[Management of ischemic stroke in the acute phase]. / Prise en charge de l'infarctus cérébral à la phase initiale.

Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.

[Acute management of spontaneous intracerebral hemorrhage]. / Prise en charge aiguë des hémorragies intracérébrales spontanées.

Intracerebral hemorrhage accounts for approximately 15% of the 115,000 strokes occurring each year in France. Although therapeutic strategies are more limited than for ischemic stroke, major points in the management of intracerebral hemorrhage can reduce short term morbidity and mortality by limiting the expansion of the hematoma and the occurrence of early complications, and long term patients' outcome by reducing the risk of recurrence. This article aims to update the key elements that contribute to improve of the prognosis of intracerebral hemorrhage patients.

Clinical features of pain in amyotrophic lateral sclerosis: A clinical challenge.

Pain in amyotrophic lateral sclerosis (ALS) is paradoxical in this disease of the upper and lower motor neurons. As such, it remains an underestimated and neglected clinical problem because it is poorly identified by physicians, its mechanisms are numerous and its treatments are generally not effective. Pain may be primary in the form of cramps, spasticity and neuropathy, or secondary as nociceptive pain, and may arise before the first motor symptoms. It may also lead to depression and, in all cases, affect patients' daily activities and quality of life. Given the high frequency of pain in ALS, the use of analgesic or sedative drugs is necessary and should reduce the course of the disease. Nevertheless, it is important to understand the pathophysiological mechanisms of pain in ALS, and to train physicians how to detect ALS pain early on and provide dedicated treatments. In France, the implementation of ALS centers is a positive response to the public-health problem resulting from this disorder.

Pain after stroke: A review.

Pain after stroke (PAS) is a common clinical problem that is both underdiagnosed and undertreated. Yet, it induces depression and cognitive troubles, and impairs quality of life. To provide tools for practitioners, this report describes the most common PAS syndromes, including central post-stroke pain, spasticity and contractures, shoulder pain and complex regional pain syndromes, as well as headache and chondrocalcinosis, along with their risk factors, their prevention and their specific treatments. In addition, to ensure that the compulsory post-stroke clinical assessment in France is optimal, it is recommended that clinicians be trained in how to diagnose and treat PAS, and even to prevent it by early identification of at-risk patients, with the aim to improve patients' motor and cognitive functions and quality of life.

[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.

Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety.

BACKGROUND: In the context of the development of telemedicine in France to address low thrombolysis rates and limited stroke infrastructures, a star-shaped telestroke network was implemented in Burgundy (1.6 million inhabitants). We evaluated the safety and effectiveness of this network for thrombolysis in acute ischemic stroke patients. METHODS: One hundred and thirty-two consecutive patients who received intravenous thrombolysis during a telemedicine procedure (2012-2014) and 222 consecutive patients who were treated at the stroke center of Dijon University Hospital, France (2011-2012) were included. Main outcomes were the modified Rankin scale (mRS) score and case fatality at 3 months. Comparisons between groups were made using multivariable ordinal logistic regression and logistic regression analyses, respectively. RESULTS: Baseline characteristics of telethrombolysis patients were similar to those of patients undergoing thrombolysis locally except for a higher frequency of previous cancer and pre-morbid handicap, and a trend towards greater severity at admission in the former. The distribution of mRS scores at 3 months was similar between groups, as were case-fatality rates (18.9% in the telethrombolysis group versus 16.5%, P = 0.56). In multivariable models, telethrombolysis did not independently influence functional outcomes at 3 months (odds ratio for a shift towards a worse outcome on the mRS, 1.11; 95% confidence interval, 0.74-1.66, P = 0.62) or death (odds ratio, 0.86; 95% confidence interval, 0.44-1.69, P = 0.66). CONCLUSION: The implementation of a regional telemedicine network for the management of acute ischemic stroke appeared to be effective and safe. Thanks to this network, the proportion of patients who benefit from thrombolysis will increase. Further research is needed to evaluate economic benefits.

[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.

Stroke care organization overcomes the deleterious 'weekend effect' on 1-month stroke mortality: a population-based study.

BACKGROUND AND PURPOSE: Suffering a stroke during the weekend is associated with a poorer prognosis. The impact of implementing a dedicated stroke care network in Dijon, France, in 2003 on 30-day mortality in strokes/transient ischaemic attacks (TIA) occurring during weekends/bank holidays was evaluated. METHODS: All cases of stroke and TIA from 1985 to 2010 were identified from a population-based registry, using multiple overlapping sources of information. Demographics and clinical data were recorded. Cox regression models were used to evaluate associations between day of onset (weekdays versus weekends/bank holidays) and 30-day all-cause mortality. Data were stratified according to time periods [before (1985-2003) and after (2004-2010) implementation of the stroke network] and stroke subtypes (ischaemic stroke and intracerebral hemorrhage). RESULTS: Of the 5864 recorded patients, 1465 (25%) had their event during weekends/bank holidays. Patients with stroke/TIA during weekdays were comparable with those with stroke/TIA during weekends/bank holidays for baseline characteristics. Excess mortality was observed in patients with stroke/TIA during weekends/bank holidays during 1985-2003 (18.2% vs. 14.0%, P < 0.01) but not during 2004-2010 (8.4% vs. 8.3%, P = 0.74). Onset during weekends/bank holidays was associated with a higher risk of 30-day mortality during 1985-2003 (adjusted hazard ratio 1.26; 95% CI 1.06-1.51, P = 0.01), but not during 2004-2010 (adjusted hazard ratio 0.99; 95% CI 0.69-1.43, P = 0.97). CONCLUSION: The deleterious effect of weekends/bank holidays on early stroke mortality disappeared after the organization of a dedicated stroke care network in our community. Our findings provide strong support for the implementation of quality improvement initiatives in order to attenuate inequalities in the management of stroke patients.

Prestroke antiplatelet therapy and early prognosis in stroke patients: the Dijon Stroke Registry.

BACKGROUND AND PURPOSE: Previous antiplatelet therapy (APT) in cardiovascular prevention is common in patients with first-ever stroke. We aimed to evaluate the prognostic value of APT on early outcome in stroke patients. METHODS: All first-ever strokes from 1985 to 2011 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, prestroke treatments and clinical information were recorded. Multivariate analyses were performed to evaluate the associations between pre-admission APT and both severe handicap at discharge, and mortality at 1 month and 1 year. RESULTS: Among the 4275 patients, 870 (20.4%) were previously treated with APT. Severe handicap at discharge was noted in 233 (26.8%) APT users and in 974 (28.7%) non-users. Prestroke APT use was associated with lower odds of severe handicap at discharge [adjusted odds ratio (OR): 0.79; 95% confidence interval (CI): 063-1.00; P = 0.046], non-significant better survival at 1 month [adjusted hazard ratio (HR): 0.87; 95% CI: 0.70-1.09; P = 0.222] and no effect on 1-year mortality (HR: 0.94; 95% CI 0.80-1.10; P = 0.429). In stratum-specific analyses, APT was associated with a lower risk of 1-month mortality in patients with cardioembolic ischaemic stroke (HR: 0.65; 95% CI: 0.43-0.98; P = 0.040). CONCLUSIONS: APT before stroke was associated with less severe handicap at discharge, with no significant protective effect for mortality at 1 month except in patients with cardioembolic stroke. No protective effect of APT was observed for mortality at 1 year. Further studies are needed to understand the mechanisms underlying the distinct effects of prior APT observed across the ischaemic stroke subtypes.

Serum 25-hydroxyvitamin D predicts severity and prognosis in stroke patients.

BACKGROUND AND PURPOSE: We aimed to evaluate the association between 25-hydroxyvitamin D (25(OH)D) levels and both clinical severity at admission and outcome at discharge in stroke patients. METHODS: From February 2010 to December 2010, consecutive stroke patients admitted to the Department of Neurology of Dijon, France, were identified. Clinical information was collected. Serum concentration of 25(OH)D was measured at baseline. Stroke severity was assessed at admission using the NIHSS score. Functional impairment was evaluated at discharge using the modified Rankin scale (m-Rankin). Multivariate analyses were performed using logistic regression models. RESULTS: Of the 386 recorded patients, serum 25(OH)D levels were obtained in 382 (median value = 35.1 nM; IQR = 21-57.8). At admission, 208 patients had a NIHSS ≤5, with a higher mean 25(OH)D level than that observed in patients with moderate-to-high severity (45.9 vs. 38.6 nM, P < 0.001). In multivariate analyses, a 25(OH)D level in the lowest tertile (<25.7 nM) was a predictor of a NIHSS ≥6 (OR = 1.67; 95% CI = 1.05-2.68; P = 0.03). The mean 25(OH)D level was lower in patients with moderate-to-severe handicap at discharge (m-Rankin 3-6) than in patients with no or mild handicap (35.0 vs. 47.5 nM, P < 0.001). In multivariate analyses, the lowest tertile of 25(OH)D level (<25.7 nM) was associated with a higher risk of moderate-to-severe handicap (OR = 2.06; 95% CI = 1.06-3.94; P = 0.03). CONCLUSION: A low serum 25(OH)D level is a predictor of both severity at admission and poor early functional outcome in stroke patients. The underlying mechanisms of these associations remain to be investigated.

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.

One-year survival of demented stroke patients: data from the Dijon Stroke Registry, France (1985-2008).

BACKGROUND AND PURPOSE: Dementia is a frequent condition after stroke that may affect the prognosis of patients. Our aim was to determine whether post-stroke dementia was a predictor of 1-year case-fatality and to evaluate factors that could influence survival in demented stroke patients. METHODS: From 1985 to 2008, all first-ever strokes were recorded in the population-based stroke registry of Dijon, France (150, 000 inhabitants). Dementia was diagnosed during the first month following stroke, according to DSM-III and DSM-IV criteria. Survival was evaluated at 1 year and multivariate analyses were performed using Cox proportional hazards to identify independent predictive factors. RESULTS: We recorded 3948 first-ever strokes. Among these stroke patients, 3201 (81%) were testable, and of these, 653 (20.4%) had post-stroke dementia (337 women and 316 men). Demented patients had lower 1-year survival than patients without dementia (82.9% vs. 86.9%, P = 0.013). However, in multivariate analysis, dementia did not appear as an independent predictor of 1-year death. In demented stroke patients, age >80 years old, severe handicap at discharge, recurrent stroke within the first year and subarachnoid haemorrhage were associated with a higher risk of 1-year death, and the risk was lower in the study period 2003-2008. CONCLUSIONS: Dementia after stroke is not independently associated with an increased risk of death at 1 year. In recent years, 1-year case-fatality decreased in demented as well as in and non-demented patients suggesting that improvements in the management of stroke also benefited the most fragile patients.

Comparative epidemiology of stroke and acute myocardial infarction: the Dijon Vascular project (Diva).

BACKGROUND: Despite a common pathophysiological mechanism (ie, atherosclerosis) and similar vascular risk factors, few reliable studies have compared the epidemiology of stroke and acute myocardial infarction (AMI). METHODS: All first ever cases of stroke and AMI in Dijon, France (151 846 inhabitants) from 2001 to 2006 were prospectively recorded. The 30 day case fatality rates (CFRs) and vascular risk factors were assessed in both groups. RESULTS: Over the 6 years, 1660 events (1020 strokes and 640 AMI) were recorded. Crude incidence of stroke was higher than that of AMI (112 vs 70.2/100 000/year; p<0.001). With regard to sex, the relative incidence of stroke compared with AMI was 0.88 (95% CI 0.60 to 1.29; p = 0.51) in women <65 years and 2.32 (95% CI 1.95 to 2.75; p<0.001) in those >65 years whereas it was 0.60 (95% CI 0.42 to 0.86; p<0.001) in men below 55 years, 1.01 (0.81 to 1.24, p = 0.96) in those between 55 and 75 years and 2.01 (95% CI 1.48 to 2.71; p<0.001) at 75 years and older. CFRs at 30 days were similar for stroke and AMI (9.80% vs 9.84%; p = 0.5). Hyperglycaemia (>7.8 mmol/l) at onset was significantly associated with higher CFR in both stroke and AMI patients. The prevalence of male sex, hypercholesterolaemia and diabetes was higher in AMI patients whereas hypertension was more frequent in stroke patients. CONCLUSION: These findings will help health care authorities to evaluate future needs for stroke and AMI services, and to develop secondary prevention strategies.

[What has changed for stroke at the beginning of the 21st century]. / Les accidents vasculaires cérébraux : ce qui a changé au début du xxi(e) siècle.

INTRODUCTION: Striking developments in stroke epidemiology, initially based on the results of the Framingham study, have greatly improved our neuroepidemiological knowledge of the disease. STATE OF ART: The development of stroke registries has made it possible to evaluate the descriptive epidemiology of stroke and its evolution. With the increasing use of CT-scan, MRI, and either cardiac or vascular imaging, the diagnosis of stroke and its subtypes has been made easier. Over the last 20 years, a decrease in the incidence and mortality of stroke has been observed in Western countries. In contrast, in Dijon, which has the only population-based stroke registry in France, stable incidence rates have been reported. However, over the same period, age at stroke onset has risen by five years in men and eight years in women, which is probably related to both population aging and improvements in primary prevention and general health. The reported decrease in case-fatality rates suggests better acute management of stroke patients, and explains in part the increase in the prevalence of stroke. In addition, the assessment of vascular risk factors has demonstrated that high blood pressure remains the principal risk factor for both ischemic and hemorrhagic stroke, and that antihypertensive treatment is able to reduce stroke incidence. PERSPECTIVES: Epidemiology studies could make it possible to measure the impact of new therapeutic strategies applied in both primary and secondary prevention. CONCLUSION: Prevention, diagnosis, and acute treatment of stroke have considerably improved, but cerebrovascular diseases together with myocardial infarction remain the leading cause of death. Despite the absence of a rise in the incidence of stroke, its prevalence has increased. This is due to the decrease in case-fatality rates. As a consequence, there is an urgent need to organize health networks around stroke. Moreover, the rise in stroke-free life expectancy is a positive finding that reflects improvements in prevention.

[Stroke in neonates and children]. / Les accidents vasculaires cérébraux du nouveau-né et de l'enfant.

The clinical presentation, risk factors, causes, vital or functional prognosis, and acute management options for stroke occurring in neonates and children are specific, differing from those observed in young adults. Compared with the adult population, less is known about the epidemiology of stroke in the under-18 population where the disease could become more frequent because of advances in both neonatal resuscitation techniques for cerebral disorders and neuroimaging techniques enabling the diagnosis of small lesions. Clinical features are often delayed, especially in neonates, and unlike epilepsy or dystonia of the affected limb, which are frequent complications, aphasia is rather rare. The most frequent causes of stroke at the beginning of life are cardiac embolism, for ischemic stroke, and arteriovenous malformations, for intracerebral hemorrhage. Acute management at this age is specific. This article reviews the literature on the epidemiological and clinical features, the main causes, and the acute management guidelines of stroke occurring in newborn infants and children and highlights the need for neurologists to have comprehensive knowledge of this disease.

Dijon's vanishing lead with regard to low incidence of stroke.

BACKGROUND: Towards the end of the 20th century, the city of Dijon, France, had a lower incidence of stroke than that found in other studies. It was hypothesized that genetic and environmental factors were responsible for this so-called French paradox. We aim to evaluate recent changes in stroke incidence to determine whether or not the Dijon exception still exists. METHODS: The population-based stroke registry of Dijon ascertained all first-ever strokes from 2000 to 2006. We calculated incidence to compare recent results with those obtained from a previous study period (1985-1999) and those of other population-based studies covering both the end of the 20th and the beginning of the 21st century. RESULTS: From 2000 to 2006, 1205 strokes were recorded. Crude and age-standardized incidence (to European and World population) rates were respectively 113, 107 and 72/100,000/year. No change was observed between 1985-1999 and 2000-2006, whereas other studies reported declining incidence. CONCLUSION: The incidence of stroke in Dijon remained lower than that found in similar studies, but the difference compared with results observed for the 20th century is shrinking. Therefore, the Dijon exception is decreasing, suggesting that it was rather an advance in prevention strategies that has diminished.

Epidemiology of ischemic stroke from atrial fibrillation in Dijon, France, from 1985 to 2006.

BACKGROUND: Atrial fibrillation (AF) is strongly associated with age, and epidemiologic studies are needed to evaluate the impact of both aging of the population and the use of anticoagulant therapy in patients with AF on the incidence of cardioembolic stroke with AF (CE/AF stroke). METHODS: We evaluated trends in incidence rates, risk factors, prestroke therapy, and survival in CE/AF stroke from a prospective population-based registry, from 1985 to 2006. RESULTS: A total of 3,064 ischemic strokes, including 572 (18.7%) CE/AF strokes, were recorded. Over the 22 years, a decrease in the incidence of overall CE/AF stroke was noted (incidence rate ratio 0.9858, 95% confidence interval [CI] 0.9731-0.9986; p = 0.03). We observed a higher prevalence of previous AF, previous myocardial infarction, and patients aged >70 years in CE/AF stroke (p < 0.0001) whereas hypercholesterolemia was more prevalent in other ischemic strokes (p = 0.003). A significant increase in the use of anticoagulants and antiplatelet agents was noted, and was particularly pronounced for CE/AF stroke with previous AF. For CE/AF stroke, survival rates were 72% at 1 month (95% CI 0.68-0.76), 52% at 1 year (95% CI 0.48-0.56), and 43% at 2 years (95% CI 0.39-0.48), and remained lower than those of other ischemic stroke. CONCLUSIONS: The decrease in the incidence of cardioembolic/atrial fibrillation stroke in our study was probably due to a slight increase in the utilization of antithrombotic therapy in patients with atrial fibrillation, but the use of such therapies will have to increase further because of the expected aging of the population in coming years.

[Stroke in elderly: what have we learned from stroke epidemiology in younger people]. / Les accidents vasculaires cérébraux du sujet âgé : ce que nous a appris l'épidémiologie du sujet jeune.

Stroke in the elderly has more major differences compared to young people: it is the first complication of atherothrombosis disease associated with the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption and sleep apnea syndrome; AVC is the first consequence of atrial fibrillation; from a clinical point of view, seizure at the onset of the stroke is more frequent; prognosis is characterized by a high risk of dementia (20%); primary and secondary prevention is very efficacious even in very old patients, not only on the risk of stroke, but also on the risk of dementia; time trends at Dijon show a slight decrease of incidence rates of stroke only over 85 years, while prevention of stroke has taken advantage of real progress in precocious diagnosis and innovative treatments. In contrast, we observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke, reaching five years in men and eight years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention.