible to improve the quality of diagnosis and treatment. To measure the muscle strength, we have at the present time a wide choice of tools. The most common and easy method is manual muscle testing, but its main inconvenience is its subjectivity. The manual muscle testing seems to be more appropriate for assigning grades 0 to 3 over 5. Hand held dynamometers give objective and quantifiable values. They are easy to use however the procedures, the positioning of the limb segment without or with the influence of the gravity, the stabilization or not of the joint, the experience of the clinician are responsible for a important errors of measurement which it is necessary to take into account in the follow-up of the programs of muscular training. The isokinetic testing machines are considered as golden standard, they offer a good stabilization of the patient, accurate end repeatable measurement and no examiner bias. Their clinical uses are limited due the lack of portability and the time required doing the measurements. All of these methods need an optimal level of the child participation and a good motor control. The spasticity and the contractures may interfere in the quality of the measurement. In the rehabilitation filed even if the strength improvement is important to reduce the disability, activity-based intervention are also necessary for reducing activity limitation in children with cerebral palsy.     

Tuberculomes cérébraux : à propos de six cas

Introduction

Despite the resurgence of tuberculosis, partly due to HIV infection, central nervous system involvement remains rare, accounting for only 2 to 5% of all tuberculosis forms.

Patients et method

We report six cases of brain tuberculomas occurring in patients free of HIV infection and hospitalized between 2001 and 2006 in the internal medicine department of a Tunisian military hospital (Tunis).

Results

Four patients had an underlying defect. Headache, fever, consciousness disorders, deficit disorder or cerebellar syndrome are the main symptoms. Tuberculomas were multiple and disseminated in four cases and localized in the brain stem in two cases. Positive diagnosis could be established in two cases on the basis of the pathology results of a brain biopsy or detection of Mycobacterium tuberculosis in the cerebrospinal fluid; the diagnosis was presumptive in the other cases. Five patients recovered under antituberculosis treatment maintained on average 13 months (11 to 16 months). Steroid treatment was associated in five patients and tapered off for four to six weeks. One 78-year-old diabetic patient died in a context of cachexia with multiple organ failure.     

La dépression vasculaire : évolution des malades et du concept

Late life depression differs from early life depression by no history of mood disorders, and by presence of vascular risk factors, cognitive decline and hyperintensities on MRI. A sub-type of depression is the vascular depression. We present a 6.2 years follow-up of five vascular depressed patients. The severity of depression was high with suicide attempt in three cases. Apathy and pharmacological resistance were reported. Non pharmacological management was more efficacious. Vascular dementia was the final diagnosis for three patients whose two had neuropathological diagnosis. It would be necessary to ameliorate the delimitation of the definition of vascular depression to distinguish them from mild cognitive impairment and from vascular dementia. The specificity of the treatment and the characteristics of the follow-up are arguments to realize a MRI when a patient has a late life depression.     

Développement cérébral en psychiatrie de l’enfant et de l’adolescent. Approche par l’imagerie

Modifications in cerebral development have either been demonstrated or their presence is probable in a number of psychiatric disorders which arise during childhood or adolescence. Their detection depends on new methods of image analysis; examples are presented in this article. These methodological innovations permit the quantification of anatomical or functional imaging data, not only in patient groups, but also on an individual basis. This new technology could concern diagnostic aid, psychopathological information, therapeutic evaluation, and sometimes detecting a disorder. The implementation of this type of research depends on the organization of clinico-methodological networks for setting up the relevant databases.     

Rééducation de la position assise de l’enfant paralysé cérébral infantile. Les moyens préventifs orthopédiques non chirurgicaux. Présentation d’un cas clinique

There are several sitting positions, which need a specific control of adjustment against gravity and a postural organization available to be learnt. The acquisition of sitting position is a very important step of child's functional development: this step is a very crucial point for clinicians who take care of rehabilitation of children affected by cerebral palsy because these children have abnormalities of functions against gravity and bad propioceptive informations. There are several and different pathological factors that could disturb the sitting position and it is very important to know these factors to prevent the orthopaedic problems and offer the most suitable chair for each child. For the most part, the children affected by cerebral palsy, especially if they belong to 3 or 4%, spend in sitting position 80% of their living time. If the child spends a lot of his time in a particular position, we must pay attention to the postural abnormalities and their orthopaedic outcomes. For this reason, it is very important to understand the importance of preventive treatment and clinic assessment oriented to identify the abnormalities. The educational and therapeutic strategies should be organized in an integrated and multidisciplinary way.     

Biomarqueurs cérébraux fonctionnels non invasifs de la performance motrice : supervision cérébrale pour la rééducation motrice en infirmité motrice cérébrale

For several years, studies have investigated non-invasive functional brain biomarkers derived from EEG signals in healthy people. Such biomarkers allow assessment of cortical dynamics in relation to the level of motor performance. Thus, similar biomarkers could be specifically engineered for persons with Cerebral palsy (CP) in order to provide the therapist new rehabilitation tools such as brain monitoring systems. This article presents a brief state-of-the-art research line related to these biomarkers, their current limitations and possible solutions, as well as their potential use for brain monitoring of individuals with CP in rehabilitation settings.     

Évaluation du recrutement des muscles fessiers dans les exercices de rééducation chez le jeune paralysé cérébral

Gluteus muscles weakness, especially Gluteus Maximus and Gluteus Medius ones are frequently reported in Cerebral Palsy (CP) walking children. Thus, their reinforcement in rehabilitation is often justified. Many physiotherapy exercises solicit their recruitment, but their efficiency was not yet reported. Ten different exercises are assessed and compared using surface electromyography (EMGs). The activity of Gluteus Maximus and Gluteus Medius muscles was recorded in 18 CP and eight asymptomatic children while realizing those exercises. The levels of muscular activation were compared between each exercise, and the existence of patterns was sought in the group of CP children. CP children measures were also compared to those recorded for valid children. This study gives classification of the exercises with respect to their efficiency for the recruitment of Gluteus Medius and Gluteus Maximus. The activity of these muscles in the various phases of the exercises is stated. Finally selection criterions between the exercises are proposed according to rehabilitation objectives of the pelvic belt.     

Apnée du sommeil et paralysie cérébrale à l’âge adulte. À propos de trois observations

Respiratory disorders are frequent in cerebral palsy with restrictive and also obstructive disorders. Obstructive sleep apnea has been described in childhood but there are few data about this problem in adults. Usually clinical symptoms are snoring, apneas, nycturia, sleepiness, awakenings, headache, cognitive disorders, and depressive syndrome. Obesity is a strong risk factor. Moreover, prevalence increases with age in adults. We report three cases of adults with cerebral palsy suffering from obstructive sleep apnea. Particularities of this syndrome are discussed in cerebral palsy. Diagnosis may be difficult because of the existing impairment, which can mask specific clinical signs. According to the risk of impairment worsening and of cardiovascular disease, obstructive sleep apnea must be evoked in case of any doubt. Individuals who are suspected of having obstructive sleep apnea should undergo polysomnography to confirm the presence and severity of sleep disordered breathing.     

Le réseau cérébral par défaut : rôle cognitif et perturbations dans la pathologie

Introduction

A “resting state” or “default mode network” has been highlighted in functional neuroimaging studies as a set of brain regions showing synchronized activity at rest or in task-independent cognitive state.

State of the art

A considerable and increasing number of studies have been conducted over the last few years so as to unravel the cognitive function(s) of this brain network.

Perspectives

This review gives an overview of anatomical, physiological and phenomenological data regarding the default mode network. Different hypotheses have been proposed regarding the role of this network. Several studies have highlighted its involvement in autobiographical memory, prospection, self, attention, and theory of mind. The influence of the attention level and consciousness onto resting state brain network activity has also been discussed. Specific changes have been described in normal aging, Alzheimer's disease (AD) and multiple sclerosis (MS).

Conclusions

These studies altogether contribute to a better definition of the default mode network, in terms of implicated brain structures, subtending mechanisms, and potential cognitive roles. For instance, similarities and relationships were found between self-related brain activity and resting-state activity in regions belonging to this network, namely posterior cingulate and prefrontal areas that may reflect introspective activity experienced, more or less consciously, when the brain is not specifically engaged in a cognitive task. As a whole, the default mode network appears as a non human-specific intrinsic functional network, active all over the life from birth until aging where it is progressively modified, and sensitive to different pathologies including AD and MS. On the other hand, many points remain to be clarified concerning this network, such as the exact part of its activity dedicated to self-related cognitive processes (introspection, imaginary mental scenario based on past autobiographical experiences) and that involved in a sentinel-like attentional process designated to react to possible environmental events. Indeed, it seems that this network is functional even in case of low level of consciousness, i.e., during light sleep. Conversely, a loss of self and environment perception as in coma, deep sleep or anesthesia might modulate its connectivity along the anteroposterior axis, i.e., frontal activity disappearance associated with a parietal reinforcement of connectivity. Since studies aiming at highlighting these points are still uncommon to date, exhaustive and objective explorations are needed to better understand all these resting state processes.     

Apports des dispositifs robotisés à la rééducation du membre supérieur hémiplégique

Introduction

Poststroke rehabilitation care has evolved considerably over the last decade. The emergence of the concepts of brain plasticity and motor learning has led to the development of new therapeutic approaches. Most of the new strategies are based on movement therapy, which can have a real impact on neurological recovery, sometimes with significant functional benefit for the patient.

State of the Art

In this context of evolving practices, the hemiplegic arm is the subject of special attention. Considering the often unfavorable “natural” prognosis and the relatively limited impact of conventional therapies; researchers have focused work on new alternatives. Cooperation between developers of technological advances and the medical community has led to the development of innovative therapeutic options often based on the use of specific technological tools (functional electric stimulation, virtual reality, transcranial magnetic stimulation…) to solicit or facilitate movement.

Perspectives/conclusion

Robot-assisted rehabilitation lies within this scope. The positive results reported in the most recent publications and the growing interest for this type of therapy in the fields of medical and engineering research should open the way for extremely promising prospects. The technological performance of new robots has nevertheless raised a large number of unanswered questions, implying a significant amount of further research.     

Une méningovascularite infectieuse de Lyme révélée par des accidents ischémiques cérébraux successifs

Introduction

Infectious vascularitis is an unusual cause of ischemic stroke (IS). We report a case of Lyme meningovascularitis complicated with multiple IS.

Case report

A 64-year-old man, without any cardiovascular risk factor, was admitted for a right hemiparesia with a left thalamic hypodensity on the initial cerebral CT scan. No cause for this presumed IS could be identified. Later, the patient developed cognitive impairment and a bilateral cerebellar syndrome. Multiple infarcts and multiple intracranial stenosis were seen on cerebral MRI with magnetic resonance angiography (MRA). Cerebrospinal fluid tests showed meningitis and positive Lyme serology with an intrathecal specific anti-Borrelia antibody index. Antibiotic treatment was followed by good biological and partial clinicoradiological outcome.

Conclusion

The diagnosis of Lyme neuroborreliosis should be entertained as a possible cause of IS in highly endemic zones.