La prévention secondaire diffère-t-elle entre des patients coronariens et des patients ayant des antécédents d'ischémie cérébrale ?

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Etude des patients admis aux urgences pour motif neurologique et ayant bénéficié d'une imagerie cérébrale

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Evaluation de la prise en charge des vertiges aux urgences médicales du CHRU de Lille

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Etats des lieux de la pratique de la Ponction Lombaire aux urgences adultes du CHRU de Lille (Etude observationnelle)

Contexte : Le recours à la ponction lombaire (PL) aux urgences est utilisé pour la recherche d une infection du système nerveux central, d une hémorragie méningée ou encore d une polyradiculonévrite. La gravité potentielle des pathologies suspectées impose un délai précoce de réalisation et rend la démarche thérapeutique une urgence absolue. Méthode : Etude rétrospective réalisée sur un an entre 2010 et 2011, incluant l ensemble des patients qui ont bénéficiés d une PL aux urgences adultes. Nous avons évalué l incidence, les motifs de réalisation, la rentabilité de la PL et les modalités de prise en charge dans un contexte d urgence et nous avons proposé une procédure standardisée de prise en charge. Résultats : L incidence des PL (n=235) était de 0,9% des admissions. Le motif le plus fréquent représenté comme indication de réalisation de la PL était les céphalées (42,1%). Le délai médian de réalisation de la PL était de 5,9 heures (0,6 35,3), le délai était plus court à 4,9 heures (0,9 29,3) pour le motif syndrome méningé et 4,1 heures (1,3 13,9) pour le motif céphalée fébrile. Le recours à d une imagerie cérébrale avant la PL (72,8% des cas) allonge le délai de réalisation de deux heures. Les diagnostics retrouvés étaient méningite virale dans 54 cas dont 11 cas de Méningo-encéphalite (23%), méningite bactérienne dans 12 cas (5,2%), polyradiculonévrite dans 7 cas (3%), hémorragie méningée dans 1 cas (0,4%). Le délai médian d administration de l antibiothérapie pour le diagnostic méningite était de 7,1 heures. La rentabilité diagnostique des PL était de 20,9%. Conclusion : Notre étude fait apparaitre un délai élevé de prise en charge et d administration de l antibiothérapie. Nos résultats peuvent contribuer à améliorer la filière de prise en charge des ponctions lombaires selon les recommandations actuelles. Il semble nécessaire d optimiser la prise en charge et de proposer une procédure afin de prioriser les patients admis pour un motif de syndrome méningé ou céphalée fébrile.LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Etude de la population admise aux urgences pour crise convulsive (modalités d'admission et de prise en charge)

LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Predictors of outcome in patients with cerebral venous thrombosis and intracerebral hemorrhage

BACKGROUND AND PURPOSE: Although intracerebral hemorrhages are frequent in patients with cerebral venous thrombosis, and lead to worse outcome, predictors of outcome in cerebral venous thrombosis patients with intracerebral hemorrhages have never been evaluated in adequately powered studies. METHODS: This study was conducted as a part of the International Study on Cerebral Vein and Dural Sinus Thrombosis. We evaluated predictors of outcome in cerebral venous thrombosis patients who had an "early intracerebral hemorrhage," ie, intracerebral hemorrhages already present at time of diagnosis of cerebral venous thrombosis by a logistic regression analysis, with a modified Rankin scale 3 to 6 at month 6 as dependent variable. The same analysis was performed with "delayed intracerebral hemorrhages," ie, intracerebral hemorrhages that occurred after the diagnosis of cerebral venous thrombosis, as dependent variable. RESULTS: Of 624 patients recruited in International Study on Cerebral Vein and Dural Sinus Thrombosis, 245 (39%) had an early intracerebral hemorrhage: at month 6, 51 (21%) of them had a modified Rankin Scale 3 to 6. Independent predictors of having modified Rankin scale 3 to 6 at month 6 were older age (adjusted odds ratio for 1-year increase in age, 1.05; 95% CI, 1.02 to 1.08); male gender (adjusted odds ratio, 3.25; 95% CI, 1.29 to 8.16); having a deep cerebral venous system thrombosis (adjusted odds ratio, 5.43; 95% CI, 1.67 to 17.61) or a right lateral sinus thrombosis (adjusted odds ratio, 2.56; 95% CI, 1.03 to 6.40); and having a motor deficit (adjusted odds ratio, 2.94; 95% CI, 1.21 to 7.10). Of the 36 patients who had a delayed intracerebral hemorrhage, those who had a modified Rankin scale 3 to 6 at month 6 were less likely to have received heparin at the acute stage, and more likely to have had early intracerebral hemorrhage. CONCLUSIONS: Among patients with early intracerebral hemorrhage, those who were older, men, had a thrombosis of the deep cerebral venous system or of the right lateral sinus, and a motor deficit were at higher risk for death or dependency at month 6. This subgroup of patients with predictors of poor outcome can be the target for new therapeutic strategie

Which factors influence the resort to surrogate consent in stroke trials, and what are the patient outcomes in this context?

International audienceBACKGROUND:The provision of informed consent is a prerequisite for inclusion of a patient in a clinical research project. In some countries, the legislation on clinical research authorizes a third person to provide informed consent if the patient is unable to do so directly (i.e. surrogate consent). This is the case during acute stroke, when the symptoms may prevent the patient from providing informed consent and thus require a third party to be approached. Identification of factors associated with the medical team's decision to resort to surrogate consent may (i) help the care team during the inclusion process and (ii) enable the patient's family circle to be better informed (and thus feel less guilty) about providing surrogate consent.METHODS:Patients included in the BIOSTROKE cohort (initially dedicated to the analysis of factors influencing stroke severity) were divided into two groups: those having provided informed consent directly and those for whom a third party (such as a family member) had provided surrogate consent. We compared the groups in terms of the initial clinical characteristics (age, gender, type of stroke, severity on the National Institutes of Health Stroke Scale (NIHSS), pre-stroke cognitive status according to the Informant Questionnaire on Cognitive Decline in the Elderly, and the stroke's aetiology) and the functional and cognitive impairments (according to the NIHSS, the modified Rankin score (mRS) and the Mini Mental State Examination) on post-stroke days 8 and 90.RESULTS:Three hundred and ninety five patients were included (mean ± SD age: 67 ± 15 years; 53% males). Surrogate consent had been obtained in 228 cases, and 167 patients had provided consent themselves. The patients included with surrogate consent were likely to be older and more aphasic, with a pre-existing cognitive disorder and more severe stroke (relative to the patients having provided consent). In terms of recovery, the patients included with surrogate consent had a worse functional prognosis (day 90 mRS ≥3: 57.6%, compared with 16.8% in patients having provided consent themselves; p < 0.0001) and a worse cognitive prognosis (day 90 MMS < 24: 15.4% and 4.8%, respectively; p < 0.002). The mortality rate was significantly higher in the surrogate consent group.CONCLUSIONS:We found that in addition to age, aphasia and stroke severity, pre-stroke cognitive status is a factor that should prompt the care team to consider requesting surrogate consent for participation in a clinical study. Given that the unfavourable outcome in patients with surrogate consent is often due to their initial clinical state (rather than inclusion in a trial per se), the issue of the family's feelings of guilt (and how to avoid these feelings) should be further addressed

Understanding Neuropathy Features in the Context of Nitrous Oxide Abuse: A Combined Electrophysiological and Metabolic Approach

Background: The incidence of neurological complications associated with nitrous oxide (N2O) abuse, including N2O-induced myelopathy and neuropathy, has risen in the past decade. N2O-induced neuropathy often presents as a subacute axonal pathology; however, demyelinating patterns mimicking Guillain–Barré syndrome have also been observed. This study explores the metabolic pathophysiology of N2O-induced neuropathy, focusing on the alteration in metabolism to provide a deeper understanding of the biochemical pathways influencing the diverse electrophysiological patterns observed. Methods: We conducted a combined metabolic and electrophysiological exploration of 35 patients who underwent electromyographic exams at our referral center over a three-year period for sensorimotor symptoms linked to recreational N2O use. We collected demographic, clinical, radiological, electrophysiological, and biological data. Patients were categorized into axonal or demyelinating groups based on their electrophysiological patterns, and metabolic parameters were compared. Results: Our cohort predominantly exhibited a length-dependent sensorimotor axonal symmetrical neuropathy affecting the lower limbs. Among the patients, 40% met the demyelinating criteria, with four patients exhibiting conduction blocks. The demyelinating group had a significantly higher peripheral neuropathy disability (PND) score at diagnosis. Elevated homocysteine and methylmalonic acid (MMA) levels were noted in all patients, but these were lower in the demyelinating group. Conclusions: This study highlights the diverse electrophysiological manifestations of N2O-induced neuropathy and underscores the potential role of metabolic parameters as biomarkers to understand its pathophysiology. Lower hyperhomocysteinemia and MMA levels were observed in demyelinating patterns. In this study, we did not observe further improvement, but it is well-known that demyelinating features have a better prognosis related to the further remyelination. These findings contribute to a better understanding of N2O-related neuropathic damage and could guide future therapeutic interventions based on biochemical–neurophysiological stratifications