[Reflex epilepsy with seizures induced by mental calculation, playing chess and scrabble]

Reflex seizures induced by higher mental activity is rare. We report the case of a young man with myoclonic jerks and generalized tonico-clonic convulsion precipitated by calculation, playing chess and scrabble. Routine EEG, including hyperventilation and photic stimulation, showed no abnormality. Tests stimulation procedures, including spatial tasks, induced focal and generalized EEG spike-wave complex and myoclonic jerks. Valproate was effective in reducing epileptic seizures during a follow-up period of three years. Comparison of our case with previously reported reflex epilepsy with seizures induced by higher mental activity is discussed.

[Lateral bulbar infarctions. Distribution, etiology and prognosis in 40 cases diagnosed by MRI]

Recent advances in lateral medullary syndrome have focused on otoneuro-ophthalmology and magnetic resonance imaging (MRI). To reevaluate lateral medullary infarcts, 40 non fatal cases (30 men and 10 women, mean age 57.5 years) accounting for 4.5 p. 100 of overall cerebral infarcts were consecutively included in a prospective study using MRI in all cases. Thirty three patients were investigated using transfemoral or magnetic resonance angiography. Besides classical symptomatology, visual disorders were usually noted: diplopia (n = 18), transient visual tilt of the surrounding (n = 4), skew deviation (= 4), esotropia (n = 2) or conjugate gaze deviation (n = 2). The middle part of the medulla was affected in 35 cases. When associated, ipsilateral peripheral facial palsy and/or deafness were linked to the involvement of the pontomedullary junction (n = 3) while ipsilateral hemiparesis (Opalski's syndrome, n = 4) was linked to the involvement of the lower medulla and the cervicomedullary junction. MRI showed an associated cerebellar infarct in 35 p. 100 of cases. Of 33 patients angiographically investigated, 27 (82 p. 100) had stenosis or occlusion of the ipsilateral vertebral artery, usually affecting the intracranial portion, when 3 had isolated posterior inferior cerebellar artery occlusion. Atherosclerosis was recognized as the main cause of lateral medullary infarcts (n = 25). Other miscellaneous etiologies were diagnosed: coagulopathy (n = 2), spontaneous arterial dissection (n = 2), dolichoectatic artery (n = 1), arteriolopathy (n = 1) or cardiogenic embolism (n = 1). At the term of follow-up (mean: 35 +/- 24 months), 33 patients were free of residual handicap, 8 had experienced recurrent vertebrobasilar infarcts, including 3 medullary infarcts (median ipsilateral, n = 1 or lateral contralateral, n = 2), and 3 were died of basilar artery thrombosis complicating extensive atherosclerosis of the intracranial vertebrobasilar system.

Circulating immune complexes in various forms of Behçet's disease

BACKGROUND

The etiology of Behçet's disease (BD) is uncertain but there is strong evidence that the immune system is implicated in its pathogenesis.

METHODS

We assessed circulating immune complexes (CIC) in peripheral blood of 34 patients with BD, forming eight clinical groups, using a laser nephelometer to obtain more insight in the pathogenesis of different clinical forms of BD. Twenty healthy controls and eight patients with recurrent oral ulcerations were also included in the study.

RESULTS

Levels of CIC were significantly higher in patients (1.83 +/- 0.93 microgram/mL) than in controls (0.84 +/- 0.51 microgram/mL; P < 0.001). High titers were found in the groups of patients with erythema nodosum (3.14 +/- 0.44 microgram/mL), neurologic manifestations (2.9 +/- 0.58 microgram/mL), and ocular manifestations (2.34 +/- 0.93 microgram/mL). Compared to patients with recurrent oral ulcerations (1.91 +/- 0.77 microgram/mL), the mean value of CIC in patients with BD did not differ significantly, but the groups of patients having erythema nodosum, positive pathergy, and neurologic manifestations had significantly higher levels (P < 0.05) and the group of patients at the mild end of the spectrum (group 8) had a significantly lower level (1.09 +/- 0.41 microgram/mL) (P < 0.05). Only the groups having erythema nodosum, positive pathergy, and neurologic manifestations had significantly higher levels of CIC when compared to other groups lacking these clinical features, whereas group 8 had a significantly lower level (P < 0.05) when compared to all other groups.

CONCLUSION

Our results show that CIC may be involved in the pathogenesis of BD, especially in those clinical forms of the disease with erythema nodosum, neurologic manifestations, and ocular manifestations. Patients at the mild end of the BD spectrum do not show significant changes in CIC levels compared to healthy control subjects. We can, therefore, suggest that in BD CIC may be implicated more in the pathogenesis of some features than of others.

[Characterization of gestural disorders in primary progressive apraxia: diagnostic and nosographic contribution]

Five cases are reported of patients with so-called primary progressive apraxia, defined as a slowly worsening disturbance of gestural abilities, without other major cognitive changes during a long period, in relation to degenerative cortical atrophy. All five cases, as other cases in the literature, share the following common features: 1) asymmetrical onset of upper limb clumsiness, more often involving the left side, later involving the contralateral side and lower limbs; 2) after a variable delay, the occurrence of symptoms suggesting subcortical involvement (akinesia, limb stiffness, various kinds of movement disorders, dystonia, paresis of vertical gaze); 3) diffuse cortical atrophy typically more pronounced in the superior parietal cortex opposite to the first side affected. The unusual nature of apraxia in all these cases is pointed out and referred to as Luria's "kinesthaesic apraxia", ascribed to a loss of "selectivity" of distal elementary movements. This pattern of symptoms and their specific outcome could represent a distinct entity.

[Athymhormic syndrome caused by bilateral striato-capsular infarction. Moyamoya disease in adults]

A 49 year-old women with no medical history suddenly presented bilateral striato-capsular infarct causing frontal-like behavioural disturbances associating inertia with loss of drive, interest and affect, and preservation of intellectual function ("athymhormic syndrome" or "loss of psychic self-activation"). Ischaemic lesions mainly affected right globus pallidus and left lentiform nucleus with no involvement of the caput of the nuclei caudati. Such changes were close to anoxic lesions known to cause the same symptomatology. Infarction was attributed to a Moyamoya disease on angiographic data. Bilateral involvement of basal ganglia, arterial borderzones or both, may explain the frequent occurrence of neuropsychological disturbances in Moyamoya disease.

Mutism and auditory agnosia due to bilateral insular damage--role of the insula in human communication

We report a case of transient mutism and persistent auditory agnosia due to two successive ischemic infarcts mainly involving the insular cortex on both hemispheres. During the 'mutic' period, which lasted about 1 month, the patient did not respond to any auditory stimuli and made no effort to communicate. On follow-up examinations, language competences had re-appeared almost intact, but a massive auditory agnosia for non-verbal sounds was observed. From close inspection of lesion site, as determined with brain resonance imaging, and from a study of auditory evoked potentials, it is concluded that bilateral insular damage was crucial to both expressive and receptive components of the syndrome. The role of the insula in verbal and non-verbal communication is discussed in the light of anatomical descriptions of the pattern of connectivity of the insular cortex.

Diverging asymmetries of temporo-parietal cortical areas: a reappraisal of Geschwind/Galaburda theory

The general theory on the biological foundations of cerebral dominance formulated in 1985 by Geschwind and Galaburda entirely relies on a postulated causal relationship between anatomical asymmetry of the planum temporale and functional lateralization of the human brain, but does not take into account asymmetry of another cortical region, the parietal operculum. In 40 normal volunteers whose handedness was specified by the Edinburgh Handedness Inventory, we assessed asymmetries of these two regions on MRI sagittal scans. For both measurements, a significantly larger leftward asymmetry was found in the 24 consistent right-handers compared to the 16 non-right-handers. Moreover, the combination, for each subject, of the two indices of asymmetry, yielded four different subtypes between which handedness distribution significantly differed. We conclude that planum temporale and parietal operculum asymmetries may be divergent and that their convergence is strongly associated with right-handedness. Functional and developmental implications of these findings are discussed by reference to the Geschwind/Galaburda theory.

[Pseudovascular laterobulbar syndrome secondary to astrocytoma]

A patient presented with an atypical left lateral medullary syndrome (LMS) mimicking a stroke. Magnetic resonance imaging demonstrated a tumour in the left dorsolateral part of the medulla. Biopsy revealed a grade II astrocytoma. The patient died two weeks after surgery. Nine pathologically verified previous cases of LMS caused by a tumour are reviewed. LMS is invariably atypical because of associated supratentorial or extensive brainstem symptomatology. Onset is usually progressive but stroke-like onset has been occasionally reported. Glial tumours as a cause of LMS are less frequent than metastasis. Successful treatment has been reported in a case of low grade astrocytoma.

[Cerebral infarction in patients aged 16 to 35 years. Prospective study of 52 cases]

OBJECTIVES

Aetiologies of cerebral ischemic events in young adults are various and often contraversial: atherosclerosis plays a role after age 35 years, cardioembolism is often recognized as the major cause, and numerous new predisposing conditions have been described. To evaluate very premature cerebral infarction, we studied prospectively 52 consecutive patients (34 women and 18 men) aged 16-35 years (mean 28.6 +/- 5.6 years) admitted over a 6-year period for an arterial cerebral infarct identified on CT, on MRI or both.

METHODS

All patients were investigated using a standard protocol including cerebral angiography, transthoracic echocardiography, 24-hour Holter ECG monitoring, coagulation inhibitors levels, lupus anticoagulant testing, HIV and syphilitic serologies. Additional investigations were performed in a majority of patients: transesophageal echocardiography in 33, contrast echocardiography in 50, and anticardiolipin antibodies levels in 38.

RESULTS

The arterial distribution of infarction did not differ from that of overall stroke patients. Sixteen cases were classified as certain aetiologies, including cardiac diseases with high embolic risk (n = 9), spontaneous arterial dissection (n = 4), moya-moya disease (n = 1), atherosclerosis (n = 1), and inherited antithrombine III deficiency (n = 1). Eighteen cases were classified as possible aetiologies including cardiac diseases with low embolic risk (n = 11) such as mitral valve prolapse or atrial septal aneurysm, miscellaneaous arteriopathies (n = 3) such as arterial dysplasia, antiphospholipid antibodies syndrome (n = 1) and migrainous stroke (n = 3). The 18 last cases were classified as unknown aetiologies, despite all patients but one had at least one vascular risk factor: this group significantly differed from the formers in that the patients were more frequently women using oral contraceptive associated with tobacco consumption, hypercholesterolemia, or both. Two patients died acutely and the survivors were followed 31 +/- 18 months. Three patients experienced recurrent stroke. Functional outcome was assessed using the Rankin scale on admission and 6 to 12 months after the onset of stroke: patients evaluated < or = 2 (no to mild handicap) were 31% on admission and 82% after recovery. Twenty six p. cent remained unable to resume a work.

CONCLUSION

Despite extensive evaluation, identification and classification of aetiologies of cerebral infarction in young adults should be cautious because the risk as well as the pathogenesis of many potential causes still need to be defined.

[Spinal dural fistula with peri-medullar venous drainage]

Clinical and neuroradiological findings of 8 patients with a spinal dural arteriovenous fistula are reviewed. Disturbance of micturition or defecation and weakness of the legs were always present and the most frequent initial symptom was a progressive spastic paraparesis. Duration of symptoms before diagnosis was 2 years. Lumbar puncture showed elevation of proteins and myelography demonstrated dilated perimedullar posterior veins. In every case, magnetic resonance imaging of the spinal cord (T2- weighted images) revealed intramedullary high signal intensity of the conus medullaris and selective angiography confirmed the site of the dural fistula. Each patient was treated with endovascular method consisting in liquid adhesive embolization (0.2 cc of N-butyl cyanoacrylate) with hyperselective catheterism of the dorsospinal artery. Embolization procedure was successful in 6 cases with large improvement of leg weakness and partial regression of disturbed micturition and defecation. The pathophysiological mechanisms explaining the clinical signs are discussed.

[Lateral thalamic infarction. 22 cases]

Isolated lateral thalamic infarcts (LThl) are rare. They often produce lacunar syndromes, and their main cause is thought to be an hypertensive arteriolopathy. To verify these data, we reviewed 639 cerebral infarcts demonstrated by CT and/or MRI and included in a hospital stroke registry over a 4-year period. We identified 22 cases (3.5 p. 100) of isolated LThl (right LThl: 15; left LThl: 7). Nineteen had MRI study. There were 13 men and 9 women of mean age 65 years. None had the complete Dejerine-Roussy syndrome: sensory disturbances 21 cases, hemiparesis 7, hemiataxia 5, involuntary movements 4. They were divided in group 1 (14 cases) with prominent sensory symptomatology and group 2 (8 cases) with prominent motor symptomatology. The pulvinar and the ventral posterior thalamic nucleus were affected in both groups while adjacent nuclei such as ventral lateral or lateral posterior were more often affected in group 2. All patients but one had good recovery but 13 developed thalamic pain severely interfering with social activities in 5 cases. Several findings suggested that rather an arteriolopathy than large vessels disease or cardiogenic embolism had been a major cause in this series: 1) all patients but one (including 2 with a potential cardiac source of embolism) were hypertensive or diabetic, 2) lesions were small infarcts in the territory of perforators, 3) patients did not experience premonitory as well as subsequent cerebral events suggestive of vertebrobasilar atherosclerosis while 2 experienced deep cerebral hypertensive hemorrhage, and 4) neuro-imaging found additional asymptomatic lacunes in numerous patients. However, in the absence of angiography in most patients, these results do not preclude a potential role of artery-to-artery microembolism.

Functional and magnetic resonance imaging correlates of callosal involvement in multiple sclerosis

To investigate functional and anatomical features of callosal involvement in multiple sclerosis (MS), performances of 90 patients with definite MS and 25 matched normal control subjects were compared on three tasks exploring interhemispheric transfer of auditory, sensory, and motor information: a verbal dichotic listening task, a crossed tactile finger localization task, and an alternate finger tapping task. Each patient also underwent a magnetic resonance imaging (MRI) scan (1) to appreciate the extent of white-matter changes by a semiquantitative evaluation of hemispheric brain MRI hyperintensities and (2) to measure the degree of total and regional callosal atrophy using an automatized method of partition of the midsagittal callosal area. Interhemispheric transfer and/or integration was impaired in patients with MS for all modalities explored and proportional to both degree of callosal atrophy and diffusion of white-matter lesions. Moreover, in good agreement with data obtained from partial commissurotomy studies, performance on each functional task was predominantly associated with atrophy of one part of the callosum, namely left-ear dichotic suppression with the posterior callosal region, alternate finger tapping with the anterior region, and cross-localization with midanterior and posterior regions. Finally, a subgroup of patients without MRI white-matter hyperintensities also showed significant impairment of callosal function and relative atrophy of the callosum. These findings suggest the potential clinical value of callosal involvement in MS and the usefulness of MS as a model of interhemispheric disconnection.

[Primary progressive aphasia (Mesulam syndrome)]

Primary progressive aphasia is defined as a gradually appeared and gradually worsening disorder of speech without any major alteration of the other cognitive functions. It is regarded by some authors as a syndrome which may be due to various degenerative diseases of the cerebral cortex (notably Alzheimer's disease, owing to its frequency), while others see in it an autonomous disease related to a neuropathological process that is distinct from the main degenerative dementias. The principal clinical particularity of primary progressive aphasia is that it spares the patient's autonomy for a long time, but ultimately turns into global dementia. Despite the diversity of aphasic aspects accompanied or not, in neuroimaging, by morphological and metabolic asymmetry to the expense of the left hemisphere, a review of the autopsy cases published shows that the vast majority corresponded to a neuropathological pattern devoid of the characteristic features of Alzheimer's disease and nearer to Pick's disease. In practice, the diagnosis of Alzheimer's disease can be excluded in all patients whose clinical presentation and cerebral neuroimaging results are compatible with primary progressive aphasia. Moreover, the fact that this new clinicoanatomical entity has been individualized constitutes a definite step towards a better comprehension of degenerative dementias.

[Pure cerebellar infarction. Thirty cases]

Infarcts in the territory of cerebellar arteries, often involving both brainstem and cerebellum, have been well recognized in recent pathological and clinicoradiological studies. To evaluate the situation of pure cerebellar infarcts (PCI) we studied 30 consecutive cases of symptomatic PCI (22 men and 8 women, mean age 58 +/- 17 years) admitted over a 5-year period and selected on the basis of brain computed tomography completed by magnetic resonance in 20 cases and angiography in 15 cases. PCIs accounted for 53 percent of cerebellar infarcts, 10 percent of vertebrobasilar infarcts and 3.2 percent of all cerebral infarcts. The arterial territories involved were the superior cerebellar artery (SCA) in 13 cases (alone in 8 cases), the anterior inferior cerebellar artery in 2 cases, the posterior inferior cerebellar artery (PICA) in 17 cases (alone in 13 cases) and border areas in 5 cases (associated with SCA or PICA). The symptoms were the same in the arterial territories involved (SCA versus PICA), except for dysmetria and vestibular syndrome which were more frequent respectively in SCA territory infarction (P < 0.001) and in PICA territory infarction (P < 0.01). Certain or presumed causes were cardiogenic embolism (23 percent), atherosclerosis (43 percent) and other identified causes, such as oral contraceptives or temporal arteritis (10 percent). They remained undetermined in 24 percent of the cases. Although most patients were severely disabled in the acute stage (Barthel index < 60 in 21 cases), 90 percent recovered subsequently (Barthel index about 100 and 0-2 score on modified Rankin scale). Our findings indicate that symptomatic PCIs are rare; their main causes (cardioembolism and atherosclerosis) do not differ in frequency from those of all cerebral infarcts collected in stroke registries and their functional prognosis is good in almost all cases.

Putaminal necrosis after methanol intoxication

Images

Preservation of urosexual functions after radical cystectomy

Nerve-sparing radical cystectomy with ileocecal bladder substitute is highly recommended for male patients with schistosomal bladder carcinoma and for selected male patients with transitional cell carcinoma. Twenty-three patients underwent this procedure with preservation of the distal one third of prostatic capsule and inframontanal urethra, reinforcement of the ileocecal valve, and tightening of the two levator ani muscles over the cecourethral anastomosis. Urodynamic study revealed that the closed ileocecal segment is a highly compliant reservoir, and coupled with a reinforced ileocecal valve and distal urethral mechanism resulted in a low incidence of ureteral reflux (15%) and a high degree of urinary continence (100% by day and 40% by night). The procedure does not appear to undermine the principles of oncologic surgery, offers the psychologic and functional benefits of urethral micturition for all patients, and preserves erectile potency in half of them.

Infarction in the territory of the anterior inferior cerebellar artery: report of five cases

The clinical and MRI features were correlated in five cases of infarction in the territory of the anterior inferior cerebellar artery. The lateral portion of the pons area was affected in four cases, the middle cerebellar peduncle in two, and the cerebellar hemisphere in three. The lesion was restricted to the cerebellar hemisphere in one patient. In no case did the clinical features conform to the classical description.