Eric Berger

Seizures and Epilepsy following Strokes: Recurrence Factors

Background and Purpose: Though there have been many reports on poststroke seizures, there is still much we do not know about them. Using a large cohort of stroke patients we analyzed the characteristics of the seizure(s) and the rate and factors involved in seizure recurrence. Methods: Out of the 3,205 patients admitted for a first-ever stroke to our department between 1984 and 1994, we retrospectively studied the data of all patients with a first-ever seizure and analyzed their evolution. Two types of seizure(s) were defined: ‘early-onset’ seizures (occurring within the 14 days following the stroke) and ‘late-onset’ ones (after the 14th day). Results: 159 patients were included in the study, i.e. 4.96%. There were 116 ischemic strokes and 43 primary hematomas. Cortical involvement was found in 87% of the patients. Early-onset seizures occurred in 57 patients and late-onset ones in 102 patients, 76% of which were observed within 2 years. Follow-up was performed in 135 patients with a mean follow-up period of 47 months; 68 of them presented a seizure recurrence. A 2nd seizure occurred more often in the patients with late-onset seizures (p < 0.01); recurrence was either single (24 patients) or multiple (44 patients). Univariate analysis demonstrated 3 factors for multiple recurrences: hemorrhagic component, low Rankin scale after the initial seizure and occipital involvement. Multivariate analysis determined 2 factors: occipital involvement and late onset of the 1st seizure as a predictive model of multiple recurrences. Conclusions: This study confirms that poststroke seizures are frequent and must be divided into 2 types: early-onset (≤14 days) and late-onset seizures. It demonstrates that a significantly lower rate of patients with early-onset seizures develop another seizure, i.e. epilepsy, than do patients with late-onset seizures. Other factors are involved in recurrence suggesting that poststroke epilepsy probably occurs in a chronically injured brain. The problem of treatment remain unanswered.

Impact of Emergency Room Neurologists on Patient Management and Outcome

The frequency and impact of in-patient assessment by a neurologist in the emergency room (ER) setting remain largely underestimated. The objective of our study was to analyse the impact of neurologist in-patient management. Methods: Over a period of 12 months, we prospectively recorded the demographics of patients requiring examination in the ER, the ER team’s tentative neurological diagnosis, the neurology team’s final diagnosis and patient outcomes. The time interval between admission, call for a neurologist and the assessment by the neurologist were recorded. Results: Assessments by neurologists were performed in 14.7% (1,679/11,421) of all patients admitted to the ER. The mean time between admission and examination was 32 (± 36) min, irrespective of the day of the week, and dependent on the tentative diagnosis: shorter for stroke and status epilepticus (p < 0.05) and longer for confusion and vertigo (p < 0.05). The initial causes for examination were: stroke (33.1%), epilepsy (20%), loss of consciousness (9%), headaches (9%), confusion (5.4%), peripheral nervous system disorders (4.4%), vertigo (4.2%), cognitive dysfunctions (4%), gait disorders (3.2%) and miscellaneous (7.1%). Overall, false positive or negative diagnoses were produced by the ER in 37.3 and 36.6% of ER admissions, respectively. A complete change of diagnosis by the neurologist was found in 52.5% of patients. Of the patients undergoing a neurological examination, 18.4% were able to go home, 31.8% were admitted to the stroke unit, 32.4% to the general neurology unit and 17.4% to other departments. Conclusion: Our study stresses the need for a neurologist in the ER, both in quantitative terms and for the benefit of patient management.

Role of a Stroke Data Bank in Evaluating Cerebral Infarction Subtypes: Patterns and Outcome of 1,776 Consecutive Patients from the Besançon Stroke Registry

The purpose of this study was to estimate the frequency of various risk factors, courses and outcome of infarct subtypes in a large hospital-based stroke registry. Methods: From 1987 to 1994, 1,776 stroke patients with a first-ever infarction were included in the Besançon Stroke Registry. All patients were evaluated by a standard protocol (risk factors, stroke onset, stroke courses, clinical characteristics, neuroimaging, Doppler ultrasonography and cardiac investigations). Outcome was evaluated at 30 days using the Rankin scale. Results: There were 1,012 men (mean age 67.2 ± 13.7 years) and 764 women (mean age 71.4 ± 15.6 years). At least two neuroimaging examinations were performed in 81.4% (n = 1,446) of the patients and an infarct was visible in 80.9% (n = 1,436). The second neuroimaging examination (CT or MRI) was performed after 8.2 ± 1.6 days. 85.4% of patients were admitted on the first day of the stroke: 28.3% within 3 h and 48.4% within 6 h. In addition, stroke severity was well correlated with the short time interval between stroke onset and admission. Past medical history of hypertension was the major risk factor occurring in 57.5% of all types of infarction. While diabetes was more frequently found in small deep infarct, atrial fibrillation and history of heart failure were found in anterior circulation infarcts. The distribution of clinical presentations was conventional. Hemorrhagic transformation was found in 14.9% of the patients, especially in MCA and PCA infarcts. In all patients, logistic regression analysis determined independent predictive factors for death: clinical deterioration at the 48th hour (OR 7.5, 95% CI 4.9–11.3), initial loss of consciousness (OR 3.3, 95% CI 2.1–4.9), age (OR 1.05, 95% CI 1.03–1.06), complete motor deficit (OR 2.6, 95% CI 1.7–3.8), history of heart failure (OR 1.9, 95% CI 1.3–3.0), lacunar syndrome (OR 0.25, 95% CI 0.10–0.60) and regressive stroke onset (OR 0.24, 95% CI 0.10–0.52). However, the outcome was clearly correlated with the infarct location. The in-hospital mortality rate was lowest in patients with small deep infarct (2.9%) or border zone infarcts (3.4%) and the highest in patients with total middle cerebral artery infarct (47.4%) or multiple infarcts (27.6%). Conclusion: Our registry appears to be a useful tool to understand the course and outcome of a large group of nonselected patients with subtypes of infarction. It can also help to analyze the influence of specific stroke management in the different categories of stroke types.

Olfactory Dysfunction in Multiple Sclerosis: Evidence of a Decrease in Different Aspects of Olfactory Function

Background/Aims: Numerous authors have described olfactory dysfunction in multiple sclerosis (MS) in recent years. The aim of this study was to specify the aspects of olfactory perception that are most affected and to identify any correlations with clinical, anatomical and functional data. Methods: 50 patients with remitting or secondary progressive MS were included. Personal data were collected (medical history, characteristics of their disease, depression and disability scores and number of lesions on cerebral imaging). An olfactory test (Sniffin Sticks®) was used to evaluate subjects’ olfactory function. Results: The odor detection threshold is the most sensitive marker, with 40% of patients presenting hyposmia. The ability to identify odors is affected later on, and is inversely correlated with the level of disability. Conclusion: Our results confirm that several aspects of olfactory function are altered in MS, particularly those aspects requiring greater cognitive involvement, such as discrimination and identification of odors.

Limited Impact of the Summer Heat Wave in France (2003) on Hospital Admissions and Relapses for Multiple Sclerosis

Patients with multiple sclerosis (MS) often report worsening of symptoms with increased environmental temperature. The aim of this paper was to determine whether or not the heat wave of the summer of 2003 in France was responsible for an increase in hospital admissions and relapses in MS patients. MS patients who were hospitalized between January 1, 2000 and December 31, 2003 were identified, and we established which patients were suffering relapses. Hospitalization and relapse seasonality were examined and analyzed according to ambient temperature variations. We did not observe a greater number of hospital admissions and relapses during the summer of 2003 compared to the previous 3 years. Results showed that MS hospitalizations display a significant trough in the winter season, especially in December, but no significant peak season or month was observed. There was no statistically significant correlation between mean ambient temperature and the number of admissions and relapses. The adverse symptoms associated with high temperatures that are usually observed in MS patients may require rapid rises in ambient temperate or in internal body temperature.

Interferon γ, IL2, IL4, IL10 and TNFα Secretions in Multiple Sclerosis Patients Treated with an Anti-CD4 Monoclonal Antibody

In order to better understand the mechanisms of action of a monoclonal anti-CD4/BF5 antibody(mAb), cytokine secretions were studied in 14 multiple sclerosis (MS) patients treated in a phase 1 trial. Secretion patterns of IFNγ, IL2, IL4, IL10 and TNFα by peripheral blood mononuclear cells were studied before (DO) and after (D30) the treatment. We decided to undertake this study because in a previous one we observed no variations in serum levels of TNFα, IFNγ, IL1, IL6. Results showed significant reductions in IFNγ IL2 and TNFα secretions after treatment. The anti-CD4 mAb seemed to act on both Th1- and Th2-cells but with preferential action on Th1-cells. Results on Th2-cells were less obvious even though a significant decrease in IL10 was observed. There was no correlation between any of the immunological markers studied and disease activity. This study demonstrates that pharmacological modifications of the CD4 receptor can induce variations in several cytokine secretion levels. It also stresses the role pl...

Stiff leg syndrome and myelitis with anti-amphiphysin antibodies: a common physiopathology?

culty in walking. The symptoms had first appeared 2 weeks earlier. Her medical history included type 2 diabetes treated with metformin and a thyroid goiter treated with surgery and levothyroxine. On clinical examination, she presented permanent hypertonia in the lower limb and bilateral dystonia of the extensor hallucis longus muscles. Intermittent spasms were associated with hypertonia. The spasms lasted several seconds and were spontaneous, painful, and made worse by anxiety and cutaneous stimulation. The tibialis anterior muscles were hypertrophied. Electroneuromyography (ENMG) carried out under diazepam was normal. Cerebral and medullary MRI ( fig. 1 ) were normal. A PET scan showed an anomaly on the right breast. A mammography, breast ultrasound and biopsy confirmed the diagnosis of infiltrating canal carcinoma of the breast. The standard biological assessment was normal. Cerebrospinal fluid (CSF) tests showed pleocytosis (14 white blood cells), a high protein level (0.81 g/l) and intrathecal IgG synthesis with monoclon al bands. Other biological examinations were done: Lyme disease, HTLV (1 and 2) and tetanus serology were negative. Tests for antiphospholipid, antinuclear and anti-GAD antibodies were negative. No antiDear Sir, Stiff man syndrome is a rare neurological pathology first described in 1956 by Moersch and Woltman [1] . Four forms of the illness have been identified: stiff person syndrome, which is characterized by contractions and axial muscle rigidity; progressive encephalomyelitis with rigidity, characterized by diffuse rigidity and cognitive disorders; jerking stiff man syndrome, characterized by limb myoclonus and respiratory disorders; and stiff leg syndrome (SLS), which is characterized by focal rigidity and is different in various ways [2] . Anti-GAD antibodies are positive in only 15% of cases of SLS. Contractions and rigidity affect only one or two limbs. A paraneoplastic etiology is rarely associated with it. Medullary and cerebral MRI do not usually show any abnormalities [3] . We report the case of a patient suffering from SLS with anti-amphiphysin antibodies revealing breast cancer, with paraneoplastic transverse myelitis (TM) images appearing later in MRI with no as sociated neurological deficit.