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Hypoglycemia is a classic cause of coma and can result in irreversible neuronal loss. Until now, the main prognostic factors were depth of hypoglycemia and duration of coma. We report the case of a 55-Year-old woman who suffered severe hypoglycemic coma with abnormal cortico- subcortical diffusion weighted MR images. These MRI abnormalities preceded severe atrophy of these cerebral areas. This findings suggests that diffusion abnormalities in hypoglycemic coma may be related to neuronal loss and may thus have prognostic value.

Ataxic hemiparesis is a syndrome in which pyramidal and cerebellar signs occur on the same side. Few authors have suggested that signs or symptoms can orientate toward a supratentorial or toward an infratentorial lesion. We have studied the risk factors and the clinical symptoms of 61 patients consecutively admitted for an ataxic hemiparesis due to a lacunar infarct diagnosed with MRI. The MRI was normal in 2 cases. A tandem lacunar infarct was found in 9 cases (pons and internal capsule in 5 cases, pons and corona radiata in 4 cases) and a clinico-radiological correlation was performed in 50 cases. The comparison of risk factors did not show any difference between the infratentorial (n = 10) and the supratentorial groups (n = 40) excepting for the history of coronary disease. The history of coronary disease was statistically more frequent in the infratentorial group. No difference was found for clinical findings between the 2 groups.

Stroke units can improve outcome after stroke as demonstrated by a meta-analysis which evidenced a reduction of the odds ratio for mortality (18 +/- 8 p. 100) and for poor outcome, death, or institutional care (25 +/- 10 p. 100), and death or dependancy (29 +/- 11 p. 100). Improved quality of life and shorter hospital stay have not been so clearly established. Stroke units are helpful in organizing acute neurology care. Moreover, stroke units are involved in teaching and research. Their development should be promoted in hospitals.

Five out of 160 cases of lacunar infarcts were preceded or followed by intracerebral hemorrhage. Four patients were hypertensive. This association raises the question of a common risk factor in lacunar infarct and intracranial hemorrhage. The possibility that these different stroke types may be due to the same arteriolar pathology is discussed.

Multiple cranial nerve palsies frequently occur in patients with cephalic zoster. Nevertheless, to our knowledge, involvement of the glossopharyngeal (IXth), vagus (Xth) and accessory (XIth) nerves has not yet been reported. We report a case of jugular foramen syndrome with palatolaryngeal herpetic eruption, aseptic meningitis and a high level of serum antibody to varicella-zoster virus.

Spasticity following upper motor neuron lesion can be alleviated by few treatments such as physiotherapy, drugs and neurosurgery. However, they all have side effects, limitations or lack of selectivity. We tentatively used the paralyzing effects of botulinum toxin. Since the late 1970's the use of this toxin has increased and it has been extended to numerous muscles and diseases of various causes. In this pilot and open study we use botulinum toxin in spasticity. Eight patients (7 stroke, 1 head injury) with longstanding severe spasticity (minimum: 12 months, maximum: 15 years) were included. Spasticity greatly interfered with their activity in daily life and was resistant to oral antispastic medications. Six patients suffered from pain and 4 had cutaneous lesions especially maceration of the palm of the hand. A-botulinum toxin was injected with a 30-gauged needle. The sites chosen for injection were the following muscles: biceps brachii, brachioradialis, flexor digitorum, flexor carpi, tibialis anterior, flexor digitorum longus. Altogether 41 injections were performed. There were no side effects. Spasticity was improved in all patients. Five patients reported significant pain relief on a visual analogical scale. Most of them reported a benefit in their limb tone and referred to subjective improvement in the activity of daily life and nursing. The beneficial effects of one injection lasted more than 5 months. Seven patients received a second course of treatment. A double-blind study of botulinum toxin in spasticity is to be undertaken to assess its effectiveness and safety when prescribed in the required dose to treat this condition.

Apomorphine, a dopaminergic agonist was given over a period of 12 months to 14 parkinsonian patients suffering from severe L-dopa induced on-off effects. Nine patients (mean age: 52 years; mean age at onset of the disease: 37 years), were treated by continuous infusion with a portable minipump, and 5 others by multiple injections with a penject. The mean duration of daily off periods was reduced by two thirds in all patients. The motor fluctuation intensity was only diminished in the 9 patients treated by continuous infusion. These patients received a mean apomorphine daily dose of 93 mg and L-dopa dosage was reduced by 53 p. 100. Red fibrous subcutaneous nodules occurred at the injection sites in all patients treated by infusion. This study confirms the effectiveness of subcutaneous apomorphine administration in the treatment of severe motor fluctuations.

Stereotactic ventral intermediate nucleus (Vim) thalamotomy may improve drug resistant severe parkinsonian tremor. However, tremor may recur and bilateral thalamotomy is known to induce unacceptable side effects in a proportion of patients. A high frequency (130 Hz) chronic Vim stimulation was performed in 4 parkinsonian patients, 2 of them having previously undergone a thalamotomy on the other side. Tremor was suppressed in all patients at the price of slight paresthesias. This improvement has been lasting from 2 to 14 months. Beneficial and adverse effects were suppressed at once each time the stimulation was stopped. These preliminary results are encouraging but a longer delay and more patients are obviously needed.

Four patients with focal brainstem ischemic strokes and various types of horizontal oculomotor disturbances have been studied clinically and radiologically. One had a six nerve palsy, one a unilateral internuclear ophthalmoplegia, one a Fisher's one-and-a-half syndrome, and one a paramedian pontine reticular formation syndrome with a sixth nerve palsy. In all patients a C.T. Scan and a Magnetic Resonance Imaging (MRI) were obtained. The MRI study was performed on a CGR Magniscan 5000 with a superconducting magnet of 0.5 Tesla. In all patients a hypersignal in T2 weighted images was shown and corresponded to the brainstem infarct. MRI allowed accurate delineation of the lesion and clinico-radiologic correlations in three patients. But the low specificity of MRI does not permit to distinguish edema from necrosis, gliosis or demyelination in a region with a pathological MRI signal. In one patient this low specificity and perhaps partial volume effects decreased the accuracy of the clinico-topographic correlation.

An acute administration of various doses of apomorphine, a dopaminergic agonist, and of dopaminergic receptor blockers (domperidone, sulpiride, haloperidol), was double-blindly achieved in a parkinsonian patient also suffering from dyskinesia. Apomorphine improved tremor and dyskinesia proportionnally to the dose. Domperidone did not prevent from this beneficial effect whereas sulpiride or haloperidol revealed a competitive antagonism versus apomorphine.

54 patients with idiopathic Parkinson's disease (PD), 26 patients with Alzheimer's disease (AD) and 18 control subjects, all over 55, have performed neuropsychological tests, evaluating global intellectual function (Rosen's cognitive scale, WAIS digit symbol, WAIS similitude and WMS logical memory tests) and visuospatial functions (Rey lacunar pictures, Poppelreuter and Benton line orientation tests). AD group results were distinctly different from those of the PD and the control groups (p less than 0.001). In the PD group, only the Rosen's scale total score and the visuospatial tests were slightly altered (p less than 0.05). In a PD subgroup with a normal Rosen's scale result, the Benton line orientation test was different from controls (p less than 0.05). In another PD subgroup with Rosen's scale score comparable to a midly impaired AD subgroup, all the neuropsychological tests were abnormal. Only the WAIS digit symbol test, altered in this PD subgroup, was different comparing these 2 subgroups (p less than 0.05). With regard to the PD total group, the neuropsychological perturbed PD subgroup was older, had a longer duration of disease, a higher depression's score, less tremor and a worse equilibrium. These results might reflect a neuropsychological defect heterogeneity among PD patients, related to various pathophysiological hypothesis which are discussed in this paper.

Palsies of the lower cranial nerves caused by a compressive pathological carotid artery are not common. Three cases of paralysis of the hypoglossal nerve, hypoglossal and vagus, hypoglossal, glossopharyngeal and vagus nerves, are reported. In 2 patients the symptoms were related to an extracranial carotid artery aneurysm below the base of the skull and in 1 patient to a spontaneous carotid dissecting aneurysm. It is possible that some localized arterial dissecting aneurysms evolve to a localized aneurysmal sac, especially if they are located between Cl and the base of the skull. The tongue paralysis disappeared in 2 patients.

A 64 year old man was admitted for an ataxic hemiparesis. Magnetic resonance imaging (MRI) suggested a lacunar infarct. The lesion was located in the postero-lateral part of the contralateral thalamus, sparing the internal capsule.

A man underwent Magnetic Resonance Imaging (MRI) of the left carotid artery 11 days after a spontaneous dissection of this vessel. T1 weighed images were obtained in the frontal and axial planes. There was a hyperintense lesion expanding the arterial wall due to the hematoma. The image of the lumen was narrowed. These findings corresponded to the angiographic abnormalities. In this case MRI was able to diagnose specifically and non invasively carotid artery dissections. Its sensitivity remains to be evaluated.

In 5 cases of sporadic spinal muscular atrophy in young adults the muscular atrophy was localized in the hands and forearms. Age at onset ranged from 7 to 20 years. The duration of the disease was less than 5 years in 3 patients and more than 15 years in 2. Electromyography showed neurogenic anomalies in all wasted muscles, denervation potentials being also present in the proximal muscles of the upper limbs and distal muscles of the lower limbs in 2 patients. Motor nerve conduction velocity and sensory nerve action potentials were normal. Advantages of a topographic classification of the distal form of chronic spinal muscular atrophy are discussed. Spinal cord MRI was performed in 4 patients with a 0.5 Tesla superconducting magnet using surface coils, using a T1-weighted spin-echo technique (ET 26 ms; RT 500 ms) and a T2-weighted spin-echo technique (ET 90, 180 ms; 2,000 ms). With the T1 technique, axial MRI sections 7 to 9 mm thick of spinal cord showed a normal image between C1 and C4, and a flattened image between C5 and T1. This was considered as a possible spinal cord segmental atrophy.

A case of hematoma involving probably the reticular formation of the medulla oblongata is reported. Examination showed a soft palate paresis and an ipsilateral axial lateropulsion without vertigo or oculomotor disorders. The mechanism of the lateropulsion is discussed. During the spontaneous recovery a transient hydrocephalus was observed.

The infarction in the territory of the anterior choroidal artery may induce a sensory motor impairment and neuropsychological symptoms close to those observed in some thalamic lesions. In a right handed man with a left sided infarction, language disturbances and constructional apraxia were observed. Cerebral blood flow measurements were performed 4 days after the stroke with the 133Xenon inhalation method. A decrease of mean hemispheric values was observed on both sides but more so on the left hemisphere, in the left frontoparietal regions. 98 days after the stroke language and constructional apraxia have partially improved. We have drawn a parallel between blood flow variations and neuropsychological signs. The cortical deafferentation caused by the interruption of the thalamo-cortical projections may explain the focalized decrease in cerebral blood flow values in the left hemisphere.

The aim of imaging the brain in Multiple Sclerosis (MS) is to prove the dissemination of lesions, so critical for the diagnosis and so difficult to ascertain clinically. Our study included 21 patients with clinically definite (12) and probable (9) MS. A 21 patients underwent a neurological standard examination, a double-dose delayed CT scan and a Magnetic Resonance Imaging with a superconducting 0.5 Tesla magnet. Jointed slices were performed with a T2-weighted Spin-Echo sequence (TE 60, 120; TR 2000 msec). MRI detected 640 lesions in 20 patients while CT scan detected only 24 lesions in 9 patients. Technical limiting factors are discussed. Abnormalities in MRI were high-intense spots, blotches and streaks, located predominantly in the periventricular area. Capping lesions were common around the ventricular horns. "Plaques" were visualized in the posterior fossa. For each patient, the total surface of the lesions was calculated and was found to be related with the presence of lesions and with the cortical atrophy on CT scan. A correlation between the surface of lesions calculated by MRI and the disability scale was found especially in the group of patients with clinically proven cerebral lesions, while patients with predominantly spinal forms had a significantly lower surface of lesions. This finding could yield a new quantitative evaluation of the MS pathologic process which could be used to assess therapeutic efficacy.

Six patients with a clinical diagnosis of lateral medullary infarction have been studied by CT scan and Magnetic Resonance Imaging (MRI). The MRI study was performed on a CGR Magniscan 5000 with a superconducting magnet of 5 Tesla. In all patients T2 weighted images (TR = 2000, TE 60, 120) in joined section of 9 or 6 mm thickness were obtained in the axial plane. Three patients were also studied in T1 weighted sequences (TR = 500, TE = 28). A lateral medullary infarct was shown in 5 patients. MRI findings were consistent with a hemorrhagic infarct in one case. Occlusion of a vertebral artery was suggested in 2 cases and was confirmed by angiography. In 3 cases, an associated ipsilateral cerebellar infarct was demonstrated. The CT scan had only shown bleeding in the medulla oblongata in the hemorrhagic infarction case, and a cerebellar infarction in another case. Some clinical manifestations are discussed with regard to the results of MRI. MRI appears as the best current method to improve clinico-topographic correlations in medullary infarcts.