Gérard Besson

Atherosclerotic Disease of the Aortic Arch and the Risk of Ischemic Stroke

BACKGROUND Atherosclerotic disease of the aortic arch has been suspected to be a potential source of cerebral emboli. We conducted a study to quantify the risk of ischemic stroke associated with atherosclerotic disease of the aortic arch. METHODS Using transesophageal echocardiography, we performed a prospective case-control study of the frequency and thickness of atherosclerotic plaques in the ascending aorta and proximal arch in 250 consecutive patients admitted to the hospital with ischemic stroke and 250 consecutive controls, all over the age of 60 years. RESULTS Atherosclerotic plaques > or = mm in thickness were found in 14.4 percent of the patients but in only 2 percent of the controls. After adjustment for atherosclerotic risk factors, the odds ratio for ischemic stroke among patients with such plaques was 9.1 (95 percent confidence interval, 3.3 to 25.2; P < 0.001). Among the 78 patients who had brain infarcts with no obvious cause, 28.2 percent had plaques > or = 4 mm in thickness, as compared with 8.1 percent of the 172 patients who had infarcts whose possible or likely causes were known (odds ratio, 4.7; 95 percent confidence interval, 2.2 to 10.1; P < 0.001). Plaques of > or = 4 mm in the aortic arch were not associated with the presence of atrial fibrillation or stenosis of the extracranial internal carotid artery. In contrast, plaques that were 1 to 3.9 mm thick were frequently associated with carotid stenosis of > or = 70 percent. CONCLUSIONS These results indicate a strong, independent association between atherosclerotic disease of the aortic arch and the risk of ischemic stroke. The association was particularly strong with thick plaques. Atherosclerotic disease of the aortic arch should be regarded as a risk factor for ischemic stroke and as a possible source of cerebral emboli.

European Stroke Initiative Recommendations for Stroke Management

This article summarises recommendations for acute management of stroke by the European Stroke Initiative (EUSI), on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Prospective study of lacunar infarction using magnetic resonance imaging.

Using computed tomography and magnetic resonance imaging, we prospectively studied 100 patients hospitalized with a lacunar infarct. Our aim was to evaluate the capabilities of magnetic resonance imaging in the detection and delineation of lacunes in a project of clinicotopographic correlations. Seventy-nine patients had a classic lacunar syndrome; 35 had pure motor stroke, 26 had ataxic hemiparesis, seven had sensorimotor stroke, and 11 had pure sensory stroke. A miscellaneous group of 21 patients had less typical lacunar syndromes, primarily with brainstem signs and symptoms. Among a total of 153 lacunes, magnetic resonance imaging detected at least one lacune appropriate to the symptoms in 89 patients. In 16 patients at least two lesions correlated with the clinical features, and precise clinicotopographic correlations were possible in 68 patients. Magnetic resonance imaging was more effective when it was performed a few days after the stroke. Lesions causing different types of lacunar syndromes had significantly different volumes, suggesting that the size of the lesion may influence clinical features. Magnetic resonance imaging may be the imaging technique of choice in the study of lacunar syndromes.

Long-term prognosis of symptomatic lacunar infarcts. A hospital-based study.

This study concerns the long-term prognosis of lacunar infarcts. Methods We report the analysis of our hospital-based series of 178 patients consecutively admitted for a lacunar syndrome due to a lacunar infarct diagnosed with computed tomography and magnetic resonance imaging. Demographic data, medical history, vascular risk factors, and imaging data were recorded for each patient. The follow-up was 35 ±22 months. Results The lacunar syndrome was pure motor hemiparesis in 69 patients (39%), ataxic hemiparesis in 45 patients (25.4%), pure sensory stroke in 15 patients (8.5%), sensorimotor stroke in 14 patients (7.9%), and miscellaneous syndrome in 34 patients (19.2%). The 4-year survival rate was 80±4% and the 4-year survival rate without recurrent stroke was 85 ±3.5%. Using Cox proportional-hazards analysis, the predictors of death were age (P<.02), diabetes mellitus P<.05), and cigarette smoking (P<.05). We did not find any predictors of recurrence. After 1 year, 74% of the patients had mild or no disability. Using logistic regression analysis, the predictive factors of disability were age more than 70 years P<.01), diabetes (P<.01), history of stroke or transient ischemic attack (P<.05), and type of lacunar syndrome P<.01). Imaging data, number of lacunes, and presence of leukoaraiosis were not predictors of outcome. Conclusions Our study suggests that with a high survival rate, a low recurrence rate, and a relatively good functional recovery, lacunar infarcts have a relatively favorable prognosis.

Hemiplegia in posterior cerebral artery occlusion.

We report 4 patients with hemiplegia due to a posterior cerebral artery occlusion. Associated clinical signs were aphasia, alexia or a neglect syndrome, hemianopia, and hemisensory loss. Hemiplegia was due to infarction in the lateral midbrain. The level of the occlusion in the posterior cerebral artery may be located distal to the junction with the posterior communicating artery.

Pure sensory stroke due to a pontine lacune.

A 53-year-old hypertensive man presented with the sudden onset of an isolated lemniscal sensory syndrome of the entire left side of his body. Magnetic resonance images showed a small lacune in the right paramedian pons corresponding to the location of the medial lemniscus.

Risk Factors for Lacunar Infarcts

Lacunar infarcts represent a stroke subgroup with controversial risk factors. Lacunar syndromes may be divided into two groups: the classic group (pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome, sensorimotor stroke) and the miscellaneous group including all other lacunar syndromes. We studied risk factors of 200 consecutive patients with symptomatic lacunar infarcts diagnosed by magnetic resonance imaging. This study tested whether lacunar infarcts represent a homogeneous subgroup of strokes or not. Using descriptive and bivariate statistics, we found that the prevalences of arterial hypertension and cigarette smoking are lower in the miscellaneous group. Analysis of variance shows a significant difference in age between subgroups without interaction of sex. Nevertheless, using multivariate analysis, we did not find a difference between subgroups. Thus, lacunar infarcts seem to be a homogeneous subgroup of strokes, and the miscellaneous group of lacunar infarcts may be included into the lacunar infarct group and not into the vertebrobasilar large-artery infarct group.

Medical treatment of acute ischemic stroke.

Progress in general symptomatic therapy such as avoidance of complications through nursing care, rehabilitation, and secondary prevention of stroke yield a better quality of life to stroke patients. Unfortunately, no specific drug therapy for acute stroke has been proven to be of benefit in controlled trials. However, new drugs and drug therapies such as thrombolytic therapy, 5-hydroxytryptamine agonists, NMDA receptor antagonists, and free radical scavengers are being studied.

Hospital Admission and Acute Stroke Units

Cerebrovascular diseases are medical emergencies. Hospital admission rates for stroke vary from 40 to 80% depending on the country. The burden of stroke in terms of hospital expenditures and health co

Should One Use Echocardiography or Contrast Transcranial Doppler Ultrasound for the Detection of a Patent Foramen Ovale after an Ischemic Cerebrovascular Accident

Patent foramen ovale is frequently associated with embolic cerebrovascular accidents. The diagnosis of patent foramen ovale is easier since the advent of transesophageal echocardiography. However, this method is semi-invasive and is not readily available in all units. Contrast transcranial Doppler ultrasound enables the detection of the passage of a contrast material injected into a peripheral vein to the cerebral circulation across an orifice which is most often a patent foramen ovale. Contrast transcranial Doppler ultrasound may facilitate, with a high sensitivity and specificity, the diagnosis of a patent foramen ovale when a transesophageal echo is not possible. However, transesophageal echocardiography remains the preferred test especially in the young since other potentially embolic sources, such as a thrombus in the left atrium, may be demonstrable.