Efficacité des injections intradétrusoriennes répétées de toxine A dans l'hyperactivité vésicale d'origine neurologique

PURPOSE

Toxin injections are an effective treatment for neurogenic detrusor overactivity. The efficacy of repeat injections is not well documented. The objective of this study was to evaluate the efficacy of repeat injections of toxin A to the detrusor in patients with neurogenic overactive bladders.

MATERIALS AND METHODS

Patients who had received 300-UI injections of Botox(R) were retrospectively studied. The clinical data included continence, duration of the absence of incontinence, changes in anticholinergic dosage or pad use and patient satisfaction. Urodynamic data analyzed were maximal cystometric capacity, bladder contraction and detrusor pressure during contraction. Data were analyzed by Wilcoxon and Kruskal-Wallis tests. RESULTS-DISCUSSION: Data for 42 patients (30 men, 12 women) were analysed. Pathologic features were trauma to the spinal cord, multiple sclerosis or varied causes of myelopathy. Patients received 1 to 6 injections of Botox(R). The mean duration of efficacy was 6 months. Efficacy did not differ among successive injections. Anticholinergic drugs were discontinued in 43% of patients and pad use in 48%. A total of 80% of the patients were satisfied with the treatment. Bladder contraction disappeared in 70% of patients. The mean maximal cystometric capacity increase was 144 ml.

CONCLUSION

Clinical and urodynamic data show that repeat injection of toxins to the detrusor remains an effective therapy for neurogenic bladder overactivity. Efficacy for continence is maintained during successive injections.

Santé publique et traumatismes crâniens graves. Aspects épidémiologiques et financiers, structures et filières de soins

The management of persons with traumatic brain injury affects a large spectrum of interventions from acute phase to the hospital discharge and the return to community. The incidence of brain injuries on mortality and morbidity constitutes a serious problem in front of the Health Administration. The traffic accidents remain the main cause but the falls in elderly are increasing. In the both cases preventive measures can be efficiency. In France, each year, there are about 150,000 new cases, 8000 of them will be dead and 4000 with coma. It is likely that 30,000 persons are living to day with important sequela of a brain injury. The management requires various types of interventions, each of them with specific and specialized techniques. It is necessary to have an overview of the problem and to work together in a comprehensive network. So French Health Ministry has just published an official note to precise some directives and co-ordination of the different interventions.

Trachéotomie et traumatisme crânien grave : pour qui ? Pourquoi ? Quand ? Comment ?

The aim of this study is to determine, from the data available in the literature, the indications of tracheostomy in brain injured patients, the incidence and risk factors for complications and the follow-up required until decannulation. The incidence of tracheostomy is 10% in TBI and 50 to 70% in subpopulations with a Glasgow Coma Scale (GCS) below 9. Early complications are not specific. The most frequent late complication is laryngotracheal stenosis, which occurs in 15% and is more frequently observed in the most severe patients with major hypertonia. It is likely that tracheostomy, if needed, should be performed early and the prognosis as to whether it will be required, can be made at the end of the first week. The follow-up of these patients includes surveillance of multiresistant colonisations and systematic performance of fibroscopy before decannulation. Cuffless, small diameters, soft tracheostomy tubes, are preferred on the long-term unless the risk of aspiration remains high.

Treatment of spasticity with intrathecal Baclofen administration: long-term follow-up, review of 40 patients

STUDY DESIGN

Case series of a consecutive sample. Retrospective audit.

OBJECTIVE

To analyze the long-term safety and efficacy of intrathecal baclofen (ITB), and technical incidents.

SETTING

Neurosurgical and Physical Medicine Departments of two university hospitals in western France.

METHODS

The medical records of 40 patients who underwent ITB pump placement for the treatment of severe chronic spasticity were reviewed. Patients were eligible independently of the origin of the spasticity (spinal cord origin 33, brain damage 8). They underwent a final assessment with clinical examination and questionnaire in 2001. Ashworth scale scores were assessed, patient satisfaction was rated on a visual analog scale (VAS), functional independence before and after treatment was classified as bed-ridden, wheelchair dependent or ambulant, and the frequency and nature of complications were noted.

RESULTS

The average follow-up period was of 4 years. The average Ashworth score at the final assessment was 1.8+/-0.6. Average patients satisfaction was 7.4/10+/-2.21 on VAS. In all, 85% would have undergone the procedure again if they had to make the decision. In 85% of the cases the ambulation status was unchanged. Technical incidents occurred at least once in 37% of the patients (due to the catheter in 58% and to the pump in 42%). They included catheter disconnections (4), migration (4), kinks (3), obstruction (3), development of fibrosis (3), disconnection of pump reservoir (2), porosity of pump membrane (2), unexplained pump dysfunction (4) leakage, and subcutaneous collection (5). Severe pharmacological side effects requiring transfer to intensive care unit occurred in 12% of cases, 80% of which were directly related to pump refill procedures.

CONCLUSION

ITB remained effective in the long term and patients were satisfied. Nevertheless, complications were frequent, involving mainly the catheters, which would require further technical improvements.

Neuroprotective effect of gacyclidine. A multicenter double-blind pilot trial in patients with acute traumatic brain injury

The aim of this study was to assess the safety and efficacy of intravenous (IV) injections of gacyclidine, a novel NMDA receptor antagonist, for neurological and functional recovery following acute traumatic brain injury. This multicenter, prospective, randomized, placebo-controlled, double-blind study compared four parallel groups. Two IV doses were administrated (placebo, 2x0.005mg/kg, 2x0.001mg/kg, 2x0.02mg/kg): the first dose was given within 2 hours following the trauma, and the second dose 4 hours after the first. Fifty-one patients were enrolled and 48 studied between March 1995 and June 1997 in France. Evaluation criteria for safety were physical examination, cardiovascular parameters, blood chemistry, hematology, ECG, and neuropsychological changes monitored after medication. Primary evaluation criteria for efficacy was the Glasgow coma scale complemented by the initial CT-scan and Glasgow outcome scale, motor deficiencies, neuropsychological changes, and functional indenpendence at D90 and D365 or endpoint. Intracranial pressure (ICP) monitoring was not taken into account because all the clinical centers participating in this study did not use this technique in daily practice during the inclusion period. Twelve patients died during the follow-up period, none of these deaths being related to the drug. Serious adverse events (181) were reported by most of the patients with no significant differences between groups. Only 10 of these adverse events were considered to be drug-related. Safety-related laboratory tests did not show any relevant changes. Concerning efficacy, the predefined prognostic factors (initial CT-scan score, initial Glasgow Coma Scale and occurrence of low systolic blood pressure during the first 24 hours) largely determinated the patient's outcome. When the prognostic factors were taken into account together with the dose level in a logistic regression model, gacyclidine showed a beneficial long-term effect and a best dose-result in the 0.04mg/kg treated group. Data obtained in this clinical trial appeared sufficient to warrant a European multicenter study on gacyclidine using the same evaluation criteria and ICP monitoring.

[Post-traumatic endocrine deficits : analysis of a series of 93 severe traumatic brain injuries]

OBJECTIVE

The aim of the study is to measure the incidence in severe traumatic brain injury of endocrine deficits with special consideration for hypotestosteronemia in male patients.

PATIENTS AND METHODS

Retrospective analysis of a series of 115 TBIs consecutively admitted to our brain injury unit. Endocrine screening is routinely performed at admission and includes radioimmunological assays for T3, T4, TSH, testosterone or oestradiol and progesterone, FSH, LH and cortisol. Twenty-two records were incomplete and excluded from further analysis. The analysis relies on 93 records among which those of 75 males.

RESULTS

One partial hypothyroidism of pituitary origin (low T3, T4 and TSH and no raise of TSH after stimulation by TRH) and one posthypophyseal deficit were found. The incidence of hypotestosteronemia is 28%. All are of central origin (low testosterone and low or normal LH). In one case the hypothalamic origin is demonstrated by the considerable increase of LH after injection of GnRH. We found no correlation between the occurrence of endocrine deficit and either the Glasgow Coma Scale or the existence of basal skull fracture.

DISCUSSION - CONCLUSION

These results show that endocrine deficits are not exceptional in TBIs and that isolated hypotestosteronemia is frequent. These deficits are not necessarily all of functional origin, but further studies including longitudinal follow up are required to conclude on this point. Further studies addressing the opportunity of substitution in some patients should also be conducted.

[Post-traumatic syringomyelia]

Clinical and neuroradiological data were recorded in a series of 73 spinal cord injured patients (33 in Nantes, 40 in Paris-Bicêtre) in whom a post traumatic syringomyelia (PTS) developed. These findings and a review of the literature allow to point out some of the main characteristics in such a pathology. Clinical symptoms are frequent, the commonest of them are pain and sensory loss but any alteration of the neurological status after spinal cord injury has to be considered. Magnetic resonance imaging (MRI), sagittal and axial T1 and T2 weighted images, confirms the diagnosis of syrinx (area with the same signal intensity as CSF extending beyond the site of the initial lesion at least on 2 vertebral segments). MRI allows the diagnosis when it is performed in the follow up of asymptomatic patients. So PTS is not infrequent in spinal cord injured patients, for some of them in the first year after the trauma. The highest incidence is found in patients with complete thoracic lesions. Pathophysiology and surgical management have to take into account post traumatic residual stenosis of the vertebral canal.

Ischaemic myelopathy following aortic surgery or traumatic laceration of the aorta

Paraplegia is one of the major complications following repair of aortic aneurysms or congenital malformations and from trauma of the aorta. In a series of 12 surviving patients we describe the clinical features as well as the evolution and pathophysiology of ischaemic lesions of the spinal cord. The clinical characteristics: loss of tendon reflexes, preservation of light touch sensation and bladder function, and the special topography of pin prick impairment, suggest involvement of the central grey matter. This lesion of the grey matter is incomplete in most of the patients and tends to extend for 2-10 segments. In some cases it can extend downward to the conus resulting in complete flaccid paraplegia. On follow-up we have observed limited improvement in most cases. No patient has recovered fully. Except in cases of traumatic laceration, where symptoms existed before surgery, paraplegia followed surgical repair in all other cases. Ischaemia can be related to the duration and the site of crossclamping of the aorta. Clamping above the left subclavian artery and/or a ligation of the intercostal arteries without previous visualisation of the spinal cord arteries can be dangerous. Other factors such as the phenomena of revascularisation and the presence of free radicals are discussed. These could explain delayed postischaemic spinal cord hypoperfusion.

Post-traumatic syringomyelia and post-traumatic spinal canal stenosis: a direct relationship: review of 75 patients with a spinal cord injury

This study aims to demonstrate predictive factors for post traumatic syringomyelia (PTS), and in particular to correlate the role of insufficiency of reduction of a spinal fracture with the occurrence of syringomyelia. One hundred and twenty-eight spinal cord injured patients (SCI) were studied during the years 1992 and 1993. Among them, 75 underwent a complete and reliable evaluation including: review of the initial vertebral lesion, and of the surgery report, and a radiological study of the lesion site with standard X-rays, a CT scan, and an MRI. The CT Scan included slices in sagittal reconstructions and in the axial plane at the site of injury with the calculation of a percentage of canal stenosis in the two planes of the space. An MRI was carried out with T1 and T2 weighted images, including sagittal entire cord images in addition to sagittal and axial slices centred on the site of injury. A syrinx was diagnosed in 28% of the patients. The occurrence of a syrinx is significantly correlated with spinal canal stenosis in the sagittal plane (delta D) with a P < 0.001 and in the axial plane (delta S) (P < 0.05). This present study demonstrates the major role of the insufficiency of reduction of the vertebral lesion in the genesis of a syrinx. The quality of the initial treatment of the vertebral injury is the first step in the prevention of a syrinx. The treatment of a syrinx, besides techniques of drainage, must also take into account the spinal realignment.

Load compensation tasks evoke tremor in cerebellar patients: the possible role of long latency stretch reflexes

'Tremor' is one of the clinical signs of cerebellar dysfunction. Its nature remains subject to debate, one hypothesis being that of a predominant role of peripheral afferences in its genesis. This study was designed to study whether load compensating tasks, evoking sudden stretch, and thus stimulation of peripheral afferences induced tremor in cerebellar patients. We study the kinematics and EMG pattern of a load compensating task which consists of maintaining a constant elbow position despite the onset and cessation of a 2 Nm torque loading the elbow flexors in eight cerebellar patients and six controls. Angular position and velocity, and EMG of the biceps and triceps are recorded at a sampling rate of 1 kHz. In normal subjects, trajectories are simple with little overshoot of the aimed position. EMG analysis shows a long latency stretch response (LLSR) which initiates a phasic and then tonic voluntary activity. In cerebellar patients, the two prominent cinematic features are hypermetria and tremor. The stretch response is of the same latency, but the EMG pattern is modified with bursts of activity related to the tremor. These results show severe perturbations of load compensating tasks in cerebellar patients. We discuss the possible role of the exaggeration of LLSR in both hypermetria and tremor.

Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease

OBJECTIVE

This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both.

DESIGN

The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means.

RESULTS

Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy.

CONCLUSION

Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before restoring to tracheostomy if weaning fails.

[Bladder-sphincter disorders in patients with spinal cord injuries]

Improvement in the management of neuropathic bladders in spinal cord injury has considerably increased the life expectancy of these patients. The classical classification in central or peripheric neuropathic bladders, now leave place to a functional, clinical, and urodynamic classification. Three periods define the evolution of the neuropathic bladders: the initial period (drainage), the reeducation phase, and the stabilized period. Urodynamic investigations detect situations of risk (high intravesical pressures) and allow therapeutic adjustment. Intermittent catheterization has transformed neuro-urology and allowed deliberate choice of retention. Long term follow up is imperative (urodynamic study, echography, intravenous urography) to avoid secondary degradation.

[Environments and handicaps]

Chronic deficiencies have been known ever since man left traces of his own existence but have increased since the 19th century. The number of people with chronic deficiencies in France is close to five millions, of which 1,2 million are very severe. This figure does not include occasional deficiencies due to age or "normal" transitory situations of life. These deficiencies engender disabilities which themselves create a handicap. Particular attention to environmental conditions is required to cope with such situation and try and equalize opportunities and reduce exclusion. This is a part of the scope of medicine if the aim is, as Pr. B. Glorion reminded us recently "to treat and cure but also maintain the patients physical and moral equilibrium". Reeducation is concerned with the person, rehabilitation with the adaptation of the individual and collective environment. It is in intervening in this area, that it becomes possible to reduce otherwise overwhelming inequalities. "What constitutes real democracy is not to recognise equals but to make them equal" (Gambetta). While it remains necessary to answer to the requirements of individual situations, it is on the wider and collective front that solutions must be found in order to deal with the greater situational difficulties of collective life. To be efficient, the principles of action must leave behind conventional classifications and attempt to solve the functional difficulties: daily life activities, transportation, work, education, access to social life. Given pressure from individuals, often grouped in associations, and from medical practitioners sensitive to these problems, laws have been passed and local authorities have adapted infrastructures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aggravation following anaesthesia in a case of unknown lateral amyotrophic sclerosis (author's transl)]

A 66 year old man whose activity was almost normal underwent a lombar sympathectomy under general anesthesia (thiopental, gallamine, N2O). Immediately after recovery an acute respiratory distress became evident. It was due to a respiratory paralysis on which neostigmine had no effect. Neurologic examination showed the symptoms of an amyotrophic lateral sclerosis which had remained unknown so far. The respiratory paralysis persisted and one year later artificial ventilation is still necessary almost continuously. Two aspects of this very rare observation are discussed: first the cause and mecanisms of the aggravation of the neurologic disease following anesthesia, secondly the rather unusually important part played by the respiratory paralysis in this case of lateral amyotrophic sclerosis.

[Therapeutic use of tiapride in movement disorders]

Tiapridal was given to twenty-four patients suffering from dyskinesias. Therapeutic efficacity seems to the etiology. Not any fonctitonal improvement was observed in parkinsonism with dyskinesia consecutive to Dopa therapy. On the other hand a good efficacity was found in the treatment of choreas with a quite good tolerance; the functional result will depend of the evolutive state of the disease.

[Chronic ischemia of the anterior horn of the lumbar swelling of the spinal cord. Angiographic study in a subject with herniation of the T12-L1 discs]

On the basis of a case of almost pure involvement of the anterior horn with chronic progression in an individual with a low thoracic herniated disc (T12-L1), the hypothesis is discussed of the role of ischaemia of the lumbar swelling. Angiographic arguments (displacement of the anterior spinal axis and unusual distribution of anterior spinal afferents) perhaps make it reasonable to speak of "chronic ischaemic poliomyelitis" in the absence of pathological examination.

[Striato-nigral degeneration. Clinical and anatomic study of a case which responded favorably to L-Dopa]

The authors have reported the case of a 65 year old woman followed for almost 4 years with an akineticrigid Parkinsonian syndrome which responded well to levodopa. Waning of response finally occurred and despite the addition of a peripheral dopa decarboxylase inhibitor the patient died suddenly. Autopsy examination revealed pure nigro-striatal degeneration without any additional pathology. The report deals primarily with purity of the Parkinsonian picture and especially with the conspicuous and prolonged effect of levodopa.

[The relationship between the course of bismuth encephalopathy and the amount of bismuth in blood and urine]

Study of the course of bismuth encephalopathy following the ingestion of a bismuth salt in relation to blood and urinary bismuth levels indicates a close parallel between the improvement in the clinical picture and the decrease in the degree of toxic impregnation of the body. This confirms the direct responsibility of bismuth for the disorder. Regression of myocolonic movements goes with the fall in blood bismuth levels, whilst improvement in the confusional syndrome is aomewhat delayed. There is a significant correlation between bismuth levels in the blood and urine. The excretion of bismuth is slow, and the persistence of blood and urinary bismuth levels higher than normal for several weeks after the acute phases and the interruption of the ingestion of bismuth salts reflects the existence of stable bonds between the metal and cellular constituents. The authors have observed a non-negligeable solubility of bismuth sub-nitrate in certain drinking waters, which brings up the hypothesis of a possible role of the hydrosobulity of bismuth in the pathogenesis of the intoxication.