Pierre Decavel

Verbal Fluencies and Fampridine Treatment in Multiple Sclerosis.

Background/Aims: Fampridine is sometimes reported to improve cognition and especially the information-processing speed. Motor improvement might be a confounding factor. The aim of this study was to evaluate the effects of fampridine on verbal fluencies in patients with multiple sclerosis (MS). Methods: Fifty MS patients were included in a prospective monocentric open label trial with a mean Expanded Disability Status Scale of 5.3 ± 1.1. Assessments of verbal phonological and semantic fluencies were repeated twice (within 1 week) before fampridine treatment and twice after fampridine treatment in order to have the maximal practice effect. Gait velocity and fatigue (visual analogical scale) were also assessed. Distribution into gait responders, gait non-responders, fluency responders and fluency non-responders, was described. Results: Verbal fluencies were significantly higher after fampridine treatment. No correlation was observed between phonological fluency improvement and semantic fluency improvement. Gait responders and gait non-responders did not present significant differences in verbal fluency performance and fatigue score. No correlation between gait velocity improvement and fatigue improvement compared with verbal fluency improvement was observed. Conclusion: Our results suggest that fampridine could have a selective procognitive effect on phonological fluency in MS, even in the gait non-responder patients.

Reliability of NIHSS by telemedicine in non‐neurologists

Dear Editor, the majority of stroke patients do not receive thrombolysis because they are still managed in general wards in community hospitals rather than in stroke units (1). This has negative consequences for stroke patients who require rapid assistance and specialist expertise (2–4). Our prospective study aimed to assess the reproducibility and reliability of National Institutes of Health Stroke Scale (NIHSS) scoring by telemedicine. The tests were performed by two local bedside examiners (neurologists and nonneurologists) and two remote examiners (junior and senior neurologists). All 11 NIHSS items along with their different grades were tested. The mean duration was 15:09 min. The overall video quality was judged as being excellent to fairly good in 96% of cases and none of the 28 patients had to be excluded for technical reasons. The mean NIHSS scores were 9·32 and 9·14 for the local and remote neurologists, and 9·11 and 8·93 for the local and remote non-neurologists, respectively. Concordance was high between the two neurologists (Fig. 1); for the NIHSS items, there were only two weighted Kappa coefficients <0·75. In nine cases, total NIHSS scores were identical, and a deviation of 2 points was observed in only four cases. Fewer concordances were noted between the local and remote nonneurologists (Fig. 1), with two weakly correlated items (facial palsy, ataxia), and six items with a weighted Kappa coefficient <0·75. Total NIHSS scores were identical in five patients and deviation was observed in 11 patients (2 points in six cases and 3 points in five cases). Overall, the maximum difference in NIHSS scoring was always <4 points. NIHSS scores can thus be reproduced, obviously, by local and remote neurologists and above all by non-neurologists. It is therefore possible for both neurologists and non-neurologists to remotely and accurately assess the clinical status of a stroke patient and make decisions regarding thrombolysis by telemedicine.

Predicting Acute Ischaemic Stroke Outcome Using Clinical and Temporal Thresholds

Background. Few studies have analysed the natural course of cerebral ischaemia for predicting outcome. We aimed to determine the early clinical findings and the thresholds for deficit severity and symptom duration that make it possible to stratify outcome. Methods. We included 154 patients with transient ischaemic attack or ischaemic stroke. Stroke profiles and neurological status were assessed from onset to 24 hrs, on admission, at 48 hrs, and at discharge. Outcomes were evaluated using the modified Rankin Scale. Positive and negative predictive values were calculated for the different thresholds. The model was subsequently evaluated on a new prospective cohort of 157 patients. Results. Initial National Institute of Health Stroke Scale (NIHSS) score <5 and symptoms regressing within 135 min were predictive of good outcome. Initial NIHSS score >22 and symptom stability after 1,230 min were predictive of physical dependency or death. Conclusions. Low and high NIHSS cut-off points are effective positive predictive values for good and poor outcomes. Thresholds for symptom duration are less conclusive.

Les infarctus cérébelleux

Cerebellar infarction can be difficult to diagnose because the clinical picture is often dominated by fairly non-specific symptoms, which are more indicative of a benign condition. When cerebellar infarction affects the brainstem, the semiology is richer, and pure cerebellar signs are rendered less important. A perfect knowledge of the organisation of the cerebellar artery territories is required, regardless of the infarct topography. This knowledge is essential for making an accurate diagnosis, understanding the mechanisms and organising a treatment plan. Clinical algorithms for the treatment of dizziness, headaches and vomiting would improve the selection of candidates for brain imaging. Thus, the early identification of patients with a high risk of subsequent deterioration would lead to a better prognosis in cases of cerebellar artery territory infarction.

Gait tests in multiple sclerosis: Reliability and cut-off values

BACKGROUND Gait limitation is one of the most common disabilities in people with multiple sclerosis (MS). Several studies have used gait parameters to determine the effects of different therapies. However, few studies have determined their reproducibility, also the therapeutic effects could be overestimated. RESEARCH QUESTION To examine the reproducibility in gait measurements during short and long distances. METHODS In this cross-sectional study we recruited a group of MS patients and compare it to a control group. The participants performed the following tests in a fixed order: a 25-foot walk at a comfortable speed, at a fast speed and during a dual task, a timed up-and-go test (TUG) and a six- minute walk test (6MWT). Two measurements were conducted a week apart. Systematic error was evaluated by the Student t-test, reliability by the intra-class correlation coefficients (ICC) and agreement by the minimum detectable change (MDC95). RESULTS A total of 58 people with MS and 19 healthy people were included. The absence of systematic error was only found for the fast speed condition. The reliability of the gait parameters had moderate to high ICC values (ICC > 0.7) except for the dual task cost (DTC) which was 0.45. The MDC95 was higher in people with MS compared to healthy people, and it was higher in people with MS for gait speeds in all conditions (> 34%). For the TUG and 6MWT, the MDC95 were 51.5% and 31.7% respectively. For people with MS the smallest MDC95 was found for the stance time for all conditions (6.8%), whereas the highest was found for the dual task cost (158.7%). SIGNIFICANCE The MDC95 values were higher than the cut-off point based on the minimally important clinical difference (MICD) proposed in previous studies. Thus, the MDC95 should be used as a cut-off rather than MICD values.

Multiple Sclerosis and Clinical Gait Analysis before and after Fampridine: A Systematic Review

Background: Gait impairment is one of the most disabling symptoms in people with multiple sclerosis (PwMS). Fampridine, has demonstrated a positive effect on gait speed in PwMS after 14 days of treatment but the long-term effects have not yet been demonstrated. This study reviews the long-term effects of fampridine on gait in PwMS. Summary: This systematic review was conducted according to the PRISMA statement. Studies were considered long term if treatment exceeded 28 days. From the 498 studies identified, 18 (2,200 patients) fulfilled all eligibility criteria. Only 3 studies followed-up patients for >1 year and one of these showed a non-significant improvement in the gait speed. Key Messages: Fampridine seems to be beneficial at improving gait speed in PwMS in the long term. Further long-term studies are needed on related gait and functional parameters.

Multiple sclerosis, clinical gate analysis before and after fampridine: A systematic review

Introduction Gait impairment appears as one of the most common and disabling symptoms in people with multiple sclerosis (PwMS). Few symptomatic treatments exist at the progressive phase of the disease. Fampridine (4-aminopyridine) an inhibitor of the potassium channels has demonstrated a positive effect on gait speed in PwMS with gait disturbance. The effects are well established on gait speed after 14 days of treatment but the effect on long-term is not yet demonstrated. This study aimed to review the short- and long-term effects of fampridine on gait in PwMS. Materials–method This systematic review has been conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Literature searches on MEDLINE, Embase, and COCHRANE covered prospective randomized controlled and non-randomized studies. Studies were considered as long-term if treatment exceeded more than 28 days. This limit was arbitrarily determined by doubling the deadline of treatment efficiency of 14 days determined by the French National Authority for Health. Outcomes of interest were gait parameters after treatment. Results From 498 studies identified, 18 (2200 patients) fulfilled all eligibility criteria. Five of these articles were in favor of a significant improvement in Timed 25 Foot Walk (T25FW), after 14 days of treatment (between 11.2 and 34.8%). Only 3 studies made a follow-up over 1 year and one of them showed a significant improvement of gait speed in T25FW of 11.2%. Only one study investigated other gait spatiotemporal parameters than speed on long-term (3 months) and showed an improvement of gait cadence (11%) and step length (12.8%). Discussion–conclusion Fampridine seems to be beneficial in improving gait speed in PwMS at short-term and long-term. It would be advisable to complete these studies by other long-terms study and other gait (spatiotemporal, kinematics) and functional parameters.

G - 21 Évolution des patients avec un accident vasculaire cérébral à Dijon de 1985 à 2004

Introduction La prise en charge de la pathologie neurovasculaire evolue depuis plusieurs annees modifiant le statut vital et fonctionnel des patients. Objectifs Nous realisons une analyse epidemiologique du devenir des patients avec un premier accident vasculaire cerebral (AVC) sur une longue periode et sur une population non selectionnee. Methodes Nous avons etudie l’evolution du nombre de deces sur 20 ans, et du handicap par l’indice de Rankin, ainsi que l’etat clinique a l’entree dans le service de neurologie chez les patients ayant presente un premier AVC identifie dans un registre continu de population sur la periode 1985-2004. Resultats La repartition du type d’AVC etait la suivante : 3 142 infarctus, 341 hematomes et 74 hemorragies meningees. Sur 20 ans, la mortalite a baisse de 0,94 p. 100 par an (p Discussion La baisse de la mortalite observee a Dijon confirme la tendance observee dans la plupart des autres registres. Le registre de Dijon est cependant le seul a etre continu. L’amelioration de l’evolution des patients avec un AVC est notable malgre l’augmentation de l’âge de survenue du premier evenement. Conclusion Sur une periode de 20 ans, il a ete observe a Dijon, une diminution de 50 p. 100 de la mortalite des patients avec un AVC sans majoration du handicap lourd.