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Background. Unrecognized visual deficits (VDs) following an acquired brain injury (ABI) may impact clients’ rehabilitation. Little is known about evaluation tools used in vision rehabilitation. Purpose. To systematically explore the literature describing evaluation tools used for VD on adults with ABI. Method. Using a scoping review methodology, we searched in MEDLINE(Ovid), Embase, CINAHL, PsycINFO, and the grey literature from inception to 2020. Quantitative and thematic analyses were performed. Findings. Of the 83 studies reporting on 86 evaluation tools, 47% used multiple tools to assess VD. Tools were mostly used by occupational therapists and psychologists to evaluate intermediate, intermediate to high, and high-level visual skills. Clinicians tend to select specific tools that focus on different levels of the hierarchy of visual skills. Implications. Future research should investigate the optimal timeframe for assessment of VD and the psychometric properties of tools to ensure comprehensive VD evaluation.

Introduction: Doppler sonography of the cervical segment of the carotid arteries is becoming a popular tool for evaluating atherosclerosis of the carotid artery. We present the audit of findings on carotid ultrasound examination among patients with clinical suspicion and risks for cerebrovascular disease and possible correlates in Northern Nigeria. Materials and Methods: We performed carotid ultrasound examination on all patients referred for screening and clinical suspicion of cerebrovascular disease within the year 2017. The patients' characteristics, risk factors, presence of atheroma and characteristic of the atheroma, degree of stenotic disease as well as the presence of incidental ultrasound findings were reviewed and documented. Results: Out of the 62 patients, 55 (88.7%) of them had various degrees and types of atheromatous plaques in different segments of the cervical carotid arteries, whereas 7 (11.3%) were normal. The predominant risk factor was smoking followed by diabetes mellitus, whereas the highest indication for the scan was transient ischemic attack. Incidental thyroid lesions such as nodules and cysts were encountered in 14 (22.6%) of the patients. There is a statistically significant difference between sex and age with the side of lesion, degree of stenosis, segment involved, and type of atheromatous plaque. Conclusion: There is a statistically significant difference between sex and age with the side of lesion, degree of stenosis, segment involved, and type of atheromatous plaque. About one-fifth of our patients had incidental thyroid lesions. Therefore, routine screening of population at risk is highly recommended.

L’épidémiologie des causes virales a été profondément modifiée avec l’avènement de la pandémie due au SARS-COV-2 fin 2019. Celle-ci, dans sa forme sévère, s’est avérée associée à un risque accru d’AVC ischémique et hémorragique. Ces AVC surviendraient suite à un mécanisme inflammatoire dans lequel interviendrait un orage de cytokines. Le virus pourrait également directement s’introduire dans le cerveau via les voies olfactives, le processus d’internalisation du virus faisant intervenir sa glycoprotéine S de surface et l’enzyme de conversion de l’angiotensine 2. Enfin les sujets victimes de ces formes sévères d’infection à la COVID-19 sont également souvent porteurs de facteurs de risque vasculaires majeurs (obésité, diabète, hypertension artérielle), co-facteurs de sévérité pour la Covid-19. Parmi les autres virus classiquement impliqués dans la survenue d’évènements cérébrovasculaires l’infection au VIH, interviendrait par le biais d’une vascularite. Si elle est en net recul en Afrique et dans le monde en raison de la généralisation des thérapies antirétrovirales, la prolongation de la survie chez les sujets traités expose à une recrudescence des AVC chez les sujets âgés vivant avec le VIH. Alors que l’association AVC-VIH touchait surtout les sujets jeunes avant l’ère des thérapies antirétrovirales, on l’observe aujourd’hui plus fréquemment chez les sujets de plus de 50 ans, chez lesquels il semble persister un sur-risque d’AVC, malgré l’efficacité du traitement antirétroviral. Enfin, beaucoup plus rarement, la vascularite à Virus Varicelle-Zona, le virus de l’hépatite virale C et le virus de la dengue peuvent être impliqués dans la survenue des AVC. Le tableau clinique de ces AVC d’origine virale est non spécifique. Il peut être évoqué devant le contexte épidémique actuel et les signes pulmonaires associés pour la Covid-19, la survenue de l’AVC dans un contexte infectieux, un antécédent récent de varicelle ou de zona, une immunodépression au VIH connue ou découverte.. Le diagnostic repose sur la mise en évidence de l’ADN du virus dans le LCR ou la conjonction d’arguments épidémio-cliniques. La prise en charge est également non spécifique incluant dans certains cas, un traitement antiviral spécifique et parfois une corticothérapie.

Bonan M2S; International audience; Balance disorders related to disturbances in perception of spatial reference systems are common especially after right hemispheric stroke. Mental misrepresentation of bodily orientation in space is then often superimposed upon other factors affecting imbalance such as motor and sensory impairments. Traditional rehabilitation for balance recovery has not been specifically designed to improve balance disorders related to spatial cognition. The traditional approach, consisting of stimulating the conscious perception of body orientation in space, is demanding and laborious. The approach based on sensorial stimulation is completely different. The relevance of this method lies in the fact that, firstly it is specifically active in the cognitive component of balance disorders; and secondly, it can passively be applied with minimal patient participation, which is of particular importance for this patient group characterized by disorders of attention and concentration. These techniques, such as proprioceptive, visual or vestibular stimulation, have been found to correct spatial neglect but also postural bias. Clinical and data from functional neuro-imaging suggest a direct central action on cortical structures involved in the elaboration of spatial representation. These are promising techniques for the rehabilitation of postural disturbances related to spatial cognition disorders but are as yet at the stage of preliminary results

SummaryAtrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called “non-valvular” AF. The distinction between “valvular” and “non-valvular” AF remains a matter of debate. Currently, “valvular AF” refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of “non-valvular” AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of “non-valvular” AF. Obviously, we should no longer consider the classification of AF as “valvular” (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, “valvular AF” refers to patients with mitral stenosis or artificial heart valves. Patients with “non-valvular AF” may have other types of valvular heart disease. One should emphasize that “non-valvular AF” does not exclude patients with some types of valvular heart disease from therapy with NOACs.

Introduction Sleep apnea syndrome (SAS) frequently occurs after a stroke. Its association with a poor prognosis is open to discussion. Objective To study, in a physical and rehabilitation medicine (PRM) unit, the possible repercussions of SAS on neurological and functional recovery as well as attentional abilities following a stroke. Patients and methods Forty-five patients, all of whom had recently had a stroke without previously documented SAS, were screened using the ApneaLink® system. An apnea-hypopnea index (AHI) score ≥10 was considered as indicative of SAS. The NIHSS, Fugl-Meyer (FM) and Functional Independence Measure (FIM) Scales were applied on admission and at two months as means of assessing neurological and functional recovery, which was expressed by the difference between the first and the second scores (delta FM, delta NIHSS, delta FIM). The Battery Attention William Lennox (BAWL) Test was given once in order to evaluate attention disorders. SAS severity was categorized according to the AHI. We compared the groups formed (mild, moderate and severe) using the same method. Results Twenty-eight patients (62.2%) presented AHI ≥ 10. Stroke characteristics were comparable in the SAS+ and the SAS– groups, with average post-stroke time lapse of 26 days, initial average FIM score of 71.2 points ± 26.3 and initial average NIHSS score of 8.9 ± 4.9. The demographic characteristics of the two groups were likewise comparable with the exception of age, as the SAS+ group was pronouncedly older (65.4 vs. 53.5 years). As for delta FIM, which evaluated functional recovery, it averaged 31.8 ± 20.6. Cases of SAS were found to be mild (37.1%), moderate (28.6%) or severe (34.3%). No significant difference was observed on admission or at 2 months as regards the clinical scales or the BAWL test between the two groups or according to severity, except for the NIHSS score at 2 months in the severe sub-group. Discussion and conclusion This study did not demonstrate the supposed repercussions of SAS on the recovery or attentional abilities of post-stroke patients. The tests were maybe given too early; they should take place at a lengthier time interval after the stroke, and also to be more complete.

The functional consequences of spasticity can be corrected by local, pharmacological or surgical treatments once the spastic muscle has been identified. However, this diagnosis can be tricky when the muscle in question is rarely involved in spasticity or when its mechanical action is unusual or poorly characterized. Here, we present the case of a man presenting with left hemiplegia after an ischaemic stroke. His gait was perturbed by foot clonus in the sagittal plan, which persisted after selective neurotomy of the gastrocnemius and soleus but disappeared after neurotomy of the peroneus longus. Clonus triggered by pushing up under the whole of the forefoot in the direction of dorsiflexion may not be related to spasticity of the triceps surae. We recommend screening for foot clonus by first pushing up on the sole of the foot under all five metatarsals. In a second step, selectively pushing up under the first metatarsal joint enables the physician to evidence spasticity of the peroneus longus.

RésuméL’objectif du traitement antithrombotique au cours de la fibrillation atriale est de prévenir les accidents emboliques, et en premier lieu au niveau des artères cérébrales. Le bénéfice des antivitamines K (AVK) a été largement démontré par des essais randomisés. Les AVK réduisent le risque d’accident vasculaire cérébral et d’embolies systémiques de plus de 60%. Le bénéfice absolu est plus important chez les patients à haut risque embolique, notamment chez ceux ayant eu un infarctus cérébral ou un accident ischémique transitoire. Les AVK augmentent le risque d’hémorragie extra-ou intracérébrale, mais le bénéfice clinique net est pratiquement toujours en faveur du traitement. Pourtant, les AVK restent très largement sous-ou mal utilisés en routine. On estime que seulement un patient sur deux reçoit des AVK, que parmi les patients traités une large proportion n’est pas dans la fenêtre thérapeutique, et que beaucoup de patients finissent par interrompre le traitement. L’efficacité de l’aspirine pour prévenir les accidents emboliques est faible ou marginale et ce traitement n’est pas dénué de risque de complications hémorragiques. Ce traitement reste pourtant largement prescrit. L’association aspirine-clopidogrel est plus efficace que l’aspirine, mais est associée á un excés de risque d’hémorragie. Cette association doit étre préférée á l’aspirine seule chez les patients ayant une contre-indication formelle aux anticoagulants.SummaryAntithrombotic treatments in patients with atrial fibrillation aim to prevent thromboembolic events, especially cerebral embolisms. The benefit of vitamin K antagonists (VKAs) has been widely demonstrated in randomized clinical trials. VKAs reduce the risk of stroke by approximately two-thirds. The absolute benefit of VKAs is increased in patients at high risk of thromboembolic events, including those with a history of ischaemic stroke or transient ischaemic attack. Yet, VKAs remain widely underused or misused. Among patients eligible for VKA treatment, only half receive VKAs. Many of those who are on VKAs are outside the therapeutic window most of the time and many patients stop treatment after a few years. The efficacy of aspirin in preventing thromboembolic events in patients is small or marginal and this treatment is also associated with bleeding complications. The combination of aspirin and clopidogrel is more efficacious than aspirin alone in preventing thromboembolic complications and should be preferred to aspirin in patients who have definite contraindications to oral anticoagulants.

RésuméEn septembre 2012 a été publiée une mise à jour des recommandations de la Société Européenne de Cardiologie parues en 2010. Cette mise à jour précise que tous les patients atteints de fibrillation atriale doivent être anticoagulés sauf ceux de moins de 65 ans ayant une fibrillation atriale (FA) isolée. Une recommandation de classe I, niveau de preuve A précise que peuvent être utilisés comme anticoagulants les antivitamines K, le dabigatran, médicament antithrombine ou les anti-Xa (rivaroxaban et apixaban). Il est donné une préférence aux nouveaux anticoagulants (classe IIa, niveau de preuve A), du fait de leur meilleur rapport bénéfices/risques, principalement en raison de la diminution du nombre d’hémorragies intracrâniennes observée dans les essais qui ont permis l’enregistrement de ces médicaments. On trouvera également dans ces recommandations une mise à jour sur les dispositifs d’occlusion de l’oreillette gauche, sur la cardioversion, principalement pour introduire dans la cardioversion pharmacologique la possibilité d’utiliser le vernakalant. Il y a d’autre part une importante mise à jour sur la place de la dronédarone qui doit être totalement évitée en cas d’insuffisance cardiaque. Enfin, une mise à jour a été faite sur l’ablation permettant, dans certains cas bien spécifiques, d’envisager celle- ci en première intention, mais sa place principale demeure après échec de médicament antiarythmique. Récemment ont également été publiées un certain nombre de recommandations nord- américaines : mises à jour ACC/AHA, recommandations ACCP, recommandations ASA/AHA et enfin recommandations canadiennes. Globalement, on peut considérer qu’il n’existe pas de différence majeure dans les choix stratégiques thérapeutiques entre ces recommandations nord-américaines et les recommandations européennes.SummaryIn September 2012, an update to the 2010 European Society of Cardiology guidelines was published. The main recommendation was that all patients with atrial fibrillation (AF) must be anticoagulated, except for patients aged

Background: Stroke can be prevented with treatments targeted at hypertension, diabetes mellitus, hyperlipidemia and atrial fibrillation, but this is often hampered by under-diagnosis and under-treatment of those risk factors. The magnitude of this problem is not well-studied in sub-Saharan Africa. Materials and Methods: We conducted a cross-sectional survey of stroke patients at a tertiary hospital during January 2010 to July 2013 to determine patient awareness of a pre-existing stroke risk factor and prior use of anti-hypertensive, anti-diabetic, antiplatelet and lipid-lowering agents. We also investigated whether gender and school education influenced patient awareness and treatment of a stroke risk factor prior to stroke. Results: Three hundred and sixty nine stroke patients presented during the study period, of which 344 eligible subjects were studied. Mean age at presentation (±SD) was 55.8 ± 13.7 years, and was not different for men and women. Hypertension, hyperlipidemia, diabetes and atrial fibrillation were prevalent among 83.7%, 26.5%, 25.6% and 9.6% patients respectively. Awareness was high for pre-existing diabetes (81.8%) and hypertension (76.7%), but not for hyperlipidemia (26.4%) and atrial fibrillation (15.2%). Men were better educated than women (p = 0.002), and had better awareness for hyperlipidemia (37.3% versus 13.5%; p = 0.009). Men were also more likely to take drug treatments for a stroke risk factor, but the differences were significant. Conclusions: A high rate of under-diagnosis and under-treatment of hypertension, hyperlipidemia and atrial fibrillation contributes to the stroke burden in sub-Saharan Africa, especially among women. Public health measures including mass media campaigns could help reduce the burden of stroke.

Objective To study work re-entry by patients having suffered a stroke at least 3 years previously. Patients and methods This was a retrospective survey in which a questionnaire was administered to all patients admitted after a first stroke to the “La Tour de Gassies” Centre for Physical and Rehabilitation Medicine (CPRM) in France between January 2005 and June 2007 and who were in work at the time of the incident. Results Fifty-six of the 72 included patients (78%) completed and returned the survey questionnaire. The mean age at the time of the stroke was 48.3 ± 10.1. Eighteen (32.1%) of the 56 patients returned to work after their stroke (mean post-stroke time interval: 19.2 ± 13.4 months). Negative prognostic factors for a return to work were living alone, the presence of severe functional impairment and the presence of speech disorders. Positive prognostic factors included specific, professional support and early involvement of the occupational physician. Patients who resumed driving were more likely to return to work and there was a positive correlation between the time to work re-entry and the time to resumption of driving. Conclusion Close cooperation between occupational health services and CPRM appears to be necessary to speed the return to work by stroke patients.

International audience; L’épilepsie vasculaire se définit par la répétition de crises spontanées plus d’une semaine après une lésion vasculaire cérébrale confirmée, en rapport avec cette lésion vasculaire. Elle touche 2 à 4 % des patients. La période à risque maximal de développer une épilepsie vasculaire est comprise entre le 1er et le 18e mois après un AVC. L’AVC est une pathologie fréquente de la personne âgée, survenant dans 75 % après 65 ans. L’épilepsie vasculaire touche essentiellement des personnes âgées. Le diagnostic de crises d’épilepsie n’est pas toujours facile chez ces patients aux antécédents d’AVC. La récurrence des crises chez le sujet âgé définissant la maladie épileptique peut être rencontrée dans d’autres pathologies neurologiques notamment telles que les maladies infectieuses en zone tropicale, tumorales, ou post-traumatiques. Les crises partielles motrices avec ou sans généralisation secondaire seront plus facilement repérées par l’entourage, d’où leur fréquence relative plus importante. La gravité initiale de l’AVC et la présence d’une lésion corticale dans un territoire carotidien favoriseraient la survenue d’une épilepsie vasculaire. Si l’EEG reste un examen indispensable au diagnostic, c’est l’enregistrement d’une crise en EEG-vidéo qui confirme le diagnostic. L’évolution de l’épilepsie vasculaire est souvent favorable, les crises étant habituellement peu fréquentes. Elles sont souvent contrôlées par un traitement antiépileptique en monothérapie. Au-delà d’une période de deux semaines après l’AVC, la survenue d’une crise liée à cette lésion expose à un risque de récidive suffisamment élevé, il semble logique de proposer un traitement antiépileptique.

Background. – After stroke, the early and persistent decline in aerobic capacity leads to diminish walking capacities. The aim of the study is to investigate the effects of aerobic cycloergometer interval-training on the walking performances in subacute and chronic stroke survivors. Method. – A prospective design was used. Fourteen patients whose stroke had occurred more than 3 months and less than 2 years performed an aerobic training session with a cycloergometer for 8 weeks. A maximal exercise test, a 6-min walking test, a 20-m test and an isokinetic muscle strength test were realized before and after training session. Results. – There was a significant increase after aerobic training in maximal power (Pmax) (mean 23.2%, P < 0.0001), in VO2peak (mean 14.8%, P = 0.04), and in the knee extension and flexion muscle peak torque on the nonparetic side and extension on the paretic side in isokinetic mode (mean from 13 to 29%, P = from 0.019 to P = 0.0007) and in the walking performances on the 6-min walk test (mean 15.8%, P = 0.0002). Conclusion. – Patients with subacute and chronic stroke can improve aerobic capacity, muscle strength and walking performances after cycloergometer interval-training. Although these results must be interpreted with caution considering the small size of our sample, they suggest that aerobic training is a safe and potentially effective training after stroke and an alternative to walking treadmill training. # 2010 Elsevier Masson SAS. All rights reserved.

Summary Background While there are convergent data suggesting that overall cardiovascular mortality is increased in patients with rheumatoid arthritis, the relative contributions of myocardial infarction and stroke remain unclear. Aims We sought to clarify this issue by conducting a meta-analysis of cohort studies on myocardial infarction and stroke in patients with rheumatoid arthritis. Methods A MEDLINE search from January 1960 to September 2009 and abstracts from international conferences from 2007 to 2009 were searched for relevant literature. All cohort studies reporting on standardized mortality ratio or incidence rate ratio of myocardial or stroke associated with rheumatoid arthritis, with available crude numbers, were included. STATA meta-analysis software was used to calculate pooled risk estimates. Results Seventeen papers fulfilled the inclusion criteria, corresponding to a total of 124,894 patients. Ten studies reported on standardized mortality ratio for fatal myocardial infarction, which ranged from 0.99 to 3.82. The overall pooled estimate was 1.77 (95% confidence interval [CI] 1.65–1.89). Incidence rate ratio for myocardial infarction was reported in five studies; the pooled estimate was 2.10 (95% CI 1.52–2.89). Nine studies reported on fatal stroke, with standardized mortality ratio ranging from 1.08 to 2.00; the pooled estimate was 1.46 (95% CI 1.31–1.63). The pooled incidence rate ratio for stroke (three studies) was 1.91 (95% CI 1.73–2.12). Conclusion Our results show that risks of myocardial infarction and stroke are increased in patients with rheumatoid arthritis. In addition, both account for the observed increased mortality in individuals with rheumatoid arthritis.

Objectives To observe whether medical complications, the evolution of neurological disorders and dependence and/or the discharge destinations are different for patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery compared to patients treated medically for severe or malignant cerebral infarction in the same cerebral territory, during their hospitalization in a physical medicine and rehabilitation department. Patients and methods This retrospective study compared patients treated by craniectomy for malignant cerebral infarction in the middle cerebral artery and patients treated medically for severe or malignant cerebral infarction in the same cerebral territory. Patients were paired according to age, lesion side and hospitalization period. Results Twelve patients treated by craniectomy (age 43 ± 10.44) were paired with 12 patients treated medically (age 49 ± 7.66). The two groups were comparable in terms of general undesirable medical events. The medical events related to craniectomy are described. The evolution of patient deficiencies, the length of the hospital stay (194 ± 118.93 days vs 152 ± 94.64 days), the Functional Independence Measure at discharge (87 ± 21.28 vs 95 ± 22.19) and the number of direct home discharges (7 vs 9) did not significantly differ between groups. Discussion and conclusion No more medical problems were observed in the patients treated by craniectomy than in the patients treated medically, except for the medical events specifically related to craniectomy, which extended the hospital stay but had no major repercussions.

The objective is to define as early as possible appropriate criteria for managing patients who have had a cerebrovascular accident (CVA), or stroke, beginning in the Neurovascular and Acute Care Services, in order to facilitate the patient's return home (or the equivalent of home) or continuing care in the most appropriate health care facility.Three clinical assessment tools are used in the initial care phase because they are robust and reproducible:– the National Institutes of Health Stroke Scale (NIHSS) score appears to be the best clinical assessment tool. It is the reference scale used during the acute phase of a stroke because it predicts the patient's chances of recovery and the medium-term functional recovery;– the Glasgow Coma Scale (GCS) is an initial assessment tool useful in predicting the medium-term evolution in terms of level of consciousness, essentially in cases of cerebral hemorrhage or severe cerebral infarction;– the Barthel Index (BI), scored from 0 – 100, is used during the first seven days after a stroke, and the index's progression over the following two weeks is a factor in predicting the functional recovery of stroke patients.The values of these tools must take the markers of clinical stability into account during the initial phase. These markers also have a predictive value:– the curve of the relationship between blood pressure (BP) and the prognosis of stroke patients would have a U-shape, with extreme BP values having a negative influence;– hyperthermia and hypoxia are also early predictive factors of poor functional and vital prognoses;– the presence and continuation of urinary incontinence and/or swallowing disorders are important predictive factors for a poor functional prognosis and a higher mortality rate in the medium term.Complementary examinations make it possible to approximate the anatomical, metabolic and physiological status of the injured cerebral parenchyma early on, when the processes of reparation and plasticity restoration have already begun. The reparation process is a complex multifactor phenomenon that can, at any moment, be called into question; it cannot be predicted with certainty by complementary examinations only, at least at the current level of knowledge.Two parameters seem decisive in using imaging to predict stroke recovery: MRI exploration of the cerebral parenchyma and the exploration of vascular permeability via perfusion imaging. Currently, the place of functional and molecular imaging appears to be limited. Among the possible neurophysiological explorations, only motor evoked potentials (MEP) represent a simple, non-invasive, low-cost procedure that can have additional prognostic value. Hyperglycemia also has a negative impact on the functional and vital prognoses. The usefulness of biomarkers has not yet been validated.Other clinical factors influence the prognosis. Though age is an aggravating factor in the vital prognosis of stroke patients, it cannot be considered an independent factor in the functional prognosis due to the multiple co-morbidities associated with age. Diabetes, ischemic cardiopathies and atrial fibrillation are co morbidities that worsen the functional and vital prognoses of stroke patients.Cognitive disorders without dementia also have a negative influence on the functional prognosis, particularly hemi spatial neglect and phasic disorders accompanied by comprehension problems. Post-stroke dementia plays a very detrimental role. However, even though they can delay the acquisition of increased autonomy, cognitive disorders are not an obstacle for rehabilitation, and depression apparently has no influence on the rehabilitation results.Family is an essential factor. Family support is a necessary condition for the patient's discharge from the hospital and affects the length of the hospital stay. Wide-ranging effective organized family support improves the patient's functional status. The factors that make it possible for the patient to return home are the existence of home support, a moderate level of impairment and being of the masculine gender. Social rank and socioeconomic status also play a role: when rank and status are low, they are not only stroke risk factors but also increase the risks of poststroke mortality and of institutionalization.For the health care system to perform well, stroke management plans must respect two requirements:– individual requirement: the best possible match between the patient's needs and possibilities and the follow-up services, without missing any patient opportunity for an optimal return to normalcy;– organizational requirement: early intervention and the optimal transfer time in order to insure system flexibility and make it possible for the greatest number of patients to benefit from care in a specialized facility, particularly during the acute phase of the stroke.Patients will preferably be directed towards:– an intermediary or Intensive Care facility and then a rehabilitation facility specialized in brain injuries. Patients with severe impairment (NIHSS over 16), when they are conscious and off artificial ventilation, with or without a tracheotomy; malignant stroke patients, postdecompressive hemicraniectomy; and stroke patients with basilar trunk occlusion, after thrombolysis recanalization;– a follow-up and rehabilitation care facility specialized in neurological disorders. Patients with medium-level hemiplegia (NIHSS between 5 and 15 and/or Barthel Index≥20) who begin to improve in the first 7 days and younger patients with more serious hemiplegia if there is no rehabilitation facility specialized in brain injuries nearby;– a non-specialized follow-up and rehabilitation care facility or one that is specialized in the disorders of polypathologic elderly patients who are dependent or at risk of being dependent. Patients with serious hemiplegia without any signs of recovery in the first 7 days, who have multiple indicators of a poor prognosis (Barthel Index45).Two factors are essential for the success of such early returns home:– a home visit carried out before the patient's discharge;– a multidisciplinary team (physiotherapists, occupational therapist, speech therapist, doctor, nurse and social worker) who, at the end of the patient's hospital stay, takes responsibility for appropriate patient care immediately following the patient's discharge, for a period of approximately three months and a minimum frequency of four sessions per week.The Early Supported Discharge (ESD) model developed in Anglosaxon countries, which facilitates and conditions this kind of discharge plan, does not correspond exactly to the French health system's Hospitalisation à domicile (HAD), but the correspondence between the two is worth exploring. In the absence of a multidisciplinary intervention, the early long-term intervention (at least 5 months) of an occupational therapist in the patient's home can reduce the patient's level of impairment after an early return home (less than 1 month after the stroke).Maintaining the patient in his/her home starts by identifying the needs of both the patient and the caregivers, updating these needs as the situation evolves. The multidisciplinary team plays an important role in maintaining, even increasing, the patient's autonomy, and improving the patient's quality of life and that of his/her caregivers, while ensuring an optimal level of safety in the home. This is accomplished by educating both the patient and caregivers and by home interventions. The failure to maintain the patient at home can be caused by the worsening of the patient's condition (e.g., intercurrent disorders, loss of autonomy) or unpredictable factors (e.g., death of the patient's spouse), but also by the exhaustion of the patient's caregivers.When patient autonomy backslides or the patient loses interest, the intervention of a multidisciplinary team in the home of the stroke patient can help to reduce the deterioration rate of the activities of daily living (ADLs) and increase the patient's capacity to do personal activities. This intervention consists of repeat visits in the three months that follow the patient's discharge from the hospital. The health care providers and the caregivers need information about transfer techniques, adapting and using technical aids, fall prevention and the development of safety strategies for the home, improving communication difficulties, and adapting to the patient's visual disturbances and emotional changes. In the absence of a structured multidisciplinary team, occupational therapy can have a positive effect on personal and instrumental ADLs and social participation. Physiotherapy in the home alone doesn’t seem to have a significant effect on the patient's functional capacities.

Most studies of functional outcomes in hemiplegic stroke patients use standard disability rating scales (such as the Barthel Index). However, planning the allocation of assistance and resources requires additional information about these patients’ expectations and needs. Aims of the study To assess functional independence in daily living and house holding, changes in home settings, type of technical aid and human helps, and expectations in hemiplegic patients 1 to 2 years after the stroke. Methods Sixty-one out of 94 patients admitted to the neurovascular unit of French university hospital for a first-ever documented stroke were consecutively enrolled. The study was restricted to patients under 75, since patients over 75 do not follow the same care network. Patients were examined at their homes or interviewed by phone 17 months (on average) after the stroke. Standard functional assessment tools (such as the Barthel Index and the instrumental activities of daily living [IADL] score) were recorded, along with descriptions of home settings and instrumental and human help. Lastly, patients and caregivers were asked to state their expectations and needs. Results Although only one person was living in a nursing home after the stroke, 23 (34%) of the other interviewees had needed to make home adjustments or move home. Seven patients (11%) were dependent in terms of the activities of daily living (a Barthel Index below 60) and 11 (18%) had difficulty in maintaining domestic activities and community living (an IADL score over 10). Although the remaining patients had made a good functional recovery, 23 were using technical aids and 28 needed family or caregiver assistance, including 23 patients with full functional independence scores. Twenty-five patients (42%) were suffering from depression as defined by the diagnosis and statistical manual of mental disorders (4th edition, text revision, DSM IV-R). The patients’ prime concerns were related to recovery of independence, leisure activities and financial resources. Family members’ expectations related to the complexity of administrative matters, lack of information and the delay in service delivery. Discussion and conclusion In under-75 hemiplegic stroke patients, high scores on standard disability rating scales do not always mean that no help is required.

Objectives The goal of early supported discharge (ESD) is to reduce the duration of in-patient care in stroke units (SUs) and to optimize the management of pre- and post-discharge rehabilitation. Here, we report on and discuss ESD's effects on various outcome parameters in stroke patients. Methods Analysis of randomized, controlled studies and meta-analyses identified in the Medline and Cochrane databases. Results ESD interventions have been evaluated in more than 10 studies. Most of the included patients had suffered from mild or moderate strokes. Meta-analyses have shown that when compared with standard care, ESD has a positive effect on the risk of death or institutionalisation, death or dependence and participation in instrumental activities of daily living (iADL). In-patient hospitalization in the SU and the overall cost of care were significantly lower. Individual studies showed variability in the inclusion criteria, type of care, comparisons performed and conclusions drawn. ESD's superiority in terms of the risk of death or dependency was mainly reported in a Norwegian study and that in terms of iADL was reported in a Swedish study. There was no specific effect on functional impairment and personal ADL (pADL). Discussion This technique reduces the length of the in-patient stay and the overall cost of care while lowering the risk of death or institutionalisation and promoting participation in iADL. However, studies on this topic are heterogeneous.

Le myxome cardiaque est une tumeur histologiquement bénigne, souvent découverte fortuitement à l'échocardiographie. Elle reste néanmoins grave par ses complications, notamment emboliques. Nous rapportons le cas d'un myxome de l'oreillette gauche compliqué de syndrome coronarien aigu et de multiples accidents vasculaires cérébraux ischémiques. Le diagnostic d'accidents emboliques est retenu devant l'association d'une tumeur intracardiaque emboligène, des AVCI et un SCA en l'absence de lésions d'athérosclérose et l'absence de thrombus intracardiaque. Le patient a bénéficié d'une exérèse chirurgicale de la tumeur avec des suites opératoires simples. Nous illustrons à travers cette observation le potentiel embolique du myxome qui rend cette tumeur redoutable et nous insistons sur l'intérêt d'une prise en charge chirurgicale urgente.

In stroke patients with severe persistent neurological deficits, alternative therapeutic modalities are limited. Stem cell therapy might be an opportunity when the safety profile of this approach will be achieved. This review will give possible mechanisms of restoration of function in animals and a statement of clinical trials in humans. The sources of neural stem cells for therapeutic use will be detailed. Potentials mechanisms of transplanted cell-mediated recovery are described with a particular emphasis on ipsilesional post-stroke plasticity. The optimal conditions for cell transplant therapy after stroke are evoked but not yet clearly defined. Finally, since multimodality imaging will be crucial in the post-transplantation patient assessment, the final part describes recent advances in the in vivo monitoring of repair progress.

presentant une aphasie totale (score ASRS de Goodglass et Kaplan a 0) n’a pu passer l’entretien. Celui-ci a ete difficile chez 3 patients (deux ASRS 1, un ASRS 2), possible avec reformulations chez 16, et facile chez les 12 autres. Il existe des differences significatives avec les scores des temoins dans 5 des 6 categories CIF notamment pour les itemsRP entretien du linge, deplacements exterieurs, courses et achats, budget, relations avec des inconnus, loisirs de groupe, vie associative et demarches administratives. Parmi les facteurs d’environnement, le soutien social est juge satisfaisant dans 79,5%des situations. Les attitudes des autres sont jugees 3 a 4 fois plus souvent facilitatricesqu’obstacles. Le facteurSystemeset politiques est facilitateur pour Soins personnels, Vie domestique, Vie communautaire, mais plutot obstacle pour Relations et Loisirs. Discussion.– La GMAP est applicable a la plupart des personnes aphasiques, mais des versions multi-sources seront utiles chez ces patients. Le modele CIF parait pertinent pour comprendre leurs difficultes de participation. Reference [1] Belio C, Prouteau A, Koleck M, Saada Y, Merceron K, Destaillats JM, et al. Participation in patients with psychic and/or cognitive impairments. Annals PRM 2013 [in print]..

Background: Informal care giving can be burdensome particularly where the option of institutionalized informal care scarcely exist. Objective: To look at the burden of informal caregivers of stroke survivors using the Zarit burden interview (ZBI). Method: 64 stroke survivors were assessed for demographics of age, gender, duration of follow-up since discharged from in-patient care, modified Rankin score at the time of discharge and at the time of evaluation for this study and the most important informal care giver at home was also assessed for whether care giving was telling on their health or life in any negative way. All the caregivers were subsequently assessed with the ZBI. Results: Mean age of most important informal care givers was 40.67 ± 14.27 years and the sex distribution was 33(51.6%) female and 29(45.4%) males. 21(32.8%) reported that caregiving was a health burden. Mean ZBI scores were significantly higher (30.19 ± 14.81 vs 20.30 ± 12.96, P < 0.01) in those that reported that caregiving was telling on their health. ZBI overall rating of burden of caregiving was also significantly associated with whether caregiving was telling on the health of caregiver (P = 0.01) and also symmetrically agreed with whether the burden of caregiving was telling on health (k = 0.33, P < 0.01). The sensitivity and specificity of ZBI were 70% and 68.4% respectively on ROC statistics (AUC = 0.67, P = 0.017). Conclusion: Reported burden of informal caregiving of about 33% is in our opinion huge. The moderate sensitivity and specificity of the ZBI means it could be safely used in the population studied.

Les auteurs rapportent 3 cas d'enfants congolais drepanocytaires dont la premiere manifestation documentee est un accident vasculaire cerebral. Sous un traitement fait d'hydroxyuree et d'une kinesitherapie de reeducation, l'evolution dans deux cas sur trois a ete favorable. La necessite d'evoquer le diagnostic de drepanocytose en cas d'AVC de l'enfant est soulignee, meme en l'absence d'antecedents significatifs, ainsi que les alternatives possibles de prise en charge.

INTRODUCTION: Les accidents vasculaires cerebraux constituent un veritable probleme de sante publique en Afrique avec une charge importante. Les donnees fiables sur sa reelle charge economique sont rares en Afrique. L'objectif de cette etude etait d'evaluer le cout direct hospitalier des AVC a Parakou au Benin. METHODES: Il s'agissait d'une etude transversale economique ayant inclus des patients hospitalises pour un AVC a l'hopital de Parakou entre le 1er Juin 2010 au 31Mai 2011. Les donnees concernant les differents postes de consommation ont ete collectees selon la methode dite bottom-up. Le cout etait envisage du point de vue de la societe et du patient. L'unite du cout etait le franc CFA (valeur en 2011). Une regression lineaire multiple etait utilisee pour determiner les meilleurs predicteurs du cout. RESULTATS: Ils etaient 78 patients dont 52 hommes, âges en moyenne de 57 ans ± 10.9. Le NIHSS moyen etait de 14,4. Le taux de mortalite etait de 20,5%. Le cout direct moyen etait de 316.810,3 (±230.774,8) F CFA (environ 704 ± 512 Euros). Les grands postes de consommation etaient les explorations paracliniques (34.3%) les soins et medicaments (28.4%) et les frais d'hospitalisation (17.9%). Les meilleurs predicteurs du cout eleve etaient un AVC hemorragique, un NIHSS eleve a l'admission et une longue duree d'hospitalisation. CONCLUSION: Cette etude suggere un cout eleve de la prise en charge actuelle des AVC a Parakou.

Mots cles : Heminegligence ; Accident vasculaire cerebral ; Stimulation cerebrale ; TDCS Problematique.– Le syndrome d’heminegligence est une deficience frequente consecutive a un accident vasculaire cerebral. Parmi les theories explicatives de ce syndrome, le concept de competition interhemispherique est evoque [1]. Toute intervention visant a modifier cet equilibre pourrait presenter un interet dans le traitement de la negligence. Les stimulations cerebrales non invasives (transcranial Direct Current Stimulation [tDCS] et repetitive Transcranial Magnetic Stimulation [rTMS]) ont montre leur capacite a moduler l’excitabilite cerebrale [2]. Ces techniques ont peu ete evaluees dans cette indication ; les travaux publies concernent essentiellement la rTMS [3,4]. Materiel et methodes.–Dans cette etude pilote, nous avons tente de repliquer en tDCS les resultats obtenus en rTMS. Deux patientes ont beneficie, lors de deux sessions, d’une tDCS parietale gauche soit inhibitrice soit placebo. Les performances dans des tâches visuoperceptives (bissection de lignes et test des cloches) ont ete evaluees avant, pendant et apres la stimulation. Resultats.– Pour l’une des patientes, le biais de bissection a diminue pendant la stimulation reelle (biais de 0,8 % contre 18,5 % en pre-test) mais pas placebo (22,4 % contre 17,3 %) ; l’exploration visuelle etait meilleure (+30 % de cibles identifiees, –4,1 % en condition placebo). Pour la seconde patiente, le biais de bissection etait stable ; l’exploration visuelle etait meilleure apres stimulation reelle (+26 % de cibles, –3,2 % en condition placebo). Discussion.– Ces premiers resultats confirment la possibilite d’une amelioration des performances depatients heminegligents pendant une stimulation.Unnombre plus important de patient est necessaire afin de confirmer ces premiers resultats.

SummaryPatent foramen ovale and obstructive sleep apnoea are frequently encountered in the general population. Owing to their prevalence, they may coexist fortuitously; however, the prevalence of patent foramen ovale seems to be higher in patients with obstructive sleep apnoea. We have reviewed the epidemiological data, pathophysiology, and the diagnostic and therapeutic options for both patent foramen ovale and obstructive sleep apnoea. We focus on the interesting pathophysiological links that could explain a potential association between both pathologies and their implications, especially on the risk of stroke.

Review; International audience; Acute ischemic stroke is a leading cause of death and severe disability in industrialised countries and also in many developing countries. An excessive amount of free radicals is generated during cerebral ischemia, which significantly contributes to brain damage. Therefore, an increasing interest has been devoted to the potential benefits of antioxidant compounds in ischemic stroke patients. In this review, we examined the most relevant observational studies concerning the relationship between dietary antioxidants and ischemic stroke as well as clinical trials investigating the effects of single or multiple antioxidant supplementation in the prevention or treatment of acute ischemic stroke. Furthermore, we reviewed the most promising antioxidant compounds, i.e. dehydroascorbic acid, tocotrienol, tocopherol, flavonoids, resveratrol and gingko biloba, tested in animal models of acute ischemic stroke. Finally, we carefully evaluated the reasons for the discrepancy between experimental and clinical studies, and provided recommendations to improve the translation of the results obtained in animal models to patients with acute ischemic stroke.

Background: Incidence of intracerebral hemorrhage (ICH) is twice as high as in Western countries. Prognostic factors for predicting function outcome and mortality play a major role in determining the treatment outcome. Methods: A prospective study of male and female patients ≥12 years with primary nontraumatic intracranial hemorrhage were included. Hemorrhage caused by trauma, anticoagulant or thrombolytic drugs, brain tumor, saccular arterial aneurysm or vascular malformation were excluded. Functional outcome of patients was determined by modified Rankin's scale. Glasgow Coma Scale (GCS) score and ICH score were calculated for each patient. Results: Hypertension was present in 45 out of 49 patients (92%) with ICH of basal ganglia. Hypertension was significantly associated with worst clinical outcome. Mortality was high if the patient was comatose/stuporous compared to drowsy state (P < 0.0001). Mortality was found to be high when the size exceeded 30 cm3. High ICH score, low GCS score at the time of admission, presence of intraventricular hemorrhage, and midline shift were significantly associated with poor clinical outcome. Conclusions: Intracranial hemorrhage can be deleterious if present with low GCS score, high ICH score, intraventricular extension, and midline shift.

Mots cles : Griffe des orteil ; Accident vasculaire cerebral Objectifs.– La griffe d’orteil est une affection frequente et invalidante chez les patients hemiplegiques. Malheureusement en France, il n’existe ni recommandations ni consensus sur son traitement. L’objectif de ce travail est de proposer aux reeducateurs une grille de decision consensuelle afin de faciliter la decision dans la prise en charge des griffes d’orteil. Methode.– Dans un premier temps, nous avons construit un schema decisionnel sur l’attitude vis-a-vis d’une griffe des orteils en synthetisant les donnees de la litterature et l’experience du service de MPR de Toulouse. Ensuite, nous avons fait evaluer cet arbre decisionnel par des medecins nationaux experts dans ce domaine, afin de proposer une grille decisionnelle consensuelle. L’evaluation concernait, tout d’abord, la qualite globale de l’arbre decisionnel et la realisation d’un bloc nerveux a la xylocaine avant la realisation d’une injection de toxine botulique. Puis, dans le cadre d’une participation des muscles intrinseques a la griffe, objectivee par un bloc du nerf tibial posterieur a la cheville positif, etait analyse le choix des muscles a toxiner : court flechisseur des orteils ou carre plantaire. Enfin, la prescription d’un traitement orthopedique par semelles avec appui retrocapital etait evoquee. Resultats.– Ce sondage a suscite un reel interet de la part des experts contactes avec un taux de reponse de 100 % dans des delais tres courts. Globalement, cette grille decisionnelle est partagee par la plupart des experts choisis qui evalue son utilite a 6/10. Ils proposent majoritairement un traitement par semelles avec appui retrocapital et n’effectuent pas souvent de bloc nerveux avant de toxiner. De plus, en cas de participation des muscles intrinseques a la griffe, ils ont plus l’habitude de toxiner le muscle court flechisseur des orteils. Discussion.– La realisation de cette enquete a permis soulever la problematique medicolegale des blocs consideres par l’ASFAR comme des actes d’anesthesie, alors que de nombreux MPR le font dans leur service. Enfin, d’un point de vue methodologique, il serait interessant de renouveler cette demarche pour faciliter la prise en charge des principales deficiences des patients hemiplegiques comme le stiff-knee ou le varus equin.