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Objective: To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients., Methods: 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion., Results: The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not., Conclusion: Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.

Background: Many patients may be mentally incompetent or physically unable to give informed consent at the acute stage of stroke. Accordingly, we aimed to investigate the modalities of informed consent in urgent therapeutic stroke trials, the awareness of patients and relatives regarding stroke clinical trials and the impact of decision making on patients and relatives., Methods: We present a study of 56 acute ischemic stroke patients who were randomized in 4 trials (2 trials testing neuroprotective agents, 1 testing thrombolysis and 1 testing antithrombotic agents). A standardized questionnaire was used to assess the modalities of informed consent in this setting., Results: The mean age was 67.1 (SD 12.6) years. The mean baseline Scandinavian Stroke Scale (SSS) score was 23.8 (SD 10.5). Only 13 patients (23% of cases) gave consent while relatives gave consent for 43 patients (77%). The main reason for not getting consent from the patient was aphasia in 29 patients (67.4%). Multiple logistic regression analysis showed that the two independent factors influencing the ability to give consent are age and baseline neurological deficit as assessed by the SSS score. Concerning the psychological impact of consent, none of the 10 patients who answered our questionnaire declared feeling uncomfortable when giving consent, while 7 out of the 13 relatives who could be reached declared they felt uncomfortable, mainly because of the psychological stress induced by urgent decision making., Conclusions: Our study emphasizes the specific ethical difficulties of informed consent in the setting of acute stroke research. Only a minority of patients are able to give consent at the acute stage. Increasing age and neurological deficit are independent predictors of inability to give consent. Thus, the responsibility for consent usually relies on relatives with potential inaccuracy of decision concerning the patient's wish or even conflict of interest. Further evaluation of the psychological impact of decision on relatives is needed in this setting of acute stroke., (Copyright (c) 2005 S. Karger AG, Basel.)

Introduction: The onset of post-anoxic encephalopathies can be delayed after the acute hypoxic injury., Case Report: We present the case of a 45-year-old woman who achieved complete recovery from an episode of hypoxia related to a suicide attempt (ingestion of benzodiazepine). Three weeks later she developed a confusional state with akinetic mutism and parkinsonism. Brain CT-scan showed bilateral hemispheric white matter hypodensities. MRI showed extensive bilateral hyperintensities on T2-weighted and Flair sequences within the hemispheric white matter and the globus pallidus. EEG showed diffuse slow activity. All investigations for leukodystrophies were negative. Brain biopsy showed normal cortex and widespread demyelination with axonal sparing in the underlying white matter. The patient experienced a partial clinical recovery., Conclusion: The clinical course and the results of paraclinic investigations were consistent with the diagnosis of delayed post-anoxic leukoencephalopathy.

In this prospective MRI study, we evaluated the impact of the site of occlusion on multiple baseline perfusion parameters and subsequent recanalization in 49 stroke patients who were given intravenous tissue plasminogen activator (tPA). Pretreatment magnetic resonance angiography (MRA) revealed an arterial occlusion in 47 patients: (1) internal carotid artery (ICA) + M1 middle cerebral artery (MCA) occlusion (n=12); (2) M1 MCA occlusion (n=19); (3) M2 MCA, distal branches of the MCA and anterior cerebral artery (ACA) occlusion (n=16). Patients with ICA occlusion had significantly larger DWI, PWI and mismatch lesion volume on pretreatment MRI compared to patients with other sites of occlusion. The differences in cerebral blood flow (CBF) and peak height were significantly higher in patients with ICA occlusion compared to patients with other sites of occlusion (P=0.03 and P=0.04, respectively). Day 1 MRA showed recanalization in 28 patients (60%). The rate of recanalization was significantly different depending on the site of occlusion: 33% in ICA + M1 MCA occlusion, 63% in M1 MCA occlusion and 81% in either M2 MCA, distal branches of the MCA or ACA occlusion (P=0.002). Our data suggest that CBF and peak height are the most relevant MRI parameters to assess the severity of hemodynamic impairment in regard to the site of occlusion.

We hypothesized that pretreatment magnetic resonance imaging (MRI) parameters might predict clinical outcome, recanalization and final infarct size in acute ischemic stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA). MRI was performed prior to thrombolysis and at day 1 with the following sequences: magnetic resonance angiography (MRA), T2*-gradient echo (GE) imaging, diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI). Final infarct size was assessed at day 60 by T2-weighted imaging (T2-WI). The National Institutes of Health Stroke Scale (NIHSS) score was assessed prior to rt-PA therapy and the modified Rankin Scale (m-RS) score was assessed at day 60. A poor outcome was defined as a day 60 m-RS score >2. Univariate and multivariate logistic regression analyses were used to identify the predictors of clinical outcome, recanalization and infarct size. Forty-nine patients fulfilled the inclusion criteria. Baseline NIHSS score was the best independent indicator of clinical outcome (p=0.002). A worse clinical outcome was observed in patients with tandem internal carotid artery (ICA)+middle cerebral artery (MCA) occlusion versus other sites of arterial occlusion (p=0.009), and in patients with larger pretreatment PWI (p=0.001) and DWI (p=0.01) lesion volumes. Two factors predict a low rate of recanalization: a proximal site of arterial occlusion (p=0.02) and a delayed time to peak (TTP) on pretreatment PWI (p=0.05). The final infarct size was correlated with pretreatment DWI lesion volume (p=0.025). Recanalization was associated with a lower final infarct size (p=0.003). In conclusion, a severe baseline NIHSS score, a critical level of pretreatment DWI/PWI parameters and a proximal site of occlusion are predictive of a worse outcome after IV rt-PA for acute ischemic stroke.

An increased incidence of ischemic stroke has been reported in patients with Crohn's disease. Cerebral infarcts are usually considered as a complication of the hypercoagulable state associated with this inflammatory bowel disease (IBD). The association between Crohn's disease, hyperhomocysteinemia and large-artery stroke of the young has rarely been reported. A 39-year-old woman, with prior medical history of Crohn's disease and hypertension, presented with an ischemic stroke of the left internal carotid artery (ICA) territory. Etiological workup disclosed bilateral high-grade ICA stenosis and atheroma of the subclavian and vertebral arteries. Exhaustive search for prothrombotic factors showed inflammation, with an increased level of fibrinogen and factor IX, and a marked hyperhomocysteinemia. Both vitamin B1 and vitamin B6 plasmatic levels were decreased. Heterozygous C677T methylene-tetrahydrofolate reductase gene mutation was present. This observation highlights the combined proatherogenic effect of vitamin B deficiency-induced hyperhomocysteinemia and inflammation leading to large-artery stroke of the young in the setting of Crohn's disease. Our case report stresses the importance of vitamin deficiency screening in patients with IBD in terms of stroke prevention.

Background: Little is known about the coagulation factors as predictors of cerebral bleeding in rt-PA thrombolysis. The aim of this study was to determine what early coagulation parameters could predict early hemorrhagic lesions., Methods: Consecutive patients were included in the Lyon rt-PA protocol. Early hematomas (within 24 hours), diagnosed on an anatomoradiological basis (symptomatic and not symptomatic) were considered for the study. Fibrinogen and fibrin(ogen) degradation products (FDP) were assessed at entry and at 2 and 24 hours after the beginning of thrombolysis., Results: Of 157 patients, 11 had early parenchymal hematomas (7%), 31 had early hemorrhagic infarcts (19.7%), and 115 had no bleeding (73.2%). In logistic regression, FDP at 2 hours was the single predictor of parenchymal hematomas (OR: 2.5; CI: 1.09 to 5.8), whereas an increase of FDP >200 mg/L multiplied the odds of parenchymal hematoma by 4.95 (IC: 1.09 to 22.4). Early parenchymal hematomas were indicative of a poor prognosis at 3 months (P=0.001)., Conclusions: Early parenchymal hematomas appear as both "malignant" and exclusively related to an explosive increase of FDP at 2 hours, ie, an early fibrinogen degradation coagulopathy (EFDC). All patients scheduled to rt-PA thrombolysis should have an assay of FDP 2 hours after the beginning of thrombolysis: patients with an established EFDC (FDP >200 mg/L) should be monitored specifically, with no antithrombotic drug during the first 72 hours. Patients with FDP >100 mg should share the same monitoring.

Presented are the clinical data of 18 consecutive patients who were treated by IV recombinant tissue plasminogen activator (r-TPA) for suspected vertebrobasilar (VB) acute ischemia within 7 hours. The mean delay for treatment was 5 +/- 3.6 hours. Mean baseline NIH Stroke Scale score was 17 +/- 4. At 3 months, 10 patients were independent (modified Rankin Scale [mRS] score = 0 to 2), whereas 8 patients showed a poor outcome (mRs = 3 to 6). IV r-TPA in VB ischemia in a 7-hour window may be safe and efficient.

Headache of subacute onset, associated with other signs of increased intracranial pressure, represents the most frequent symptom of cerebral thrombophlebitis. We report a case of subarachnoid hemorrhage as a rare presentation of cerebral thrombophlebitis. Unfractionated intravenous heparin treatment resulted in resolution of subarachnoid hemorrhage on control brain CT scan and quick clinical recovery.

Background and Purpose: To replace digital subtraction angiography (DSA) in carotid stenosis evaluation, noninvasive imaging techniques have to reach a high concordance rate. Our purpose is to compare the concordance rates of contrast-enhanced MR angiography (CEMRA) and CT angiography (CTA) with Doppler ultrasound (DUS) in clinical routine practice., Methods: We evaluated prospectively with DUS, CEMRA, and CTA 150 patients suspected of carotid stenosis. The overall concordance rates of the 3 techniques were calculated for symptomatic stenosis > or =50% and > or =70%, for asymptomatic stenosis > or =60%, and for occlusion. For the carotid arteries treated by surgery (n=97), the results of each method and combined techniques were recorded, and misclassification rates were evaluated from surgical reports., Results: The overall concordance rates of DUS-CEMRA, DUS-CTA, and CEMRA-CTA were not statistically different. However, the concordance rate of DUS-CEMRA (92.53%) was significantly higher than that for DUS-CTA (79.10%) in the surgical asymptomatic stenosis group (P=0.0258). CTA considered alone would misclassify the stenosis in a significant number of cases (11 of 64) in the surgical asymptomatic group compared with CEMRA (3 of 67) and DUS (1 of 66) (P=0.0186 versus MRA, P=0.0020 versus DUS)., Conclusions: With the techniques as utilized in our study, the overall concordance rates of combined noninvasive methods are similar for measuring carotid stenosis in clinical routine practice, but in asymptomatic carotid stenosis, the decision making for surgery is significantly altered if DUS and CTA are considered in place of DUS and CEMRA.

We describe a case of a 70-Year-old man who presented subacute pseudo-dementia due to a dural fistula. Neurological assessment and the reversibility of the symptoms after embolization support the originality of this observation.

Admission delay remains the main cause for stroke patient exclusion from urgent therapeutic protocols. Public lack of knowledge about stroke symptoms may result in delay in seeking medical care and late presentation at hospital. Lack of knowledge of risk factors for stroke may also hamper compliance with stroke prevention practices. The aim of this prospective study using a standardized questionnaire was to evaluate the stroke awareness of acute stroke patients in France. From July 2, 1998 to July 2, 1999, 166 consecutive stroke patients were admitted at our stroke unit. Among the 91 patients who were able to answer the questionnaire during the first 48 hours, only 19 patients (21 p.cent) thought they were having a stroke before their arrival at the hospital, 38 patients (42 p.cent) did not know a single sign of stroke and 33 patients (36 p.cent) did not know a single risk factor of stroke. The most common risk factors named by the patients were smoking and hypercholesterolemia (named by 31 patients (34 p.cent) and 19 patients (21 p.cent), respectively). The most common warning signs named by the patients were paralysis of one side of body or one limb and speech disturbance (named by 40 patients (44 p.cent) and 15 patients (16 p.cent), respectively). Female sex and "knowing somebody who had a stroke" were significantly associated with awareness of signs of stroke in multivariate analysis. Educational public programs regarding stroke awareness are needed in France. Educational campaigns must stress the risk factors and symptoms of stroke and the appropriate response in the hopes of reducing admission delay and improving stroke prevention.

Unlabelled: The significance of early ischemic changes (EICs) on CT remains controversial. MRI may provide relevant information in patients with EICs., Methods: EICs were assessed in patients with acute ischemic stroke. MRI was promptly performed at presentation after CT and repeated on day 1. The relationship between EICs and MRI parameters was assessed with one-way ANOVA for analysis of continuous variables and by the chi2 test for the analysis of variables with a binary outcome., Results: Fourty-eight patients underwent CT and MR imaging before treatment with recombinant tissue plasminogen activator (age: 63 +/- 14 years). EICs were graded as absent in 28 patients, <33% in 15 patients, and >33% of the middle cerebral artery (MCA) territory in 5 patients. NIHSS score was higher in patients with EICs that covered more than one third of the MCA territory (19 +/- 3) compared to those without EICs (12 +/- 5; p = 0.04). Patients who had major EICs had a larger acute lesion volume in diffusion-weighted imaging (DWI; 140 +/- 78 cm3) compared to those without EICs (33 +/- 51 cm3, p < 0.0001). Regional cerebral blood flow, regional cerebral blood volume, time to peak and mean transit time values were not significantly different in the study groups., Conclusion: EICs reflect mainly a larger DWI lesion., (Copyright 2004 S. Karger AG, Basel)

Background: Old asymptomatic microbleeds (MBs) visualized on T2-weighted MRI are indicative of microangiopathy. They may be a marker of increased risk of intracerebral hemorrhage (ICH) following thrombolysis. However, data regarding this potential risk are limited., Methods: A retrospective analysis of pretreatment T2-weighted MRI was performed in consecutive stroke patients who received intravenous tissue plasminogen activator (tPA). We aimed to assess the impact of MBs on the risk of cerebral bleeding. The frequency and location of MBs were assessed and compared with the location of ICH after thrombolysis., Results: Forty-four patients were studied. MBs were present on pretreatment MRI in 8 cases (18.2%). At day 1, symptomatic ICH occurred in none of 8 patients with MBs versus 1 of 36 patients without (NS). At day 1, ICH occurred in 3 of 8 patients with MBs versus 10 of 36 patients without (NS). At day 7, symptomatic ICH occurred in 1 of 8 patients with MBs versus 2 of 36 patients without (NS). At day 7, ICH occurred in 5 of 8 patients with MBs versus 12 of 36 patients without (NS). No ICH occurred at the site of an MB. ICH occurred within the ischemic area in all patients who bled., Conclusions: Our study suggests that stroke patients with a small number of MBs on pretreatment MRI could be treated safely with thrombolysis. Larger prospective studies are needed to address the predictive value of detection of MBs with regard to the risk of tPA-induced ICH., (Copyright 2004 S. Karger AG, Basel)

Prediction of hemorrhagic transformation (HT) in patients treated by intravenous recombinant tissue-type plasminogen activator (rt-PA) is a challenging issue in acute stroke management. HT may be correlated with severe hypoperfusion. Signal changes may be observed at susceptibility-weighted magnetic resonance imaging (MRI) within large perfusion defects. A signal drop within cerebral veins at T2*-weighted gradient-echo MRI may be expected in severe ischemia, and may indicate subsequent risk of HT. The authors prospectively searched for an abnormal visibility of transcerebral veins (AVV) within the ischemic area in patients with hemispheric ischemic stroke, before they were treated with intravenous rt-PA therapy. Any correlation between AVV and baseline clinical or MRI findings, or further HT, was noted. An AVV was present in 23 of 49 patients (obvious, n = 8; moderate, n = 15), and was supported by severe hemodynamic changes at baseline MRI. The AVV was correlated with the occurrence of parenchymal hematoma type 2 at computed tomography during the first week (r = 0.44, P = 0.002). Five of six type 2 parenchymal hematomas occurred in association with obvious AVV. At multiple regression analysis, two baseline MRI factors had an independent predictive value for HT risk during the first week: the AVV and the cerebral blood volume ratio (Nagelkerke R2 = 0.48).

Purpose: Effective collateral blood flow seem to be an important factor associated with a small infarct volume and a good clinical outcome. We aimed to assess leptomeningeal collateral blood flow on source perfusion-weighted images in patients with acute stroke., Materials and Methods: 29 patients with proximal middle cerebral artery occlusion (MCA alone, n=17; MCA + internal carotid artery [ICA] occlusion, n=12) were evaluated with MRI at baseline before thrombolytic therapy, and at day 60. Clinical evaluation was performed at days 0 and 60 with the National Institutes of Health Stroke Scale (NIHSS) score, and at day 60 with the modified Rankin score. We assessed (on source images of the dynamic contrast-enhanced T2*-weighted perfusion [PWI] sequence) the presence of a hypointensity consistent with delayed contrast arrival within the global perfusion deficit (delayed perfusion sign). We analyzed the extent of the area demonstrating such delayed perfusion (DP area) on source images of the PWI sequence, and compared it with the global perfusion (GP) abnormality shown by time-to-peak maps. We calculated the Spearman rank correlation coefficient between the DP/GP ratio and: 1. age; 2. clinical scores; 3. site of occlusion [MCA alone versus ICA+MCA occlusion]; 4. DWI lesion size at day 0, and T2WI lesion size at day 60; 5. PWI-derived parameters (time-to-peak [TTP], relative cerebral blood volume [rCBV], relative cerebral blood flow [rCBF], and peak height). All tests were bilateral and a p value<0.05 was considered as significant., Results: Delayed perfusion areas of various size were found within the global perfusion deficit in all patients. High DP/GP ratio values were significantly correlated with: 1. better clinical scores at day 0 and day 60 (all p<=0.04); 2. smaller lesions at day 0 DWI and at day 60 T2WI (all p<=0.004); 3. ICA patency (r=0.49, p=0.01); 4. lower TTP delays, and higher values of rCBV, rCBF, and peak height., Conclusion: These preliminary data suggest that a delayed contrast filling observed on native perfusion-weighted images may be a marker of leptomeningeal collateral blood flow, and may lead to better clinical and morphological outcomes in acute ischemic stroke.

The authors studied 16 consecutive cases of cerebral venous thrombosis (CVT). Clinical outcome was good or excellent in 14 patients. Comprehensive hypercoagulable screening was done at least 3 months after the onset of CVT, including evaluation of genetic coagulation disorders and plasma levels of homocysteine and factor VIII. This screening was positive in 12 patients (75%). An acquired prothrombotic factor was identified in 9 of these 12 patients. Elevation of factor VIII plasma level was the most common coagulation disorder (8 patients).

We report the case of a 72-year-old left-handed woman presenting with episodes of paresthesias of the left arm and dysarthria consistent with transient ischemic attacks. The diffusion MRI showed hypersignals of the right corona radiata suggesting recent ischemic process whereas gradient-echo MRI revealed multiple small hypointense regions consistent with petechial hemorrhages restricted to the corticosubcortical regions. Gadolinium-enhanced, T1-weighted MRI showed focal meningeal enhancement. The diagnosis of cerebral amyloid angiopathy was supported by leptomeningeal biopsy. The association of ischemic suffering, petechial haemorrhage and meningeal enhancement as demonstrated by multisequence MRI highly suggest a cerebral amyloid angiopathy.

In patients with acute ischemic stroke, early recanalization may save tissue at risk for ischemic infarction, thus resulting in smaller infarcts and better clinical outcome. The hypothesis that clinical and diffusion- and perfusion-weighted imaging (DWI, PWI) parameters may have a predictive value for early recanalization and final infarct size was assessed. Twenty-nine patients were prospectively enrolled and underwent sequential magnetic resonance imaging (1) within 6 hours from hemispheric stroke onset, before thrombolytic therapy; (2) at day 1; and (3) at day 60. Late infarct volume was assessed by T2 -weighted imaging. At each time, clinical status was assessed by the National Institutes of Health Stroke Scale (NIHSS). Twenty-eight patients had arterial occlusion at day 0 magnetic resonance angiography (MRA). They were classified into two groups according to day 1 MRA: recanalization (n = 18) versus persistent occlusion (n = 10). Any significant differences between these groups were assessed regarding (1) PWI and DWI abnormality volumes, (2) relative and absolute time-to-peak (TTP) and apparent diffusion coefficient within the lesion on DWI; and (3) day 60 lesion volume on T2 -weighted imaging. Univariate and multivariate logistic regression analysis showed that the most powerful predictive factors for recanalization were lower baseline NIHSS score and lower baseline absolute TTP within the lesion on DWI. The best predictors of late infarct size were day 0 lesion volume on DWI and day 1 recanalization. Early PWI and DWI studies and day 1 MRA provide relevant predictive information on stroke outcome.

Background and Purpose: We designed a prospective sequential pretreatment and posttreatment MRI study to assess the relation between neuroimaging parameters and clinical outcome in patients treated with intravenous recombinant tissue-type plasminogen activator (rtPA)., Methods: Patients with symptoms of acute hemispheric ischemic stroke were recruited. The National Institutes of Health Stroke Scale (NIHSS) score was assessed at baseline and at days 1, 7, and 60, and the modified Rankin scale (mRS) at day 60, by which outcome was classified in terms of independence (mRS score 0, 1, or 2) or severe disability or death (mRS score 3 through 6), was assigned. Multimodal stroke MRI was performed at presentation and repeated at day 1. MRI procedures included magnetic resonance angiography, T2* gradient-echo sequence, echoplanar imaging, and isotropic diffusion- (DWI) and perfusion-weighted (PWI) imaging. Patients were treated with intravenous rtPA after MRI completion., Results: Twenty-nine patients (16 men and 13 women; mean+/-SD age, 65+/-14 years) underwent MRI; the mean time from symptom onset to treatment was 255+/-62 minutes. Twenty-six patients had a vessel occlusion, and 15 patients experienced a partial (Thrombolysis in Myocardial Infarction [TIMI]-2) or total (TIMI-3) recanalization at day 1, whereas 11 patients had a persistent occlusion. Mean NIHSS scores at day 60 were 5.7+/-5.4 if recanalization had occurred and 14+/-2 in cases of persistent occlusion. According to the mRS, 13 patients were independent (mRS 0 through 2), whereas severe disability or death (mRS 3 through 6) was observed in 15 patients. A better outcome was observed when recanalization was achieved (r=-0.68, P=0.0002). PWI volume and time to peak (TTP) within the DWI lesion assessed before therapy were correlated with day-60 NIHSS score (PWI volume: r=0.51, P=0.006, TTP: r=0.35, P=0.07). The day-0 DWI abnormality volume was well correlated with day-60 NIHSS score (r=0.58, P=0.001). Multiple regression linear analysis showed that 2 factors mainly influenced clinical outcome: (1) recanalization, with a high correlation with NIHSS score at day 60 (P=0.0001) and (2) day-0 DWI lesion volume, which is closely associated with day-60 NIHSS score (P=0.03)., Conclusions: Baseline DWI volume and recanalization are the main factors influencing clinical outcome after rtPA for ischemic stroke.

A 78-year old man developed an acute intracranial hypertension followed by central left facial palsy. CT Scan and MRI revealed an ischemia within the right lenticulostriate arteries territory and a hemorrhagic infarction of a pituitary adenoma without extrinsic carotid artery compression. Neuroophthalmologic examination and hormonal screening were normal. Though pituitary apoplexy and stroke might represent a fortuitous association, several mechanisms underlying such clinical picture are advanced.

Fabry's disease, also called angiokeratoma corporis diffusum universal, is a rare cause of stroke in the young. We report the case of a 39-year-old man who presented with relapsing vertebro-basilar ischemic strokes. Biological tests showed the presence of an aseptic meningitis and a biological inflammatory syndrome, suggesting a particularly progressive illness. The possible mechanisms involved in this exceptional association are discussed.

Background and Purpose: T2*-weighted gradient-echo MRI is known to detect old microbleeds (MBs), considered indicative of microangiopathy. MBs might be a potential risk factor for early cerebral bleeding (CB) after ischemic stroke. Therefore, we assessed the impact of MBs on the occurrence of CB after cerebral infarction., Methods: We included prospectively stroke patients who had documented ischemic damage. The imaging protocol involved baseline CT scan, T2*-weighted gradient-echo MRI, diffusion-weighted imaging, T2-weighted imaging, and magnetic resonance angiography and had to be performed within 24 hours after symptom onset. The assessment of CB with T2*-weighted gradient-echo sequence necessitated a focal area of signal loss either within the ischemic area revealed by diffusion-weighted imaging or remote from it. Old MBs were defined on T2*-weighted images as homogeneous rounded areas of signal loss without surrounding edema. CT scan was systematically repeated within the first week to verify CB as diagnosed by the T2* weighted sequence., Results: One hundred patients (mean age, 60 +/- 13 years; range, 19 to 83 years; 58 men, 42 women) met the inclusion criteria. MBs were seen in 20 patients on T2*-weighted imaging. Multivariate logistic regression analysis revealed that age, diabetes, previous use of antithrombotic drugs, evidence of an atherothrombotic source of stroke, and lacunar infarct were significantly associated with MBs (P<0.0001). CB was diagnosed in 26 patients: at the acute stage by T2*-gradient echo sequence in 18 patients and with CT scan performed within the first week in 8 patients. Multivariate logistic regression analysis showed that baseline National Institutes of Health Stroke Scale score, diabetes, and MBs were considered significant and independent predictors of CB (P<0.001)., Conclusions: Although the pathogenesis of CB after ischemic stroke is multifactorial, the increased observation of CB in patients with MBs suggests that the associated vascular vulnerability contributes to CB.

An 81-year old man presented with a sudden right ataxic hemiparesis. Brain CT scan showed a left anterior choroidal artery territory infarction. Biological signs of inflammation were present without any evidence of infection or neoplasm. The patient's clinical status deteriorated with fever, loss of weight and confusion. Muscle biopsy showed characteristic abnormalities of polyarteritis nodosa (PAN). Oral corticosteroids plus monthly pulse intravenous cyclophosphamide were started. A rapid clinical improvement was observed as well as the resolution of inflammation within one month. Twenty months later, the patient had recovered normal cognitive function and was able to carry out all usual activities. We describe the CNS complications of PAN and the therapeutic options.

The presence of a thrombus on initial arteriography is directly related to the baseline NIHSS score. Magnetic resonance angiography (MRA) offers a noninvasive and rapid assessment of large cerebral vessel patency. We aimed at evaluating (1) the baseline NIHSS score as a tool for predicting the likelihood of an occluded artery on MRA and (2) the course of stroke within the first week according to the presence of a cerebral arterial occlusion. Patients were enrolled in this prospective study according to the following criteria: (1) acute cerebral ischemia with a neurological deficit lasting >1 h, and (2) brain MRI performed within 24 h of stroke onset. The NIHSS score assessment was performed on admission and at day 1 and day 7. The MRI protocol included: (1) T2-weighted Turbo spin echo, (2) echo-planar imaging isotropic diffusion, (3) T2*-gradient echo sequence, and (4) time of flight MRA (3D TOF Turbo MRA). The presence of a symptomatic cerebral arterial occlusion on MRA was systematically screened. Fifty-four patients were studied. Median age was 60 years. Mean time from stroke onset to NIHSS assessment was 170 +/- 95 min. The mean baseline NIHSS score was 13.5 +/- 7.3. The mean time from stroke onset to MRI was 384 +/- 171 min. MRA was readable in 50 cases. An arterial occlusion was detected in 23 patients (46%). The median baseline NIHSS score was significantly higher in the group of patients with occlusion than in the group of patients without occlusion (18 vs. 7, p = 0.01). The predictive probability to demonstrate an arterial occlusion was related to the baseline NIHSS score. None of the patients with an NIHSS score of 1-6 (11 patients) had visible occlusion, whereas 9 (43%) out of 21 patients with an NIHSS score of 7-15 and 14 (78% ) out of 18 patients with an NIHSS score above 16 had an arterial occlusion. For an increase by one point in the NIHSS score, the odds ratio for the presence of occlusion was 1.28 (95% CI: 1.11-1.46). The course of the stroke as assessed by follow-up NIHSS score was significantly more severe if an occlusion was detected. Median day 0, day 1 and day 7 NIHSS score were, respectively, 18, 16 and 13 in patients who had an occlusion versus 7, 4 and 0 in patients who had no visible occlusion (p < 0.01). A direct relation between the baseline NIHSS score and the likelihood of the presence of an occlusion on initial MRA is demonstrated. The presence of a cerebral arterial occlusion on MRA is significantly linked to a poor neurological outcome., (Copyright 2002 S. Karger AG, Basel)

Background and Purpose: Intravenous tissue plasminogen activator improves outcome after ischemic stroke when given within 3 hours of symptoms onset in carefully selected patients. However, only a small proportion of acute stroke patients are currently eligible for thrombolysis, mainly because of excessive delay to hospital presentation. We sought to determine the factors associated with early admission in a French stroke unit., Methods: We prospectively studied the admission delay of acute stroke patients in a French stroke unit during a 12-month period ending July 1999. Univariate and multivariate regression analyses were performed to evaluate the factors influencing early stroke unit admission and transport by the Emergency Medical Services (EMS) or Fire Department (FD) ambulances., Results: One hundred sixty-six patients were primarily admitted to the stroke unit, with a median admission time of 4 hours 5 minutes. Twenty-nine percent presented within 3 hours of symptoms onset and 75% within 6 hours. Univariate analysis showed that early stroke unit arrival was significantly associated with the following factors: female sex, stroke severity assessed by the National Institutes of Health Stroke Scale score, lowered consciousness, sudden onset of stroke, not living alone, recognition of symptoms by bystanders, and transport by EMS or FD ambulances. Age, ethnicity, level of education, employment status, nocturnal onset, distance from place of stroke to the stroke unit, stroke lesion location, presence of brain hemorrhage, and awareness about the symptoms and risk factors of stroke had no measurable effect on early admission. A multivariate regression model demonstrated that the most significant factors associated with early stroke unit arrival were transport by EMS or FD ambulances and sudden onset of stroke. Female sex and not living alone were also significantly associated with early admission in the multivariate model. Multivariate analysis of the mode of transport showed that transport by EMS or FD ambulances was significantly more frequent among female patients, when stroke symptoms were recognized by bystanders, and when the general practitioner was not the first medical contact., Conclusions: The present study shows that hospital arrival within the first hours of stroke is feasible in a French stroke unit. As many as 75% of the patients are admitted within the first 6 hours of stroke. This is the first study demonstrating that stroke unit admission in France is fastest in patients brought to the hospital by EMS or FD ambulances. However, only 35% of stroke patients activate the emergency telephone system and are currently transported by EMS or FD ambulances. French stroke patients should be encouraged to seek immediate medical attention by using the emergency telephone system, and stroke management should be reprioritized in the French EMS as a time-dependent medical emergency, with the same level of organization and expertise currently applied to myocardial infarction.

The authors describe the outcome of five patients with a cardiac thrombus selected among 183 patients with stroke (2.7 %) who were given IV tissue plasminogen activator (tPA). No early systemic or cerebral embolism occurred. Two patients made a complete recovery at 3 months. Two patients had a moderate outcome. One patient had late recurrent cerebral embolism and died. These data suggest that the presence of a cardiac thrombus is not associated with a high risk of recurrent embolism in patients with stroke who are given IV tPA.

The use of T2*-weighted sequences has been advocated for early differentiation between hematoma and ischemia in patients with acute stroke. Early hemorrhagic transformation of ischemic stroke is an adverse event which may occur under treatment and may impair the prognosis: our aim is to evaluate the ability of T2*-weighted gradient-echo sequence (T2* GRE) to detect post-ischemic cerebral hemorrhage. The imaging procedure included: (1) baseline CT scan at admission. (2) MRI performed within 24 h of therapy onset including: (a) dual fast spin echo T2 sequence, (b) axial isotropic echoplanar diffusion-weighted imaging sequence, (c) conventional T2* GRE, and (d) 3D TOF turbo MRA. Post-ischemic cerebral hemorrhage was diagnosed if T2* GRE detected a focal intraparenchymal area of signal loss. The diameter of this lesion had to be more than 5 mm in order to eliminate past microbleeds. (3) Patients who showed an early suspicion of bleeding on MRI promptly had a second CT scan, and, if this one was negative for bleeding, another CT scan was performed 1 day later. All the other patients had a control CT scan during the first week. Forty-five consecutive patients have been included. T2* GRE showed intracranial bleeding in seven. The diagnosis of post-ischemic cerebral bleeding was confirmed by CT in all patients. Control CT scans did not reveal any post-ischemic cerebral hemorrhage in patients with negative MRI. In one case, hemorrhage was seen earlier on MRI than on CT scan. In conclusion, T2* GRE appeared to be at least as efficient as CT scan in the detection of early post-ischemic cerebral hemorrhage.

Background and Purpose: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset., Methods: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke., Results: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1-30 cc). Four of the 10 "no-clot" patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5., Conclusion: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

Unlabelled: Standard magnetic resonance imaging (MRI) techniques failed to image adequately acute hemorrhagic transformation (HT). Therefore, computed tomography (CT) is still needed to exclude intracerebral hemorrhage. New MRI techniques such as diffusion- and perfusion-weighted imaging (DWI and PWI) may improve the early detection of HT. The utility of this approach requires a direct comparison of the sensitivity of CT with these MRI techniques., Methods: Nine patients experienced an acute carotid artery territory ischemic stroke diagnosed on a first CT performed 3.8 +/- 2 h after the onset of stroke. They underwent a second CT 12 +/- 4 h after the onset of stroke, followed 35 +/- 10 min later by an MRI protocol including: (1) an axial isotropic DWI SE echo-planar imaging (EPI) sequence; (2) time of flight MR angiography (TOF MRA); (3) PWI with an axial T(2)*-weighted gradient echo EPI sequence using 20 ml gadolinium contrast agent (Gd-DTPA); HT was characterized on DWI SE EPI as a heterogeneous area of signal loss within the ischemic area; (4) at day 7, CT was also performed in all patients who had an early suspicion of bleeding according to MRI., Results: An HT was detected exclusively with CT in 1 out of 9 patients, while an MRI pattern of HT was found in 6 out of 9 patients. In 5 of these 6 patients, the CT scan did not show an obvious pattern of HT. Day 7 CT confirmed HT in all patients who had early suspicion of bleeding according to DWI criteria., Conclusion: This study suggests that new MRI techniques may allow an early detection of HT, thus improving the management of stroke., (Copyright 2001 S. Karger AG, Basel)

The authors describe the outcomes in 11 patients who had acute ischemic stroke related to internal carotid artery (ICA) dissection and were treated with IV tissue plasminogen activator (tPA). One symptomatic intracerebral hemorrhage occurred 36 hours after tPA was given. The mean day 90 modified Rankin Scale (m-RS) score was 2.4 (+/-1.6). No death was observed at 3 months. Four patients of 11 (36.4%) made an excellent recovery (day 90 m-RS score: 0 to 1). This study demonstrates the feasibility of IV thrombolysis with tPA (0.8 mg/kg) in ischemic stroke related to ICA dissection within the first 7 hours.

Mutism defined as a complete loss of speech may be related to psychiatric or neurologic disorders. The ischemic stroke origins of mutism are often difficult to assess at the acute stage. Accordingly, the search for the underlying mechanism as the localization of the damages may be difficult by conventional radiological techniques. Diffusion-weighted (DWI) MRI may accurately identify patients with acute ischemic stroke and distinguish them from those who mimic acute stroke better than clinical and conventional neuroradiological methods. This report aims to demonstrate the utility of DWI-MRI in the diagnosis of acute mutism., (Copyright 2000 S. Karger AG, Basel.)

Objective: To study the possible specific response to recombinant tissue plasminogen activator (rtPA) thrombolysis of anterior choroidal artery (AChA) stroke., Background: Outcome and response after rtPA thrombolysis are possibly better in small-vessel infarcts, but a specific study of AChA stroke has not yet been performed., Methods: The authors proposed an open trial of IV rtPA within 7 hours in patients age 20 and 81 years with all types of internal carotid artery territory stroke if the baseline Scandinavian Stroke Scale (SSS) score was less than 48. A dose of rtPA 0.8 mg/kg was infused over 90 minutes. Of 114 consecutive patients, 9 patients (7.9%) exhibited hypodensity in the AChA territory on day 1 brain CT., Results: Seven of nine patients with AChA infarct had a primary early recovery within 6 hours after the initiation of rtPA infusion. In addition, recovery was complete in five patients and partial in two patients. No intracerebral hematoma was observed. Three patients had a "reinfarct syndrome" at 12, 25, and 48 hours respectively. However, in the two latter patients treated with IV heparin, the deficit disappeared again with the increase of heparin dose in one patient and disappeared spontaneously in the other patient. The overall outcome at day 90 was six total recoveries in nine patients (66%). Patients with a final good outcome had a slight "unstructured" hypodensity in the AChA territory on day 1 brain CT, whereas patients with a bad outcome had the classic "structured" hypodensity of AChA territory stroke., Conclusion: These data support a specific quick response of AChA territory stroke to IV rtPA thrombolysis, probably due to the small size of the artery and of the "clot." The high frequency of the reinfarct syndrome is a clinical fact that is difficult to explain. Efficient heparin treatment after 24 hours may control the reinfarct syndrome in some patients.

This report describes the observations of two patients with a several years' history of multiple sclerosis who presented sudden neurologic impairment. The symptomatology was suggestive of a non-convulsive partial status epilepsy. The clinical presentation was a paroxysmal dysphasic phenomenon in the first case without any consciousness impairment, associated with slight right hemiparesis. Electroencephalographic investigations revealed asymmetrical patterns, left-sided slow waves and periodic lateralized epileptiform discharges (PLEDs). Antiepileptic treatments were partially effective and intravenous steroids were needed for complete recovery. For the second patient, clinical presentation was acute psychiatric symptoms with disorientation, alternating manic symptomatology and mutism. Electroencephalography showed left fronto-central rhythmic continuous slow wave and spike wave activity. Intravenous antiepileptic treatment quickly improved the symptomatology. These observations draw attention to the fact that an epileptic cause should not be ruled out when a patient with multiple sclerosis presents sudden neurologic or psychiatric impairment. An early diagnosis allows immediate antiepileptic treatment. Intravenous steroids can be added to stop seizures.

Basilar artery thrombosis should be diagnosed immediately, as intra-arterial thrombolysis might improve the outcome. Diffusion-weighted (DWI)-MRI and three-dimensional time-of-flight MR angiography (3D TOF Turbo MRA) may provide additional insight into the extent of ischemia and the level of the occlusion. These methods could be helpful in the early classification of vertebrobasilar stroke, thus reserving the use of conventional angiography and possible intra-arterial thrombolysis for patients who had a severe clinical picture explained by preliminary assessments. We report the case of a 74-year-old woman who experienced a basilar artery occlusion; DWI-MRI and 3D TOF Turbo MRA provided noninvasive information concerning the level of arterial occlusion and its parenchymal ischemic impact, this leading to an intra-arterial thrombolytic therapy. These data suggest the feasibility of a noninvasive urgent diagnostic and prognostic approach with DWI-MRI and 3D TOF Turbo MRA in basilar occlusion.

Background and Purpose: The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH., Methods: Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3., Results: Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04)., Conclusions: Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.

A simultaneous decrease of cerebral blood volume (CBV) and cerebral blood flow (CBF) has been described after subcortical stroke with positron emission tomography. However, this imaging modality cannot be applied routinely to stroke patients. Dynamic susceptibility contrast-enhanced MRI techniques (DSC-MRI) might be interesting in the assessment of these effects. Dynamic T2-weighted echo planar imaging was used to produce DSC-MR images during an intravenous bolus injection of gadopentetate dimeglumine in 9 patients who experienced a subcortical stroke involving thalamus or basal ganglia and in 8 control subjects. A series of 50 consecutive images at 1-second intervals was acquired at the anatomic level of the centrum semiovale quite distant from the subcortical lesion, rCBF and rCBV were determined over frontal and parietal regions of interest and through the entire cortical mantle. DSC-MRI enabled the detection of hemodynamic changes induced by subcortical stroke. Analysis of rCBV and rCBF values showed that the hemodynamic parameters were significantly decreased on the affected side. In controls mean rCBF and rCBV values recorded over the whole cortical mantle of each hemisphere showed no significant interhemispheric asymmetry.

Abnormal intracranial venous drainage called cerebral venous angioma is usually asymptomatic. Hemorrhages and seizures may however occur. The malformation may rarely be revealed by thrombosis. We report the case of a 25-year-old right-handed woman who developed cortical thrombophlebitis subsequent to developmental venous anomalies. After a course of anticoagulant therapy, outcome was good, demonstrating that anticoagulant therapy may be indicated in spite of the high risk of hemorrhage.

Background and Purpose: Although new, large, double-blind, randomized studies are needed to establish the efficiency of intravenous thrombolysis, open trials of sufficient size may also provide novel data concerning specific outcomes after thrombolysis., Methods: An open study of intravenous rtPA in 100 patients with internal carotid artery (ICA) territory strokes between 20 and 81 years of age, with a baseline Scandinavian Stroke Scale (SSS) score of <48 at entry was conducted. Inclusion time was within 7 hours after stroke onset. rtPA (0.8 mg/kg) was infused for 90 minutes, with an initial 10% bolus. Heparin was given according to 3 consecutive protocols. The SSS evaluation was done on days 0, 1, 7, 30, and 90. CT scan was performed before treatment, on days 1 and 7. Etiological investigations included echocardiography and carotid Doppler sonography and/or angiography. Outcome at 1 year was documented by SSS score, the modified Rankin Scale (mRS) score, and a 10-point invalidity scale. Multivariate logistic regression was used to identify predictors of poor versus good outcome., Results: At day 90, 45 patients (45%) had a good result, defined as complete regression or slight neurological sequelae (mRS score of 0-1), 18 patients had a moderate outcome (mRS 2-3), and 31 patients had serious neurological sequelae (mRS 4-5). Six patients died, 2 with intracerebral hematoma after immediate heparin. Five of 11 patients (45.5%) treated between 6 and 7 hours had a good result. The overall intracerebral hematoma rate was 7%. Higher values of fibrin degradation products at 2 hours were observed in the subgroup with intracerebral hematomas. Significant predictors of poor outcome on multivariate logistic regression analysis were baseline SSS score of <15 (odds ratio [OR], 3.38; 95% confidence interval [CI], 1.07 to 10. 74; P=0.04), indistinction between white and gray matter on CT scan (OR, 6.59; 95% CI, 2.19 to 19.79; P=0.0008), and proximal internal carotid thrombosis (OR, 3.29; 95% CI, 0.99 to 10.95; P=0.05)., Conclusions: Our study confirms the safety of intravenous rtPA at a dose of 0.8 mg/kg and suggests efficacy for this drug even within 7 hours. Outcome and hematoma rates were at least as favorable as for trials of therapy with a 3-hour time window. Subgroups with a poor prognosis include low baseline neurological score, baseline CT changes, and proximal ICA thrombosis. However, approximately 30% of patients with each of these characteristics show a good outcome, so their inclusion in future routine rtPA protocols is still justified.

Background: Native valve strands might be related to the acute stage of thrombosis or might suggest a long-term valvular change. We aimed to estimate changes in the strands in patients with stroke through a serial transesophageal echocardiographic (TEE) study., Methods and Results: A study was conducted among patients who were referred for TEE for stroke or cardiac pathology. Patients had TEE examinations with a 5-MHz multiplane TEE probe. Echocardiography was repeated 3 months later in patients with stroke. TEE was performed in 180 patients admitted to cardiology units and in 160 patients referred to neurology units. Among 34 patients with valvular strands, 30 were referred to neurology for stroke, whereas 4 patients were admitted to cardiology (18.8% versus 2.2%, difference 16.5%, 95% confidence interval 10% to 22.9%, P =.001). Strands were located on the mitral valve in 16 patients, the aortic valve in 6 patients, and both left heart valves in 8 patients. Among the 38 valves with strands, 17 (44. 7%) were morphologically normal, 4 (10.5%) were thickened, 7 (18.4%) were redundant, and 10 (26.3%) had both abnormalities. TEE showed other abnormalities in 16 (53.3%) patients, whereas 14 patients had only strands. Twenty-six (86.6%) patients had a second TEE study 3 months later. Strands were not found in 4 (15.4%) patients (95% confidence interval 4.3% to 34.9%)., Conclusions: Valvular thickening or redundancy may predispose valves to strand formation. Native valve strands usually persist and thus reflect a chronic valvular change.

We report a case of spontaneous intracerebral hemorrhage occurring in a young woman and revealing Addison's disease. This autoimmune primary adrenocortical insufficiency was associated with premature ovarian failure. Exhaustive research for nonhypertensive causes of intracerebral hemorrhage was negative. Initial coagulation studies disclosed severe hypofibrinogenemia and prolonged prothrombin time related to vitamin K-dependent coagulation factor deficit. Clotting abnormalities cleared at 4 months under treatment with hydrocortisone. Glucocorticoids are potent regulators of fibrinogen biosynthesis, increasing fibrinogen secretion. We conclude that primary adrenocortical insufficiency induced this hemorrhagic diathesis leading to spontaneous intracerebral hemorrhage. This latter has never been reported in Addison's disease. Primary adrenocortical insufficiency should be considered as a rare potential cause of nonhypertensive intracerebral hemorrhage.

The occurrence of intracerebral hemorrhage during an acute attack of migraine remains questionable. A normotensive migrainous woman experienced multiple intracerebral hemorrhages. No drug abuse was recorded, but bleeding occurred after the use of several antimigrainous drugs. Angiography revealed severe vasospasm of both anterior cerebral arteries. Subsequent brain MRI and MRI angiography failed to show any vascular abnormalities. Echocardiography and an exhaustive biological evaluation ruled out an alternative condition favoring intracerebral hemorrhage. Multiple intracerebral hemorrhages in migraine may exceptionally be related to vasospasm leading to arterial wall injury. Intracranial arterial vasospasm could be precipitated by excessive vasoactive therapy.

Thalamic lesions may induce a diffuse hypometabolism and subsequent decrease of cortical cerebral blood flow (rCBF) and cerebral blood volume (rCBV). Up to now PET was used to assess these changes. However this latter method cannot be applied routinely to stroke patients because it is expensive and not currently available. The purpose of this preliminary study was to evaluate the effects of 'pure metabolic depression' induced by thalamic stroke on rCBV and rCBF by using a non invasive method perfusion-MRI. Two patients experienced aphasia, with motor and sensory impairment related to thalamic hemorrhage. Four weeks later, dynamic T2*-weighted echo planar imaging was used to produce perfusion-MR images during an intravenous bolus injection of gadopentetate dimeglumine. A decrease of cortical rCBV and rCBF mainly confined to sensorimotor cortex was observed in both cases ipsilateral to the lesion. Although a sequential assessment of this abnormalities is needed in a larger series of patients in order to establish relevant correlations with neurological status, this preliminary study indicates that perfusion-MRI might be a practical and promising tool in the assessment of cortical rCBV and rCBF changes.

Background: There is increasing evidence that serotonergic neurotransmission may be damaged in poststroke pathological crying. A correlation between the clinical severity of pathological crying and the size of stroke-induced serotonergic pathway lesions is commonly accepted. We present a case of severe pathological crying after a limited left anterior choroidal artery territory infarction., Case Description: A right-handed 55-year-old man who was a heavy smoker was admitted to the hospital after a right hemiplegia of sudden onset. Clinical examination revealed a right global hemiplegia including the face and a right hemihypoesthesia. Cerebral CT scan and MRI showed an infarct in the retrolenticular part of the posterior limb of the left internal capsule extending upward into the posterior paraventricular corona radiata region. Transesophageal echocardiography revealed an atrial septal aneurysm of 15-mm excursion without associated patent foramen ovale. From the first day of admission, the patient exhibited very frequent and intense fits of pathological crying. Their persistence led to initiation of treatment with the selective serotonin reuptake inhibitor paroxetine on day 30. Complete and immediate resolution of pathological crying occurred 24 hours after onset of therapy. Follow-up examination at day 90 confirmed the absence of relapse of pathological crying., Conclusions: We conclude that poststroke pathological crying in our patient may have been due to unilateral disruption of the capsular ascending projections of the serotonergic brain stem raphe nuclei. A small left-sided capsular lesion may have led to severe pathological crying. This disabling condition may be reversible with selective serotonin reuptake inhibitor therapy.

We report a case of a left alien hand syndrome without grasp reflex, inter-manual conflict or sensory impairement after an infarction involving the striatum, premotor lateral cortex and colossal fibers but sparing medical premotor cortex. According to the location of the lesion, the mechanism underlying this clinical feature might mainly involve cortico-putamino-thalamo-cortical loop which links extrapyramidal system to medial premotor cortex.