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.     

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.     

Accident vasculaire ischémique bithalamique : existe-t-il un tableau évocateur ? Étude radioclinique

Introduction

Bithalamic paramedian infarcts are uncommon. This stroke results in a complex clinical syndrome.

Case report

We report four cases of bithalamic paramedian infarcts with a presumed mechanism of occlusion of a single thalamic paramedian artery.

Discussion

This normal anatomic variant corresponds to an asymmetrical common trunk for the two thalamosubthalamic paramedian arteries arising from a P1 segment (type IIb in the G. Percheron classification dating from 1977). A literature analysis (from 1985 to 2006) allowed us to identify the most widely reported clinical signs. Four main clinical findings are described: vertical gaze palsy (65%), memory impairment (58%), confusion (53%) and coma (42%). We also found these symptoms in our patients but rarely associated; however, all four patients had exhibited episodes of drowsiness. In this article, we discuss the anatomy-function correlation responsible for such clinical variability.

Conclusion

Clinicians should be aware of this diagnosis to better understand the imaging results which provide confirmation. Although the literature describes frequently severe consciousness disorders such as coma, this diagnosis must also be considered in patients presenting a simple fluctuation of consciousness, e.g. hypersomnia.     

Infarctus cérébral, infection VIH et syphilis méningovasculaire : étude de trois cas

Introduction

Various clinical manifestations can occur in syphilis, especially meningovascular syphilis. We report three cases of ischemic stroke related to meningovascular syphilis and HIV infection.

Case reports

Three men, aged 30, 31 and 41, presented typical neurologic deficit leading to the diagnosis of ischemic stroke. Radiographic investigations showed internal carotid thrombosis in two patients, and a basilar stenosis in the third. CSF analysis and blood samples revealed meningovascular syphilis associated with HIV infection. The other explorations were normal.

Conclusion

Due to the reemergence of syphilis, search for Treponema pallidum infection should be systematic in young stroke victims.     

Hémorragie méningée focale et angiopathie amyloïde cérébrale : une association non fortuite

Introduction

Cerebral amyloid angiopathy is a degenerative angiopathy due to amyloid deposits in the walls of the meningeal and cortical vessels. It is considered as a major cause of cerebral hemorrhage to the elderly. It was recently demonstrated that the association of focal meningeal bleedings and cerebral hemorrhage is very suggestive of cerebral amyloid angiopathy. In contrast, the links between subarachnoid hemorrhage and amyloid angiopathy are less well-known.

Cases reports

We report nine cases of cerebral amyloid angiopathy. The clinical presentation was variable, but all had at least one inaugural meningeal bleeding. As cortico-meningeal biopsies were not performed the Boston criteria were used to establish the diagnosis.

Conclusion

Cerebral amyloid angiopathy is an underestimated cause of subarachnoid hemorrhage. Our observations show that this diagnosis should be evoked when focal meningeal bleeding occurs without head trauma or when focal subarachnoid hemorrhage is followed by a subcortical hematoma in an elderly subject.     

Polynévrite, crise convulsive, syndrome cérébelleux, complication d’un traitement par métronidazole. Apport de l’IRM

Introduction

Neurological complications of metronidazole are rare, predominantly peripheral neuropathies, especially in patients on a long-term high-dose regimen. Cerebellar syndrome or seizures are less frequently reported. The concomitant occurrence of the three complications is exceptional.

Case report

We report herein a case with these three complications as side effects of metronidazole. For the cerebellar syndrome, the T2-weighted brain MRI showed a rounded and well-delimited zone of high signal intensity in the cerebellar dentate nuclei, extending up to the protuberance and the subthalamic nucleus, bilaterally and symmetrically.

Conclusion

Neurological complications are possible when a treatment with metronidazole is prescribed for a long duration or at high dose. In our patient, the clinical abnormalities and MRI signs regressed a few months after treatment withdrawal.     

Stimulation cérébrale profonde et troubles de la marche dans la maladie de Parkinson

Introduction

Gait disorders and freezing of gait (FOG) are seen in most patients with advanced Parkinson disease. Response to levodopa and deep brain stimulation is variable across patients.

State of art

Thalamic stimulation is ineffective on gait and can even worsen balance when bilaterally applied. Pallidal stimulation moderately improves gait disorders and FOG although this effect tends to wane after three to five years. Stimulation of the subthalamic nucleus (STN) improves levodopa-responsive gait disorders and FOG. However, some patients worsen after STN stimulation and others are better improved under levodopa than under STN stimulation. Synergistic effects of the two treatments have been reported. As for pallidal stimulation, there is a failure of long-term STN stimulation to improve gait, probably due to the involvement of non-dopaminergic pathways as the disease progresses. Levodopa-resistant gait disorders and FOG do not usually benefit from STN stimulation. In the rare cases of levodopa-induced FOG, STN stimulation may be indirectly effective, as it enables reduction or arrest of the levodopa treatment.

Perspectives

Pedunculopontine nucleus stimulation has recently been performed in small groups of patients with disabling gait disorders and FOG. Although encouraging, the first results need to be confirmed by controlled studies involving larger series of patients.

Conclusions

Overall, gait disorders remain a motor PD symptom that is little improved, or only temporarily, by current pharmacological and surgical treatments. Patient management is complex.     

Atteinte multiple des nerfs crâniens : atteinte multiple des nerfs crâniens au cours du tétanos céphalique. À propos d’une observation et revue de la littérature

Introduction

Cephalic tetanus is the most serious form of localized tetanus. It associates trismus with impairment of one or more cranial nerves. It was a rare condition, whose diagnosis can raise several problems.

Case report

A 49-year-old-man presented multiple and unilateral cranial nerve involvement revealing cephalic tetanus.

Conclusion

This case illustrates the importance of considering cephalic tetanus when patients present cranial nerve palsy associated with injury.     

Stimulation magnétique transcrânienne répétée (rTMS) et symptômes négatifs de la schizophrénie

Purpose

The author has endeavoured to present a qualitative review of current data on the interest of repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of negative symptoms of schizophrenia, its therapeutic impact and processes that underlie it.

Method

The method consisted in a review of the literature by an extensive consultation of the computerized Medline database.

Results

Despite the small number of controlled studies and the small sample sizes, rTMS appears to be an effective therapeutic method in the treatment of negative symptoms of schizophrenia and also helps understanding the patho-physiologic processes that underlie them (hypofrontality, dopamine hypothesis and responsiveness of the HPA axis).

Conclusion

Before any conclusion may be reached about the effectiveness of this new technology more studies are required using larger parameters for active treatment and optimal placebos (alpha-TMS at least 110 % of the motor threshold, focused on the hypo-active area).     

Cardiac myxoma complicated with cerebral aneurysms and revealed by an ischemic stroke

Introduction

Myxoma is a rare benign primary cardiac tumor. It may cause vascular complications. Neurological symptoms may precede or accompany the diagnosis of myxoma with systemic embolization occurring most often in the cerebral circulation.

Observation

We report a case of cardiac myxoma complicated with cerebral aneurysms and revealed by an ischemic stroke in a 21-year-old patient. The cardiac myxoma was discovered during the transthoracic echocardiography performed as part of the etiological work-up. Because of the high risk of embolism, the mass was resected and mitral valve surgically repaired. The postoperative outcome was uneventful.

Conclusion

Although myxoma is a benign tumor histologically, it can lead to serious complications such as systemic embolism and sudden death.     

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.     

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.     

Thrombolyse in situ dans la thrombose veineuse cérébrale

Introduction

Cerebral venous thrombosis (CVT) is uncommon with a variable clinical presentation and an unpredictable outcome. Heparin is used for first-line treatment in association with symptomatic and etiologic management. Despite adequate anticoagulation, the condition may deteriorate in some patients warranting the use of local thrombolysis (LT) known for good efficacy and safety. But there are few cases and trials upon which to base guidelines for the use of LT.

Methods

A retrospective review of the medical and radiological records of patients with CVT was managed in the Caen hospital over a six-year period. We compared clinical factors of poor prognosis and radiological findings according to treatment delivered.

Results

Thirty-six patients are treated for CVT. LT was performed in eight of them; dose-adjusted intravenous heparin was the only treatment in the 28 others. Good outcome was achieved in two thirds of the patients with functional sinus patency in all cases. Based on an analysis of the radiological data of the 36 patients, we propose a summary of radiological risk factors associated with a worsening condition despite adequate anticoagulation.

Discussion/Conclusion

Based on our experience and a review of the literature which includes 98 previous cases, LT appears to be a relative effective end safe procedure even in the presence of a hemorrhagic infarct. The treatment by LT should be considered in patients who present clinical criteria of gravity and radiological risk factors associated with failure of heparin treatment. The usefulness of LT remains to be determined in a randomized trial comparing heparin alone and heparin associated with LT.     

Régression de sténoses intracrâniennes vertébrobasilaires symptomatiques sous corticothérapie au cours d’une maladie de Horton

Introduction

Involvement of intracranial arteries in giant cell arteritis is a rare condition but often carries a fatal prognosis. Corticosteroids seem to be insufficient to avoid ischemic cerebral complications, and could even promote the occurrence of stroke. We report the case of a patient with giant cell arteritis who experienced recurrent cerebellar stroke caused by intracranial vertebrobasilar stenoses with a favorable outcome following treatment.

Case report

A 77-year-old woman presented with a 3-month history of impaired general condition. She had new-onset headaches, jaw claudication and transient vertigo, especially when she woke-up. The brain MRI showed a recent cerebellar infarction. One week later, she was hospitalized for a clinical deterioration related to a recurrent cerebellar stroke caused by intracranial vertebro-basilar stenoses. Giant cell arteritis was confirmed on the temporal artery biopsy. A treatment with high-dose oral corticosteroids was begun associated with an intensive antiplatelet therapy. The clinical outcome was favorable with rapid improvement of gait imbalance together with a complete radiological regression of the intracranial stenoses.

Conclusion

Ischemic stroke in giant cell intracranial arteritis is a severe condition without a well-defined treatment. Corticosteroid therapy improves intracranial stenoses caused by vasculitis but should be initially associated with an intensive antithrombotic therapy to avoid early recurrence of cerebral infarcts.     

Dissémination sous-arachnoïdienne de gouttelettes lipidiques par rupture d’un kyste dermoïde intracérébral

Introduction

Dermoid cysts are rare slow-growing benign tumors of the central nervous system generally diagnosed in the third to fifth decade. They are formed from inclusion of ectodermal elements during neural tube closure, and are mostly located along the cranial or spinal midline axis. They cause many non specific symptoms such as headache and seizures, and may spontaneously rupture spreading fatty droplets into the ventricles and subarachnoid spaces. Rupture of dermoid cysts causes sequelae which may vary from no symptoms to death. In general, subtotal surgical removal is required for ruptured dermoid cysts.

Case reports

We report two cases of ruptured intracranial dermoid tumor with non-specific clinical presentations. The first rupture was asymptomatic and discovered on brain magnetic resonance imaging (MRI) performed for other purposes. The second case was identified on brain imaging performed because of daily headache. These dermoid cysts were not surgically treated. Surveillance was advised because of the spontaneously favourable outcome observed in both cases.

Conclusion

Surgical removal is not the only treatment of ruptured dermoid cyst. Monitoring with brain MRI can be sufficient if the rupture has no severe clinical impact.     

Neuromarketing: When marketing meet neurosciences

Introduction

The emergence of brain imaging in recent years has been accompanied by an alliance between neuroscientists and marketers. This collaboration gave birth to “neuromarketing”, a new field that uses imaging techniques with the aim of resolving marketing issues.

State of the art

Several studies have shown that pleasure felt at the sight of a product or after its consumption, is activated by a reward system involving ventral striatum. Since then, marketers seeking exploit this data and have found that some marketing actions can generate added satisfaction in a placebo-like manner. However, neuromarketing suffer from many limits that are a barrier to its development and its scope is restricted.

Perspectives

Through this article, we attempt to give an overview on neuromarketing and its neural correlates while provide a perspective toward the use of field for less commercial purposes.

Conclusion

The neuromarketing is a new field which efficiency is not proven. Its results must be interpreted with caution.     

Ischemic strokes related to benign primitive cardiac tumours

Background

We report three cases of ischemic cardioembolic strokes related to benign primary cardiac tumours (two fibromas and one fibroelastoma).

Case reports

This is a retrospective study over a five years period (from December 2004 to December 2009) in a French community hospital. Data on hospital strokes were obtained from the informatics department. Three benign primary cardiac tumours were found as the cause of acute neurological manifestations: a 45-year-old woman with a fibroelastoma revealed by a brain infarction, a 29-year-old man with a myxoma revealed by a transient ischemic attack, and a 46-year-old woman with a myxoma revealed by a brain infarction. Rankin scores performed at least 18 months after cardiac tumour surgery were respectively of 0, 0 and 2.

Conclusion

Our study confirms that this is a rare event even if those tumours seem to have a high embolic potential (myxomas). Anyway, long-term functional outcome seems to be good.     

Thrombose veineuse cérébrale et polyradiculonévrite aiguë révélant un lupus érythémateux disséminé

Introduction

Neurological manifestations of systemic lupus erythematosus are frequent and polymorphic. In 40% of cases, lupus can be revealed by neurological symptoms. Cerebral nervous system complications predominate and can be a negative factor for prognosis. Peripheral features are rare and various and can compromise functional prognosis, sometimes with fatal outcome.

Case report

We report the case of a 30-year-old woman who presented a cerebral venous thrombosis of the superior longitudinal sinus. Outcome was favorable with antibiotics and anticoagulants. Four months later, she developed an acute polyradiculoneuritis associated with an inflammatory syndrome and positive tests for antinuclear antibody and antinuclear anti-DNA. The diagnosis of neurolupus was retained on the basis of four criteria of the American college of Rheumatology. The patient was given steroid therapy associated with a course of intravenous immunoglobulin. She has fully recovered her deficit.

Conclusion

Cerebral venous thrombosis and acute polyradiculonévrites are rare events in systemic lupus erythematosus. Early diagnosis and management are crucial.     

Névralgie amyotrophiante héréditaire à forme sévère sans mutation du gène SEPT9

Introduction

Hereditary neuralgic amyotrophy (HNA) is a rare condition characterized by recurrent episodes of painful paralysis preferentially affecting the brachial plexus. It is often linked to a mutation in the SEPT9 gene.

Case report

A 69-year-old female patient experienced a dozen episodes of severe neurological deficit mainly affecting the brachial plexus and the phrenic and recurrent nerves. The diagnosis of HNA without SEPT9 gene mutation was retained.

Discussion

HNA can have significant sequelae. A genetic heterogeneity exists and mutations in the SEPT9 gene may not be found. Immunomodulatory and corticosteroid treatments have sometimes proved to be effective.     

Angioplastie-stenting transluminale percutanée après dissection des troncs supra-aortiques

Introduction

Spontaneous dissection of cervical arteries is one of the major causes of stroke in young patients. The recommended treatment is curative anticoagulation. However, in selected cases, this treatment could fail or meet contraindications. In such cases, an endovascular stent-assisted angioplasty could be successful.

Case report

We report the case of a 47-year-old patient with spontaneous dissection of the carotid and vertebral arteries. Despite optimized anticoagulant therapy, cerebral perfusion was low. An endovascular stent-assisted angioplasty was performed in the intra- and extracranial segments of the right internal carotid artery. Consequently by improving the intracranial circulation, normal functioning was restored with no immediate complications and the patient remained free of complications at 16-month follow-up.

Conclusion

Dissections of cervical arteries that lead to a chronic reduction in brain perfusion might benefit from endovascular stent-assisted angioplasty.