[Hemiplegia and return to domicile]

OBJECTIVE

We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation.

MATERIAL AND METHOD

This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05.

RESULTS

Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence.

CONCLUSION

The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.

[Multiple cerebral infarcts associated with livedo secondary to anti-cancer therapy with interleukin 2 and interferon alpha]

Anticancer drugs rarely cause strokes. We report the case of a woman treated for a kidney cancer by IL2 and IFN alpha, having developed multiple strokes associated with a livedo. The responsibility of IL2 and IFN alpha seemed likely. The association with a transitory livedo suggested that the pathological process might be a cerebral angiopathy with arterial vasospasms.

[The physiopathology of migraine]

Although the neurobiological causative factors are now beginning to be understood, to a large extent the complex mechanisms involved in migraine remain an enigma, with the appearance of a transient unilateral cephalic pain, possibly preceded by a protean aura and associated with several other symptoms. The factors involved include three clinical signs or symptoms, i.e., pain, the aura (focalized neurological and neurosensory signs), and accompanying symptoms (e.g., sensory, psychological, or digestive); and three anatomical sites, i.e., the brain, the meningeal or intracranial vessel and a peripheral cranial nerve, the trigeminus (V). Familial hemiplegic migraine (FHM) has led to a consideration of the genetic origin of ionic channel-dependent pathologies (channelopathies), while certain other arguments which are for the most part indirect favor the hypothesis of abnormalities, again possibly of genetic origin, in the central neurotransmitters (including serotonin), which are involved in the transmission of pain messages and in vasomotor control. However, the main point is that each of the sites involved has its specific pharmacopoeia, which can contribute towards the treatment of migraine.

Analysis of time management in stroke patients in three French emergency departments: from stroke onset to computed tomography scan

The aim of this study was to determine and identify the factors associated with shortening or lengthening time interval from stroke onset to performance of computed tomography (CT) scan in stroke patients admitted to three French emergency departments. All suspected stroke patients were eligible (n = 317). The time intervals between stroke onset and presentation to the emergency department and between CT scan request and CT scan performance were determined. Twelve variables likely to influence time interval before presentation to the emergency department, and five variables likely to influence time interval before CT scan performance were evaluated using stepwise regression analysis. Of the 317 patients included in the study, the mean time interval from stroke onset to CT scan performance for 180 patients was 7 hours 46 minutes (466 minutes). The mean time interval between stroke onset and presentation to the emergency department was 4 hours 36 minutes (276 minutes), varying according to the study site, level of initial severity, medical contact before admission, witnesses at stroke onset, and mode of transportation. The mean time interval between request and CT scan performance was 2 hours 14 minutes (134 minutes), varying upon the site, hour of CT scan request, type of stroke and level of severity at admission. It is concluded that current delays in stroke management are often incompatible with early treatment. The public needs to be informed and admission procedures reorganized. Improved response to the urgency of ischaemic stroke is required as well as direct access to the scanner during periods of scheduled use.

[Clinical diagnosis of cerebral ischemic accidents]

The diagnosis of stroke is relatively easy in the elderly. However, this is not the case for transient ischemic attacks or when misleading or unusual symptoms are present. Clinical examination remain an essential step: being fast, inexpensive and always possible by the family doctor, it permits to decide quickly how to handle the patient and to estimate the localization and the mechanism of the vascular lesion, which is necessary in order to guide and interpret complementary examinations. Given the now available treatments, it seems essential to inform the public on the cerebral vascular signs and symptoms. Indeed, recognition of transient ischemic attacks and hospital admission delays for strokes have to be improved.

[Angioplasty of atheromatous hemodynamic stenoses of intracranial vertebral arteries]

We describe three patients presenting transient ischemic attacks or minor stroke, relapsing despite anticoagulation and antiplatelet therapy, in relation to tight stenosis of the intracranial vertebral arteries, without functional communicating arteries. Percutaneous transluminal angioplasty was successfully performed. We have a 6, 24 and 36 months follow-up. After a review of the literature, we discuss indication and risks of this procedure.

Reappraisal of Rasmussen's syndrome with special emphasis on treatment with high doses of steroids

Eight patients with Rasmussen's syndrome and epilepsia partialis continua were treated with high doses of steroids, including pulses of methylprednisolone and prednisone in decreasing doses. Three patients exhibited clinical, radiological, or histological evidence of bilateral involvement. Epilepsy and focal deficit decreased within six months in seven patients. Only five patients, in whom steroid treatment had begun less than 15 months after the onset of epilepsia partialis continua, experienced a lasting effect although they had periodic episodes of transient relapse. Treatment with high doses of steroids seems advisable during the first year after onset of epilepsia partialis continua, before hemiplegia has developed and in cases with bilateral involvement.

Down-beat nystagmus: case report with magnetic resonance imaging and surgical treatment

A woman with down-beat nystagmus (DBN) underwent magnetic resonance imaging (MRI), which showed a syringomyelic cyst in the medulla. Surgical treatment of the cyst ended the abnormal eye movement. This case demonstrates the use of MRI for the diagnosis of DBN. It also shows the value of surgical treatment when a cyst is responsible for this symptom, as in Arnold-Chiari malformation.

[Severe cerebellar symdrome during aprindine treatment (author's transl)]

The authors, report a case of severe cerebellar syndrome, (preventory to remain standing) and connect with the dose of aprindine. This complication is coming with a little dose, facilitated with a minor renal insufficiency and a pre-existent neurologic disorder.

[A case of familial muscle weakness corrected by exercise (author's transl)]

The symptom described as muscle weakness corrected by exercise appears to be part of the recessive form of congenital myotonia, of which it can constitute the dominant clinical manifestation in some cases. This symptom coincides with decrements of the action of potentials to repetitive stimulations in the electromyogram, which may be particularly severe in these same cases. These observations contribute to the modification and precision of the description of the recessive form of Thomsen's disease, but their pathogenicity remains unclear.