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Intravenous alteplase is the only thrombolytic treatment approved for patients with acute ischemic stroke (AIS). Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units. The purpose of the present work was to provide an up-to-date set of expert consensus statements on the use of tenecteplase in AIS.Members of the working group were selected by the French Neurovascular Society. RCTs comparing tenecteplase and alteplase in the treatment of AIS were reviewed. Recent meta-analysis and real-life experience data on tenecteplase published until 30th October 2021 were also analyzed. After a description of the available data, we tried to answer the subsequent questions about the use of tenecteplase in AIS: What dosage of tenecteplase should be preferred? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Then expert consensus statements for tenecteplase use were submitted. In October 2021 the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved.A set of three expert consensus statements for the use of tenecteplase within 4.5hours of symptom onset in AIS patients were issued: (1) It is reasonable to use tenecteplase 0.25mg/kg when mechanical thrombectomy (MT) is planned. (2) Tenecteplase 0.25mg/kg can be used as an alternative to alteplase 0.9mg/kg in patients with medium- or small-vessel occlusion not retrievable with MT. (3) Tenecteplase 0.25mg/kg could be considered as an alternative to alteplase 0.9mg/kg in patients without vessel occlusion.These expert consensus statements could provide a framework to guide the clinical decision-making process for the use of tenecteplase according to admission characteristics of AIS patients. However, existing data are limited, requiring inclusions in ongoing RCTs or real-life registries.

Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days.Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR=0.90 [95%CI 0.46-1.77] P=0.769) or mortality (OR=0.75 [0.37-1.49] P=0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR=0.43 [0.16-1.16] P=0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR=1.08 [0.62-1.88] P=0.767).Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.

Early glycemic variability (GV) in diabetic patients is a poor prognosis factor following cardiovascular events. However, its influence on the course of acute ischemic stroke (AIS) with large vessel occlusion remains unclear. We investigated the relationship between high GV during acute stroke and three-month functional outcome among patients treated with combined intravenous thrombolysis and endovascular therapy for large vessel occlusion.A single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent thrombolysis and mechanical thrombectomy between January 2015 and May 2017. Early GV was assessed using standard deviation (SD) of blood glucose levels for the first 24hours. The main outcome was functional status at three months as defined by the modified Rankin scale (mRS). Secondary outcomes were change in NIHSS score from baseline to 24hours and occurrence of severe hemorrhagic transformation. Multivariate logistic regression analyses including GV, admission glycemia and mean glycemia were performed.Among the 93 patients evaluated, 26 had early high GV (≥20.9mg/dl). High GV was associated with poor functional outcome (OR=8.00; 95%CI [1.34-47.89]; P=0.02) unlike admission glycemia and mean glycemia (OR=2.92; 95%CI [0.51-16.60]; P=0.23 and OR=0.36; 95%CI [0.05-2.6]; p=0.31, respectively). High GV was not associated with NIHSS at 24hours or hemorrhagic transformation.Acute high GV contributes to poorer functional outcome following AIS related to large vessel occlusion and should be considered as a new target in acute stroke management.

BACKGROUND AND PURPOSE: Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke. MATERIALS AND METHODS: We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion). RESULTS: In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0–2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%–14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%–68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%–35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%–94.6%). CONCLUSIONS: Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.

Antithrombotic drugs (ADs) are the mainstay of secondary prevention of thrombotic vascular diseases. Management of patients under long-term treatment with ADs admitted for acute cerebrovascular disease, either ischemic stroke (IS) or intracerebral hemorrhage (ICH), has become a frequent situation that might influence decision-making processes from diagnosis to therapeutic strategies. The aim of this review is to summarize current data from the literature to help clinicians in their decisions for stroke care in patients taking ADs. While a large body of data have made it possible to codify the management of patients presenting IS or ICH under antiplatelet drugs and vitamin K antagonists, the increasing use of direct oral anticoagulants (DOAs) and future development of new antiplatelet drugs raise new problems. Development of rapid assessment tools measuring specific biological activity and reversion agents dedicated to each class of DOAs should make it possible to optimize individual therapeutic strategies. This review highlights the main steps of IS and ICH management from early identification of ADs, and use of dedicated biological assays, to the stepwise strategy to apply revascularization or reversal therapies and finally the resumption of ADs with a focus on individual clinical and radiological characteristics for more personalized care.

The objectives were to analyze changes from 2012 to 2017 in different management times of stroke patients included in the Aquitaine stroke Observatory (ObA2). The studied times (onset-to-needle time-ONT, onset-to-door time-ODT, door-to-imaging time-DIT, door-to-needle time-DNT and imaging-to-needle time-INT) were described as median, interquartile ranges and proportion of patients within the recommended median time goals (ODT under 4hours, DIT within 20min; for thrombolyzed patients, DIT under 20min and a ONT under 4:30) to be compared with an objective of 50% of patients within said time goal. Globally, ODT was 160min, with 43.6% to 59.6% of patients within the ODT goal along the study period. With no improvement over time, the proportion of patients within the DIT goal stayed stable and at a low level (range: 5.5-7.0%) for all patients, decreasing from 25.2% to 11.4% for thrombolyzed patients. The proportion of thrombolyzed patients within the DNT goal varied from 15.1% to 30.3% during study period. These results highlight the urgent need for action to improve in-hospital management of stroke patients, focusing on delays between admission and imaging.

Resume Environ 10 % des patients presentant un accident vasculaire cerebral sont traites par un anticoagulant oral, de type anti-vitamine K, antithrombine ou anti-Xa au moment de leur admission. Ces traitements vont modifier la strategie therapeutique usuelle a la fois des infarctus et des hemorragies intracerebrales. En presence d’un infarctus cerebral la decision de thrombolyse dependra de la severite des symptomes, du delai d’admission depuis le debut des symptomes, du delai depuis la derniere prise medicamenteuse et de dosages biologiques specifiques. La thrombectomie sera priorisee devant toute occlusion proximale. Dans le cadre d’une hemorragie cerebrale l’utilisation de strategies de reversions specifiques du traitement anticoagulant reposant sur le CCP pour les AVK et les inhibiteurs du facteur Xa et l’idarucizumab pour le dabigatran, sera proposee en association au controle tensionnel. A l’issue d’une ischemie ou d’une hemorragie cerebrale l’indication et le delai de reintroduction du traitement anticoagulant seront evalues a la lumiere du risque individuel thrombotique et hemorragique.

Introduction La prise en charge des Accidents vasculaires cerebraux (AVC), notamment ischemiques (AVCi), constitue une urgence vitale et fonctionnelle absolue. En France, les delais de prise en charge intrahospitaliere des AVCi restent a ameliorer, en particulier entre l’admission du patient et la premiere imagerie. Afin d’identifier des leviers d’amelioration, de nombreux auteurs ont recherche les facteurs cliniques, sociodemographiques et organisationnels associes aux delais de prise en charge des AVCi. Aucune information n’est cependant disponible quant au lien entre ces delais et les facteurs structuraux hospitaliers mobilises dans la prise en charge de ces patients. Objectif Identifier les facteurs structuraux hospitaliers (presence d’Unite neurovasculaire (UNV), presence d’imagerie de resonnance magnetique (IRM), temps de trajet entre les services) associes au delai admission-imagerie des AVCi. Methodes Les sejours pour AVCi pris en charge dans six etablissements participant a l’Observatoire Aquitain des accidents vasculaires cerebraux (ObA2) entre le 1er janvier 2012 et le 31 decembre 2018 ont ete inclus. Les transferts depuis d’autres etablissements de sante et les sejours avec un delai symptome-admission superieur a 24 heures ont ete exclus. Les donnees cliniques et de prise en charge etaient celles collectees en routine dans ObA2. La date de mise en œuvre des IRM et la saturation des urgences ont ete obtenues aupres des organismes competents. Le temps de trajet entre les services a ete mesure par un recueil specifique. Des regressions lineaires multivariees avec et sans intercept aleatoire ont ete utilisees pour les analyses d’associations. L’ajustement a porte sur les variables suivantes : âge, sexe, severite de l’AVC, annee, antecedents cardiovasculaires, facteurs de risques cardiovasculaires et nombre de passage aux urgences le jour de prise en charge. Les donnees manquantes ont ete imputees par imputation multiple. Des analyses de sensibilite pour prendre en compte l’incertitude de l’imputation ont ete realisees. Resultats Au total, 10 121 sejours ont ete inclus. La presence d’une UNV (β=0,30 ; IC : [0,23 ; 0,36]) et le temps de trajet entre les services (β=0,15 ; IC : [0,07 ; 0,25]) etaient associes au delai admission-imagerie. La presence d’une IRM n’etait pas associee au delai admission-imagerie (β=0,03 ; IC : [-0,04 ; 0,10]). Seule l’analyse du lien entre delai et temps de trajet a vu ses resultats modifies au cours des analyses de sensibilite. Conclusion La presence d’une UNV au sein de l’etablissement et un temps de trajet plus long entre les services correspondent aux caracteristiques structurelles des etablissements de sante identifiees comme associees a des delais admissions-imageries allonges. Ces resultats sont sources de pistes d’actions pour l’amelioration des delais de prise en charge des AVC. Pour les etablissements avec UNV, la creation d’une filiere d’accueil specifique pour les AVC au sein de ces grandes structures pourrait etre une piste a explorer, alors que pour les etablissements de proximite, pour lesquels l’acces a l’imagerie est plus rapide, la prise en compte du parcours patient, notamment en brancard, lors des restructurations des differents services de prise en charge apparait comme une piste d’amelioration pour continuer a gagner du temps sur le delai admission-imagerie.

Background: \ud Patent foramen ovale (PFO) is a contributor to embolic stroke of undetermined source (ESUS). Subgroup analyses from previous studies suggest that anticoagulation could reduce recurrent stroke compared with antiplatelet therapy. We hypothesised that anticoagulant treatment with rivaroxaban, an oral factor Xa inhibitor, would reduce the risk of recurrent ischaemic stroke compared with aspirin among patients with PFO enrolled in the NAVIGATE ESUS trial.\ud \ud Methods: \ud NAVIGATE ESUS was a double-blinded, randomised, phase 3 trial done at 459 centres in 31 countries that assessed the efficacy and safety of rivaroxaban versus aspirin for secondary stroke prevention in patients with ESUS. For this prespecified subgroup analysis, cohorts with and without PFO were defined on the basis of transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE). The primary efficacy outcome was time to recurrent ischaemic stroke between treatment groups. The primary safety outcome was major bleeding, according to the criteria of the International Society of Thrombosis and Haemostasis. The primary analyses were based on the intention-to-treat population. Additionally, we did a systematic review and random-effects meta-analysis of studies in which patients with cryptogenic stroke and PFO were randomly assigned to receive anticoagulant or antiplatelet therapy.\ud \ud Findings: \ud Between Dec 23, 2014, and Sept 20, 2017, 7213 participants were enrolled and assigned to receive rivaroxaban (n=3609) or aspirin (n=3604). Patients were followed up for a mean of 11 months because of early trial termination. PFO was reported as present in 534 (7·4%) patients on the basis of either TTE or TOE. Patients with PFO assigned to receive aspirin had a recurrent ischaemic stroke rate of 4·8 events per 100 person-years compared with 2·6 events per 100 person-years in those treated with rivaroxaban. Among patients with known PFO, there was insufficient evidence to support a difference in risk of recurrent ischaemic stroke between rivaroxaban and aspirin (hazard ratio [HR] 0·54; 95% CI 0·22–1·36), and the risk was similar for those without known PFO (1·06; 0·84–1·33; pinteraction=0·18). The risks of major bleeding with rivaroxaban versus aspirin were similar in patients with PFO detected (HR 2·05; 95% CI 0·51–8·18) and in those without PFO detected (HR 2·82; 95% CI 1·69–4·70; pinteraction=0·68). The random-effects meta-analysis combined data from NAVIGATE ESUS with data from two previous trials (PICSS and CLOSE) and yielded a summary odds ratio of 0·48 (95% CI 0·24–0·96; p=0·04) for ischaemic stroke in favour of anticoagulation, without evidence of heterogeneity.\ud \ud Interpretation: \ud Among patients with ESUS who have PFO, anticoagulation might reduce the risk of recurrent stroke by about half, although substantial imprecision remains. Dedicated trials of anticoagulation versus antiplatelet therapy or PFO closure, or both, are warranted.\ud \ud Funding: \ud Bayer and Janssen.

Resume Pathologies cerebrovasculaires Le benefice de la thrombectomie a la phase aigue de l’infarctus cerebral est maintenant etabli lorsqu’il existe une occlusion proximale d’une artere intracrânienne, independamment de son mecanisme etiologique. L’indication des anticoagulants dans les dissections des troncs supra-aortiques demeure incertaine alors que le controle de la tension arterielle reste determinant dans la prevention des recidives d’hemorragies intracerebrales. Epilepsie Le developpement d’un parcours de soins specialise apres la survenue d’une premiere crise et l’affectation d’un psychiatre au sein des centres tertiaires ameliorent de maniere significative la prise en charge de l’epilepsie. Les taux de concordance diagnostiques entre neurologues analysant les memes observations sont faibles, montrant que le diagnostic de l’epilepsie reste difficile. Une atrophie temporale est frequemment observee dans l’epilepsie debutante du sujet âge. Mouvements anormaux D’importants progres ont ete realises ces dernieres annees dans la connaissance de la physiopathologie de la maladie de Parkinson, ce qui a ete confirme a ce congres par la decouverte de nouveaux biomarqueurs, en particulier genetiques, qui peuvent aboutir a de futurs traitements. Des progres marques concernent aussi la determination de l’histoire naturelle des maladies neurodegeneratives depuis leur phase prodromale jusqu’a leur classification neuropathologique sur la base des depots intracerebraux de proteines anormales. Demences Les communications sur la maladie d’Alzheimer ont precise la valeur respective des biomarqueurs dans le diagnostic in vivo, les espoirs therapeutiques qui reposent principalement sur des essais d’immunisation anti-Aβ des les stades precliniques (et non plus prodromaux) de la maladie, afin d’inflechir l’evolution de la perte neuronale. Au-dela des diverses et nombreuses presentations sur la genetique et la physiopathogenie des demences, des resultats prometteurs de la stimulation cerebrale dans la depression resistante au traitement medical ont ete presentes. Neuropathies peripheriques On retiendra les bons resultats enregistres avec l’ibudilast dans la sclerose laterale amyotrophique en association avec le riluzole, et ceux, prometteurs avec le patisiran dans la neuropathie amyloide familiale a transthyretine. La piste hereditaire semble se confirmer pour les neuropathies a petites fibres douloureuses. Le diagnostic des lymphomes du systeme nerveux peripherique reste difficile et leur traitement decevant. La caracterisation de nouveaux auto-anticorps dans les polyneuropathies inflammatoires demyelinisantes chroniques est en progres avec de possibles implications therapeutiques. Sclerose en plaques (SEP) La biotine dans les formes progressives de SEP et le daclizumab dans les formes a poussees paraissent etre des traitements prometteurs. L’alemtuzumab pourrait devenir le recours en cas d’echec d’un ou plusieurs autres traitements. Le teriflunomide, le dimethyle fumarate et le fingolimod ont confirme leur efficacite et gardent une tolerance acceptable. Outre l’insuffisance en vitamine D et le tabac, qui sont des facteurs de risque confirmes, l’insuffisance en testosterone (chez les hommes) et l’obesite sont des facteurs de risque emergents, sur lesquels on pourrait agir aussi.

L’accidente ischemico transitorio (TIA) e una perdita focale e transitoria di una funzione cerebrale o retinica, di comparsa brutale, interamente regressiva e senza segni di infarto alla diagnostica per immagini cerebrale. Esso rappresenta un segnale d’allarme e richiede una gestione in urgenza assoluta in un ambiente specialistico. Infatti, il 20-30% degli accidenti ischemici costituiti (AIC) e preceduto da TIA e il 10% dei TIA andra incontro a un AIC entro tre mesi, in assenza di una gestione terapeutica precoce. Dopo conferma del TIA mediante l’interrogatorio, sono necessari un esame clinico rigoroso e una diagnostica per immagini cerebrale, in quanto le diagnosi differenziali sono numerose. Una valutazione rapida dell’eziologia dovra essere realizzata per iniziare senza ritardi il trattamento adeguato. Gli esami complementari ricercheranno principalmente un’aterosclerosi delle arterie intra- o extracraniche, una sorgente cardiaca o aortica di embolia, una microangiopatia cerebrale e, piu raramente, una dissecazione. Il trattamento antitrombotico dipendera dalla causa del TIA. Infine, il TIA e spesso testimonianza di una malattia aterosclerotica generalizzata, il che giustifica la ricerca di una coronaropatia e di un’arteriopatia obliterante degli arti inferiori e il trattamento dei principali fattori di rischio associati.

Introduction Plusieurs essais cliniques randomises ont prouve l’efficacite de la thrombectomie en association avec la thrombolyse (T + T) comparativement a la thrombolyse seule dans la prise en charge des infarctus cerebraux (IC). Bien que pratiquee en France depuis 2015, la T + T n’est pas remboursee par l’Assurance maladie. Pour aider a la decision de remboursement, nous proposons une evaluation medico-economique de la thrombectomie, dans la perspective de l’Assurance maladie. Methodes Notre analyse repose sur un arbre de decision pour modeliser les trois premiers mois de prise en charge, et sur un modele de Markov pour modeliser la prise en charge au-dela de trois mois et jusqu’a 20 ans apres l’IC. Un panel d’experts incluant neurologues, neuro-radiologues, pharmacien, economiste et epidemiologistes a valide la structure du modele. Une etude de micro-costing a ete menee au CHU de Bordeaux pour estimer le cout reel de la thrombectomie. Nous avons effectue une revue systematique de la litterature pour les autres parametres du modele (couts des autres prises en charge, utilite et probabilites de transition). Une meta-analyse a effets aleatoires de six essais cliniques randomises a ete effectuee pour estimer l’efficacite de T + T et de la thrombolyse seule a trois mois post IC. Le ratio d’efficience est exprime en cout par annee de vie gagnee en etat de parfait bien-etre (QALY). L’incertitude sur la valeur des parametres du modele a ete prise en compte dans une analyse probabiliste et par une analyse de la valeur de l’information. Resultats Le cout reel de la thrombectomie etait de 6707€ (ecart-type : 2357€). Comparativement a la thrombolyse seule et pour une population cible de 8000 individus, la prise en charge des IC par T + T engendrerait un surcout de 39,98 millions d’€ pour l’assurance maladie pour un benefice clinique de 2717 QALYs. Le ratio cout-utilite de T + T par rapport a la thrombolyse est ainsi estime a 14 715 €/QALY gagne. L’analyse de sensibilite deterministe montrait un ratio d’efficience inferieur a 30 000 € par QALY gagne des la troisieme annee post IC. L’analyse probabiliste montrait une probabilite d’efficience de la thrombectomie de 85,5 % pour un ratio cout-utilite seuil de 30 000€/QALY. Pour ce meme ratio seuil, la valeur attendue de l’information parfaite ou valeur monetaire de l’incertitude liee a une decision d’inscrire la thrombectomie sur la liste des actes rembourses par l’Assurance maladie, s’elevait a 43,63 millions d’euros. Concernant les parametres de notre modele, la valeur attendue de l’information partielle parfaite etait la plus elevee pour le score d’utilite chez les personnes independante au-dela de trois mois post IC (17,97 millions d’€) et pour le temps medical dans la realisation de la thrombectomie (9,46 millions d’€). Conclusion La prise en charge des IC par T + T est plus couteuse que la thrombolyse seule mais le gain en efficacite est tel que T + T peut etre consideree comme un acte efficient dans la perspective de l’Assurance maladie. Cette analyse du cout reel de la thrombectomie et de son efficience en association avec la thrombolyse doit permettre de prendre une decision concernant la tarification de cet acte.

Multivariate analysis of associations between pre-stroke and stroke characteristics, mRS at three months and death in the first 7 days (multiple linear regressions). (DOCX 22 kb)

Contexte L’etude EOLE a pour objectif principal d’evaluer l’impact en situation reelle des traitements a visee cardiovasculaire recommandes dans la prevention secondaire de l’infarctus du myocarde (IDM) sur la mortalite totale a six ans (betabloquants, aspirine, autres antiagregants plaquettaires [AAP], statines seules, inhibiteurs de l’enzyme de conversion [IEC] seuls, supplementation pharmacologique en omega 3 [Om3]). Les premiers resultats de l’analyse finale montrent une mortalite totale a six ans moins importante qu’attendue, avec une question sur le niveau de surmortalite par rapport a la population generale de meme sexe et âge. Objectifs Estimer la mortalite totale de la cohorte EOLE et le ratio standardise de mortalite (SMR) par rapport a la population generale de meme sexe et âge. Methode EOLE est une etude de cohorte observationnelle nationale de patients presentant un IDM recent (≤ 3 mois), inclus par des cardiologues hospitaliers et liberaux et suivis pendant six ans. Le statut vital des patients a ete obtenu a partir du registre national des deces, complete par les informations du cardiologue participant ou a defaut du medecin traitant ou du patient/famille. L’exposition aux traitements de prevention secondaire recommandes a l’inclusion etait definie comme tout traitement prescrit par le cardiologue et/ou declare par le patient. La methode de Kaplan-Meier a ete utilisee pour estimer la probabilite de la mortalite totale a six ans. Le calcul du SMR tient compte des annees de suivi et a ete standardise sur l’âge, et le sexe a partir des donnees nationales de mortalite de l’Insee pour l’ensemble de la cohorte, ainsi que pour les hommes et les femmes, avec l’intervalle de confiance a 95 % (IC95 %) et le test de Breslow et Day. Resultats Entre mai 2006 et juin 2009, 596 cardiologues ont inclus 5523 patients analysables : âge median 61,0 ans, 77,6 % d’hommes, 9,6 % de fumeurs, 16,7 % de diabetiques, 44,6 % avec de l’hypercholesterolemie, 43,6 % d’hypertendus, et 8,1 % avec une FEVG Conclusion Les premiers resultats de l’analyse finale de l’etude EOLE montrent un niveau d’exposition a la plupart des traitements de prevention secondaire recommandes a l’inclusion tres eleve avec un taux relativement modere de mortalite a six ans (13,1 %). Cette mortalite reste un peu superieure a celle de la population generale, de facon non significative pour les hommes et significative pour les femmes, mais loin de la surmortalite post-infarctus de la fin des annees 1990. Cette relativement faible mortalite couplee a un niveau tres eleve d’exposition complique les analyses usuelles d’une cohorte exposes–non exposes.

Objectif L’etude EOLE a pour objectif principal d’evaluer l’impact en situation reelle des traitements a visee cardiovasculaire recommandes dans la prevention secondaire de l’infarctus du myocarde (IDM) sur la mortalite totale a six ans. L’objectif de cette analyse est d’etudier l’impact de la non-reponse aux auto-questionnaires attendus (AQ) sur la mortalite totale. Methode EOLE est une cohorte observationnelle nationale de patients presentant un IDM recent, inclus par des cardiologues hospitaliers et liberaux et suivis pendant six ans, avec des AQ patients de suivi a completer a 6 mois, 2, 3, 4, 5, et 6 ans. Le statut vital des patients a ete obtenu a partir du registre national des deces, complete par les informations du cardiologue participant ou a defaut du medecin traitant ou du patient/famille. L’exposition aux traitements de prevention secondaire recommandes (betabloquants, aspirine, autres antiagregants plaquettaires [AAP], statines seules, inhibiteurs de l’enzyme de conversion [IEC] seuls, supplementation pharmacologique en omega 3) a l’inclusion etait definie comme tout traitement prescrit par le cardiologue et/ou declare par le patient, et a chaque suivi comme tout traitement declare par le patient. Le risque relatif (HR) de non-reponse aux AQ attendus sur la mortalite a six ans a ete evalue avec un modele de Cox en tant que variable dependante du temps, ajuste sur l’âge, le sexe, les facteurs de risque cardiovasculaire a l’inclusion et l’exposition a chacun des traitements de prevention secondaire recommandes a l’inclusion (les auto-questionnaires etant attendus uniquement pour les patients non decedes et non sortis etude). Resultats Sur les 5527 patients inclus, 49,2 % etaient repondants (reponse a tous les AQ attendus) et 50,8 % non-repondants (≥ 1 non-reponse a un AQ attendu). Compares aux non-repondants, les repondants etaient a l’inclusion plus âges (63 ± 12 versus 61 ± 14 ans), avec un peu plus d’hommes (79 % versus 77 %), plus de retraites (59 % versus 49 %), moins d’obeses (IMC ≥ 30, 18 % versus 20 %), moins de fumeurs (6 % versus 13 %), moins de diabetiques (15 % versus 19 %), moins d’antecedent d’IDM (12 % versus 14 %). L’exposition aux traitements de prevention secondaire recommandes etait elevee dans les deux groupes : betabloquant 90,7 % et 88,7 %, antiagregant plaquettaire 99,6 % et 99,3 %, statine 96,9 % et 94,8 %, IEC/ARAII 83,2 % et 81,7 %, omega 3 17,3 % et 14,3 %, respectivement. La mortalite totale a six ans etait de 13,1 % (IC95 % [12,3 %–14,1 %]) pour l’ensemble de la cohorte. Le HR ajuste pour les non-repondants etait de 3,2 (IC95 % [2,7–3,7]). Conclusion Cette analyse montre un impact majeur de la non-reponse aux AQ attendus sur la mortalite a six ans dans le post-IDM. Ceci implique que les methodes d’imputation des donnees manquantes usuelles, comme la LOCF ou imputations multiples, ne permettraient pas d’estimer valablement l’exposition, basee sur les AQ, des traitements de prevention secondaire au cours du temps.

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Intracranial hemorrhage (ICH) complications are uncommon at hemophilic patients.We report three cases of ICH occurring in hemophilic patients. Contributing factors were identified in two patients: hemophilia severity, presence of inhibitor, hepatitis C virus infection, and high blood pressure. No contributing factor was identified in the last patient.Rapid diagnosis of ICH is crucial in hemophilic patients. A search for contributing factors, both those specific to hemophilia, and those favoring ICH in the general population, is essential to optimize therapeutic care. Specific substitutive treatment for the deficient factor is a difficult management challenge.

The Guillain-Barre syndrome, an acute polyradiculonevritis (PRN), usually appears after a post-infectious immuno-allergic reaction. We report a case of acute PRN following cranial surgery. Post-surgical Guillain-barre syndrome is rarely described. We reviewed the pathophysiological mechanisms possibly involved in this disease that have to be evoked in patients with abnormal post-surgical neurological symptoms.

Resume Introduction Les manifestations neurologiques sont frequentes au cours des syndromes de choc toxique (SCT). Cependant elles dominent rarement le tableau clinique. Observation Nous rapportons un cas d’encephalopathie catameniale recurrente, dominee par des crises comitiales, et revelatrice d’un SCT menstruel.

Resume Les accidents vasculaires cerebraux survenant chez des patients ayant une tumeur maligne peuvent relever d’etiologies diverses. Nous rapportons un cas d’adenocarcinome bronchique avec thrombose veineuse pulmonaire s’etendant dans l’oreillette gauche revele par des infarctus cerebraux multiples.

Atherosclerosis is a major cause of ischemic stroke. Despite important therapeutic advances, the risk of recurrence of vascular events remains very high. The partial failure of these strategies is to some extent related to the lack of patient adherence to their treatments and to the fact that therapeutic targets are not reached. The aim of the present study was to evaluate the influence of a short atherosclerosis prevention program on vascular risk reduction in stroke patients.Ninety-five patients with a first ischemic stroke related to atherosclerosis or with a high vascular risk profile were recruited. Three months later, a global evaluation of the atherosclerotic disease and of the vascular risk factors was performed combined with several education sessions on vascular risk factors and way of life. A follow-up evaluation was performed several months later to investigate the number of vascular events and the vascular risk profile.Median follow-up was 684 days after stroke. At follow-up, 91.3% of patients were taking a cholesterol-lowering drug, 95.6% an anti-thrombotic agent, and 78% an angiotensin converting enzyme inhibitor. A persistent decrease in tobacco use and an improvement in glycemic control were observed. During follow-up, 3.2% of patients died; none of the deaths were related to a vascular event. During the 22-month follow-up, 7.6% of patients experienced a major vascular event, acute coronary syndrome or stroke.Compared with results in the literature, this study illustrates the positive influence of a short atherosclerosis prevention program combining depiction of atherosclerotic lesions and education of vascular risk factors on the quality of long-term post-stroke prevention.

The Guillain-Barré syndrome, an acute polyradiculonevritis (PRN), usually appears after a post-infectious immuno-allergic reaction. We report a case of acute PRN following cranial surgery. Post-surgical Guillain-barré syndrome is rarely described. We reviewed the pathophysiological mechanisms possibly involved in this disease that have to be evoked in patients with abnormal post-surgical neurological symptoms.

The clinical diagnosis of Marchiafava-Bignami disease (MBD) can be difficult. Acute demyelination of the corpus callosum is characteristic of the disease. The authors report the use of MR diffusion-weighted imaging (DWI) in six cases of acute MBD. They show that apparent diffusion coefficient restriction of the corpus callosum and cortical lesions were associated with a higher mortality rate and more severe cognitive sequelae.

The clinical presentation of primary cerebral lymphoma can take on many forms.We report the case of a patient who experienced recurrent neurological events mimicking stroke with normal brain MRI. A late performed MRI showed a mesencephalic lesion. A biopsy was obtained and led to the diagnosis of primary B cell lymphoma.This observation illustrates the diagnostic challenge of this rare disorder with a poor prognosis.

Calcified aortic stenosis (CAS) is an unusual cause of cerebral infarct. The presence of cerebral intra-vascular or intra-parenchymatous calcifications, symptomatic or not, is suggestive of the diagnosis of CAS. We report two patients who experienced stroke induced by spontaneous calcic emboli from a calcified aortic valve and underline the importance of brain CT scan.

Neurological clinical manifestations are often observed in toxic shock syndromes. However they unusually dominate the clinical picture.We present a case of recurrent catamenial encephalopathy, with epileptic seizures, revealing a menses toxic shock syndrome.

Stroke in patients with malignant tumor are associated with various aetiologies. We report a case of lung adnocarcinoma with pulmonary vein thrombosis appending into the left atrial revealed by multiple cerebral infarcts.

Neurological complications of cosmopolitan parasitosis are rare. We report a case of a cerebral and systemic vasculitis secondary to a visceral larva migrans syndrome associated with a Toxocara canis and Fasciola hepatica co-infestation.

Neurological manifestations are uncommon after taking kava-kava. We report three cases of meningismus, two of them with focal neurological manifestations, after kava-kava absorption.

Spinal cord abscess is an unusual cause of progressive paraplegia. We report the case of a 75-year-old man who presented Chlamydia pneumoniae bronchopulmonary infection with secondary spinal cord localization. Little clinical improvement was observed with antibiotic therapy, but the neuroradiological course was favorable.

Introduction La compression medullaire est une urgence diagnostique et therapeutique. Les epidurites metastatiques et infectieuses, la hernie discale et l’hematome epidural sont les principales causes de compression extra-durale dorsale. Observations Dossier n : 20060667. Mme P, 58 ans, tabagique chronique, sans antecedents, fut hospitalisee en cardiologie pour une douleur thoracique aigue. Le bilan cardiologique se revela normal et la douleur ceda en quelques heures. Le lendemain au reveil Mme P ressentit une instabilite a la marche et des paresthesies des membres inferieurs. Devant la persistance des symptomes apres un mois une exploration neurologique fut decidee. L’examen neurologique revela un syndrome cordonal posterieur de niveau D1 avec une marche ataxique, une absence de deficit moteur, de syndrome pyramidal et de troubles vesico-sphincteriens. L’examen general n’objectiva pas d’anomalie. L’IRM medullaire montra une compression medullaire de niveau D1 par une masse extradurale iso-intense T1 et T2 et se rehaussant en peripherie apres injection de gadolinium et une lyse de l’isthme de D1. La scintigraphie osseuse mit en evidence une hyperfixation C7 isolee. Le scanner throraco-abdomino-pelvien, la mammographie et l’ensemble du bilan biologique, inflammatoire, infectieux et neoplasique se revelerent sans particularite. Une exerese de la lesion et une biopsie vertebrale furent realisees. L’examen anatomo-pathologique demontra l’existence d’une actinomycose osteo-articulaire avec kyste synovial. Discussion L’actinomycose est une infection granulomateuse a grand polymorphisme clinique, rare et souvent meconnue. Elle est due a des bacteries filamenteuses saprophytes de la cavite buccale et du tractus gastro-intestinal : les Actinomyces. L’espece A. israelii est la plus souvent en cause en pathologie humaine. Les compressions medullaires, les abces cerebraux et les meningo-encephalites en sont les principales presentations neurologiques. Conclusion Bien que l’actinomycose soit une cause rare de compression medullaire elle doit etre evoquee devant la presence d’une lesion extra-durale n’ayant pas fait la preuve de son origine.