Efficacité et tolérabilité de la neurostimulation bipallidale dans les syndromes tardifs provoqués par les neuroleptiques (étude prospective multicentrique sur 20 patients suivis pendant 1 an)

Objectif. Les syndromes tardifs sont des mouvements anormaux involontaires chroniques provoqués par les neuroleptiques. Ils peuvent être invalidants et retentir sur la qualité de vie. Leur prise en charge médicale est souvent décevante. Les premiers résultats du groupe français d'étude de la neurostimulation dans les dyskinésies tardives (STARDYS) suggèrent l'efficacité de la stimulation cérébrale profonde sur 10 patients suivis pendant 6 mois. Notre objectif est de confirmer l'efficacité et la bonne tolérabilité de la stimulation bipallidale dans les syndromes tardifs, en complétant cette série par 10 patients supplémentaires. Méthodes. Vingt patients présentant un syndrome tardif sévère, ont participé à cet essai multicentrique thérapeutique de phase II. Avant stimulation bipallidale, puis à 3, 6 et 12 mois, des évaluations motrices (scores ESRS et AIMS), cognitives, psychiatriques, et de qualité de vie ont été réalisées. A 6 mois, une évaluation en double aveugle stimulation éteinte et allumée a été faite. Les évènements indésirables étaient recensés à chaque visite. Résultats. Une diminution significative de 51% de l'ESRS (p < 0,0001) et de 44% de l'AIMS (p <0,0001) était constatée dès 3 mois et persistait à 12 mois. Tous les sous-scores de l'ESRS étaient concernés. L'évaluation en double aveugle confirmait cette amélioration motrice, avec une diminution moyenne de l'ESRS de 46% (p < 0,0001). Malgré les comorbidités psychiatriques, aucune dégradation cognitive n'a été retrouvée. Il existe même une amélioration cognitive sur le score total de la MATTIS et une tendance à l'amélioration de l'humeur est constatée. Trois patients ont présenté des évènements indésirables graves liés à l'intervention, non spécifiques des syndromes tardifs. Conclusion. Cette étude confirme l'efficacité de la stimulation bipallidale dans les syndromes tardifs, sur les composantes dystonique, choréique et parkinsonienne, avec une bonne tolérabilité cognitive et psychiatrique. Il s'agit de la plus grande cohorte de patients traités par cette procédure.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Added value of 18F-florbetaben amyloid PET in the diagnostic workup of most complex patients with dementia in France: A naturalistic study

International audienceIntroductionAlthough some studies have previously addressed the clinical impact of amyloid positron emission tomography (PET), none has specifically addressed its selective and hierarchical implementation in relation to cerebrospinal fluid analysis in a naturalistic setting.MethodsThis multicenter study was performed at French tertiary memory clinics in patients presenting with most complex clinical situations (i.e., early-onset, atypical clinical profiles, suspected mixed etiological conditions, unexpected rate of progression), for whom cerebrospinal fluid analysis was indicated but either not feasible or considered as noncontributory (ClinicalTrials.gov: NCT02681172).ResultsTwo hundred five patients were enrolled with evaluable florbetaben PET scans; 64.4% of scans were amyloid positive. PET results led to changed diagnosis and improved confidence in 66.8% and 81.5% of patients, respectively, and altered management in 80.0% of cases.DiscussionHigh-level improvement of diagnostic certainty and management is provided by selective and hierarchical implementation of florbetaben PET into current standard practices for the most complex dementia cases

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&lt;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