B. Guillon

Ischemia-modified Albumin and Heart Fatty Acid–binding Protein: Could Early Ischemic Cardiac Biomarkers Be Used in Acute Stroke Management?

BACKGROUND The detection of biomarkers such as ischemia-modified albumin (IMA) and heart fatty acid-binding protein (HFABP) is used in the early diagnosis of acute myocardial infarction. As these biomarkers are not organ specific, we tested them in the neurovascular field. METHODS A total of 41 patients with acute stroke were enrolled (31 ischemic strokes and 10 intracerebral hemorrhages). IMA and HFABP levels were measured in serum samples collected within 4.5 hours of stroke onset. Clinical, imaging, and outcome data were recorded. RESULTS No difference in baseline IMA or HFABP was found between patients with ischemic and hemorrhagic stroke. There was no correlation among biomarker levels at admission, National Institutes of Health Stroke Scale score, or stroke volume. Neither of the biomarkers could predict short-term prognosis. CONCLUSIONS IMA and HFABP do not appear to be relevant in acute stroke management.

Early Sitting in Ischemic Stroke Patients (SEVEL): A Randomized Controlled Trial.

Background Extended immobility has been associated with medical complications during hospitalization. However no clear recommendations are available for mobilization of ischemic stroke patients. Objective As early mobilization has been shown to be feasible and safe, we tested the hypothesis that early sitting could be beneficial to stroke patient outcome. Methods This prospective multicenter study tested two sitting procedures at the acute phase of ischemic stroke, in a randomized controlled fashion (clinicaltrials.org registration number NCT01573299). Patients were eligible if they were above 18 years of age and showed no sign of massive infarction or any contra-indication for sitting. In the early-sitting group, patients were seated out of bed at the earliest possible time but no later than one calendar day after stroke onset, whereas the progressively-sitting group was first seated out of bed on the third calendar day after stroke onset. Primary outcome measure was the proportion of patients with a modified Rankin score [0–2] at 3 months post stroke. Secondary outcome measures were a.) prevalence of medical complications, b.) length of hospital stay, and c.) tolerance to the procedure. Results One hundred sixty seven patients were included in the study, of which 29 were excluded after randomization. Data from 138 patients, 63 in the early-sitting group and 75 in the progressively-sitting group were analyzed. There was no difference regarding outcome of people with stroke, with a proportion of Rankin [0–2] score at 3 months of 76.2% and 77.3% of patients in the early- and progressive-sitting groups, respectively (p = 0.52). There was also no difference between groups for secondary outcome measures, and the procedure was well tolerated in both arms. Conclusion Due to a slow enrollment, fewer patients than anticipated were available for analysis. As a result, we can only detect beneficial/detrimental effects of +/- 15% of the early sitting procedure on stroke outcome with a realized 37% power. However, enrollment was sufficient to rule out effect sizes greater than 25% with 80% power, indicating that early sitting is unlikely to have an extreme effect in either direction on stroke outcome. Additionally, we were not able to provide a blinded assessment of the primary outcome. Taking these limitations into account, our results may help guide the development of more effective acute stroke rehabilitation strategies, and the design of future acute stroke trials involving out of bed activities and other mobilization regimens. Trial Registration ClinicalTrials.gov NCT01573299

Imagerie des accidents vasculaires cerebraux en urgence

Resume Depuis 25 ans, les progres de la Neuroradiologie ont bouleverse la prise en charge de l’accident vasculaire cerebral (AVC). En effet, l’apparition du scanner dans les annees 70 a permis de differencier l’accident vasculaire cerebral ischemique de l’hemorragique. C’est maintenant l’imagerie par resonance magnetique (IRM) qui doit etre privilegiee car elle apporte de nouvelles informations essentielles a l’optimisation du traitement. Grâce a l’IRM de diffusion il est possible de visualiser, en moins d’une minute et precocement, l’etendue de la souffrance cerebrale. Le couplage de l’imagerie de diffusion avec la technique de perfusion permet de reperer le tissu hypoperfuse mais encore viable, menace de necrose, en l’absence de reperfusion. Parallelement, l’imagerie vasculaire IRM non invasive permet de rechercher la cause de l’AVC sur les vaisseaux a destinee cerebrale, mais aussi au niveau de la vascularisation cerebrale elle-meme. Le « sauvetage » de cette « zone de penombre » est au centre de la prise en charge en urgence de l’accident vasculaire ischemique. En cas d’accident vasculaire hemorragique, cette meme imagerie permet de rechercher une lesion vasculaire cerebrale causale (anevrysme, malformation arterio-veineuse, thrombophlebite etc.) et d’envisager son traitement, en privilegiant, quand c’est possible, la voie endovasculaire (Neuroradiologie Interventionnelle).

ARM des vaisseaux cervico-encéphaliques : technique, principales applications cliniques

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

Le syndrome de vasoconstriction cérébrale réversible

The reversible cerebral vasoconstriction syndrome (RCVS) is an under-estimated transient acute cerebrovascular disorder. It has long been mistaken as central nervous system vasculitis whereas it is now believed to result from an acute but prolonged vasospasm of cerebral arteries. This disorder can be precipitated by postpartum or vasoactive drug. However, it occurs spontaneously in a significant number of cases. The characteristic clinico-radiological presentation and disease course of the RCVS has been delineated only recently. Mean age at onset is 40-45 years, with a female predominance. A provocative factor can be identified in 12-60% out of the patients. Clinical presentation is predominantly marked by recurrent thunderclap headaches, but can be complicated with focal neurological deficit or seizures. Brain imaging is normal in most cases, but can reveal hemorrhagic or ischemic complications. Cortical subarachnoid hemorrhage is a suggestive finding. A posterior reversible encephalopathy syndrome (PRES) can be seen occasionally. Cerebral angiography reveals multifocal arterial narrowing with string and bead appearance. Cerebrospinal fluid reveals no or mild abnormalities. The disease resumes spontaneously within several days to weeks, whereas vasoconstriction reverses within 1 to 3 months. This clinico-radiological presentation should be promptly recognized in order to avoid unnecessary investigations and aggressive treatment, and lead to search for a triggering factor. Further studies are required in order to clarify the precipitating role of several drugs, and clinical trials are needed to reduce the occurrence of strokes.

NR-WS-46 Syndrome de vasoconstriction cerebrale reversible versus angeites du systeme nerveux central : etude de 15 angiopathies

Objectifs Preciser les etiologies des angiopathies cerebrales diffuses isolees documentees par arteriographie et leurs caracteristiques clinico-radilogiques. Materiels et methodes Etude retrospective de l’ensemble des patients ayant beneficie entre 2000 et 2006 d’une arteriographie cerebrale au CHU de Nantes et dont les renseignements cliniques ou le compte rendu contenait les mots vascularite, angeite ou arterite. Resultats Sur 25 patients evalues, 10 ont ete exclus : 6 presentaient une lesion focale, 2 avaient une arteriographie normale et 2 sont decedes. Sur les 15 patients presentant des stenoses intracrâniennes multiples et multifocales : 4 avaient une affection concomitante evolutive. Finalement 11 presentaient une atteinte neurologique isolee, dont 2 d’origine atheromateuse et 2 presumee inflammatoire, sans preuve histologique. Au total, 7 patients ont un tableau de syndrome de vasoconstriction cerebrale reversible (RCVS) avec des cephalees aigues voire ictales (4 cas), durant moins de 2 semaines, avec saignement intracrânien dans 5 cas. Dans 4 cas, la regression des images angiographiques etait affirmee par l’imagerie non invasive. Une patiente gardait des sequelles neurologiques, aucune ne recidivait a distance. Conclusion Dans notre experience, le RCVS est la premiere cause d’angiopathie cerebrale diffuse isolee. Les cephalees aigues et l’hemorragie cortico-piale focalisee de la convexite semblent en etre les meilleurs elements diagnostiques.

3225 Technique d’exploration des vaisseaux cervico-encephaliques : ARM

Objectifs pedagogiques Apres un bref rappel de l’anatomie vasculaire, nous exposerons la place des differentes techniques (TOF 2D, 3D, PC, ARM 3D gado et ARM dynamique) et indications rendant possible l’imagerie des vaisseaux cervico-encephaliques. Nous montrerons l’interet, les artefacts et les limites de l’ARM dans la pathologie atheromateuse stenosante ou occlusive, dans les dissections carotidiennes et vertebrales ainsi que dans les dysplasies vasculaires ou vascularites cerebrales. De ce bilan vasculaire non invasif dependra l’orientation therapeutique initiale. Dans le cadre des AVC hemorragiques, nous aborderons le role et l’interet de l’ARM dans le depistage et le controle des anevrismes intracrâniens et egalement l’apport des nouvelles sequences d’ARM dynamique avec injection de gadolinium dans la detection de malformations vasculaires cerebrales (MAVc et fistules durales). L’ARM du versant veineux sera detaillee sur le plan technique et clinique. Enfin, nous proposerons un protocole d’ARM pour le bilan realise lors des urgences neurovasculaires. Resume L’ARM ou angiographie par resonance magnetique est devenue un outil incontournable en routine de l’exploration des accidents vasculaires cerebraux (AVC). Elle nous fournit une imagerie non invasive performante des vaisseaux cervico-encephaliques permettant la detection et le diagnostic des anomalies vasculaires. L’ARM complete utilement, lors du meme examen, l’analyse par IRM du parenchyme cerebral.