G. Couvreur

Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)

Background and Purpose— There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods— We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score ≤3) at 6 months’ follow-up (primary outcome) between the 2 treatment groups. Results— After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score ≤3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (P=0.18 and P=0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (P<0.0001). Conclusions— In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Stable Stroke Incidence Rates but Improved Case-Fatality in Dijon, France, From 1985 to 2004

Background and Purpose— With the progress in stroke prevention, it is important to evaluate the epidemiological trends of strokes over a long period and from a nonselected population-based perspective. Methods— We estimated changes in incidence, case-fatality rates, severity, risk factors and prestroke use of preventive treatments for first-ever strokes, from a continuous 20-year well-defined population-based registry, from 1985 to 2004. Results— We recorded 3142 ischemic strokes, 341 primary cerebral hemorrhages and 74 subarachnoid hemorrhages. During the 20-year study, the age at first stroke onset increased by 5 years in men and 8 years in women. Comparing the 1985 to 1989 and the 2000 to 2004 periods, age- and sex-standardized incidences of first-ever strokes were stable except for lacunar strokes whose incidence significantly increased (P=0.01) and for cardioembolic stroke whose incidence significantly decreased (P=0.01). Twenty-eight-day case-fatality rates decreased significantly mainly for lacunar strokes (P=0.05) and for primary cerebral hemorrhages (P=0.03). The proportion of hypercholesterolemia and diabetes significantly increased (P<0.01). In contrast, the proportion of myocardial infarction significantly decreased (P=0.02). Prestroke antiplatelets and anticoagulants treatment significantly increased (P<0.01). Conclusions— The age- and sex-standardized incidences of first strokes in Dijon have been stable over the past 20 years and were associated with an increase in age at stroke onset, a decrease in case-fatality rates, and an increased use of antiplatelet treatments.

Ischaemic stroke subtypes and associated risk factors: a French population based study

Background: There is little reliable population based information about the distribution of risk factors among the various ischaemic stroke subtypes, even though determining risk factor profiles is of major importance to develop targeted preventive strategies. Methods: The distribution of first ever ischaemic stroke subtypes was established in a prospective population based study conducted in Dijon, France (152 606 inhabitants). Cases were collected between January 2005 and December 2006, and were classified using TOAST classification. Vascular risk factors were recorded to determine a risk factor profile for each subtype. Results: 332 patients with first ever ischaemic stroke (150 men and 182 women) were recorded. Adjusted incidence to world population was 54/100 000/year. The distribution of ischaemic stroke subtypes was as follows: 119 (35.8%) cases of large artery atherosclerosis, 89 (26.8%) small artery occlusions, 81 (24.4%) cardioembolisms and 43 (13%) other and undetermined causes. The most frequent vascular risk factor was hypertension, irrespective of the ischaemic stroke subtype, with a total prevalence of 62%. Using multivariate regression, a positive association between cardioembolism and age (OR 1.051; 95% CI 1.026 to 1.076; p<0.001) was demonstrated and between small artery occlusion and either high blood pressure (OR 1.86; 95% CI 1.06 to 3.27; p = 0.03) or hypercholesterolaemia (OR 2.23; 95% CI 1.33 to 3.76; p = 0.02). Conclusion: This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.

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. AF = atrial fibrillation; CE = cardioembolic; CI = confidence interval; IRR = incidence rate ratios.

Trends in the Incidence of Transient Ischemic Attacks, Premorbid Risk Factors and the Use of Preventive Treatments in the Population of Dijon, France from 1985 to 2004

Background: We describe the epidemiological trends of transient ischemic attack (TIA) in a 20-year population-based pilot study. Methods: Trends in the incidence, risk factors and pre-TIA use of preventive treatments for TIA were observed from 1985 to 2004 according to the classic definition in the population of the city of Dijon, France (150,000 inhabitants). Results: The raw and standardized incidence of TIA were stable over time. We observed a significant increase in the mean age at TIA onset in women only. The prevalence of hypercholesterolemia and diastolic blood pressure ≧90 mm Hg among patients with TIA increased significantly. This contrasts with falls in smoking and in history of previous myocardial infarction. Conclusion: The stability of classic TIA incidence, despite the rise in the proportion of elderly people, and the increase in the mean age at onset in women may be considered as a medical progress.

Variation saisonniere des accidents vasculaires cérébraux et influence des conditions météorologiques

Resume Le but de cette etude etait d’analyser la repartition saisonniere et mensuelle des differents sous-types d’accidents vasculaires cerebraux (AVC), ainsi que l’influence des parametres meteorologiques conventionnels sur leur survenue. L’etude, fondee sur les donnees de population du registre des AVC de la ville de Dijon, a inclus 3 287 patients ayant eu un accident vasculaire cerebral au cours des annees 1985 a 1998. La repartition saisonniere a mis en evidence une baisse estivale pour tous les sous-types d’AVC, la difference entre les saisons etant significative pour l’infarctus cerebral, l’infarctus cardioembolique et l’infarctus atherothrombotique des grosses arteres, ainsi que pour le total des AVC. L’automne et le printemps furent les saisons a plus haut risque cerebrovasculaire, avec un pic significatif en octobre pour l’infarctus cerebral. Les correlations avec les donnees meteorologiques ont montre une influence de la temperature, de l’humidite relative, de la vitesse du vent, de l’insolation ou de la neige sur certains sous-types d’AVC. Ces resultats different parfois de ceux d’etudes anterieures realisees sous d’autres climats et en presence d’autres facteurs de risque, ce qui souligne la necessite de proceder a des etudes epidemiologiques regionales si l’on veut determiner les relations entre saisons, facteurs meteorologiques et AVC.

NeuroépidémiologieLes accidents vasculaires cérébraux : ce qui a changé au début du xxie siècleWhat has changed for stroke at the beginning of the 21st century

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.

Apport de l’évaluation écologique des troubles exécutifs dans la sclérose en plaques

Resume Introduction La sclerose en plaques (SEP) est la maladie neurologique invalidante du sujet jeune la plus frequente. La prevalence des troubles cognitifs est de 40 a 65 p. 100 dans la SEP. Les troubles cognitifs sont la deuxieme cause de handicap et sont a l’origine d’une alteration de la qualite de vie chez un grand nombre de patients. L’evaluation de ces troubles est souvent prise en defaut par les examens psychometriques habituels. Objectifs L’objectif principal de notre etude etait d’apprecier la sensibilite d’un test ecologique par rapport aux tests psychometriques standards dans l’evaluation des troubles executifs de la SEP. Methodes Vingt sujets porteurs d’une SEP cliniquement certaine ont ete apparies en âge, sexe, lateralite manuelle et niveau intellectuel pre-morbide a 20 sujets volontaires sains. Les performances psychometriques executives des 2 groupes ont ete comparees. L’ensemble des performances a ces tests formait un score composite (SFE). Le test ecologique utilise etait le test des commissions sous sa forme « papier-crayon ». Resultats Les performances psychometriques des sujets SEP etaient heterogenes et significativement diminuees pour le test des fluences alphabetiques (p = 0,01) et pour le test des commissions (p = 0,01). Il existait un lien significatif entre les performances au test des commissions et le score SFE (p = 0,009). Conclusions Les performances au test des commissions sont sensibles pour l’evaluation des troubles executifs et leur correlation avec le score global des fonctions executives evalue par la psychometrie est forte. Le test de commissions est plus sensible que la psychometrie classique dans l’evaluation des fonctions executives chez les sujets SEP. Nous proposons de completer l’evaluation psychometrique avec ce test lorsque celle-ci s’avere normale alors que le patient se plaint de difficultes cognitives.

Comparaison de l’immunofixation après électrophorèse sur gel d’agarose avec la focalisation isoélectrique dans la détection des bandes oligoclonales d’IgG du liquide céphalo-rachidien de patients atteints de sclérose en plaques

Resume Introduction Une synthese intrathecale d’immunoglobulines (Ig), avec une distribution electrophoretique oligoclonale des IgG du liquide cephalo-rachidien (LCR) est detectee dans 90 p. 100 des scleroses en plaques (SEP) cliniquement certaines. La technique preconisee pour mettre en evidence des bandes oligoclonales est la focalisation isoelectrique (FIE). Cependant, une technique plus rapide et moins couteuse s’est developpee : l’immunofixation des IgG apres electrophorese sur agarose (IEA). Methodes L’objectif de l’etude est de verifier la concordance des resultats de ces deux techniques realisees sur 74 couples serum-LCR de patients atteints de SEP et 103 de sujets temoins, puis de determiner leur sensibilite et leur specificite respective. Resultats La concordance entre les resultats de la FIE et de l’IEA a ete excellente (Kappa = 0,84). La sensibilite de la FIE (78 p. 100) n’etait pas significativement differente de celle de l’IEA (74 p. 100) (p = 0,3). Il en a ete de meme pour leurs specificites obtenues dans le groupe des 103 sujets temoins (FIE 93 p. 100 ; IEA 95 p. 100 ; p = 0,2). Conclusion L’IEA, technique semi-automatisee et rapide, est une bonne alternative a la technique de la FIE plus contraignante.

Grossesse et sclérose en plaques

Because multiple sclerosis is a disease that affects young women, the question of pregnancy frequently arises early in the management of the disease. Although the relapse rate decreases during the nine months of pregnancy, it rises significantly during the first trimester post-partum, affecting one third of patients. Pregnancy has no influence on disability progression. Patients have no particular difficulties during pregnancy, labor or delivery. No significant fetal risk has been reported. Neither breast-feeding nor epidural analgesia is deleterious. Disease-modifying treatment must be stopped before conception.