Manifestations neurologiques et neuroradiologiques dans la maladie de Rendu-Osler

LYON1-BU Santé (693882101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Cerebral imaging in infectious endocarditis: A clinical study

International audienceBACKGROUND:Because neurological failure is the most frequent extra-cardiac complication in Infectious Endocarditis (IE), a brain computerised tomography (CT) scan is usually performed. The benefits of magnetic resonance imaging (MRI) have not been clearly established. This study aims to clarify the prevalence and type of cerebral lesions in IE detected using MRI and to compare them with those detected using CT scans.METHODS:In the Grenoble University Hospital, patients diagnosed with definite or possible endocarditis according to Duke's criteria were screened from 2010-2012. Brain CT and MRI were performed as soon as possible after diagnosis.RESULTS:Of the 62 patients with IE who underwent at least one cerebral imaging within 3 weeks of diagnosis, Streptococcus (29) and Staphylococcus (14) were the main micro-organisms present. Twenty-eight (45%) patients underwent cardiac surgery. Eight (13%) died before discharge. Twenty (32%) had neurological symptoms. A brain CT-scan was performed on 53 (85%) patients and a MRI was performed on 43 (69%) patients. CT was pathological in 26 (49%) patients, whereas 32 (74%) MRI demonstrated abnormalities. The MRI lesions were classified as follows: ischaemia (48%), microbleeds (34%), haemorrhages (16%), abscesses (9%) and microbial aneurysms (4%). Of the 37 patients who underwent both MRI and CT examinations, ischaemia (48% vs 35%) and microbleeds (34%) demonstrated the difference between the two imaging methods.CONCLUSION:Through the early diagnosis of cerebral damage, even in asymptomatic cases, MRI may have a role in the IE management, influence any surgical decision and assist in prognosis assessment

Potentially stress-induced acute splanchnic segmental arterial mediolysis with a favorable spontaneous outcome

A 62-year-old woman presented with hemithoracic anesthesia and acute abdominal pain following a violent psychological stress. Magnetic resonance imaging showed a thoracic hematoma with arachnoiditis of the spinal cord. Tomography revealed a typical aspect of segmental arterial mediolysis with multiple aneurysms and stenoses of the splanchnic arteries, confirmed by abdominal arteriography. There was no argument for hereditary, traumatic, atherosclerotic, infectious, or inflammatory arterial disease. Segmental arterial mediolysis was diagnosed on the basis of the radiologic data and probably involved both medullary and splanchnic arteries. The patient spontaneously recovered and was in good health 18 months later

Non-ischemic cerebral enhancing lesions after intracranial aneurysm endovascular repair: a retrospective French national registry

International audienceBackground Non-ischemic cerebral enhancing (NICE) lesions are exceptionally rare following aneurysm endovascular therapy (EVT). Objective To investigate the presenting features and longitudinal follow-up of patients with NICE lesions following aneurysm EVT. Methods Patients included in a retrospective national multicentre inception cohort were analysed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm EVT, with no other confounding disease. Results From a pool of 58 815 aneurysm endovascular treatment procedures during the study sampling period (2006–2019), 21/37 centres identified 31 patients with 32 aneurysms of the anterior circulation who developed NICE lesions (mean age 45±10 years). Mean delay to diagnosis was 5±9 months, with onset occurring a month or less after the index EVT procedure in 10 out of 31 patients (32%). NICE lesions were symptomatic at time of onset in 23 of 31 patients (74%). After a mean follow-up of 25±26 months, 25 patients (81%) were asymptomatic or minimally symptomatic without disability (modified Rankin Scale (mRS) score 0–1) at last follow-up while 4 (13%) presented with mild disability (mRS score 2). Clinical follow-up data were unavailable for two patients. Follow-up MRI (available in 27 patients; mean time interval after onset of 22±22 months) demonstrated persistent enhancement in 71% of cases. Conclusions The clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms. Clinical course is most commonly benign, although persistent long-term enhancement is frequent

Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey

International audienceBackground Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France. Methods In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC). Results All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications. Conclusion This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field

Social and clinical vulnerability in stroke and STEMI management during the COVID-19 pandemic: a registry-based study

Objective This study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment elevation myocardial infarction (STEMI) patients.Design Two cohorts of STEMI and stroke patients in the Aquitaine neurocardiovascular registry.Setting Six emergency medical services, 30 emergency units, 14 hospitalisation units and 11 catheterisation laboratories in the Aquitaine region in France.Participants This study involved 9218 patients (6436 stroke and 2782 STEMI patients) in the neurocardiovascular registry from January 2019 to August 2020.Primary outcome measures Care management times in both cohorts: first medical contact-to-procedure time for the STEMI cohort and emergency unit admission-to-imaging time for the stroke cohort. Associations between social (deprivation index) and clinical (age >65 years, neurocardiovascular history) vulnerabilities and care management times were analysed using multivariate linear mixed models, with an interaction on the time period (pre-wave, per-wave and post-first COVID-19 wave).Results The first medical contact procedure time was longer for elderly (p<0.001) and ‘very socially disadvantaged’ (p=0.003) STEMI patients, with no interaction regarding the COVID-19 period (age, p=0.54; neurocardiovascular history, p=0.70; deprivation, p=0.64). We found no significant association between vulnerabilities and the admission imaging time for stroke patients, and no interaction with respect to the COVID-19 period (age, p=0.81; neurocardiovascular history, p=0.34; deprivation, p=0.95).Conclusions This study revealed pre-existing inequalities in care management times for vulnerable STEMI and stroke patients; however, these inequalities were neither accentuated nor reduced during the first COVID-19 wave. Measures implemented during the crisis did not alter the structured emergency pathway for these patients.Trial registration number NCT0497920

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons