First-ever acute ischemic strokes in HIV-infected persons: A case-control study from stroke units.

OBJECTIVE: The stroke risk for persons living with human immunodeficiency virus (PLHIVs) doubled compared to uninfected individuals. Stroke-unit (SU)-access, acute reperfusion therapy-use and outcome data on PLHIVs admitted for acute ischemic stroke (AIS) are scarce. METHODS: AIS patients admitted (01 January 2017 to 31 January 2021) to 10 representative Paris-area SUs were screened retrospectively from the National Hospitalization Database. PLHIVs were compared to age-, initial NIHSS- and sex-matched HIV-uninfected controls (HUCs). Outcome was the 90-day modified Rankin Scale score. RESULTS: Among 126 PLHIVs with confirmed first-ever AIS, ~80% were admitted outside the thrombolysis-administration window. Despite antiretrovirals, uncontrolled plasma HIV loads exceeded 50 copies/mL (26% of all PLHIVs; 38% of those ≤55 years). PLHIVs' stroke causes by decreasing frequency were large artery atherosclerosis (LAA), undetermined, other cause, cerebral small-vessel disease (CSVD) or cardioembolism. No stroke etiology was associated with HIV duration or detectable HIVemia. MRI revealed previously unknown AIS in one in three PLHIVs, twice the HUC rate (p = 0.006). Neither group had optimally controlled modifiable cardiovascular risk factors (CVRFs): 20%-30% without specific hypertension, diabetes, and/or dyslipidemia treatments. Their stroke outcomes were comparable. Multivariable analyses retained good prognosis associated solely with initial NIHSS or reperfusion therapy. Older age and hypertension were associated with CSVD/LAA for all PLHIVs. Standard neurovascular care and reperfusion therapy were well-tolerated. INTERPRETATION: The high uncontrolled HIV-infection rate and suboptimal CVRF treatment support heightened vigilance to counter suboptimal HIV suppression and antiretroviral adherence, and improve CVRF prevention, mainly for younger PLHIVs. Those preventive, routine measures could lower PLHIVs' AIS risk.

Cathodal Transcranial Direct Current Stimulation in Acute Ischemic Stroke: Pilot Randomized Controlled Trial.

Background and Purpose: In acute stroke, preventing infarct growth until complete recanalization occurs is a promising approach as an adjunct to reperfusion therapies to reduce infarct size and improve outcome. In rodent models, cathodal transcranial direct current stimulation (C-tDCS) decreases peri-infarct depolarizations and reduces infarct volume. We hypothesized that C-tDCS would nonpharmacologically reduce infarct growth in hyperacute middle cerebral artery territory stroke patients receiving reperfusion therapy. Methods: STICA (Cathodal Transcranial Direct Stimulation in Acute Middle Cerebral Artery Stroke) was a pilot single-center, double-blind, 2-arms 1:1 randomized trial evaluating the safety, feasibility, and efficacy of C-tDCS versus sham stimulation in patients eligible for recanalization therapies. Magnetic resonance imaging was obtained both on admission and 24 hours later. The primary end point was 24-hour infarct growth. Secondary outcomes were (1) National Institutes of Health Stroke Scale score difference between day 7 and admission and (2) 3-month modified Rankin Scale score. Results: Forty-five patients were randomized. Median magnetic resonance imaging-to-C-tDCS start time was 45 minutes; C-tDCS was started before completion of recanalization procedure in all patients. The intervention proved feasible in all patients. No major adverse effects occurred in either group. There was no significant difference between active and sham groups for any end point. However, an apparent trend towards smaller infarct growth in the C-tDCS arm was observed in the whole group (unadjusted median difference [IC95%]: −2.2 mL [−12.2 to 1.5]) and in the prespecified subsamples with moderate-to-severe stroke and large vessel occlusion (−5.7 mL [−21.6 to 2.6] and −7.7 mL [−24.2 to 2.6], respectively). Conclusions: C-tDCS was feasible and well tolerated. No significant difference was found between the active and sham groups. However, the data suggest potential benefits of C-tDCS in patients with National Institutes of Health Stroke Scale score of >10 or large vessel occlusion. Using the observed effect size and standard α=5% and ß=20%, samples of 102 and 86, respectively, can be estimated for future trials in patients with these characteristics. Randomized trials particularly targeting these populations may be warranted.

Cervical Artery Dissection in Young Women: Risk of Recurrence During Subsequent Pregnancies.

OBJECTIVES: To assess the risk of recurrence of cervical artery dissection (CAD) during pregnancy and puerperium in women with a history of CAD and then help physicians with providing medical information to women who wish to become pregnant. METHODS: Women aged 16-45 years who were admitted to our center for a CAD between 2005 and 2017 were identified from the hospital database, and those with spontaneous and symptomatic CAD were included. They were then contacted to answer a questionnaire that was specifically designed in regard to the recurrence of CAD and pregnancies after the primary CAD. RESULTS: Ninety-one patients satisfied our inclusion criteria, and 89 were included in the analysis. During a median follow-up of 7.0 years, 4 women (4.4%) had recurrent CAD, although none during pregnancy or puerperium. Eighteen women (20%) had a total of 20 full-term pregnancies, occurring at least 6 months after CAD. Of these 20 pregnancies, 13 (65%) were vaginal deliveries, and 7 (35%) were cesarean sections. The reason for the absence of pregnancies after the initial CAD was unrelated to the vascular event in 89% of cases, but 8% of the women had been advised by a physician to avoid any future pregnancy or they had been recommended to undergo abortion or sterilization. CONCLUSION: In this study, there were no CAD recurrences during subsequent pregnancies or postpartum, irrespective of the type of delivery. Thus, pregnancy after a history of CAD appears to be safe.

Acute ischemic stroke in adolescents.

OBJECTIVE: Adolescence represents a transition period between childhood and adulthood, and only limited information exists about stroke characteristics in this population. Our aim was to describe the clinical and neuroradiologic features, etiologies, initial management, and outcome of ischemic stroke in adolescents. METHODS: This retrospective cohort study evaluated all consecutive patients 10 to 18 years with a first-ever ischemic stroke hospitalized between 2007 and 2017 in 10 French academic centers representing a population of ≈10 million. Extracted data from the national database served as validation. RESULTS: A total of 60 patients were included (53% male, median age 15.2 years). Diagnosis at first medical contact was misevaluated in 36%, more frequently in posterior than anterior circulation strokes (55% vs 20% respectively, odds ratio 4.8, 95% confidence interval 1.41-16.40, p = 0.01). Recanalization treatment rate was high (n = 19, 32%): IV thrombolysis (17%), endovascular therapy (11.7%), or both IV and intra-arterial thrombolysis (3.3%); safety was good (only 1 asymptomatic hemorrhagic transformation). Despite thorough etiologic workup, 50% of strokes remained cryptogenic. The most common determined etiologies were cardioembolism (15%), vasculitis and autoimmune disorders (12%, occurring exclusively in female patients), and arterial dissections (10%, exclusively in male patients). Recurrent ischemic cerebrovascular events occurred in 12% (median follow-up 19 months). Recurrence rate was 50% in patients with identified vasculopathy but 0% after cryptogenic stroke. Functional outcome was favorable (Rankin Scale score 0-2 at day 90) in 80% of cases. CONCLUSIONS: Ischemic strokes in adolescents harbor both pediatric and adult features, emphasizing the need for multidisciplinary collaboration in their management. Recanalization treatments appear feasible and safe.

Individual recovery profiles of manual dexterity, and relation to corticospinal lesion load and excitability after stroke -a longitudinal pilot study.

OBJECTIVES: In this longitudinal pilot study, we investigated how manual dexterity recovery was related to corticospinal tract (CST) injury and excitability, in six patients undergoing conventional rehabilitation. METHODS: Key components of manual dexterity, namely finger force control, finger tapping rate and independence of finger movements, were quantified. Structural MRI was obtained to calculate CST lesion load. CST excitability was assessed by measuring rest motor threshold (RMT) and the amplitude of motor evoked potentials (MEPs) using transcranial magnetic stimulation (TMS). Measurements were obtained at two weeks, three and six months post-stroke. RESULTS: At six months post-stroke, complete recovery of hand gross motor impairment (i.e., maximal Fugl-Meyer score for hand) had occurred in three patients and four patients had recovered ability to accurately control finger force. However, tapping rate and independence of finger movements remained impaired in all six patients at six months. Recovery in hand gross motor impairment and finger force control occurred in patients with smaller CST lesion load and almost complete recovery of CST excitability, although RMT or MEP size remained slightly altered in the stroke-affected hemisphere compared to the unaffected hemisphere. The two patients with poorest recovery showed persistent absence of MEPs and greatest structural injury to CST. DISCUSSION: The findings support good motor recovery being overall correlated with smaller CST lesion, and with almost complete recovery of CST excitability. However, impairment of manual dexterity persisted despite recovery in gross hand movements and grasping abilities, suggesting involvement of additional brain structures for fine manual tasks.

Regional Pediatric Acute Stroke Protocol: Initial Experience During 3 Years and 13 Recanalization Treatments in Children.

BACKGROUND AND PURPOSE: To evaluate hyperacute management of pediatric arterial ischemic stroke, setting up dedicated management pathways is the first recommended step to prove the feasibility and safety of such treatments. A regional pediatric stroke alert protocol including 2 centers in the Paris-Ile-de-France area, France, was established. METHODS: Consecutive pediatric patients (28 days-18 years) with confirmed arterial ischemic stroke who had acute recanalization treatment (intravenous r-tPA [recombinant tissue-type plasminogen activator], endovascular procedure, or both) according to the regional pediatric stroke alert were retrospectively reviewed during a 40-month period. RESULTS: Thirteen children, aged 3.7 to 16.6 years, had recanalization treatment. Median time from onset to magnetic resonance imaging was 165 minutes (150-300); 9 out of 13 had large-vessel occlusion. Intravenous r-tPA was used in 11 out of 13 patients, with median time from onset to treatment of 240 minutes (178-270). Endovascular procedure was performed in patients time-out for intravenous r-tPA (n=2) or after intravenous r-tPA inefficiency (n=2). No intracranial or peripheral bleeding was reported. One patient died of malignant stroke; outcome was favorable in 11 out of 12 survivors (modified Rankin Scale score 0-2). CONCLUSIONS: Hyperacute recanalization treatment in pediatric stroke, relying on common protocols and adult/pediatric ward collaboration, is feasible. Larger systematic case collection is encouraged.

Impact of uterine balloon tamponade on the use of invasive procedures in severe postpartum hemorrhage.

INTRODUCTION: The aim of this study was to assess the impact of tamponade when uterotonic agents fail, on the need for surgery or interventional radiology. MATERIAL AND METHODS: All women who received sulprostone for postpartum hemorrhage were retrospectively compared over two periods [December 2008 to December 2010 without use of tamponade (period 1) and June 2011 to June 2013 with use of tamponade (period 2)] in the case of sulprostone failure (STROBE compliant retrospective cohort study). During period 2, interventional radiology or surgery was used only in the case of tamponade failure. RESULTS: 165 women were included (74 for period 1, 91 for period 2). The rate of interventional radiology or surgery significantly decreased from period 1 (21 of 74 women, 28.4%) to period 2 (six of 91 women, 6.6%, p = 0.0003). The rate of assumed failure of uterotonic agents was higher for period 2: 22 of 74 women (29.7%) during period 1, and 41 of 91 (45.1%, p = 0.0439) during period 2. The success rate of tamponade was 92.1% (35 of 38 women). CONCLUSIONS: Although the efficacy of tamponade should be viewed in the light of its widespread use, our findings confirm that tamponade significantly reduces the need for interventional radiology or surgery for postpartum hemorrhage treatment.

AMOBES (Active Mobility Very Early After Stroke): A Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Intensive physical therapy (PT) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control. METHODS: This multicentre randomized controlled trial compared soft PT (20-min/d apart from respiratory needs) and intensive PT (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (D) 90 and D0 assessed by the Fugl-Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. All analyses were by intent to treat. RESULTS: We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59-77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl-Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12-40) and 22.0 (12-56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria. CONCLUSIONS: Very early after stroke, intensive exercises may not be efficient in improving motor control. This conclusion may apply to mainly severe stroke. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01520636.

Cost-effectiveness analysis of epilepsy surgery in a controlled cohort of adult patients with intractable partial epilepsy: A 5-year follow-up study.

OBJECTIVE: Despite its well-known effectiveness, the cost-effectiveness of epilepsy surgery has never been demonstrated in France. We compared cost-effectiveness between resective surgery and medical therapy in a controlled cohort of adult patients with partial intractable epilepsy. METHODS: A prospective cohort of adult patients with surgically remediable and medically intractable partial epilepsy was followed over 5 years in the 15 French centers. Effectiveness was defined as 1 year without a seizure, based on the International League Against Epilepsy (ILAE) classification. Clinical outcomes and direct costs were compared between surgical and medical groups. Long-term direct costs and effectiveness were extrapolated over the patients' lifetimes with a Monte-Carlo simulation using a Markov model, and an incremental cost-effectiveness ratio (ICER) was computed. Indirect costs were also evaluated. RESULTS: Among the 289 enrolled surgery candidates, 207 were operable-119 in the surgical group and 88 in the medical group-65 were not operable and not analyzed here, 7 were finally not eligible, and 10 were not followed. The proportion of patients completely seizure-free during the last 12 months (ILAE class 1) was 69.0% in the operated group and 12.3% in the medical group during the second year (p < 0.001), and it was respectively 76.8% and 21% during the fifth year (p < 0.001). Direct costs became significantly lower in the surgical group the third year after surgery, as a result of less antiepileptic drug use. The value of the discounted ICER was 10,406 (95% confidence interval [CI] 10,182-10,634) at 2 years and 2,630 (CI 95% 2,549-2,713) at 5 years. Surgery became cost-effective between 9 and 10 years after surgery, and even earlier if indirect costs were taken into account as well. SIGNIFICANCE: Our study suggests that in addition to being safe and effective, resective surgery of epilepsy is cost-effective in the medium term. It should therefore be considered earlier in the development of epilepsy.

Updated French guidelines for diagnosis and management of pelvic inflammatory disease.

BACKGROUND: Pelvic inflammatory disease (PID) is commonly encountered in clinical practice. OBJECTIVES: To provide up-to-date guidelines on management of PID. SEARCH STRATEGY: An initial search of the Cochrane database, PubMed, and Embase was performed using keywords related to PID to identify reports in any language published between January 1990 and January 2012, with an update in May 2015. SELECTION CRITERIA: All identified reports relevant to the areas of focus were included. DATA COLLECTION AND ANALYSIS: A level of evidence based on the quality of the data available was applied for each area of focus and used for the guidelines. MAIN RESULTS: PID must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade C). Pelvic ultrasonography is necessary to exclude tubo-ovarian abscess (grade B). Microbiological diagnosis requires vaginal and endocervical sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ofloxacin and metronidazole for 14days (grade B). Treatment of tubo-ovarian abscess is based on drainage if the collection measures more than 3cm (grade B), with combined ceftriaxone, metronidazole, and doxycycline for 14-21days. CONCLUSIONS: Current management of PID requires easily reproducible investigations and treatment, and thus can be applied worldwide.

Cyclosporine in acute ischemic stroke.

OBJECTIVES: We examined whether IV administration of cyclosporine in combination with thrombolysis might reduce cerebral infarct size. METHODS: Patients aged 18 to 85 years, presenting with an anterior-circulation stroke and eligible for thrombolytic therapy, were enrolled in this multicenter, single-blinded, controlled trial. Fifteen minutes after randomization, patients received either an IV bolus injection of 2.0 mg/kg cyclosporine (Sandimmune, Novartis) or placebo. The primary endpoint was infarct volume on MRI at 30 days. Secondary endpoints included infarct volume according to the site (proximal/distal) of arterial occlusion and recanalization after thrombolysis. RESULTS: From October 2009 to July 2013, 127 patients were enrolled. The primary endpoint was assessed in 110 of 127 patients. The reduction of infarct volume in the cyclosporine compared with the control group was overall not significant (21.8 mL [interquartile range, IQR 5.1, 69.2 mL] vs 28.8 mL [IQR 7.7, 95.0 mL], respectively; p = 0.18). However, in patients with proximal occlusion and effective recanalization, infarct volume was significantly reduced in the cyclosporine compared with the control group (14.9 mL [IQR 1.3, 23.2 mL] vs 48.3 mL [IQR 34.5, 118.2 mL], respectively; p = 0.009). CONCLUSIONS: Cyclosporine was generally not effective in reducing infarct size. However, a smaller infarct size was observed in patients with proximal cerebral artery occlusion and efficient recanalization. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that in patients with an acute anterior-circulation stroke, thrombolysis plus IV cyclosporine does not significantly decrease 30-day MRI infarct volume compared with thrombolysis alone.

Magnetic Resonance Imaging-DRAGON score: 3-month outcome prediction after intravenous thrombolysis for anterior circulation stroke.

BACKGROUND AND PURPOSE: The DRAGON score, which includes clinical and computed tomographic scan parameters, showed a high specificity to predict 3-month outcome in patients with acute ischemic stroke treated by intravenous tissue plasminogen activator. We adapted the score for patients undergoing MRI as the first-line diagnostic tool. METHODS: We reviewed patients with consecutive anterior circulation ischemic stroke treated ≤ 4.5 hour by intravenous tissue plasminogen activator between 2003 and 2012 in our center, where MRI is systematically implemented as first-line diagnostic work-up. We derived the MRI-DRAGON score keeping all clinical parameters of computed tomography-DRAGON (age, initial National Institutes of Health Stroke Scale and glucose level, prestroke handicap, onset to treatment time), and considering the following radiological variables: proximal middle cerebral artery occlusion on MR angiography instead of hyperdense middle cerebral artery sign, and diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI ASPECTS) ≤ 5 instead of early infarct signs on computed tomography. Poor 3-month outcome was defined as modified Rankin scale >2. We calculated c-statistics as a measure of predictive ability and performed an internal cross-validation. RESULTS: Two hundred twenty-eight patients were included. Poor outcome was observed in 98 (43%) patients and was significantly associated with all parameters of the MRI-DRAGON score in multivariate analysis, except for onset to treatment time (nonsignificant trend). The c-statistic was 0.83 (95% confidence interval, 0.78-0.88) for poor outcome prediction. All patients with a MRI-DRAGON score ≤ 2 (n=22) had a good outcome, whereas all patients with a score ≥ 8 (n=11) had a poor outcome. CONCLUSIONS: The MRI-DRAGON score is a simple tool to predict 3-month outcome in acute stroke patients screened by MRI then treated by intravenous tissue plasminogen activator and may help for therapeutic decision.

[Anticoagulant treatment in patients with atrial fibrillation, according to risk factors for stroke]. / Indication des anticoagulants dans la fibrillation auriculaire au regard du risque cérébrovasculaire.

Atrial fibrillation (AF) is a common and serious condition in the elderly, concerning about 10% of people over 80. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Approximately 15% of patients admitted for ischemic stroke have AF and the proportion increases with age, reaching about 40% in people over 80. Compared to patients with stroke unrelated to AF, patients with AF-associated stroke suffer from more severe strokes with an increased risk of remaining disabled after the event and have a higher risk of stroke recurrence. Although most ischemic strokes in AF patients are probably cardioembolic, due to migration of thrombi originating from the left atrial appendage, many elderly patients will be found to have other potential causes of stroke, such as extracranial or intracranial atherosclerotic stenosis, aortic arch atheroma, or small vessel disease. The absolute risk of stroke in patients with AF varies widely depending on associated risk factors, the most important being age over 75 and previous stroke or transient ischemic attack. Several scoring systems have been developed to help clinicians estimate the stroke risk on an individual basis and to guide the choice of the most appropriate preventive therapy. The management of AF in the elderly should involve a detailed evaluation of the patient's functional status and social situation. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. The benefits of VKAs have been largely shown in patients with AF and appear to be even more important among elderly people. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal and cognitive functions.

Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial.

BACKGROUND: Hemiplegia and hemiparesis are the most common deficits caused by stroke. A few small clinical trials suggest that fluoxetine enhances motor recovery but its clinical efficacy is unknown. We therefore aimed to investigate whether fluoxetine would enhance motor recovery if given soon after an ischaemic stroke to patients who have motor deficits. METHODS: In this double-blind, placebo-controlled trial, patients from nine stroke centres in France who had ischaemic stroke and hemiplegia or hemiparesis, had Fugl-Meyer motor scale (FMMS) scores of 55 or less, and were aged between 18 years and 85 years were eligible for inclusion. Patients were randomly assigned, using a computer random-number generator, in a 1:1 ratio to fluoxetine (20 mg once per day, orally) or placebo for 3 months starting 5-10 days after the onset of stroke. All patients had physiotherapy. The primary outcome measure was the change on the FMMS between day 0 and day 90 after the start of the study drug. Participants, carers, and physicians assessing the outcome were masked to group assignment. Analysis was of all patients for whom data were available (full analysis set). This trial is registered with ClinicalTrials.gov, number NCT00657163. FINDINGS: 118 patients were randomly assigned to fluoxetine (n=59) or placebo (n=59), and 113 were included in the analysis (57 in the fluoxetine group and 56 in the placebo group). Two patients died before day 90 and three withdrew from the study. FMMS improvement at day 90 was significantly greater in the fluoxetine group (adjusted mean 34·0 points [95% CI 29·7-38·4]) than in the placebo group (24·3 points [19·9-28·7]; p=0·003). The main adverse events in the fluoxetine and placebo groups were hyponatraemia (two [4%] vs two [4%]), transient digestive disorders including nausea, diarrhoea, and abdominal pain (14 [25%] vs six [11%]), hepatic enzyme disorders (five [9%] vs ten [18%]), psychiatric disorders (three [5%] vs four [7%]), insomnia (19 [33%] vs 20 [36%]), and partial seizure (one [<1%] vs 0). INTERPRETATION: In patients with ischaemic stroke and moderate to severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after 3 months. Modulation of spontaneous brain plasticity by drugs is a promising pathway for treatment of patients with ischaemic stroke and moderate to severe motor deficit. FUNDING: Public French National Programme for Clinical Research.

MR imaging helps predict time from symptom onset in patients with acute stroke: implications for patients with unknown onset time.

PURPOSE: To assess the value of magnetic resonance (MR) imaging parameters as surrogate markers of stroke duration. MATERIALS AND METHODS: The study was approved by the Ethics Committee of Ile de France III and was found to conform to generally accepted scientific principles and ethical standards. The authors studied 130 patients with acute stroke of known onset time who underwent 1.5-T MR imaging within 12 hours of the onset of stroke symptoms. Fluid-attenuated inversion recovery (FLAIR), diffusion-weighted (DW) imaging, and apparent diffusion coefficient (ADC) ratios were computed by using three-dimensional regions of interest to outline signal intensity changes on DW images and then projecting them onto the contralateral hemisphere. Imaging ratios in 63 patients who underwent imaging 0-3 hours after symptom onset were compared with those in 67 patients who underwent imaging more than 3 hours after onset by using the Student t test and receiver operating characteristic curves. The accuracy (sensitivity, specificity, and 95% confidence intervals [CIs]) of lesion visibility on FLAIR images in the prediction of a stroke onset time of less than 3 hours was assessed by two independent observers. RESULTS: Differences in imaging ratios between patients imaged 0-3 hours after symptom onset and those imaged more than 3 hours after onset were statistically significant (P < .001). The FLAIR ratio showed a positive correlation with the time from symptom onset (Pearson correlation coefficient, 0.63). Receiver operating characteristic curves indicated that the FLAIR ratio could reliably identify patients imaged 0-3 hours after symptom onset, reaching 90% sensitivity (95% CI: 83%, 98%) and 93% specificity (95% CI: 86%, 99%) when using a 7% cutoff. Stroke imaged within 3 hours could also be identified by means of visual inspection of FLAIR and DW MR images, with 94% sensitivity (95% CI: 88%, 100%) and 97% specificity (95% CI: 93%, 101%). CONCLUSION: Signal intensity changes on 1.5-T FLAIR MR images can be used as a surrogate marker of stroke age, either qualitatively or quantitatively. This suggests that MR imaging might be used as a "clock" for determining stroke age in patients with an unknown onset time, potentially increasing the number of patients who are eligible for thrombolysis.

Management and outcome of patients with transient ischemic attack admitted to a stroke unit.

BACKGROUND: The way in which patients with transient ischemic attack (TIA) are investigated and treated varies substantially worldwide. There are no data on the management and outcome of TIA patients admitted to a stroke unit. We assessed to what extent rapid management of TIA patients admitted to a stroke unit led to specific treatments which can prevent stroke and evaluated the early risk and predictors of stroke in these patients. METHODS: From January 2003 to November 2005, 203 consecutive patients with a recent (<48 h) TIA were admitted to our stroke unit. All patients had a diffusion-weighted imaging (DWI) on admission, a standardized etiological workup, and were followed up to 3 months. RESULTS: The median (interquartile range) time from TIA onset to admission to the stroke unit was 12 h (5-25). DWI revealed acute lesions in 64 patients (32%). Of the 203 patients, 147 (72%) were treated by antiplatelet therapy and 56 (28%) with high doses of heparin, soon after their admission. In addition, 7 patients (3%) had a carotid revascularization. The risk of stroke was 2.5% (95% CI, 0.3-4.7) at 1 week, and 3.5% (1.0-6.1) at 3 months. In multivariate analysis, a score > or =5 at the previously validated ABCD score (HR = 5.0; 1.0-25.8; p = 0.06) and the presence of DWI abnormalities (HR = 10.3; 1.2-86.7; p = 0.03) were independent predictors of stroke at 3 months. CONCLUSION: Early management of TIA in a stroke unit leads to specific treatments in a significant proportion of cases. The presence of acute lesions on DWI and the ABCD score predict the 3-month risk of stroke after TIA.

Reversible cerebral angiopathy: efficacy of nimodipine.

Reversible cerebral angiopathy (RCA) is responsible for disabling headache and potential stroke complications. Most patients respond poorly to analgesics. We describe four patients with typical RCA whose headache rapidly disappeared after IV nimodipine treatment was initiated.

[Brain imaging patterns after stroke]. / Ischémie cérébrale: quelle imagerie et quel bilan etioloqique?

The advent of new imaging techniques, such as diffusion-weighted sequences, has a great impact on the diagnostic imaging in stroke. The aim of the present paper is to review the brain imaging patterns after stroke, highlight the usefulness of imaging technique for the diagnosis and etiological work-up after stroke. Three causes of ischemic stroke (cerebral venous thrombosis, aortic arch atheroma, patent foramen ovale) are detailed.