Consensus in stroke management?
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Cerebrovascular Disorders↗
Biomedical subjects
J Bogousslavsky
Publications and source records attributed to J Bogousslavsky.
Subjective experience and behavior in acute stroke: the Lausanne Emotion in Acute Stroke Study.
OBJECTIVE: To assess subjective experience in acute stroke and to correlate it with stroke features, acute emotional behavior, and impact on seeking of medical care. METHODS: The authors studied patients with acute first-ever stroke prospectively. During the first 4 days they rated subjective experience (happiness, sadness, irascibility, and fear); behavioral reactions, using a specifically designed scale; and mood (Hamilton anxiety and depression). Fifty-three patients (30 men, 23 women; age, 60 +/- 19 years) completed the 3-month follow-up. RESULTS: Seventeen patients failed to seek medical care spontaneously. Sixteen patients presented behavioral reactions of overt sadness, 20 presented indifference, 12 presented aggressiveness, 20 presented disinhibition, and 16 presented denial. Eight patients were anosognosic and 12 were anosodiaphoric. Twenty-four patients expressed happiness, 20 expressed sadness, 7 expressed anger, and 11 expressed fear. Ten patients with aphasia could be interviewed, but four required delayed questioning. Denial reactions and anosognosia were independent. Acute denial reactions were not dependent on the side of stroke, but were more frequent after deep lesions (p < 0.010). Patients with a denial reaction had a tendency to present less subjective experience of fear (p < 0.078) and a higher occurrence of delayed depression (p < 0.02). Intergroup comparison of all measures showed that lack of seeking care was related to reactions of indifference (p < 0.007), a tendency toward a less subjective experience of fear (p < 0.078), poor recall of the acute event (p < 0.001), decreased nosognosia (p < 0.001), and right-side lesions (p < 0.035). CONCLUSIONS: Patients with acute behavioral denial had a decreased occurrence of subjective experience of fear and a more frequent occurrence of delayed depression. These denial reactions were independent of anosognosia. A subjective experience of fear was related to appropriate care seeking. An impaired subjective experience of fear may contribute, as with anosognosia, to an increased delay in consultation. All other emotional reactions were dissociated from the patients' subjective experience.
Acute Disease↗
Myocarditis of mixed connective tissue disease: favourable outcome after intravenous pulsed cyclophosphamide.
A 30-year-old woman with mixed connective tissue disease was admitted with Wernicke's aphasia and progressive dyspnoea with chest pain. Multiple brain infarcts on a computed tomographic scan were compatible with a thromboembolic aetiology. Echocardiography showed marked hypokinesia of the posterior wall, biventricular dilatation and a decreased left-ventricle ejection fraction (40%). A diagnosis of myocarditis was made on myocardial biopsies disclosing interstitial lymphocytic infiltrates and myocardial fibre necrosis. A treatment with steroids and monthly pulsed cyclophosphamide was introduced. The heart function rapidly improved as assessed by a left-ventricle ejection fraction of 55% and remained stable 17 months thereafter.
Adult↗
Stroke: the neurological emergency.
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Cerebrovascular Disorders↗
Clinical trial update: neuroprotection against acute ischaemic stroke.
One of the most recent advances and hopes in stroke therapy concerns neuroprotection, which has recently been investigated in several clinical trials. Furthermore, some new neuroprotective drugs, which are based on newly identified cellular and molecular mechanisms that underlie the development of focal ischaemic injury, will be tested in stroke patients in the future. It must be emphasized, however, that the concept and application of neuroprotection must remain within the frame of the global network and organization of acute stroke care, because neuroprotection at best may become only a link among many other management strategies for acute stroke.
Acute Disease↗
Multiple large and small cerebellar infarcts.
To assess the clinical, topographical, and aetiological features of multiple cerebellar infarcts,18 patients (16.5% of patients with cerebellar infarction) were collected from a prospective acute stroke registry, using a standard investigation protocol including MRI and magnetic resonance angiography. Infarcts in the posterior inferior cerebellar artery (PICA)+superior cerebellar artery (SCA) territory were most common (9/18; 50%), followed by PICA+anterior inferior cerebellar artery (AICA)+SCA territory infarcts (6/18; 33%). One patient had bilateral AICA infarcts. No infarct involved the PICA+AICA combined territory. Other infarcts in the posterior circulation were present in half of the patients and the clinical presentation largely depended on them. Large artery disease was the main aetiology. Our findings emphasised the common occurrence of very small multiple cerebellar infarcts (<2 cm diameter). These very small multiple cerebellar infarcts may occur with (13 patients/18; 72%) or without (3/18; 22%) territorial cerebellar infarcts. Unlike previous series, they could not all be considered junctional infarcts (between two main cerebellar artery territories: 51/91), but also small territorial infarcts (40/91). It is suggested that these very small territorial infarcts may be endzone infarcts, due to the involvement of small distal arterial branches. It is possible that some very small territorial infarcts may be due to a microembolic process, but this hypothesis needs pathological confirmation.
Adult↗
Death from ischemic stroke in the anterior circulation: the contralateral carotid matters.
Death from acute hemispheric infarction is commonly associated with stroke size, but the potential role of the internal carotid artery (ICA) in this phenomenon is poorly understood. The aim of the present study was to analyse the relation between the degree of ipsilateral and contralateral ICA stenosis, infarct type and death. We studied 2,148 first-ever stroke patients with anterior circulation infarction from the Lausanne Stroke Registry. Doppler ultrasonography with frequency spectral analysis and Duplex-scanning were performed systematically during the acute phase of stroke. The patients were divided into groups according to the degree of ipsilateral and contralateral ICA stenosis. The case fatality ratios (CFR) at hospital discharge were obtained for each group. Several clinical features including age, stroke topography, level of consciousness, limb weakness on admission, type of onset, hyperglycemia, previous transient ischemic attack, cardiac ischemia, cardiac arrhythmia and left ventricular hypertrophy were also studied. Mortality increased significantly with ipsilateral ICA stenosis: </=50% stenosis, 2.8%, (44/1,549); >50% and </=90% stenosis, 3.5%, (6/170); >90% stenosis, 5.6%, (24/429); p = 0.026, but not significantly with contralateral ICA stenosis. However, patients without ipsilateral ICA stenosis had significantly higher mortality when contralateral stenosis was present: 16.7% (3/18) versus 2.7% (41/1,531), p = 0.013. This corresponded to an increased frequency of strokes involving the whole middle cerebral artery territory, with impaired consciousness at onset of stroke. Patients with ipsilateral stenosis had similar CFR independently of the presence or absence of contralateral stenosis. In conclusion, patency of the contralateral ICA may be an important contributory factor of larger infarction and indirectly of stroke mortality in patients with no ipsilateral stenosis.
Acute Disease↗
[Facial myositis: a localized form of generalized myositis?].
We report a case of myositis presenting as an apparently unique progressive facial weakness. The only biological abnormality after an 8-year follow-up was an immunocytoma. Molecular analyses excluded facioscapulohumeral muscular dystrophy. Based on this single case and a review of the literature, we suggest a continuum between focal myositis and generalized myositis.
Diagnosis, Differential↗
Ataxic hemiparesis: an old debate for Lacune aficionados.
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Ataxia↗
Different predictors of neurological worsening in different causes of stroke.
OBJECTIVES: To investigate clinical determinants of neurological worsening and to delineate its predictors. DESIGN: Restrospective analysis of the data from the Lausanne Stroke Registry. PATIENTS: A total of 3038 patients with first-ever stroke consecutively admitted to a primary-care stroke center. MAIN OUTCOME MEASURES: Neurological worsening in the acute phase of stroke. RESULTS: Neurological worsening was observed in 38% of 300 patients with brain hemorrhage, 34% of 1968 patients with noncardioembolic infarction, and 15% of 770 patients with cardioembolic infarction (P<.001). Neurological worsening was significantly less frequent in patients with small-artery disease than in those with large-artery atherosclerosis or other causes. A logistic multiple regression model in patients with noncardioembolic infarction showed age less than 65 years, hypertension, lesion outside the superficial anterior circulation, absence of transient ischemic attack, and reduced level of consciousness as the independent factors in the patients with small-artery disease, while it showed involvement of the posterior circulation and reduced level of consciousness in the patients with large-artery atherosclerosis. Severe functional disability or death was more common in patients with neurological worsening, both in patients with large-artery atherosclerosis and in those with small-artery disease (18% vs 9%; P<.001). CONCLUSIONS: Determinants of neurological worsening may include causative aspects rather than just the evolution of the ischemic or hemorrhagic process itself. For a better comprehension and treatment of neurological worsening, the causative and pathophysiological conditions underlying stroke should be differentiated as early as possible.
Adolescent↗
Preventing stroke recurrence in patients with patent foramen ovale: antithrombotic therapy, foramen closure, or therapeutic abstention? A decision analytic perspective.
Emphasis on the role of patent foramen ovale as a potential risk factor for ischemic paradoxical stroke has recently increased. Current therapeutic options for secondary stroke prevention include long-term antithrombotic therapies and invasive closure of the defect, but selective indications have not been evaluated. Therefore we developed a Markov-based decision analysis model for a hypothetical cohort of patients 55 years of age with presumed paradoxical embolism, measuring for each therapy the risks of stroke recurrence, treatment-related complications, and death after 5 years and the quality-adjusted life-years. Over a wide range of stroke risk recurrence (0.8% per year to 7% per year), the gain provided by closure of the defect exceeded the one obtained by other therapeutic options. When the risk exceeded 0.8% per year and 1.4% per year, respectively, this was also verified for anticoagulation and antiplatelet therapies compared with therapeutic abstention. Therapeutic abstention was the preferred strategy under 0.8% per year. Sensitivity analyses identified key parameters influencing the choice of therapy. These included estimates of stroke recurrence, bleeding rates, surgery-related case fatality rates, and age. Considering the risks of treatment and the devastating consequences of a recurrent stroke, our model suggests that if the estimated risk of paradoxical stroke recurrence is > 0.8% per year, therapeutic abstention becomes the worst option. Above this threshold secondary stroke prevention with anticoagulation therapy or surgical closure of the defect is the preferred strategy, and assessment of both the risk of stroke recurrence and the risk related to therapeutic options should guide individual therapeutic decision making.
Cardiac Surgical Procedures↗
Diagnosis as a guide to stroke therapy.
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Cerebral Angiography↗
Familial cardiomyopathy and distal myopathy with abnormal desmin accumulation and migration.
Desminopathies form a heterogeneous group of myopathies characterised by pathological aggregations of desmin. We report a family, where mother and daughter presented with an atrioventricular block and a slowly progressive distal muscular weakness, with non-homogeneous focal atrophy on computed tomography scans. The mother developed a severe global heart insufficiency necessitating a heart transplantation at 56 years of age. Skeletal muscle biopsies were characterised by inclusion bodies strongly expressing desmin and alpha B-crystallin, with a predominantly subsarcolemmal localisation. Ultrastructurally most inclusions corresponded to non-membrane bound granulo-filamentous material with disruption of myofibrils. An immunoblot showed a hyperintense desmin band at 53 kDa and a second band at 49 kDa, the latter being absent in controls. The cardiac muscle of the explanted heart showed very similar inclusions. These cases illustrate that in this distinct subtype of desminopathies the cardiac muscle alterations are comparable with those observed in skeletal muscle, and suggest the possibility of a primary desmin pathology.
Adult↗
[Skew deviation].
BACKGROUND: Skew deviation is a vertical ocular misalignment of prenuclear origin. Although well described in the literature, it is still probably underdiagnosed. Natural history of skew deviation is not well described in the literature. PURPOSE: To describe the clinical presentations, etiologies and follow-up of skew deviation. METHODS: Retrospective study of 29 patients diagnosed with skew deviation between 1993 and 1996. RESULTS: The commonest cause was cerebrovascular accident (12/29) and the commonest localisation was mesencephalic (9/29). Other causes included surgery (7/29), tumor (4/29), trauma (3/29), degeneration (3/29), inflammatory (2/29), increased intracranial pressure (1/29). Other localisations included cerebellum (5/29), ponto-mesencephalic (3/29), and medulla (2/29). Vertical diplopia was always accompanied by other neuro-ophthalmologic abnormalities. 69.2% (18/26) patients were totally asymptomatic after 7.5 months. 30.8% (8/26) were still symptomatic (diplopia). One patient required surgery, three patients were relieved with prisms, one patient needed monocular occlusion. One patient died during follow-up and precise data were lacking in two symptomatic patients. CONCLUSION: Skew deviation is not so rare, 10% of the cases referred to us for diplopia in 3 years. The diagnosis of skew deviation should be entertained when vertical diplopia cannot be explained by pathology of extraocular muscles, peripheral or central cranial nerve III or IV palsies, myasthenia, or orbital pathology. Prognosis for recovery in patients with skew deviation is good. 70% will recover, after a median time of 7.5 months. Surgery should be postponed at least for 12 months.
Adolescent↗
Mechanisms of second and further strokes.
OBJECTIVES: The mechanisms underlying recurrent stroke may be complex and multifactorial, but they have not been studied systematically. The aim was to analyse the different patterns and pathophysiological mechanisms of second and further strokes. METHODS: Recurrent stroke patterns and mechanisms were studied in 102 patients admitted with second or further strokes to the stroke centre in Lausanne University Hospital. RESULTS: The patients with an initial cardioembolic stroke experienced recurrent stroke of the same type most often, followed by those with initial non-lacunar non-cardioembolic stroke, brain haemorrhage, and lacunar stroke (77%, 65%, 58%, and 48% respectively). Forty two per cent of the recurrent strokes in patients with an initial brain haemorrhage were ischaemic, whereas patients with ischaemic stroke only occasionally suffered brain haemorrhage (5%). In patients with brain haemorrhage, the lobar location predominated in both the first and all episodes (69% and 78% respectively), suggesting a small, occult arteriovenous malformation or cerebral amyloid angiopathy rather than hypertensive small artery disease. The functional disability of patients after an initial lacunar stroke was significantly better than in patients with other stroke subtypes (p<0.001), but the difference became non-significant after recurrent stroke (p=0.26). CONCLUSIONS: Most of the recurrent strokes were of the same type as the first episode for both cardioembolic and non-lacunar non-cardioembolic stroke, however, about half of the patients with an initial brain haemorrhage or a lacunar stroke experienced other types of stroke recurrently. The findings suggest that the coexistence of multiple aetiologies may play a major part in determining the mechanism of stroke recurrence. The study is an important step in understanding the patterns of stroke recurrence, which may be critical for better prevention.
Aged↗
Face-arm-trunk-leg sensory loss limited to the contralateral side in lateral medullary infarction: a new variant.
Two patients are reported on who experienced loss of pain and temperature sensation in the entire contralateral hemibody but sparing the ispsilateral face (pure sensory stroke pattern) related to acute lateral medullary infarction. In both patients MRI showed a notch-like retro-olivary ischaemic lesion in the ventromedial tegmentum with preservation of the far lateral medulla. The mediolateral lesion involved the crossed lateral spinothalamic tract and the ventral trigeminothalamic tract, corresponding to sensory loss in the contralateral face, arm, and upper trunk. The ventrolateral extension of infarct damaged the far lateral part of the spinothalamic tract, corresponding to sensory loss in the contralateral lower trunk and leg. The findings suggest that hemisensory loss of the spinothalamic type involving-and limited to-the whole hemibody can occur in infarction in the lower brainstem. This form of pure sensory stroke may be classified as type IV of sensory loss in lateral medullary infarction.
Abdomen↗
Pure sensory syndromes in thalamic stroke.
We studied 25 patients with an acute thalamic stroke (infarct or hemorrhage) on CT or MRI scan and sensory dysfunction, among the 3,628 patients with first-time stroke included in the Lausanne Stroke Registry. Twelve patients had a right-sided infarct, 11 a left-sided infarct, and 2 a left-sided thalamic hemorrhage. Sensory symptoms or signs were the only clinical abnormality. The presumed causes of stroke were small artery disease in 21 patients including both cases of hemorrhage, emboligenic heart disease in 2, while the etiology of ischemic stroke was undetermined in 2 patients. Nine patients had a loss of all modalities of sensation with faciobrachiocrural distribution, 5 patients suffered dissociated sensory loss with faciobrachiocrural distribution and 11 patients showed a dissociated involvement of sensation with a partial distribution pattern. The inferolateral region (thalamogeniculate arteries) was involved in all patients. Six patients complained of pain and/or dysesthesias during the stroke; 5 of them had involvement of the nucleus ventrocaudalis (in 3 with damage to the nucleus ventro-oralis intermedius, and in one to the pulvinar) and 1 patient had involvement of the nucleus ventro-oralis intermedius. Eighteen patients complained of paresthesias in the contralateral part of the body; 16 of them had involvement of the nucleus ventrocaudalis (in 4 with damage to the nucleus ventro-oralis intermedius, in 1 with damage to the nucleus ventro-oralis intermedius, and nucleus ventro-oralis externus, and in one with damage to the nucleus parvocellularis and pulvinar). Four patients developed delayed pain and/or dysesthesias; all of them had involvement of the nucleus ventrocaudalis (in 1 with damage to the nucleus parvocellularis and pulvinar). Time lag from stroke onset to developing pain ranged from 2 to 15 days (mean 10.5 days). One patient with dissociated involvement of sensation with a partial distribution pattern had paresthesias and dissociated hemisensory loss involving position sense without pain and temperature sensations. This patient had involvement of the posterolateral part of the nucleus ventrocaudalis. In conclusion, sensory dysfunction and delayed pain are more often found in thalamic lesions that involve the nucleus ventrocaudalis, and nucleus ventro-oralis intermedius. Restricted sensory abnormalities correlate with very small lesions located in critical areas within these nuclei.
Adult↗