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Oral anticoagulants dramatically reduce the risk of embolic stroke in patients with atrial fibrillation (AF). However, each year, 1 to 3 % of patients will present an ischemic stroke despite being on oral anticoagulant. These events can result from efficacy fluctuations, non-cardioembolic stroke, or insufficient efficacy despite appropriate anticoagulation. There are several therapeutic options depending on presumed mechanism of ischemic stroke. However, none of these options has been specifically evaluated in appropriate studies. These options include: reinforcement of education or change in VKA drugs in case of documented therapeutic fluctuations, adjunction of aspirin, change to direct oral anticoagulants, or percutaneous left-appendage closure.

Fibromuscular dysplasia (FMD) is an uncommon, segmental, nonatherosclerotic arterial disease of unknown etiology, involving intermediate-sized arteries in many areas of the body. It affects primarily women. FMD is often asymptomatic and discovered as an incidental finding. It can, however, be associated with ischemic stroke spontaneous dissection, intracranial aneurysm, and hemodynamic compromise of the distal circulation, and therefore can be a cause of cerebral ischemic symptoms or subarachnoid hemorrhage in some patients.

Stroke is a disabling and very heterogeneous disease that has beneficiated from major therapeutic improvements over the past 25 years both in terms of preventive strategies and acute care. The better knowledge of the epidemiology of stroke has allowed to recognize the worldwide burden of the disease, and to identify the vascular risk factors. This article reviews the main current data about the epidemiology of stroke.

Atherosclerotic carotid stenosis is a risk factor for stroke and other vascular events. Preventive medical treatment is based on the elimination of risk factors and the use of antithrombotic drugs. Surgery remains the standard revascularization treatment. The benefits of carotid surgery are especially important for severe (or = 70%) symptomatic carotid stenosis. The benefits of surgery for moderate (or =60%) asymptomatic stenosis or for moderate (50-69%) symptomatic stenosis are slight, particularly in women. The treatment decision requires consideration of individual factors to optimize the risk/benefit ratio.

Antiplatelet therapy is the reference treatment for secondary prevention after noncardioembolic ischemic stroke. The main aim of the Match study was to compare the combination of aspirin (75 mg) and clopidogrel (75 mg) with clopidogrel (75 mg) alone in secondary prevention after recent ischemic stroke or transcient ischemic attack in high-risk patients. The incidence of the composite principal endpoint (ischemic stroke, myocardial infarction, vascular death, or acute ischemic event causing hospitalization) was 15.7% at 18 months in patients in the aspirin-clopidogrel arm, compared with 16.7% in the placebo-clopidogrel arm. The relative risk reduction (6.4%) was not significant (95%CI, -4.6 to 16.3; p=0.244). Patients receiving the combination of aspirin and clopidogrel had more life-threatening bleeding than those treated by clopidogrel alone (2.6% vs 1.3%; 95%CI, 1.3 to 2.6; p0.001). Recruitment that began too late and an over-selected population, with overrepresentation of patients with diabetes and small vessel disease in particular, may partly explain these negative results.

Atherosclerosis of carotid and vertebrobasilar arteries is a strong risk factor for ischemic stroke, as well as a strong and independent predictor of myocardial infarction and vascular death. Within the past years, the important progress made in the knowledge of carotid atherosclerosis prognosis has contrasted with the lack of studies for vertebral atherosclerosis. In patients with carotid atherosclerosis, the risk of stroke is clearly related to the severity of stenosis and the risk of recurrent ipsilateral stroke is much higher than the risk of a first-ever stroke. Patients with intracranial atherosclerosis seem to carry a high risk of stroke. Therapies for the prevention of vascular events in patients with carotid and vertebrobasilar atherosclerosis include modification of arterial risk factors, antithrombotic therapies and sometimes carotid surgery. When the benefit of surgery is very high for patients with symptomatic severe carotid stenosis, this benefit is small for those with symptomatic moderate or asymptomatic severe carotid stenosis. New medical strategies and the advantages of angioplasty are currently under investigation.

Diffusion tensor imaging allows a 3D analysis of water molecular motion and an exploration of white matter tracts integrity and orientation. We report a diffusion tensor study of wallerian degeneration of the corticospinal tract following a capsulo-lenticular hemorrhage in a 49-year old man. Reduced anisotropy (loss of fiber coherence) with preserved diffusivity of the damaged corticospinal tract was observed. This highlights the feasibility of diffusion tensor imaging on clinical MR units and its ability to quantify the degree of white matter tract destruction.

Stiff limb syndrome is a recently described variant of stiff man syndrome and is characterized by limb stiffness and spasms. Unlike stiff man syndrome, stiff limb syndrome is rarely associated with anti GAD antibodies, poorly improves after symptomatic treatment, and has a relapsing and remitting course. Both stiff man and stiff limb syndromes are frequently associated with auto-immune diseases. We report a case of a 70-year old man who presented with a stiff limb syndrome associated with symptoms highly suggestive of Hashimoto's encephalopathy. The signs of encephalopathy dramatically resolved after corticosteroid treatment, and remissions was complete after 12 months. The stiff limb syndrome had a remitting course despite symptomatic treatment including diazepam, baclofen and vigabatrin and immunomodulating treatments including corticoid and intravenous immunoglobulins.

Central nervous system (CNS) demyelinating episodes have been described following numerous vaccines but there is no definite conclusion about a causal relationship. Recently, in France, in the context of an Expanded Program on Immunization, several cases of CNS demyelination have been observed following injection of recombinant hepatitis B (HB) vaccine, leading to great concern.We performed a hospital-based case-control study of 121 patients with a first episode of CNS demyelination occuring between July 1993 and December 1995 and 121 age and sex matched controls seen in the same period. Data on vaccinations history of cases and controls were collected by a postal questionnaire and confirmed by a phone interview.Adjusted odds ratio (OR) obtained from conditional logistic regression between a first episode of CNS demyelination and any vaccination were equal to 1.4 (95 p. 100 CI 0. 5-4.3) for an exposure within the 60 previous days and 2.1 (95 p. 100 CI 0.7-6.0) for an exposure within the 61-180 previous days. Similar results were found for HB vaccine exposure within the 60 previous days (adjusted OR=1.7, 95 p. 100 CI 0.5-6.3) or within the 61 to 180 previous days (adjusted OR= 1.5, 95 p. 100 CI 0.5-5.3).These findings did not permit to exclude confidently an association between HB vaccine and the occurrence of a first CNS demyelinating episode.

Paraneoplastic limbic encephalitis (PLE) is a manifestation of clinico pathological entity encephalo-myelo-neuropathy associated with anti-neuronal antibodies type 1 (ANNA-1 also called anti-Hu). Isolated PLE is rare. We reported a case of PLE in a 61-year-old heavy smoker man. An inappropriate antidiuretic hormone secretion syndrome was associated. Cranial MRI showed hyperintensity in amygdalo-hippocampic regions on T2 weighted sequences which appeared hypointense on T1-weighted sequences without gadolinium enhancement. Anti-Hu antibodies were absent in serum and in CSF. Despite chemotherapy, he died 18 months after disease onset. Our patient presented PLE without myelonouropathy and without ANNA-1 which suggests a different immunopathology.

Sufficient recanalization is achieved by thrombectomy only in 70-80% of cases and often after several attempts. Better adaptation of the treatment to the thrombus could improve this result. Current knowledge of intracranial thrombus is limited in both diagnostic and therapeutic applications. For this reason, we wished to study: 1) the variability over time of the appearance of intracranial thrombus on MRI in the acute phase of cerebral infarction; 2) the response to different thrombectomy techniques depending on the type of thrombi.The probability of observing a Susceptibility Vessel Sign (SVS) on the T2* sequence increases with the time between the onset of symptoms and MRI images acquisition, highlighting the existence of dynamic phenomena modifying the composition of the thrombus during its incubation period at the occlusion site. SVS- thrombi, corresponding to fibrin-rich thrombi, which are elastic and difficult to extract, seem to be more frequent during the early therapeutic window. These variations will be confirmed by a radio-histological correlation. On the other hand, rapid removal of the stent during thrombectomy increases the chances of complete recanalization after a single pass in both in vitro experiments with fibrin-rich thrombus (RR=4.00; 1.11-14.35; Pint=0.048) and in vivo with SVS- thrombus (RR 95%IC = 4.30 [1.80-10.24]). This technique was also effective regardless of the type of thrombus, in vitro (RR=1.83; 95%CI, 1.12-2.99) and in vivo in a large series of 320 patients (OR, 2.88 [1.81-4.59]). A randomized trial is needed to confirm these results., Une recanalisation suffisante n’est obtenue par la thrombectomie que dans 70-80% des cas et bien souvent après plusieurs tentatives. Mieux adapter le traitement au thrombus pourrait permettre d’améliorer ce résultat. Les connaissances actuelles sur le thrombus intracrânien présentent des applications limitées tant sur le versant diagnostic que thérapeutique. C’est pour cela que nous avons souhaité étudier : 1) la variabilité au cours du temps de l’aspect du thrombus intracrânien en IRM à la phase aigüe de l’infarctus cérébral ; 2) la réponse à différentes techniques de thrombectomie en fonction du type de thrombi.La probabilité d’observer un Susceptibility Vessel Sign (SVS) sur la séquence T2* augmente en fonction du temps entre le début des symptômes et la réalisation de l’IRM; mettant en évidence l’existence de phénomènes dynamiques modifiant la composition du thrombus lors de sa période d’incubation au site d’occlusion. Les thrombus SVS-, correspondant à des thrombus riches en fibrine, élastiques et difficiles à extraire semblent plus fréquents lors de la fenêtre thérapeutique précoce. Ces variations seront confirmées par une corrélation radio-histologique. D’autre part, un retrait rapide du stent lors de la thrombectomie permet d’augmenter les chances de recanalisation complète au premier passage en lors d’expériences in vitro sur thrombus riche en fibrine (RR=4.00; 1.11-14.35; Pint=0.048) comme in vivo sur thrombus SVS- (RR 95%IC = 4.30 [1.80-10.24]). Cette technique s’avère également efficace quel que soit le type de thrombus, in vitro (RR=1.83; 95%CI, 1.12-2.99) et in vivo dans une large série de 320 patients (OR, 2.88 [1.81-4.59]). Une étude randomisée est nécessaire pour confirmer ces résultats.

National audience; En 2017, l’ONDPS a reçu la mission, de la part de la ministre de la santé Agnès Buzyn, de lancer une étude sur la prise en charge de la santé sexuelle et reproductive des femmes. L’une des particularités de cette prise en charge tient à la pluralité des acteurs : sages-femmes, médecins généralistes, gynécologues médicaux et obstétriciens. Les compétences de chacun sont pour partie bien différentes mais aussi pour partie communes et qui, de ce fait, se superposent. L’intensité des tensions entre professionnels soulève la question des formes de coopérations possibles. C’est dans cet objectif que l’ONDPS a confié au Laboratoire d’études et de recherche en sociologie (LABERS), une étude sur les relations entre ces différents professionnels, à partir des enseignements de l’histoire et de l’analyse sociologique. Ce rapport présente le résultat de leur étude et vise à mieux appréhender les pratiques de coopération, de délégation, les habitudes de travail mais aussi les résistances à cette coopération.

Background and purpose. In patients with acute ischaemic stroke, early recanalization with IV thrombolysis and/or mechanical thrombectomy correlates with good functional outcome. However, the accessibility to these treatments is heterogeneous and the use of telemedicine may reduce these geographical disparities. Method. Among the residents in Western Normandy hospitalized for an acute ischemic stroke in the hospitals of Western Normandy between January 2013 and December 2017, we determined the rate of treatment with IV thrombolysis or/and mechanical thrombectomy, overall and according to their place of residence. We also compared the treatment rate before (2013-2015) and after (2016-2017) the implementation of telemedicine in Western Normandy. Results. In 2013-2017, among the 10,733 stroke patients (mean age=72years, 51% of men), 893 (8%) were treated with IV thrombolysis and/or mechanical thrombectomy. The proportion of patients treated IV thrombolysis or/and mechanical thrombectomy ranged from 3% to 28%.The proportion of treated patients varied based on the place of residence, and was lower in the subgroup of patients living in rural area and further away from the hospitals. The rate of treatment significantly increased from 8% to 12% (p

Introduction. Socio-economic factors involvement in response to the reperfusion treatment of acute ischemic stroke is badly known. The aim of the study is to evaluate functional outcome at 3 months of ischemic stroke treated by reperfusion and to evaluate if this prognosis relies on socio-economic factors. Methods. This retrospective observational study include all patients living in West Normandy who benefits intraveinous thrombolysis and/or mechanical thrombectomy treatment between 2013 and 2017. Datas was collected in the 5 regional stroke units. Socio-economic informations of the city of residence was collected and a socio-economic deprivation index calculated. Modified Rankin scale ≤ 2 define a good functional outcome. Results. There was 893 reperfusion treatment with good functional outcome at 3 months in 363 (49%) cases. Multivariate analysis ajusted on age and on initial NIHSS found that no ischemic cardiopathy (OR=0,63, IC 95% [0,40 ; 0,99]) and ischemic stroke (OR=0,48, IC 95% [0,25 ; 0,92]) history was associated with good outcome. On univariate analysis, a good socioeconomic deprivation index was associated with good outcome (p=0,023). Significance vanished in multivariate analysis. Discussion. Our findings on patient outcome at 3 months are agreed with those rapported in literature and international registers. No evidence of socio-economics factors impact on outcome has been demonstrated.; Introduction. Le rôle de l’environnement socioéconomique est mal connu dans la réponse au traitement d’un infarctus cérébral (IC) traité par recanalisation. L'objectif était d'évaluer le pronostic fonctionnel des patients à 3 mois d'un IC traité par recanalisation et d'évaluer si ce pronostic dépend de facteurs socioéconomiques. Matériel et Méthode. Cette étude observationnelle inclut tous les patients résidant en Normandie Occidentale et ayant reçu un traitement de recanalisation, par thrombolyse intra-veineuse et/ou par thrombectomie mécanique, entre le 01/01/2013 et le 31/12/2017. Les données ont été recueillies dans les 5 unités neurovasculaires de la région. Les données socio-économiques des communes de résidence des patients, ont été récupérées, un index de déprivation socio-économique a été calculé. Un bon pronostic fonctionnel à 3 mois était défini par un score de Rankin modifié ≤ 2. Résultats. 893 patients ont été traités par recanalisation. 363 (49%) avaient un bon pronostic à 3 mois. En analyse multivariée, après ajustement sur l'âge et le NIHSS moyen initial, l'absence d'antécédent d'infarctus cérébral (OR=0,48, IC 95% [0,25 ; 0,92]) et de cardiopathie ischémique (OR=0,63, IC 95% [0,40 ; 0,99]) était associée à un bon pronostic. En analyse univariée, un index de déprivation socio-économique favorable est corrélé à un meilleur pronostic à 3 mois (p=0,023). La différence disparaît en multivarié. Discussion. Le pronostic des patients dans notre étude sont en accord avec ceux de la littérature et des registres internationaux. Nous n'avons pas mis en évidence de différence significative de pronostic selon le niveau socioéconomique des patients.