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Background:: Advance announcement of forthcoming brain death has developed to enable intensivists and organ procurement organisation coordinators to more appropriately, and separately from each other, explain to relatives brain death and the subsequent post-mortem organ donation opportunity., Research Aim:: The aim was to assess how potentially involved healthcare professionals perceived ethical issues surrounding the strategy of advance approach., Research Design:: A multi-centre opinion survey using an anonymous self-administered questionnaire was conducted in the six-member hospitals of the publicly funded East of France regional organ and tissue procurement network called 'Prélor'., Participants:: The study population comprised 460 physicians and nurses in the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Units and the Emergency Departments., Ethical Considerations:: The project was approved by the board of the Lorraine University Diploma in Medical Ethics and the Prélor Network administrators., Main Findings:: A slight majority of 53.5% of respondents had previously participated in an advance relatives approach: 83% of the physicians and 42% of the nurses. A majority of healthcare professionals (68%) think that the main justification for advance relatives approach is the comprehensive care of the dying patient and the research of his or her most likely opinion (74%). The misunderstanding of the related issues by relatives is an obstacle for 47% of healthcare professionals and 51% think that the answer given by the relatives regarding the most likely opinion of the person regarding post-mortem organ donation really corresponds to the person opinion in only 50% of the cases or less., Conclusion:: Time given by advance approach should be employed to help and enable relatives to authentically bear the values and interests of the potential donor in the post-mortem organ donation discussion. Nurses' attendance of advance relatives approach seems necessary to enable them to optimally support the families facing death and post-mortem organ donation issues.

Background and Purpose—Whether all acute stroke patients with large vessel occlusion need to undergo intravenous thrombolysis before mechanical thrombectomy (MT) is debated as (1) the incidence of post-thrombolysis early recanalization (ER) is still unclear; (2) thrombolysis may be harmful in patients unlikely to recanalize; and, conversely, (3) transfer for MT may be unnecessary in patients highly likely to recanalize. Here, we determined the incidence and predictors of post-thrombolysis ER in patients referred for MT and derive ER prediction scores for trial design. Methods—Registries from 4 MT-capable centers gathering patients referred for MT and thrombolyzed either on site (mothership) or in a non MT-capable center (drip-and-ship) after magnetic resonance– or computed tomography–based imaging between 2015 and 2017. ER was identified on either first angiographic run or noninvasive imaging. In the magnetic resonance imaging subsample, thrombus length was determined on T2*-based susceptibility vessel sign. Independent predictors of no- ER were identified using multivariable logistic regression models, and scores were developed according to the magnitude of regression coefficients. Similar registries from 4 additional MT-capable centers were used as validation cohort. Results—In the derivation cohort (N=633), ER incidence was ≈20%. In patients with susceptibility vessel sign (n=498), no-ER was independently predicted by long thrombus, proximal occlusion, and mothership paradigm. A 6-point score derived from these variables showed strong discriminative power for no-ER (C statistic, 0.854) and was replicated in the validation cohort (n=353; C statistic, 0.888). A second score derived from the whole sample (including negative T2* or computed tomography–based imaging) also showed good discriminative power and was similarly validated. Highest grades on both scores predicted no-ER with >90% specificity, whereas low grades did not reliably predict ER. Conclusions—The substantial ER rate underlines the benefits derived from thrombolysis in bridging populations. Both prediction scores afforded high specificity for no-ER, but not for ER, which has implications for trial design.

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care., Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered., Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14-2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low., Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons., Funding: Medtronic., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Intravenous thrombolysis with alteplase alone cannot reperfuse most large-artery strokes. We aimed to determine whether mechanical thrombectomy in addition to intravenous thrombolysis improves clinical outcome in patients with acute ischaemic stroke., Methods: THRACE is a randomised controlled trial done in 26 centres in France. Patients aged 18-80 years with acute ischaemic stroke and proximal cerebral artery occlusion were randomly assigned to receive either intravenous thrombolysis alone (IVT group) or intravenous thrombolysis plus mechanical thrombectomy (IVTMT group). Intravenous thrombolysis (alteplase 0·9 mg/kg [maximum 90 mg], with an initial bolus of 10% of the total dose followed by infusion of the remaining dose over 60 min) had to be started within 4 h and thrombectomy within 5 h of symptom onset. Occlusions had to be confirmed by CT or magnetic resonance angiography. Randomisation was done centrally with a computer-generated sequential minimisation method and was stratified by centre. The primary outcome was the proportion of patients achieving functional independence at 3 months, defined by a score of 0-2 on the modified Rankin scale, assessed in the modified intention-to-treat population (ie, patients lost to follow-up and those with missing data were excluded). Safety outcomes were analysed in the per-protocol population (ie, all patients who did not follow the protocol of their randomisation group precisely were excluded from the analysis). THRACE is registered with ClinicalTrials.gov, NCT01062698., Findings: Between June 1, 2010, and Feb 22, 2015, 414 patients were randomly assigned to the IVT group (n=208) or the IVTMT group (n=204). Four patients (two in each group) lost to follow-up and six (four in the IVT group and two in the IVTMT group) with missing data were excluded. 85 (42%) of 202 patients in the IVT group and 106 (53%) of 200 patients in the IVTMT group achieved functional independence at 3 months (odds ratio 1·55, 95% CI 1·05-2·30; p=0·028). The two groups had no significant differences in mortality at 3 months (24 [12%] deaths of 202 patients vs 27 [13%] of 206; p=0·70) or symptomatic intracranial haemorrhage at 24 h (four [2%] of 185 vs three [2%] of 192; p=0·71). Common adverse events related to thrombectomy were vasospasm (33 [23%] patients) and embolisation in a new territory (nine [6%])., Interpretation: Mechanical thrombectomy combined with standard intravenous thrombolysis improves functional independence in patients with acute cerebral ischaemia, with no evidence of increased mortality. Bridging therapy should be considered for patients with large-vessel occlusions of the anterior circulation., Funding: French Ministry for Health., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aim: Practitioners are faced with a substantial challenge when considering recombinant tissue plasminogen activator (rt-PA) therapy for older patients with ischemic stroke. Patients aged over 80 years suffer from the most severe cerebral infarcts. The benefit of rt-PA treatment compared with single standard care only in stroke units remains to be clearly assessed., Methods: We collected data from 321 patients aged over 80 years admitted for acute cerebral infarction to the stroke unit of Nancy University Hospital in France between 1 January 2009 and 31 December 2012. Patients were stratified into two groups: treated or not with rt-PA. Baseline characteristics and outcome were collected and compared between both groups. Good outcome at 3 months was defined as modified Rankin Scale score ≤2., Results: The 55 patients treated with rt-PA had a higher National Institute of Health Stroke Scale score on admission than those without (15 vs 5; P < 0.001). They were more likely to have intracranial haemorrhage (20 vs 5%; P < 0.001) without an increased mortality rate (28 vs 27%; P = 0.95). Multivariate analysis showed a more favorable outcome (odds ratio 7, 95% confidence interval 3-16.5; P < 0.001). Slightly higher percentages of patients with modified Rankin Scale ≤2 were found after intention-to-treat analysis (49 vs 45%) and after exclusion of patients with baseline modified Rankin Scale >2 (57 vs 54 %), but without reaching significance (P > 0.05)., Conclusions: Rt-PA therapy would appear to improve prognosis in the elderly with ischemic stroke. This suggests that age alone should no longer be a barrier to rt-PA therapy. Geriatr Gerontol Int 2016; 16: 843-849., (© 2015 Japan Geriatrics Society.)

Background and Purpose: Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system., Participants and Methods: A single-centre opinion survey of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013., Ethical Considerations: The project was approved by the board of the Lorraine University Diploma in Medical Ethics., Results: Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor's family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient's care. But more than 75% of respondents think that the advance patient's consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France., Conclusion: The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families' support. But they ask to require previously expressed patient's consent and family's approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy., (© The Author(s) 2014.)

Background: Recommended treatments for spontaneous intracranial hypotension (SIH) range from bed rest only to neurosurgery. However, the serious form of SIH is poorly defined. A better description of patient characteristics and their outcome may help define therapeutic options., Methods: We reviewed 24 cases of patients with SIH and separated them into 2 groups according to whether or not they presented with signs of severity at admission: disturbance of consciousness, subdural hematomas (SDHs), and cerebral venous thrombosis., Results: Nine patients (37%) were classified as having a serious form of SIH: six (25%) presented SDHs; three (12%) disturbance of consciousness; and one (4%) cerebral venous thrombosis. Bed rest and epidural blood patches (EBPs) were sufficient to treat all patients in the nonserious form group and 4 patients in the serious form group. Two patients (8%) had to undergo cerebrospinal fluid leak repair, and 3 others (12%) evacuation of SDHs. Outcome was good in both groups, with only one (4%) death due to extensive SDHs. Times to diagnosis in the serious form group (63 vs. 35 days, P = 0.052) and to recovery (9 months vs. 5 months, P = 0.088) tended to be higher without reaching difference., Conclusions: The presence of SDHs, disturbance of consciousness, and a trend toward a longer time to diagnosis and recovery seem to define the serious form of SIH. These patients may require exploration and surgical repair of cerebrospinal fluid leak, only after failure of conservative measures--bed rest and time--and EBP, with good outcome., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Withdrawing artificial nutrition in palliative care is an issue that often leads to ethical dilemmas among health care providers, despite clinical guidelines., Objectives: To describe the experience of health care providers confronted with the withdrawing of artificial nutrition at the end of life and identifying the factors related to the level of ethical dilemmas., Methods: Cross-sectional survey questionnaire of all the nurses and nurses' aides working in medicine, surgery, and palliative care departments of a regional hospital and who have already been confronted with the withdrawal of artificial nutrition., Results: Of 818 questionnaires sent, 274 were returned (response rate 33.5%); 60% (163) of the care providers who responded were involved in withdrawing artificial nutrition at the end of life. Among these, 42 (25.8%) had always or often been affected with ethical dilemmas, and 97 (60%) responded that withdrawing artificial nutrition had always or often been preceded by a multidisciplinary discussion. Items significantly associated with a high level of ethical dilemmas were (1) existence of differences in opinion within the health care team, (2) lack of information regarding the indication of the withdrawal of artificial nutrition, (3) feeling uncomfortable with the patient and his or her relatives, (4) guilt, (5) feeling of abandonment of care, and (6) uneasiness., Conclusion: Health care providers seem to have a lack of information and consensus regarding the withdrawal of artificial nutrition at the end of life. The ethical dimension of withdrawing artificial nutrition in palliative care has a strong impact on care providers, regardless of the circumstances of the withdrawal., (© The Author(s) 2014.)

Diagnosis of cerebral cortical venous thrombosis in patients with postdural puncture headache (PDPH) is usually secondary to changes in headache pattern or cerebral infarctions. Nevertheless, incidental discovery of asymptomatic forms on brain imaging has never been reported before and its management thus remains ill-defined. We describe 2 cases of patients with asymptomatic cortical vein thrombosis in the context of PDPH. In both cases, brain computed tomography (CT) scans showed an isolated cortical vein thrombosis without cerebral damage. Neurological examination revealed the typical orthostatic feature of PDPH, independently of cortical vein thrombosis which was considered as a radiological incidental finding. Clinical and radiological signs resolved after bed rest, oral caffeine, and anticoagulation therapy. Asymptomatic cortical vein thrombosis may be found on radiological exploration, even basic like brain CT scan without contrast, of PDPH. Utility of anticoagulation therapy, which could increase the risk of cerebral hemorrhagic complications in this specific context, has to be assessed., (Copyright © 2014 by the American Society of Neuroimaging.)

Background: Cerebrovascular events in neuroborreliosis are a rare condition described only in isolated or small case series. No specific clinical or radiological features have been identified, and diagnosis is based on very different criteria., Methods: We retrospectively describe cases diagnosed in the Stroke Unit of Nancy Hospital, located in the endemic area of the northeast of France. We also reviewed other cases found in the literature., Results: We identified 5 cases in our center and 57 other reported cases. Mean age was 39 years (range 5 to 77). Possible previous contact with Borrelia burgdorferi (B burgdorferi) was found in about half of cases. Additional neurologic symptoms (headache, cognitive impairment, and/or gait disturbance) were found in 44% of cases. Cerebral imaging revealed both ischemic (87%) and hemorrhagic lesions (13%) with a multiterritorial aspect in 22% of strokes, and signs of vasculitis in 71%. Analysis of cerebrospinal fluid (CSF) revealed lymphocytic meningitis in 90% of cases and elevated protein level in 86%. CSF/serum anti-B burgdorferi antibody index (AI) was positive in 91% of cases. Outcome was favorable after appropriate antibiotic treatment. Our 5 patients presented a modified Rankin scale score 0-1, without any stroke recurrence, after a median follow-up of 2.8 years., Conclusions: The diagnosis of Lyme neuroborreliosis should be considered for patients with cerebrovascular events without obvious cause living in an endemic area, in the presence of repeat multiterritorial strokes at short intervals, other neurologic symptoms, a history of B burgdorferi infection, and radiological signs of vasculitis. Diagnosis can be confirmed by CSF analysis with AI but with an incomplete sensitivity., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Context: In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality., Objectives: To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not., Methods: Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital., Results: Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified., Conclusion: The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences., (© The Author(s) 2014.)

Background: Working memory is the most impaired cognitive domain in the acute phase of stroke. In a context where anxiety is highly prevalent, close attention must be paid to anxiety which could mimic mild to moderate working memory impairments. This is the first study to assess the contribution of state anxiety (the currently experienced level of anxiety) to the working memory (verbal, visuospatial) in patients with first-ever acute stroke without severe cognitive impairment., Methods: 28 patients with first-ever acute stroke and 41 matched control subjects were exposed to a neutral condition and an anxiogenic condition in which verbal (VWM) and visuospatial working memory (VSWM) performance and state anxiety were assessed. State anxiety was assessed before the beginning of the experiment (baseline), after the neutral condition and after the anxiogenic condition., Results: The mean state anxiety score was higher in patients than in controls in the neutral (z = 1.9, p<0.05) and anxiogenic (z = 2, p<0.05) conditions despite a similar level at baseline. Multiple regression analyses with a dummy variable 'group' (patients vs controls) showed that increased state anxiety in patients contributed significantly more to both reduced VWM (β = -0.93, p<0.05) and VSWM (β = -1, p<0.05) performance between the neutral and anxiogenic conditions compared to controls., Conclusions: In a stressful context, the contribution of state anxiety to reduced working memory performance is more pronounced in patients with acute stroke than in controls. These results are of particular relevance for clinicians assessing patients in the acute phase of stroke in which anxiety is highly prevalent., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Reports of occurrence of deep vein thrombosis during intensive sport are scarce. While a few cases have been described in the cerebral territory, these are only in the context of traumatism or anabolic agent consumption. Thus, causality with exercise remains uncertain and the mechanisms hypothetic. We present the case of a young athlete who experienced two episodes of severe cerebral venous thromboses (CVT), both during intensive training, in the absence of any other known thrombogenic factor., Case Presentation: A healthy 26-year-old man presented a thrombosis of the superior sagittal sinus during recent intensive training for a triathlon. Investigation at the time found no drug or anabolic steroid consumption, or any hematologic or coagulation disturbance. Anticoagulation therapy was initiated for 10 months with good outcome. One year later, soon after returning to intensive exercise, mainly running, the patient presented a thrombosis of the straight sinus complicated by bithalamic hyperintensities observed on T2 magnetic resonance imaging sequences. Anticoagulation treatment was reinitiated and led to repermeabilization of the cerebral vein and reversibility of thalamic abnormalities. Four months later, the patient was free of headache and had no cognitive impairment. He continues to practice intensive sport with vitamin K antagonist as preventive treatment., Conclusion: This is the first case report of recurrent CVT in a context of intensive sport, without any other thrombogenic features, suggesting a causal link. Intensive exercise should be considered as a potential promoting factor of CVT and investigated during routine examination.

Background and Purpose: We aimed at comparing the long-term benefit-risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis., Methods: Long-term follow-up study of patients included in Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), a randomized, controlled trial of carotid stenting versus endarterectomy in 527 patients with recently symptomatic severe carotid stenosis, conducted in 30 centers in France. The main end point was a composite of any ipsilateral stroke after randomization or any procedural stroke or death., Results: During a median follow-up of 7.1 years (interquartile range, 5.1-8.8 years; maximum 12.4 years), the primary end point occurred in 30 patients in the stenting group compared with 18 patients in the endarterectomy group. Cumulative probabilities of this outcome were 11.0% (95% confidence interval, 7.9-15.2) versus 6.3% (4.0-9.8) in the endarterectomy group at the 5-year follow-up (hazard ratio, 1.85; 1.00-3.40; P=0.04) and 11.5% (8.2-15.9) versus 7.6% (4.9-11.8; hazard ratio, 1.70; 0.95-3.06; P=0.07) at the 10-year follow-up. No difference was observed between treatment groups in the rates of ipsilateral stroke beyond the procedural period, severe carotid restenosis (≥70%) or occlusion, death, myocardial infarction, and revascularization procedures., Conclusions: The long-term benefit-risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis favored endarterectomy, a difference driven by a lower risk of procedural stroke after endarterectomy. Both techniques were associated with low and similar long-term risks of recurrent ipsilateral stroke beyond the procedural period., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00190398., (© 2014 American Heart Association, Inc.)

The rural district of the Meuse (East France) has a high number of elderly patients for whom prognosis of ischaemic strokes is poor with high-haemorrhagic transformation risk of intravenous tissue plasminogen activator (rt-PA). This disadvantage is made worse by the distances a patient has to travel to the nearest stroke unit. We set out to assess the effectiveness of a telestroke system implemented in this area. Between October 2010 and February 2012, data from each "tele-expertised" patient were collected. 53 patients were examined. Diagnosis of ischaemic stroke was confirmed in 43 cases (81 %), and intravenous rt-PA treatment performed in 21 cases (40 %). In the treated patient group, median age was 73 years, with 29 % of octogenarians. Baseline National Institutes of Health Stroke Scale (NIHSS) was 16, with 29 % ≥ 20. The median onset to needle time was 169 min, and the median door to needle time was 69 min. Intracranial haemorrhage occurred in 3 cases (14 %), and was symptomatic in two (10 %). At 3 months, median NIHSS was 6, 6 patients (29 %) presented a favourable outcome (modified Rankin scale ≤ 1) and 3 (14 %) had died. In rural areas, for elderly patients with severe ischaemic strokes, telemedicine appears to be a way of improving accessibility and benefits of rt-PA treatment.

Context: Ischemia of the cervical spinal cord is a rare complication of spontaneous vertebral artery dissection (VAD) and usually involves the ventral portion. We describe a less evocative clinical presentation and images of unilateral posterior spinal cord infarction due to spontaneous VAD in order to facilitate early diagnosis., Findings: A previously fit 30-year-old man presented with persistent headaches and proximal motor deficit of the right arm. He was diagnosed with spontaneous dissection of both vertebral arteries, with occlusion of the right one, and the right carotid artery. Neurological examination also revealed a right C2-C3 tactile sensory loss, with unilateral proprioceptive deficit below. Brain images revealed small bilateral cerebellar infarcts which could not be responsible for the clinical symptoms. Magnetic resonance imaging of the spinal cord showed a right posterior cervical spinal cord infarction. The patient achieved nearly complete recovery after several weeks of anticoagulation and rehabilitation., Conclusion and Clinical Relevance: Infarction of the caudal portion of the cervical spinal cord, especially unilateral, caused by spontaneous VAD, has rarely been described and is certainly under-diagnosed due to less suggestive symptoms, like unilateral and mainly sensory deficit. Nevertheless, early diagnosis of this condition is important to guide patient management and rehabilitation.

The authors report on 3 rare cases of ruptured lenticulostriate artery (LSA) aneurysms that were heralded by deep cerebral hematomas. The hematomas were unilateral in 2 cases and bilateral in 1; in the bilateral case, only a single LSA aneurysm could be identified on the right side of the brain. Because of their small size (≤ 2 mm), fusiform aspect, and deep location within the brain, all of the aneurysms were treated conservatively. There was no hemorrhage recurrence, and follow-up angiography demonstrated spontaneous thrombosis in 2 of the 3 cases. The clinical course was favorable in 2 of the 3 patients. The course in the patient with the bilateral hematoma was marked by an ischemic event after the initial episode, resulting in an aggravation of deficits. The cause of this second event was uncertain. Because our knowledge about the natural history of LSA aneurysms is incomplete, there is no consensus concerning a therapeutic strategy. The authors' experience in 3 reported cases leads them to think that a conservative approach involving close angiographic monitoring may be proposed as first-line treatment. If the monitored aneurysm then persists or grows in size, its occlusion should be considered. Nonetheless, other studies are needed to further strengthen the legitimacy of this strategy.

Objective: In view of the negative impact of anxiety on working memory, we induced anxiety in 26 patients with acute stroke and 33 healthy controls, and studied how the anxiety affected their emotional reactivity and how the reactivity affected their verbal and visuospatial working memory. We compared the overall findings with those in 1 of our patients (C.B.) who had presented with an abnormally high level of state anxiety., Methods: We gave verbal and visuospatial 1-back tasks under both neutral and anxiogenic conditions, and we compared participants' working memory scores, self-reported levels of state anxiety, and electrodermal activity., Results: When comparing performance in the neutral condition, the control and patient groups exhibited disrupted verbal working memory, which was associated with greater electrodermal activity and higher state anxiety during the anxiogenic condition. Although patient C.B. also had heightened electrodermal activity during the anxiogenic condition, she experienced a significant reduction in her state anxiety. Her verbal working memory was better during the anxiogenic than the neutral condition., Conclusions: Because of the phonological (subvocal speech) nature of verbal working memory, a higher level of anxious apprehension could explain the increase in state anxiety and the corresponding disruption of verbal working memory in our patient and control groups during the anxiogenic condition. C.B.'s lower state anxiety and selective improvement in verbal working memory during the anxiogenic condition suggest that she felt less anxious apprehension.

Increased ischemic stroke risk is observed in patients with inflammatory bowel disease (IBD). Causes and physiopathological aspects of cerebral infarct, in this specific population, are less often described. There is little information to provide guidelines for the best curative and preventive treatment. We report 2 cases of ischemic strokes due to internal carotid thrombus in patients during active phase of IBD. Ulceration of early atherosclerotic plaques activated by a hypercoagulation state may cause a thrombus. A combined therapy with heparin and corticosteroids was used for both our patients. Lysis of the thrombus was obtained after several days without surgical treatment and shown by ultrasonography. These cases highlight an aetiology of stroke in patients with IBD and use of a synergic treatment to respond to hypercoagulability in link with IBD. Benefits and safety of this therapy should be confirmed with clinical studies.

Background and Purpose: Aspirin is the most commonly used antiplatelet treatment during the acute phase of cerebral ischemic events. It inhibits the production of thromboxane (TX) A(2), a powerful platelet activator. Despite this protection, early ischemic recurrences are frequent and considered clinical failures of this therapy. Only a few trials have focused on the use of antiplatelet therapy during this phase, and none has described the laboratory effect of the first dose of aspirin given after an ischemic cerebral event. However, this study may help clinicians to understand the mechanisms of early recurrences, and to design new therapeutic strategies, in particular for patients already treated with a daily dose of aspirin., Method: We studied laboratory parameters of the first 300-mg oral dose of aspirin given within 48 h after an ischemic cerebral event. Two blood samples were taken from all of the patients: the first during the third hour following aspirin intake (T1) and the second during the twenty-fourth hour (T2). For patients already treated with a daily dose of aspirin, a supplementary sample was taken before aspirin intake (T0). Platelet reactivity was studied on the basis of serum TXB(2) levels, a metabolite of TXA(2), and light transmission aggregometry after stimulation of platelet-rich plasma by arachidonic acid and by two concentrations of collagen, i.e. 2 µg/ml (Col2), dependent on the TXA(2) pathway, and 20 µg/ml (Col20), independent of the TXA(2) pathway. Results with Col2 were related to results with Col20 (Col2/20 ratio) to limit the impact of variations induced by the effects of preanalytical conditions., Results: Fifty patients were included. TXB(2) values (p < 0.001) and relative values of the Col2/20 ratio (p = 0.037) were significantly higher at T2 compared to T1. For patients already treated with aspirin, TXB(2) levels (p < 0.001) were significantly lower at T1 compared to T0, and the Col2/20 ratio tended to decrease (p = 0.096)., Conclusion: Platelet reactivity recovers within 24 h following the first 300-mg oral dose of aspirin during the acute phase of a cerebral ischemic event as demonstrated by an increase in TXB(2) levels, and the Col2/20 ratio, at T2 compared to T1. This would favor early ischemic recurrences. However, for patients already treated with aspirin, this dose is able to decrease TXB(2) levels and to complete the inhibition of the TXA(2) pathway, which shows the utility of this prescription in this case., (Copyright © 2012 S. Karger AG, Basel.)

Background: Essential thrombocythemia (ET) is considered as a rare cause of stroke, partially because of difficulties to identify it when platelet count is not greatly elevated. However, early detection of ET is important because, without adapted treatment, recurrent thromboses are frequent., Method: We collected, retrospectively, data from 14 cases of stroke patients with ET. Clinical characteristics, ischaemic stroke, laboratory data (platelet and leucocyte count, haemoglobin, JAK2 V617F mutation, culture of haematopoietic progenitors) and treatment were reviewed. Every patient has been interviewed by phone to evaluate outcome., Results: The population consisted of nine women and five men with ages ranging from 40 to 87 years. Most of the patients (12) had atherosclerotic risk factors and two presented a thrombus in the internal carotid. ET was diagnosed early after the onset of stroke except in two patients. The platelet count was under 600*10(9) /L for five patients. Mutation JAK2 V617F was found for eight patients. Thirteen patients were treated with an association between antiplatelet and cytoreductive treatment and did not present further thrombosis. Median follow-up is 2.8 years., Conclusion: These cases emphasize the problems of diagnosing ET at the onset of the stroke. Complete blood count has to be carefully read and ET can be suspected even if platelet count is not greatly increased. Diagnosis must be confirmed by haematologist to initiate appropriate treatment., (© 2010 The Author(s). European Journal of Neurology © 2010 EFNS.)

This case describes the treatment of an 84-year-old male patient with acute bi-frontal ischemic stroke, due to thromboembolic occlusion of the A1 segment of the left anterior cerebral artery (ACA) only. The National Institutes of Health Stroke Scale (NIHSS) was 11. Intravenous fibrinolysis was performed with a good outcome. Repermeabilization of both ACA was demonstrated by imaging and, 24 h after treatment, NIHSS was 0. Although intravenous thrombolysis is mostly used for middle cerebral artery occlusion, this case emphasizes the benefit of this treatment for an ischemic stroke due to embolization of the A1 segment of the left ACA only. It is all the more original in that it describes an unusual treatment for this arterial territory, and with this anatomic particularity.

This case describes the medical history of a 61-year-old woman treated for cerebral venous thrombosis (CVT) leading to diagnosis of essential thrombocythemia (ET). During treatment with unfractionated heparin, after initial improvement of clinical state, signs of cerebral hypertension reappeared. Although the platelet count decreased, heparin-induced thrombocytopenia (HIT) was only suspected 2 days later when it dropped below the standard 150 × 10(9) L(-1) threshold. HIT diagnosis was confirmed by the presence of anti-PF4/heparin IgG. This late finding was the cause of the extension of CVT with worsening of cerebral hypertension necessitating decompressive craniectomy. Elevated basal platelet count due to ET can delay diagnosis and treatment of HIT. In this case, physicians should be more attentive to platelet count variations rather than thrombocytopenia threshold.

Background: Operative management of patients with persistent N2 disease after induction therapy is still debated., Methods: One hundred fifty-three consecutive patients underwent pneumonectomy from January 1999 until July 2005; 28 patients (18.3%) had persistent N2 disease after induction therapy (group 1), 32 patients (20.9%) had pathologic stage N0 or N1 after induction therapy (group 2), and 93 patients (60.8%) with pathologic N2 disease underwent immediate surgery (group 3). Short-term end points were operative mortality at 30 and 90 days and major complications. Long-term end points were 5-year survival and disease-free survival rates., Results: Demographics of the three groups were similar (age, sex, side of operation, type of chemotherapy, smoking status, and comorbidity such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease). Thirty-day postoperative mortality was 10.7% in group 1, 3.1% in group 2 (p = 0.257), and 4.3% in group 3 (p = 0.201); 90-day postoperative mortality was 10.7% in group 1, 12.5% in group 2 (p = 0.577), and 9.7% in group 3 (p = 0.558). Incidence of major postoperative complications was similar. Five-year survival rate was 32.2% (median, 28 months; 95% confidence interval, 7 to 43) in group 1, 34.8% (median, 27 months; 95% confidence interval, 7 to 47) in group 2 (p = 0.685), and 12.4% (median, 15 months; 95% confidence interval, 11 to 19) in group 3 (p = 0.127). No statistical difference was found in terms of 5-year event-free survival, or regarding the side of pneumonectomy., Conclusions: Our results suggest that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.

The association of spontaneous intracranial hypotension (SIH) with cerebral venous thrombosis (CVT) is rare. We are reporting two new cases. In one case, CVT is extensive concerning three sinuses and bilateral parietal cortical veins and, in the other case, only a cortical vein is involved. Both the patients presented had no thrombosis risk factors. There is certainly a link between these two pathologies. SIH should be considered as a risk factor of CVT. Modification of symptoms of SIH leading to CVT must be known to start early treatment.

Aim: To carry out an appropriate overview and inventory of the teaching of ethics within the European Union Schools of Medicine., Methods: A questionnaire was sent by email to 45 randomly selected medical schools from each of 23 countries in the European Union in February 2006., Results: 25 schools of medicine from 18 European countries were included (response rate = 56%). In 21 of 25 medical schools, there was at least one ethics module. In 11 of 25 medical schools, the teaching of ethics was transversal. Only one of the responding schools did not teach ethics. The mean time invested in ethics teaching was 44 h during the overall curriculum., Conclusions: Ethics now has an established place within the medical curriculum throughout the European Union. However, there is a notable disparity in programme characteristics among schools of medicine.

Background: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid., Methods: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day., Results: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups., Conclusion: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Background: There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center., Methods: The charts of 298 patients operated on between January 1999 and July 2005 were reviewed. Patients were divided into two groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fistula and acute respiratory distress syndrome. Statistical analyses were performed using SPSS 11.0 software., Results: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; patients were older in group 2 (61.83+/-9.58 years vs 57.75+/-8.94 years; p=0.003) and there were more female patients in group 2 (17.2% vs 5.0%; p=0.010). Post-operative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p=0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p=0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p=0.652); incidence of bronchopleural fistulas was 1.7% in group 1 and 5.5% in group 2 (p=0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p=0.675)., Conclusion: In opposition to previous reports, induction chemotherapy did not significantly jeopardize post-operative outcome following pneumonectomy in our experience.

Background: The reliability of duplex scanning (DS) for the diagnosis of internal carotid artery dissections (ICAD) is not clear., Methods: Nine DS signs known to be suggestive for the diagnosis of ICAD were compared between 70 patients with ICAD and 70 matched patients without dissection., Results: Visible internal tapering occlusion, regular eccentric narrowing channel, ectasia beyond the carotid bulb, resistive index asymmetry, blood flow slowdown, ophthalmic artery blood flow inversion, and biphasic flow are more frequent in cases than in controls (p < 0.001). Atheroma plaques were absent in 80% of ICAD. When DS direct signs and hemodynamic signs were studied, sensitivity was 90% and specificity 60%., Conclusion: Diagnosis of ICAD by DS could be improved if direct signs were combined with hemodynamic signs, giving a high sensitivity and a rather good specificity., (Copyright 2007 S. Karger AG, Basel.)

Background: Carotid stenting is less invasive than endarterectomy, but it is unclear whether it is as safe in patients with symptomatic carotid-artery stenosis., Methods: We conducted a multicenter, randomized, noninferiority trial to compare stenting with endarterectomy in patients with a symptomatic carotid stenosis of at least 60%. The primary end point was the incidence of any stroke or death within 30 days after treatment., Results: The trial was stopped prematurely after the inclusion of 527 patients for reasons of both safety and futility. The 30-day incidence of any stroke or death was 3.9% after endarterectomy (95% confidence interval [CI], 2.0 to 7.2) and 9.6% after stenting (95% CI, 6.4 to 14.0); the relative risk of any stroke or death after stenting as compared with endarterectomy was 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At 6 months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). There were more major local complications after stenting and more systemic complications (mainly pulmonary) after endarterectomy, but the differences were not significant. Cranial-nerve injury was more common after endarterectomy than after stenting., Conclusions: In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. (ClinicalTrials.gov number, NCT00190398 [ClinicalTrials.gov].)., (Copyright 2006 Massachusetts Medical Society.)

Arterial stiffness assessed by the pulse wave velocity (PWV), a non-invasive and reproducible method, predicts cardiovascular morbidity and mortality. The main determinants of arterial stiffness are well established in younger and middle-aged populations, but much less in the elderly. The aim of this study was to describe the determinants of arterial stiffness in elderly apparently healthy subjects. The study included 221 voluntary subjects born before 1944 (mean age 67.4+/-5.0 years), who had a standard health check-up at the 'Centre de Médecine Préventive' of Nancy. Arterial stiffness was evaluated by measuring the carotid-femoral PWV with the PulsePen automatic device. Clinical and biological parameters were evaluated at the same day. Measurements were valid and analysed in 207 subjects (94 women). Mean PWV was 9.39+/-2.64 m/s. Men showed higher PWV values than women (9.99+/-2.56 vs 8.66+/-2.56, P<0.001). In univariate analysis, PWV was correlated with age (r=0.26, P<0.001) and mean arterial pressure (MAP) (r=0.40, P<0.001), and these relationships were similar in men and women. Subjects with hypertension (P<0.001), diabetes mellitus (P<0.001) and obesity (P<0.01) had higher values of PWV. In multiple regression analysis, PWV correlated positively and independently with age, male gender, MAP and diabetes mellitus. In conclusion, in an apparently healthy elderly population, the main determinants of arterial stiffness are the age, MAP, diabetes and gender. Our study also shows that the gender-related differences in arterial stiffness observed in middle-aged subjects are maintained in the elderly.

Objective: This study compares accuracy of sampling versus formal node dissection in patients with primary lung cancer., Patients and Methods: During a 4-month period, 208 consecutive patients (172 men, 36 women) without bulky disease underwent resection for primary lung cancer in three centers. The surgeon first sampled the main lymph node stations, and subsequently performed a radical mediastinal dissection. Endpoints were accuracy of prediction for stage N2 and radicality of node sampling compared to dissection., Results: Resection consisted of 1 segmentectomy, 142 standard lobectomies, 6 bilobectomies, 14 sleeve-lobectomies, and 45 pneumonectomies. There were 108 squamous cell carcinomas, 621 adenocarcinomas, 18 bronchoalveolar carcinomas, 8 large cell carcinomas, 4 adenosquamous carcinomas and 8 neuroendocrine carcinomas. Primary tumor was stage T1 in 49 patients, T2 in 110, T3 in 43, and T4 in 6. Lymph node status (dissection) was N0 in 113, N1 in 35, and N2 in 60 patients. N2 disease concerned a single node in 16, a single node station in 19, and multiple levels in 25. Both N1 and N2 nodes were diseased in 36 patients. Sampling adequately recognized N2 disease in 31 patients (52%). Multiple level N2 was accurately identified in 10 patients (40%). Resection based on sampling would have been incomplete in 53 patients (88%)., Conclusion: Radical mediastinal dissection is a mandatory adjunct to resection for lung cancer with curative attempt.

Background: This study evaluates the impact of the underlying disease upon the surgical outcome of bronchoplastic lobectomy, comparing typical carcinoid tumours with primary lung carcinoma., Patients and Methods: This retrospective study includes 98 consecutive patients (78 males, 20 females). Eighteen patients had a typical carcinoid tumour (group 1), and 80 had a primary bronchial carcinoma (group2). Fifty-six patients underwent bronchoplasty with full sleeve resection (10 patients from group 1, 46 from group 2) and 42 patients had a bronchoplasty with bronchial wedge resection (8 from group 1 and 34 from group 2). Right upper lobectomy was the most common procedure. We compared demographic data, surgical indications, the type of bronchoplasty and postoperative complications., Results: The average age in group 1 (38.5+/-16.3 years; range 15-77) was significantly lower than in group 2 (61.4+/-9.5 years; range 14-75) (p<0.001). There were no postoperative deaths. Procedure-specific complications (anastomotic dehiscence and atelectasis) were found in 7 patients (8.75%) in group 2 (of which, three had a combination of two of the above-mentioned complications) but none (0%) in group 1 (p=0.23). Seven patients from group 2 (8.75%) required treatment for a residual pneumothorax for none (0%) in group 1 (p=0.23). The mean duration for air leak was comparable in both groups (p=0.366). Three patients (16.67%) from group 1 had non-surgical complications compared to 17 (21.25%) in group 2 (of which, one had a combination of two non-surgical complications) (p=0.35)., Conclusion: Bronchoplastic resection is a safe operation in patients with carcinoid tumours and should be the reference for treatment.

Objective: To investigate on the feasibility, safety, and effectiveness of a new bioabsorbable material for lung staple-line reinforcement., Methods: This prospective open trial included 66 patients (mean age of 56+/-17 years) who underwent various types of lung resection using staplers with knitted calcium alginate sleeves for buttressing (FOREseal, Laboratoires Brothier, Nanterre, France) at three academic centers: 29 lobectomies, 22 emphysema surgeries, 15 wedge resections or lung biopsies. Intraoperative air leakage was assessed at a mean respiratory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, was assessed daily. The follow-up period was of 6 months., Results: No technical problem linked to the device occurred. Hemostasis of the cutting edges was completed in all patients. Fifty-six percent of the patients had no intraoperative air leak and 27.3% had grade 1 leaks. Mean postoperative air leaks and thoracic drainage times were 1.9+/-2.3 days and 6+/-5.3 days, respectively. In-hospital mortality was nil. There was no empyema. Mean hospital stay was 9.1+/-6.6 days. At follow-up, one patient underwent lung transplantation, and pathology of the explanted specimen showed the absence of device-related foreign-body inflammation. One patient complained from metalloptysis, and another one, with a metastatic invasive aspergillosis, developed an infectious recurrence that required reoperation., Conclusions: FOREseal is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement. A randomized comparative study is now in progress.

Background: Symptomatic intracranial atherothrombotic stenoses (ICAS) are associated with high rates of cerebrovascular ischemic events., Objective: To conduct a prospective multicenter study to evaluate the natural history of ICAS and, in those patients refractory to medical treatment, the outcomes associated with intracranial angioplasty., Methods: Patients aged 18 to 80 were enrolled with symptoms attributed to a single ICAS of > or =50%. Optimal medical therapy of vascular risk factors and preventive antithrombotic therapy were at the discretion of the local investigator. Patients were eligible for intracranial angioplasty after experiencing recurrent stroke despite medical therapy. Neurologic and ultrasonographic examinations were performed at study inclusion, 3 months after enrollment, and every 6 months of follow-up thereafter, for 36 months., Results: One hundred two patients were included, with a mean age of 63.3 +/- 10.4 years. Intracranial artery stenoses involved the vertebral artery in 22.5%, the basilar artery in 25.5%, the middle cerebral artery in 26.5%, and the internal carotid artery in 25.5%. In 27.4% of the patients, the stenoses had clinical hemodynamic characteristics. During a mean follow-up of 23.4 months, 38.2% of the patients had a cerebrovascular event: ischemic stroke in 13.7% and TIA in 24.5%. Among patients with a hemodynamically significant stenosis, 60.7% had a recurrent stroke or TIA in the territory of the stenotic artery; this association was significant in univariate analysis. Twenty-eight patients underwent an endovascular procedure with a neurologic periprocedural complication rate of 14.2%. The overall vascular death rate was 8.8%., Conclusions: Despite medical treatment, the 2-year recurrence rate of ischemic events in the territory of the stenotic artery was 38.2%. Cardiovascular events occurred in 18.6% of patients. Clinically significant hemodynamic stenoses were associated with stroke recurrence and may help identify a high risk subset of patients.

Background: Management of vascular risk factors is not optimal in stroke patients. We assessed the control of hypertension, smoking and stopping of oral contraceptive in 581 consecutive young cryptogenic ischemic stroke patients followed in the PFO-ASA study and we identified factors associated with inadequate management., Methods: At each follow-up visit, blood pressure (BP), smoking and use of oral contraceptive were recorded. Data were analyzed at 6 months, 1 and 2 years. Hypertension was defined as systolic BP > or = 140 or diastolic BP > or = 90 mm Hg, recorded in at least two follow-up visits. Current smoking was defined as more than one cigarette per day reported during at least one follow-up visit., Results: During follow-up, 36% of patients were hypertensive and 30% were smokers. Among the 90 hypertensive patients at baseline, 60-68% remained with high BP and among the 278 patients who were current smokers at baseline, 54-58% still smoked during follow-up. Age (OR = 1.05, 95% CI 1.02-1.08), male sex (OR = 1.42, 95% CI 0.93-2.18), body mass index > or = 27 (OR = 2, 95% CI 1.27-3.17) and known hypertension (OR = 3.08, 95% CI 1.80-5.28) were significantly associated with hypertension during follow-up. Tobacco consumption at baseline (OR = 35.2, 95% CI, 19.3-64.2), alcohol consumption at baseline (OR = 2.7, 95% CI 1.4-5.2) and Rankin < or = 2 (OR = 2.6, 95% CI 1.4-4.9) were independently associated with persistent smoking. Among the 114 women who were using combined estrogen-progesterone pills at baseline, 96.5% stopped., Conclusions: Major risk factors for stroke are poorly controlled after stroke, even in the context of a prospective clinical study in young adults., (Copyright 2005 S. Karger AG, Basel.)

Intravenous fibrinolysis (IVF) with rt-PA (alteplase) provides significant benefits in acute ischaemic stroke when it is given within the first three hours following stroke onset. Intra-arterial fibrinolysis (IAF) with pro-urokinase in PROACT II study provides quite the same benefit in the first 6 hours. IVF and IAF have never been compared. To compare the efficacy and safety of IVF and IAF with urokinase given within the first 6 hours of acute ischaemic stroke. Patients fulfilling the selection criteria were randomly assigned to receive urokinase 900,000 units via intravenous or intra-arterial routes. This randomised monocentre study was done between December 1995 and August 1997. The primary outcome was defined as the number of patients with a modified Rankin score of 2 or less. Secondary outcomes included mortality, frequency of symptomatic intracranial haemorrhage (SIH), neurological and functional scores. Fourteen patients were given IVF and 13 IAF. The study was terminated by the National Health Authorities when 27 patients had been included because of the mortality rate. Seven patients (26%) died, 4 in the IV group (oedematous infarct in 3 and recurrence in 1), 3 in the IA group (SIH in 2, and oedematous infarct in 1). Patients given IVF were treated significantly earlier (4:16 h vs 5:24 h; p=.007). Although IA patients showed greater and earlier improvement there was no significant difference in primary and secondary outcomes. Because of premature termination, the trial was too small to provide any reliable and conclusive results. Intra-arterial fibrinolysis began significantly later than IV fibrinolysis but it gave non-significantly better results in this prematurely terminated study.

Fibroblast growth factors (FGF), hepatocyte growth factor (HGF) and their receptors, FGFR and c-Met, are essential components of the regulatory networks between the epithelium and mesenchyme in embryonic lung, but their respective roles in tumour growth are not clear. We performed allelotyping at loci containing the candidate genes FGFR-1-2-3-4, FGF-1-2-7-10, c-Met and HGF in 36 non-small cell lung cancer (NSCLC) (20 squamous-cell carcinomas (SQC) and 16 adenocarcinomas (ADC)), by surrounding each locus with two microsatellites (MS), as close as possible to the genes of interest. Unexpectedly, SQC and ADC were frequently altered at all of these loci, and SQC showed more simultaneously altered loci. In ADC, alterations at the 15q13-22 locus (FGF7 candidate gene) were significantly more frequent. Thus, these loci showed different patterns of molecular alterations between SQC and ADC. Finally, alterations at loci containing FGFR and HGF candidate genes were inversely correlated to the lymph node status in SQC and ADC, respectively.

The majority of lung cancer patients have tumor-derived genetic alterations in circulating plasma DNA that could be exploited as a diagnostic tool. We used fluorescent microsatellite analysis to detect alterations in plasma and tumor DNA in 34 patients who underwent bronchoscopy for lung cancer, including 11 small cell lung cancer (SCLC) and 23 nonsmall cell lung cancer (NSCLC) (12 adenocarcinomas, 11 squamous cell carcinomas) and 20 controls. Allelotyping was performed with a selected panel of 12 microsatellites from 9 chromosomal regions 3p21, 3p24, 5q, 9p, 9q, 13q, 17p, 17q and 20q. Plasma DNA allelic imbalance (AI) was found in 88% (30 of 34 patients), with a similar sensitivity in SCLC and NSCLC. In the 24 paired available tumor tissues, 83% (20 of 24) presented at least 1 AI. Among these patients, 85% (17 of 20) presented also at least 1 AI in paired plasma DNA, but the location of the allelic alterations in paired plasma and tumor DNA could differ, suggesting the presence of heterogeneous tumor clones. None of the 20 controls displayed plasma or bronchial DNA alteration. A reduced panel of six markers (at 3p, 5q, 9p, 9q) showed a sensitivity of 85%. Moreover, a different panel of microsatellites at 3p and 17p13 in SCLC and at 5q, 9p, 9q and 20q in NSCLC patients could be specifically used. Analysis of plasma DNA using this targeted panel could be a valuable noninvasive test and a useful tool to monitor disease progression without assessing the tumor., (Copyright 2003 Wiley-Liss, Inc.)

Background: Determination of tumor clonality has implications for molecular characterization and the optimal treatment of cancer. Allelotyping allows detection of the two alleles, maternal and paternal, and provides additional information regarding clonal genetic defects. The presence of allelic imbalances (AI) in tumors is a general event, but is not necessary at the same allele (alternative AI). The authors' goal was to determine whether the presence of alternative AI (AA) was a marker of heterogeneity and prognosis., Methods: To further analyze the heterogeneity of lung tumors, tumor DNA released in the plasma was compared with primary tumor DNA from 24 lung carcinoma patients. The comparison was performed by allelotyping using 12 microsatellites targeting 9 chromosomal regions, taking in each case leukocyte DNA as reference. To extend and confirm these observations, 26 primary colorectal carcinomas with paired synchronous liver metastasis were analyzed using an enlarged panel of 33 microsatellites., Results: AA were observed in 40% (20 of 50) of all patients, in 25% (6 of 24) of lung carcinoma patients but at a higher level, and in 54% (14 of 26) of colorectal carcinoma patients. They affected different chromosome localizations and each tumor stage. In both types of cancer, patients with AA had a higher AI mean frequency in their primary tumor., Conclusions: Detection of AA is an original marker of heterogeneous tumors, demonstrating that independent events occurred on specific genetic sites required for cancer progression., (Copyright 2003 American Cancer Society.DOI 10.1002/cncr.11324)

Purpose: To evaluate three-dimensional (3D) digital subtraction angiography (DSA) as a supplement to two-dimensional (2D) DSA in the endovascular treatment (EVT) of intracranial aneurysms., Materials and Methods: In 22 ruptured aneurysms, neck visualization, aneurysm shape, and EVT feasibility were analyzed at 2D DSA (anteroposterior, lateral, and rotational views) and at maximum intensity projection (MIP) and surface shaded display (SSD) 3D DSA. The possibility of obtaining a working view for EVT at 3D DSA and the relevance of measurements in choosing the first coil also were assessed., Results: Two-dimensional DSA images clearly depicted the aneurysm neck in four of 22 aneurysms; MIP images, in 10; and SSD images, in 21, but SSD led to overestimation of the neck size in one aneurysm. Aneurysm shape was precisely demonstrated in five of 22 aneurysms at 2D DSA, in eight at MIP, and in all cases at SSD. In two of 22 aneurysms, EVT seemed to be nonfeasible at 2D DSA; however, SSD demonstrated feasibility and EVT was successfully performed. In one aneurysm, only SSD demonstrated the extension of the neck to a parent vessel, which was proved at surgery. Working views for EVT were deduced from 3D DSA findings in 20 of 21 aneurysms. The choice of the first coil was correct in 19 of 21 aneurysms., Conclusion: Three-dimensional DSA is valuable for evaluating the potential for EVT, finding a working view, and performing accurate measurements.

Background: Video-assisted thoracoscopic surgery (VATS) requires one-lung ventilation with a properly collapsed lung. This study compared the Broncho-Cath double-lumen endotracheal tube with the Wiruthan bronchial blocker to determine the advantages of one device over the other during anaesthesia with one-lung ventilation for thoracoscopy., Methods: Thirty-five patients undergoing VATS were randomly assigned to one of two groups. Sixteen patients received a left-sided double-lumen tube (DLT) and nineteen a Wiruthan bronchial blocker (BB). The BB group was subdivided in two: BB in the right mainstem bronchus (BBR) for right-sided VATS (9 patients), BB in the left mainstem bronchus (BBL) for left-sided VATS (10 patients). The position of the devices was checked using a fibreoptic bronchoscope. The following variables were measured: 1) number of unsuccessful placement attempts; 2) number of malpositions of the devices; 3) time required to place the device in the correct position; 4) number of secondary dislodgements of the devices after turning the patient into the lateral decubitus position. The quality of lung deflation was evaluated by the surgeons who were blinded to the type of tube being used., Results: The number of unsuccessful placement attempts was one in the DLT group (1/16), three in the BBL group (3/10) and none in the BBR group (0/9). The number of malpositions was significantly greater in the BBL group (10/10) compared to the DLT group (2/16) and to the BBR group (1/9) (P<0.001). The time (mean+/-SD) required to place a BBL was 4.21 min+/-1.28, significantly longer than the time required to place a DLT (2.26 min+/-0.55, P<0.0006) or a BBR (2.41 min+/-0.53, P<0.008). The difference in placement time between DLT and BBR was not significant. The number of secondary dislodgements was one in the DLT group, one in the BBR group and none in the BBL group (NS). The quality of lung deflation was judged excellent or fair in all patients in the DLT and the BBL groups and poor in 44% of the patients in the BBR group., Conclusion: It took significantly longer to place a left BB than a DLT (P<0.0006) or a right BB (P<0.008). The number of initial malpositionings of the left BB was significantly greater than in the other groups (P<0.001). The quality of lung deflation was better in the BBL and in the DLT groups than in the BBR group. We conclude that for routine use during left-sided VATS, the use of a DLT is preferable to a left BB because of its greater ease of placement. For right-sided VATS, DLT and right BB showed the same facility of placement but the DLT provided a better quality of lung deflation.

Objective: Having demonstrated a poor prognosis of operable lung cancer in patients with previous head and neck malignancies, we intended to evaluate prognosis of lung cancer in patients with a history of extrapulmonary and extracervical malignancies., Methods: The population of this study included 55 patients; these were 40 males and 15 females, with a mean age 64.4+/-8.6 years. The previous malignancy was considered tobacco-induced in 15 patients (kidney, two; bladder, ten; esophagus, three), hormone-dependant in 18 (breast, six; female genital, eight; prostate, four), and miscellaneous in 22 (leukemia, four; skin, seven; colon, 11). Following complete resection, 25 patients were classified stage I, 13 were stage II, and 17 were stage IIIA., Results: There were two early perioperative deaths (3.6%), and three during the second month owing to cardiovascular complications. At the conclusion of the study (July 1st, 1997), 32 further patients had died (58.2%): 25 had progression of lung cancer, one had progression of previous malignancy, and six were without evidence of disease. Five-year survival (Kaplan-Meier) was estimated 47+/-10.2% in stage I (median 44 months), 30.8+/-15.6% in stage II (median 26 months), and 16. 7+/-9.9% in stage IIIA (median 17 months). When excluding five early perioperative deaths, 5-year survival was 51.1+/-10.6% in stage I (median 93 months), 33.3+/-16.7% in stage II (median 36.5 months), and 19.0+/-11.2% in stage IIIA (median 20.5 months). Comparing the three groups defined according to location of previous malignancy, there was no significant difference neither in stage distribution (chi(2)=1.326; P=0.857), nor in 5-year survival estimates: 38.9+/-12. 9% (median 27 months) after tobacco-induced malignancies, 38.9+/-11. 5% (median 24 months) following hormone-dependant malignancies, and 28.4+/-10.2% (median 28 months) following miscellaneous cancers (chi(2)=0.059; P=0.9707)., Conclusions: In opposition to data collected in patients with previous head and neck cancer, survival estimates according to stage were contained within the universally accepted range no high risk group has been identified. Resection of lung cancer with curative intent is a fair option in patients with previous extrapulmonary malignancy.