Prospective observational study of stroke in Cayenne, Tours and Besançon: The BECATOUR study

BACKGROUND

Stroke is a major public health issue. Its epidemiology is still poorly known in French Guiana.

METHOD

We conducted a prospective observational study including 100 consecutive patients hospitalized for stroke in Cayenne (in French Guiana), and Tours and Besançon (in metropolitan France). We compared their age, medical history, cardiovascular risk factors, pre-admission Rankin score, Glasgow and NIHSS scores, usual treatments, acute phase management, type of stroke, duration of hospitalization, mechanism of stroke according to TOAST classification, NIHSS and Rankin scores at discharge, discharge treatments, and mode of discharge.

RESULTS

In French Guiana, the average age of patients was 7years lower (62 y), patients were more frequently affected by hypertension (75%) and diabetes (31%). Lacunar strokes were overrepresented (16.1%), and infarctions of cardioembolic origin were underrepresented (12%). NIHSS entry and Glasgow scores were similar between French Guiana and mainland France. Acute management was different: thrombolysis rate (9.3%) was 3 to 4 times lower, thrombectomy was not available. Fewer patients were transferred to rehabilitation centers and more patients were transferred to home hospitalization.

DISCUSSION

In Tours and Besançon, patients eligible for thrombectomy were overrepresented. This bias explains the overrepresentation of more severe infarctions and probably the overrepresentation of strokes of cardioembolic origin. Infarctions of undetermined origin were more numerous in French Guiana because patients were often discharged from hospital with an incomplete cardiological workup.

CONCLUSION

Despite some caveats, the profile of patients admitted for stroke in French Guiana is different from mainland France. The establishment of a stroke unit and an information campaign on the symptoms of stroke would allow better management.

Bonnes pratiques en matière de télémédecine

La télémédecine ou médecine à distance s’est imposée aux soignants à la faveur de la pandémie à SARS-Cov2. Elle doit être considérée comme un outil capable d’améliorer la pratique d’une médecine moderne. Ce texte en rappel les règles d’exercice et incite à en organiser l’enseignement.

Acute telestroke in France: A systematic review

BACKGROUND

Acute telestroke is the use of telemedicine to improve acute stroke care. It has demonstrated to be a safe and effective medical practice. Since 2011, acute telestroke has been promoted by the Ministry of Health in France, and in 2018 many regions were in the process or completion of implementing telestroke. The objective of this study was to describe acute telestroke implementation in France.

METHODS

A systematic review was conducted using PubMed and ScienceDirect databases. Articles and abstracts in English and French, published between January 1st, 2000 to April 30th, 2018 were used. Studies conducted in France and that had presented an outcome evaluation of a regional acute telestroke activity were included. No meta-analysis was conducted.

RESULTS

A total of 24 studies (14 in French, 10 in English) were included, with 13 published articles (7 indexed on PubMed) and 11 abstracts. Among the 13 published articles, there were seven observational retrospective studies, one quasi-experimental before-after study, one experimental randomised controlled trial, and four medico-economic studies. All telestroke network models of care were drip-and-ship with hub and spoke organisation. The case-control studies did not show a difference with or without telemedicine. The territorial thrombolysis rate was measured in two regions, with an increase in Franche-Comté from 0.2% (2004) to 9.9% (2015), and a relative increase of 76% in Nord-Pas-de-Calais between 2009-2010 and 2012.

CONCLUSION

Implementation of acute telestroke in France had a positive clinical and public health impact but the evaluation remained limited and needs to be supported.

National survey on telemedicine education and training among medical students and residents in France

Key messages

Telemedicine education and training should be provided to medical students and resident during their curriculum. Medical schools and residency programs need to integrate and apply telemedicine in their programs.

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.

Moya-Moya syndrome after cranial radiation for optic glioma with NF1. Case report and literature review of syndromic cases

INTRODUCTION

Moya-Moya angiopathy is a neurovascular disease that predisposes to ischemic or hemorrhagic strokes. It is generated by a steno-occlusion of the terminal portion of the internal carotid arteries, which induces the development of abnormal neovessels in the deep regions of the brain. Some pathologies such as sickle cell disease, Down syndrome or Graves' disease may be associated with Moya-Moya angiopathy. These syndromic forms harbor several differences compared with idiopathic Moya-Moya disease.

CASE REPORT

We report the case of a young patient who presented with a syndromic form of Moya-Moya angiopathy after cranial radiation therapy for an optic glioma associated with type 1 neurofibromatosis treated by combined revascularization. We discuss the particularities of syndromic forms, in their presentation and management based on a review of the literature.

CONCLUSION

Many diseases can be associated with Moya-Moya syndrome. Symptomatic patients should undergo surgery, but the risk of postoperative complications appears to be greater than that encountered in patients with non-syndromic Moya-Moya angiopathy.

Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening

OBJECTIVE

To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS).

METHODS

The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135).

RESULTS

Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09).

CONCLUSION

It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.

Protocol Design Challenges in the Detection of Awareness in Aware Subjects Using EEG Signals

Recent studies have evidenced serious difficulties in detecting covert awareness with electroencephalography-based techniques both in unresponsive patients and in healthy control subjects. This work reproduces the protocol design in two recent mental imagery studies with a larger group comprising 20 healthy volunteers. The main goal is assessing if modifications in the signal extraction techniques, training-testing/cross-validation routines, and hypotheses evoked in the statistical analysis, can provide solutions to the serious difficulties documented in the literature. The lack of robustness in the results advises for further search of alternative protocols more suitable for machine learning classification and of better performing signal treatment techniques. Specific recommendations are made using the findings in this work.

Advantages of susceptibility-weighted magnetic resonance sequences in the visualization of intravascular thrombi in acute ischemic stroke

BACKGROUND

In gradient echo magnetic resonance imaging (MRI), intravascular thrombi (IT) can appear as vascular susceptibility artifacts, linked to local presence of intra-arterial deoxyhaemoglobin, and called susceptibility vessel signs (SVS).

AIMS

Our objectives were to evaluate the sensitivity of susceptibility-weighted sequences, such as T2* weighted angiography (SWAN) in the visualization of SVS compared with T2*, to consider whether it enabled a better understanding of the importance of SVS, and to compare cerebral circulation regulation profiles according to the localization of the SVS (i.e. proximal or distal).

METHODS

We prospectively studied the clinical and imaging data of 78 consecutive patients admitted for acute cerebral ischemia to the stroke unit of Besançon University Hospital between 1 April 2009 and 31 January 2010.

RESULTS

An SVS was visualized in 44/78 (56%) patients using SWAN and in 13/78 (16%) patients using T2*. All the SVS visible using T2* were also visible on the SWAN. The inter-observer kappa score was 0·72 [CI (0·53-0·91)] for T2*, 0·72 [CI (0·57-0·87)] for SWAN, and weighted kappa was 0·77 [CI (0·61-0·92)] for both T2* and SWAN. When an MCA occlusion was visible on MRA imaging (22/78 patients), a SVS was visualized in 7/22 cases (31·8%) using T2* and in 20/22 cases (91%) using SWAN. When the occlusion was visible in the M1 or M2 segments (17/78 patients), an SVS was visualized in 6/17 cases (35·3%) using T2* and in 15/17 cases (88·2%) using SWAN. When the occlusion was visible in the M3 segment (5/78 patients), an SVS was visualized in 1/5 cases (20%) using T2* and in 5/5 cases (100%) using SWAN. Presence of SVS was not associated with cardioembolic etiology of the stroke.

CONCLUSIONS

SWAN was more sensitive than T2* in the visualization of SVS in the intracranial arteries during the acute phase of ischemic stroke. Our study shows that the low number of SVS visualized using T2* in previous studies is probably related to a lack of sensitivity of the sequence, rather than to the nature or age of the thrombus. The greater sensitivity of SWAN seems to be linked to the visualization of SVS in cases of small thrombi.

[Specific treatment for intracerebral hemorrhage. Experts' recommendations: stroke management in the intensive care unit]

Spontaneous intracerebral hemorrhages represent from 10 to 15% of strokes. They can be defined by the eruption of arterial blood within the cerebral parenchyma. Clinical signs are not specific and the diagnosis can only be made using brain imaging techniques (CT or magnetic resonance imaging). Management of intracerebral hemorrhage combines general measures (neurovascular intensive care unit, treatment of high blood pressure and of neurotoxic factors) with more specific measures including correction of coagulation abnormalities and, in some cases, neurosurgical treatment.

[Toxocara canis cerebral vasculitis revealed by iterative strokes]

INTRODUCTION

Cerebral vasculitis is a rare and severe condition, posing problems for diagnosis and treatment. Toxocara canis cerebral vasculitis is exceptionally rare, with only 4 cases having been reported. We report an additional case revealed by iterative strokes.

OBSERVATION

A 49-years-old Laotian man presented with right ACA infarction associated with contrast enhancement of cerebrospinal fluid, and multiple segmental stenoses in small and medium caliber encephalic arteries, in a context of hypereosinophilia and chronic headaches. Laboratory tests showed lymphocytic meningitis and T. canis antibody IgE in the blood and CSF. The diagnosis of T. canis cerebral vasculitis was retained. During follow-up, the patient presented again with left pontine hemorrhagic stroke. Conventional cerebral angiography confirmed progression of vasculitis despite treatment.

CONCLUSION

This case-report illustrates the diagnostic and therapeutic difficulties associated with vasculitis.

[Telemedicine and fibrinolysis in Franche-Comté]

INTRODUCTION

The aim of our study was to compare the efficacy and safety of intravenous thrombolysis of cerebral ischemia as it has been established in a distant hospital (DH) through telemedicine tools or in neurovascular unit of the University Hospital of Besançon.

METHOD

Our work was conducted retrospectively at the University Hospital of Besançon from 1 January 2003 to December 31, 2009.

RESULTS

Fibrinolysis was introduced at the university hospital in 98/161 patients (61%) and a DH in remote 63/161 patients (39%). A favorable neurological outcome (Rankin 0/1) was observed in 27/98 patients (27.5%) treated at University Hospital and in 25/63 (39.5%) patients in a DH. There was no significant difference between the two subgroups. Symptomatic hemorrhagic transformation occurred in 5/98 (5%) patients treated at University Hospital and in 1/63 (1.5%) patients treated in DH. There was no significant difference between the two subgroups.

CONCLUSION

Our study shows that fibrinolysis remotely using the tools of telemedicine has, from 2003 to 2009, in Franche-Comté deal effectively and without risk of a significant proportion of patients.

Time course of odorant- and trigeminal-induced activation in the human brain: an event-related functional magnetic resonance imaging study

It is well known that most odorants stimulate the trigeminal system but the time course of the brain regions activated by these chemical stimulations remains poorly documented, especially regarding the trigeminal system. This functional magnetic resonance imaging (fMRI) study compares brain activations resulting from the contrast between two odorant conditions (one bimodal odor and one relatively pure olfactory stimulant) according to the duration of the stimulation (i.e. one inhalation, or three or six successive inhalations). The results show striking differences in the main brain regions activated according to these durations. The caudate nucleus and the orbitofrontal cortex are only involved in short-duration stimulations, and the posterior insular cortex and post-central gyrus (SI) are only activated by long duration stimulations. Different regions of the frontal, temporal and occipital lobe are activated depending on the duration but mainly during medium-duration stimulations. These results expand on the findings of previous studies and contribute to the description of temporal networks in trigeminal perception.

[Cerebellar infarction]

Cerebellar infarction can be difficult to diagnose because the clinical picture is often dominated by fairly non-specific symptoms, which are more indicative of a benign condition. When cerebellar infarction affects the brainstem, the semiology is richer, and pure cerebellar signs are rendered less important. A perfect knowledge of the organisation of the cerebellar artery territories is required, regardless of the infarct topography. This knowledge is essential for making an accurate diagnosis, understanding the mechanisms and organising a treatment plan. Clinical algorithms for the treatment of dizziness, headaches and vomiting would improve the selection of candidates for brain imaging. Thus, the early identification of patients with a high risk of subsequent deterioration would lead to a better prognosis in cases of cerebellar artery territory infarction.

Pontomedullary sulcus infarct: a variant of lateral medullary syndrome

With the advent of magnetic resonance imaging (MRI) technology, it is now possible to identify and determine the precise location of medullary infarcts. The lateral part of the medulla is most commonly affected by infarction. Classifications of lateral medullary infarcts are usually based on anatomical data, using rostrocaudal and dorsoventral axes to establish correlations with clinical symptoms. Different subtypes of lateral medullary syndrome, depending on location, shape and size of the infarct, have been described in the literature. We report a rare case of a patient presenting with an unusual clinical picture in relation to an infarct specifically located in the lateral part of the pontomedullary sulcus.

[Fatal giant cell arteritis with severe bilateral involvement of the vertebral arteries]

With steroid therapy, it is commonly considered that prognosis is good in giant cell arteritis. However serious or even fatal complications may occur. Here we report the case of a patient who developed fatal giant cell arteritis with severe stenosis of both vertebral arteries and right carotid siphon. Several similar cases have been reported in the literature. Initially diagnosis may be difficult because neurological manifestations are intermittent and classical signs of giant cell arteritis may be lacking. In such condition the reason of poor outcome is unknown and therapy remains empiric.

Adaptive tele-application for remote neurology diagnosis

This paper presents the Collaborative Tele-Neurology (TeNeCi) project which allows practitioners to use telecommunication technologies to provide medical information and services for neurological diseases. Specificities of remote neurology are described and the Cooperative Application Framework (CAliF) multimedia platform on which TeNeCi relies is presented. The technical requirements of such a project in terms of communication and consistency management, audio and video transmissions, and network support, as well as implementation of TeNeCi was evaluated. The software used in this application is composed of several services, such as a Digital Imaging and Communications in Medicine (DICOM) explorer, a DICOM viewer, and a security service. Tests performed on this first TeNeCi release showed good results, and allowed us to explore a larger collaborative experimentation between hospitals in France and Switzerland.

[Diagnosis and follow-up of cervical arterial dissections--results of the SFNV-SFNR study]

INTRODUCTION

the objective of this study was to determine the role of radiological techniques in the diagnosis, assessment of severity and follow-up of cervical arterial dissections.

MATERIAL AND METHODS

from 1995 to 2001 a multicentre retrospective study was conducted in 24 hospital centers. A multiple-choice questionnaire was sent to each center in order to collect clinical information and imaging details regarding the diagnosis and follow-up of cervical arterial dissections.

RESULTS

information was gathered on 459 patients, comprising a total of 384 carotid artery dissections and 170 vertebral artery dissections. A mean of 4.85 diagnostic examinations per patient were conducted. Morphological imaging of the brain by CT or by MRI was performed on all except 3 patients. Cervical Doppler ultrasound examination was the most frequently performed test throughout the entire study period (performed in 87% of patients). Conventional arteriography was a routinely employed test in 1995 whereas by 2001 it comprised only 31.2% of requested examinations, having been progressively replaced by MRI and MRA scanning, which comprised 60% of all examinations performed by 2001. A combination of cervical Doppler ultrasonography, axial MRI and MRA of the neck vessels were performed in 39.6% of patients in 2001. Examination of the intracranial vessels was performed by transcranial Doppler ultrasound in 40% of cases and by MRA in 30% of cases. For the follow-up of arterial dissections, an average of 1.4 examinations was performed per patient. The majority of such follow-up examinations comprised Doppler ultrasound and/or MRA of the neck arteries.

CONCLUSION

The imaging diagnosis and follow-up of cervical arterial dissections will increasingly rely on non-invasive imaging techniques.

Syndrome PHACE (S) d’expression incomplète

INTRODUCTION

Hemangiomas are the most common benign tumors in childhood. In rare cases, they can be associated with dysmorphic malformations. The acronym, the PHACE (S) syndrome, was recently described by Frieden et al. in 1996 as a large facial or cervical Hemangioma, associated with one or more of the following systemic abnormalities including:Posterior fossa malformation, Arterial abnormalities, Coarctation of the aorta and/or cardiac defects, Eye abnormalities and Sternal clefts.

CASE REPORT

A 2 year-old girl presented with a large left hemifacial hemangioma. The rest of the clinical examination was normal. Initially, simple clinical surveillance was scheduled. The outcome was good with almost complete regression of the hemangioma by the age of 8. However, there were remains to the left of the upper lip and plastic surgery was scheduled. Pre-operative conventional arteriography revealed the complete, asymptomatic, absence of the ipsilateral internal carotid artery. Cerebral MRI and cardiac ultrasonography were normal. In the absence of somatic manifestations, regular clinical surveillance was decided on.

DISCUSSION

Large facial or cervical hemagiomas can be associated with one or more systemic abnormalities described by the PHACE (S) acronym. Its prevalence is unknown, but is shows marked female preponderance. Among the systemic abnormalities, neurological and cardiac malformations predominate. Hence the PHACE (S) syndrome must be recognized. Moreover, in patients presenting with large facial or cervical hemangioma, the following examinations should be performed: neurological examination and cerebral MRI to rule out abnormality of the posterior fossa, completed by a sequence of angio-MRI in the search for cerebral artery malformations; cardiovascular exploration, completed by echocardiography in the case of doubt and examination of the eyes and sternum. Lastly, the enhanced risk of laryngeal sub-glottis hemangioma should be kept in mind.

Exploration d’un déficit neurologique

The first step in the evaluation of patients with neurological deficit is to obtain expert clinical evaluation to achieve accurate and complete characterization. The type of neurological deficit, its mode of onset, the presence or absence of associated signs and symptoms, and a differential diagnosis must first be described. This will allow identification of the probable site of CNS involvement and appropriate imaging evaluation to be performed. A multi-disciplinary approach with constant correlation between clinical, imaging and pathological findings will enable clinicians to provide patients accurate diagnoses, appropriate prognostic evaluation and optimal management.

Céphalées dans un contexte d’urgence

Headaches constitute one of the most frequent reason of consultation. Their causes are extremely varied. The first step consists in the analysis of the characteristics of the pain and the associated signs in order to distinguish primary and secondary headaches. Primary headaches, including migraines and tension-type headaches are the most frequent types and do not require imaging evaluation. Secondary headaches are related to an organic cause and require specific investigations. In case of suspected symptomatic or secondary headaches, brain imaging plays an important role in the etiologic work-up. The main purpose of imaging in an emergency setting is to diagnose a life-threatening disease.