Search

Efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) is strongly time dependent in acute stroke management. We investigated the impact of a direct magnetic resonance imaging (MRI) room admission protocol in order to reduce in-hospital delays.We implemented a protocol of direct MRI room admission, bypassing the Emergency Department. We compared in-hospital delays, clinical and functional outcomes using National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores, between patients hospitalized via this protocol and those admitted via the standard workflow and treated by IVT and/or MT. The primary endpoint was the proportion of patients with door-to-needle time (DTN) ≤ 60minutes.Among 308 consecutive patients included, 62 underwent direct MRI room admission. The proportion of patients with DTN ≤ 60minutes was higher in the intervention group compared to the control group (82.5% vs. 17.8%, P0.001), and median DTN was lower (45min vs. 75min, P0.001). Despite a functional benefit at discharge on dichotomized mRS (mRS [0-2, as independence]: 66.1% vs. 51.2%, P=0.003), the difference was no longer statistically significant at six months (68.4% vs. 57.4%, P=0.10).Direct MRI room admission of stroke alerts is associated with an important reduction of treatment times and improves functional outcomes.

A key issue for posturography is the expression of robust results, in a simplified way. Most studies of individuals post-stroke concern the chronic phase, with small sample sizes.By reducing the number of posturographic indices, we aimed to determine an optimal dataset and understand typical postural behaviors in the subacute post-stroke phase.In this cross-sectional study ancillary to the DOBRAS cohort, individuals were assessed as soon they could complete a full posturography session (with and without vision) after a first hemispheric stroke. Body-weight distribution on the mediolateral (ML) axis, position of the center of pressure on the antero-posterior (AP) axis, and postural sway on both axes were computed. Balance ability in daily life was quantified with the Postural Assessment Scale for Stroke. Data were analyzed by principal component and hierarchical clustering analyses as well as multiple linear regression.We enrolled 95 individuals (median age: 67.0 years [Q1; Q3 56.0; 72.0]; 68% males). Vision suppression had a marginal effect, only increasing postural sway. Regardless of the visual condition, posturographic behavior was captured by a set of 3 indices that explained almost all the information. One postural sway index (ML or AP) gave more information (48%) than both position indices (ML 26% and AP 15%). These 3 indices identified 3 standing behaviors: 1) stable and symmetric, 2) asymmetric, unstable, and positioned backward, and 3) very unstable and positioned forward. Balance ability in daily life was explained (49% of the information, 95%CI [35; 63]) by weight-bearing asymmetry and postural sway on the ML axis, which played an independent role (both p10Three typical behaviors allow standing after stroke: described by only 3 posturographic indices. Weight-bearing asymmetry is not the primary parameter and should not be considered in isolation as an outcome. To increase the feasibility of posturography in the early subacute phase and to simplify evaluation sessions, trials could be limited to eyes open.NCT03203109.

Background Stroke, as the third cause of death in developed countries, is a public health issue. Atrial fibrillation is an important cause of ischemic stroke and its prevention is efficient with oral anticoagulation. However, oral anticoagulation can be contraindicated because of hemorrhagic risk related to these treatments. Percutaneous left atrial appendage occlusion is a new alternative of oral anticoagulation for patients with atrial fibrillation and high risk of cardio-embolic stroke but contraindicated for oral anticoagulation. Methods We describe in this paper the procedure of left atrial appendage occlusion with the Amplatzer cardiac plug device, used in our center in Grenoble university hospital, for the first three patients who have been treated with this device. These three patients (one man and two women) have all atrial fibrillation with neurological complication of this arrhythmia, as ischemic stroke. Oral anticoagulation is indicated to prevent another ischemic stroke. However, they all have a high risk of cerebral bleeding for different reasons (cavernomatosis, history of intracerebral hemorrhage and aneurysm of the polygon of Willis). Consequently, they have a high risk of cardio-embolic complication but contraindication for oral anticoagulation. They have been treated by left atrial appendage occlusion with Amplatzer cardiac plug device by percutaneous and trans-septal access. Then, they have been followed by neurologist and cardiologist, with clinical and paraclinical evaluation by echocardiography. Results Our three first patients have been successfully implanted, without periprocedural complication. No latest adverse event was observed, and particularly no cardiac or neurologic adverse event. Conclusion The technique of left atrial appendage occlusion is a very interesting and promising technique for ischemic stroke prevention in patient with high risk of cardio-embolic complication because of atrial fibrillation, but high risk of bleeding and contraindication for oral anticoagulation. Because of frequency of both atrial fibrillation and contraindication for oral anticoagulation, occlusion of the left atrial appendage should become an interesting alternative for many patients. However, it remains an invasive procedure and efficacy and indications need to be evaluated in further clinical trials. Risk/benefit ratio must be carefully assessed and compared to that of the new anticoagulant drugs.

Resume Un patient de 56 ans a ete admis aux urgences pour tableau d’hemiparesie droite associee a une aphasie, dans un contexte d’hyperglycemie majeure sans autres troubles ioniques. Le diagnostic de myelinolyse centropontine a ete retenu apres analyse de l’imagerie par resonance magnetique, retrouvant des lesions typiques situees au niveau du tronc cerebral. Ses symptomes ont regresse en quelques jours apres correction de l’hyperglycemie. Ce diagnostic rare et de mecanisme physiopathologique encore incertain n’est donc pas a meconnaitre et doit etre differencie des accidents vasculaires cerebraux. Il est associe a une forte hyperosmolarite, qui doit etre corrigee de maniere prudente.

One out of four ischemic strokes in France occurs in adults under 65 years old. About a third of them remain unexplained even after an extensive etiological assessment. A large part of these unexplained strokes could be linked to illegal drug abuse, and 10 % are estimated to be directly linked to illegal drugs in some international studies. The most frequently incriminated recreational drug remains cocaine, via several mechanisms. However, several other illegal drugs, some very commonly used such as cannabis, are suspected to have an important role in neurovascular diseases. In this article, we reviewed the epidemiological, pathophysiological and clinical studies, published in the international literature over the past 30 years. The drug-caused stroke epidemiology needs to be more precisely studied, as well as the underlying mechanisms depending on each drug. This is a public health issue that affects an economically active population, as stroke is the first cause of acquired handicap in adults.

Objectif L’objectif de cette etude est d’evaluer les resultats des patients operes d’une stenose carotidienne symptomatique responsable d’un infarctus cerebral apres une revascularisation precoce ( Methodes De juillet 2010 a juin 2014, les patients ayant presente un infarctus cerebral et ayant beneficie d’une chirurgie carotidienne dans les 3 mois apres le debut des symptomes ont ete colliges. Il s’agit d’une serie continue, monocentrique et retrospective. La prise en charge preoperatoire a ete identique pour chaque patient : evaluation par un neurologue avec le score National Institute of Health Stroke Scale (NIHSS), realisation systematique d’une imagerie cerebrale (TDM ou IRM) pour eliminer un infarctus hemorragique, evaluation du degre de stenose carotidienne (> 60 %) par echo-Doppler et angio-TDM ou angio-IRM. Un traitement medical optimal a ete delivre des le diagnostic confirme et les patients eligibles ont beneficie d’une thrombolyse. Deux sous-groupes ont ete individualises : – le groupe A concernait les patients qui ont beneficie d’une revascularisation dans les 14 premiers jours apres le debut des symptomes ; – le groupe B les patients qui ont ete operes entre 15 jours et 3 mois apres le debut des symptomes. La mortalite, le taux d’infarctus cerebral et les complications cardiaques postoperatoires ont ete analyses. Resultats Soixante et onze patients ont ete operes d’une stenose carotidienne symptomatique avec un infarctus cerebral (73,2 % d’hommes, 26,8 % de femmes, âge moyen de 71 ans [47–91]). Pendant la meme periode, 447 patients ont ete operes d’une stenose carotidienne. Dix-neuf patients ont ete revascularises precocement (groupe A) et 52 ont ete operes tardivement (groupe B). Le NIHSS moyen a l’admission dans le groupe A etait de 3 [0–7] avec un delai moyen de prise en charge chirurgicale de 9,5 jours [3–14] ; l’infarctus cerebral etait confirme dans 89,5 % des cas par une IRM et le degre moyen de stenose carotidienne etait de 80 % [50–95]. Dans le groupe B, le NIHSS moyen etait plus severe (5 [0–27] ; p = 0,04), le delai moyen de prise en charge etait de 42 jours [15–92], une IRM cerebrale etait realisee chez 76,9 % des patients et le degre moyen de stenose carotidienne etait de 75 % [50–95]. Dix patients du groupe B ont beneficie d’une thrombolyse. Toutes les revascularisations ont ete realisees sous anesthesie generale. Un shunt selectif a ete utilise chez 5 patients du groupe A et chez 7 patients du groupe B (26,4 % vs 13,5 % ; p = 0,1). Le suivi a un mois de 98,6 % des patients (1 perdu de vue) n’a montre dans le groupe A aucune complication postoperatoire ; dans le groupe B, on observait 2 hematomes cerebraux (3,8 %) responsables d’AVC. Conclusion Cette etude retrospective confirme le resultat satisfaisant des revascularisations carotidiennes precoces apres infarctus cerebral. Une selection clinique et radiologique rigoureuse des patients permet d’eviter les complications neurologiques precoces.

Traumatic internal carotid artery dissection may result from a direct blow to anterolateral aspect of the neck, or an extreme extension and rotation of the neck. Traumas involved are variable ranging from high speed motor vehicle accident to trivial traumas. The most frequent presentations of carotid artery dissection are stroke, Horner syndrome, and paralysis of a cranial nerve. Time of ischemic signs onset is very variable too, diverging from immediate to several months delay. We report the case of a 60-year-old woman, who was assaulted by a young man. Immediately, she complained of headache and posterior cervical pain. Three months later she developed a left hemifacial paralysis. MRI and MRA showed a dissection of the left internal carotid artery. The causal relationship between the trauma and the carotid artery dissection as well as forensic issues are discussed.

Les accidents vasculaires cerebraux (AVC) representent la premiere cause de handicap de l’adulte. En ameliorant la neuroprotection endogene et la plasticite cerebrale (neuro-synaptogenese, angiogenese, oligodendrogliogenese, immunomodulation), la therapie cellulaire est tres prometteuse. Ses mecanismes d’action dependent de la cellule choisie : effet neurotrophique paracrine de l’injection de cellules souches « peripheriques », telles que les cellules souches mesenchymateuses (CSM), ou remplacement cellulaire plus direct pour les cellules souches neurales. Avec une large fenetre therapeutique post-AVC, la therapie cellulaire peut etre utilisee pour de nombreux patients. Cependant, les delais, les doses et les voies d’administration restent debattus. Parmi les nombreuses cellules disponibles, les CSM sont les plus etudiees dans les essais cliniques. Les premiers essais pilotes ont montre une bonne tolerance apres une injection intraveineuse et suggerent un benefice sur la recuperation fonctionnelle post-AVC. A l’avenir, les approches translationnelles restent essentielles pour optimiser les therapies cellulaires avec eventuellement l’utilisation de therapies combinees et/ou de biomateriaux, et les essais cliniques multicentriques en cours devront venir valider les premiers resultats prometteurs. En prenant en compte les questions en suspens sur la meilleure procedure et la securite (e.g. tumorigenicite, immunogenicite), nous pouvons esperer que la therapie cellulaire post-AVC representera une strategie innovante pour reduire le handicap post-AVC de nombreux patients.