Aude Triquenot-Bagan

Proportion of single-chain recombinant tissue plasminogen activator and outcome after stroke

Objective: To determine whether the ratio single chain (sc)/(sc + 2 chain [tc]) recombinant tissue plasminogen activator (rtPA) influences outcomes in patients with cerebral ischemia. Methods: We prospectively included consecutive patients treated with IV rtPA for cerebral ischemia in 13 stroke centers and determined the sc/(sc + tc) ratio in the treatment administered to each patient. We evaluated the outcome with the modified Rankin Scale (mRS) at 3 months (prespecified analysis) and occurrence of epileptic seizures (post hoc analysis). We registered Outcome of Patients Treated by IV Rt-PA for Cerebral Ischaemia According to the Ratio Sc-tPA/Tc-tPA (OPHELIE) under ClinicalTrials.gov identifier no. NCT01614080. Results: We recruited 1,004 patients (515 men, median age 75 years, median onset-to-needle time 170 minutes, median NIH Stroke Scale score 10). We found no statistical association between sc/(sc + tc) ratios and handicap (mRS > 1), dependency (mRS > 2), or death at 3 months. Patients with symptomatic intracerebral hemorrhages had lower ratios (median 69% vs 72%, adjusted p = 0.003). The sc/(sc + tc) rtPA ratio did not differ between patients with and without seizures, but patients with early seizures were more likely to have received a sc/(sc + tc) rtPA ratio >80.5% (odds ratio 3.61; 95% confidence interval 1.26–10.34). Conclusions: The sc/(sc + tc) rtPA ratio does not influence outcomes in patients with cerebral ischemia. The capacity of rtPA to modulate NMDA receptor signaling might be associated with early seizures, but we observed this effect only in patients with a ratio of sc/(sc + tc) rtPA >80.5% in a post hoc analysis.

Imaging Characteristics of Venous Parenchymal Abnormalities

Background and Purpose— There are few published data on the patterns of parenchymal imaging abnormalities in a context of cerebral venous thrombosis (CVT). The objectives of the present study were to describe the patterns of parenchymal lesions associated with CVT and to determine the lesion sites. Methods— We included 44 consecutively hospitalized patients with CVT and parenchymal lesions on magnetic resonance imaging. The diagnosis of CVT had been confirmed by magnetic resonance imaging/magnetic resonance venography. Magnetic resonance imaging patterns for CVT were retrospectively analyzed with regard to the lesion’s type, shape, and site. Results— The most frequent stroke subtype was hemorrhagic ischemia (in 56.8% of cases), followed by intracerebral hematoma (in 22.72% of cases) and nonhemorrhagic ischemia (in 20.45% of cases). Although there were no significant differences between these 3 groups with regard to the clinical and radiological characteristics, we observed a nonsignificant trend (P=0.08) toward a shorter time interval between hospital admission and magnetic resonance imaging for nonhemorrhagic stroke. The CVT parenchymal abnormalities were centered on 6 main foci and were related to the site of venous occlusion: (1) the inferior parietal lobule (n=20; 44.5%), associated mainly with occlusion of the transverse sinus (n=10) or pure cortical veins (n=10); (2) the inferior and posterior temporal regions (n=10; 22.75%), associated mainly with occlusion of the transverse sinus (n=9); (3) the parasagittal frontal region (n=6; 13.6%), associated mainly with occlusion of the superior sagittal sinus (n=4) or the transverse sinus (n=4); (4) the thalamus (n=5; 11.3%) associated with occlusion of the straight sinus (n=5); (5) the cerebellar hemisphere (n=2; 4.5%), associated in both cases with occlusion of the transverse sinus; and (6) the deep hemispheric regions (n=3; 6.8%), associated with occlusion of the superior sagittal sinus in all cases. Conclusions— Parenchymal lesions caused by CVT display specific anatomic patterns, which is mainly determined by the site of venous occlusion.

Impact of an intrahospital mobile thrombolysis team on 3-month clinical outcomes in patients benefiting from intravenous thrombolysis for acute ischemic stroke

INTRODUCTION/OBJECTIVE The benefits of thrombolysis in patients presenting with acute ischemic stroke (IS) are highly time-dependent. The aim of our study was to evaluate the clinical benefit, after 3 months, of an intrahospital mobile thrombolysis team (MTT) for thrombolysis in IS. PATIENTS AND METHODS A total of 95 consecutive patients treated with IV tPA for acute IS at the neurology department of Rouen University Hospital between 1 January and 31 December 2015 were retrospectively identified. Patients who had benefited from mechanical thrombectomy or hemicraniectomy were excluded. The study compared 33 patients who had benefited from our MTT (thrombolysis whatever the location and as soon as possible by a specific nurse) with 62 patients treated in the usual way (thrombolysis only at the stroke unit). Management timescales, inhospital and 3-month clinical outcomes, and imaging data were also compared between the two groups. RESULTS Demographic data and factors known to influence the clinical course after thrombolysis were similar between the two groups (P>0.05). However, use of the MTT allowed significant decreases in the median onset-to-treatment (OTT) time of 26min and median door-to-needle (DTN) time of 27min (P<0.001). The proportion of patients with a DTN time<60min was higher in the MTT group than in the usual care (UC) group: 64% vs. 14%, respectively (P<0.001), according to American Heart Association/American Stroke Association guidelines. Although there was a smaller proportion of negative 3-month outcomes (modified Rankin Scale score: 6; 6% vs. 16%) and a larger proportion of highly favorable 3-month outcomes (mRS score: 0-1; 79% vs. 64%) in the MTT vs. UC groups, respectively, these differences were not statistically significant (P>0.05). DISCUSSION/CONCLUSION Use of an MTT is a simple way to reduce thrombolysis delays, and the present results encourage us to improve the system to make it even more effective and available for all patients.

Brain developmental venous anomaly thrombosis

A 62-year-old man was admitted for partial motor seizures and headaches. His medical history included arterial hypertension, obstructive sleep apnea syndrome and migraine. Because of his migraine, he had received an MRI 4 years earlier on which a right frontal developmental venous anomaly (DVA) had been fortuitously discovered. At admission, the patient presented with headaches since 2 weeks, different from his usual migraine headaches. The headache was permanent, more painful, and not relieved by usual analgesics. He had no focal neurological deficits. Brain MRI (Fig. 1a–d) revealed a filling defect in the collecting vein of the known right frontal DVA with limited perifocal edema on FLAIR and intravascular hypointensity on T2*, compatible with the diagnosis of DVA thrombosis. Brain MRI revealed no additional vascular malformations. Standard biological data were normal. Extensive laboratory investigations revealed isolated elevate D-dimer (730 ng/ml; N\ 500). Protein C, protein S, antithrombin III, antiphospholipid and anticardiolipin b2glycoprotein-1 complex antibodies were within the normal range. Factor V Leiden, prothrombin, and Janus Kinase 2 mutations were absent. Intravenous heparin infusion was rapidly introduced followed by daily oral vitamin K antagonists (fluindione 20 mg per day). Levetiracetam (500 mg twice per day) was also introduced. Three months later, repeated brain MRI (Fig. 1e–h) showed complete resolution of DVA thrombosis with complete recanalization of the DVA. Six months later, levetiracetam and fluindione were definitively stopped and the patient had no seizure or thrombosis recurrence. DVAs are the most commonly observed cerebral vascular malformations, with an incidence rate of[2 % [1]. Two-thirds of DVAs have a supratentorial location [2]. In the vast majority of cases, DVAs follow a benign clinical course and do not require follow-up imaging studies or specific medical management. Hemorrhagic risk associated with DVAs is very low and is estimated approximately 0.22–0.68 % per year [3]. Thrombosis of DVAs or their collecting veins is rare [4, 5] and may lead to a variety of complications including venous ischemic infarction, parenchymal hemorrhage, venous congestive edema, or subarachnoid hemorrhage. Pathophysiological mechanisms of DVAs thrombosis remain unclear. Risk factors for venous thrombosis, altered venous flow and lack of smooth muscle cells and elastic connective tissue increasing venous pressure in DVAs may play a role in the thrombotic process [1, 2]. There are no clear guidelines on DVA thrombosis treatment but many authors recommend that thrombosed DVAs must be approached with the same workup and treatment regimen as cerebral venous thrombosis [2]. When a compressive brain hematoma or edema requires surgical management, DVA collecting vein must be spared to avoid venous infarction [2]. Of note is that DVAs can be associated with other vascular malformations and, in cases of hemorrhage related to DVAs, cavernous malformations (CMs) are the most often encountered causative malformation. CMs are associated with DVAs in 13–40 % of cases [2]. CMs may be difficult to identify in the setting of a DVA presenting with & Romain Lefaucheur romain.lefaucheur@chu-rouen.fr

Suspected subdural hematoma.

A 71-year-old woman was admitted for 3 inaugural right-sided focal seizures. Shortly before, she had experienced a minor head trauma. Her neurological examination finding was normal. A brain computed tomographic scan and magnetic resonance imaging (MRI) showed abnormalities supporting the diagnosis of chronic subdural hematoma (SDH), with a subcutaneous collection regarding this subdural hematoma (Figure, A-C). She did not undergo surgery, and monitoring with brain MRI was recommended. Three months later, while partial seizures persisted despite anti-epileptic treatment (levitiracetam, 2000 mg/d), follow-up brain MRI showed increased extra-axial and subcutaneous gadolinium-enhanced masses (Figure, D and E). Given this unusual subdural hematoma evolution and radiological worsening of the suspected hematoma, craniotomy and biopsies were performed. The histopathology findings revealed a low-grade B-cell marginal zone lymphoma involving dura with bone and scalp invasion. The patient underwent radiotherapy after surgery, which reduced the residual mass. Six months later, her neurological condition deteriorated with progressive appearance of a right hemiparesis, aphasia, and drug-resistant epilepsy.

In-hospital delays to stroke thrombolysis: Out of hours versus regular hours and reduction in treatment times through the creation of a 24/7 mobile thrombolysis team

BACKGROUND The main aim of this study was to evaluate the impact of the implementation of a mobile thrombolysis team (MTT) on time to thrombolysis treatment depending on patient admission time: regular hours (RH) or out of hours (OH). METHODS 504 consecutive patients treated with IV tPA or with combined IV tPA and mechanical thrombectomy for acute ischemic stroke were retrospectively included between 1st January 2013 and 31st December 2017. Three sub-periods were identified: 2013-2014, 2015-2016, and 2017 during which patients were treated with the usual care (UC), by the MTT or with UC according to their time of admission, or by the MTT, in the three time periods respectively. We compared in-hospital delays according to patient admission time. RESULTS In 2013-2014, 133 patients were included. Both median door-to-needle (DTN) and imaging to needle (ITN) times were shorter for patients admitted during RH than OH, respectively 75 min versus 85 min and 52 min versus 57 min (P < 0.05), and the proportion of patients with DTN ≤ 60 min was 23% versus 9% (P < 0.05), respectively. In 2015-2016, 223 patients were included. DTN and ITN times were shorter for patients admitted during RH and treated by the MTT than during OH with UC, respectively 54 min versus 78 min and 24 min versus 47 min (P < 0.001), and the proportion of patients with DTN ≤ 60 min was 64% versus 21% (P < 0.001), respectively. In 2017, there was no difference concerning in-hospital delays regardless of patient admission time (P > 0.05). DISCUSSION DTN time was significantly longer for patients admitted OH. We suggest that the implementation of an around-the-clock MTT would allow a reduction of in-hospital delays and similar times to thrombolysis treatment regardless of admission time.

Innominate artery dissection and stroke after rifle recoil

Cervical artery dissection is a frequent cause of stroke, more so in young patients. Innominate artery (IA) dissection is uncommon, and most often associated with dissection of other major arteries like the aorta. The leading cause of IA injury is high-energy thoracic trauma, as in motor vehicle crash. IA dissection after blunt trauma is rare. We described here the unusual case and iconography of an isolated IA dissection after rifle recoil initially presenting as a stroke.

Severe dizziness following rivaroxaban introduction in a parkinsonian patient: Drug-drug interaction?

La Presse Medicale - In Press.Proof corrected by the author Available online since vendredi 2 octobre 2015