Lou Grangeon

Differential Diagnosis of Dementia with High Levels of Cerebrospinal Fluid Tau Protein.

BACKGROUND Total Tau concentration in cerebrospinal fluid (CSF) is widely used as a biomarker in the diagnosis of neurodegenerative process primarily in Alzheimers disease (AD). A particularly high Tau level may indicate AD but may also be associated with Creutzfeldt-Jakob disease (CJD). In such situations little is known about the distribution of differential diagnoses. OBJECTIVE Our study aimed to describe the different diagnoses encountered in clinical practice for patients with dementia and CSF Tau levels over 1000 pg/ml. We studied the p-Tau/Tau ratio to specify its ability to distinguish AD from CJD. METHODS Patients (n = 202) with CSF Tau levels over 1000 pg/ml were recruited in three memory clinics in France. All diagnoses were made using the same diagnostic procedure and criteria. RESULTS Patients were diagnosed with AD (n = 148, 73.2%), mixed dementia (n = 38, 18.8%), CJD, vascular dementia (n = 4, 2.0% for each), Lewy body dementia, and frontotemporal dementia (n = 3, 1.5% for each). Dispersion of CSF Tau levels clearly showed an overlap between all diagnoses. Using the p-Tau/Tau ratio suggestive of CJD (<0.075), all CJD patients were correctly categorized and only two AD patients were miscategorized. This ratio was highly associated with CJD compared to AD (p < 0.0001). CONCLUSION Our study showed that in clinical practice, extremely high CSF Tau levels are mainly related to diagnosis of AD. CJD patients represent a minority. Our results support a sequential interpretation algorithm for CSF biomarkers in dementia. High CSF Tau levels should alert clinicians to check the p-Tau/Tau ratio to consider a probable diagnosis of CJD.

Impact of an intrahospital mobile thrombolysis team on 3-month clinical outcomes in patients benefiting from intravenous thrombolysis for acute ischemic stroke

INTRODUCTION/OBJECTIVE The benefits of thrombolysis in patients presenting with acute ischemic stroke (IS) are highly time-dependent. The aim of our study was to evaluate the clinical benefit, after 3 months, of an intrahospital mobile thrombolysis team (MTT) for thrombolysis in IS. PATIENTS AND METHODS A total of 95 consecutive patients treated with IV tPA for acute IS at the neurology department of Rouen University Hospital between 1 January and 31 December 2015 were retrospectively identified. Patients who had benefited from mechanical thrombectomy or hemicraniectomy were excluded. The study compared 33 patients who had benefited from our MTT (thrombolysis whatever the location and as soon as possible by a specific nurse) with 62 patients treated in the usual way (thrombolysis only at the stroke unit). Management timescales, inhospital and 3-month clinical outcomes, and imaging data were also compared between the two groups. RESULTS Demographic data and factors known to influence the clinical course after thrombolysis were similar between the two groups (P>0.05). However, use of the MTT allowed significant decreases in the median onset-to-treatment (OTT) time of 26min and median door-to-needle (DTN) time of 27min (P<0.001). The proportion of patients with a DTN time<60min was higher in the MTT group than in the usual care (UC) group: 64% vs. 14%, respectively (P<0.001), according to American Heart Association/American Stroke Association guidelines. Although there was a smaller proportion of negative 3-month outcomes (modified Rankin Scale score: 6; 6% vs. 16%) and a larger proportion of highly favorable 3-month outcomes (mRS score: 0-1; 79% vs. 64%) in the MTT vs. UC groups, respectively, these differences were not statistically significant (P>0.05). DISCUSSION/CONCLUSION Use of an MTT is a simple way to reduce thrombolysis delays, and the present results encourage us to improve the system to make it even more effective and available for all patients.

Management and outcome of cerebral venous thrombosis after head trauma: A case series

Cerebral venous thrombosis (CVT) is an underdiagnosed complication of head trauma. To date, initiation of anticoagulation is still a matter of debate because of the risk of worsening traumatic hemorrhage. This report describes a case series of five patients admitted for head injury complicated by CVT. The main associated radiological signs were skull fractures crossing the venous sinus and adjacent traumatic hematoma. In four patients, anticoagulation was introduced within 48-72h of CVT diagnosis, with no subsequent hemorrhagic complications. The present report and data from the literature raise the question of systematic additional venoscans when confronted by associated radiological features of post-traumatic CVT. The safety of anticoagulation in selected patients is also discussed.

Leucoencephalopathy following abuse of sniffed heroin

A 29-year-old man was admitted for acute cognitive impairment. Three weeks earlier, he had been admitted for coma due to sniffed heroin abuse responsive to naloxone infusion. At admission, the patient presented with apraxia, severe memory impairment and anosognosia. Brain MRI revealed symmetric hyperintensities of supratentorial white matter, sparing brainstem and cerebellum, on FLAIR and B1000 sequences. Four months later, repeated neuropsychological assessment revealed dramatic improvement of global cognitive functions. Toxic leucoencephalopathy excluding the cerebellum and brainstem is a rare complication of heroin abuse, and seems to concern especially patients that use heroin by sniff or injection. In these patients, cognitive troubles are predominant, prognosis seems better and infratentorial brain structures can be spared. In conclusion, our observation emphasizes that heroin-induced encephalopathy can have a favourable outcome and that imaging and clinical patterns can indicate the mode of drug administration.

Bath‐related thunderclap headache: Case report of a male patient

Bath‐related thunderclap headache (BRTH) is a rare entity, closed to reversible cerebral vasoconstriction syndrome. It is only described in middle‐aged women and mainly Asiatic ethnic origins. Role of estrogen is consequently discussed. We report here a case of a 36‐year‐old man, admitted for five episodes of thunderclap headaches, triggered by hot shower. This is the first male case of BRTH, opposing only a hormonal hypothesis. Furthermore, this African patient consolidates the non‐exclusivity of this affection to Asian ethnic origins.

Innominate artery dissection and stroke after rifle recoil

Cervical artery dissection is a frequent cause of stroke, more so in young patients. Innominate artery (IA) dissection is uncommon, and most often associated with dissection of other major arteries like the aorta. The leading cause of IA injury is high-energy thoracic trauma, as in motor vehicle crash. IA dissection after blunt trauma is rare. We described here the unusual case and iconography of an isolated IA dissection after rifle recoil initially presenting as a stroke.

Acute necrotic pancreatitis: A rare and not always fatal cause of central pontine myelinolysis

Introduction Extra and central pontine myelinolysis (CPM) are considered as osmotic demyelination syndromes (ODS) [1]. The most frequent aetiology of central pontine is rapid correction of hyponatremia. In that case, the prognosis is usually known as highly severe. Nevertheless, a few cases without osmolarity disorder are described [2]. Myelinolysis complicating an acute pancreatitis is extremely rare. To our knowledge, only 2 cases have been described in the literature [3,4]. Mechanisms involved and outcomes of CPM in a context of acute pancreatitis are still unknown. We herein describe, following the CARE guidelines, the case of a patient admitted for central myelinolysis in a context of acute pancreatitis without hyponatremia [5]. Case report A 31-year old man, with a past medical history of chronic alcoholism, was admitted with severe abdominal pain and vomiting, revealing an acute pancreatitis. Upon admission,

Indomethacin-Responsive Paroxysmal Hemicrania in an Elderly Man: An Unusual Presentation of Pituitary Apoplexy

Paroxysmal hemicrania (PH) is a rare condition classified by the International Headache Society as a trigeminal autonomic cephalalgia (TAC) with an exquisite response to indomethacin. PH mainly affects young or middle-aged people. Unlike cluster headache, very few cases of PH due to secondary lesion have been described. Pituitary apoplexy (PA) is a life-threatening condition, usually revealed by thunderclap headache. We herein report the rare case of an elderly man presenting with indomethacin-responsive PH, symptomatic of PA. This greatly broadens the diagnostic work-up for headache revealing PA and secondary headache in the elderly as well. A 83-year-old man, who had no prior history of headache, was admitted for five attacks a day of severe unilateral headaches for the last 5 days. His main antecedents included depressive syndrome and diabetes for which he was on metformin only. He experienced attacks of left retro-orbital sharping pain, lasting 20 minutes. He had neither nausea nor photophonophobia but many dysautonomic features during the attack such as ipsilateral ptosis, myosis, palpebral edema, and watering in the left eye but no explosive conjunctival injection. The patient felt restless during the attacks and there was no interparoxysmal pain. At admission, neurological examination was normal, as well as standard biological data. Considering the age of our patient, signs of giant cell arteritis were carefully researched. Due to the newonset headache and the dysautonomic features, a cervical and brain MRI were promptly performed and revealed recent PA. Indeed, MRI showed a pituitary macroadenoma measuring 14 (transverse) From the Department of Neurology, Rouen University Hospital, Rouen, France (L. Grangeon, A. Zanin, A. Rouille, D. Maltete, and E. Guegan-Massardier); Department of Radiology, Rouen University Hospital, Rouen, France (L. Moscatelli).

Suspected stroke in a pregnant woman: Usefulness of arterial spin labeling MRI sequences

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 18 aout 2016