Objective:
Data regarding cerebral venous thrombosis in North Africa are scarce. This study aims to identify the clinical features, risk factors, outcome, and prognosis of cerebral venous thrombosis ...in Tunisia.
Methods:
Data of 160 patients with radiologically confirmed cerebral venous thrombosis, hospitalized in Mongi Ben Hmida National Institute of Neurology (Tunis, Tunisia), were retrospectively collected and analyzed.
Results:
The mean age was 37.3 years with a female predominance (83.1%). The mode of onset was subacute in most cases (56.2%). Headache was the most common symptom (71.3%), and focal neurologic symptoms were the main clinical presentation (41.8%). The most common sites of thrombosis were the superior sagittal sinus (65%) and the lateral sinus (60.6%). More than 1 sinus was involved in 114 (71.2%) patients. Parenchymal lesions observed in 85 (53.1%) patients did not correlate with cerebral venous thrombosis extent. Major risk factors were obstetric causes (pregnancy and puerperium) found in 46 (38.6% of women aged <50 years) patients, followed by anemia (28.1%) and congenital or acquired thrombophilia (16.2%). Mortality rate was of 6.6%. Good outcome at 6 months (modified Rankin Scale ≤2) was observed in 105 (87.5%)of 120 patients available for follow-up. Predictors of poor outcome were altered consciousness and elevated plasma C-reactive protein levels.
Conclusion:
Clinical and radiologic presentation of cerebral venous thrombosis in Tunisia was quite similar to other parts of the world with, however, a particularly high frequency of obstetric causes. Plasma C-reactive protein level should be considered as a prognostic factor in CVT.
Inferior vena cava (IVC) diameter variability with respiration measured by ultrasound was found to be useful for the diagnosis of heart failure (HF) in ED patients with acute dyspnea. Its value in ...identifying HF in acute exacerbation of chronic obstructive pulmonary disease exacerbation (AECOPD) was not specifically demonstrated.
To determine the value of ΔIVC in the diagnosis of HF patients with AECOPD.
This is a prospective study conducted in the ED of three Tunisian university hospitals including patients with AECOPD. During this period, 401 patients met the inclusion criteria. The final diagnosis of HF is based on the opinion of two emergency experts after consulting the data from clinical examination, cardiac echocardiography, and BNP level. The ΔIVC was calculated by two experienced emergency physicians who were blinded from the patient's clinical and laboratory data. A cut off of 15% was used to define the presence (< 15%) or absence of HF (≥ 15%). Left ventricular ejection fraction (LVEF) was also measured. The area under the ROC curve, sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic and predictive accuracy of the ΔIVC in predicting HF.
The study population included 401 patients with AECOPD, mean age 67.2 years with male (68.9%) predominance. HF was diagnosed in 165 (41.1%) patients (HF group) and in 236 patients (58.9%) HF was excluded (non HF group). The assessment of the performance of the ΔIVC in the diagnosis of HF showed a sensitivity of 37.4% and a specificity of 89.7% using the threshold of 15%. The positive predictive value was 70.9% and the negative predictive value was 66.7%. The area under the ROC curve was 0.71(95%, CI 0.65-0.76). ΔIVC values were not different between HF patients with reduced LVEF and those with preserved LVEF.
Our results showed that ΔIVC has a good value for ruling out HF in ED patients consulting for AECOPD.
Background Concomitant diagnosis of neuromyelitis optica spectrum disease and pulmonary tuberculosis has rarely been reported. Case report We report a case involving a young Tunisian male patient who ...developed dry cough followed, 2 months later, by weakness in the lower limbs. The findings of central nervous system imaging and anti-aquaporin-4 antibody positivity were compatible with the diagnosis of neuromyelitis optica spectrum disease. Constellation of the clinical and the typical radiological pulmonary findings in our patient, coming from an endemic region, allowed the diagnosis of pulmonary tuberculosis, although sputum smear examination for acid-fast bacilli and cultures was negative. The patient received anti-tuberculous polytherapy associated with immunomodulation, consisting of methylprednisolone and intravenous immunoglobulins. Pulmonary infection symptoms initially improved but with no motor recovery. The patient suddenly died at home 4 months after the onset of the first symptoms. Current data regarding the clinical presentation of this underreported concomitant or associated condition, the possible pathophysiological mechanisms, and the therapeutic options were reviewed. Conclusions This case underscores the necessity to understand the exact mechanism of these coincident entities and to clarify the best immunomodulatory choice since immunosuppression targeting neuromyelitis optica spectrum disease can lead to dissemination of pulmonary tuberculosis. Keywords: Neuromyelitis optica, Pulmonary tuberculosis, Optic neuritis, Acute transverse myelitis
Inflammatory demyelinating disorders of the central nervous system are debilitating conditions of the young adult, here we focus on multiple sclerosis (MS) and neuro-Behçet disease (NBD). MS is an ...autoimmune disorder of the central nervous system. NBD, a neurological manifestation of an idiopathic chronic relapsing multisystem inflammatory disease, the behçet disease. The diagnosis of MS and NBD relies on clinical symptoms, magnetic resonance imaging and laboratory tests. At first onset, clinical and imaging similarities between the two disorders may occur, making differential diagnosis challenging and delaying appropriate management. Aiming to identify additional discriminating biomarker patterns, we measured and compared gene expression of a broad panel of selected genes in blood and cerebrospinal fluid (CSF) cells of patients suffering from NBD, MS and non inflammatory neurological disorders (NIND). To reach this aim, bivariate and multivariate analysis were applied. The Principal Analysis Component (PCA) highlighted distinct profiles between NBD, MS, and controls. Transcription factors foxp3 in the blood along with IL-4, IL-10, and IL-17 expressions were the parameters that are the main contributor to the segregation between MS and NBD clustering. Moreover, parameters related to cellular activation and inflammatory cytokines within the CSF clearly differentiate between the two inflammatory diseases and the controls. We proceeded to ROC analysis in order to identify the most distinctive parameters between both inflammatory neurological disorders. The latter analysis suggested that IL-17, CD73 in the blood as well as IL-1β and IL-10 in the CSF were the most discriminating parameters between MS and NBD. We conclude that combined multi-dimensional analysis in blood and CSF suggests distinct mechanisms governing the pathophysiology of these two neuro-inflammatory disorders.
Remitting-RelapsingMultiple Sclerosis (RRMS) and Neuro-Behçet Disease (NBD) are two chronic neuroinflammatory disorders leading to neurological damage. Herein, we investigated in these patients the ...IL-10-producing cells during the early stages of these disorders. Cellular and molecular investigations were carried out on treatment naive patients suffering from RRMS and NBD recruited at the first episode of clinical relapse. Our findings demonstrate that CSF-B cells from NBD patients, but not RRMS, are the major source of intrathecal IL-10 as compared to T-CD4 cells. Moreover, we showed a lower expression of TGF-β and IL35, in the CSF cells of NBD patients as compared to the control group. Specific in vitro CpG stimulation of peripheral blood B cells from NBD patients resulted in a concomitant early mRNA expression of IL6 and IL10 but was limited to IL10 for RRMS patients. Furthermore, mRNA expression of IL-6 and IL-10 receptors was assessed and intriguingly IL6ST receptor subunit was significantly lower in NBD CSF, but not RRMS while IL10RB was increased in both. Deciphering the role of increased IL-10-producing B cells and IL10RB despite relapsing disease as well as the discordant expression of IL6 and IL6ST may pave the way for a better understanding of the pathophysiology of these neuro-inflammatory disorders.
La thrombose veineuse cérébrale (TVC) est une maladie potentiellement sévère. Les céphalées sont des manifestations fréquentes. Cependant, l’ataxie est rarement révélatrice. Nous rapportons 2 cas de ...TVC révélée par une ataxie aiguë.
Ce sont 2 femmes (A1 et A2) âgées respectivement de 83 ans et 60 ans, aux antécédents d’hypertension artérielle. Elles ont consulté aux urgences pour des troubles de la marche installés brutalement. Elles n’avaient ni fièvre, ni céphalées, ni troubles visuels. À l’examen, la patiente A1 avait un syndrome cérébelleux stato-cinétique prédominant à gauche et une dysarthrie cérébelleuse. Alors que la patiente A2 avait une ataxie cérébelleuse isolée. Un scanner cérébral a été effectué pour les 2 patientes, montrant une hypodensité cérébelleuse gauche avec un effet de masse sur le vermis chez A1 ; et un infarctus cérébelleux gauche avec une transformation hémorragique chez A2. L’IRM cérébrale et l’angio-MR veineuse a révélé une TVC du sinus latéral gauche chez A1 et une TVC du sinus droit et du sinus latéral gauche chez A2. Les deux étaient compliquées d’un infarctus hémorragique veineux. Le bilan étiologique était négatif pour A2 et a montré une hyperhomocystéinémie chez A1. Les 2 patientes étaient traitées effectivement par une héparinothérapie.
La TVC est caractérisée par une présentation clinique variable qui touche particulièrement les sujets jeunes. Les formes du sujet âgé sont peu fréquentes et souvent trompeuses. Les TVC compliquées d’infarctus cérébelleux sont rares, celles-ci sont dues, comme nos cas, à des thromboses du sinus droit, du sinus latéral et du sinus sigmoïde parfois en association avec les veines cérébelleuses.
Ces deux cas illustrent qu’une TVC doit être évoquée devant des lésions vasculaires touchant le cervelet surtout si elles sont compliquées d’une hémorragie.
Pial arteriovenous fistulas (AVFs) are rare neurovascular malformations. They differ from arteriovenous malformations (AVMs) in that they involve single or multiple feeding arteries, draining ...directly into a dilated cortical vein with no intervening nidus. Pial and dural AVFs differ in blood supply, as the first originate from pial or cortical arteries and the latter from outside the dural leaflets. Unlike dural AVFs, most of the pial AVFs are supratentorial. The vast majority are congenital, manifesting during infancy. Acquired pial AVFs are significantly rarer and occur after vasculopathy, head trauma, brain surgery, or cerebral vein thrombosis. We describe a unique case of an acquired pial AVF in a 50-year-old man secondary to a cortical vein thrombosis manifesting as a focal-onset seizure with secondary generalization. A cerebral digital subtraction angiography revealed a low-flow pial AVF fed by a postcentral branch of the left middle cerebral artery draining to the superior sagittal sinus via a cortical vein. It also showed a collateral venous circulation adjacent to the previously thrombosed left parietal vein. There was no evidence of an associated dural AVF or venous varix. Endovascular treatment was scheduled three months later, but the angiogram preceding the embolization showed spontaneous and complete closure of the malformation. To our knowledge, this is the first case illustrating acquired pure pial AVF unaccompanied by a dural component following cortical vein thrombosis, eventually resulting in an unprompted closure.
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•A higher CD39 mRNA expression in RRMS and NBD patients as compared to control group.•A distinctive inflammatory microenvironment associated to an increase of TNF-α in RRMS CSF and ...IL-6 in NBD patients.•Decrease level of CD73 mRNA expression in the CSF of NBD as compared to RRMS patients.•In RRMS patients, a significant positive correlation of both CD39 and CD73 with IL-10 expression but not in NBD.•CD39 is frequently expressed on Treg cells in RRMS patients and on B cells in NBD.
Treg‐mediated immune suppression involves many molecular mechanisms including the cleavage of inflammatory extracellular ATP to adenosine by CD39 ectoenzyme. In the peripheral blood of Multiple Sclerosis (MS) patients, it has been suggested that CD39+ Treg cells have the potential to suppress pro-inflammatory IL-17 secreting cells. Herein, we studied cellular phenotype and mRNA expression of CD39 and CD73 ectoenzymes in the Cerebrospinal fluid (CSF) of MS patients and another neuro-inflammatory disease: the Neuro-behçet’s disease (NBD).
Using qRT-PCR, we assessed mRNA expression of CD39 and CD73 as well as anti-inflammatory (IL-10) and pro-inflammatory (IL-6, TNF-α, IL-1β) cytokines in patients Peripheral blood mononuclear cells (PBMCs) and CSF of 28 relapsing-remitting multiple sclerosis (RRMS), 20 NBD and 22 controls with non inflammatory neurological disorders (NIND). The most substantial result in the CSF was the higher expression of CD39 in both RRMS and NBD patients compared to NIND. While, the expression of CD73 in CSF samples of NBD was low. In RRMS samples, we detected a significant positive correlation of both CD39 and CD73 with IL-10 expression. Moreover, results by flow cytometry revealed a high percentage of CD39 Treg cells in RRMS CSF. CD39 was preferentially expressed on B cells of NBD. Regarding inflammatory response, we showed a significant increase of IL-6 mRNA expression in NBD patients CSF while in RRMS this increase concerned TNF-α. These results bring evidence that CD39 correlates positively with an anti-inflammatory IL-10 response in RRMS. In contrast, no such association was observed in CSF of NBD patients and CD39 was preferentially expressed on B cells.
La carence en vitamine B12 (CVB12) est fréquente chez les adultes. Les manifestations neurologiques sont polymorphes, dominées par la neuropathie et l’atteinte médullaire. L’atteinte encéphalique est ...particulièrement rare et sévère.
Décrire les particularités cliniques, paracliniques, étiologiques et évolutives des manifestations encéphaliques liées à une CVB12 dans la population tunisienne.
Une étude rétrospective a été menée au service de neurologie de l’institut de neurologie de Tunis sur 6 ans (2015–2021) incluant 66 patients ayant une CVB12 révélée par des troubles neurologiques. Nous avons sélectionné ceux qui ont présenté une atteinte encéphalique (AE). Tous les patients ont été examinés par un neurologue et explorés par un bilan biologique et une imagerie cérébrale. Les caractéristiques cliniques, radiologiques, biologiques, étiologiques et évolutives ont été étudiées.
L’AE par CVB12 était retrouvée chez 21 patients (31,8 %). L’âge moyen était 53,5 ans. Parmi ces patients, 10 avaient une thrombose veineuse cérébrale (TVC), 5 avaient un infarctus cérébral, 4 avaient des troubles cognitifs, une ataxie cérébelleuse et une psychose chez 1 patient respectivement. Le taux moyen de vitamine b12 était 97,7pg/mL. Celui de l’homocystéine était 100,1μmol/L. L’imagerie était anormale dans 90 % des. L’évolution était favorable après supplémentation dans 85,7 % des cas.
L’AE est rare, de l’ordre de 20,6 %, ce qui est comparable à notre série. Le risque de TVC et de l’infarctus cérébral est augmenté en présence d’une CVB12 et semble être médié par l’hyperhomocystéinémie. L’ataxie cérébelleuse, le syndrome démentiel, ainsi que les troubles psychiatriques peuvent être révélateur d’une CVB12. Environ 90 % des patients s’améliorent après supplémentation comme dans notre série.
La CVB12 est une étiologie fréquente et potentiellement curable de plusieurs tableaux neurologiques. Nous recommandons de faire le dosage de la vitamine B12 et de l’homocystéinémie dans toute atteinte neurologique inexpliquée.
L’encéphalopathie de Wernicke (EGW) est une pathologie carentielle causée par un déficit profond en thiamine (vitamine B1). Elle réalise une urgence diagnostique et thérapeutique. La présentation ...clinique est souvent trompeuse.
L’objectif de notre travail était de déterminer les caractéristiques cliniques, radiologiques et évolutives des EGW hospitalisés dans notre centre.
Nous avons colligé, rétrospectivement, 20 patients suivis pour une EGW confirmée et hospitalisés dans notre centre durant la période comprise entre les années 2000 et 2021.
Le sex-ratio H/F était de 0,81. L’âge moyen était de 42 ans. Les vomissements gravidiques (40 %) et l’éthylisme chronique (30 %) étaient les facteurs les plus rapportés. Les signes neurologiques les plus retrouvés étaient la confusion (65 %), l’ataxie (75 %) et l’ophtalmoplégie (70 %). Cette triade était complète chez 1/3 des patients. Les hypersignaux des tubercules mamillaires étaient les anomalies radiologiques les plus objectivées (4 cas). Une récupération était observée chez 95 % des patients après supplémentation.
Nos résultats démontraient que les facteurs favorisants de l’EGW sont en accord avec la plupart des études. La triade clinique associant ophtalmoplégie, confusion et ataxie est très évocatrice du diagnostic mais n’est présente que dans 30 % des cas. L’IRM cérébrale est un examen clé mais sa normalité n’élimine pas le diagnostic d’EGW. Le pronostic dépend de la précocité du traitement.
L’EGW est une urgence métabolique. La triade clinique ophtalmoplégie, confusion et ataxie est évocatrice. La supplémentation vitaminique précoce permet d’avoir une évolution favorable et d’éviter l’installation des séquelles irréversibles.
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