E. Castel-Lacanal

Induction of Cortical Plastic Changes in Wrist Muscles by Paired Associative Stimulation in the Recovery Phase of Stroke Patients

Background. Paired associative stimulation (PAS) combining peripheral nerve and transcranial magnetic stimulation (TMS) have been proposed to induce long-term changes in excitability of the cerebral cortex and potentially optimize motor recovery in stroke patients. Objective. This pilot study examined whether short-lasting changes in cortical excitability could be induced by a single session of PAS within the first months after stroke. Methods. Six hemiparetic patients with a subcortical stroke were included. The single session PAS protocol was applied at 1, 5, and 12 months after stroke. During the follow-up, the clinical recovery of wrist function was assessed in parallel to the PAS study by the Fugl-Meyer motor scale and dynamometry of wrist extension. Results. The PAS protocol induced a significant extensor carpi radialis motor evoked potential facilitation (mean +78.5%) on the paretic side 5 months after stroke. The facilitation was still present 12 months after stroke but on average smaller (+30 %). Conclusions. These electrophysiological findings suggest that patients with subcortical infarcts may respond to PAS in an earlier than later period after stroke. If the clinical efficacy of interventions such as PAS is confirmed, it could be proposed early as add-on therapy to optimize training-induced plasticity processes.

Neural Correlates of Proprioceptive Integration in the Contralesional Hemisphere of Very Impaired Patients Shortly After a Subcortical Stroke: An fMRI Study

Background. The effects of physiotherapy are difficult to assess in very impaired early stroke patients. Objective. The aim of the study was to characterize the impact of 4 weeks of passive proprioceptive training of the wrist on brain sensorimotor activation after stroke. Methods. Patients with a subcortical ischemic lesion of the pyramidal tract were randomly assigned to a control or a wrist-training group. All patients had a single pure motor hemiplegia with severe motor deficit. The control group (6 patients) underwent standard Bobath rehabilitation. The second, “trained,” group (7 patients) received Bobath rehabilitation plus 4 weeks of proprioceptive training with daily passive calibrated wrist extension. Before and after the training period, patients were examined with validated clinical scales and functional MRI (fMRI) while executing a passive movement versus rest. The effect of standard rehabilitation on sensorimotor activation was assessed in the control group on the wrist, and the effect of standard rehabilitation plus proprioceptive training was assessed in the trained group. The effect of 4-week proprioceptive training alone was statistically evaluated by difference between groups. Results. Standard rehabilitation along with natural recovery mainly led to increases in ipsilesional activation and decreases in contralesional activation. On the contrary, standard rehabilitation and paretic wrist proprioceptive training increased contralesional activation. Proprioceptive training produced change in the supplementary motor area (SMA), prefrontal cortex, and a contralesional network including inferior parietal cortex (lower part of BA 40), secondary sensory cortex, and ventral premotor cortex (PMv). Conclusion. We have demonstrated that purely passive proprioceptive training applied for 4 weeks is able to modify brain sensorimotor activity after a stroke. This training revealed fMRI change in the ventral premotor and parietal cortices of the contralesional hemisphere, which are secondary sensorimotor areas. Recent studies have demonstrated the crucial role of these areas in severely impaired patients. We propose that increased contralesional activity in secondary sensorimotor areas likely facilitates control of recovered motor function by simple proprioceptive integration in those patients with poor recovery.

Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study.

The efficacy of sacral neuromodulation for treating refractory idiopathic lower urinary tract dysfunction is now well established. Nevertheless, results of this technique in neurological patients are still controversial. The aim of this retrospective study was to assess the results of sacral neuromodulation in neurogenic bladder dysfunction.

Prospective study of the impact on quality of life of cystectomy with ileal conduit urinary diversion for neurogenic bladder dysfunction.

Neurogenic bladder dysfunction has a negative impact on the patients quality of life (QoL). Cystectomy with ileal conduit urinary diversion is a treatment option in patients in failure after conservative management. The objective of this study was to evaluate the impact of ileal conduit urinary diversion on the QoL of patients with neurogenic bladder dysfunction.

Neural substrates of low-frequency repetitive transcranial magnetic stimulation during movement in healthy subjects and acute stroke patients. A PET study.

The aim of the study was to investigate, with an rTMS/PET protocol, the after‐effects induced by 1‐Hz repetitive transcranial magnetic stimulation (rTMS) in the regional cerebral blood flow (rCBF) of the primary motor cortex (M1) contralateral to that stimulated during a movement. Eighteen healthy subjects underwent a baseline PET scan followed, in randomized order, by a session of Real/Sham low‐frequency (1 Hz) subthreshold rTMS over the right M1 for 23 min. The site of stimulation was fMRI‐guided. After each rTMS session (real or sham), subjects underwent behavioral hand motor tests and four PET scans. During the first two scans, ten subjects (RH group) moved the right hand ipsilateral to the stimulated site and eight subjects (LH group) moved the left contralateral hand. All remained still during the last two scans (rest). Two stroke patients underwent the same protocol with rTMS applied on contralesional M1. Compared with Sham‐rTMS, Real‐rTMS over the right M1 was followed by a significant increase of rCBF during right hand movement in left S1M1, without any significant change in motor performance. The effect lasted less than 1 h. The same rTMS‐induced S1M1 overactivation was observed in the two stroke patients. Commissural connectivity between right dorsal premotor cortex and left M1 after real‐rTMS was observed with a psychophysiological interaction analysis in healthy subjects. No major changes were found for the left hand. These results give further arguments in favor of a plastic commissural connectivity between M1 both in healthy subjects and in stroke patients, and reinforce the potential for therapeutic benefit of low‐frequency rTMS in stroke rehabilitation. Hum Brain Mapp, 2009.

Urinary complications and risk factors in symptomatic multiple sclerosis patients. Study of a cohort of 328 patients

Lower urinary tract dysfunctions (LUTD) are very common in Multiple Sclerosis (MS), have a significant social impact, while the organic impact is discussed. We studied urinary complications and their risk factors in our cohort of MS patients, in order to improve the management of LUTD in MS.

Preliminary results of botulinum toxin A switch after first detrusor injection failure as a treatment of neurogenic detrusor overactivity

To assess the results of onabotulinum toxin detrusor injections when abobotulinum toxin detrusor injection failed.

Post-stroke hemiplegia rehabilitation: evolution of the concepts.

Stroke rehabilitation has undergone a revolution over the last three decades. Cohort studies have consistently reinforced the importance of post-stroke rehabilitation to stimulate recovery, but the concepts of empirical methods originally proposed by therapists to rehabilitate these patients have not withstood clinical analysis. Functional neuroimaging and animal models have unveiled the mechanisms underlying functional recovery and helped teams understand its limitations and improvement modalities. These neuroscience discoveries constitute the grounds needed to understand the emergence of new technologies: robotics and virtual reality. The objective of this review of the literature was to select key works in this field to better understand current therapeutic possibilities.

Prospective Evaluation of Laparoscopic Assisted Cystectomy and Ileal Conduit in Advanced Multiple Sclerosis

OBJECTIVE To assess the morbidity, mortality, and impact on quality of life and renal function after laparoscopic cystectomy and ileal conduit in patients with multiple sclerosis with lower urinary tract symptom refractory to conservative management. MATERIALS AND METHODS A prospective study was conducted between February 2004 and December 2010 on 44 consecutive patients with multiple sclerosis who underwent laparoscopic cystectomy and ileal conduit for lower urinary tract symptom. Median Expanded Disability Status Scale score was 8 (6.5-8.5). Mean duration of multiple sclerosis was 19.3 ± 7.9 years. The quality of life was determined using the validated Qualiveen questionnaire preoperatively and at minimum 6 months after the surgery. RESULTS No conversion to open surgery was required. Postoperative morbidity rate was 18.2%; minor (Clavien ≤ 2) and major (Clavien ≥ 3) complications occurred in 13.6% and 6.8%, respectively. Mean follow-up was 44.5 ± 20.6 months. Complications noted were asymptomatic ureteroileal stenosis (n = 6) and pyelonephritis (n = 3). Neurological status and Expanded Disability Status Scale score remained stable throughout. Renal function remained unchanged. Limitations, constraints, and specific urinary impact index subscores of the Qualiveen were significantly improved at 6 months time. CONCLUSION Laparoscopic cystectomy and ileal conduit for lower urinary tract symptom in advanced multiple sclerosis is a safe procedure with low complications. Neurological status and renal function remain stable and quality of life improves and continues to remain improved during long-term follow-up, suggesting this to be an attractive option in patients with advanced multiple sclerosis with lower urinary tract symptom refractory to conservative treatment.

Cystectomie laparoscopique et urétérostomie transiléale pour troubles vésico-sphinctériens d’origine neurologique. Evaluation de la morbidité

Resume Objectifs Evaluer la morbidite et la mortalite de la cystectomie laparoscopique associee a une ureterostomie transileale pour traiter les troubles vesico-sphincteriens d’origine neurologiques. Materiel Etude prospective realisee entre fevrier 2004 et avril 2006, aupres de 26 patients consecutifs, d’âge moyen 55,0 ± 12,7 ans, ayant beneficie d’une cystectomie laparoscopique pour des troubles vesicosphincteriens d’origine neurologique. La pathologie neurologique etait une Sclerose en Plaques (SEP) dans 20 cas, un traumatisme medullaire dans 4 cas et une myelite transverse dans 2 cas. Le score ASA median preoperatoire etait de 3 (2-3). Resultats Aucune conversion n’a ete necessaire. Une complication per-operatoire a ete notee (plaie vasculaire). Aucun deces peri-operatoire n’a ete constate. La sonde naso-gastrique a ete maintenue en post-operatoire en moyenne 8,69 ± 5,9 heures. Le delai moyen de reprise de boissons etait de 1,4 ± 0,7 jours et celui de reprise de l’alimentation de 2,6 ± 1,0 jours. Le delai moyen de reprise du transit etait de 3,8 ± 3,2 jours. La duree moyenne d’hospitalisation en unite de soins intensifs etait de 3,9 ± 1,1 jours. Deux complications postoperatoires ont ete notees chez le meme patient (un ileus et un encombrement bronchique). La prise post-operatoire de morphi-niques a ete necessaire dans 60% des cas. La duree moyenne d’hospitalisation etait de 10,3 ± 4,1 jours. Deux complications post-operatoires tardives ont ete notees chez la meme patiente (deux pyelonephrites). Conclusion La cystectomie laparoscopique chez les patients neurologiques est peu morbide, permettant une realimentation precoce des patients et une duree d’hospitalisation moderee.