From mothership to drip-and-ship: Effects of staff shortages at a comprehensive stroke center.

BACKGROUND: Mechanical thrombectomy (MT) has been shown to be effective in the acute phase of ischemic stroke. Current data suggests that the drip-and-ship and mothership telestroke models are equally effective for its administration. We describe the consequences of changing the telestroke model due to staff shortages in a comprehensive stroke center (Besançon), which was replaced by a more distant one (Dijon). METHODS: We conducted a retrospective analysis of all patients referred for MT from January 2015 to December 2018. We analyzed the time between symptom onset and arrival in the angiography suite. We also calculated number of thrombectomies divided by number of days on call, and rate of thrombectomies relative to the number of strokes in each group. RESULTS: In Besançon, 205 patients underwent an MT procedure, versus 43 patients in Dijon. A further four patients were transferred to Dijon but not treated. The time from symptom onset to arrival in the angiography suite was longer for Dijon; 334min versus 281min for Besançon (p<0.001). The percentage of thrombectomies performed per day on call was higher for Besançon: 18.6% versus 13.2% in Dijon (p=0.026). CONCLUSIONS: Over the study period, the time from symptom onset to angiography suite was longer for patients who were transferred to Dijon. The period in which the Besançon hospital experienced the greatest lack of personnel corresponded to a decrease in the number of MTs performed.

Adult moyamoya angiopathy in Bourgogne-Franche-Comté: Epidemiology, diagnosis and management.

INTRODUCTION: Moyamoya angiopathy (MMA) is a progressive steno-occlusive disease of the distal internal carotid arteries mainly described in Asia. It induces the development of collateral vascular networks to reduce chronic cerebral hypoperfusion. Symptoms depend on the patient's age in Asia: children are at greater risk of transient or constituted ischemic events, whereas adults are more exposed to hemorrhagic stroke. Data from the literature seem to show that the pattern of MMA in western countries differs from that in Asia. MATERIAL AND METHODS: A retrospective study of patients with MMA was conducted in Bourgogne-Franche-Comté (mid-eastern France). Clinical data (symptoms, risk factors, age at diagnosis, number and timing of recurrences, type of treatment) as well as radiological data (angiographic findings, Suzuki's grade) were analyzed. RESULTS: Seventeen adult patients (9 men, 53%) were followed at the university hospitals of Besançon and Dijon from 2009 to 2016. Fourteen patients (83%) had bilateral disease. The mean age at diagnosis was 49 years (±16), 83% of the patients were Caucasian and 17% originated from Maghreb. Only 17% of the hemispheres had a hemorrhagic form. Ischemic form was more frequent before diagnosis with transient ischemic attack (24% of patients) and stroke (83% of patients). With medical treatment, 9 patients suffered from stroke recurrence (53% of patients) with an average delay of 22.7±34 months. Three patients (18%) had combined surgical management by encephelo-synangiosis and superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis, without symptom recurrence after treatment with an average follow up of 14 months. CONCLUSION: MMA remains a rare cerebrovascular disease in Europe and requires multidisciplinary care. Epidemiological analysis showed differences with the Asian population, especially the predominance of ischemic forms in adults.

[Moyamoya disease: Diagnosis, clinical features, evolution and treatment in 10 patients]. / Maladie de Moyamoya : aspects diagnostiques, cliniques, évolutifs et thérapeutiques chez 10 patients.

INTRODUCTION: Moyamoya disease is a rare chronic cerebrovascular disease. The objective of this article is to report the different clinical and radiological presentations and describe treatments and clinical course of this disease. METHODS: We searched for patients with Moyamoya disease diagnosed at a French university hospital. The diagnosis was based on arteriographic records showing uni- or bilateral stenosis of distal intracranial internal carotid arteries or middle cerebral arteries associated with a classic collateral network imparting a puff of smoke aspect. Data about clinical and radiological symptoms were analyzed for all identified patients. RESULTS: Ten patients were recorded between 2009 and 2014 including one child and nine adults. The initial presentation was intracerebral hemorrhage in two patients, ischemic stroke in six, and either exercice-related transient ischemic attacks or syncope in two. Recurrent events were noted in four patients. Four patients had one or several recurrent vascular events. Eight patients were given medical treatment and none underwent surgery. Secondary Moyamoya syndrome was suspected in two patients, all the others one were considered idiopathic. CONCLUSION: Moyamoya disease is a rare but potentially severe illness. The initial presentation is more frequently an ischemic stroke; recurrences are frequent. The diagnosis is based on arteriography, which is also recommended to search for a cause.

Vascular aphasia outcome after intravenous recombinant tissue plasminogen activator thrombolysis for ischemic stroke.

INTRODUCTION: No data about the specific outcome of aphasia after thrombolysis are available. Our aim was to describe the severity and type of aphasia after stroke thrombolysis. METHODS: This retrospective cohort study included consecutive aphasic patients hospitalized in the Stroke Unit of Dijon (University Hospital, France) between 2004 and 2009 for a first-ever ischemic stroke of the left middle cerebral artery. Aphasic syndromes and their severity (French version of the Boston Diagnostic Aphasia Examination) were evaluated during the first week and 3 months after stroke. RESULTS: In multivariate analyses, the severity of aphasia in the 37 thrombolysed patients was milder than in the 38 nonthrombolysed patients during the first week (adjusted OR = 10.13, 95% CI: 2.43-42.28, p = 0.002) and at 3 months (adjusted OR = 8.44, 95% CI: 2.76-25.80, p = 0.001). The frequency of mild aphasia (conduction or atypical) was not significantly higher in thrombolysed patients during the first week after stroke (adjusted OR = 5.80, 95% CI: 0.82-41.16, p = 0.079). CONCLUSION: The severity of aphasia during the first week and 3 months after stroke is milder in thrombolysed than in nonthrombolysed patients, perhaps because of a greater frequency of conduction and mild atypical aphasia.

[Rheumatoid arthritis and meningeal nodules]. / Polyarthrite rhumatoïde et nodules méningés.

INTRODUCTION: Rheumatoid nodules are possible extra-articular manifestations of rheumatoid arthritis. These lesions are mainly located in subcutaneous tissues but may also rarely affect deep organs, exceptionally the meninges. CASE REPORT: We report herein a case of meningeal nodules observed in a 52-year-old man with rheumatoid arthritis who underwent brain MRI to explore an acute visual impairment. Subsequent MRIs showed similar new lesions contrasting with total regression of the initially observed lesions. The final control brain MRI performed four years after the onset of the ocular symptoms disclosed total involution of all the extra-axial nodular lesions, a course highly suggestive of meningeal rheumatoid nodules. CONCLUSION: During the follow-up period of this case, the patient was treated with methotrexate at doses too low to cross the blood brain barrier. Consequently, it is most likely that the meningeal lesions developed during the natural course of the disease. Despite the non-specific features of the first imaging findings, the radiological changes observed over time were consistent with the final diagnosis of rheumatoid nodules.

Endovascular treatment of symptomatic intracranial atheromatous stenosis: a single center study of 21 consecutive cases.

OBJECTIVES: This retrospective single-center study evaluated the technical success as well as the periprocedural and long-term complications of angioplasty with stenting of symptomatic intracranial atheromatous stenosis. PATIENTS AND METHODS: From January 2005 to December 2010, 21 patients were treated by angioplasty with stent implantation for symptomatic atheromatous intracranial stenosis greater or equal to 50% at least 7 days after a stroke. RESULTS: The median population age was 65 years (range: 41-88 years), and 76% (16/21) of the candidates had a history of transient ischemic attack (TIA) or stroke before the event qualifying them for an endovascular procedure. In addition, 86% (18/21) were taking antithrombotic medication at the time of the qualifying event. Technical success was obtained in all cases. The periprocedural stroke or death rate was 9.5% (2/21), and there was no other stroke or death after 30 days during the mean follow-up of 1.4 years. CONCLUSION: Endovascular treatment of symptomatic intracranial atherothrombotic stenosis can lead to severe complications, particularly during the periprocedural period, but it also represents the only alternative treatment for patients who fail with medical therapy. Future studies need to focus on improvement of periprocedural complications. Essentially, this should include more rigorous selection of candidates as well as a better understanding of the pathophysiological mechanism(s) of the ischemic phenomenon related to stenosis.

[Idiopathic intracranial hypertension: From physiopathological mechanisms to therapeutic decision]. / Hypertension intracrânienne idiopathique : des mécanismes physiopathologiques à la décision thérapeutique.

Clinical features include visual disturbances, headaches, and pulsatile tinnitus that can be associated with reduced quality of life, and a risk of irreversible visual impairment in some cases. Obese women of childbearing age represent the main at-risk population, and the incidence of the disease is increasing because of rising prevalence of obesity worldwide. In addition, an imbalance in sex hormones is reported as a contributing risk factor. The pathophysiology of idiopathic intracranial hypertension involves a disturbance of the evacuation pathway of intracranial fluids caused by the increase in intracranial venous pressure. Brain imaging is useful for diagnosis with several signs including bilateral stenosis of the transverse sinuses that plays a major role in the pathogenesis of the disease by creating a positive feedback loop that increases intracranial venous hypertension and contributes to clinical manifestations. Treatment aims to relieve symptoms and prevent permanent visual impairment. Drug therapies including acetazolamide and topiramate have moderate effectiveness. Among invasive treatments, transverse sinus stenting seems to be the most interesting option to consider in drug-resistant patients. Weight loss remains essential to achieve a sustainable improvement by reducing central venous pressure. Future randomized trials are expected to reach a consensus on this treatment.

[Focal subarachnoid hemorrhage and cerebral amyloid angiopathy: a non-fortuitous association]. / Hémorragie méningée focale et angiopathie amyloïde cérébrale : une association non fortuite.

INTRODUCTION: Cerebral amyloid angiopathy is a degenerative angiopathy due to amyloid deposits in the walls of the meningeal and cortical vessels. It is considered as a major cause of cerebral hemorrhage to the elderly. It was recently demonstrated that the association of focal meningeal bleedings and cerebral hemorrhage is very suggestive of cerebral amyloid angiopathy. In contrast, the links between subarachnoid hemorrhage and amyloid angiopathy are less well-known. CASES REPORTS: We report nine cases of cerebral amyloid angiopathy. The clinical presentation was variable, but all had at least one inaugural meningeal bleeding. As cortico-meningeal biopsies were not performed the Boston criteria were used to establish the diagnosis. CONCLUSION: Cerebral amyloid angiopathy is an underestimated cause of subarachnoid hemorrhage. Our observations show that this diagnosis should be evoked when focal meningeal bleeding occurs without head trauma or when focal subarachnoid hemorrhage is followed by a subcortical hematoma in an elderly subject.

[Rupture of intracranial dermoid cyst with disseminated lipid droplets]. / Dissémination sous-arachnoïdienne de gouttelettes lipidiques par rupture d'un kyste dermoïde intracérébral.

INTRODUCTION: Dermoid cysts are rare slow-growing benign tumors of the central nervous system generally diagnosed in the third to fifth decade. They are formed from inclusion of ectodermal elements during neural tube closure, and are mostly located along the cranial or spinal midline axis. They cause many non specific symptoms such as headache and seizures, and may spontaneously rupture spreading fatty droplets into the ventricles and subarachnoid spaces. Rupture of dermoid cysts causes sequelae which may vary from no symptoms to death. In general, subtotal surgical removal is required for ruptured dermoid cysts. CASE REPORTS: We report two cases of ruptured intracranial dermoid tumor with non-specific clinical presentations. The first rupture was asymptomatic and discovered on brain magnetic resonance imaging (MRI) performed for other purposes. The second case was identified on brain imaging performed because of daily headache. These dermoid cysts were not surgically treated. Surveillance was advised because of the spontaneously favourable outcome observed in both cases. CONCLUSION: Surgical removal is not the only treatment of ruptured dermoid cyst. Monitoring with brain MRI can be sufficient if the rupture has no severe clinical impact.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Cricoid cartilage and esophagus: CT scan study of the dynamic variability of their relative positions.

INTRODUCTION: Cricoid pressure occludes the esophagus (E) by compressing it between the cricoid cartilage (CC) and the body of the sixth cervical vertebra (C6). This technique is used to prevent passive regurgitation during the induction of anesthesia in patients at high risk for regurgitation. Failures of this technique had been described and a possible displacement of the E relative to the CC had been reported, but there is no study about displacement during antero-posterior movements of the head. AIM: The aim of our study was to evaluate the displacement of the CC relative to the cervical E, during flexion and extension movements of the head. MATERIALS AND METHODS: We retrospectively studied X-ray computed tomography (CT) images of 21 patients with suspected cervical trauma. Patients were in the supine position. In the first series of images, the head was positioned at maximal flexion by means of a support placed under the external occipital protuberance. In the second series of images, the head was maintained in extension by means of a support placed under the shoulders. Each position was obtained as far as possible within the limits of pain and restricted movement. In flexion and extension, we used the lowest slice from the cricoid cartilage. The variables measured were: diameters of CC (CD) and E (OD), left and right lateral displacements of E. RESULTS: A total of 13 CT were analyzed. CD and OD as well as OD/OC ratios did not vary significantly in flexion and extension. We noticed 61.5 and 92.3% (respectively in flexion and in extension) of left or right displacement: 23% of patients presented right displacement in both flexion and extension; 38.5% of patients did not present any right displacement in flexion or in extension; 61.5% of patients presented left displacement in both flexion and extension. More generally, almost 92% of patients presented displacement either in flexion or extension, or both. DISCUSSION: In our study, it can be seen that the E is clearly displaced with regard to the CC, that this displacement is favored by extension. Only 2/13 patients have an "over than 3 mm" displacement in extension whereas 5/13 in flexion. So, even if there are more displacements in extension, they are inferior to 3 mm and may not be considered as significant considering the occlusion of E. According to our results, the extension position of the head produces more displacement of the E but should preserve the containment of the cricoid pressure if we consider the thickness of the E wall.

[Post-traumatic tarsal tunnel syndrome: interest of muscular MRI]. / Syndrome du canal tarsien post-traumatique : intérêt de l'IRM musculaire.

INTRODUCTION: Tarsal tunnel syndrome is a compressive neuropathy of the tibial nerve with multiple causes. This syndrome is difficult to diagnose and can be missed because of its subjective symptomatology. OBSERVATION: In our patient, suspected post-traumatic tarsal tunnel syndrome was confirmed at MRI. This case highlights muscle signal anomalies caused by their denervation in the tibial nerve territory. CONCLUSION: MRI can provide supplementary information to the electromyography (EMG) and contribute to positive and etiologic diagnosis of peripheral nerve lesions.

[Stroke in young adults with celiac disease]. / Accident vasculaire cérébral ischémique de l'adulte jeune au cours de la maladie coeliaque. A propos de deux observations.

INTRODUCTION: Celiac disease is a common condition with a prevalence of about 1%. Clinical extradigestive presentations are various and stroke can be one of the neurological manifestations. EXEGESIS: Two cases of stroke occurring in young adults are described, leading to the diagnosis of celiac disease. Hyperhomocysteinemia or cerebral arterial vasculopathy in one case and antiphospholipid syndrome in the other case are thought to be involved in the pathogenesis of stroke during celiac disease. CONCLUSION: The possible presence of celiac disease should be discussed in unexplained young adult stroke.

[Acute management of ischemic stroke in 2017]. / Prise en charge aiguë des infarctus cérébraux en 2017.

Acute management of ischemic stroke is a burning topic in 2017 since stroke represents the leading cause of acquired handicap in adults. Over the last past years, major improvement took place, especially with the demonstration of the efficacy of mechanical thrombectomy, thus needing to better organize care pathways, and optimize access to neurologists and interventional neuroradiology platforms. Intensive care stroke units remain the pivotal place of patients' management. A multidisciplinary coordination is required, with continuous teaching of all the actors involved in stroke management, so as to increase the number of patients who could benefit from available active treatments.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

Reliability of computed tomographic angiography in the diagnosis of brain death.

OBJECTIVE: This study examined the validity of cerebral computed tomographic (CT) angiography in the diagnosis of brain death (BD) compared with conventional cerebral angiography. METHODS: This prospective, monocentric study was performed over a 24-month period and included 43 patients, at least 18 years of age, with clinical criteria of BD. All patients underwent cerebral CT angiography and then cerebral angiography. To confirm BD, the CT scan had to show the absence of perfusion of A2 anterior cerebral artery segments (A2-ACA), M4 middle cerebral artery segments (M4-MCA), P2 posterior cerebral artery segments (P2-PCA), basilar artery, internal cerebral veins, and finally the great cerebral vein. Cerebral angiography showed cerebral blood flow arrest at the level of the foramen magnum for posterior circulation and carotid siphon for anterior circulation. RESULTS: For 30 patients, BD was confirmed by both examinations. For 13 patients, cerebral angiography confirmed BD, whereas CT angiography still showed cerebral perfusion; the divergence rate was 30.2%. CONCLUSIONS: CT angiography seems to be a promising exam to confirm BD. However, the divergence with cerebral angiography is significant mainly concerning A2-ACA, which are proximal. It may be possible to only use the absence of opacification of M4-MCA, P2-PCA, basilar artery, and venous blood return to remain in conformity with the French law. In all cases, the international medical community should obtain a consensus for the interpretation of CT angiography to use it extensively as a complementary exam for BD.

[Nasopharyngeal tonsillolith: a report of 31 cases]. / Les tonsillolithes nasopharyngés au scanner: à propos de 31 cas.

OBJECTIVE: Nasopharyngeal tonsilloliths are less well known to radiologists than palatine tonsil lithiases. The possibility of routinely available fine slices during CT scans of the head and neck prompted a retrospective study on the causes and radiological signs and patterns of nasopharyngeal tonsilloliths. MATERIAL AND METHODS: A total of 515 CT scans were retrospectively re-examined looking for calcifications of the posterior wall of the nasopharynx. One patient with this type of calcification underwent a cerebral MRI as part of the etiological workup of his faintness, which also provided a study of the nasopharyngeal wall. The size, density, and position of these calcium concretions were analyzed with CT in all cases. RESULTS: In 31 patients (18 men, 13 women), we discovered one or several calcifications in the pharyngeal mucous area, between 2 and 5.5 mm in size, with a median density of 202 HU. In two cases, we observed that these calcifications adhered to an adenoid cyst, whereas in three cases, the patients had both palatine tonsil and nasopharyngeal calcifications. None of the 31 patients had previously had an adenoidectomy. Sagittal CT and MRI images clearly localized all these calcifications before the pharyngobasilar fascia. DISCUSSION: The position of these nasopharyngeal calcifications in front of the pharyngobasilar fascia means that a calcified vestige of the notochord can be ruled out. Moreover, the simultaneous presence of nasopharyngeal tonsil and palatine tonsil calcifications in three patients is an additional argument for considering these calcifications of the posterior wall of the nasopharynx as tonsilloliths, all of which, representing 6% of the CTs in our series, were asymptomatic. CONCLUSION: The nasopharyngeal tonsilloliths are stones less than 1 cm in size lodged in the pharyngeal tonsils that are frequently detected on CT when there are no clinical symptoms.