Christelle Blanc

Temporal Trends in Sex Differences With Regard to Stroke Incidence: The Dijon Stroke Registry (1987–2012)

Background and Purpose— We evaluated temporal trends in stroke incidence between men and women to determine whether changes in the distribution of vascular risk factors have influenced sex differences in stroke epidemiology. Methods— Patients with first-ever stroke including ischemic stroke, spontaneous intracerebral hemorrhage, subarachnoid hemorrhage, and undetermined stroke between 1987 and 2012 were identified through the population-based registry of Dijon, France. Incidence rates were calculated for age groups, sex, and stroke subtypes. Sex differences and temporal trends (according to 5-year time periods) were evaluated by calculating incidence rate ratios (IRRs) with Poisson regression. Results— Four thousand six hundred and fourteen patients with a first-ever stroke (53.1% women) were recorded. Incidence was lower in women than in men (112 versus 166 per 100 000/y; IRR, 0.68; P<0.001), especially in age group 45 to 84 years, and for both ischemic stroke and intracerebral hemorrhage. From 1987 to 2012, the lower incidence of overall stroke in women was stable (IRR ranging between 0.63 and 0.72 according to study periods). When considering stroke subtype, a slight increase in the incidence of ischemic stroke was observed in both men (IRR, 1.011; 95% confidence interval, 1.005–1.016; P=0.001) and women (IRR, 1.013; 95% confidence interval, 1.007–1.018; P=0.001). The sex gap in incidence remained unchanged in ischemic stroke and intracerebral hemorrhage. Conversely, the lower subarachnoid hemorrhage incidence in women vanished with time because of an increasing incidence. Conclusions— The sex gap in stroke incidence did not change with time except for subarachnoid hemorrhage. Despite lower rates, more women than men experience an incident stroke each year because of a longer life expectancy.

Takotsubo Cardiomyopathy Following Acute Cerebral Events

Objective: Takotsubo cardiomyopathy (TCM) is characterized by transient apical ventricular dysfunction typically induced by acute stress. Acute cerebral events including ischemic stroke (IS) or epileptic events (EEs) may be associated with massive catecholamine release. We aimed to identify the characteristics and outcomes of patients who experienced the Takotsubo syndrome complicated by IS or EE. Methods: Between 2008 and 2013, 87 patients were admitted to our intensive care unit for TCM. Of these, 6 had previously experienced acute cerebral symptoms within 2 days of experiencing either IS or EE. Takotsubo syndrome was diagnosed on cardiac MRI, echocardiography, electrocardiography (ECG), biology and coronary angiography data. Results: Five women and 1 man were included in the study. The mean age was 63.7 ± 20.1 years (range 44-84). Four of them (67%) initially presented an acute IS and 2 (33%) had EE. The suspected brain injury was found in the insular cortex for 4 patients and the posterior fossa for 2 patients. Hemiparesis, aphasia and cerebellar symptoms were the main neurological signs. Abnormal ECG findings including ST-segment elevation (33%) or T-wave inversion (50%) developed between a few hours and 48 h after the onset of the IS or EE. Peak troponin was 1.8 (0.79-14.11) µg/l. A transient reduction in the left ventricular ejection fraction (46 ± 12%) with apical hypokinesis was found using echocardiography. Two (33%) patients went on to develop acute heart failure. Coronary angiography confirmed the lack of significant coronary stenosis for all 6 patients. Conclusion: TCM can develop within the first few days after an acute cerebral event. It occurs predominantly in women with insular or posterior fossa lesions and is possibly induced by vegetative reactions.

Increasing early ambulation disability in spontaneous intracerebral hemorrhage survivors

Objective To evaluate temporal trends in early ambulatory status in patients with spontaneous intracerebral hemorrhage (ICH). Methods All patients with ICH between 1985 and 2011 were prospectively registered in a population-based registry in Dijon, France, and included in the study. Outcomes of ICH survivors were assessed at discharge from their stay in an acute care ward with the use of a 4-grade ambulation scale. Time trends in ambulation disability and place of discharge were analyzed in 3 periods (1985–1993, 1994–2002, and 2003–2011). Multivariable ordinal and logistic regression models were applied. Results Five hundred thirty-one patients with ICH were registered, of whom 200 (37.7%) died in the acute care ward. While the proportion of deaths decreased over time, that of patients with ambulation disability increased (odds ratio [OR] 1.67, 95% confidence interval [CI] 0.87–3.23, p = 0.124 for 1994–2002; and OR 1.97, 95% CI, 1.08–3.60, p = 0.027 for 2003–2011 vs 1985–1993 in ordinal logistic regression). The proportion of patients dependent in walking rose (OR 2.11, 95% CI 1.16–3.82, p = 0.014 for 1994–2002; and OR 2.73; 95% CI 1.54–4.84, p = 0.001 for 2003–2011), and the proportion of patients discharged to home decreased (OR 0.49, 95% CI 0.24–0.99, p = 0.048 for 1994–2002; and OR 0.32, 95% CI 0.16–0.64, p = 0.001 for 2003–2011). Conclusion The decrease in in-hospital mortality of patients with ICH translated into a rising proportion of patients with ambulation disability at discharge. A lower proportion of patients returned home. These results have major implications for the organization of postacute ICH care.

A Puzzling Ocular Motility Disorder: Apparent Up-Gaze Fatigability in a Patient With Oculomotor Nerve Compression

ABSTRACT We report the case of a woman who developed right third nerve dysfunction with synkinesis and ocular neuromyotonia secondary to a compressive arterial aneurysm. Surprisingly, our examination showed a downward drift of the right eye in sustained up-gaze resulting in transient hypotropia, suggesting either fatigability of the superior rectus or contraction of the inferior rectus. We believe this ocular motility pattern is secondary to a co-contraction of the inferior rectus in up-gaze caused by synkinesis (explaining the downward drift), followed by failure of the inferior rectus to relax upon return to primary position caused by ocular neuromyotonia (explaining the hypotropia).

Temporal trends in the premorbid use of preventive treatments in patients with acute ischemic cerebrovascular events and a history of vascular disease: The Dijon Stroke Registry (1985–2010)

INTRODUCTION Although secondary prevention in patients with arterial vascular diseases has improved, a gap between recommendations and clinical practice may exist. OBJECTIVES We aimed to evaluate temporal trends in the premorbid use of preventive treatments in patients with ischemic cerebrovascular events (ICVE) and prior vascular disease. METHODS Patients with acute ICVE (ischemic stroke/TIA) were identified through the population-based stroke registry of Dijon, France (1985-2010). Only those with history of arterial vascular disease were included and were classified into four groups: patients with previous coronary artery disease only (CAD), previous peripheral artery disease only (PAD), previous ICVE only, and patients with at least two different past vascular diseases (polyvascular group). We assessed trends in the proportion of patients who were treated with antihypertensive treatments and antithrombotics at the time of their ICVE using multivariable logistic regression models. RESULTS Among the 5309 patients with acute ICVE, 2128 had a history of vascular disease (mean age 77.3±11.9, 51% men; 25.1% CAD 7.5% PAD, 39.8% ICVE, and 27.5% poylvascular). A total of 45.8% of them were on antithrombotics, 64.1% on antihypertensive treatment, and 34.4% on both. Compared with period 1985-1993, periods 1994-2002 and 2003-2010 were associated with a greater frequency of prior-to-ICVE use of antithrombotics (adjusted OR=5.94; 95% CI: 4.61-7.65, P<0.01, and adjusted OR=6.92; 95% CI: 5.33-8.98, P<0.01, respectively) but not of antihypertensive drugs. Consistent results were found when analyses were stratified according to the type of history of arterial vascular disease. CONCLUSION Patients with ICVE and previous vascular disease were still undertreated with recommended preventive therapies.

Authors' Reply to the Letter by Madias Entitled ‘Stroke or Seizures, and Takotsubo Syndrome: A Possibly Underdiagnosed Association'

fore, further studies are needed to assess the pathophysiological hypotheses. It appears to be crucial to consider patients from a global perspective, and one of the most significant illustrations is the link between the heart and the brain in the management of cerebrocardiovascular diseases. For example, a direct link between damage in specific regions of the brain, such as the insular cortex, and the incidence of cardiac death has been suggested [4] . In terms of perspectives, it would be interesting to study the clinical and preclinical inter-relation between the brain and heart in ischemic processes. To achieve this goal, we are currently developing a strong collaboration between reDear Sir, We thank Dr. Madias for his interest in our work [1] in which we tried to illustrate a clear relationship between neurologic and cardiologic fields of research. We totally agree that the brain and heart are linked in several affections, especially in Takotsubo syndrome (TTS). In this disease, stroke could be either the cause or the consequence of TTS. In our study published in European Neurology [2] , we assumed that ischemic stroke or epileptic events affecting specific brain regions could induce a massive catecholamine release, as suggested by other authors [3] . We acknowledge that we did not investigated blood catecholamine levels because of the retrospective nature of the study. ThereReceived: January 4, 2016 Accepted: January 4, 2016 Published online: February 2, 2016

0137 : Takotsubo cardiomyopathy following acute cerebral events

Objective Takotsubo cardiomyopathy is characterized by a transient apical ventricular dysfunction typically induced by an acute stress. Acute cerebral events including ischemic stroke (IS) or Epileptic Event (EE) may both be associated with massive catecholamine release. We aimed to identify the characteristics and outcomes of patients who experienced Takotsubo syndrome complicating an IS or EE. Methods Between 2008 and 2013, 87 patients were admitted in our Intensive Care Unit for suspected Takotsubo syndrome, of whom 6 previously experienced acute cerebral symptoms with either IS or EE, within two days. Takotsubo syndrome was diagnosed on Cardiac Magnetic Resonance, echocardiographic, electrocardiographic, biological and coronary angiography data. Results Five women and one man were included. The mean age was 63.7±20.1 years old (range: 44-84). Four of them (67%) presented initially an acute IS and two (33%) had EE. The suspected culprit brain injury was the insular cortex for three patients or posterior fossa for two patients. Hemiparesis, aphasia and cerebellar symptoms were the main neurological signs. Abnormal ECG findings including ST segment elevation (33%) or T waves inversion (50%) developed between few hours and 48 hours after the onset of IS or EE. Troponin peak was at 1,8 (0,79-14,11) μg/L. A transient alteration of the left ventricular ejection fraction (46±12%) with apical hypokinesis was found at echocardiography. Two (33%) patients developed an acute heart failure. Coronary angiography confirmed the lack of significant coronary stenosis for all the patients. Conclusion Takotsubo cardiomyopathy can develop early within in the first days after an acute cerebral event, predominantly in women with insular or posterior fossa lesions and induced by possible vegetative reactions. The author hereby declares no conflict of interest

January 16th, Friday 20150118: Takotsubo cardiomyopathy following acute cerebral events

Objective Takotsubo cardiomyopathy is characterized by a transient apical ventricular dysfunction typically induced by an acute stress. Acute cerebral events including ischemic stroke (IS) or Epileptic Event (EE) may both be associated with massive catecholamine release. We aimed to identify the characteristics and outcomes of patients who experienced Takotsubo syndrome complicating an IS or EE. Methods Between 2008 and 2013, 87 patients were admitted in our Intensive Care Unit for suspected Takotsubo syndrome, of whom 6 previously experienced acute cerebral symptoms with either IS or EE, within two days. Takotsubo syndrome was diagnosed on Cardiac Magnetic Resonance, echocardiographic, electrocardiographic, biological and coronary angiography data. Results Five women and one man were included. The mean age was 63.7±20.1 years old (range: 44-84). Four of them (67%) presented initially an acute IS and two (33%) had EE. The suspected culprit brain injury was the insular cortex for three patients or posterior fossa for two patients. Hemiparesis, aphasia and cerebellar symptoms were the main neurological signs. Abnormal ECG findings including ST segment elevation (33%) or T waves inversion (50%) developed between few hours and 48 hours after the onset of IS or EE. Troponin peak was at 1,8 (0,79-14,11) µg/L. A transient alteration of the left ventricular ejection fraction (46±12%) with apical hypokinesis was found at echocardiography. Two (33%) patients developed an acute heart failure. Coronary angiography confirmed the lack of significant coronary stenosis for all the patients. Conclusion Takotsubo cardiomyopathy can develop early within in the first days after an acute cerebral event, predominantly in women with insular or posterior fossa lesions and induced by possible vegetative reactions.