Medical demography at stroke centers: Current situation in France.

INTRODUCTION: Following the 2010-2014 French national stroke action plan, the number of stroke center (SC) has gradually increased in France, allowing a homogeneous coverage and access to neurovascular care in organized and territorially defined structures. However, operational difficulties within SCs have been progressively reported over the last few years. The objective of this study was to identify the medical staff shortages in SC that may contribute to these difficulties. METHODS: A survey on the medical staffing level as of January 1, 2021 was sent to all French SC managers. Specific questions related on vacancies, need of interim medical staff, and participation in out-of-hour healthcare services. RESULTS: Among the 139 SC managers contacted, 122 (88%) filled in the questionnaire. Analysis of the data showed that over 879 physician positions opened, 163 (18.5%) remained vacant for a mean of two years, and that in 51 SCs (41.9%), more than two positions were unfilled. In 13 of these 51 SCs, the out-of-hour healthcare services relied on less than four practitioners, defining a critical situation, and three other SCs had to close temporarily (2) or permanently (1). Moreover, 39.2% of SCs with at least one vacancy used interim physicians, for a median period of 12.5 weeks/year (IQR 5-18). CONCLUSION: This study highlights the significant medical staff shortage in French SCs. In the absence of urgent measures, more SCs will close, jeopardizing the regional network and access to care for stroke patients.

Tenecteplase in acute ischemic stroke: Review of the literature and expert consensus from the French Neurovascular Society.

BACKGROUND: Intravenous alteplase is the only thrombolytic treatment approved for patients with acute ischemic stroke (AIS). Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units. The purpose of the present work was to provide an up-to-date set of expert consensus statements on the use of tenecteplase in AIS. METHODS: Members of the working group were selected by the French Neurovascular Society. RCTs comparing tenecteplase and alteplase in the treatment of AIS were reviewed. Recent meta-analysis and real-life experience data on tenecteplase published until 30th October 2021 were also analyzed. After a description of the available data, we tried to answer the subsequent questions about the use of tenecteplase in AIS: What dosage of tenecteplase should be preferred? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Then expert consensus statements for tenecteplase use were submitted. In October 2021 the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved. EXPERT CONSENSUS: A set of three expert consensus statements for the use of tenecteplase within 4.5hours of symptom onset in AIS patients were issued: (1) It is reasonable to use tenecteplase 0.25mg/kg when mechanical thrombectomy (MT) is planned. (2) Tenecteplase 0.25mg/kg can be used as an alternative to alteplase 0.9mg/kg in patients with medium- or small-vessel occlusion not retrievable with MT. (3) Tenecteplase 0.25mg/kg could be considered as an alternative to alteplase 0.9mg/kg in patients without vessel occlusion. CONCLUSIONS: These expert consensus statements could provide a framework to guide the clinical decision-making process for the use of tenecteplase according to admission characteristics of AIS patients. However, existing data are limited, requiring inclusions in ongoing RCTs or real-life registries.

TICI-RANKIN mismatch: Poor clinical outcome despite complete endovascular reperfusion in the ETIS Registry.

INTRODUCTION: Endovascular treatment (EVT) is a well-established technic for acute ischemic stroke, but despite a high recanalization rate of near 80%, at 3 months roughly 50% of patients have a poor functional outcome with a modified Rankin score (mRS) ≥3. The aim of this study was to determine predictive factors of poor functional outcomes in patients with complete recanalization after EVT, defined as modified thrombolysis in cerebral infarction (mTICI) 3. PATIENTS AND METHODS: This retrospective analysis based on the prospective multicenter ETIS registry (endovascular treatment in ischemic stroke) in France included 795 patients from January 2015 and November 2019 with acute ischemic stroke due to anterior circulation occlusion and prestroke mRS 0-1, treated with EVT and who achieved complete recanalization. Univariate and multivariate logistic regression models were used to identify predictive factors of poor functional outcome. RESULTS: 365 patients (46%) showed a poor functional outcome (mRS>2). In backward-stepwise logistic regression analysis, poor functional outcome was independently associated with older age (OR per 10-year increase, 1.51; 95%CI, 1.30 to 1.75), higher admission NIHSS (OR per 1 point increase, 1.28; 95%CI, 1.21 to 1.34), absence of prior intravenous thrombolysis (OR, 0.59; 95%CI, 0.39 to 0.90), and an unfavorable 24-hour NIHSS change (24h-baseline) (OR, 0.82; 95%CI, 0.79 to 0.87). We calculated that patients whose 24h NIHSS decreased by less than 5 points are more at risk of a poor outcome, with a sensitivity and a specificity of 65.0%. CONCLUSION: Despite complete reperfusion after EVT, half of patients had a poor clinical outcome. These patients, who were mainly older with a high initial NIHSS and an unfavorable post-EVT 24h NIHSS change, could represent a target population for early neurorepair and neurorestorative strategies.

Prognosis and risk factors associated with asymptomatic intracranial hemorrhage after endovascular treatment of large vessel occlusion stroke: a prospective multicenter cohort study.

BACKGROUND AND PURPOSE: Asymptomatic intracranial hemorrhage (aICH) is a common occurrence after endovascular treatment (EVT) for acute ischemic stroke (AIS). The aims of this study were to address its impact on 3-month functional outcome and to identify risk factors for aICH after EVT. METHODS: Patients with AIS attributable to anterior circulation large vessel occlusion who underwent EVT were enrolled in a multicenter prospective registry. Based on imaging performed 22-36 h post-EVT, we included patients with no intracranial hemorrhage (ICH) or aICH. Poor outcome defined as a 3-month modified Rankin Scale (mRS) score 4-6 and overall 3-month mRS score distribution were compared according to presence/absence of aICH, and aICH subtype using logistic regression. We assessed the risk factors of aICH using a multivariate logistic regression model. RESULTS: Of the 1526 patients included in the study, 653 (42.7%) had aICH. Patients with aICH had a higher rate of poor outcome: odds ratio (OR) 1.88 (95% confidence interval [CI] 1.44-2.44). Shift analysis of mRS score found a fully adjusted OR of 1.79 (95% CI 1.47-2.18). Hemorrhagic infarction (OR 1.63 [95% CI 1.22-2.18]) and parenchymal hematoma (OR 2.99 [95% CI 1.77-5.02]) were associated with higher risk of poor outcome. Male sex, diabetes, coronary artery disease, baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score, number of passes and onset to groin puncture time were independently associated with aICH. CONCLUSIONS: Patients with aICH, irrespective of the radiological pattern, have a worse functional outcome at 3 months compared with those without ICH after EVT for AIS. The number of EVT passes and the time from onset to groin puncture are factors that could be modified to reduce deleterious ICH.

Search for Neutrinoless Quadruple-ß Decay of

We report the results of a first experimental search for lepton number violation by four units in the neutrinoless quadruple-ß decay of ^{150}Nd using a total exposure of 0.19 kg yr recorded with the NEMO-3 detector at the Modane Underground Laboratory. We find no evidence of this decay and set lower limits on the half-life in the range T_{1/2}>(1.1-3.2)×10^{21} yr at the 90% C.L., depending on the model used for the kinematic distributions of the emitted electrons.

[Cerebrovascular malformation revealed during the prethrombolysis workup in acute ischemic stroke. Impact on therapeutic decision making]. / Malformation vasculaire cérébrale découverte dans le bilan pré-thrombolyse d'un infarctus cérébral. Impact sur la décision thérapeutique.

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke is contraindicated in patients harboring an asymptomatic intracranial vascular malformation, whether it is incidentally discovered at the time of the initial cerebral imaging or previously known. Because thrombolysis is associated with a risk of serious intracerebral hemorrhage, it is theoretically possible that this treatment increases the risk of bleeding or rupture of these malformations. However, this risk seems very low in clinical practice. We report two cases, one with a probable brainstem cavernous malformation treated with alteplase for a supratentorial ischemic stroke who developed just after treatment a fatal brainstem hemorrhage, and another one with asymptomatic dural arteriovenous fistula, treated by endovascular thrombectomy solely. This approach was safe and effective, and the patient had an endovascular embolization of the fistula one month later as it became symptomatic. Based on the literature, we discuss the bleeding risk of asymptomatic intracranial vascular malformations in acute ischemic stroke patients treated with alteplase, depending on the type of malformation (intracranial aneurysm, arteriovenous and cavernous malformation or fistula), and the alternative therapeutic options.

[Ischemic stroke related to pauci-symptomatic acute aortic dissection. Risks of intravenous thrombolysis]. / Infarctus cérébral par dissection aortique pauci-symptomatique. Les risques de la thrombolyse, à propos de deux observations.

INTRODUCTION: Acute aortic dissection involving the cervical arteries often induces cerebral infarction. In this context, there is a high risk of hemorrhage and thrombolytics are contra-indicated. OBSERVATION: We report two patients with a cerebral infarction which occurred after a pauci-symptomatic and undiagnosed aortic dissection treated with thrombolysis. The outcome was poor for both patients. DISCUSSION: Ischemic strokes related to acute aortic dissection often involve the right carotid artery territory and may manifest without pain. A systematic assessment of supra-aortic arteries might help to identify the underlying diagnosis. CONCLUSION: Acute aortic dissection should be systematically mentioned in the management of the acute ischemic stroke.

Measurement of the ßß decay half-life of 130Te with the NEMO-3 detector.

We report results from the NEMO-3 experiment based on an exposure of 1275 days with 661 g of (130)Te in the form of enriched and natural tellurium foils. The ßß decay rate of (130)Te is found to be greater than zero with a significance of 7.7 standard deviations and the half-life is measured to be T(½)(2ν) = [7.0 ± 0.9(stat) ± 1.1(syst)] × 10(20) yr. This represents the most precise measurement of this half-life yet published and the first real-time observation of this decay.

The BiPo-3 detector.

The BiPo-3 detector is a low radioactive detector dedicated to measuring ultra-low natural contaminations of 208Tl and 214Bi in thin materials, initially developed to measure the radiopurity of the double ß decay source foils of the SuperNEMO experiment at the µBq/kg level. The BiPo-3 technique consists in installing the foil of interest between two thin ultra-radiopure scintillators coupled to low radioactive photomultipliers. The design and performances of the detector are presented. In this paper, the final results of the 208Tl and 214Bi activity measurements of the first enriched 82Se foils are reported for the first time, showing the capability of the detector to reach sensitivities in the range of some µBq/kg.

[Exacerbation of tonicoclonic seizures in a juvenile myoclonic epileptic taking lamotrigine]. / Accentuation des crises tonico-cloniques sous lamotrigine dans l'épilepsie myoclonique juvénile.

INTRODUCTION: Lamotrigine is an anti-epileptic drug considered as a first-line therapy in idiopathic generalised epilepsy. Lamotrigine is well-tolerated and secondary aggravation of epileptic syndromes has rarely been reported. CASE REPORT: We report the case of a 19 year-old man with juvenile myoclonic epilepsy in whom lamotrigine lead to the exacerbation of generalised tonico-clonic seizures, reversible when lamotrigine was stopped and substituted by valproic acid. CONCLUSION: Lamotrogine may induce exacerbation of generalised tonico-clonic seizures and myoclonic jerks in juvenile myoclonic epilepsy.

[Intracranial aneurysms presenting with ischemic stroke]. / Anévrysmes intracrâniens révélés par une ischémie cérébrale.

PURPOSE: To report four cases of patient with an acute ischemic event as a presenting symptom of a berry aneurysm. PATIENTS AND METHODS: One male and three female (aged range 38 to 65 years) patients were admitted for acute stroke. The neuroradiologic finding disclosed aneurysm thrombosis, inferior to twenty five millimetres in three cases. Lumbar puncture was done in one case and showed subarachnoid haemorrage. DISCUSSION: We will discuss the hypothesis leading to the mechanism of aneurysm thrombosis. Two theories will be presented: "hemodynamic" and "parietal" modifications. We will propose a management protocol for these patients with atypical presentation of intracranial aneurysms given the potential risk of rupture. CONCLUSION: The natural history of intracranial aneurysms is still not fully understood. Nevertheless, aneurym thrombosis may occur and lead to ischemic stroke.

[Imported cerebral malaria]. / Neuropaludisme d'importation.

Cerebral malaria is one of the most serious complications of Plasmodium falciparum infection. Its diagnosis may sometimes be difficult. We report the case of a 63-year-old woman who presented with abdominal pain and nausea, rapidly followed by delirium and stupor, a few days after a travel in Africa. No prophylactic measures were prescribed. The main clinical features concerning cerebral malaria, diagnostic tools and therapeutic measures are discussed.

[The finding of incidental intracranial lesions with magnetic resonance imaging]. / Découverte fortuite d'une lésion intracrânienne en imagerie par résonance magnétique.

INTRODUCTION: Incidental findings on brain MRI are not rare since the development of MRI as a diagnostic and clinical research tool. STATE OF THE ART: Prevalence of cerebral incidental finding, based on research volunteers participating in studies, is estimated from 1.7 to 4 percent. The most frequently detected lesions are intracranial tumors (meningioma, arachnoid cysts, neuro-epithelial tumor) and vascular malformations. PERSPECTIVES: A better knowledge of the spontaneous outcome of incidental findings would allow adequate management of these patients. CONCLUSION: Clinicians should be aware of the outcome of incidental findings, to reassure patients or trigger a work-up if necessary.

[MR-angiography of the head and neck vessels: technical considerations and clinical indications]. / ARM des vaisseaux cervico-encéphaliques: technique, principales applications cliniques.

Magnetic resonance angiography (MRA) is a very valuable tool in the routine evaluation of patients with stroke syndrome. It provides powerful noninvasive imaging of the cervical and intracranial vessels allowing the detection and the diagnosis of vascular anomalies. MRA usefully supplements, during the same examination, the analysis by MRI of the cerebral parenchyma. We will describe the indications of the various techniques (MRA with and without injection of contrast media) and show the value, artifacts and limitations of MRA in atherosclerotic stenosis or occlusive disease and in arterial dissections. This noninvasive vascular assessment will depend on the initial therapeutic orientation. Within the framework of the hemorrhagic stroke, we will discuss the role and the interest of dynamic MR angiography in the tracking and control of intracranial aneurysms and also the contribution of this newer sequences with gadolinium injection in the detection of cerebral vascular malformations.

Arterial wall properties in carotid artery dissection: an ultrasound study.

BACKGROUND: Cervical artery dissection is often attributed to an underlying arteriopathy related to a generalized extracellular matrix defect. OBJECTIVE: The authors compared the hemodynamic and morphologic properties of the carotid artery, as assessed noninvasively by ultrasonography, in patients with spontaneous internal carotid artery dissection (ICAD) and control subjects. METHOD: Twenty-six patients who experienced ICAD more than 6 months before evaluation were compared with 26 controls matched for age, sex, and height. Cases and controls had ultrasound measurement of common carotid artery diameter and diameter change during the cardiac cycle, bulbar and suprabulbar internal carotid artery diameters, and common carotid artery intima-media thickness. The unaffected carotid artery in cases was compared with the carotid artery of the same side in controls. RESULTS: Common carotid artery relative diameter change was significantly higher in cases than controls, whereas other measurements were not significantly different between the groups. In multivariate analyses, the highest tertile of common carotid artery relative diameter change was associated with the risk of ICAD (OR, 10.0; 95% CI, 1.8 to 54.2; p = 0.002) CONCLUSION: An underlying arteriopathy, presumably related to an extracellular matrix defect, may be present in patients with spontaneous ICAD.

Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection.

OBJECTIVE: To evaluate the clinical course of aneurysms developed during extracranial internal carotid artery (ICA) dissection. BACKGROUND: Aneurysms developed during extracranial ICA dissection are detected angiographically in 5 to 40% of cervical artery dissections. The clinical and radiologic course of these aneurysms is not known, and it is not known how they should be treated. METHODS: Fifty-eight consecutive patients with extracranial ICA dissection were reviewed, and those with radiographically detectable dissecting aneurysm at the acute stage or during early follow-up were included in this study. All patients had regular clinical and MR angiography examinations. Sixteen patients (27.5%) with a total of 20 ICA dissecting aneurysms were followed for a mean period of 36.9+/-21 months (range, 10 to 93 months). RESULTS: No clinical symptoms suggestive of aneurysmal rupture or embolization from the aneurysm were identified. Extracranial ICA aneurysms remained unchanged in 65% of patients, were resolved in 5% of patients, and decreased in size in 30% of patients. CONCLUSIONS: The clinical course of dissecting aneurysms was benign, although spontaneous radiologic resolution occurred rarely. Medical management with antiplatelet therapy alone (after early anticoagulation) is generally sufficient, and surgical management was seldom required.

Migraine and the risk of cervical artery dissection: a case-control study.

The association between migraine and cervical artery dissection (CAD) was explored in a hospital-based case-control study. Migraine was present in 49.1% (23/47) of patients with CAD and in 21% (11/52) of patients hospitalized for a cerebral ischemic event not related to a CAD (adjusted odds ratio = 3.6; 1.5 to 8.6, p = 0.005). This result supports the hypothesis that an underlying arterial wall disease could be a predisposing condition for migraine.

Internal carotid artery dissection: an update.

Carotid artery dissection is a major cause of cerebral infarction in the young. The extracranial portion of the internal carotid artery is much more frequently involved than the intracranial portion. In up to 20% of cases it is bilateral or associated with vertebral artery dissection. It is mainly characterised by local signs such as headache or facial pain, Horner's syndrome, lower cranial nerve palsies and pulsatile tinnitus, followed a few hours or days later by signs of cerebral or retinal ischemia. Ultrasound investigations show signs of distal stenosis or occlusion, highly suggestive of dissection, but the best diagnostic tool is presently the association of magnetic resonance imaging (MRI) and MR angiography which tend to replace intra-arterial angiography. The prognosis is highly variable: excellent in cases limited to local signs, but very poor leading to death or major sequelae in about 15% of cases. Various treatments have been suggested but no controlled trial has ever been performed in this condition. Heparin in the acute stage followed by warfarin or aspirin for 3 to 6 months is most commonly used.

[Progressive multifocal leukoencephalopathy and pulmonary sarcoidosis]. / Leucoencéphalopathie multifocale progressive et sarcoïdose pulmonaire.

An association of progressive multifocal leukoencephalopathy (PML) and sarcoidosis in a 47 year-old-woman is reported. This is the third case in which PML has been diagnosed by PCR. Clinical, biological and radiological features were in agreement with previous findings in immunologically suppressed patients. JC virus should be systematically detected by PCR in blood and cerebrospinal fluid (CSF) in patients with sarcoidosis presenting neurological and radiological PML manifestations.