Gaëlle Godeneche

Restless Legs Syndrome and Pregnancy: Follow-Up of Pregnant Women before and after Delivery

Aims: To describe the frequency of restless legs syndrome (RLS) in a French population of randomly selected women during their third trimester of pregnancy and its evolution up to 3 months after delivery and to identify potential factors associated with the improvement of RLS after delivery. Methods: A cross-sectional questionnaire survey. Results: 186 pregnant women living in a French town were included. 32% of women were affected by RLS during the third trimester of their pregnancy. Multiple pregnancies and iron intake during pregnancy were significantly associated with RLS during the third trimester. RLS disappeared after delivery among 64.8% of the women, and by less than 2 weeks after delivery in half of them. This improvement after delivery was not associated with the number of previous pregnancies, the RLS severity and iron intake during pregnancy, peridural anaesthesia, caesarean section, delivery complications, newborn weight, breastfeeding, dopaminergic agent intake after delivery, and with the absence of RLS before pregnancy. Conclusions: RLS affects one third of pregnant women during their third trimester and usually improves after delivery. Although there is no allowed treatment, most of the time only counselling and iron status assessment should be provided.

Cerebral abscesses in hereditary haemorrhagic telangiectasia: A clinical and microbiological evaluation

OBJECTIVES Hereditary haemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder that can lead to neurological manifestations including strokes and cerebral abscesses. Our objectives were to describe clinical, radiological, bacteriological, and outcome characteristics of patients with cerebral abscess and HHT, and to concurrently compare this group with a control group with cerebral abscess, but without HHT. PATIENTS AND METHODS Patients with HHT and cerebral abscess in 5 French medical centers were included. Their clinical, radiological, biological data and prognosis were compared to the data of unselected patients with cerebral abscesses but without HHT included during the same period of time. RESULTS Twenty-six patients (13 men and 13 women; 44.7±17.2; range 12-79 years), with HHT and cerebral abscess were included. A pulmonary arteriovenous malformation (AVM) was present in all cases. Cerebral abscesses were solitary, supratentorial, and mostly lobar. In all cases, pathogens were anaerobic or facultative anaerobic germs (particularly streptococcus). No death was observed, but various sequels were present in up to two-thirds of the patients. We observed a recurrence of the cerebral abscess in 4 patients with a mean delay of 81 months. In comparison with the control group, cerebral abscesses were generally of later recurrence and significantly more often unique and less often due to staphylococcus. CONCLUSION HHT cerebral abscesses are particularly linked to pulmonary arteriovenous malformations and anaerobic germs. Their clinical, radiological and bacteriological characteristics are quite different than in a control group with more solitary brain localizations, no staphylococcus infection and a significantly longer interval to recurrence.

Restless legs syndrome and pregnancy: a questionnaire study in the Poitiers District, France.

Aims: To perform a large and detailed epidemiologic study on restless legs syndrome (RLS) during pregnancy in a European country. Methods: A cross-sectional questionnaire survey. The questionnaire was distributed by the medical staff in different outpatient waiting rooms (obstetrics and gynecology department of the university hospital, obstetrics and gynecology department of a private clinic, private midwives, private obstetrician-gynecologists, radiological centers before fetal ultrasound examination and general practitioners) in a French town and its surrounding area (200,000 inhabitants): A woman was considered affected if she met the International RLS Study Group criteria for RLS diagnosis. Results: 1,022 pregnant women living in a French town were included. 24% of women were affected by RLS during their pregnancy. The disease was strongly related to the third trimester of pregnancy and had a significant impact on sleep leading to severe nocturnal and diurnal consequences with a high consumption of sleep medication. Conclusions: RLS affects one quarter of pregnant women, essentially during the third trimester and represents an important public health issue with sleep medication intake.

Sleep disorders and multiple sclerosis: a clinical and polysomnography study.

Background: Patients with multiple sclerosis (MS) report sleep disturbances (SD) and excessive daytime sleepiness (EDS) more frequently than the general population. Our objectives were to evaluate SD and EDS in MS patients and to test the reliability of subjective sleep questionnaires. Methods: Demographic and clinical characteristics of unselected consecutive patients with MS were collected. Different questionnaires were used to assess quality of sleep, daytime sleepiness, fatigue, anxiety, depression and quality of life (QoL). Nocturnal polysomnography and Multiple Sleep Latency Test (MSLT) were performed in 25 selected MS patients with fatigue and with or without EDS. Results: 205 MS patients were enrolled. More than half of the MS patients were classified as ‘poor sleepers’. In multivariate analysis, SD were correlated with disability, fatigue, depression, QoL, and pain, but not with EDS. Subjective sleepiness evaluated with the Epworth Sleepiness Scale and SD with the Pittsburgh Sleep Quality Index were not correlated with the results of the objective assessments of vigilance (MSLT) and sleep. Conclusions: SD and EDS are frequent among MS patients. Objective assessment of vigilance and sleep can be challenging but MS patients who are poor sleepers should receive immediate assessment and treatment in order to improve QoL.

Awareness within the French population concerning stroke signs, symptoms, and risk factors

BACKGROUND Effective implementation of early treatment strategies for stroke requires prompt admission to hospital which could be delayed for several reasons such as poor awareness of population. OBJECTIVE To assess current public knowledge of stroke. METHODS We randomly selected 411 persons living in Poitou-Charentes (area of nearly 1,700,000 persons in France) and performed an open-ended questionnaire regarding stroke risk factors, stroke warning signs, source of information, and stroke attitude. RESULTS Most of the patients (62.3%) were able to name three risk factors but not to report the most important and less than half of the respondents were able to recognize one or more stroke warning sign. Predictors of adequate knowledge of both stroke risk factors and warning signs were similar and included age and sources of information (books, magazines and newspapers or family members or relatives who have suffered from a stroke or general practitioner). CONCLUSIONS This study emphasizes that knowledge of stroke risk factors and warning signs was moderate at best. Improvements can only result from using a broad range of sustained educational efforts through simple and understandable school education or public media.

Obstetrical Outcome of Young Women with a Past History of Cerebral Venous Thrombosis

Background: This study was designed to review the obstetrical outcome of a consecutive series of cerebral venous thrombosis (CVT) affecting fertile women over a long period of time. Methods: From a computerized database of four hospitals of a French region (Poitou-Charentes), we selected patients admitted to hospital for CVT between January 1995 and February 2012. All the case notes were re-examined by two neurologists to confirm the initial diagnosis of CVT. The criterion of inclusion in our study was the occurrence of CVT in a woman ≤40 years of age. All the patients were recontacted by telephone in September 2012 and could be seen in an outpatient clinic. The data of interest were: occurrence of subsequent pregnancies, outcome of these pregnancies, their possible complications, their management with respect to preventive medication, details on the birth and the neonate. Results: Out of 190 consecutive patients hospitalized for CVT, 62 women aged ≤40 years were included (mean age 27.2 ± 6.7 years at the time of their cerebrovascular event). The mean duration of follow-up was 89.5 ± 60.6 months (median: 76 months). There were 45 pregnancies in 24 of the women. Among these 45 pregnancies, 1 was in progress, 24 were completed resulting in normal children, whereas 20 were terminated (5 voluntary abortions, 14 miscarriages and 1 medical abortion). During the pregnancies recorded, there was one recurrence of CVT and no extra-CVT. Various management strategies were adopted, depending on the identified cause(s) for CVT and the medical history of the patient. Conclusions: Our study confirms that the occurrence of a CVT in young women is not a contraindication for subsequent pregnancy. However, it points to a high incidence of miscarriage. Apart from this fact, there is no increase in materno-fetal complications during pregnancy and childbirth, and the neonates are healthy. The risk of recurrence of a CVT or extra-CVT during subsequent pregnancy is low but most of patients were on preventive antithrombotic medication.

Study of accessory deep peroneal nerve motor conduction in a population of healthy subjects.

AIM OF THE STUDY The short extensor muscle of the toes (extensor digitorum brevis) is innervated by the deep peroneal nerve (DPN) but can also receive innervation from an accessory deep peroneal nerve (ADPN), a branch of the superficial peroneal nerve (SPN). PATIENTS AND METHODS We conducted a systematic electrophysiological study of the DPN and ADPN in 200 healthy subjects (400 legs). RESULTS We found the presence of an ADPN in 13.5% of the subjects (8.5% of the legs). On average, ADPN amplitudes and motor potential areas were one-fifth of those for the corresponding DPN. Without this systematic search, most of the ADPN would not have been detected. Comparative study of electrophysiological parameters in patients with and without ADPN showed a significantly higher (P<0.0001) DPN motor potential area ratio (distal/proximal ratio) in subjects without an ADPN. CONCLUSION Even though electrophysiological identification of the ADPN is generally not easy (in simple DPN motor conduction studies), the nerve can sometimes be clinically symptomatic (ankle pain). Evaluation of the DPN motor potential area ratio (distal/proximal ratio) heightens the detection of ADPN.

Chapter 104 – Neurodermatology

Since the skin and the central and/or peripheral nervous system share a common source (the ectoderm), numerous genetic and acquired diseases (infectious, tumoral or autoimmune disorders) equally affect both. Neurologic diseases or symptoms such as stroke, cerebral or medullary vascular malformations, peripheral, brain or medullary tumors, epilepsy, ataxia, neurologic infections, or cognitive disorders (dementia, mental retardation) may be associated with specific cutaneous manifestations of which the discovery can facilitate the final diagnosis, thereby leading to specific treatment and/or genetic investigations. Careful examination of the skin, hair, and nails by the neurologist is consequently of the utmost importance; when unusual abnormalities of the skin are discovered or when greater expertise is required, consultation with a dermatologist is frequently advisable.

Long-term outcome of basilar stenosis in Erdheim-Chester disease: A case report.

Background:Erdheim–Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis. This inflammatory myeloid neoplasm is frequently complicated by neurological symptoms, but stroke is an exceptional manifestation of this disease. Methods:We report the case of a 59-year-old woman who presented a vertebrobasilar stroke secondary to infiltration and severe stenosis of the basilar artery, improved after interferon-alpha therapy. We performed a review of the relevant literature and reported the few other cases described. Results:With our patient, we have found only 7 observations of cerebrovascular disorder in ECD. Most of them had supravascular arteries involvement. Conclusion:Stroke is a rare treatable and potentially reversible complication of ECD. The pathophysiological processes explaining stroke in this disease are uncertain, but periarterial stenosis of cerebral arteries may be a mechanism.

Management of acute central retinal artery occlusion: Intravenous thrombolysis is feasible and safe.

Background Although acute central retinal artery occlusion is as a stroke in the carotid territory (retinal artery), its management remains controversial. The aim of this study was to assess the feasibility and safety of intravenous thrombolysis delivered within 6 h of central retinal artery occlusion in French stroke units. Methods We performed a retrospective analysis of patients treated with intravenous alteplase (recombinant tissue-plasminogen activator), based on stroke units thrombolysis registers from June 2005 to June 2015, and we selected those who had acute central retinal artery occlusion. The feasibility was assessed by the ratio of patients that had received intravenous alteplase within 6 h after central retinal artery occlusion onset among those who had been admitted to the same hospital for acute central retinal artery occlusion. All adverse events were documented. Results Thirty patients were included. Visual acuity before treatment was limited to “hand motion”, or worse, in 90% of the cases. The mean onset-to-needle time was 273 min. The individuals treated with intravenous alteplase for central retinal artery occlusion represented 10.2% of all of the patients hospitalized for central retinal artery occlusion in 2013 and 2014. We observed one occurrence of major bleeding, a symptomatic intracerebral hemorrhage. Conclusion When applied early on, intravenous thrombolysis appears to be feasible and safe, provided that contraindications are given due consideration. Whether intravenous thrombolysis is more effective than conservative therapy remains to be determined. In order to conduct a well-designed prospective randomized control trial, an organized network should be in place.