Admission dans une unité neuro-vasculaire (allocation d une ressource rare)

Les unités neurovasculaires (UNV) ont fait la preuve de leur efficacité pour la diminution de la mortalité et du handicap chez les patients souffrant d' accidents vasculaires cérébraux (AVC). Les différents textes des agences de santé recommandent que tout patient présentant un AVC y soit hospitalisé. L accès à l UNV pour les AVC aigus, implique plusieurs acteurs de la filière dite d amont de l UNV. Il s agit principalement des sapeurs pompiers, des SAMU, et des urgentistes. En Ile-de-France, comme dans d autres régions, le nombre de lits d UNV ne permet pas de prendre en charge l ensemble des AVC. Comment les médecins orientant à la phase aiguë les patients suspects d AVC prennent-ils en compte la rareté de la ressource que sont les lits d UNV ? L analyse de 160 questionnaires complétés par les médecins pompiers, les médecins des SAMU, les urgentistes et les neurologues vasculaires d Ile-de-France montre que les médecins définissent des patients non prioritaires pour l hospitalisation en UNV, à différents degrés selon leur rôle dans la prise en charge. Chez les médecins de la filière d amont, qui proposent les patients à l UNV, cette sélection est liée à la perception d une difficulté d orientation des patients âgés ou en dehors des critères de thrombolyse. Pour les neurologues, les choix restent difficiles et complexes dans la mesure où ils considèrent que tout patient bénéficie de l UNV. Le problème soulevé est celui du rationnement implicite des lits d UNV par les professionnels de santé alors même que les enjeux de ce rationnement dépassent le cadre médical strict. S il est rendu nécessaire par le caractère limité de la ressource, le triage devrait faire l objet d une réflexion entre professionnels de santé et de discussions publiques car il soulève des questions et des valeurs qui engagent la société toute entière.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

[Contribution of arterial spin labeling to the diagnosis of sudden and transient neurological deficit].

International audienceMRI is the gold standard exploration for sudden transient neurological events. If diffusion MRI is negative, there may be a diagnostic doubt between transient ischemic attack and other causes of transient neurological deficit. We illustrate how sequence arterial spin labeling (ASL), which evaluates cerebral perfusion, contributes to the exploration of transient neurological events. An ASL sequence was performed in seven patients with a normal diffusion MRI explored for a transient deficit. Cortical hyperperfusion not systematized to an arterial territory was found in three and hypoperfusion systematized to an arterial territory in four. ASL helped guide early management of these patients

Extensive basal ganglia edema caused by a traumatic carotid-cavernous fistula: a rare presentation related to a basal vein of Rosenthal anatomical variation

International audienceThe authors report a very rare presentation of traumatic carotid-cavernous fistula (CCF) with extensive edema of the basal ganglia and brainstem because of an anatomical variation of the basal vein of Rosenthal (BVR). A 45-year-old woman was admitted to the authors' institution for left hemiparesis, dysarthria, and a comatose state caused by right orbital trauma from a thin metal rod. Brain MRI showed a right CCF and vasogenic edema of the right side of the brainstem, right temporal lobe, and basal ganglia. Digital subtraction angiography confirmed a high-flow direct CCF and revealed a hypoplastic second segment of the BVR responsible for the hypertension in inferior striate veins and venous congestion. Endovascular treatment was performed on an emergency basis. One month after treatment, the patient's symptoms and MRI signal abnormalities almost totally disappeared. Basal ganglia and brainstem venous congestion may occur in traumatic CCF in cases of a hypoplastic or agenetic second segment of the BVR and may provoke emergency treatment

Axial Diffusivity of the Corona Radiata at 24 Hours Post-Stroke: A New Biomarker for Motor and Global Outcome

International audienceFractional anisotropy (FA) is an effective marker of motor outcome at the chronic stage of stroke yet proves to be less efficient at early time points. This study aims to determine which diffusion metric in which location is the best marker of long-term stroke outcome after throm-bolysis with diffusion tensor imaging (DTI) at 24 hours post-stroke. Twenty-eight thrombo-lyzed patients underwent DTI at 24 hours post-stroke onset. Ipsilesional and contralesional FA, mean (MD), axial (AD), and radial (RD) diffusivities values were calculated in different Regions-of-Interest (ROIs): (1) the white matter underlying the precentral gyrus (M1), (2) the corona radiata (CoRad), (3) the posterior limb of the internal capsule (PLIC) and (4) the cerebral peduncles (CP). NIHSS scores were acquired at admission, day 1, and day 7; modified Rankin Scores (mRS) at 3 months. Significant decreases were found in FA, MD, and AD of the ipsilesional CoRad and M1. MD and AD were also significantly lower in the PLIC. The ratio of ipsi and contralesional AD of the CoRad (CoRad-rAD) was the strongest diffusion parameter correlated with motor NIHSS scores on day 7 and with the mRS at 3 months. A Receiver-Operator Curve analysis yielded a model for the CoRad-rAD to predict good outcome based on upper limb NIHSS motor scores and mRS with high specificity and sensitivity. FA values were not correlated with clinical outcome. In conclusion, axial diffusiv-ity of the CoRad from clinical DTI at 24 hours post-stroke is the most appropriate diffusion metric for quantifying stroke damage to predict outcome, suggesting the importance of early axonal damage

Treatment times, functional outcome, and hemorrhage rates after switching to tenecteplase for stroke thrombolysis: Insights from the TETRIS registry

International audienceIntroduction: The encouraging efficacy and safety data on intravenous thrombolysis with tenecteplase in ischemic stroke and its practical advantages motivated our centers to switch from alteplase to tenecteplase. We report its impact on treatment times and clinical outcomes. Methods: We retrospectively analyzed clinical and procedural data of patients treated with alteplase or tenecteplase in a comprehensive (CSC) and a primary stroke center (PSC), which transitioned respectively in 2019 and 2018. Tenecteplase enabled in-imaging thrombolysis in the CSC. The main outcomes were the imaging-to-thrombolysis and thrombolysis-to-puncture times. We assessed the association of tenecteplase with 3-month functional independence and parenchymal hemorrhage (PH) with multivariable logistic models. Results: We included 795 patients, 387 (48.7%) received alteplase and 408 (51.3%) tenecteplase. Both groups (tenecteplase vs alteplase) were similar in terms of age (75 vs 76 years), baseline NIHSS score (7 vs 7.5) and proportion of patients treated with mechanical thrombectomy (24.1% vs 27.5%). Tenecteplase patients had shorter imaging-to-thrombolysis times (27 vs 36 min, p < 0.0001) mainly driven by patients treated in the CSC (22 vs 38 min, p < 0.001). In the PSC, tenecteplase patients had shorter thrombolysis-to-puncture times (84 vs 95 min, p = 0.02), reflecting faster interhospital transfer for MT. 3-month functional independence rate was higher in the tenecteplase group (62.8% vs 53.4%, p < 0.01). In the multivariable analysis, tenecteplase was significantly associated with functional independence (OR a 1.68, 95% CI 1.15–2.48, p < 0.01), but not with PH (OR a 0.68, 95% CI 0.41–1.12, p = 0.13). Conclusion: Switch from alteplase to tenecteplase reduced process times and may improve functional outcome, with similar safety profile

Early neurological deterioration following thrombolysis for minor stroke with isolated internal carotid artery occlusion

International audienceBackground and purpose: Better understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions.Methods: From a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no-END patients were compared for (i) pre-treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow-up imaging.Results: Seventy-four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre-treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3-12.2; P = 0.015). On follow-up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no-END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no-END, END was strongly associated with a poor 3-month outcome.Conclusions: Early neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site-largely a function of underlying stroke etiology-may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting

Infarct probability map of the patient cohort.

<p>Infarct probability map overlaid on a diffusion-weighted volume of a selected patient. Color map corresponds to the percentage of patients with infarcted tissue in a given voxel. Z-coordinates are in MNI space.</p

Receiver-Operator Curve (ROC) models for CoRad-rAD.

<p>ROC analyses presented are for an upper limb (UL) score of ≤ 1 at day 7 and a modified Rankin Scale (mRS) score of ≤ 1 and ≤ 2 at three months. The optimal threshold of CoRad-rAD (compromise between specificity and sensitivity) for each model is given with the associated area under the curve (AUC), accuracy (Acc), specificity (Spec), and sensitivity (Sens). For each model, the upper bound of 100% negative predictive power (NPV) and the lower bound of 100% positive predictive value (PPV) are given.</p><p>Receiver-Operator Curve (ROC) models for CoRad-rAD.</p