[Transesophageal echography and peripheral arterial embolism. A new etiologic approach. Apropos of 87 cases]

This prospective study (September 1989 to November 1990) was undertaken to evaluate the utility of transesophageal echocardiography in acute peripheral ischaemic syndromes. After embolectomy or thrombolysis, 87 patients with an average age of 69.7 years underwent not only the usual investigations (conventional echocardiography, abdominal ultrasonography and Holter monitoring) but also transesophageal echocardiography within 2 days of the ischaemic events (lower limb 84%, multiple embolism 11%, recurrent embolism 13%). Atrial fibrillation was documented in 44 patients (50.5%), 19 patients had chronic arterial disease (22%), 8 patients had valvular heart disease (9%) and 2 patients had a blood disorder (2%). Transthoracic echocardiography only demonstrated one left ventricular apical thrombus whereas transesophageal echocardiography showed residual thrombus in 22 patients (25%) mainly in the left auricle but also in the descending thoracic aorta (8 patients) as a mobile, pediculated thrombus or lining an aortic aneurysm, thereby opening up new therapeutic possibilities. In addition, double aortic dissection was diagnosed in a patient who was not echogenic, isolated spontaneous contrast in 20 patients (23%) and other abnormalities in 7 patients (8%). Statistical analysis showed a significant relationship between the presence of thrombus and/or spontaneous contrast in the left atrium and/or left auricle and the size of the left atrium (Fisher test - p = 0.0073), and the presence of a supraventricular arrhythmia (chi 2 test).

[Long-term selegiline tolerance in the treatment of Parkinson's disease]

Tolerability is one of the main problems of the long-term use of antiparkinsonian drugs, especially in the advanced stages of Parkinson's disease. Since 1988, we have performed a prospective study to assess the clinical and therapeutic factors which may influence the tolerability of a new antiparkinsonian drug, selegiline. 168 patients, with a mean age of 68, were treated with selegiline in combination with L-Dopa or with L-Dopa and a dopamine agonist (bromocriptine, lisuride or piribedil). After an average of 19 months, 23 adverse effects (13.7%) were noted during the first three months of treatment with selegiline. Discontinuation was required in only 10 cases (5.9%) with 9 out of 10 for a psychotic episode. Neither age, nor the stage of the disease, nor the dose of levodopa in combination with selegiline or the presence of mental disturbances seemed to be predicting factors for appearance of a psychic episode. If selegiline with levodopa or with bromocriptine and levodopa appeared to be safe antiparkinsonian combinations, significant psychic side effects occurred with piribedil in combinations with selegiline and levodopa. A possible explanation was that selegiline potentiates piribedil side-effects.

Some clinical aspects of late onset parkinsonism

Thirty-six parkinsonian patients were selected by age of onset of over 70 and a minimum of five years duration of illness. The mean age of onset was 73.5 years and 30 patients were still alive after a mean of 7.2 years. We found that late onset Parkinson's disease has a relatively benign course with more "axial symptoms" especially dysarthria, freezing and postural instability. Dyskinesias and fluctuations are rare and dementia occurs in few patients in spite of their old age.

Hemifacial spasm due to pontine infarction

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[Randomized study during a year of early combination of L-dopa/lisuride in Parkinson disease]

The tolerance and efficacy of dopatherapy associated to lisuride or placebo were compared in 74 de novo patients with Parkinson's disease in a prospective randomized trial. Only non depressed and non demented patients, previously treated with low doses of levodopa during less than one year, were included in this study. Mean age was 59 (range 36-68). After 12 months, the mean dosage of levodopa was higher in the placebo group than in the lisuride group (318 +/- 121 and 274 +/- 74 mg daily respectively). We observed a different decrease in the Unified Parkinson's Disease Rating Scale with better scores in the lisuride group than in the placebo group, especially for the motor items (p less than 0.001) and the daily living (p less than 0.0001). The tolerance was similar in the two groups. This trial will be continued in open conditions over a period of 4 years to appreciate the incidence of motor fluctuations in the two groups.

[Contribution of imaging to the study of aortic aneurysms]

All aortic aneurysms require a positive diagnosis, a differential diagnosis and an assessment of extension. Several exploratory methods can be contemplated. In patients with warning symptoms, conventional radiology may point to the diagnosis. The reference method remains retrograde aortography which may be either conventional and seriographic or, better, radiocinematic with orthogonal projections and, if possible, digital. The site and morphology of the aneurysm, and in particular its inner channel are thus demonstrated. Computerized tomography is less invasive and usually of great value, notably for the horizontal, thoracic and abdominal aorta, not only to confirm the diagnosis but also to determine the size of the inner channel, parietal thrombi and aortic walls, as well as relations with nearby structures. Other, totally non-invasive methods are widely utilized to explore aortic aneurysms. These are ultrasonography and its variants (notably Doppler-echocardiography and the transoesophageal route), and magnetic resonance imaging which provides three-dimensional and anatomical views of the vessel. These last two examinations alone usually confirm and outline the aortic aneurysms. They must therefore be utilized as first-line examination, arteriography it is various forms being reserved for emergencies or special cases.

[Urine retention following herpes zoster meningoencephalitis]

A case of retention of urine after ophthalmic zoster is reported. The sphincter vesicae disorder was of central origin, being caused by a meningoencephalitis. The patient progressively recovered. The respective responsibilities of brain suffering and meningeal involvement in these urinary tract disturbances are discussed.

Percutaneous atherectomy with the Kensey catheter: early and midterm results in femoropopliteal occlusions unsuitable for conventional angioplasty

Forty-six femoropopliteal occlusions in 44 patients (aged 45-95 years) were recanalized with the percutaneous rotating tip atherectomy catheter completed by balloon dilatation. Thirty-one patients had tight intermittent claudication of the lower limbs, five had resting pain and 10 had skin disorders. The length of the occlusion ranged from 2 to 24 cm. Of 46 procedures, 40 (87%) were immediately successful (increase of mean Doppler systolic ankle-arm index from 0.44 to 0.89) and six (13%) were failures. In two it was impossible to pass through the lesion and in four arterial perforation occurred without any clinical consequences. Of the six failures, five occurred in calcified arteries. Five recanalizations (11%) reoccluded within 48 hours, bringing the total number of early failures to 11. Of these 11 failures, nine were treated by femoropopliteal vein bypass and two by medical treatment only. Two postoperative asymptomatic posterior tibial artery embolisms were treated medically, and one popliteal artery embolism was treated using a Fogarty catheter. At the present time, 25 of 35 primary successes had been followed for six months, and 20 for 12 months with primary patencies 18 of 25 (72%) and 14 of 20 (70%), respectively. If massively calcified lesions are excluded, femoropopliteal recanalization with the percutaneous rotary Kensey atherectomy catheter followed by balloon catheter dilatation is efficacious and reliable with an 80% primary success rate and a 70% patency rate at one year.

Management of focal intracranial infections: is medical treatment better than surgery?

Three groups of patients with single hemispheric brain abscesses or subdural empyemas, from 1 to 5 cm large, with similar initial prognosis, have been treated either by medical treatment alone (20), aspiration (21), or excision (15). Differences in survival were not found, but medical treatment alone was better for long term sequelae. Surgical procedures (either aspiration or excision) were better for both isolation of the organism and the hospital stay before discharge. In spite of good results, it is unwise to conclude too strongly in favour of no surgical treatment as this study was not randomised.

Periventricular and white matter magnetic resonance imaging hyperintensities do not differ between Alzheimer's disease and normal aging

We studied normotensive and nondiabetic subjects, free of cardiac disorders, to determine whether Alzheimer's disease is a possible factor of magnetic resonance imaging (MRI) white matter or periventricular hyperintensities, and to investigate relationships between computed tomographic scan and MRI changes. We failed to reveal (1) any difference in the severity of MRI white matter and periventricular hyperintensities between patients and controls, (2) any correlation of MRI white matter and periventricular hyperintensities with either ages or Mini-Mental State Examination scores. We found (1) a poor interobserver agreement, and (2) a correlation between computed tomographic scan and MRI white matter changes but not between computed tomographic and MRI periventricular changes. We conclude that MRI periventricular and white matter hyperintensities are frequent incidental findings in the elderly and do not significantly differ between patients with Alzheimer's disease and healthy controls.

[Refsum's disease. Apropos of 2 cases disclosed by myocardiopathy]

Refsum's disease is a polyneuropathy due to a hereditary error in the metabolism of a fatty acid, phytanic acid, usually leading to cardiac failure only at an advanced stage of the disease. The authors report the case of two brothers with Refsum's disease revealed by a heart failure before the clinical stage of the peripheral neuropathy. In the younger brother, the affection started at the age of 22 years by an acute pulmonary oedema which revealed a dilated, hypokinetic myocardiopathy, associated with retinitis pigmentosa, ptosis, anosmia and biological myolysis. The normal plasma concentration of phytanic acid measured several times led to the conclusion of Kearns-Sayre syndrome even if certain aspects were atypical (moderate conduction disorders, no characteristic aspect in the muscle biopsy). Five years later, the older brother, aged 28, presents a dyspnea on effort which leads to the discovery of a hypokinetic, hypertrophic myocardiopathy, slightly dilated, associated with cardiac conduction disorders, retinitis pigmentosa, anosmia and biological myolysis. The plasma concentration of phytanic acid being very high. Refsum's disease was diagnosed and the diagnosis of younger brother was corrected. From the study of these two cases, the characteristics of the cardiac disorders can be specified: the cardiopathy can reveal the disease and correspond to a dilated or hypertrophic myocardiopathy. The diagnosis of the disease can be difficult because the plasma phytanic acid may remain at normal level, thus requiring the assay of the activity of phytanate oxydase. The existence of ophthalmologic signs (retinitis pigmentosa or progressive ophthalmoplegia externa) associated with a myocardiopathy must systematically lead to a search for Refsum's disease, this diagnosis having fundamental therapeutic implications (died, even plasmapheresis).(ABSTRACT TRUNCATED AT 250 WORDS)

[Embolectomy in massive lung embolism]

Pulmonary embolism was first described by Laennec in 1819. After introduction of the Trendelenburg surgical technique, Kirschner, in 1925, performed the first successful embolectomy. In a review of the literature, in 42 patients, survival rate was 45% on use of a modified Trendelenburg method employing cross-clamping of the vena cava. The use of this intervention can still be considered justified if extracorporeal circulation is not available. Establishment of the indication and anatomical fundamentals The indication for surgical embolectomy is considered established in the presence of massive pulmonary arterial obstruction with pending death of the patient. The difficulty lies in identification of the patient with massive pulmonary embolism who will succumb and in defining the extent of pulmonary arterial obstruction which will lead to death. Limitation of the indication to only those patients in shock led to mortality rates up to 93%. Immediate death after pulmonary embolism is not the rule. Of 52 patients with massive pulmonary embolism, 50% survived more than two hours; in those with no preexistent cardiopulmonary disease up to eight hours. Surgical intervention can be considered accordingly. Anatomically, massive pulmonary embolism implies at least 60 to 70% obstruction of the pulmonary arterial bed. In 85 of 100 patients who died of pulmonary embolism, voluminous emboli were found in both pulmonary arteries. In the presence of preexistent cardiopulmonary disease, lesser degrees of obstruction can lead to a critical condition. In consideration of the indication as above, the following comments are considered appropriate: 1. Quantification of the obstruction: Pulmonary angiography remains the most appropriate diagnostic examination. The degree of obstruction can be quantified according to a number of indices. As of 60%-obstruction, surgical intervention can be considered. 2. Justification of embolectomy: The classical indication can be established in 2 to 6% of the patients based on treatment-refractory hypotension. In Table 1, the classical stages of massive pulmonary embolism are shown with the indication for embolectomy being considered as of stage IV but these characteristics are unreliable in everyday practice. If surgery is delayed until vasoactive drugs are no longer effective, an irreversible condition is frequently incurred in spite of operative removal of the obstruction. More favorable results can be achieved when the indication for surgery is based only on the degree of obstruction since, in this case, the condition of shock will not be prolonged and a hemodynamically-stable patient can be subjected to surgery. 3. Thrombolytic treatment

Dystrophic neuropeptidergic neurites in senile plaques of Alzheimer's disease precede formation of paired helical filaments

The relationship between peptidergic neurites and paired helical filaments (PHF)-positive neurites in Alzheimer's disease (AD) senile plaques (SP) was studied using combined fluorescence and bright field optics. Cryostat sections of AD hippocampi were first stained by thioflavine-S and immunolabeled with antisera raised against different neuropeptides: somatostatin 28(1-12) (som 28(1-12)), somatostatin 14 (som 14), neuropeptide Y (NPY), cholecystokinin (CCK) and substance P (sP). Secondly, using the elution-restaining procedure, sections were immunolabeled with anti-tau/PHF. In immature SP, clusters of abnormal, swollen neurites were found. The dystrophic, strongly peptidic-positive neurites contained less PHF than the poorly positive ones. Cell bodies, exhibiting a peptidic content, could be found within SP without any alteration. These results suggest the following sequence of events: an extracellular poisoning mechanism, perhaps the amyloid substance, first changes the structure of presynaptic endings and causes the formation of ballooning dystrophic neurites filled with their normal peptidic content. Subsequently, intracellular degradation occurs with formation of the PHF. Then the other structures such as dendrites and perikarya are damaged by the same mechanism. Therefore this phenomenon seems to precede any formation of PHF in SP.

Condition scoring scheme for small east African goats in Zimbabwe

A body condition scoring for Small East African type goats in Zimbabwe is described. This measure is less affected by confounding variables than is body weight as an estimate of animal's condition and nutritional state. Furthermore, it requires no special equipment. Using this scheme it is shown that condition score is significantly correlated with a parametric measure of condition (r = 0.5, P less than 0.01) in adult females and that changes in condition score are significantly correlated to percentage changes in body weight (rs = 0.5, P less than 0.01) for all ages. A change of condition score of 1 represents on average a 12% change in body weight.

Dystrophic peptidergic neurites in senile plaques of Alzheimer's disease hippocampus precede formation of paired helical filaments

The relationship between peptidergic dystrophic neurites and paired helical filament (PHF)-positive neurites in Alzheimer's disease (AD) senile plaques (SPs) was studied using combined fluorescence and bright-field optics. Cryostat sections of AD hippocampi were first stained with thioflavine-S and immunolabelled with antisera raised against different neuropeptides: somatostatin-28(1-12), somatostatin-14, neuropeptide Y, cholecystokinin (CCK) and substance P. Secondly, using the elution-restaining procedure, sections were immunolabelled with anti-tau/PHF. In immature SPs, clusters of abnormal, swollen neurites were found. The dystrophic, strongly peptidic-positive neurites contained fewer PHFs than the poorly positive ones. Cell bodies, exhibiting a peptidic content, could be found within SPs without any alteration. These results suggest the following sequence of events: an extracellular poisoning mechanism, perhaps the amyloid substance, first changes the structure of presynaptic endings and causes the formation of ballooning dystrophic neurites filled with their normal peptidic content. Subsequently, intracellular degradation occurs with formation of the PHFs. Then the other structures such as dendrites and perikarya are damaged by the same mechanism. Therefore, this phenomenon seems to precede any formation of PHFs in SPs.

Two outbreaks of trichinosis caused by horsemeat in France in 1985

Two outbreaks of trichinosis occurred in France in August and October of 1985 and 1,073 cases in all were identified. In the first outbreak, two localities were involved: the town of Melun and the 14th district of Paris. To determine the origin of the contamination, three case-control studies were carried out: among patients' families, among the populations of these two areas, and among the inmates in the prison of Melun. In the second outbreak, cases again occurred in Paris but in a different district (the 12th), in the city's suburbs, and in other towns scattered throughout France. Although no parasites were found in any of the meat examined in either outbreak, results of the study indicate that infection was due to horsemeat consumption and led to the incrimination of two carcasses, one imported from a slaughterhouse in the United States and the other from West Germany. These findings led the French Ministry of Agriculture to order the inspection for trichinosis of all meat from horses slaughtered both in France and in countries exporting horsemeat to France.

Chorea associated with oral contraception

Three patients developed chorea while receiving oral contraceptives. Two were young patients whose chorea developed long after treatment had been started and disappeared soon after it had been discontinued. The third patient had acute amphetamine-induced chorea after prolonged oral contraception. Prolonged administration of female sex hormones is a possible cause of chorea in women who have not previously had chorea or rheumatic fever.

"Hemicrania continua": the first bilateral case?

The patient reported had had a continuous headache involving the whole skull for 7 years. Many drugs had failed to relieve the pain, but with indomethacin the headache completely disappeared within 3 days. Nine months later the treatment was discontinued without any relapse. This variety of headache, not previously reported, was quite similar to the "hemicrania continua" except for its localization.

Comparison of propranolol, sotalol, and betaxolol in the treatment of neuroleptic-induced akathisia

In earlier open studies, beta-blockers were found to be effective in the treatment of neuroleptic-induced akathisia. In the present study, 16 patients with severe neuroleptic-induced akathisia successively received low doses of three beta-blockers--propranolol, sotalol, and betaxolol. There was rapid and complete improvement in seven of 16 patients (and partial improvement in three patients) treated with betaxolol. The efficacy of propranolol and betaxolol and failure of sotalol in treating neuroleptic-induced akathisia suggest a central mechanism of action.

Bilateral spontaneous dissection of extracranial vertebral arteries

A previously healthy 35-year-old man suddenly developed vertebrobasilar ischaemia while playing tennis. Cerebral arteriography revealed a dissecting aneurysm of the cervical portion of both vertebral arteries. The neurological deficit and the angiographic features resolved with anticoagulant treatment alone. Only 15 patients with non-traumatic extracranial vertebral artery dissection have been previously reported. It is necessary to recognize the condition very quickly, because the authors consider that anticoagulation is required as an emergency.

Severe hypoglycorrhachia after subarachnoid hemorrhage. Two cases with spontaneous recovery in adults

We report two patients with severe hypoglycorrhachia after a subarachnoid hemorrhage. They had no obvious meningeal infection, and they spontaneously recovered within a few weeks. Such cases have previously been reported in neonates, but exceptionally in adults. Contrary to detailed cases from the literature, our patients recovered without antibiotics, and hypoglycorrhachia was very severe.

[Radiculo-spinal discomfort and Scheuermann's disease. 12 cases]

Twelve cases of Scheuermann's disease associated with neurological disorders are reported. The relation between the two conditions can be established through herniated disc, kyphotic angulation or spinal cyst. A more interventionist attitude is justified by the progress and results of neuroradiological investigations and surgical techniques.

Isthmus and ligament interrelationships: a computerized analysis of the spatial relationships of the hinge structures in unionid mussels

A study of the isthmus and ligament in unionid mussels was undertaken employing methods specifically designed to preserve the in vivo relationships of these interrelated structures. Serial sections of the hard and soft tissues were used for two-dimensional analysis. From these, a tridimensional computerized reconstruction was developed. Special dissections of the undisturbed isthmus were also utilized. By using such methodologies, a new description of the ligament has been developed employing such terminology as the foliated ligament and the posterior folding laminae. Similarly, for the isthmus, an anterior lyre, a pallial crest, a pallial peduncle, and a posterior lyre are described. Such entities are both morphologically and physiologically related to the shell and ligament.

Thoracic disk herniation and Scheuermann's disease

The authors report 6 cases of thoracic disk herniations in patients with Scheuermann's disease. They underline the relationship between the neurological symptomatology and Scheuermann's disease by the herniation and evolution in their treatment by a new surgical approach.

Clinical and biochemical heterogeneity in conditions with phytanic acid accumulation

Phytanic acid accumulation has for more than 20 years been used as a diagnostic criterion of Refsum's disease. Recently, however, phytanic acid has also been found in peroxisomal disorders (Zellweger's syndrome, neonatal adrenoleukodystrophy, infantile Refsum's syndrome, rhizomelic chondrodysplasia punctata). The 17 patients with Refsum's disease in the present study had serum phytanic acid values differing from 73 to less than 0.5 mg/dl (normal). alpha-Oxidation of phytanic acid in skin fibroblast cultures showed a defective capacity in all, with only small differences in residual activity. Phytanic acid determinations in serum from 3 of the 7 patients with peroxisomal disorders showed slightly elevated levels in 2. The alpha-oxidation capacity in the fibroblasts was defective in all, with a residual activity similar to that of Refsum's disease. An assay of the alpha-oxidation capacity may be useful in the diagnosis of both Refsum's disease and the peroxisomal disorders. The distinction between Refsum's disease and the peroxisomal disorders can easily be done on a clinical basis.

Right superior vena cava draining into the left atrium with left superior vena cava draining into the right atrium

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[Evaluation of the amnesia caused by restricted thalamic infarcts--6 cases]

The amnesic syndrome is analysed in 6 infarctions restricted to the thalamic area. Bilateral lesions were linked to more definite deficits; the anterograde forgetting was unequivocal at the initial stage and affected both verbal and visual memory. In unilateral lesions, deficits were far more discrete and there was no evidence enough for assuming a strict hemispheric specialisation, left for verbal memory, and right for visual memory. These cases and others from the literature suggested that amnesia is more important and pure in infarctions of the anterior part of the thalamus.

Management of subdural intracranial empyemas should not always require surgery

Seven patients with subdural empyema were initially treated by antibiotics without surgery. Six have recovered without sequelae. One required delayed surgery and has recovered with epilepsy. The authors emphasise the use of CT for the diagnosis and follow-up of subdural empyema, the principles and modalities of non-surgical treatment, and the good results, especially for late morbidity.

Astereognosis and amyotrophy of the hand with neurinoma of the second cervical nerve root

A case of astereognosis and amyotrophy of the right hand is reported, which was caused by a large extradural neurinoma of the C2 nerve root. The quick and complete recovery which followed surgery suggested a vascular mechanism as the cause of the neurological deficits.