Marie Caillier

Ischaemic stroke subtypes and associated risk factors: a French population based study

Background: There is little reliable population based information about the distribution of risk factors among the various ischaemic stroke subtypes, even though determining risk factor profiles is of major importance to develop targeted preventive strategies. Methods: The distribution of first ever ischaemic stroke subtypes was established in a prospective population based study conducted in Dijon, France (152 606 inhabitants). Cases were collected between January 2005 and December 2006, and were classified using TOAST classification. Vascular risk factors were recorded to determine a risk factor profile for each subtype. Results: 332 patients with first ever ischaemic stroke (150 men and 182 women) were recorded. Adjusted incidence to world population was 54/100 000/year. The distribution of ischaemic stroke subtypes was as follows: 119 (35.8%) cases of large artery atherosclerosis, 89 (26.8%) small artery occlusions, 81 (24.4%) cardioembolisms and 43 (13%) other and undetermined causes. The most frequent vascular risk factor was hypertension, irrespective of the ischaemic stroke subtype, with a total prevalence of 62%. Using multivariate regression, a positive association between cardioembolism and age (OR 1.051; 95% CI 1.026 to 1.076; p<0.001) was demonstrated and between small artery occlusion and either high blood pressure (OR 1.86; 95% CI 1.06 to 3.27; p = 0.03) or hypercholesterolaemia (OR 2.23; 95% CI 1.33 to 3.76; p = 0.02). Conclusion: This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.

Trends in Incidence, Risk Factors, and Survival in Symptomatic Lacunar Stroke in Dijon, France, From 1989 to 2006 A Population-Based Study

Background and Purpose— Lacunar infarcts are usually regarded as benign stroke, but population-based studies are required to assess the exact place of this stroke subtype in cerebrovascular pathology. Methods— We evaluated trends in incidence rates, risk factor profiles, and survival rates in symptomatic lacunar stroke from a prospective population-based registry from 1989 to 2006. Results— We recorded 2536 ischemic strokes. Among these, 715 (28%) were lacunar infarcts (354 men and 361 women). From 1989 to 2006, we observed a significant rise in the incidence of lacunar stroke in the 2 sexes considered together (relative risk, 1.02; 95% CI, 1.005 to 1.035; P=0.007), whereas the variation was not significant in either men or women when considered separately. Incidence rates significantly increased in young patients under 65 years old (relative risk, 1.049; 95% CI, 1.0175 to 1.0817; P=0.002). Concerning the distribution of cerebrovascular risk factors, lacunar stroke differed from nonlacunar stroke only with regard to the lower prevalence of a history of atrial fibrillation in the former (P<0.001). For lacunar infarcts, survival rates were 96% at 1 month (95% CI, 0.94 to 0.97), 86% at 1 year (95% CI, 0.83 to 0.89), and 78% at 2 years (95% CI, 0.75 to 0.81) and were significantly higher than those for nonlacunar stroke (hazard ratio, 2.05; 95% CI, 1.70 to 2.47; P<0.001). Conclusion— Our results suggest a significant increase in the incidence rates of lacunar stroke with a relatively good short-term prognosis in terms of survival. The association among hypertension, diabetes mellitus, and lacunar stroke was no stronger than the association between these 2 risk factors and nonlacunar stroke.

Decrease in the Stroke Case Fatality Rates in a French Population-Based Twenty-Year Study

Background: The aim of the study was to estimate trends in stroke case fatality in a French population-based study over the last 20 years, and to compare trends in men and women. Methods: We prospectively ascertained first-ever strokes in a well-defined population-based study, from 1985 to 2004, in Dijon (France) (150,000 inhabitants). The study was both specific and exhaustive. The follow-up made it possible to analyze case fatality, according to stroke subtypes and sex. Results: From the ascertainment of 3,691 strokes divided in 1,920 cerebral infarcts from large artery atheroma, 725 cerebral infarcts from small perforating artery atheroma, 497 cardioembolic infarcts, 134 cerebral infarcts from undetermined mechanism, 341 primary cerebral hemorrhages and 74 subarachnoïd hemorrhages, we observed a significant decrease in 28-day case fatality rates of almost 25% (p = 0.03). Case fatality rates decreased in men aged >75 years (p = 0.01) and in women aged >75 years (p = 0.02) and >65 years (p = 0.03). The magnitude of the decrease was smaller in women but not significantly so. According to stroke subtypes, case fatality rates significantly decreased for small perforating artery infarct (p = 0.04) and for primary cerebral hemorrhage (p = 0.03). In multivariate regression analyses, hemorrhagic stroke, the first period of the study (1985–1989), blood hypertension, previous myocardial infarction and age <85 years had a negative effect. Conclusion: This is the first population-based study using continuous ascertainment over a period of 20 years that has demonstrated a significant reduction in case fatality rates. We did not observe any significant differences between men and women.

Trends in the Incidence of Transient Ischemic Attacks, Premorbid Risk Factors and the Use of Preventive Treatments in the Population of Dijon, France from 1985 to 2004

Background: We describe the epidemiological trends of transient ischemic attack (TIA) in a 20-year population-based pilot study. Methods: Trends in the incidence, risk factors and pre-TIA use of preventive treatments for TIA were observed from 1985 to 2004 according to the classic definition in the population of the city of Dijon, France (150,000 inhabitants). Results: The raw and standardized incidence of TIA were stable over time. We observed a significant increase in the mean age at TIA onset in women only. The prevalence of hypercholesterolemia and diastolic blood pressure ≧90 mm Hg among patients with TIA increased significantly. This contrasts with falls in smoking and in history of previous myocardial infarction. Conclusion: The stability of classic TIA incidence, despite the rise in the proportion of elderly people, and the increase in the mean age at onset in women may be considered as a medical progress.

Involuntary masturbation and hemiballismus after bilateral anterior cerebral artery infarction

Ischemia of the areas supplied by the anterior cerebral artery is relatively uncommon. In addition, combined hemiballismus and masturbation have rarely been reported in patients with cerebrovascular disease. We describe herein a 62-year-old right-handed man simultaneously exhibiting right side hemiballismus and involuntary masturbation with the left hand after bilateral infarction of the anterior cerebral artery territory. Right side hemiballismus was related to the disruption of afferent fibers from the left frontal lobe to the left subthalamic nucleus. Involuntary masturbation using the left hand was exclusively linked to a callosal type of alien hand syndrome secondary to infarction of the right side of the anterior corpus callosum. After 2 weeks, these abnormal behaviours were completely extinguished. This report stresses the wide diversity of clinical manifestations observed after infarction of the anterior cerebral artery territory.

Dissémination leptoméningée après chirurgie d’un adénocarcinome de l’ethmoïde

INTRODUCTION Although rare, adenocarcinoma is the most frequent neoplasm of the ethmoid sinus and must be regarded as an occupational disease secondary to chronic wood dust exposure. Few cases with neurological metastasis have been reported. CASE REPORT We report the cases of two patients who developed a multiple cranial nerve disorder for the first case and a cauda equina syndrome for the second, after ethmoid adenocarcinoma surgery. CONCLUSION Diagnosis of carcinomatous meningitis is difficult and is based on clinical data, CSF analysis and gadolinium-enhanced T1-weighted brain and spinal cord MRI. The implication of surgery is discussed. Prognosis of such a disorder is poor.

Rare E196K mutation in the PRNP gene of a patient exhibiting behavioral abnormalities.

Genetic transmissible spongiform encephalopathies (TSEs) account for approximately 10-15% of overall human prion diseases worldwide, but genotype-phenotype correlations remain incomplete. Here we report the case of an 80-year-old man who developed rapidly progressive behavioral abnormalities and myoclonus following a stroke. Repeated electroencephalography (EEG) revealed a general slowing of the basic activity, as well as several episodes of triphasic waves, with neither periodic activity nor recorded seizure. 14.3.3 protein was detected in cerebral cerebrospinal fluid, and direct sequencing of the PRNP gene showed an E196K mutation associated with homozygosity for methionine at codon 129. The patient was diagnosed with probable genetic prion disease with a Creutzfeldt-Jakob disease-like phenotype. The PRNP E196K mutation has only rarely been described in the literature, and generally patients exhibited an atypical initial phenotype, mainly involving abnormal behavioral features. Further observations are needed to confirm this particular clinical pattern associated with the mutation.

Réunion commune de la SFN et de la SFNV 8–10 octobre 2008Les accidents vasculaires cérébraux du sujet âgé : ce que nous a appris l’épidémiologie du sujet jeuneStroke in elderly: What have we learned from stroke epidemiology in younger people

Stroke in the elderly has more major differences compared to young people: it is the first complication of atherothrombosis disease associated with the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption and sleep apnea syndrome; AVC is the first consequence of atrial fibrillation; from a clinical point of view, seizure at the onset of the stroke is more frequent; prognosis is characterized by a high risk of dementia (20%); primary and secondary prevention is very efficacious even in very old patients, not only on the risk of stroke, but also on the risk of dementia; time trends at Dijon show a slight decrease of incidence rates of stroke only over 85 years, while prevention of stroke has taken advantage of real progress in precocious diagnosis and innovative treatments. In contrast, we observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke, reaching five years in men and eight years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention.

Leukocyte Telomere Length: A Focus on Cerebrovascular Events

Telomeres are specialized DNA structures located at the ends of chromosomes. Their length is reduced at each cell cycle, especially when the cumulative burden of oxidative stress is high. The purpose of this study was to determine the associations between telomere length and clinical and biological risk factors in ischemic stroke patients. A total of 215 stroke patients hospitalized in the Dijon, France, stroke unit were prospectively and continuously included from January to September, 2004. The telomere length measured from peripheral blood leukocytes--leukocyte telomere length (LTL)--was determined by real-time quantitative polymerase chain reaction. The results were compared with clinical and biological variables of interest collected at admission to find significant associations. Possible relationships between LTL and stroke subtypes were evaluated. A multiple regression that included all the variables significantly associated (p<0.20) with LTL in univariate analysis and age and subtypes of stroke confirmed a significant association with age (p<0.001), homocysteinemia (p=0,049), and levels of both antiphospholipid antibodies (p=0.019) and triglycerides (p=0.007). Linearity was verified and confirmed for each variable. The subtype of stroke did not significantly affect telomere length. We were able to highlight significant associations between LTL and certain cerebrovascular risk factors in a general population of stroke patients. These associations did not depend on the ischemic stroke subtype.

G - 8 Aspect clinique et radiologique des infarctus du corps calleux

Introduction Le syndrome de dysconnexion du corps calleux est peu observe en pathologie neuro-vasculaire. Nous rapportons une serie de 9 cas. Observation Le tableau clinique s’est traduit par 2 aspects tres distincts : d’une part un syndrome de dysconnexion classique du corps calleux, et d’autre part un trouble de la marche de type frontal. Un syndrome de dysconnexion du corps calleux a ete observe dans 4 cas sur 9 en relation avec un infarctus large et unique du corps calleux ou plusieurs infarctus predominant sur la partie anterieure du corps calleux. La semeiologie clinique fut caracterisee par une apraxie idemotrice de la main gauche et une apraxie constructive. Le syndrome de la main etrangere fut observe dans 3 cas. Les troubles de la marche de type frontal (petits pas, elargissement du polygone de marche, demi-tour sur pivot, abduction des bras) furent constates dans 3 cas rattaches a l’IRM a des lesions multiples de type lacunaire sur une grande etendue du corps calleux et dans les regions latero-calleuses. Discussion Les correlations anatomo-cliniques des infarctus du corps calleux ne sont pas aisees car l’infarctus n’est pas systematiquement limite au corps calleux et d’autres lesions ischemiques peuvent coexister. De plus, le syndrome de dysconnexion calleuse est plus frequemment observe en pathologie tumorale. Conclusion Les infarctus du corps calleux ne sont pas rares et leur semeiologie doit etre connue pour que les malades soient pris en urgence selon les Recommandations concernant la prise en charge des infarctus cerebraux.