Alain Yelnik

Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)

Background and Purpose— There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods— We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score ≤3) at 6 months’ follow-up (primary outcome) between the 2 treatment groups. Results— After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score ≤3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (P=0.18 and P=0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (P<0.0001). Conclusions— In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Perception of Verticality After Recent Cerebral Hemispheric Stroke

Background and Purpose— Perception of the subjective visual vertical (SVV) is affected by cerebral hemispheric lesions. Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances. There is still uncertainty about the possible effects of a visual field defect and of the side and site of the lesion. This study was conducted to assess SVV with the head upright or tilted and to explore its relation to a visual field defect, visuospatial neglect, and the site of lesion. Methods— Forty patients with hemiplegia after a recent hemispheric stroke (20 with left and 20 with right stroke) were studied. The site of the lesion was determined on CT scan, with special attention focused on the vestibular cortex. A neurological examination with determination of the visual field and visual neglect was conducted before SVV was tested. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. Measures were repeated with binocular and monocular vision and with the head upright or tilted to the right or left. Results— SVV was abnormally deviated in 23 of 40 patients (57%). The deviation was significantly greater among patients with a right or left hemispheric lesion than among healthy controls (−2.2° and 1.5° versus 0.2°); the same applied to the range of uncertainty (7.6° and 4.7° versus 1.9°). SVV deviation was not significantly related to the location of the lesion but was closely related to visuospatial neglect. The “E” effect observed in controls with the head tilted, ie, an SVV shift in the direction opposite to the head tilt, was not observed in hemiplegic patients with the head tilted toward the nonparetic side. Conclusions— Recent hemispheric stroke affects SVV perception, which is closely correlated to visuospatial neglect. It is suggested that the E effect might be mediated by the stretching of the somatosensory structure of the neck.

Clinical tools for assessing balance disorders.

Three main issues have to be addressed by the examination of a patient complaining from balance disorders: physiopathology and aetiology, severity and consequences, and evolution. A precise clinical analysis must be then conducted, including close anamnesis and clinical examination, with scale measurements depending on the objectives. Daily consequences can be assessed by the Dizziness Handicap Inventory, which considers a large field of daily activities. The International Classification of Functioning evaluates activities and participation, influence of environmental factors, and quality of life. Then, patients examination aims at objectifying and measuring the balance disorder. Quantified measurement is possible even in a simple doctors office. Clinical scales for balance assessment should be used for a standardized assessment and to allow comparison of different subjects. Although the Tinetti test is the most-widely used in older people, it is quite approximate. The Berg Balance Scale has also been first validated in older people, it is rather easy to use, but uncertainty between two close scores is frequent. The Timed Up-and-Go Test is the simplest one and probably the most reliable. The Unipodal Stance Testing is also a simple test and a good predictor of fall. The Functional Ambulation Classification focuses attention on the physical support needed by the patient during walking. The Postural Assessment Scale for Stroke Patients (PASS) is easy to use after a recent stroke. Instrumental analysis by means of static and dynamic platforms, often coupled together with accelerometers or video, can be used to complete the clinical examination. Its main interest is to contribute to give insight into physiologic and pathologic mechanisms underlying the postural trouble.

Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: a randomised, double blind, placebo controlled study of botulinum toxin A

Objective: This randomised, double blind, placebo controlled, two parallel group study was conducted to assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain in stroke patients with spastic hemiplegia. Methods: A single dose of botulinum toxin A (500 Speywood units) or placebo was injected into the subcapularis muscle. Pain was assessed using a 10 point verbal scale. Subscapularis spasticity was assessed by the change in passive shoulder lateral rotation and abduction. Upper limb spasticity was assessed using the Modified Ashworth Scale for shoulder medial rotators, and elbow, wrist and finger flexors. Assessments were carried out at baseline and at weeks 1, 2 and 4. Results: Twenty patients (10 patients per group), 11 with ischaemic stroke and 9 with haemorrhagic stroke, completed the study. Pain improvement with botulinum toxin A was observed from week 1; score difference from baseline at week 4 was 4 points versus 1 point with placebo (p = 0.025). Lateral rotation was also improved, with a statistically significant difference compared with placebo at week 2 (p = 0.05) and week 4 (p = 0.018). A general improvement in upper limb spasticity was observed; it was significant for finger flexors at week 4 (p = 0.025). Conclusions: Subscapularis injection of botulinum toxin A appears to be of value in the management of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post-stroke shoulder pain.

Influence of subjective visual vertical misperception on balance recovery after stroke

Background: Subjective visual vertical (SVV) perception can be perturbed after stroke, but its effect on balance recovery is not yet known. Aim: To evaluate the influence of SVV perturbations on balance recovery after stroke. Methods: 28 patients (14 with a right hemisphere lesion (RHL) and 14 with a left hemisphere lesion (LHL)) were included, 5 were lost to follow-up. SVV perception was initially tested within 3 months after stroke, then at 6 months, using a luminous line, which the patients adjusted to the vertical position in a dark room. Mean deviation (V) and uncertainty (U), defined as the standard deviation of the SVV, were calculated for eight trials. Balance was initially assessed by the Postural Assessment Scale for Stroke (PASS), and at 6 months by the PASS (PASS6), a force platform (lateral and sagittal stability limits (LSL6 and SSL6)), the Rivermead Mobility Index (RMI6) and gait velocity (v6). Functional outcome was also assessed by the Functional Independence Measure at 6 months (FIM6). Results: The scores for balance and for FIM6 were related to the initial V value: PASS6 (p = 0.01, τ = −0.38); RMI6 (p = 0.002, τ = −0.48), LSL6 (p = 0.06, τ = −0.29), SSL6 (p = 0.004, τ = −0.43), v6 (p = 0.01, τ = −0.36) and FIM6 (p = 0.001, τ = −0.49), as well as to the initial U value: PASS6 (p = 0.03, τ = −0.32), RMI6 (p = 0.02, τ = −0.35), SSL6 (p = 0.005, τ = −0.43) and FIM6 (p = 0.01, τ = −0.38). Conclusions: Initial misperception of verticality was related to a poor score for balance after stroke. This relationship seems to be independent of motricity and neglect. Rehabilitation programmes should take into account verticality misperceptions, which could be an important factors influencing balance recovery after stroke.

Quality of life after decompressive craniectomy for malignant middle cerebral artery infarction.

Malignant middle cerebral artery (MCA) infarction is a devastating condition leading to early death in nearly 80% of cases due to the rapid rise of intracranial pressure despite maximum medical management of the ischaemic brain oedema.1 Decompressive craniectomy (DC) has been proposed to prevent brain herniation in malignant MCA infarction, but it remains controversial in the absence of randomised controlled trials and because of the fear of a severe residual disability after surgery.1–4 We present herein the results of a quality of life assessment using patient and proxy versions of the Stroke Impact Scale (SIS) in eight patients 12–30 months after craniectomy for malignant MCA infarcts. Between March 1999 and November 2000, all consecutive patients with malignant MCA infarction were treated by DC and durotomy at Lariboisiere Hospital if they were younger than 55 years of age, had a complete MCA infarct as defined by complete MCA territory CT ischaemic changes, and a severe hemiplegia with altered level of consciousness with further neurological deterioration due to brain oedema, and if a close family member gave informed consent. Exclusion criteria were: prestroke moderate to severe disability defined by a modified Rankin scale (mRS)⩾2, haemorrhagic transformation involving more than 50% of the MCA territory, and significant contralateral ischaemia. Disability was assessed …

Rehabilitation of balance after stroke with multisensorial training: a single-blind randomized controlled study.

Objective. To compare 2 rehabilitation strategies to improve balance after stroke: (1) a multisensorial approach based on higher intensity of balance tasks and exercise during visual deprivation and (2) a conventional neurodevelopmentaltheory-based treatment (NDT) that used a general approach for sensorimotor rehabilitation. Methods . This prospective, multicenter, randomized, parallel-group study measured outcomes with blinded assessors. Sixty-eight patients able to walk without human assistance were entered from 3 to 15 months (mean, 7 months) after a first hemispheric stroke. They received 20 sessions in 4 weeks of NDT or multisensorial rehabilitation. On day 0, day 30, and day 90, assessment included the Berg Balance Scale (BBS), posturography, gait (velocity, double stance phase, climbing 10 steps, amount of walking per day), the Functional Independence Measure, and the Nottingham Health Profile. Results. All subjects improved significantly in balance and walking parameters. Regarding the main dependent variable (BBS on day 30), no difference between groups was found. Analysis of secondary outcomes suggested small differences in favor of the experimental group, but the differences are not likely to be clinically relevant. Conclusion. No evidence was found for the superiority of a multisensorial rehabilitation program in ambulatory patients with impairments beyond the time of inpatient therapy. Additional studies are recommended.

Drug treatments for spasticity

Drug treatments for spasticity A.P. Yelnik , O. Simon , D. Bensmail , E. Chaleat-Valayer , P. Decq , P. Dehail , V. Quentin , P. Marque , B. Parratte , F. Pellas , M. Rousseaux , J.-M. Trocello , M. Uzzan , N. Dumarcet l a Department of Physical and Rehabilitation Medicine, GH Lariboisiere-F.-Widal, AP–HP, universite Paris-7, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France b Department of PRM, hopital R.-Poincare, CHU Versailles-St-Quentin-Garches, AP–HP 104, boulevard R.-Poincare, 92380 Garches, France c CMPR-Les Massues, 92, rue du Dr-Edmond-Locard, 69000 Lyon, France d Department of Neurosurgery, CHU H.-Mondor, AP–HP, 51, avenue du Marechal-de-Lattre-de-Tassigny, 94000 Creteil, France e Department of PRM, hopital Xavier-Arnozan, avenue du Haut-Leveque, 33000 Bordeaux, France f Department of PRM, hopital Saint-Maurice, 14, rue du Val-d’Osne, 94410 Saint-Maurice, France g Department of PRM, CHU Rangueil, 31000 Toulouse, France h Department of PRM, CHU Besancon 2, place St-Jacques, 25000 Besancon, France i Department of PRM, CHU Caremeau, place du Pr-Robert-Debre, 30000 Nimes, France j Department of PRM, hopital Swynghedauw, 59037 Lille, France k Department of Neurology, hopital Saint-Antoine, AP–HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France l Agence francaise de securite sanitaire des produits de sante (Afssaps), 143, boulevard Anatole-France, 93200 Saint Denis, France

Evolution of Subjective Visual Vertical Perturbation After Stroke

Objective. The perception of visual verticality is often perturbed after stroke and might be an underlying component of imbalance. The aim of this study was to describe the evolution of visual vertical (VV) perturbation and to investigate the factors affecting it. Methods. Thirty patients with hemiplegia after a single hemispheric stroke (17 left lesioned [LL] and 13 right lesioned [RL]) were studied. Visual verticality was tested within 45 days of stroke, and then at 3 and 6 months. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. The differences between patients’ adjustments and vertical were calculated. The effects on VV evolution of the side, size, type, and location of the lesion were tested. Results. Sixty percent of the recent stroke patients had an initial inaccurate perception of verticality, and 39% of these patients recovered during the 1st 3 months after stroke. The evolution of VV tilt depended on the side of the lesion (P = 0.01), with better recovery in LL patients. None of the other factors studied affected VV normalization. Conclusions. The poorer recovery of vertical perception after right-side stroke might be due to the predominant role of the right hemisphere in spatial cognition, and might be involved in the poorer recovery of balance after stroke in RL patients.

Treatment of Pain and Limited Movement of the Shoulder in Hemiplegic Patients with Botulinum Toxin A in the Subscapular Muscle

Three poststroke hemiplegic patients were treated by injecting Botulinum toxin A (BtxA) into the subscapularis muscle, to reduce pain and increase the range of motion in the shoulder. According to the described procedure, 250 units of Dysport toxin were injected through a 0.8-mm diameter needle with electrostimulation guidance. In the 3 cases, injection of BtxA reduced pain and improved the range of motion, especially abduction and external rotation, of the hemiplegic shoulder. This result confirms the role of spasticity in hemiplegic shoulder pain and the beneficial effects of Botulinum toxin injection into the subscapularis muscle deserve to be confirmed in further series.