Erdheim-Chester disease. Clinical and radiologic characteristics of 59 cases

We made a retrospective evaluation of clinical and radiologic features, treatment, and outcome of Erdheim-Chester disease, a rare non-Langerhans cell histiocytosis. We had 7 patients coming from 3 French teaching hospitals and reviewed 52 cases from the literature. These cases were considered to have Erdheim-Chester disease when they had either typical bone radiographs (symmetrical long bones osteosclerosis) and/or histologic criteria disclosing histiocytic infiltration without features for Langerhans cell histiocytosis (no S-100 protein, no intracytoplasmic Birbeck granules). Ages at diagnosis ranged from 7 to 84 years (mean +/- SD = 53 +/- 14 yr) with a male/female ratio of 33/26. Bone pain was the most frequent clinical sign (28/59), mostly located in the lower limbs. Exophthalmos and diabetes insipidus were found in respectively 16/59 and 17/59 patients. General symptoms (fever, weight loss) and "xanthomas" (mainly located on the eyelids) were present in 11/59 patients. Retroperitoneal involvement was found in 17/59 patients. Skeletal X-ray showed typical osteosclerosis of the diaphysis of the long bones in 45/59 patients. Bone radiographs showed osteolytic lesions of the flat bones (skull, ribs) in 8 patients. Histologic diagnosis was performed after a bone biopsy (28 patients), a retroorbital biopsy (9 patients), and/or a biopsy of the retroperitoneal infiltration or the kidney (11 patients). Six of our 7 patients but only 5 of 52 patients from the literature had the complete histologic criteria, disclosing no Birbeck granules or S-100 immunostaining. In other cases, histologic results usually described a xanthogranulomatous infiltration by foamy histiocytes nested in fibrosis. Treatment was corticotherapy (20/59), chemotherapy (8/59), radiotherapy (6/59), surgery (3/59) and immunotherapy (1 patient). Twenty-two patients died after a mean follow-up of 32 +/- 30 mo (range, 3-120 mo). In conclusion, Erdheim-Chester disease may be confused with Langerhans cell histiocytosis as it sometimes shares the same clinical (exophthalmos, diabetes insipidus) or radiologic (osteolytic lesions) findings. However, it also appears to have distinctive features. Patients are older and have a worse prognosis than those with Langerhans cell histiocytosis, and the diagnosis relies on the association of specific radiologic and histologic findings.

[Behavior assessment in Alzheimer type dementia using the disruptive behavior questionnaire]

OBJECTIVES

We developed a disruptive behavior questionnaire designed for persons living close to the patient in order to assess behavior disorders in Alzheimer type dementia.

METHODS

The study included 111 patients with criteria for diagnosis of Alzheimer type dementia. The questionnaire was used to assess the patients 15 days after withdrawal of psychotropic drugs. A partially-structured interview was also conducted by a psychiatrist in 20 cases.

RESULTS

There was no relationship between the different behavior disorders and the mini-mental-state score or the social and cultural situation. Answers to the questionnaire and responses given during the interview were nearly identical.

CONCLUSION

There has been little effort to assess behavior disorders compared with cognitive disorders in patients with Alzheimer type dementia. Behavior assessment should be an integral part of patient evaluation since cognitive and non-cognitive disorders are independent and certain therapeutics may be effective in behavior disorders.

[MRI aspect and course of supra-tentorial sarcoidosic lesions]

Central nervous system lesions resulting from sarcoidosis occur in 5% of cases, but supratentorial mass lesions are uncommon. We report 3 cases of intracranial pseudo-tumoral lesions, due to sarcoidosis: 1 woman and 2 men. Clinical features included left facial myoclonus, headache and vertigo, right hemiparesis and unique general seizure. Sarcoidosis was diagnosed upon conjonctival biopsy in the first case, infiltrative lesions of the lungs and mediastinal lymph nodes in the second case, and intracerebral lesion plus lymph nodes biopsies in the last case. In the first case, CT scan and MRI images showed diffuse subcortical high signal, suggesting pachymeningitis with vasogenic oedema. In the second case, GT scan and MRI revealed numerous small granuloma in the left rolandic area, and one in the striatum. In the third case, CT scan showed an enlargement of the left temporal horn, due to an enhanced left periventricular lesion. MRI with gadolinium showed that the lesion encircled the ventricle horn. In all cases, clinical and radiological improvement was obtained after corticoid therapy.

White matter magnetic resonance imaging hyperintensity in Alzheimer's disease: correlations with corpus callosum atrophy

We have previously demonstrated with MRI that as well as marked white matter involvement in late-onset Alzheimer's disease (AD), atrophy of the corpus callosum may also be present. This finding prompted us to study possible correlations between atrophy of the corpus callosum and white matter hyperintensity (WMH) and between white matter lesions and the severity of the disease. We compared the corpus callosum and white matter lesions on MRI from 15 AD patients and 15 controls. The white matter lesions were scored according to the Scheltens' rating scale. We found a significant reduction of the area of the corpus callosum and more severe white matter lesions in AD patients than in controls. Both atrophy of the corpus callosum and the severity of lesions depended mainly on the diagnosis of senile dementia of the Alzheimer type and on age but not on the diagnosis of presenile AD. We demonstrated a negative correlation between white matter lesions scores and areas of corpus callosum in AD patients and no correlation between the white matter lesions and the severity of the disease. We demonstrated that white matter lesions including WMH and atrophy of the corpus callosum are more frequent in AD than in controls. The predominance of white matter lesions in senile AD may be explained by the combination of aging and disease processes.

Cognitive and psychiatric impairment in herpes simplex virus encephalitis suggest involvement of the amygdalo-frontal pathways

The long-term neuropsychological and psychiatric sequelae of herpes simplex virus encephalitis (HSVE) and their relationship to the volume of temporal lesions and to amygdala and hippocampus damage remain undefined. We have conducted a prospective study of long-term sequelae in 11 patients with clinically presumed HSVE and detection of HSV DNA in the cerebrospinal fluid by polymerase chain reaction. Six months after encephalitis, patients underwent neuropsychological and language assessment. At the same stage, single photon emission computed tomography (SPECT) evaluated the occurrence of hypoperfusion with an index of asymmetry. MRI was used for the measurement of amygdala, hippocampus and cerebral lesions by two blind neurologists. The volume of the amygdala and hippocampus was compared with those of five controls, matched for age and level of education. Long-term memory disorders were seen in 6 patients, associated with the larger lesions and damage of at least two structures. Long-term behavioural changes with emotionalism, irritability, anxiety or depression were prominent in 7. Left prefrontal hypoperfusion appeared in 8 patients, associated with psychiatric disorders in 7 and left amygdala damage in 6. The reduction of amygdala and hippocampus volume was correlated with the overall volume of lesions. Different patterns of mesial temporal lobe damage occurred, involving either amygdala alone, or amygdala and hippocampus, but never hippocampus alone. MRI volumetric measurements in HSVE could be a good indicator of long-term prognosis. Persistant behavioural changes could be related to an amygdala and frontal dysfunction.

Atrial natriuretic factor secretion: a role for atrial systolic ejection force?

The increase in plasma concentration of atrial natriuretic factor in heart transplant patients has not been fully elucidated. Besides an eventual pressure or volume overload leading to passive atrial distension, the atrial tension developed during atrial systole, or atrial ejection force, which may be increased by the transplantation procedure, is an important determinant of atrial natriuretic factor release. We therefore determined the plasma concentration of atrial natriuretic factor and the maximal atrial ejection force in 15 heart transplant patients and 8 controls, matched for age and body mass. Atrial ejection force, as defined as the force exerted by the left atrium to accelerate blood into the left ventricle during atrial systole, was obtained using combined two-dimensional imaging and doppler echocardiography. Serum creatinin concentrations, heart rate [91.9 (SD 13.2) vs 71.8 (SD 10.9) beats.min-1], mean arterial blood pressure [103.9 (SD 9.8) vs 87.4 (SD 5.8) mmHg, 13.85 (SD 1.31) vs 11.65 (SD 0.77) kPa], left ventricular posterior wall thickness and interventricular septum thickness were higher in heart transplant patients compared to controls. Plasma concentration of atrial natriuretic factor was also elevated in heart transplant patients [63.9 (SD 18.1) vs 34.0 (SD 3.2) pg.ml-1; P < 0.001]. In contrast, although the left atrial area was greater in heart transplant patients [28.2 (SD 4.8) vs 15.8 (SD 2.5) cm2; P < 0.001], mitral area, transmitral Doppler A-wave maximal velocity and atrial ejection force were similar in transplant and in control patients [7.7 (SD 3.5) vs 8.9 (SD 2.8) kdyn, 77 (SD 35) vs 89 (SD 28)mN]. No significant correlation was observed between concentration of atrial natriuretic factor and atrial ejection force, either in heart transplant patients or in controls. Thus, the elevated plasma concentration of atrial natriuretic factor observed in these heart transplant patients was multifactorial in origin, and was considered to depend upon an hypersecretion rather than upon a decreased clearance rate. Moreover, it is suggested that the atrial ejection force was unlikely to have participated in this enhanced release of atrial natriuretic factor.

Sundowning syndrome in demented patients without neuroleptic therapy

Characterisation of sundowning syndrome, defined as 'an exacerbation of symptoms indicating increased arousal or impairment in late afternoon, evening or at night, among elderly demented individuals', is complicated by neuroleptic therapy and frequent failure to specify the nature of the associated dementia. Screening by a memory disorders unit of an institutionalized population of 30 neuroleptic-free demented patients revealed 8 sundowners, with diagnoses of probable Alzheimer's disease (n = 5), frontal lobe dementia (n = 1), Lewy body disease (n = 1), and sequelae of herpes encephalitis (n = 1). Sundowners did not differ from non-sundowners in age, Mini Mental State score, degree of temporal and spatial disorientation or perceptual delusion. Sundowning was related to restlessness (P < 0.0001), sleep disorder (P < 0.003) and a history of hypotension lipothymia (P < 0.08). These results provide further evidence for a chronobiological explanation of sundowning syndrome.

[Results of surgical treatment of acute traumatic aortic rupture]

Between 1967 and 1994 48 patients have been treated at our institution for acute rupture. Two patients died before operation, in two cases the operative attempt had to be abandoned with irreversible cardiopulmonary arrest, and in 44 patients surgical correction could be performed, The rupture was complete in 14 cases and incomplete in 30. In 25 patients surgery consisted of direct suture, in one patient an aortoplasty was performed, and in 18 patients a dacron tube interposition was necessary. In 7 cases the clamp and repair technique was applied, and in 37 cases extracorporeal circulation was installed. The hospital mortality amounted to 18% and was mainly contributable to the concomitant injuries. Two patients presented with paraplegia at admission, both died; postoperative paraplegia occurred in two instances, once after 48 hours. The late results were in the majority of the cases influenced by orthopedic or neurological sequelae, only one patient had to be reoperated for a false aneurysm. Our results and the review of the literature lead to the following conclusions: In spite of an optimized emergency care system, many patients with aortic rupture die before any surgical intervention. The installation of extracorporeal circulation can decrease the incidence of postoperative paraplegia; in our experience the administration of heparin does not increase the risk of bleeding from concomitant injuries. Direct suture represents the correction of choice. The long-term results are excellent.

[Acute and reversible myoclonic encephalopathy, extrapyramidal syndrome, polyneuropathy caused by chronic disulfiram poisoning]

This 44-year woman was admitted for weight loss and global intellectual slowing. She had mild chronic alcoholic neuropathy. She was discontinued alcoholic consumption for 6 months and was given disulfiram (1.5 g/day) since then. She developed over a 5-day period acute neuropathy, confusion and extrapyramidal symptoms with oculo-cephalogyric and dystonic movements and myoclonus. Electromyography revealed a severe polyneuropathy. After disulfiram withdrawal, confusion and extrapyramidal symptoms disappeared within a few days, but sensitivo-motor deficit improved more slowly. Nerve biopsy was suggestive of a pure axonal neuropathy.

Restoration of gait by functional electrical stimulation for spinal cord injured patients

In this clinical study, we report the results of functional electrical stimulation for the ambulation of paraplegic patients without long leg braces (LLB), according to the Parastep approach. Of 13 SCI patients with complete neurological lesions included in this trial, 12 progressed to independent ambulation with the aid of the Parastep. The average walking distance was 76 m, with a maximum of 350 m, and the mean speed 0.2 m s-1. Compared to the situation with long leg braces, which in fact are given up by most paraplegic patients, long term home use seems to be much more important. Tolerance of this method is satisfactory. The psychological benefits of the device are remarkable. From this experience, it is concluded that this method is valuable for the restoration of standing and walking in the long term management of spinal cord injury patients.

The long term outcome in 149 patients with spinal cord injury

A longitudinal follow-up study of 149 spinal cord injured patients is presented. Ninety two patients have been visited and interviewed at home 7-10 years after injury (28% died during the follow-up). Disability was assessed using the Functional Independence Measure (FIM), and was correlated with the neurological level, impairment and spasticity. The handicap was assessed using the Reintegration to Normal Living Index (RNLI). Multivariate analysis showed a correlation with age, neurological impairment, sexual impairment, living conditions and social life. There was a high correlation with depression and the Functional Independence Measure. The early neurological examination correlated with their long term disability but not with their handicap.

Propriospinal myoclonus in tetraplegic patients: clinical, electrophysiological and therapeutic aspects

Propriospinal myoclonus is a rare and relatively little studied complication of spinal cord injury. We report two patients with an extension-producing myoclonus presenting with tetraplegia caused by cervical trauma. Rhythmic extension jerks of the trunk and lower limbs appeared several weeks after their injury in a context of severe spasticity. The characteristics of these jerks were determined by polymyography of 12 muscles. They lasted between 306 and 1127 ms with a frequency of 0.3 to 0.5 Hz. By comparing latencies their origin was found to be in the lumbar cord from which there was a slow (2 m s-1) upward and downward spread. Oral treatment with baclofen and sodium valproate was partially successful in one patient, but ineffective in the other. Intrathecal 75 or 100 micrograms baclofen produced a striking, complete disappearance of myoclonus prompting the implantation and successful use of a baclofen pump in one patient. These two new cases suggest the existence of a lumbar generator in which myoclonic extension jerks originate, and demonstrate a new therapeutic alternative in intrathecal baclofen for patients resistant to oral medication.

Cortical mapping of Alzheimer pathology in brains of aged non-demented subjects

1. The presence of Alzheimer-type neurofibrillary pathology and amyloid deposits within the brains of 27 aged non-demented subjects was investigated by immunoblotting and immunohistochemistry using antibodies directed against pathological Tau proteins 55, 64 and 69 and beta A4 respectively. 2. The abnormal Tau triplet, a biochemical marker of neurofibrillary degeneration was quantified by western blot and densitometric analysis in several cortical areas including the entorhinal cortex (EC), hippocampus and Brodmann areas (BA) 38, 20, 22, 35, 9, 44 and 39. 3. The abnormal Tau triplet was detected in the EC and the hippocampus of most of the controls aged over 70 years. In few control cases abnormal Tau proteins were also detected in the isocortex, in BA38 alone or also in BA20. Some cases and especially those with Tau pathology in the temporal lobe contained numerous senile plaques (SP) in the neocortex. 4. The authors conclude that control cases with Tau pathology in the temporal lobe and numerous SP in the neocortex were likely to be subclinical stages of AD whereas others with Tau pathology exclusively detected in the EC and hippocampus and without or few SP in the neocortex were related to normal aging.

[Dacrystic and asystolic epileptic seizures]

A 33-year-man with an encephalopathy of unknown aetiology, had an history of epilepsia for 30 years. Different types of seizures were seen, including grand mal and frontal attacks. Epilepsia was associated with mental retardation and behavioral disorders. At the age of 33, he was admitted for repetitive general convulsions. Epilepticus status lasted for two weeks and improved with vigabatrin et clonazepam. General seizures, frontal motor convulsions with arms and trunk antepulsion, and dacrystic attacks were seen. The latter seemed to be like normal crying because they were accompanied by lacrimation, contorted and mournful facies, and sobbing sounds. One year later, repetitive cardiac arrests occurred during a new epilepticus status. Cardiac arrests, observed on ECG holter lasted 10 to 24 seconds, without cardiac dysfunction. EEG patterns on ECG holter lasted 10 to 24 seconds, without cardiac dysfunction. EEG patterns included theta and delta activity with rhythmic slow wave epileptic activity, predominating on right side, in temporal areas. CT scan was normal. MRI showed right cerebral atrophy, prevailing in the temporo-mesial region, with right temporal horn enlargement. This case report of dacrystic seizures, the first one with MRI study, suggests that temporo-mesial structures of the non-dominant hemisphere may be involved in dacrystic and asystolic attacks.

Mean term follow-up of a series of post-traumatic syringomyelia patients after syringo-peritoneal shunting

We report the follow-up of a series of post-traumatic syringomyelia patients treated by syringo-peritoneal shunting (SPS). The neurological status was determined following the international ASIA/IMSOP standards for neurological classification of spinal cord injury; this was completed by a modified Silberstein classification that identifies the ascending neurological symptoms as well as the increasing myelopathic symptoms in patients with post-traumatic syringomyelia. Magnetic resonance imaging (MRI) was systematically performed to assess the presence of a postoperative residual syrinx or of meningeal fibrosis. Eight patients were studied (five men, three women) with an age ranging from 17 to 54 years (mean of 30.7 years) at the time of the spinal cord injury. Three had a complete or nearly complete paraplegia, five were incomplete. The post-traumatic syringomyelia was diagnosed from 2 to 8 years after the spinal cord injury and was treated by syringo-peritoneal shunting. Early complications occurred in three patients: (1) displacement of the catheter, (2) obstruction of the catheter, and (3) haematomyelia, which disappeared after a new surgical procedure was performed. The postoperative follow-up ranged from 3 to 9 years (mean of 4.5 years). The neurological level decreased in every case and the ascending neurological symptoms decreased or were stabilised in seven patients. The postoperative ASIA/IMSOP scores and the increasing myelopathic symptoms improved in four patients but worsened in the four others, incomplete. The MRI showed an important decrease of the syrinxes in every patient associated with a serious meningeal fibrosis in five cases. Syringo-peritoneal shunting seems to be efficient in the treatment of the syrinx but may have a poor effect regarding the prevention of meningeal fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuroradiologic aspects of Chester-Erdheim disease

In three cases of histologically proved Chester-Erdheim disease there was a large anterior epidural lesion from C-3 to L-2 in one patient; dural masses and orbital infiltration in a second patient; and dural, choroid plexus, retroorbital, and hypophyseal lesions in a third patient. Diabetes insipidus, exophthalmia, long bone lesions, and retroperitoneal infiltration were present.

[Value of gene amplification of herpesviruses in the diagnosis and treatment of acute viral encephalitis]

Positive diagnosis of Herpes simplex virus (HSV) encephalitis was rarely obtained in the past, when brain biopsy had been performed. Other tests (HSV antigen and HSV antibodies detection and interferon alpha measurement, in cerebrospinal fluid) failed to prove HSV infection. Polymerase chain reaction has been proposed for accurate and rapid diagnosis of HSV encephalitis. With 35 cycles of a DNA polymerase sequence duplication, sensitivity reaches 95% and specificity 100%. HSV PCR is a useful tool for the diagnosis of acute encephalitis. This should be available in many neurologic clinics. Therapeutic consequences include rapid disruption of aciclovir when clinical features, MRI study and negative PCR suggest non herpetic encephalitis.

[Strongyloides stercoralis myelitis]

A 66 year-old man presented with a myelitis associated with eosinophilia in blood and cerebrospinal fluid. Specific serological procedures in blood and stool examinations led to the diagnosis of myelitis due to Strongyloides stercoralis. Physiopathology of medullary lesions is discussed. To our knowledge, this is the first report of myelitis in the course of Strongyloides infection.

Which factors predict cognitive decline in Parkinson's disease?

The study assessed cognitive decline in non-demented, non-depressed patients with well defined Parkinson's disease and determined the predictive value for cognitive decline of different motor symptoms. Motor disability was measured with the Unified Parkinson's disease rating scale, impairment in activities of daily living, levodopa test, and long term clinical follow up. Neuropsychological evaluations included modified mini mental state, fluency, Wechsler logical memory, Wisconsin card sorting test, and the Montgomery and Asberg depression rating scale. Fifty three patients fulfilling clinical criteria for idiopathic Parkinson's disease were studied. Cognitive performance on initial testing was significantly correlated with education and disease duration but not with age at disease onset. Cognitive performance on retesting after three years of follow up was significantly reduced. This reduction was significantly greater in the late onset group, in patients with isolated dystonic dyskinesiae, and in patients with a lower percentage of motor improvement on levodopa. Cognitive decline in idiopathic Parkinson's disease may depend on both the prevalence of non-dopaminergic lesions and the topography of dopaminergic denervation. Predictive factors for cognitive decline, especially in executive tasks, relate more to non-dopaminergic than to dopaminergic lesions.

Verbal fluency in dementia of frontal lobe type and dementia of Alzheimer type

This study compares semantic (category) and letter-initial verbal fluency performance in dementia of frontal lobe type, dementia of Alzheimer type, and control subjects matched for age, sex, and level of education. As well as demographic characteristics, patients were matched for severity of dementia as estimated by the mini mental scale (23.2 (SD 4.9)). All patients with dementia of frontal lobe type had a frontal hypoperfusion on single photon emission computed tomography whereas patients with dementia of Alzheimer type showed mainly posterior deficits. Patients had significantly lower verbal fluency than controls but those with dementia of frontal lobe type did not differ from those with dementia of Alzheimer type in the number of words generated, intrusions, or preservations. Category fluency was more impaired than letter fluency in both dementias. No correlation between frontal index, frontal/parietal index, and fluency was found. Verbal fluency tests are sensitive tools for detecting dementia but do not seem useful in distinguishing between patients with dementia of Alzheimer type and those with dementia of frontal lobe type in early disease.

Behavioral effects of trazodone in Alzheimer's disease

BACKGROUND

Central serotonin depletion may contribute to the anxiety, restlessness, irritability, and affective disturbance seen in a variety of psychiatric conditions, particularly dementia of the Alzheimer's type (DAT) in which brain concentrations of both 5-hydroxytryptamine (5-HT) and its 5-hydroxyindoleacetic acid (5-HIAA) metabolite are reduced.

METHOD

Trazodone, a serotonergic antidepressant with alpha 2-adrenergic blocking activity, was administered to 13 patients with DAT in an open 10-week pilot study at a dose of 25 mg t.i.d. Behavioral and affective disturbance was assessed pretreatment and posttreatment using semistructured interview and Jouvent's Depressed Mood and Gottfries-Brane-Steen scales.

RESULTS

Irritability, anxiety, restlessness, and affective disturbance were all decreased (p < .05). No side effects were observed. Mean Mini Mental State scores were unaffected by treatment.

CONCLUSION

The hypothesis that trazodone corrects behavioral and affective disturbance induced by serotonin depletion in DAT requires confirmation in a double-blind placebo-controlled trial.

Evolution of carotid restenosis after endarterectomy

Some 176 consecutive carotid endarterectomies performed during 1987 were assessed after 11.5 and 44 months. There were four perioperative deaths. At mean follow-up of 32.5 months the 50% restenosis rate progressed from 9.7% to 11.9%. Of the 168 carotid arteries with a normal patency at discharge, 36 showed progression of stenoses as judged by duplex scanning during the observation period of 44 months. Twenty-nine stenoses were present within 1 year and seven developed between 12 and 44 months. Successive assessments revealed marked differences in the evolution of restenoses which usually depended on the degree of severity reached at the end of the first year: 44% progressed, 28% regressed and only 28% remained stable. The risk of late occlusion in vessels with a < 50% restenosis at 1 year was below 1% and the risk of progressing to a stenosis > 50% was 3.3%. Assessment at 56 months was limited to patients who had a restenotic lesion during the first 44 months. It confirmed that the disease was still unstable with progression in 7% of cases and regression in 10%. This study did not demonstrate any significant restenosis after 20 endarterectomies using the eversion technique compared with an incidence of 13.4% after 156 standard endarterectomies.

Long-term thalamic stimulation in Parkinson's disease: postmortem anatomoclinical study

Parkinsonian tremor may be suppressed by thalamic stimulation. For an equivalent clinical efficacy, its obvious advantage over micro-thalamotomy is its reversibility. This patient experienced postural tremor at the age of 44 years and akineto-rigid syndrome 8 years later. At the age of 60 years, intrathalamic stimulation was applied over a long-term period of 43 months until death and was efficient on tremor with low stimulation. This case is the first with anatomic verification. The extent of the lesion provoked by the electrode is very small. The location of the stimulation site was in the medio-inferior part of the intermedius complex at the entrance of cerebello-thalamic fibers. The stimulation of the cerebellar afferent axons could be the cause of the clinical effect. The stimulation site corresponds to the thalamic source of the precentral and accessory motor cortex, which correlates with changes observed in our PET study showing a regional cerebral blood flow decrease in cerebellar nuclei and also in precentral and accessory motor cortex. The places and mechanisms of the effects of stimulations and lesions could be different.

Marchiafava-Bignami disease: use of contrast media in CT and MRI

We report two cases of Marchiafava-Bignami disease studied by CT and MRI. Both patients displayed persistent confusion and a disconnection syndrome but had a favourable outcome. In both cases, CT with intravenous contrast medium revealed enhancement of the corpus callosum in the early stage. MRI showed gadolinium uptake in both the genu and splenium of the corpus callosum in one case, 8 days after the onset. Three weeks after admission, cystic lesions appeared in the corpus callosum on MRI T1-weighted sagittal images in both cases. Contrast medium uptake may be useful in the diagnosis of Marchiafava-Bignami disease.

Motor memory and the preselection effect in Huntington's and Parkinson's disease

Patients with Huntington's disease (HD) and Parkinson's disease (PD) show different patterns of preserved and impaired memory performance. This study investigates explicit memory for movements in HD and PD with a linear positioning apparatus using Dick et al.'s procedure (J. Gerontol. 43, 127-135, 1988). In the first experiment, 12 HD patients were compared to 12 matched-controls. HD patients were more impaired than the controls by the delay between criterion and recall movements, whether the delay was filled or unfilled. Switching the limb between criterion and recall movements did not lead to more effects in HD patients and in controls. In the second experiment, 12 non-demented PD patients were compared to matched-controls. PD patients were more impaired than controls when the recall movement was executed with the contralateral hand, but were not more affected by the delay. In both experiments, HD and PD patients, as well as the controls, recalled self-generated preselected movements better than imposed movements. These results suggest the existence of distinct forms of motor memory impairment in some subcortical neurodegenerative diseases.

Methylenetetrahydrofolate reductase deficiency revealed by a neuropathy in a psychotic adult

Images

[Contribution of morphological imaging in the diagnosis of dementia. I--Alzheimer disease]

In patients with Alzheimer's disease, morphological neuroimaging techniques usually reveal signs of global cerebral atrophy which gradually worsen over time and depends on age and severity of the cognitive decline. Because of the lack of artifacts and of a more appropriate angle, magnetic resonance imaging scans may visualize a prominent atrophy of the medial temporal lobes, including hippocampal structures. Hippocampal atrophy is relatively specific of Alzheimer's disease before 65 and is related to the severity of memory disorders. White matter changes in patients without cerebrovascular risk factors are not more severe in patients with presenile Alzheimer's disease than in age-matched controls. They are, however, more severe in patients with senile onset than in age-matched controls. These findings suggest that white matter changes in patients with senile onset are consistent with a diagnosis of Alzheimer's disease.

[Huntington disease. Current state of research]

Huntington's disease is a hereditary disease with autosomal dominant transmission which generally occurs in adults. The gene was discovered in 1983 and the genetic abnormality in March 1993. The most commonly recognized clinical manifestation is choreiform movements although other signs often appear more invalidating to family and friends. Cognitive decline, modifications in behaviour, and sometimes psychiatric disturbances are perceived as the major handicap in everyday life. In this review, emphasis has been placed on late onset forms of the disease. Recent research has focused on morphologic and functional imagery, the neuropathologic stages of selective neurone loss beginning in the striatum, and the role of excitotoxic amino-acids. Certain ethical considerations must be addressed when determining prognosis. Predictive tests and follow-up must be prepared and conducted scrupulously and proposed to voluntary, informed, major subjects at risk. Tests should be performed by a qualified laboratory working on anonymous samples, independent of the clinical team, and should be given to the subject orally by a genetic counsellor. A prenatal test may be requested by parents at risk. The question of treatment, which to date can only offer symptomatic relief, should be re-addressed in light of the recent discovery of the mutation published in March 1993.

[Evaluation of coronary risk in patients with subrenal abdominal aortic aneurysm]

Atheroma lesions are often found in multiple localizations. In addition, operative mortality for aneurysms of the non-ruptured sub-renal aorta is mainly related to coronary risk. In an attempt to reduce coronary risk, coronarography was performed in all patients (n = 297) from January 1989. Operation for the aneurysm was performed in 192 patients (reasons for not operating were small size of the aneurysm, other contraindication). There were 5 deaths, all related to coronary artery disease. Coronary bypass was performed in 42 patients either before (n = 38) or at the same time (n = 4) as the operation for the aneurysm of the aorta. There were no operative deaths. These results clearly demonstrate the importance of search and treatment of associated coronary lesions in all patients with an aneurysm of the subrenal abdominal aorta. Coronary lesions should be treated whenever morphology allows.

SPECT data in a case of secondary Capgras delusion

Capgras' delusion (CD) may be secondary to a neurologic lesion, particularly in the right frontal or occipital regions. A 40-year-old woman with multiple sclerosis underwent SPECT during and after an episode of CD. Analysis during delusion showed an uptake defect in the right parietal cortex with an 11% index of asymmetry (normal: < or = 4%). Post-delusion SPECT showed decreased bifrontal and biparietal cortical uptake indices but a normal index of asymmetry. Functional brain imaging may provide clues to the psychopathology of CD.

Does carotid eversion endarterectomy and reimplantation reduce the risk of restenosis?

Two hundred twelve eversion endarterectomies of the internal carotid artery and reimplantation in the common carotid artery were performed between January 1985 and July 1990. A total of 206 patients with stenosis of 75% or more and with redundancy and tortuosity of the internal carotid artery underwent this procedure. Cumulative mortality and neurologic morbidity were 2.4%. Forty patients died during the course of follow-up, seven of neurologic causes (17.1%). Duplex scans of 107 operated carotid arteries were obtained an average of 27.1 months after surgery. Restenosis of > 50% was encountered in three patients (1.9%), two asymptomatic patients (1.3%) with > 75% restenosis and one symptomatic patient with occlusion (0.6%). These results contrast with a 13.5% rate of restenoses > 50% (including 5.9% of restenoses > 75% and 1.7% occlusions) observed after 156 consecutive endarterectomies performed and closed by direct suture by the same surgical team in 1987 at a mean follow-up of 44 months. We believe that this technique can be used more often because the the operative and long-term risks are not any greater than those of the other methods of carotid revascularization. Eversion endarterectomy associated with reimplantation is especially indicated when the internal carotid artery is elongated, is < 4 mm wide, and occurs in women.

Unilateral loss of facial flushing and sweating with contralateral anhidrosis: harlequin syndrome or Adie's syndrome?

A 45-year-old woman presented with a 10 year history of asymmetrical facial flushing and sweating after exertion or in hot weather. During these episodes the right side of her face remained dry and white, while the left side normally flushed. Sweating was impaired on the left side in the limbs and trunk. She also had areflexia in the lower limbs and slow pupillary reactions to light and darkness, as seen in Adie's syndrome. The topography of the sweating disorder suggested that the lesion involved the sympathetic pathways at the level of spinal cord. The relationship with the harlequin syndrome and related disorders is discussed.

[Psychometric study in Huntington disease]

Thirty-two patients suffering from Huntington's disease (HD) were tested with a short neuropsychological tests battery in order to make a global evaluation of their cognitive functions, and to ascertain whether the tests would be sensitive enough, even in the first stages of the disease, and whatever the individual neuropsychological profile, to be, possibly, an assessment tool for treatment efficacy. Nineteen HD presented with a "mild" form of the disease [stage I and II of Shoulson and Fahn (1979)], 7 men and 12 women, with a duration of illness of nearly 5 years and 13 HD presented with a "moderate" form (stage III and IV), 5 men and 8 women, with a duration of illness of nearly 8 years. These 2 groups had a comparable age at the assessment time (nearly 47) and did not differ, significantly, for the age at onset (39 and 43 respectively), duration of illness or psychiatric disorders. Each test result was reduced to its number of standard-deviations apart the normal mean-value for the same sex, age and study level group.(ABSTRACT TRUNCATED AT 250 WORDS)

A positron emission tomography study of patients with acute carbon monoxide poisoning treated by hyperbaric oxygen

Seven patients with an acute and severe carbon monoxide intoxication were treated with hyperbaric oxygen and underwent a positron emission tomographic examination 2-5 days after the acute event. Although the final clinical outcome was good in all patients, ischaemic changes were observed. Three patients with temporary sequelae after hyperbaric oxygen treatment showed the most severe changes, mainly in striatum and thalamus. Although positron emission tomographic examination cannot predict the final outcome, it can show the regions at risk for development of late complications following carbon monoxide poisoning.

Chronic thalamic stimulation improves tremor and levodopa induced dyskinesias in Parkinson's disease

Chronic thalamic stimulation was performed in 10 Parkinsonian patients with disabling tremor and poor response to drug therapy. During the stereotactic procedure, an electrode was introduced in the ventralis intermediate nucleus of the thalamus. Test stimulation was performed during the intra-operative procedure and a few days after surgery using an external stimulator. When tremor was obviously reduced by thalamic stimulation, an internal stimulator was implanted under the clavicle. Tremor was initially suppressed in all cases and reappeared whenever stimulation was stopped. Patients were followed for 22 to 34 months. Tremor was controlled in eight cases but reappeared after three months in two cases. Levodopa induced dyskinesias were observed before electrode implantation in 5 cases. They consisted of peak-dose choreic or ballistic dyskinesias in 4 cases and biphasic dystonic dyskinesias in 3 cases. Peak-dose dyskinesias were greatly improved or suppressed in all cases. Biphasic dyskinesias were improved in 2 cases. Thalamic stimulation was well tolerated. Mild dystonic hand posture related to the deep brain stimulation was observed in one case. No neuropsychological side-effects were noted. Thalamic stimulation could prove to be an adequate treatment for resistant tremor and levodopa induced dyskinesias.

Parkinson's disease and basal ganglia calcifications: prevalence and clinico-radiological correlations

We reviewed computerized tomograms (CT) for basal ganglia and dentate nucleus calcifications in 79 patients with Parkinson's disease (PD), 54 patients with Alzheimer's disease (AD) and 109 controls aged 50 or more. When it was determined, no patient had disturbances in calcium metabolism. We found: (1) 30 subjects out of 242 (12.3%) with calcification located within the lenticular nucleus in 28. (2) Calcifications were unilateral in 11 and asymmetric in 11. (3) The prevalence of calcifications was 21.5% in PD, 9.2% in AD and 7.3% in controls and were significantly more severe in PD than in C and AD (P less than 0.02). (4) PD patients with calcifications were clinically indistinguishable from those without calcification. (5) Calcifications within the basal ganglia were not associated with a levodopa-resistance. We suggest the basal ganglia calcifications are more frequent in PD, but we cannot explain why, since post-synaptic lesions have never been showed in PD.

Evidence for a common network of brain structures involved in parkinsonian tremor and voluntary repetitive movement

Repeated measurements of regional cerebral blood flow (rCBF) were obtained in 7 patients who underwent a stereotactic thalamic electrode implantation in the nucleus ventralis intermedius (nVIM) of the thalamus for severe hemi-parkinsonian tremor. Using positron emission tomography and oxygen-15 labelled water, rCBF was studied in each patient in two conditions: in absence of tremor, e.g. under nVIM electrical stimulation, and in presence of tremor. X-ray tomograms permitted individual definition of anatomical regions of interest. In presence of tremor, normalized rCBF increases were observed in the following regions: postcentral (13.6 +/- 8.4%, P = 0.0003), precentral (7.7 +/- 8.8%, P = 0.016), paracentral (7.7 +/- 8.4%), supplementary motor (8.2 +/- 10.4%, P = 0.025), caudate nucleus (5.7 +/- 7.6%, P = 0.03), vermis (9.7 +/- 7.3%, P = 0.007), cerebellar grey nuclei (9 +/- 6%, P = 0.016) on the electrode side and on the contralateral vermis (17.8 +/- 7.5%, P = 0.0003) and cerebellar grey nuclei (22 +/- 6.3%, P = 0.0004). These results clearly indicate an activation of the sensory-motor cortex, as well as an involvement of the supplementary motor area and the cortico-cerebellar pathways in Parkinsonian resting tremor (PRT). They demonstrate that PRT shares common network of brain structures with repetitive voluntary movement.

Control of tremor and involuntary movement disorders by chronic stereotactic stimulation of the ventral intermediate thalamic nucleus

The authors report on the long-term results of chronic stereotactic stimulation of the ventralis intermedius thalamic nucleus performed in 14 cases of disabling and intractable tremor. There were 10 patients with parkinsonian tremor and four with essential tremor. Three of the 10 parkinsonian patients had previously undergone contralateral thalamotomy. Tremor was assessed by clinical evaluation, surface electromyography, accelerometer, and videotape recordings before and after stimulation. The deep-brain electrode was implanted in the ventralis intermedius nucleus according to stereotactic procedure and connected to a subcutaneous pulse generator after a stimulation test period. Tremor suppression or reduction was obtained in all cases with high-frequency (130 Hz) stimulation. Marked functional improvement was maintained in 11 patients with a mean follow-up interval of 17 months. Levodopa-induced dyskinesias observed in five parkinsonian patients prior to surgery were improved or suppressed in four cases by thalamic stimulation. Stimulation was continued during the day and stopped at night in eight cases. Six patients were stimulated night and day to avoid a rebound effect which appeared as soon as the pulse generator was stopped. The only side effects were hand tonic posture in one case and persistent paresthesia in another case. The mechanism of action of this attractive treatment may be a functional alteration of the thalamic discharging area. The authors conclude that this technique is a good alternative to thalamotomy, especially when the risks of high-frequency coagulation are severe in frail and older patients.