on behalf of the DECIMAL InvestigatorsBackground and Purpose-There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction.The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods-We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score Յ3) at 6 months' follow-up (primary outcome) between the 2 treatment groups. Results-After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score Յ3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (Pϭ0.18 and Pϭ0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (PϽ0.0001). Conclusions-In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Background and Purpose-Although diabetes is a strong risk factor for stroke, it is still unclear whether stroke subtype, severity, and prognosis are different in diabetic and nondiabetic patients. We sought to evaluate stroke features, prognosis, and functional outcome in patients with diabetes compared with patients without diabetes. Methods-In a European Union Concerted Action involving 7 countries and 4537 patients hospitalized for a first-in-a-lifetime stroke, defined according to the Oxfordshire Community Stroke Project criteria, we collected data on demographics, risk factors, clinical presentation, and outcome. We used logistic regression to examine the relationship between diabetes and outcome at 3 months (disability, handicap, and death), controlling for risk factors, clinical presentation, and demographics. Results-Overall, diabetes was present in 937 patients (21%). Diabetic patients, compared with those without diabetes, were more likely to have limb weakness (PϽ0.02), dysarthria (PϽ0.001), ischemic stroke (PϽ0.001), and lacunar cerebral infarction (Pϭ0.03). At 3 months, the case fatality rates were not higher in the diabetic groups (Pϭ0.33). Handicap (Rankin Scale) and disability (Barthel Index) were significantly higher in diabetic patients (Pϭ0.005 and Pϭ0.016, respectively). Conclusions-Stroke in diabetic patients has a specific clinical pattern and a poor prognosis in terms of motor function, which emphasizes the need for early diagnosis and treatment of every case of diabetes.

Background and Purpose-With the progress in stroke prevention, it is important to evaluate the epidemiological trends of strokes over a long period and from a nonselected population-based perspective. Methods-We estimated changes in incidence, case-fatality rates, severity, risk factors and prestroke use of preventive treatments for first-ever strokes, from a continuous 20-year well-defined population-based registry, from 1985 to 2004. Results-We recorded 3142 ischemic strokes, 341 primary cerebral hemorrhages and 74 subarachnoid hemorrhages.During the 20-year study, the age at first stroke onset increased by 5 years in men and 8 years in women. Comparing the 1985 to 1989 and the 2000 to 2004 periods, age-and sex-standardized incidences of first-ever strokes were stable except for lacunar strokes whose incidence significantly increased (Pϭ0.01) and for cardioembolic stroke whose incidence significantly decreased (Pϭ0.01). Twenty-eight-day case-fatality rates decreased significantly mainly for lacunar strokes (Pϭ0.05) and for primary cerebral hemorrhages (Pϭ0.03). The proportion of hypercholesterolemia and diabetes significantly increased (PϽ0.01). In contrast, the proportion of myocardial infarction significantly decreased (Pϭ0.02). Prestroke antiplatelets and anticoagulants treatment significantly increased (PϽ0.01). Conclusions-The age-and sex-standardized incidences of first strokes in Dijon have been stable over the past 20 years and were associated with an increase in age at stroke onset, a decrease in case-fatality rates, and an increased use of antiplatelet treatments.

Monoclonal antibodies reacting with pellicular antigens of Toxoplasma gondii tachyzoites have been selected among hybridomas produced against this organism by immunofluorescence assay. These antigens have been further characterized by immunofluorescence on living zoites, Western immunoblotting and immunoprecipitation of lactoperoxidase surface radio-iodinated tachyzoite lysates. The simultaneous characterization of 5 different surface antigens (P43, P35, P30, P23, P22) some of which have already been studied individually allowed a better definition of these antigens and the characterization of a yet undescribed surface molecule (P23).

The decrease in the incidence of cardioembolic/atrial fibrillation stroke in our study was probably due to a slight increase in the utilization of antithrombotic therapy in patients with atrial fibrillation, but the use of such therapies will have to increase further because of the expected aging of the population in coming years.

As cobalamin C disease and related disorders of homocysteine metabolism are treatable conditions, homocysteinaemia should be included in the investigations of patients with progressive neurological deterioration, unexplained psychiatric disturbances or recurrent thromboembolic events.

This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.

A striking feature of toxoplasmic seroconversion is the prominent and early IgM response to a low molecular weight antigen of 4-5 kDa. Two different monoclonal antibodies directed against the 4-5 kDa antigen have been generated and used to characterize this molecule. Using these monoclonal antibodies, we could demonstrate the surface localization of the low M(r) antigen by immunofluorescence and immuno-electron microscopy assays. By immunoblotting, we observed that one of the monoclonal antibodies was unable to recognize the 4-5 kDa antigen in tachyzoites propagated in cell culture, indicating an epitope variability between Toxoplasma gondii tachyzoites grown in vivo and in vitro. We discuss the implications of this latter finding in the design of diagnostic reagents.