[Importance of cognitive disorders in internal medicine: Pathophysiology, diagnosis, management. The example of systemic lupus erythematosus]

Systemic diseases, which are in France mainly monitored in internal medicine, affect multiple organs or tissues. While cutaneous or articular manifestations are the most common, neurological involvement is often associated with severity. Diagnosis of peripheral (e.g, neuropathies) or central (e.g, myelitis) nervous disorders is quite easy through clinical examination and dedicated complementary tests. However, neuropsychological manifestations that affect cognition, including memory, attention, executive functions or reasoning, are difficult to diagnose, sometimes trivialized by practitioners. Their causes are often numerous and interrelated. Nevertheless, these cognitive manifestations are closely related to patients' quality of life, affecting their social life, family dynamics and professional integration but also the treatment adherence. The purpose of this review, focused on the example of systemic lupus erythematosus, is to raise awareness of cognitive dysfunction in systemic diseases including their management from diagnosis to treatments. The final aim is to go further into setting up research groups and care programs for patients with cognitive impairment followed in internal medicine.

Determinants of Medical Direct Costs of Care among Patients of a Memory Center

BACKGROUND

Alzheimer's disease and related diseases (ADRD) are a major cause of health-related cost increase.

OBJECTIVES

This study aimed to estimate the real medical direct costs of care of patients followed at a memory center, and to investigate potential associations between patients' characteristics and costs.

DESIGN

Cross-sectional analyses conducted on matched data between clinical data of a cohort of patients and the claims database of the French Primary Health Insurance Fund.

SETTING

Memory center in France.

PARTICIPANTS

Patients attending a memory center with subjective cognitive complaint.

MEASUREMENTS

Medical or nonmedical direct costs (transportation) reimbursed by the French health insurance during the one year after the first memory visit, and socio-demographic, clinical, cognitive, functional, and behavioral characteristics were analyzed.

RESULTS

Among 2,746 patients (mean ± SD age 79.9 ± 8 years, 42.4% of patients with dementia), the total direct cost was on average € 9,885 per patient during the year after the first memory visit: € 7,897 for patients with subjective cognitive complaint, € 9,600 for patients with MCI, and € 11,505 for patients with dementia. A higher functional and cognitive impairment, greater behavioral disorders, and a higher caregiver burden were independently associated with a higher total direct cost. A one-point decrease in the Instrumental Activities of Daily Living score was associated with a € 1,211 cost increase. The cost was higher in patients with Parkinson's disease, and Lewy body disease compared to patients with AD. Diabetes mellitus, anxiety disorders and number of drugs were also significantly associated with greater costs.

CONCLUSIONS

Higher real medical direct costs were independently associated with cognitive, functional, and behavioral impairment, diabetes mellitus, anxiety disorders, number of drugs, etiologies as well as caregiver burden in patients attending a memory center. The identification of factors associated to higher direct costs of care offers additional direct targets to evaluate how interventions conducted in patients with NCD impact direct costs of care.

[Medication management of hypertension and heart failure in older patients: What happens to therapeutic changes after hospitalization?]

PURPOSE

The objective of this study was to objectivize if the cardiovascular therapeutic changes performed during hospitalization of older patients with hypertension and/or heart failure (HF), were maintained in ambulatory 3 month after hospitalization.

METHODS

This is a longitudinal study conducted in a geriatric unit. Patients over 65 years with hypertension and/or HF, who had at least one change in cardiovascular medicaton during hospitalization, and who accepted the 3-month follow-up were included in the longitudinal study. At admission, during hospitalization and 3 months after hospitalization data concerning cardiovascular medication were collected.

RESULTS

During hospitalization, 142 (73.6%) patients had at least one change in hypertension and/or HF medication. Overall, 249 changes were performed. Forty-one patients received follow-up at 3 months. At 3 months, therapeutic changes were maintained by 48.8% of the general practitioners (n=20 patients). For the rest, 41.5% of the patients had benefited from new therapeutic changes (28 changes for 10 patients) and 9.7% of the general practitioners (n=4 patients) had restored the initial prescription before hospitalization.

CONCLUSIONS

Medication review performed by geriatricians and pharmacists during hospitalization resulted in 249 changes. These changes aimed at limiting iatrogenic disease, by reducing overtreatment and potentially inappropriate prescriptions. Difficulties in the patient care continuity between the hospital and ambulatory setting have been identified.

[White matter hyperintensities in ageing: Pathophysiology, associated cognitive disorders and prevention]

White matter hyperintensities (WMH), also known as leukoaraïosis are very common neuroradiological manifestations in the elderly. The main risk factors for WMH are age and high blood pressure. The vascular origin of these lesions is classically accepted and WMH are considered as one feature of the small vessel disease. WMH may be associated with clinical symptoms, depending notably on their importance according to age. They are associated with increased mortality, strokes and changes in cognition with a higher risk of dementia (vascular dementia or Alzheimer's disease). Modification of vascular risk factors could have a beneficial effect, but few evidences from controlled trials are available.

482Direct oral anticoagulant rivaroxaban in very old and frail patients: A one-year prospective follow-up of a large-scale cohort (SAFIR-AC)

Background/Introduction

Age is one of the strongest predictors/risk factors for ischemic stroke in subjects with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) have been shown to be effective in the prevention of this condition; however, clinical evidence on bleeding risk with this therapeutic strategy in very old and frail geriatric patients is poor.

Purpose

To assess bleeding risk in French geriatric patients aged ≥80 years and diagnosed with AF newly treated with rivaroxaban.

Methods

Subjects, presenting to one of 33 geriatric centers, with non-valvular AF and recent initiation of a treatment with rivaroxaban were enrolled in the study and followed-up every 3 months for 12 months. Clinical and routine laboratory data and evaluation scores, such as HAS-BLED, HEMORR2HAGES, ATRIA, and CHA2DS2-VASc, as well as comprehensive geriatric evaluation were reported. Major bleeding, as defined in ROCKET AF study, was reported at each visit, and this primary outcome was adjudicated by an independent committee. Results of this cohort were compared with findings from a similar cohort treated with vitamin K antagonists (VKAs) from the same centers (n=924).

Results

A total of 1045 subjects were enrolled in the study of whom 995 (95%) had a one-year follow-up (analyzed population). The mean (standard deviation (SD)) age was 86.0 (4.3) years, with the majority of patients being female (61%), 23% aged 90 years or older, and 48% having an estimated glomerular filtration rate (eGFR) <50 mL/min. The main comorbidities were hypertension in 77% of subjects, malnutrition 49%, anemia 43%, dementia 39%, heart failure 36%, and falls 27%. The mean (SD) score for CHA2DS2-VASc was 4.8 (1.4), HAS-BLED 2.4 (0.9), Mini-Mental State Examination (MMSE) 21.5 (6.9), Activities of Daily Living (ADL) 4.4 (1.9), and Charlson Comorbidity Index 6.7 (2.0). The one-year rate of major bleeding events was 6.4% of which 0.8% were fatal and 1.1% intracranial hemorrhages (ICH), whereas the one-year rate of ischemic stroke was 1.4% and all-cause mortality 17.9%. Computed with VKA cohort findings and adjusted for age, gender, eGFR and Charlson score, this would result in a hazard ratio of 0.54 (95% confidence interval [CI], 0.38 to 0.78) for major bleeding, 0.36 (0.17 to 0.76) for ICH, 0.62 (0.29 to 1.33) for ischemic stroke, and 0.82 (0.65 to 1.02) for all-cause mortality, in favor of rivaroxaban.

Conclusions

This is the first large-scale prospective study in geriatric population in AF subjects treated with DOAC (rivaroxaban) Major bleeding risk appeared higher in very old than younger population, however major bleeding and ICH rates were significantly lower with rivaroxaban than with VKAs when used in the same geriatric population. This study indicates that Rivaroxaban can be used in very old and frail patients for the treatment of non-valvular AF.

Acknowledgement/Funding

Unrestricted grant from Bayer

How to explore the needs of informal caregivers of individuals with cognitive impairment in Alzheimer's disease or related diseases? A systematic review of quantitative and qualitative studies

BACKGROUND

This study aims to review the methodologies used to identify the needs, the existing needs assessment instruments and the main topics of needs explored among caregivers of patients with mild cognitive impairment to dementia.

METHODS

MEDLINE, PsycINFO, The Cochrane Library and Web of science were searched from January 1980 to January 2017. Research studies in English or French were eligible for inclusion if they fulfilled the following criteria: quantitative, qualitative and mixed method studies that used instrument, focus group or semi-structured interviews to assess the informal caregiver's needs in terms of information, coping skills, support and service.

RESULTS

Seventy studies (n = 39 quantitative studies, n = 25 qualitative studies and n = 6 mixed method studies) met the inclusion criteria and were included. Thirty-six quantitative instruments were identified but only one has been validated for the needs assessment of dementia caregivers: the Carer's Needs Assessment for Dementia (CNA-D). The main areas of needs explored in these instruments were: information, psychosocial, social, psychoeducational and other needs.

CONCLUSIONS

No instrument has been developed and validated to assess the needs of informal caregivers of patients with cognitive impairment, whatever the stage and the etiology of the disease. As the perceived needs of caregivers may evolve with the progression of the disease and the dementia transition, their needs should be regularly assessed.

Factors associated with changes in exposure to anticholinergic and sedative medications in elderly hospitalized patients: multicentre longitudinal study

BACKGROUND AND PURPOSE

Elderly patients exposed to drugs with anticholinergic or sedative properties may have an increased risk of adverse events. This study aimed to assess the relationship between patient characteristics and changes of exposure to anticholinergic and sedative medications during their hospital stay.

METHODS

A multicentre longitudinal study was set up on hospitalized patients (aged ≥65 years) using at least one drug at admission. The primary outcome was change of exposure to anticholinergic and sedative drugs between admission and discharge. Sociodemographic characteristics of the patients, comorbidities, life habits and information about the hospital stay (origin of admission, reasons for hospitalization) were collected.

RESULTS

The study included 337 patients (mean age, 85.4 years) with an average hospital stay of 30.1 ± 37.5 days. The drug burden index increased during the hospital stay among males (P = 0.03), patients for whom the reason for hospitalization was either a stroke (P = 0.001) or inability to stay in their own home (P = 0.001), and patients with diabetes mellitus (P = 0.009). In the adjusted model, drug burden index increased among patients hospitalized for stroke, inability to stay in their own home or post-surgery, and for patients with diabetes mellitus or hypertension.

CONCLUSIONS

The drug management of elderly patients during hospital stays may increase exposure to anticholinergic and sedative drugs. Although the anticholinergic and sedative properties may be in relation to the therapeutic purpose, they also represent an unexpected risk. Physicians and clinical pharmacists should consider performing optimization of the drug prescriptions for patients at risk.

Neuroimaging correlates of neuropsychiatric symptoms in Alzheimer's disease: a review of 20 years of research

Assessing morphological, perfusion and metabolic brain changes preceding or associated with neuropsychiatric symptoms (NPSs) will help in the understanding of pathophysiological underlying processes in Alzheimer's disease (AD). This review aimed to highlight the main findings on significant associations between neuroimaging and NPSs, the pathophysiology to elucidate possible underlying mechanisms, and methodological issues to aid future research. Research papers published from January 1990 to October 2015 were identified in the databases PsycInfo, Embase, PubMed and Medline, using key words related to NPSs and imaging techniques. In addition to a semi-systematic search in the databases, we also performed hand searches based on reported citations identified to be of interest. Delusions, apathy and depression symptoms were particularly associated with brain changes in AD. The majority of studies disclosed an association between frontal lobe structural and/or metabolic changes and NPSs, implicating, interestingly, for all 12 NPSs studied, the anterior cingulate cortex although temporal, subcortical and parietal regions, and insula were also involved. Given the high degree of connectivity of these brain areas, frontal change correlates of NPSs may help in the understanding of neural network participation. This review also highlights crucial methodological issues that may reduce the heterogeneity of results to enable progress on the pathophysiological mechanisms and aid research on NPS treatments in AD. Based on a broad review of the current literature, a global brain pattern to support the huge heterogeneity of neuroimaging correlates of NPSs in AD and methodological strategies are suggested to help direct future research.

Evaluation of a mobile team dedicated to behavioural disorders as recommended by the Alzheimer Cooperative Valuation in Europe joint action: observational cohort study

BACKGROUND AND PURPOSE

Preventing behavioural crises appears to be crucial to promote quality of life of the patient-caregiver dyad, to reduce inappropriate hospitalizations and to delay institutionalization. The Alzheimer Cooperative Valuation in Europe promotes mobile care to prevent patients from severe behavioural and psychological symptoms in dementia. This study assessed the potential efficacy of a mobile team for Alzheimer's disease on hospitalization sparing and behavioural disorder reduction.

METHODS

A cohort study was set up from 1 January 2012 to 31 December 2013 by the Clinical and Research Memory Centre of Lyon (France). It included patients with behavioural and psychological symptoms living at home or in a nursing home. An interview explored the alternative patient pathways used by general practitioners (GPs) if the mobile team had not existed (hospitalization sparing). The Neuropsychiatry Inventory score was assessed at inclusion and 30 days later. The sample included 424 consecutive patients with Alzheimer's disease or related disorders and behavioural disorders at any cognitive and functional stage of the disease, taken in charge by the mobile team.

RESULTS

Amongst the 424 patients (84.0 ± 7.2 years), 220 (51.9%) hospitalizations were considered by their GPs and 181 (82.3%) were avoided. The Neuropsychiatric Inventory score declined after mobile team intervention (45.8-29.9, P < 0.001). Sleep and appetite disorders, endangered situation and caregiver burnout were associated with higher risk of hospitalization at 30 days.

CONCLUSIONS

The mobile team for Alzheimer's disease allows a high proportion of hospitalizations related to behavioural disorders to be avoided and may help to reduce behavioural disorders.

Performance of cognitive tests, individually and combined, for the detection of cognitive disorders amongst community-dwelling elderly people with memory complaints: the EVATEM study

BACKGROUND AND PURPOSE

Dementia is a leading cause of dependence amongst the aged population. Early identification of cognitive impairment could help to delay advanced stages of dependence. This study aimed at assessing the performance of three neuropsychological tests to detect cognitive disorders in elderly subjects with memory complaints.

METHODS

The EVATEM study is a prospective multicentre cohort with a 1-year follow-up. Subjects with memory complaints were selected during preventive health examinations, and three neuropsychological tests (five-word, cognitive disorders examination, verbal fluency) were administered. Two groups were identified in memory clinics: (i) cognitively healthy individuals (CHI) and (ii) mild cognitive impairment or demented individuals (MCI-DI). Cross-sectional analyses were performed on data at inclusion. The relationship between the diagnosis of MCI-DI/CHI and the neuropsychological tests was assessed using logistic regressions. The performance of the neuropsychological tests, individually and combined, to detect cognitive disorders was calculated.

RESULTS

Of 585 subjects, 31.11% had cognitive disorders (MCI, 176 subjects; DI, six subjects). Amongst the three tests studied, the odds ratio for MCI-DI was higher for the five-word test <10 [odds ratio 3.2 (1.81; 5.63)]. The best performance was observed when the three tests were combined: specificity 90.5% and sensitivity 42.4% compared to respectively 89.2% and 28.3% for the five-word test.

CONCLUSIONS

Despite the poor sensitivity of the five-word test, it seems to be the most adapted for the diagnosis of MCI-DI in older adults with a memory complaint, in prevention centres, taking into account its high specificity and its rapid administration compared to the other tests.

[Role of clinical pharmacist in the therapeutical optimization in geriatric outpatient hospital]

SETTING

Cares in outpatient hospital for elderly patients is a period of interest for multidisciplinary reassessment and pharmaceutical care of the prescription. The objective is to present the implementation of the pharmaceutical care activity at the outpatient hospital.

METHODS

Between August and October 2011, elderly patients hospitalized in the outpatient hospital for a brief appraisal had a pharmaceutical care. The clinician introduced pharmaceutical reviews in the synthesis letter for general practitioner. An analysis of the activity was carried out over 3 months.

RESULTS

A pharmaceutical care had been realized for 67 patients, mean age of 81.7 years. Among medical related problems identified, 39.6% were for potentially unnecessary medication. A stop was proposed for 44% of pharmaceutical interventions. A total of 91 pharmaceutical interventions and 13 recommendations were made and 34% of patients had potentially inappropriate medication.

CONCLUSION

According to the objective to reduce the therapeutics contributing to the iatrogenesis, this approach allowed us to undertake a multidisciplinary collaboration oriented toward the relay between hospital and city cares.

[Effectiveness of a cognitive-behavioral unit on behavioral and psychological symptoms of dementia]

INTRODUCTION

Cognitive-behavioral units (CBUs) have been created in the context of the national Alzheimer plan 2008/2012 for the management of behavioral disorders of patients suffering from Alzheimer's disease or related diseases. The Alzheimer plan promotes the evaluation of these units through the observation of the evolution of behavioral and psychological symptoms of dementia (BPSD). The aim of this study was to assess the effects of the memory center of Lyon (hospices civils de Lyon) CBU on BPSD.

PATIENTS

The neuropsychiatric inventory (NPI) was rated by the patients' caregiver (NPI-F) at admission to the CBU and 2 weeks after the discharge. The NPI was also rated by the nursing staff (NPI-NS) 3 days after admission in the CBU and at discharge.

RESULTS

All patients admitted in the CBU between July and October 2001 were included in the study for a total of 28 patients. A significant reduction of NPI-F scores between admission (58.93 ± 24.8) and 2 weeks after the discharge (27.07 ± 19.70) (P<0.0001) was observed. Improvement was specifically observed for delusions, agitation, depression, anxiety, disinhibition and aberrant motor activity symptoms. No significant changes were found on NPI-NS scores.

CONCLUSION

This study discloses benefits of CBUs in terms of BPSD reduction in patients 2 weeks after CBU discharge. These units have the potential to achieve their principal objective of reducing behavioral problems.

[Post-surgery cognitive disorders: prevention, diagnosis and treatment strategies]

Hip fracture is an important step in the autonomy evolution in elderly. As gait is particularly jeopardised after such a traumatism, cognition may also be acutely impaired. Elderly post-surgery delirium is frequent, but chronic progression of cognitive impairment and dementia may occur. The concept of cognitive reserve is crucial for understanding risk factors of post-surgery delirium in elderly. The more the cognitive reserve is decreased before such a traumatism, the higher the delirium and dementia progression risk is. A neurodegenerative disease such as Alzheimer's disease may be clinically silent prior the traumatic event, and may decompensate soon after as the cognitive reserve is not sufficient anymore. Dementia may then lead to progressive autonomy loss. A systematic interdisciplinary approach is needed to prevent frail patients from delirium, and to early cure it to decrease the risk of long-term autonomy loss.

CSF biomarkers in posterior cortical atrophy

OBJECTIVE

To describe CSF biomarker profiles in posterior cortical atrophy (PCA), which induces high-order visual deficits often associated with Alzheimer disease (AD) pathology, and relate these findings to clinical and neuropsychological assessment.

METHODS

This prospective observational study included 22 patients with PCA who underwent CSF biomarker analysis of total tau (t-tau), phosphorylated tau on amino acid 181 (p-tau181), and amyloid β (Aβ(42)). At group level, the CSF profiles of patients with PCA were compared to those of patients with typical AD and patients with other dementia (OD). Individually, the clinical presentation of patients with PCA was correlated to their CSF profile to assess the predictability of clinical features for diagnosis of underlying AD pathology.

RESULTS

At group level, the PCA biomarker profile was not different from that of the AD group, but very different from that of the OD group (p < 0.001). More than 90% of patients with PCA had CSF profiles consistent with AD. All patients with PCA with either isolated higher-order visual deficit (n = 8) or visual deficit associated with memory impairment (n = 11) had CSF profiles consistent with AD. Only one of the 3 patients with PCA with asymmetric motor signs fulfilled biological CSF criteria for AD.

CONCLUSIONS

PCA syndrome is usually associated with CSF biomarkers suggestive of AD, as shown by previous neuropathologic studies. This does not apply in case of motor signs suggesting associated corticobasal syndrome. CSF biomarkers help to discriminate AD from non-AD processes associated with this condition.

[Alzheimer's and related diseases: toward earlier and more accurate diagnosis]

Because of population ageing, the prevalence of Alzheimer's disease (AD), the most common cause of dementia, increases progressively. This condition is now considered as a public health priority. New disease modifying therapeutic strategies could be available in the next few years that would necessitate an accurate and early diagnosis of the disease. Recently developed diagnostic tools are being assessed. Development of structural brain imaging allows to measure the hippocampus volume. Metabolic imaging can assess a broad range of functional parameters such as cerebral blood flow and dopaminergic activity with single photon emission computed tomography, cerebral glucose metabolism and cerebral amyloid burden with positron emission tomography. Those imaging methods are under evaluation to appreciate cerebral abnormalities that may occur earlier than structural ones. Cerebrospinal fluid biomarkers, in particular amyloid and tau peptides, allow us to look at in vivo biochemical cerebral changes related to AD, before possible serum biomarkers. Studies are under way to confirm the relevance of these new diagnostic tools. It will help us to improve evaluation of patients with AD or related diseases.

[Near a biological diagnosis of Alzheimer's disease and related disorders]

PURPOSE

To review the current concepts in the biological diagnosis of Alzheimer's disease (AD) and related disorders.

CURRENT KNOWLEDGE AND KEY POINTS

As new therapeutics specific of AD may be available soon, early diagnosis of AD in the context of mild cognitive impairment (MCI) or dementia appears to be challenging. The high amount of atypical clinical forms of AD leads to develop new tools allowing in vivo diagnosis. New CerebroSpinal Fluid (CSF) biomarkers seem to reflect specific aspects of deep neuropathological changes observed in AD, i.e. amyloid deposits and neurofibrillary tangles. Amyloid beta-peptide 1-42 (Abeta(1-42)) and hyperphosphorylated tubulin associated unit (tau) isoforms appear to be the most sensitive and specific CSF biomarkers, the combination of these biomarkers depicting the best diagnosis value for AD. These molecules are also efficient in the prediction of the conversion from the MCI state to the dementia state of AD. Combined to clinical and neuro-imaging information, CSF biomarkers appear thus to be highly relevant in improving the early etiological diagnosis of dementia.

FUTURE PROSPECTS AND PROJECTS

The current research focalises on the development of new molecules coming from Abeta and tau protein families, in the CSF and in the serum, as well as molecules reflecting other pathological metabolism changes, as alpha-synuclein in Lewy Body Disease. The diagnosis value of CSF biological markers is so promising that they have been recently included in the research diagnosis criteria of AD.

Up-regulation of hippocampal serotonin metabolism in mild cognitive impairment

OBJECTIVE

Recent studies have suggested modifications of serotonin cerebral metabolism and of 5-HT(1A) receptors density in Alzheimer disease (AD). This study aims at exploring hippocampus 5-HT(1A) receptor density in patients at the amnesic mild cognitive impairment (aMCI) and mild AD dementia stages.

METHODS

With use of PET with a selective 5-HT(1A) antagonist, 2'-methoxyphenyl-(N-2'-pyridinyl)-p-[(18)F]fluoro-benzamidoethylpiperazine ([(18)F]MPPF), the hippocampus 5-HT(1A) binding potential (BP) was quantified in 10 patients with mild AD, in 11 patients with aMCI, and in 21 aged paired control subjects. To take into account hippocampal atrophy, a partial volume correction was applied to the [(18)F]MPPF data, leading to the calculation of a corrected BP (BP(c)). Comparison of hippocampus BP over populations was performed using Kruskal-Wallis rank analysis.

RESULTS

Hippocampus serotonergic receptor binding distinguishes patients from controls and patients with aMCI from patients with AD. In aMCI patients, the mean hippocampus BP(c) was 59% higher than the controls' (p < 0.005), and it was conversely 35% lower in patients with mild AD (p < 0.01). The difference in BP(c) values between patients with aMCI and mild AD was large, resulting in a p value of <0.0005. These differences were not related to hippocampus atrophy.

CONCLUSION

A compensatory mechanism illustrated by an up-regulation of serotonergic metabolism has been shown at the stage of amnesic mild cognitive impairment (aMCI) in contrast with a dramatic decrease at later stages of Alzheimer disease (AD). This difference of hippocampus serotonergic receptor labeling allows distinguishing of patients with aMCI from those with mild AD. Exploring 5-HT(1A) receptors with 2'-methoxyphenyl-(N-2'-pyridinyl)-p-(18)F-fluoro-benzamidoethylpiperazine PET seems to be of interest for better understanding pathophysiologic changes at early stages of AD.

Experimental treatments for human transmissible spongiform encephalopathies: is there a role for pentosan polysulfate?

Human transmissible spongiform encephalopathies (TSEs), also known as prion diseases, are caused by the accumulation of an abnormal isoform of the prion protein in the CNS. Creutzfeldt-Jakob disease in its sporadic form is the most frequent type of human TSE. At present, there is no proven specific or effective treatment available for any form of TSE. Pentosan polysulfate (PPS) has been shown to prolong the incubation period when administered to the cerebral ventricles in a rodent TSE model. Cerebroventricular administration of PPS has been carried out in 26 patients with TSEs and has been shown to be well tolerated in doses < or = 220 microg/kg/day. Proof of efficacy has been difficult because the specific and objective criteria for measurement of response have not been established yet. Preliminary clinical experience confirms extended survival in patients with variant Creutzfeldt-Jakob disease receiving intraventricular PPS; however, it is still not clear if this is due to PPS itself. Further prospective investigations of long-term intraventricular PPS administration are essential for the assessment of its effects.

Méningiome du nerf optique. L’expérience lyonnaise

Meningioma is an unfrequent optic nerve tumor. Clinical symptoms are not specific, and pathology exam not easily accessible. The diagnosis is usually based on imaging findings. We report our experience, based on twenty patients. Most of them were middle-aged women (mean age=47 years old). The optic nerve meningioma (ONM) was often revealed by visual dysfunction. Ophthalmological evaluation was altered in most patients (visual acuity, visual fields, fundi). The gold-standard exam was MRI of the optic nerve, with and without gadolinium, and with fat-sat sequences. Thirty percent of the lesions remain stable without treatment. Functional prognosis has been improved only by conformal fractionated radiotherapy, but indications and modalities remain to be specified.

Les visages et leurs émotions

In this second part, we address particularly the question of the neural mechanisms and structures involved in the recognition of facial emotional expressions that are crucial in social cognition. Emotion recognition in others can be critically impaired in some neurodegenerative and neurovascular diseases. That dysfunction sometimes correlated to disabling behavioural disorders and interpersonal communication impairment must be further understood. The results of a series of scalp and intracranial event related potential recordings, as well as recent advances in the literature, are reported. ERPs to facial emotional expressions were thus recorded in multiple subcortical and cortical areas in drug refractory epileptical patients implanted with depth electrodes. The roles of amygdala, insula and prefrontal cortex located at crossroads between perceptive analysis and emotional conceptual knowledge are particularly underlined. Altogether, these studies demonstrate that facial expressions are widely processed in space and time, some structures reacting very early and automatically, others providing a sustained reaction depending on the attention.

Les visages et leurs émotions

Faces represent a crucial vector of interhuman communication. The message transmitted by the face has multiple features. Recognition of each feature can be impaired independently or in combination with others. In order to understand the behavioral consequences of such impairments, which can be a major social handicap, we first must specify the neural networks involved in face recognition. We propose in this first part to present the systems involved in face recognition, in particular the question of identity and prosopagnosia. Different neural networks are indeed implicated in the recognition of invariant facial features such as identity, gender, ethnicity, and recognition of variant features like facial expression and eye gaze. This paper is illustrated by some of our scalp and intracranial electrophysiological studies performed in humans allowing us to describe some aspects of face recognition dynamics combining an excellent spatial and temporal resolution. Intracranial recordings were performed in drug refractory epileptical patients implanted with depth electrodes. These studies demonstrate that numerous deep brain and cortical structures participate early and sometimes in a sustained manner in face recognition.

[Rhinocerebral mucormycosis]

INTRODUCTION

Mucormycosis is a rare and acute fungal infection which is frequently lethal. The rhinocerebral form is usually seen in diabetics, but other localizations may occur in severely immunocompromised subjects.

OBSERVATION

We report the case of a sphenoidal sinusitis associated with a probable cavernous sinus thrombosis and carotid artery thrombosis with middle cerebral artery territory infarction. Diagnosis was made on histological examination following sphenoidotomy. Early medical and surgical treatment led to a good outcome.

CONCLUSION

The diagnosis of rhinocerebral mucormycosis should be considered in the clinical setting of necrotic sinusitis and acute neurologic deficit in diabetic patients. Early diagnosis and treatment are crucial factors leading to a good outcome.

Forme de Heidenhain de la maladie de Creutzfeldt-Jakob

INTRODUCTION

Creutzfeldt-Jakob's disease has various anatomoclinical presentations including a rare form with preponderant visual signs described by Heidenhain. In this form, the visual symptoms may be isolated for a few weeks, leading to multiple ophthalmological examinations.

OBSERVATION

We report the case of a 75-year-old woman who developed isolated visual disorders which rapidly increased over a period of two months. Addition of neurological symptoms, abnormalities of EEG and positivity of 14-3-3 protein led to the diagnosis of Creutzfeldt-Jakob's disease. The patient died 14 months after the first neuroophthalmologic signs. The diagnosis was established by post-mortem examination and immuno-electrophoretic demonstration of type 1 prion protein.

CONCLUSION

Heidenhain's form of Creutzfeldt-Jakob's disease highlights the importance of general rules for prevention of iatrogenic hazard during ophthalmological examinations.

Thalamic venous infarction as a cause of subacute dementia

The clinical picture of deep cerebral vein thromboses (DCVT) usually is acute, combining vigilance disorders, headaches, and focal neurologic deficit. The authors describe a patient who presented with isolated subacute dementia as the sole manifestation of DCVT. In the setting of subacute cognitive deficit, the diagnosis of DCVT must be considered when neuroimaging shows bilateral thalamic changes. Enhanced venous MR angiography is the noninvasive method of choice to ascertain the diagnosis.

[Inflammatory optic neuropathies]

Diagnosis of inflammatory optic neuropathy is very likely in a young adult presenting acute, unilateral and painful visual loss. Relative afferent pupillary defect is a very sensitive and specific sign of optic neuropathy. Ophthalmological exam is mandatory to estimate severity of visual loss, appearance of optic disks and check for another eye disease. Magnetic resonance imaging is indicated to rule out a compressive optic neuropathy and to quantify the inflammatory lesion index, which is the best prognostic indicator of multiple sclerosis development (MRI is abnormal at entry in about 50% of patients with isolated optic neuritis). Spontaneous outcome of optic neuropathies is favourable. Corticosteroids have demonstrated efficacy only in shortening length of evolution and by using parenteral high doses. Clinical benefit from introducing beta-interferons treatment after a first episode of isolated optic neuritis remains to be evaluated. Secondary inflammatory optic neuritis (infection, vasculitis, sarcoïdosis) are rare and usually present atypical evolution or other symptoms.

Processing of facial emotional expression: spatio-temporal data as assessed by scalp event-related potentials

Event-related potentials (ERPs) were recorded in 10 adult volunteers, who were asked to view pictures of faces with different emotional expressions, i.e. fear, happiness, disgust, surprise and neutral expression [Ekman, P. & Friesen, W.V. (1975). Pictures of Facial Affect. Consulting Psychologist Press, Palo Alto, CA]. ERPs were recorded during two different tasks with the same stimuli. Firstly, subjects were instructed to pay attention to the gender of the faces by counting males or females. Secondly, they had to focus on facial expressions by counting faces who looked surprised. The classical scalp 'face-related potentials', i.e. a vertex-positive potential and a bilateral temporal negativity, were recorded 150 ms after the stimulus onset. Significant differences were found, firstly between late-latency ERPs to emotional faces and to neutral faces, between 250 and 550 ms of latency and, secondly, among the ERPs to the different facial expressions between 550 and 750 ms of latency. These differences appeared only during the expression discrimination task, not during the gender discrimination task. Topographic maps of these differences showed a specific right temporal activity related to each emotional expression, some particularities being observed for each expression. This study provides new data concerning the spatio-temporal features of facial expression processing, particularly a late-latency activity related to specific attention to facial expressions.

Total recovery after bilateral paramedian thalamic infarct

Bilateral paramedian thalamic infarcts are characterised initially by the association of acute vigilance disorders and vertical gaze palsy, followed by persisting dementia with severe mnemic disturbance, global aspontaneity and apathy. We describe a patient with a dramatic neuropsychological recovery, confirmed by testing examination and completed by a cerebral metabolism study. The pathophysiology of this type of cognitive deficit is discussed.

MRI assessment of the anatomy of optic radiations after temporal lobe epilepsy surgery

OBJECTIVE

The aim of this study was to determine the course of the temporal optic radiations.

MATERIAL AND METHODS

Eighteen patients were included in this prospective study. All of them underwent a temporal lobectomy for epilepsy, including the mesial temporal structures and a variable extent of lateral neocortex (from 2 to 7 cm behind the temporal tip). An MRI was performed 2 months postoperatively, allowing assessment of the extent of lateral resection. Postoperative visual fields were determined by automatic static perimetry (ASP).

RESULTS

(1) No patient complained of a disabling visual field deficit. (2) ASP, a highly sensitive technique, however, detected postoperative visual field deficits in 83% of patients, confined to the superior homonymous field contralateral to the resection. (3) A strong correlation was found between the presence of a visual field deficit and the extent of laterotemporal resection. (4) The smallest anteroposterior resection resulting in a field defect was limited to 20 mm from the temporal tip.

CONCLUSION

(1) This study confirms a strong correlation between postoperative visual field deficits and the extent of lateral neocortical temporal resection. (2) The anterior limit of Meyer's loop is likely to be located more rostrally than previously believed. (3) Despite this, lateral resection remains useful in some cases for seizure control.