Impact of COVID-19 pandemic on child abuse and neglect: A cross-sectional study in a French Child Advocacy Center

OBJECTIVE

This study aimed to describe the impact of the first COVID-19 lockdown in France on the activity of a Child Advocacy Center.

METHODS

This cross-sectional, observational study included all children involved in the activity of the CAC during the first lockdown, from March 16 to May 10, 2020 and the next 3 months and the corresponding periods in 2018 and 2019. Cases were considered severe when a hospitalization, social alert and/or judicial report to the prosecutor was decided.

RESULTS

Data for 1583 children were analyzed. During the lockdown, the global center activity decreased with 26.4 consultations per 100.000 children in 2018, 46 in 2019 and 20.7 in 2020 (p < 0.001). Judicial activity decreased (forensic examinations and child forensic interview recordings), whereas assessment consultations increased. Cases were more severe during the lockdown than in 2019 and 2018 (12.3, 9.4 and 6.04/100.000 children, respectively, p < 0.0001). The global activity of the center increased in the 3 months after the lockdown as compared with during the lockdown (38.2/100.000 versus 20.7/100.000, respectively, p < 0.001) but did not differ from activity in 2018 and 2019. Severe cases were more frequent in the 3 months after the lockdown than the previous years (13.7/100.000 in 2020, 9.62 in 2019 and 8.17 in 2018, p = 0.0002).

CONCLUSION

The CAC activity decreased during the lockdown in France but the increase in incidence of severe abuse cases during the lockdown and the next 3 months confirm the need for optimal screening, care and support of child abuse and neglect victims even in the context of health crisis.

[Burns by immersion in children and abuse]

AIM OF THE STUDY

Ten percent of childhood burns could arise from maltreatment. While describing 6 severe cases of inflicted scalds by immersion in children, we expose our systematic diagnostic approach of abuse and confirm the serious nature of burn when they are inflicted.

PATIENTS AND METHOD

The retrospective study concerned children hospitalized for scalds by immersion between 2013 and 2016 and for whom child abuse has been confirmed. Sex, age, burns description, needs of surgery, length of stay at hospital and protection plan set up were collected.

RESULTS

Six cases of burns by immersion due to maltreatment were identified (5 boys, 1 girl) with a median age of 12 months. The average total burn surface area was 19%. Burns were of deep second and third degree and always symmetric. Every child underwent surgery at least once. Concern information was transferred for all of them.

CONCLUSION

Teams taking care of children with burns must be trained to the difficult diagnostic of abuse or neglect so that early social interventions can be set up in case of maltreatment.

Tele-transmission of EEG recordings

EEG recordings can be sent for remote interpretation. This article aims to define the tele-EEG procedures and technical guidelines. Tele-EEG is a complete medical act that needs to be carried out with the same quality requirements as a local one in terms of indications, formulation of the medical request and medical interpretation. It adheres to the same quality requirements for its human resources and materials. It must be part of a medical organization (technical and medical network) and follow all rules and guidelines of good medical practices. The financial model of this organization must include costs related to performing the EEG recording, operating and maintenance of the tele-EEG network and medical fees of the physician interpreting the EEG recording. Implementing this organization must be detailed in a convention between all parties involved: physicians, management of the healthcare structure, and the company providing the tele-EEG service. This convention will set rules for network operation and finance, and also the continuous training of all staff members. The tele-EEG system must respect all rules for safety and confidentiality, and ensure the traceability and storing of all requests and reports. Under these conditions, tele-EEG can optimize the use of human resources and competencies in its zone of utilization and enhance the organization of care management.

Morphogenesis of a highly replicative EGFPVP22 recombinant Marek's disease virus in cell culture

Marek's disease virus (MDV) is an alphaherpesvirus for which infection is strictly cell associated in permissive cell culture systems. In contrast to most other alphaherpesviruses, no comprehensive ultrastructural study has been published to date describing the different stages of MDV morphogenesis. To circumvent problems linked to nonsynchronized infection and low infectivity titers, we generated a recombinant MDV expressing an enhanced green fluorescent protein fused to VP22, a major tegument protein that is not implicated in virion morphogenesis. Growth of this recombinant virus in cell culture was decreased threefold compared to that of the parental Bac20 virus, but this mutant was still highly replicative. The recombinant virus allowed us to select infected cells by cell-sorting cytometry at late stages of infection for subsequent transmission electron microscopy analysis. Under these conditions, all of the stages of assembly and virion morphogenesis could be observed except extracellular enveloped virions, even at the cell surface. We observed 10-fold fewer naked cytoplasmic capsids than nuclear capsids, and intracellular enveloped virions were very rare. The partial envelopment of capsids in the cytoplasm supports the hypothesis of the acquisition of the final envelope in this cellular compartment. We demonstrate for the first time that, compared to other alphaherpesviruses, MDV seems deficient in three crucial steps of viral morphogenesis, i.e., release from the nucleus, secondary envelopment, and the exocytosis process. The discrepancy between the efficiency with which this MDV mutant spreads in cell culture and the relatively inefficient process of its envelopment and virion release raises the question of the MDV cell-to-cell spreading mechanism.

[Ischemic cerebrovascular stroke of arterial origin in the child]

Comparing stroke in children with stroke in adults can provide interesting information because age and cerebral plasticity induce specific clinical features and outcome. Arterial ischemic strokes are the most frequent in childhood although the problem is not one of arteriosclerosis. Arterial dissection, Moya-Moya syndrome, and cardioembolic and thrombogenic events induced by hemoglobin diseases and hyperhomocyteinemia must be detected at the first event. In some cases, onset is marked by head trauma or an infectious syndrome. The important feature is that outcome is better than in adults and is marked by onset of hemidystonia, partial epilepsy. Aphasia is benign if stroke arises before the child has learned to write.

Stroke patterns in cardio-embolic infarction in a population-based study

The study demonstrates that clinical-radiological causes and outcome of cardio-embolic infarcts in a population-based study correspond to a well-identified stroke pattern. Cardio-embolic infarcts was diagnosed in 882 cases (37.9%) of 2,330 consecutive first-ever stroke patients included in a prospective population-based stroke registry over a 14-year period (1985-1997). Thirty-three criteria out of 98 were introduced into a monovariate analysis and the significant variable were introduced into a multivariate analysis to identify significant criteria to define stroke patterns in cardio-embolic infarction. Cardiac sources of embolus included atrial arrhythmia, valvular heart disease (19%), and cardiac failure (18%). Patients with cardio-embolic infarction showed a significantly higher rate of female predominance (p < 0.001), history of ischemic heart disease (p < 0.001), acute stroke onset (p < 0.05), headache (p < 0.05), previous treatment by anti-platelets and anti-K-vitamin (p < 0.001), Wernicke aphasia (p < 0.001), severe deficit (p < 0.001) and death (p < 0.001). After a logistic procedure, female gender and ischemic heart disease were the two independent risk factors associated with cardio-embolic stroke. Cardio-embolic stroke is a specific subtype of stroke with its own clinical, radiological, etiological and prognostic characteristics. In the acute stage, it is necessary to identify quickly this type of stroke because of severe prognosis and appropriate treatment.

MMP-2 colocalizes with caveolae on the surface of endothelial cells

We examined the spatial distribution of MMP-2 on the surface of human endothelial cells using immunofluorescence and confocal microscopy. Staining endothelial cells with MMP-2-specific antibodies revealed a punctate labeling at the basolateral side of the cell periphery, which colocalized with patches of caveolin-1, a major constituent of the caveolae. This colocalization was confirmed by immunogold electron microscopy. MT1-MMP, TIMP-2, and the alphavbeta3 integrin exhibited a similar pattern of staining, with pericellular patches that colocalized with either MMP-2 or caveolin-1. The presence of MT1-MMP and TIMP-2 in caveolae patches could be seen only after treatment with concanavalin A, which induced MMP-2 activation but had no noticeable effect on the pattern or intensity of MMP-2 immunostaining. In contrast, MMP-9 and TIMP-1 staining showed a pattern completely different from that of MMP-2 and TIMP-2, with positive spots uniformly distributed throughout the cell body. Our data show that MMP-2, its activator the MT1-MMP, and its proposed receptor, the alphavbeta3 integrin, are all targeted to the same membrane microdomains on the endothelial cell, thereby restricting matrix proteolysis to a limited microenvironment at the cell surface.

[Contribution of magnetic resonance imaging in sclerotic combined degeneration of the spinal cord due to vitamin B12 deficiency]

Subacute combined degeneration (SCD) of the spinal cord is known to present histopathologically degenerative lesions in the spinal cord, but few studies on the neuroradiological findings have so far been reported. We present the interest of initial and follow-up MR findings in three cases of SCD. In the three cases, a causal event precipitated the onset of neurological symptoms: general anesthesia for the first and the third one and folic acid treatment for the second one. Clinical evolution was favorable after specific treatment with nearly total recovery. The initial MR study disclosed lesions predominantly involving the posterior columns of the spinal cord: high intensity on T2 weighted image was seen in the initial MR study and disappeared three months after treatment in correlation with good recovery, but with a delay. The recognition of this MR pattern suggests that MRI may be used in conjunction with clinical assessment to confirm the diagnosis and to monitor the efficacity of treatment in SCD.

Incidence of transient ischemic attacks in Dijon, France. A 5-year community-based study

The aim of this study was to determine the incidence of first-ever TIA and the distribution of risk factors in those patients with TIA in Dijon. We performed a prospective population-based study in Dijon City with 135,000 inhabitants, from 1990 to 1994, using several case-collection sources. Over a 5-year period, we recorded 258 cases of first-ever TIA, giving a crude annual incidence rate of 38.68/100,000 for men and 32.70/100,000 for women. The mean age of first-ever TIA was higher in women (71.75 years) than in men (70.35 years). A CT scan was performed in 97% of the cases and silent lacunes were discovered in 17% of cases. In our 5-year study in Dijon of first-ever TIA, we found incidence rates similar to those of previous population-based studies. Our results also support the hypothesis that risk factors for TIA are similar to those for stroke.

Correlation between inter-ictal regional cerebral blood flow and sphenoidal electrodes--recorded inter-ictal spikes in mesial temporal lobe epilepsy

The objective of this study was to assess the reliability of the diagnosis of mesial temporal lobe epilepsy using EEG and sphenoidal electrodes. Inter-ictal 99 m Tc-HMPAO SPECT scans were registered in 21 patients with confirmed mesial temporal lobe epilepsy identified by scalp EEG and sphenoidal electrodes. Visual and quantitative SPECT analysis was performed blind to EEG data. An asymmetry index (AI) was measured from the ratio of two symmetrical regions of interest. A temporal lobe hypoperfusion was defined as an uptake reduced by 5% with respect to the contralateral region. Inter-ictal SPECT abnormalities were observed in 12 out of 21 patients (57%) from both visual and quantitative analysis (focal hypoperfusion in 11 cases, focal hyperperfusion in one case). In seven patients (33%) both visual and quantitative scintigraphy were normal. Abnormal AI was found in 11/15 patients with a high frequency of seizures and in 1/6 patients with a low frequency of seizures. The major data is that the probability to have an abnormal SPECT is statistically correlated to the frequency of the epileptic fits. The couple EEG recordings with sphenoidal electrodes and SPECT is sensitive and reliable in the diagnosis of mesial temporal lobe epilepsy.

Variations in stroke incidence and survival in 3 areas of Europe. European Registries of Stroke (EROS) Collaboration

BACKGROUND AND PURPOSE

Comparison of incidence and case-fatality rates for stroke in different countries may increase our understanding of the etiology of the disease, its natural history, and management. Within the context of an aging population and the trend for governments to set targets to reduce stroke risk and death from stroke, prospective comparison of such data across countries may identify what drives the variation in risk and outcome.

METHODS

Population-based stroke registers, using multiple sources of notification, ascertained cases of first in a lifetime stroke between 1995 and 1997 for all age groups. The study populations were in Erlangen, Germany; Dijon, France; and London, UK. Crude incidence rates were age-standardized to the European population for comparative purposes. Case-fatality rates up to 1 year after the stroke were obtained, and logistic regression adjusting for age group, sex, and pathological subtype of stroke was used to compare survival in the 3 communities.

RESULTS

A total of 2074 strokes were registered over the 3 years. The age-standardized rate to the European population was 100.4 (95% CI 91.7 to 109.1) per 100 000 in Dijon, 123.9 (95% CI 115.6 to 132.2) in London, and 136.4 (95% CI 124.9 to 147.9) in Erlangen. Both crude and adjusted rates were lowest in Dijon, France. The incidence rate ratio, with Dijon as the baseline comparison (1), was 1.21 (95% CI 1.09 to 1.34) in London and 1.37 (95% CI 1.22 to 1.54) in Erlangen (P:<0.0001). There were significant differences in the proportion of the subtypes of stroke between populations, with London having lower rates of cerebral infarction and higher rates of subarachnoid hemorrhage and unclassified stroke (P:<0.001). Case-fatality rates varied significantly between centers at 1 year, after adjustment for age, sex, and subtype of stroke (35% overall, 34% Erlangen, 41% London, and 27% Dijon; P:<0.001).

CONCLUSIONS

The impact of stroke is considerable, and the risk of stroke varies significantly between populations in Europe as does the risk of death. The striking differences in survival require clarification but lend weight to the evidence that stroke management may differ between northern and central Europe and influence outcome.

Migraine history and migraine-induced stroke in the Dijon stroke registry

Two thousand three hundred and eighty-nine patients with first-ever stroke were registered in the population-based Dijon Stroke Registry over an 11-year period. There was a history of migraine in 49 cases (2%), with a majority of women (2.8% versus 1.1% men) with the following distribution: 27 cases among 1,380 large-artery cerebral infarctions (1.9%), 6 cases among 358 small-artery cerebral infarctions (1.6%), 6 cases among 412 cerebral infarctions due to cardiac embolism (1.4%), 7 cases among 191 cerebral hemorrhages (3. 6%) and 3 cases among 47 subarachnoid hemorrhages (6.3%). The male/female ratio was 0.58 for the 49 strokes with a history of migraine versus 1.27 for the 2,340 strokes with no history of migraine. Twelve migraine-induced ischemic strokes occurred with an infarction of the posterior area of the brain in young patients. The annual incidence was 0.80/100,000/year (confidence interval, CI = 0. 37-1.57) with a predominance of women (1.02/100,000/year, CI = 0. 52-1.25; men: 0.57/100,000/year; CI = 0.28-1.04). We conclude that a history of migraine is more frequent in women, in particular in those with hemorrhagic strokes, and that the incidence of migraine-induced stroke in our population-based study is higher in women, although it remains low.

Multi-variate analysis predicts clinical outcome 30 days after middle cerebral artery infarction

BACKGROUND AND PURPOSE

To evaluate the functional prognostic value of proton magnetic resonance spectroscopy performed within the 5 days of an infarction of the middle cerebral artery territory, compared with previously demonstrated prognostic factors.

METHODS

Proton magnetic resonance spectroscopy was performed on 77 consecutive non-comatosed patients during the acute stage of middle cerebral artery infarction. The functional status was determined for each patient via the Orgogozo score. Proton magnetic resonance spectroscopic data were acquired in the infarction and in contra-lateral normal tissue and the results were expressed as metabolite ratios. Correlations were evaluated between the Orgogozo score at day 1 and day 30, the age, the sex, the volume of the infarction, and the metabolic ratios.

RESULTS

In a monovariate analysis, the decrease of the NAA/choline ratio was correlated with a low Orgogozo score at days 1 and 30 (P<0.05) and with a large infarction (P<0.05). A stepwise analysis showed a significant relationship between the Orgogozo score at day 30 and the Orgogozo score at day 1, the sex, the volume of infarction, and the NAA/Cho ratio within the infarction.

CONCLUSIONS

Our work demonstrates that a good clinical outcome at day 30 depends on a good initial clinical score at day 1, a small volume of infarction, a small decrease of NAA/Cho, and being of the female gender.

Incidence of multiple sclerosis in Dijon, France: a population-based ascertainment

Incidence of multiple sclerosis (MS) was prospectively determined within the population of the city of Dijon (94,000 inhabitants under 60 years old) at 47 degrees northern latitude, in Burgundy, France. All the incident cases were diagnosed according to the criteria of Poser, associated to the study of cerebrospinal fluid, evoked potentials and cerebral magnetic resonance imaging. Diagnosis was assessed in all the cases by a neurologist working either in the University Hospital (four neurologists) or in private offices (seven neurologists). The ascertainment was performed on a full 5-year period, from 1993 to 1997. Twenty-one cases were diagnosed in the population of 94,000 inhabitants, with an incidence of 6.1/100,000/year in women, 3.3/100,000/year in men and 4.3/100,000/year in both sexes. The sex-ratio female/male was 2.5. Our data are similar to those of the literature, in particular in countries around the Burgundy area. Our data allow evaluation of the burden of MS in our area and allow evaluation of the changes of incidence in the future.

[Writing disorder using a word processor: role of the left hand]

A young female secretary developed a writing disorder, exclusively expressed when using a word processor, following an ischemic vascular event involving the insula and the right posterior parietal region. There was no disturbance of laterality. The neurological examination, completed by neuropsychological tests eliminated any persistent phasic or gnostic disorders. The analysis of the text produced revealed abnormalities leading to the conclusion that the left hand was responsible for all the errors observed. A sensorimotor integration disorder produced a melokinetic apraxia which appeared to be the cause of the writing disorder which would have most likely remained unknown had the subject not been a secretary.

Cerebral metabolism after transient ischemic attack. A 1H MR spectroscopy study

Metabolic changes induced by cerebral infarction or by stenosis and occlusion of the internal carotid artery have been previously described in 1H Magnetic Resonance Spectroscopy (1H MRS). These changes are essentially characterized by decreased N-acetyl-aspartate (NAA) and increased lactate concentration. Little is known about the metabolic changes observed in the three days following a transient ischemic attack (TIA), in the absence of stenosis or occlusion of the internal carotid artery, and without visible infarction on Magnetic Resonance Imaging (MRI). We studied five patients with a TIA lasting between 30 min and 3 h, affecting the sensory and motor functions of the brachio-facial territory with or without aphasia. A Computerized Tomography Scan (CT-scan), an electro-encephalogram, cervical Doppler ultrasound and MRI with proton magnetic resonance spectroscopy were performed on the affected cerebral area and on the normal contralateral homologous cerebral area within three days of the onset of TIA. None of the five patients had stenosis or occlusion of the internal carotid artery on Doppler ultrasound, or cerebral infarction on MRI. From 1H MRS ratio measurements, we did not observe any significant changes in the NAA/Creatine ratio. However, a rise in Lactate/Creatine ratio was observed in the symptomatic non-infarcted area compared with the normal cerebral tissue. During the first three days following a transient ischemic attack, there is an increase in lactate production. This change may reflect transient local hypoperfusion which could be long enough to stimulate lactate production, but short enough not to induce infarction. This region could be at risk from infarction in the long term.

Incidence trends of ischemic stroke and transient ischemic attacks in a well-defined French population from 1985 through 1994

BACKGROUND AND PURPOSE

The changing incidence of ischemic stroke is of major concern in view of its public health impact, to define the population concerned, to identify risk factors, and to set up health-care systems. The aim of this study was to evaluate the time trends associated with the incidence of all the subtypes of ischemic stroke and transient ischemic attacks in a well-defined population for 10 years.

METHODS

Since 1985, a population registry has recorded each patient living in Dijon (France) who suffered from a cerebrovascular disease (CVD) regardless of the type of management. This study involved all patients suffering from their first ischemic stroke and their first transient ischemic attacks (TIAs) during 1 calendar year between January 1, 1985 and December 31, 1994. The incidence changes according to age, sex, and type of cerebral ischemic event (cortico-subcortical infarct, lacunar infarct, and TIA) were studied on the basis of their annual variations.

RESULTS

During the 10-year study period, 834 cortico-subcortical infarcts (52.1%), 296 lacunar infarcts (18.5%), 369 TIAs (23.1%), and 101 undetermined ischemic strokes (6.3%) were collected. The incidence of all ischemic events was relatively stable in both sexes over the 10-year period. However, the incidence rates differed according to age and type of ischemia. An increased incidence of cerebral cortico-subcortical infarct was observed in patients older than 75 years of age (+5.45% annual change [AC] in men, P<0.05; +5. 09% AC in women, NS). In parallel, a higher proportion of emboligenic cardiac arrhythmias was observed in these patients (P<0. 001). The incidence of lacunar infarcts tended to decrease, regardless of age but mainly in men under younger than 75 years of age (-12.74% AC in men, NS; +0.31% AC in women, NS). The incidence of TIAs was relatively stable in both sexes. Because our population consisted of a large number of elderly subjects, the increase in cardioembolic causes could partially explain the increased incidence of cerebral cortico-subcortical infarcts in patients older than 75 years of age.

CONCLUSIONS

These preliminary data emphasize the importance of stroke surveillance in considering the variations of the different mechanisms of ischemic cerebrovascular disease. Although the incidence of TIA is stable and the incidence of lacunes tends to decrease in men, mainly before 75 years of age, we emphasize the rise of the crude incidence of cortico-subcortical infarcts in men older than 75 years of age, induced by an increase in cardioembolic causes.

Clinical patterns of acute stroke among the three health-care systems in France

Data from 959 consecutive patients registered with the Dijon Stroke Registry were used to compare the characteristics of the patients who were admitted to the public hospital within the first days after their first stroke with those admitted to the private hospitals or who remained at home. Seven hundred and one patients (73%) were admitted to the public hospital, 185 (19%) were admitted to private hospitals and 73 (8%) remained in the community. The results show that the clinical patterns of the stroke are quite different among the three health-care systems. The clinical patterns of stroke managed in the public hospital are characterized by: a younger age (63-years-old vs, 77 and 76-years-old), earlier coma (29% vs 2.8 and 1.5%), more severe deficit (71% vs 15 and 5%), more hemorrhagic mechanism (23 vs 4.5% and 1.7%), more associated ischemic heart disease (31% vs 18 and 15%), more cardiac arrhythmia (38% vs 11 and 8%), higher case fatality rate (39% vs 8 and 2%). Therefore, we have identified three clinical patterns among the three health-care facilities. These three clinical patterns are quite different on the point of view of the clinical severity, and the associated co-morbidities. The socio-economic status is not a criteria in the choice of the health-care facility. This observed distribution is not the consequence of a voluntary policy. Copyright 1998 Lippincott Williams & Wilkins

Epilepsy in patients with multiple sclerosis: radiological-clinical correlations

PURPOSE

To determine potential mechanisms of epilepsy in patients with multiple sclerosis (MS).

METHODS

Among 402 patients with clinically and radiologically defined MS, including de novo cases, presenting to the Neurology Service, University Hospital of Dijon, we identified 17 with epileptic seizures (4.25%). Among them, the percentage with partial seizures (50%) was greater than that in the reference population.

RESULTS

In most of the patients with MS, plaques were localized in the frontal region, associated with frontal and callosal atrophy, a frontal syndrome, and severe disability status (as assessed by a standard scale). Magnetic resonance imaging (MRI) showed numerous subcortical plaques. Seizures generally were well controlled with antiepileptic drugs (AEDs).

CONCLUSIONS

Our data suggest that the subcortical plaques of MS underlie seizure activity in patients with MS and epilepsy.

The interest of surgical closure of patent foramen ovale after stroke: a preliminary open study of 8 cases

The risk of stroke and the risk of recurrent strokes in patients with patent foramen ovale (PFO) need a prevention that still remains a therapeutic problem. There are 4 preventive treatments: anti-agregants, anti-coagulants, transcatheter closure, and surgical closure of PFO. The aim of this study was to demonstrate that surgical closure of PFO is safe and useful for prevention of strokes. Eight patients with stroke and PFO diagnosed by transesophageal echography (TEE) were prospectively selected for surgical closure. It was necessary to be younger than 70 years, not to have another cause of stroke, and to have either recurrent strokes or several ischemic lesions on MRI, isolated for PFO associated with an atrial septal aneurysm, and to have a Valsalva maneuver or cough inducing the stroke. For these reasons, these patients were considered to be an homogenous group with a strong relationship between the PFO and the stroke, and with a high risk of recurrence of stroke. The 8 patients had a direct suture of the PFO with a cardiopulmonary bypass. All patients were followed-up with clinical, MRI and TEE examinations during 12 months after surgery. No surgical complications were observed. After one year, without any anticoagulant treatment, no recurrent stroke or transient ischemic attack, no new ischemic lesions on MRI, nor neuropsychological disturbance were noted. No post-surgical inter-atrial right-to-left shunting was observed. In the absence of controlled studies to guide therapeutic options, our data suggest that surgical closure of PFO in patients with stroke, is safe and efficacious to prevent recurrent stroke without any anticoagulants in the first year of follow-up. Further studies are needed to evaluate the long-term role of surgical closure of PFO as an alternative to prolonged anti-thrombotic treatment.

Coagulation abnormalities in lacunar and cortical ischemic stroke are quite different

In order to clarify the coagulation profile accompanying ischemic stroke, which may have implications on therapeutic strategies, we performed a prospective study to evaluate the hemostatic parameters in the first 24 h after the onset of cortical atherothrombotic infarct and lacunar infarction. Twenty-seven patients with cortical atherothrombotic infarction and 27 patients with lacunar infarction, diagnosed on clinical and CT-scan criteria, had blood samples taken within the first 24 h after onset of the stroke, and before anticoagulant treatment had been started. Levels of fibrinogen, von Willebrand factor, D-dimers, prothrombin factors 1 + 2, anti-thrombin III, and C-protein and S-proteins, were measured. Laboratory tests detected the following abnormalities: a protein C deficiency was observed in 1 case of cortical infarction and in 1 case of lacunar infarction; a decrease in S-protein was observed in 1 case of cortical infarction, and the presence of lupus anticoagulant in 4 cases (2 in cortical and 2 in lacunar infarction). Various degrees of coagulation activation were observed. Statistically significant activation of the coagulation was observed in the patients with cortical infarction, compared to normal patients adjusted for age: the levels of DDI were significantly raised (2298 +/- 2221 ng ml-1 vs. 750 +/- 400 ng ml-1) (p < 0.03) as were F1 + 2 levels (3.9 +/- 2.8 nmol l-1 vs. 1.5 +/- 0.9 nmol l-1). (p < 0.01). In the lacunar infarction group, there was a significant rise in F1 + 2 compared with normal patients adjusted for age (2.2 +/- 1.7 nmol l-1 vs. 1.5 +/- 0.9 nmol l-1) (p < 0.01), while the DDI level was in the normal range, when age was taken into account. In the cortical infarction group, we observed a significantly raised fibrinogen level (4.8 +/- 1.7 g l-1 vs. 3.7 +/- 1.0 g l-1) (p < 0.05) and von Willebrand factor level (271 +/- 104% vs. 178 +/- 103%) (p < 0.01) compared to the lacunar infarction group. In addition, we observed a significantly low level of S-protein in the cortical infarction group (105 +/- 29%) compared to the lacunar infarction group (127 +/- 28%) (p < 0.01). Confirmation of the role of enhanced thrombin activity in the pathogenesis of acute stroke may be an important determinant in its therapeutic management.

Stroke in children under 16 years of age. Clinical and etiological difference with adults

OBJECTIVES

The aim of this study was to re-evaluate the clinical features of stroke in children, their outcome and the place of the different mechanisms, in the light of CT-scan and magnetic resonance imaging.

METHODS

A 10-year review of the Dijon Childhood Neurology Clinic experience (1985-1995) identified 54 patients with arterial stroke. Diagnosis was established by CT-scan and angiography and by magnetic resonance imaging from 1987. When an hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following tests were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocystine in the plasma and the urine, an electrocardiogram, a Holter procedure and a cardiac echography.

RESULTS

During the 11 full calendar years of this study, we observed 54 stroke patients. There were 31 cases of ischemic stroke, representing some 57% of the total, as well as 23 cases of hemorrhagic stroke, representing 43% of the total. Of the 31 cases with ischemic stroke, 4 had no known predisposing condition, 6 occurred in children with pre-existing heart disease, 2 had moya-moya disease, 2 had leukemia, 2 had a carotid dissection, 1 had an hemolytic-uremic syndrome, and 14 were observed in patients with other associated conditions, such as infections (7 cases) or slight cranial trauma (7 cases). On CT-scan, a basal ganglia infarction was identified in 14 cases. Among the 23 hemorrhagic strokes, 9 were due to arteriovenous malformations, 2 to arterial aneurysm and 5 to cavernomas. Two cases occurred in hemophilia, 2 in idiopathic thrombocytopenic purpura, and 2 after throat infections. One case had no etiologic factor. Clinical course was marked by a low mortality rate even in hemorrhagic stroke, long-lasting seizures, and hemidystonia.

CONCLUSION

This neuro-imaging survey focused on the real place of hemorrhage and basal ganglia infarctions in children under 16 years of age, compared to adulthood. Follow-up demonstrated good or complete resolution of neurological deficits despite the frequent late hemidystonia and late epilepsy.

Unilateral lenticular infarcts: radiological and clinical syndromes, aetiology, and prognosis

OBJECTIVES

To analyse the clinical features induced by lenticular infarction found in 20 patients, and to analyse the radiological and clinical correlations.

METHODS

Eight women and 12 men, mean age 73 years, were included in this study, which was carried out from 1 January 1994 to 30 November 1996. They were characterised by the onset of a lenticular infarction, shown by CT and MRI. A complete neurological and neurocognitive examination, and photon emission computed tomography (SPECT), were performed in all the patients and there was a long clinical follow up.

RESULTS

Two distinct clinical syndromes were identified corresponding to the two anatomical areas of the lenticular nucleus: behavioural and cognitive disorders were associated with infarcts within the globus pallidus, whereas both motor disorders (dystonia) and cognitive disorders were associated with infarcts within the putamen. Outcome was excellent in all the patients for motor function, but slight cognitive disorders, problems with short term memory, and dysphasia persisted for several months. The size of the lesion did not explain these symptoms. By contrast, the slight reduction in cerebral blood flow found in the adjacent frontotemporal area may explain them by a deafferentation or a diaschisis phenomenon.

CONCLUSION

It is possible to identify the clinical symptoms of a single lesion in the pallidus nucleus and in the putaminal nucleus, in which behavioural, cognitive, and movements disorders are important. After an acute and spectacular onset, outcome is in general excellent. A disease of the small arteries must be involved.

[Agenesis of the corpus callosum: modes of manifestation in adults]

Agenesis of corpus callosum is an uncommon brain malformation that is usually detected in childhood. In adult, focal epileptic seizure is the most frequent manifestation. Otherwise, asymptomatic patients can be detected by cerebral imagery with specific criteria. Neither developmental disability nor interhemispheric transfer dysfunction are observed in those patients. Minor facial abnormalities can be found. Agenesis of corpus callosum in adult is usually paucisymptomatic. The prognosis depends on cerebral associated malformations which are involved in epilepsy and cognitive disturbances.

A hospital-based and a population-based stroke registry yield different results: the experience in Dijon, France

BACKGROUND AND PURPOSE

The aim of this study was to demonstrate the different results obtained from a population-based and a hospital-based stroke study in the same city.

METHODS

Between January 1 and December 31, 1993, we collected information on all of the first strokes in the population of the city of Dijon, in conjunction with the Dijon Stroke Registry, collecting the first-ever strokes from patients living in Dijon as well as on all the first strokes in residents and nonresidents of Dijon who were treated at Dijon University Hospital. Demographic details, medical history, vascular risk factors, stroke subtype, as diagnosed by CT scan, and mortality rates were compared between the strokes observed in the population of the city of Dijon among residents as well as nonresidents in Dijon who were treated at Dijon University Hospital.

RESULTS

We collected information on 210 strokes observed in the population of Dijon city, 171 Dijon residents and 395 non-Dijon city residents hospitalized at the University Hospital of Dijon. These three groups were quite different. The residents of Dijon treated for stroke at the University Hospital were younger and their incidence of cerebral hemorrhage, cardiac arrhythmia, ischemic heart disease and case fatality rate were higher than those from the Dijon Stroke Registry.

CONCLUSIONS

Type of stroke data bank is very important in order to describe cerebrovascular disease. Hospital-based studies tend to include more severe strokes, those occurring in a younger population, and those having a higher mortality. Population-based studies, on the other hand, give a somewhat different picture of stroke.

[Dysembryoplastic neuroepithelial tumors. A benign tumor cause of partial epilepsy in young adults]

Dysembryoplastic neuroepithelial tumor (DNT) is a newly recognized brain lesion first reported in 1988 by Daumas-Duport et al. The authors described five cases of DNT, that occurred in young people and were characterized by partial seizures. Seizures could become intractable and secondary generalised. Usually, the interictal neurological examination was normal. In most cases, computed tomography showed a supratentorial, "pseudocystic" low density appearance associated in some cases with calcific hyperdensity or focal contrast enhancement. Magnetic resonance imaging demonstrated a predominantly intracortical lesion. Common features included low signal intensity on T1-weighted images and high signal on T2-weighted images. Temporal and frontal lobes were mainly involved. Dysembryoplastic origin explained the clinical and radiological stability and the benign evolution of this tumor. Tumor resection was required only when epilepsy was intractable or when there was intracranial hypertension. Earlier intervention can prevent the physical and psychosocial damage resulting from chronic seizures and can improve the prognosis for these young patient. Histologically, DNT have been incorporated amond the category of neuronal and mixed neuronoglial tumors. Three patterns are described: a simple form with a unique glioneuronal element, a complex form with specific glioneuronal element, nodules being made of multiple variants looking like astrocytomas, oligodendrogliomas or oligo-astrocytomas, foci of dysplastic cortical disorganisation, and a non specific form. When specific glioneuronal composant is absent (50% of cases), the identification of DNT has therapeutic and prognostic implications because aggressive therapy may be avoided, sparing these young patients the long term effects of radio-or chemotherapy.

Reduced brain N-acetyl-aspartate in frontal lobes suggests neuronal loss in patients with amyotrophic lateral sclerosis

We performed proton magnetic resonance spectroscopy (1H-MRS) in three patients with amyotrophic lateral sclerosis (ALS) to evaluate the distribution and extent of cortical neuronal damage as demonstrated by decreased N-acetyl-aspartate (NAA) levels. We examined primary motor (precentral gyrus) and parietal neocortical (superior parietal gyrus) regions. ALS was defined with lower and upper motor neuron signs. Compared with matched healthy controls, ALS patients had a significant decrease in NAA levels in the primary motor cortex (p < 0.001) compared with parietal regions and homologous regions in healthy controls. Two clinical applications can be extracted: first, the upper motor neuron signs present in the ALS, come from a neuronal loss within the primary motor cortex and may explain the frontal syndrome associated with ALS. Second clinical applications of 1H-MRS could include identification of extent of upper motor neuron involvement, aiding diagnosis of syndromes presenting with an ALS-like syndrome.

Heterogeneity of microfibrils: role of thrombospondin-microfibrils in the thrombogenicity of the subendothelium

We report the results of an immunogold electron microscopical analysis on microfibrils from the arterial subendothelium showing that thrombospondin (TSP) is present on 40 nm-diameter structures joining 8-10 nm-diameter microfibrils containing fibrillin. They differ from type VI collagen which forms 3-5 nm-diameter microfibrils. TSP containing microfibrils (TSP-MF) extracted from human umbilical arteries did not contain fibrillin or type VI collagen. Blood platelet interactions with TSP-MF were not modified by anti-fibrillin or anti-type VI collagen antibodies. In situ, vWF was bound to cross-linked microfibrils, at the level of their 40 nm junction, and a double-labeling with the anti-thrombospondin and anti-vWF antibodies was observed. In vitro, vWF binding to TSP-MF was not inhibited by anti-fibrillin or anti-type VI collagen antibodies. These results suggest a structural and functional heterogeneity of microfibrils and emphasize the role of TSP-MF in the thrombogenicity of the subendothelium.

Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993

Our motivation for undertaking the present survey was to determine the incidence, the distribution, and the clinical features of ischemic and hemorrhagic strokes in children under 16 years old, in a well-defined population-based study. The survey was carried out on the population of the City of Dijon (150,000 inhibitants) from January 1, 1985 to December 31, 1993, collecting prospectively both in adulthood and in childhood (23,877 resident children). Diagnosis of stroke was established on the basis of clinical features and the mechanism was identified by CT scan from 1985 to 1987, and by CT scan and magnetic resonance imaging from 1987 to 1993. When a hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocysteine in the plasma and the urine, an electrocardiogram (EKG), a Holter procedure, and a cardiac echography. During the 9 full calendar years of this study we observed 28 stroke patients from a population of 23,877 resident children. There were 17 cases of ischemic stroke, representing some 61% percent of the total, as well as 11 cases of hemorrhagic stroke, 39% percent of the total. The average annual incidence rate was 13.02/100,000 for all strokes, 7.91/100,000 for ischemic strokes, and 5.11/100,000 for hemorrhagic strokes.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative analysis of immunogold labellings of collagen types I, III, IV and VI in healthy and pathological human corneas

BACKGROUND

We studied the distribution of collagen types I, III, IV and VI in one healthy human cornea and in seven pathological human corneas, in which the disorders were three cases of pseudophakic bullous keratopathy (two severe, one moderate) and one case each of stage IV keratoconus, chronic ulcer, vascularized cornea and disciform keratitis.

METHODS

Transmission electron microscopy examinations were performed on post-embedding immunogold-labelled sections. The staining was evaluated by gold particle count in the different tissues. The presence or absence of a given antigen was determined by statistical analysis, using a d-value test.

RESULTS

Our results on healthy corneal tissues corroborate the data available from previous studies, except for collagen type VI, which we found to be absent in Bowman's layer. In pathological corneas with a collagenous layer posterior to Descemet's membrane, collagen types I, III and especially IV were detected in this collagenous layer. Collagen types I, III and VI were detected in the anterior healed stroma of other pathological corneas, except for the keratoconus cornea, in which intense collagen III staining was observed.

CONCLUSION

The presence of collagen types I and III in the posterior collagenous layer of our pseudophakic bullous keratopathy corneas suggests that this layer corresponds to scar tissue secreted by stimulated endothelial cells.

[N-acetyl-aspartate abnormalities in internal-temporal epileptic foci using proton magnetic resonance spectroscopy]

The aim of this study was to characterize the neurochemical abnormalities related to N-acetyl-aspartate which is a neuronal marker, within an epilepticus focus located in the internal-temporal area, using proton magnetic resonance spectroscopy. Eleven patients with a mono-hippocampal epileptics focus on clinical and per-critical electroencephalographical criteria, were matched with 11 controls by age, sex and laterality. Proton spectroscopy of a volume of 8 cm3 was performed within the ipsilateral and the contralateral internal-temporal area and within the 2 hippocampus of controls. Volumetry of the ipsilateral and the contralateral hippocampus and of the 2 hippocampus of controls was performed using resonance magnetic imaging. All these measurements were performed during the interictal stage. The results were concordant to show a decrease of the ratio N-acetyl-aspartate/choline and N-acetyl-aspartate/creatine within the epilepticus focus, in relation with a hippocampal atrophy. This study finds similar results to those of other previous works. The decrease of N-acetyl-aspartate levels within the epilepticus focus could be related to a decrease of the neuronal cell density. This procedure is able to show a decrease of the levels of this metabolite within an internal temporal epilepticus focus and associated with a hippocampal atrophy.

[Gyratory epileptic seizures. Radioclinical correlations]

The authors report 3 cases of gyratory seizures whose epileptic nature was demonstrated on the following features. They appeared with a loss of consciousness. In 2 cases, they ended with a tonic-clonic generalized fit and in the 3 cases, they were mixed with other generalized seizures. From an etiological point of view, in 2 cases, a deep lesion was discovered, the first one near the paracentral lobule, the second in the para-thalamic area. The third one was an idiopathic generalized epilepsy on clinical and electroencephalographic grounds. These 3 cases focus on the difficulties to classify gyratory seizures that may appear in 2 opposite situations, namely in symptomatic partial epilepsy and in idiopathic generalized epilepsy.