Evaluation de facteurs predictifs initiaux d'une bonne indépendanece fonctionnelle des patients traités par thromblyse intraveineuse pour un infarctus cérébral

Introduction - La thrombolyse intraveineuse est un traitement efficace des infarctus cérébraux à la phase aigue. La récupération clinique à 24 heures est associée à une bonne évolution. La pratique clinique et la recanalisation artérielle qui débute précocement font supposer une récupération plus précoce. Nous présentons une étude rétrospective de la récupération clinique dans les 24 premières heures après le traitement thrombolytique. Méthodologie et résultats - 103 patients ont été traités par rt-pa IV au CHU de Limoges de 2005 à 2008. 16.5% des patients présentaient une amélioration majeure à 24 heures (baisse d'au moins 4 points du NIHSS). La récupération clinique débutait tôt après l'administration du rt-PA avec une pente maximale entre 30 minutes et 3 heures. 53.4% des patients étaient indépendants à 3 mois (Rankin compris entre 0 et 2) et 38.8% avaient un bon pronostic (Rankin =0 ou 1). L'évolution à 24 heures était significativement corrélée à la récupération à 3 mois. Les principaux facteurs retrouvés prédictifs de cette récupération sont le délai entre le début des symptômes et le traitement, un déficit initial moins important, une recanalisation artérielle et l'absence d'occlusion carotidienne. La variation du NIHSS entre le début du traitement et les 3 premières heures est significativement associée au pronostic fonctionnel à 3 mois dès la première heure (variation moyenne de 2.22 points p=0.015) et augmente jusqu'à la troisième heure. Une baisse du NIHSS > ou = à 4 points à 3 heures du début du traitement est prédictive d'indépendance à 3 mois dans 87% des cas. Conclusion - La récupération après thrombolyse par rt-PA dans les infarctus cérébraux débute précocement. A partir d'une heure elle est significativement associée à un bon pronostic à moyen terme. Cette différence augmente au cours des 3 premières heures.LIMOGES-BU Médecine pharmacie (870852108) / SudocSudocFranceF

Apport d'internet pour le maintien à domicile aprés un accident vasculaire cérébral (réalisation d'un site internet)

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Cerebral ischemia probably related to isotretinoin.

OBJECTIVE: To report a case of cerebral ischemia in a patient receiving oral isotretinoin for severe acne. CASE SUMMARY: A 30-year-old right-handed man was admitted for left facial paralysis and dysarthria. He had received oral isotretinoin 45 mg/day for 3 months for treatment of severe acne. A cerebral computed tomography scan showed hypodensity in the right middle cerebral territory corresponding to cerebral ischemia. The patient reported having experienced a similar episode 7 years before, after 3 months' treatment with oral isotretinoin. No risk factors were identified. Isotretinoin was discontinued on admission and the disorders resolved. DISCUSSION: Our patient did not present thrombotic risk factors and was not being treated with any drug other than isotretinoin; however, he developed 2 episodes of cerebral ischemia following 2 episodes of oral isotretinoin treatment. According to the Naranjo probability scale, the relationship of cerebral ischemia to administration of isotretinoin was probable. Other reports of thrombotic accidents, as well as some cases of hemorrhage in patients receiving isotretinoin, have been published. This drug seems to act on the coagulation process by a still unexplained mechanism. CONCLUSIONS: Given that isotretinoin is a treatment prescribed most frequently for adolescents and young adults and that cerebral ischemia can produce serious handicaps, an evaluation of vascular risk should be made prior to treatment with this drug

Carotid angioplasty stenting revisited: clinical and radiological (MRI) outcome.

International audienceBACKGROUND: Although carotid angioplasty and stenting (CAS) is widely used to treat carotid stenosis, recent studies point to the inferiority of the procedure compared with carotid endarterectomy. METHODS: We present 50 consecutive cases of CAS treated in our unit. Endarterectomy was contraindicated in these patients due to high operative risk. All the patients underwent a diffusion-weighted MRI (DWI) before and after the procedure and had a neurological assessment in a stroke unit. RESULTS: No deaths were recorded until 30 days after the procedure. Six patients [12%, confidence interval at 95% (CI(95)) = 3.7-20.2] had a positive DWI MRI after the procedure but only 2 (4%, CI(95) = 0-9.43) had a worse neurological status. CONCLUSION: This study shows that CAS is feasible with a low morbid-mortality rate in patients with a high surgical risk. DWI is highly sensitive to detect neurological complications after the procedure

Physical factors associated with fatigue after stroke: an exploratory study.

International audienceObjective: To look for a relationship between physical fatigue and physical parameters in patients at least 3 months post stroke. Methods: We conducted a prospective cross-sectional study of 32 poststroke patients (average duration of stroke 40 months) who were recruited among in- and outpatients followed by the Department of Physical and Rehabilitation Medicine of a university hospital. Fatigue was defi ned as a Fatigue Severity Scale (FSS) score of 4 or more. The parameters studied were age, sex, time since stroke, Demeurisse Motor Index, Barthel Index score, new Functional Ambulation Category, Berg Balance Scale, 10-meter walk test, 6-minute walk test, Dijon Physical Activity Score, Montgomery and Asberg Depression Rating Scale, Epworth Sleepiness Scale, presence of pain, and length and area of the center of pressure displacement obtained posturographically. Results: Two-thirds of patients (65.6%) were fatigued. The mean FSS score was 4.3 ± 1.8. Fatigue was not associated with the physical parameters studied; notably, there was no correlation with motor impairment, autonomy and walking capacity, or balance and physical activity. However, after multivariate analysis, we found an association between physical fatigue and time since the occurrence of stroke (P = .05). Conclusions: Our study revealed a relationship between pain and physical fatigue, as reported by 2 other studies. Poststroke fatigue management should include appropriate pain management. Further studies are necessary to determine the causes of physical fatigue after stroke

[Etiological assessment of cerebral infarct in the young. Proposals from the working group of the French Neuro-vascular Society (December 2008)] : Bilan étiologique des infarctus cérébraux du sujet jeune. Propositions du Groupe de travail de la Société française neuro-vasculaire (décembre 2008)

International audienc

Carotid artery stenting in patients with symptomatic carotid stenosis: A single-center series.

International audienceOBJECTIVES: Carotid angioplasty with stenting (CAS) in patients with carotid stenosis (CS) has become more restricted in France especially since the disclosure of such studies as EVA-3S and Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy (SPACE). This report is of a series of CS cases contraindicated for endarterectomy that underwent CAS at a French center of interventional neuroradiology. PATIENTS AND METHODS: Fifty-five patients with symptomatic CS more than 60% consecutively submitted to CAS between September 2008 and February 2011. The primary endpoint was either death or stroke within 30days of the procedure; a secondary goal was to identify any possible factors that might have influenced the success and outcome of the intervention. RESULTS: The overall periprocedural stroke/death rate at 30days was 5.4% (three out of 55patients), with three non-disabling strokes and no deaths. Twenty-seven patients (49.1%) were treated with a cerebral protection device (CPD). Stent placement was achieved in all cases. Open- and closed-cell stents were implanted in 40 (72.7%) and 15procedures (27.3%), respectively. Neither the use of a CPD, the carotid stent cell design nor any anatomical or technical factors were associated with a lower risk of stroke or death within 30days of CAS. CONCLUSION: CAS in symptomatic patients with CS contraindicated for endarterectomy in this selected French series proved feasible and safe, with acceptable levels of morbidity. Use of a CPD, type of stent (open- or closed-cell), and anatomical and technical factors had no influence on the success of the procedure or the outcome within 30days of the operation

[Management of stroke in sub-Saharan Africa: current issues] : Prise en charge des accidents vasculaires cérébraux en Afrique subsaharienne

International audienceIn sub-Saharan Africa, stroke is likely to present an increasingly important public health problem with a larger relative share of overall morbidity and mortality. Overall, sub-Saharan Health Care is characterized by a lack of human resources, lack of facilities for special investigations, and especially an absence of specific programs addressing the prevention of cardiovascular conditions. Current data on the epidemiology of stroke in sub-Saharan Africa, although sparse and fragmentary, indicate a comparatively high incidence of cerebral hemorrhage associated with high blood pressure, while ischemic stroke in black Africans still appears to be related primarily to small artery disease, HIV infection, and sickle cell disease. With urbanization, the role of large-vessel atherosclerosis is increasing. It is thus essential to coordinate government funding, health care professionals and development agencies to address this rising health problem. Access to health care needs to be better structured, and screening programs should be developed in order to identify and treat vascular risk factors. Improved training of health care professionals is also required in the areas of prevention, diagnosis and management of stroke. Implementation of best-practice recommendations for the management of stroke adapted to the specificities and resources of African countries would help rationalize the scarce resources currently available

Clopidogrel Plus Aspirin Versus Warfarin in Patients With Stroke and Aortic Arch Plaques.

International audienceBACKGROUND AND PURPOSE: Severe atherosclerosis in the aortic arch is associated with a high risk of recurrent vascular events, but the optimal antithrombotic strategy is unclear. METHODS: This prospective randomized controlled, open-labeled trial, with blinded end point evaluation (PROBE design) tested superiority of aspirin 75 to 150 mg/d plus clopidogrel 75 mg/d (A+C) over warfarin therapy (international normalized ratio 2-3) in patients with ischemic stroke, transient ischemic attack, or peripheral embolism with plaque in the thoracic aorta >4 mm and no other identified embolic source. The primary end point included cerebral infarction, myocardial infarction, peripheral embolism, vascular death, or intracranial hemorrhage. Follow-up visits occurred at 1 month and then every 4 months post randomization. RESULTS: The trial was stopped after 349 patients were randomized during a period of 8 years and 3 months. After a median follow-up of 3.4 years, the primary end point occurred in 7.6% (13/172) and 11.3% (20/177) of patients on A+C and on warfarin, respectively (log-rank, P=0.2). The adjusted hazard ratio was 0.76 (95% confidence interval, 0.36-1.61; P=0.5). Major hemorrhages including intracranial hemorrhages occurred in 4 and 6 patients in the A+C and warfarin groups, respectively. Vascular deaths occurred in 0 patients in A+C arm compared with 6 (3.4%) patients in the warfarin arm (log-rank, P=0.013). Time in therapeutic range (67% of the time for international normalized ratio 2-3) analysis by tertiles showed no significant differences across groups. CONCLUSIONS: Because of lack of power, this trial was inconclusive and results should be taken as hypothesis generating. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00235248