Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy.

BACKGROUND: Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS: We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS: Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION: In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.

Relationship between onset-to-door time and door-to-thrombolysis time: a pooled analysis of 10 dedicated stroke centers.

BACKGROUND AND PURPOSE: Inverse relationship between onset-to-door time (ODT) and door-to-needle time (DNT) in stroke thrombolysis was reported from various registries. We analyzed this relationship and other determinants of DNT in dedicated stroke centers. METHODS: Prospectively collected data of consecutive ischemic stroke patients from 10 centers who received IV thrombolysis within 4.5 hours from symptom onset were merged (n=7106). DNT was analyzed as a function of demographic and prehospital variables using regression analyses, and change over time was considered. RESULTS: In 6348 eligible patients with known treatment delays, median DNT was 42 minutes and kept decreasing steeply every year (P<0.001). Median DNT of 55 minutes was observed in patients with ODT ≤30 minutes, whereas it declined for patients presenting within the last 30 minutes of the 3-hour time window (median, 33 minutes) and of the 4.5-hour time window (20 minutes). For ODT within the first 30 minutes of the extended time window (181-210 minutes), DNT increased to 42 minutes. DNT was stable for ODT for 30 to 150 minutes (40-45 minutes). We found a weak inverse overall correlation between ODT and DNT (R(2)=-0.12; P<0.001), but it was strong in patients treated between 3 and 4.5 hours (R(2)=-0.75; P<0.001). ODT was independently inversely associated with DNT (P<0.001) in regression analysis. Octogenarians and women tended to have longer DNT. CONCLUSIONS: DNT was decreasing steeply over the last years in dedicated stroke centers; however, significant oscillations of in-hospital treatment delays occurred at both ends of the time window. This suggests that further improvements can be achieved, particularly in the elderly.

Acute stroke in patients taking an oral anticoagulant: impact of clinical pharmacist's intervention on pharmacovigilance reporting.

INTRODUCTION: Ischemic or hemorrhagic stroke can occur to patients treated with oral anticoagulants (OAC), through lack of effectiveness or overdosing. OBJECTIVE: To evaluate the impact of clinical pharmacist's intervention on pharmacovigilance (PV) reporting for OAC-treated patients hospitalized for stroke. METHODS: Monocentric prospective study in which a clinical pharmacist's intervention was performed in a stroke unit, with a focus on patients treated by OAC prior admission. A PV report was made with all data collected for cases of stroke suspected to be related to OAC therapy. Data provided by pharmacist were compared with data initially available in the patient's electronic medical records. PV reports with pharmacist intervention were compared to those without. RESULTS: During the study period, 48 patients were included in the study: 43 (89.6%) ischemic strokes with an embolic or unknown etiology, four hemorrhage strokes (8.33%), and one medication error (2.08%). A clinical pharmacist intervention was performed for 19 patients (39.6%) and provided significant additional data in all of them (100%). The information was related to adherence to treatment for 17 cases (89.5%), OAC's initial prescription date for 11 cases (57.9%) and identifying event(s) that could have interfered with the efficacy of the OAC in five cases (26.3%). For patients with pharmacist intervention, PV reports were significantly more informative in terms of date's introduction of anticoagulant, adherence to treatment, reference to weight change or concomitant event. CONCLUSIONS: clinical pharmacist's intervention with patients taking oral anticoagulants and hospitalized for acute stroke contributes to collect high-quality data for pharmacovigilance reporting.

[Intra-cerebral haemorrhages in the elderly]. / Hémorragies cérébrales du sujet âgé.

Intra-cerebral haemorrhages (ICH) account for 15% of strokes in Europe. They are associated with higher mortality and handicap than cerebral infarcts. The main risk factor is arterial hypertension. Microbleeds are associated with an increased risk of recurrence. The main two causes are lipohyalinosis of the deep perforating arteries, leading to deep ICH and cerebral amyloid angiopathy of the Abeta type, usually sporadic or associated with Alzheimer's disease, leading to recurrent lobar haemorrhages, with white matter changes and microbleeds. After having called the emergency call centre (Number 15 in France, otherwise 112 in the rest of Europe), it is important to normalise coagulation if needed, to control blood pressure and in few cases to perform surgery. To prevent the risk of recurrence, an optimal correction of blood pressure and control of antithrombotics are needed.

Measures of abdominal adiposity and the risk of stroke: the MOnica Risk, Genetics, Archiving and Monograph (MORGAM) study.

BACKGROUND AND PURPOSE: Excess fat accumulates in the subcutaneous and visceral adipose tissue compartments. We tested the hypothesis that indicators of visceral adiposity, namely, waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR), are better predictors of stroke risk than body mass index (BMI). METHODS: The association of BMI, WC, WHR, and WHtR with stroke was assessed in 31,201 men and 23,516 women, free of vascular disease at baseline, from the MOnica Risk, Genetics, Archiving and Monograph (MORGAM) study. During a mean follow-up of 11 years, 1130 strokes were recorded. Relative risks (95% CI) were calculated by Cox regression after stratification for center and adjustment for age, smoking, educational level, alcohol consumption, hypertension, diabetes, total cholesterol, high-density lipoprotein cholesterol, and BMI and model fit was assessed using log-likelihoods. RESULTS: BMI, WC, WHR, and WHtR were associated with the risk of stroke in men. After full adjustment including BMI, the relative risks for stroke remained significant for WC (1.19 [1.02 to 1.34] per 1 SD increase in WC), WHR (1.14 [1.03 to 1.26]), and WHtR (1.50 [1.28 to 1.77]). Among women, the extent of the associations with stroke risk was similar for WHtR (1.31 [1.04 to 1.65]), WC (1.19 [0.96 to 1.47]), and WHR (1.08 [0.97 to 1.22]). Further analyses by World Health Organization obesity categories showed that WC, WHR, and WHtR were associated with the risk of stroke also in lean men and women (BMI<25 kg/m2), independently of confounders, cardiovascular risk factors, and BMI. CONCLUSIONS: Indicators of abdominal adiposity, especially WHtR, are more strongly associated with stroke risk than BMI. These results emphasize the importance of measuring abdominal adiposity, especially in lean subjects.

Intravenous thrombolysis for acute cerebral ischemia in Belgrade, Serbia: comparison with Lille, France.

BACKGROUND: Worse socioeconomic situation is associated with worse outcomes in stroke cases. Whether it also influences outcomes in patients treated with intravenous thrombolysis remains unknown. The aim of this study was to test the hypothesis that outcomes are less favorable in patients treated with intravenous thrombolysis in Belgrade, Serbia, than in Lille, France. METHODS: We compared outcomes at day 7 and month 3, between 123 consecutive stroke patients treated with intravenous thrombolysis in Belgrade and 273 in Lille. RESULTS: At month 3, there was no significant difference between Belgrade and Lille in patients' excellent outcomes [modified Rankin Scale 0-1; 49.6 vs. 45.4%, odds ratio (OR): 1.21, 95% confidence interval (CI): 0.79-1.86] or in death (11.4 vs. 16.1%, OR 0.67, 95% CI: 0.35-1.27). However, compared with a subgroup of age-matched patients from Lille, Belgrade patients tended to have worse outcomes. Patients from Belgrade were 16 years younger (p < 0.0001), more likely to be men (OR 2.40, 95% CI: 1.52-3.78), and more likely to be smokers (OR 2.24, 95% CI: 1.43-3.51). Also, a trend for a slightly higher rate of symptomatic hemorrhagic transformation was registered in this group (7.3 vs. 3.3%, OR 2.32, 95% CI: 0.90-5.99). In Belgrade, patients arrived 27 min earlier to the hospital (p < 0.0001), but their door-to-needle time was 37 min longer (p < 0.0001). Compared with a subgroup of age-matched patients from Lille, they tended to have worse outcomes. CONCLUSION: Intravenous thrombolysis-treated stroke patients in Belgrade have similar outcomes and rates of complications as those from Lille.

Early epileptic seizures in ischaemic stroke treated by mechanical thrombectomy: influence of rt-PA.

BACKGROUND: The epileptogenicity of recombinant tissue-plasminogen activator (rt-PA) has been suggested, but seizures were not evaluated in randomised controlled trials. OBJECTIVE: To evaluate whether rt-PA was associated with early seizures in a cohort of consecutive patients with cerebral ischaemia. METHOD: We included consecutive adults with ischaemic stroke due to large-vessel occlusion from the North-of-France stroke network selected for a mechanical thrombectomy (MT). Patients without contraindication received i.v. rt-PA. We evaluated stroke severity with the National Institutes of Health Stroke Scale (NIHSS), and functional status with the modified Rankin scale (mRS), and recorded epileptic seizures occurring between the end of imaging and day 7. We performed statistics using propensity analyses. RESULTS: We included 1638 patients (783 men, 47.8%; median age 71 years; median NIHSS score 16; 1007 treated by rt-PA, 61.5%), in whom 60 (3.7%) developed early epileptic seizures. After adjustment on propensity scores, early seizures were associated with infections [adjusted odds ratio (adjOR) 2.86; 95% confidence interval (CI) 1.37-5.95] and delay between stroke recognition and end of MT (adjOR 1.04 for 10 min more; 95% CI 1.01-1.08), but not with rt-PA (adjOR 1.35; 95% CI 0.55-3.33). The propensity-matched analysis of 343 pairs of patients found no difference in the occurrence of early seizures between those with and without rt-PA (p = 0.386). CONCLUSION: We found no significant association between rt-PA and early epileptic seizures. If rt-PA has the potential for epileptogenicity, the magnitude of the effect should be modest compared to its favourable effect on functional outcome.

Intravenous thrombolysis for acute cerebral ischaemia: comparison of outcomes between patients treated at working versus nonworking hours.

BACKGROUND: Stroke outcomes are worse in patients admitted at nonworking hours (NWH), but whether this is also true in patients treated with intravenous (i.v.) thrombolysis has not been definitely proven. OBJECTIVE: Our aim was to test the hypothesis that stroke patients treated by i.v. rt-PA at NWH have a worse outcome than those treated at working hours (WH). METHODS: We compared outcomes at 7 days and at 3 months, between patients treated at NWH and at WH in the stroke unit of the Lille University Hospital. RESULTS: Of 252 consecutive patients [median age: 69 years; 132 men (52.4%); median National Institutes of Health Stroke Scale score: 14; median onset-to-needle time: 150 min], 134 (53.2%) were treated at NWH. They did not differ for baseline characteristics and proportion of patients with modified Rankin Scale scores 0-1 and 0-2 at 3 months. Patients treated at WH were more likely to die before 7 days (12.7 vs. 4.5%; adjusted odds ratio: 3.6; 95% confidence interval: 1.2-10.4) and at 3 months (21.6 vs. 11.4%; adjusted odds ratio: 2.2; 95% confidence interval: 1.02-4.7). The causes of death did not differ between NWH and WH. At NWH, there was no difference in baseline characteristics and outcomes of patients treated by stroke- and nonstroke neurologists. CONCLUSION: The case fatality rates were unexpectedly higher at WH than at NWH. If this finding can be reproduced and is not a chance finding, we should identify explanations, especially organisational issues, chronobiological factors or summation of subtle--nonsignificant--baseline differences.

In-hospital ischaemic stroke treated with intravenous thrombolysis or mechanical thrombectomy.

Patients with in-hospital strokes (IHS) may be eligible for recanalization therapies. The objective of this study is to compare outcomes in patients with IHS and community-onset strokes (COS) treated by recanalization therapy. We analysed data prospectively collected in consecutive patients treated by thrombolysis, thrombectomy, or both for cerebral ischemia at the Lille University Hospital. We compared four outcomes measures at 3 months in patients with IHS and COS: (1) modified Rankin scale (mRS) 0-1, (2) mRS 0-2, (3) death, and (4) symptomatic intracranial haemorrhage (ECASS 2 definition). Of 1209 patients, 64 (5.3%) had IHS, with an increasing proportion over time (p = 0.001). Their median onset-to-needle time was 128 min vs. 145 in COS (p < 0.001). They were more likely to have had a recent TIA [odds ratio (OR) 30.1; 95% confidence interval (CI) 11.5-78.7], to have been treated by vitamin K antagonist before (OR 4.2; 95% CI 1.4-12.0) and to undergo mechanical thrombectomy (45 vs. 10%, p < 0.001). They were less likely to have a pre-stroke mRS 0-1 (OR 0.22; 95% CI 0.09-0.50). After adjustment, IHS was not associated with any of the four outcome measures. Patients with IHS are treated 17 min earlier than patients with COS, but, taking into account that they were already in the hospital, delays are still too long. Their outcome does not differ from that of patients with COS, suggesting room for improvement if delays can be reduced. IHS being frequent, pre-specified pathways should be organised.

Proportion of single-chain recombinant tissue plasminogen activator and outcome after stroke.

OBJECTIVE: To determine whether the ratio single chain (sc)/(sc + 2 chain [tc]) recombinant tissue plasminogen activator (rtPA) influences outcomes in patients with cerebral ischemia. METHODS: We prospectively included consecutive patients treated with IV rtPA for cerebral ischemia in 13 stroke centers and determined the sc/(sc + tc) ratio in the treatment administered to each patient. We evaluated the outcome with the modified Rankin Scale (mRS) at 3 months (prespecified analysis) and occurrence of epileptic seizures (post hoc analysis). We registered Outcome of Patients Treated by IV Rt-PA for Cerebral Ischaemia According to the Ratio Sc-tPA/Tc-tPA (OPHELIE) under ClinicalTrials.gov identifier no. NCT01614080. RESULTS: We recruited 1,004 patients (515 men, median age 75 years, median onset-to-needle time 170 minutes, median NIH Stroke Scale score 10). We found no statistical association between sc/(sc + tc) ratios and handicap (mRS > 1), dependency (mRS > 2), or death at 3 months. Patients with symptomatic intracerebral hemorrhages had lower ratios (median 69% vs 72%, adjusted p = 0.003). The sc/(sc + tc) rtPA ratio did not differ between patients with and without seizures, but patients with early seizures were more likely to have received a sc/(sc + tc) rtPA ratio >80.5% (odds ratio 3.61; 95% confidence interval 1.26-10.34). CONCLUSIONS: The sc/(sc + tc) rtPA ratio does not influence outcomes in patients with cerebral ischemia. The capacity of rtPA to modulate NMDA receptor signaling might be associated with early seizures, but we observed this effect only in patients with a ratio of sc/(sc + tc) rtPA >80.5% in a post hoc analysis.

Influence of neurologists' experience on the outcome of patients treated by intravenous thrombolysis for cerebral ischaemia.

Intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) should be available on a 24/7 basis in hospitals admitting patients with stroke. We aimed at evaluating the influence of the number of patients previously treated with i.v. rt-PA by neurologists on patients' outcome. For each patient consecutively treated with i.v. rt-PA for cerebral ischaemia at the Lille University Hospital, we determined the number of previous treatments with rt-PA administered by the neurologist. We performed logistic regression analyses to determine the influence of the experience on the outcome evaluated by the modified Rankin scale (mRS) after 3 months, 0-1 meaning independence, and 0-2 meaning absence of handicap. We compared outcomes of patients treated by the 25% less experienced neurologists with those of trials. Forty-four neurologists treated 800 patients. The experience of the treating neurologist was independently associated with independence (adjusted odds ratio [(adj)OR] 1.062 for 10 patients more; 95% confidence interval [CI] 1.008-1.120), and absence of handicap ((adj)OR 1.076 for 10 patients more; 95%CI 1.016-1.140) at 3 months, but not with symptomatic intracerebral haemorrhage and death. The proportions of patients from the 1st quartile who were independent and without handicap at 3 months were 37.9 and 51.1%. Patients treated by less experienced neurologists, have similar outcomes than expected from trials, suggesting they benefit from thrombolysis. However, the outcome of patients treated by more experienced neurologists was slightly better. Less experienced neurologists should not be excluded from rt-PA programmes, but their practices should be evaluated and educational programmes organised.

Mortality in patients treated by intra-venous thrombolysis for ischaemic stroke.

In patients treated by intravenous (i.v.) thrombolysis, mortality rates range from 10 to 20 % at 3 months. The objective of this study was to determine the timing, causes and predictors of early (within 7 days) and delayed (8 days to 3 months) death after i.v. thrombolysis for cerebral ischaemia. We analyzed timing, causes and predictors of early and delayed mortality in a hospital-based registry of consecutive patients treated by i.v. thrombolysis for cerebral ischaemia. Of 500 patients (246 men; median age 71 years; median baseline National Institutes of Health Stroke Scale score 12; median onset-to-needle time 148 min), 76 (15.2%; 95% confidence interval [CI]: 12.3-18.6%) died within 3 months. Of 29 patients with early death, 21 (72.4%; 95% CI: 54.3-85.3%) died from neurovascular causes. Factors independently associated with early death were neurological complications and having had transient ischaemic attacks within the last 7 days. Of 47 patients with delayed death, 24 (51.1%; 95 % CI: 37.2-64.7%) died from infection, all but 1 having a modified Rankin scale >4 at 7 days. Factors independently associated with delayed death were pre-existing conditions and infections. Early and delayed mortality in ischaemic stroke patients are is highly dependent on the neurological status and response to thrombolysis. The target for reducing mortality is therefore to improve response to thrombolysis by any means, which can currently be achieved only by reducing delays.

A very early neurological improvement after intravenous thrombolysis for acute cerebral ischaemia does not necessarily predict a favourable outcome.

In patients treated by intravenous (i.v.) thrombolytic therapy for cerebral ischaemia, a very early neurological improvement (VENI) [National Institutes of Health Stroke Scale score (NIHSSS) 0, or early improvement ≥5 points], predicts a favourable outcome. VENI patients are usually excluded from trials testing complementary strategies, but a few of them have bad outcomes. To determine why VENI patients may have bad outcomes, we analysed the reasons for bad outcomes [modified Rankin Scale (mRS) score 2-6 at 3 months] in consecutive VENI patients. Of 365 consecutive patients with a pre-stroke mRS 0-1 (185 men, median age 69 years, median NIHSSS 12, median onset-to-needle time 147 min), 71 (19.5 %) had VENI. They were more likely to have had recent transient ischaemic attacks (OR 3.64, 95 % CI 1.08-12.27), higher baseline NIHSSS (median 14 vs. 11, p = 0.003) and shorter onset-to-needle times (median 135 min vs. 151, p = 0.01), and they were less likely to develop pneumonia (OR 0.27, 95 % CI 0.09-0.76) or malignant infarction (p = 0.045). In the 21 VENI patients (29.6 %) with a mRS 2-6 at 3-months, bad outcomes were due to the residual deficit in 14, secondary worsening of ischaemia in 4, intracranial haemorrhage in 2, and death from cancer in 1. One-third of VENI patients have bad outcomes, due to the residual neurological deficit in most of them. This finding suggests that VENI patients who still have a significant neurological deficit 1 h after thrombolysis should not be excluded from trials testing complementary strategies.

Baseline serum glucose concentration and symptomatic haemorrhagic transformation in non-diabetic stroke patients treated by intravenous thrombolysis.

Intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) improves outcome in ischaemic stroke, despite an increased risk of symptomatic haemorrhagic transformation (sHT). A higher baseline serum glucose concentration is associated with an increased risk of sHT. However, as most studies did not exclude diabetic patients, this effect may be partially due to diabetic micro-angiopathy. Our objective was to test the hypothesis that baseline serum glucose concentration is associated with sHT in non-diabetic patients treated by i.v. rt-PA. We analysed the influence of baseline serum glucose concentrations on sHT (ECASS2 definition) in consecutive non-diabetic patients treated by i.v. rt-PA for ischaemic stroke. Secondary end-points were death (<7 days, 8 days to 3 months, all deaths <3 months), and unfavourable outcome at 3 months (modified Rankin scale 2-6 if different from the pre-stroke value). Five hundred and five consecutive patients met inclusion criteria [242 men (47.9 %); median age 71 years (interquartile range, IQR) 57-81; median baseline national institutes of health stroke scale score 12 (IQR 6-17)]. Thirty-seven had sHT (7.3 %). After adjustment, baseline serum glucose concentrations were independently associated with sHT (adjOR: 1.176 for 1 mmol/l increase; 95 % CI: 1.020-1.357: p = 0.025). Increased admission serum glucose concentrations in non-diabetic patients treated by i.v. rt-PA for cerebral ischaemia are associated with sHT. Whether lowering serum glucose lowers the risk of sHT needs to be evaluated.

Intra-hospital delays in stroke patients treated with rt-PA: impact of preadmission notification.

Pre-hospital notification enhances thrombolysis rate and improves intra-hospital delays, but the impact of the notification to the neurologist by the emergency medical system (EMS) call centre remains unknown. Our objective was to compare pre-hospital and in-hospital delays in stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA), with and without pre-hospital notification. We compared baseline characteristics and in-hospital delays in stroke patients treated by rt-PA with a high-level notification (call to EMS and EMS-neurologist discussion), a low-level notification (call to EMS without EMS-neurologist discussion ) and no pre-hospital notification. Of 302 consecutive patients [165 women, 54.6 %; median age 74 years, interquartile range (IQR) 59-83], patients with high-level, low-level and no notification differed for the severity at admission (median National Institutes of Health Stroke Scale scores, respectively, of: 12, IQR 7-17; 9, IQR 6-15, and 8, IQR 6-14, p = 0.029). Patients with high-level notification had shorter (1) admission-to-completion of imaging times (27 min, IQR 14-35) than patients with low-level notification (35 min, IQR 17-54) or no notification (36 min, IQR 30-58) (p < 0.01); (2) door-to-needle times (49 min, IQR 39-62 vs. 57 min, IQR 39-81 vs. 63 min, IQR 51-97; p = 0.003); and (3) onset-to-needle times (140 min, IQR 110-175 vs. 155 min, IQR 106-230 vs. 182 min, IQR 131-234; p < 0.001). They did not differ for onset-to-admission time and imaging-to-needle time. Pre-hospital notification by the EMS reduces intra-hospital delays in patients eligible for rt-PA, but the benefit is higher in the case of discussion between the EMS and the neurologist before admission.

Outcome of patients with atrial fibrillation after intravenous thrombolysis for cerebral ischaemia.

The question of whether i.v. rt-PA is beneficial in patients with ischaemic stroke and atrial fibrillation (AF) remains unresolved. Our objective was to evaluate the outcome of patients with AF who received i.v. rt-PA for stroke in the registries of Lille (France) and Belgrade (Serbia). End-points were poor outcome [modified Rankin Scale (mRS) 3-6], and symptomatic haemorrhagic transformation (sHT) according to ECASS3. Of 734 consecutive patients, 155 (21.2 %) had AF. The unadjusted comparison found patients with AF to be 12 years older, more likely to be women, to have hypertension, and baseline INR > 1.2, and less likely to be smokers. They had higher baseline NIHSS scores, diastolic blood pressure, and serum glucose concentrations, and lower platelet counts. They did not differ for sHT (5.8 vs. 5.5 %; p = 0.893), but they more frequently had poor outcomes (52.3 vs. 35.2 %; p < 0.001) and death (21.9 vs. 9.0 %; p < 0.001). The only independent predictor of sHT was baseline NIHSS (adjOR 1.05 per 1 point increase; 95 % CI 1.01-1.10). Independent variables associated with poor outcome were age (adjOR 1.04 for 1 year increase; 95 % CI 1.03-1.06), baseline NIHSS (adjOR 1.17 per 1 point increase; 95 % CI 1.13-1.21), and sHT (adjOR 47.6; 95 % CI 10.2-250) but not AF. In patients treated with i.v. rt-PA for cerebral ischaemia, those with AF have worse outcomes because they are older and have more severe strokes at admission. This result suggests that we should focus on prevention and research of more aggressive strategies at the acute stage.

Cervical artery dissection: trauma and other potential mechanical trigger events.

OBJECTIVE: To examine the import of prior cervical trauma (PCT) in patients with cervical artery dissection (CeAD). METHODS: In this observational study, the presence of and the type of PCT were systematically ascertained in CeAD patients using 2 different populations for comparisons: 1) age- and sex-matched patients with ischemic stroke attributable to a cause other than CeAD (non-CeAD-IS), and 2) healthy subjects participating in the Cervical Artery Dissection and Ischemic Stroke Patients Study. The presence of PCT within 1 month was assessed using a standardized questionnaire. Crude odds ratios (ORs) with 95% confidence intervals (CIs) and ORs adjusted for age, sex, and center were calculated. RESULTS: We analyzed 1,897 participants (n = 966 with CeAD, n = 651 with non-CeAD-IS, n = 280 healthy subjects). CeAD patients had PCT in 40.5% (38.2%-44.5%) of cases, with 88% (344 of 392) classified as mild. PCT was more common in CeAD patients than in non-CeAD-IS patients (ORcrude 5.6 [95% CI 4.20-7.37], p < 0.001; ORadjusted 7.6 [95% CI 5.60-10.20], p < 0.001) or healthy subjects (ORcrude 2.8 [95% CI 2.03-3.68], p < 0.001; ORadjusted 3.7 [95% CI 2.40-5.56], p < 0.001). CeAD patients with PCT were younger and presented more often with neck pain and less often with stroke than CeAD patients without PCT. PCT was not associated with functional 3-month outcome after adjustment for age, sex, and stroke severity. CONCLUSION: PCT seems to be an important environmental determinant of CeAD, but was not an independent outcome predictor. Because of the characteristics of most PCTs, the term mechanical trigger event rather than trauma may be more appropriate.

Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥ 80 years of age.

Despite increasing life expectancy, few data exist on the outcome of elderly stroke patients treated with IV thrombolysis. We analyzed the prospectively collected data from the Lille University Hospital stroke unit on patients treated with IV rt-PA within 4.5 h, comparing patients ≥80 years to younger ones. We considered the following outcomes: neurological improvement at the acute phase (NIHSS 0 or 1 at 24 h, or if the difference between NIHSS at 24 h and at baseline was ≥4), occurrence of intracerebral haemorrhage, mortality and functional outcome in survivors (favourable if mRS ≤2 or equal to pre-stroke score) at 3 months. Predictors of vital and functional outcome were determined using logistic regression analysis. Four hundred patients were treated with IV rt-PA, 98 (25%) being ≥80 years. The proportion of patients with neurological improvement at the acute phase (31 vs. 40%, OR 0.7, 95%CI 0.4-1.2), and with ICH (19 vs. 21%, OR 0.9, 95%CI 0.5-1.7) was similar among older and younger patients. At 3 months, 35% of patients ≥80 years had died; 52% of survivors had favourable functional outcome. Using multivariate analysis, age ≥80 years was an independent predictor of death (3.4; 95%CI 1.6-7.3), and of reduced likelihood of favourable functional outcome in survivors (OR 0.3; 95%CI 0.2-0.7) at 3 months. Although outcome at 3 months is worse for older patients than for their younger counterparts, our results are encouraging with a similar proportion of patients with early neurological improvement and with ICH in old and young patients and about half of the survivors having a favourable functional outcome in patients ≥80 years.

Isolated Subarachnoidal Hemorrhage following Carotid Endarterectomy.

Cerebral hyperperfusion syndrome is a rare but well-described complication following carotid endarterectomy or stenting. Clinical signs are ipsilateral, throbbing, unilateral headache with nausea or vomiting, seizures, and neurological deficits, with or without intracerebral abnormalities on CT scan, such as brain edema or intracerebral hemorrhage. Subarachnoidal hemorrhage is rarely described especially if it occurs isolated. We describe a 74-year-old man with a history of high blood pressure, hypercholesterolemia, atrioventricular block with pacemaker, and ischemic cardiopathy with coronary bypass. He underwent right carotid endarterectomy for a 90% NASCET asymptomatic stenosis. Four days after surgery, he complained of unusual headaches with right, throbbing hemicrania. Nine days after surgery, he presented with left hemiplegia and a partial motor seizure. He had fluctuant altered consciousness, left hemiplegia, and left visual and sensory neglect. Brain CT showed right frontal subarachnoidal hemorrhage without parenchymal bleeding. Cerebral angiography found no cerebral aneurysm, no vascular malformation, but a vasospasm of the left middle cerebral artery. Transcranial Doppler confirmed this vasospasm. Evolution was favorable with no recurrence of seizures but with an improvement of the neurological deficits and vasospasm. Physicians should bear in mind this very rare complication of endarterectomy and immediately perform neuroimaging in case of unusual headache following endarterectomy or angioplasty.