Stéphane Derrey, Romain Lefaucheur, Nathalie Chastan, Emmanuel Gérardin, Didier Hannequin, Marie Desbordes and David Maltête
A collision/implantation or microlesion effect is commonly described after subthalamic nucleus (STN) implantation for high-frequency stimulation, and this is presumed to reflect disruption of cells and/or fibers. Off-period dystonia, a frequent cause of disability in patients with advanced Parkinson disease, can lead to the need for surgical treatment. The authors assessed the early effect of this microlesion on off-period dystonia.
The authors assessed 30 consecutive patients with the advanced levodopa-responsive form of Parkinson disease. The patients' symptoms were Hoehn and Yahr Scale score ≥ 3, the mean duration of their disease was 11.4 ± 3.5 years, and they had undergone bilateral implantation of electrodes within the STN for high-frequency stimulation between February 2004 and December 2006. The microlesion effect was defined by the clinical improvement (Unified Parkinson's Disease Rating Scale [UPDRS] Part III score, UPDRS Part IV, item 35) assessed the morning of the 3rd day following STN implantation, after at least a 12-hour withdrawal of dopaminergic treatment and before the programmable pulse generator was switched on (off-drug/off-stimulation mode).
Compared with baseline (off state), the microlesion effect improved the motor score (UPDRS Part III) by 27%. Subscores for tremor, rigidity, and bradykinesia respectively improved by 42, 37, and 25%. Nineteen patients (63%) suffered from off-period dystonia before surgery. Twelve (41%) reported complete relief of their symptoms in the immediate postoperative period and remained free of painful off-period dystonia throughout the 6-month follow-up period.
The author postulated that off-period dystonia alleviation may reflect both a microsubthalamotomy and micropallidotomy effect. They hypothesize, moreover, that the microlesion could play a role in the 6-month postoperative outcome.
François Proust, Emmanuel Gérardin, Stéphane Derrey, Sophie Lesvèque, Sylvio Ramos, Olivier Langlois, Eléonore Tollard, Jacques Bénichou, Philippe Chassagne, Erick Clavier and Pierre Fréger
The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context.
This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997–June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score ≤ 2) and unfavorable (mRS score > 2).
Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001).
The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.
François Proust, Olivier Martinaud, Emmanuel Gérardin, Stéphane Derrey, Sophie Levèque, Sandrine Bioux, Eléonore Tollard, Erick Clavier, Olivier Langlois, Olivier Godefroy, Didier Hannequin and Pierre Fréger
For anterior communicating artery (ACoA) aneurysms, endovascular coil embolization constitutes a safe alternative therapeutic procedure to microsurgical clip occlusion. The authors' aim in this study was to evaluate the quality of life (QOL), cognitive function, and brain structure damage after the treatment of ruptured ACoA aneurysms in a group of patients who underwent microsurgical clipping (36 patients) compared with a reference group who underwent endovascular coiling (14 patients).
At 14 months posttreatment all patients underwent evaluations by independent observers. These observers evaluated global efficacy, executive functions using a frontal assessment battery of tests (Trail making test, Stroop tasks, dual task of Baddeley, verbal fluency, and Wisconsin Card Sorting test), behavior dysexecutive syndrome (the Inventaire du Syndrome Dysexécutif Comportemental questionnaire [ISDC]), and QOL by using the Reintegration To Normal Living Index. Brain damage was analyzed using MR imaging.
In the microsurgical clipping and endovascular coiling groups, the distribution on the modified Rankin Scale (p = 0.19) and mean QOL score (85.4 vs 83.4, respectively) were similar. Moreover, the proportion of executive dysfunctions (19.4 vs 28.6%, respectively) and the mean score on the ISDC questionnaire (8.9 vs 8.5, respectively) were not significant, but verbal memory was more altered in the microsurgical clipping group (p = 0.055). Magnetic resonance imaging revealed that the incidence of local encephalomalacia and the median number of lesions per patient increased significantly in the microsurgical clipping group (p = 0.003).
In the 2 groups, no significant difference was observed regarding QOL, executive functions, and behavior. Despite the significant decrease in verbal memory after microsurgical clipping, the interdisciplinary approach remains a safe and useful strategy.
Thomas Clavier, Alexandre Mutel, Laurence Desrues, Antoine Lefevre-Scelles, Gioia Gastaldi, Mohamad El Amki, Martine Dubois, Anthony Melot, Véronique Wurtz, Sophie Curey, Emmanuel Gérardin, François Proust, Vincent Compère and Hélène Castel
Cerebral vasospasm (VS) is a severe complication of aneurysmal subarachnoid hemorrhage (SAH). Urotensin II (UII) is a potent vasoactive peptide activating the urotensin (UT) receptor, potentially involved in brain vascular pathologies. The authors hypothesized that UII/UT system antagonism with the UT receptor antagonist/biased ligand urantide may be associated with post-SAH VS. The objectives of this study were 2-fold: 1) to leverage an experimental mouse model of SAH with VS in order to study the effect of urotensinergic system antagonism on neurological outcome, and 2) to investigate the association between plasma UII level and symptomatic VS after SAH in human patients.
A mouse model of SAH was used to study the impacts of UII and the UT receptor antagonist/biased ligand urantide on VS and neurological outcome. Then a clinical study was conducted in the setting of a neurosurgical intensive care unit. Plasma UII levels were measured in SAH patients daily for 9 days, starting on the 1st day of hospitalization, and were compared with plasma UII levels in healthy volunteers.
In the mouse model, urantide prevented VS as well as SAH-related fine motor coordination impairment. Seventeen patients with SAH and external ventricular drainage were included in the clinical study. The median plasma UII level was 43 pg/ml (IQR 14–80 pg/ml). There was no significant variation in the daily median plasma UII level (median value for the 17 patients) from day 0 to day 8. The median level of plasma UII during the 9 first days post-SAH was higher in patients with symptomatic VS than in patients without VS (77 pg/ml [IQR 33.5–111.5 pg/ml] vs 37 pg/ml [IQR 21–46 pg/ml], p < 0.05). Concerning daily measures of plasma UII levels in VS, non-VS patients, and healthy volunteers, we found a significant difference between SAH patients with VS (median 66 pg/ml [IQR 30–110 pg/ml]) and SAH patients without VS (27 pg/ml [IQR 15–46 pg/ml], p < 0.001) but no significant difference between VS patients and healthy volunteers (44 pg/ml [IQR 27–51 pg/ml]) or between non-VS patients and healthy volunteers.
The results of this study suggest that UT receptor antagonism with urantide prevents VS and improves neurological outcome after SAH in mice and that an increase in plasma UII is associated with cerebral VS subsequent to SAH in humans. The causality link between circulating UII and VS after SAH remains to be established, but according to our data the UT receptor is a potential therapeutic target in SAH.