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Introduction One third of cryptogenic strokes are believed to be secondary to silent atrial fibrillation (AF) not detected by standard cardiac monitoring methods. The aim of our study was to identify the pathophysiological mechanisms leading to the onset of AF in stroke patients. Starting from the hypothesis of Coumel we approached the 3 factors involved in arrhythmias (atrial substrate, modulators, triggers). Methods We included all consecutive patients hospitalized for ischemic stroke of undetermined etiology at the admission in the Dijon stroke unit intensive care, between March and June 2018. AF screening was performed with a sequential and uninterrupted method associating continuous electrocardiographic monitoring (CEM) in intensive care unit, followed by a long lasting Holter-ECG monitoring during the whole hospitalisation. An insertable cardiac monitor (ICM) was implanted at discharge if necessary, according to current guidelines. We compared clinical, echocardiographic, rhythmic and biological data (including cardiovascular and inflammatory biomarkers such as osteoprotegerin (OPG)) between patients who remained in sinus rhythm and those developing AF. Results Among the 40 patients included, 14(35%) developed AF, of which 50% occurred within the first 48 hours after stroke. Holter-ECG monitoring during hospitalisation diagnosed 43% of AF, of which 83% occurred after the first day of monitoring, and would have not been diagnosed with a classical 24 h Holter-ECG. A model associating age ≥ 75years, left atrial indexed volume ≥ 26 ml/m2, OP ≥ 1190 pg/ml and pNN50(parasympathetic tone) on the first day of the CEM provided excellent prediction of AF occurrence (AUC 0.89, P Conclusion Our model including the three classical factors involved in arrhythmias allowed a comprehensive prediction of AF onset after stroke. The screening method for AF, using a sequential and prolonged monitoring, improved its detection while limiting the implantation of ICM.

Background Recurrent stroke is associated with increased disability and cognitive impairment, but the availability of secondary prevention measures after transient ischaemic attack (TIA) or stroke in Europe is uncertain. This limits prioritisation of investment and development of national stroke strategies. Methods National stroke representatives throughout Europe were surveyed. Consensus panels reported national data if available, or else expert opinion, estimating the availability of each intervention by quintiles of patients, dichotomised for analysis at 60%. Countries were classified into tertiles of gross domestic product per capita. Results Of 50 countries, 46 responded; 14/45 (31%) had national stroke registries and 25/46 (54.3%) had national stroke strategies incorporating secondary prevention. Respondents reported that the majority of TIA patients were assessed by specialist services within 48 hours in 74.4% of countries, but in nine countries more than 20% of patients were seen after more than seven days and usually assessed by non-specialists (7/46 countries). Eighty percent of countries deferred blood pressure assessment to primary care, whilst lifestyle management programmes were commonly available in only 46% of countries. Although basic interventions were widely available, interventions frequently not available to more than 60% of patients included: ambulatory cardiac monitoring (40% countries); prescription (26%) and continuation (46%) of statins; blood pressure control at follow-up (44%); carotid endarterectomy within one month (15%); face-to-face follow-up in hospital (33%); direct oral anticoagulants (21%). Gross domestic product per capita and reimbursement of interventions were the commonest predictors of availability of interventions. Conclusions Provision of secondary prevention varied, with gaps in care prevalent throughout Europe, particularly in lower income countries.

Stroke outcome is dependent on brain-derived neurotrophic factor (BDNF)-dependent neuroplasticity. As peripheral blood mononuclear cells (PBMC) contain BDNF, diapedesis of these cells might be followed by BDNF delivery to the ischemic brain. To test this hypothesis, we investigated the association between BDNF levels in PBMC and functional outcome in patients with ischemic stroke. BDNF was measured in PBMC that were isolated from ischemic stroke patients ( n = 40) just before (day 0) and after (days 1 and 3) fibrinolysis. Three months after stroke, patients were stratified using the modified Rankin Scale (mRS) according to the unfavorable (mRS scores 3–6) and favorable (mRS scores 0–2) functional outcome. We used univariate and multivariate logistic regressions to assess the relationship between BDNF levels in PBMC and functional outcome. BDNF levels in PBMC decreased from day 0 to day 3 in patients with unfavorable outcome, while they remained stable in patients with favorable outcome. Patients with favorable outcome exhibited at day 3 higher PBMC-BDNF levels than patients with unfavorable outcome and the levels were associated with good outcome (odd ratio: 12.0; 95% confidence interval, 1.4–106.2, P = 0.023). PBMC-BDNF levels remained a predictor of stroke outcome after adjusting from cardiovascular risk, interval between admission and fibrinolysis, stroke severity from hospital admission to discharge, lymphocytes count, neutrophils/lymphocytes ratio at admission. Favorable functional outcome in ischemic stroke patients that benefited from fibrinolysis was predicted by a high BDNF level in PBMC, suggesting that PBMC might serve as a cellular vector to deliver BDNF to the ischemic brain. Impact statement There are a great number of arguments suggesting that BDNF could be involved in stroke recovery dependent of neuroplasticity. Methods that can enhance BDNF levels in the ischemic brain could therefore have great clinical value. Peripheral blood mononuclear cells (PBMC) that contain BDNF and infiltrate early and sustainably the ischemic brain might be used as a cellular vector to deliver BDNF to the ischemic brain and consequently promote recovery. This work is important in this field to show if this BDNF derived from BDNF could exert a positive action on stroke recovery. Our main results showed that a high BDNF level at day 3 after hospital admission was associated with a 12.4 fold increase in favorable outcome after adjusting for still recognized prognostic markers. The new information in this field is this finding identifies PBMC as an attractive cellular vector to deliver BDNF to the ischemic brain.

Background and Purpose— For years, the relationship between cardiac and neurological ischemic events has been limited to overlapping pathophysiological mechanisms and common risk factors. However, acute stroke may induce dramatic changes in cardiovascular function. The aim of this study was to evaluate how prior cerebrovascular lesions affect myocardial function and signaling in vivo and ex vivo and how they influence cardiac vulnerability to ischemia-reperfusion injury. Methods— Cerebral embolization was performed in adult Wistar male rats through the injection of microspheres into the left or right internal carotid artery. Stroke lesions were evaluated by microsphere counting, tissue staining, and assessment of neurological deficit 2 hours, 24 hours, and 7 days after surgery. Cardiac function was evaluated in vivo by echocardiography and ex vivo in isolated perfused hearts. Heart vulnerability to ischemia-reperfusion injury was investigated ex vivo at different times post-embolization and with varying degrees of myocardial ischemia. Left ventricles (LVs) were analyzed with Western blotting and quantitatve real-time polymerase chain reaction. Results— Our stroke model produced large cerebral infarcts with severe neurological deficit. Cardiac contractile dysfunction was observed with an early but persistent reduction of LV fractional shortening in vivo and of LV developed pressure ex vivo. Moreover, after 20 or 30 minutes of global cardiac ischemia, recovery of contractile function was poorer with impaired LV developed pressure and relaxation during reperfusion in both stroke groups. Following stroke, circulating levels of catecholamines and GDF15 (growth differentiation factor 15) increased. Cerebral embolization altered nitro-oxidative stress signaling and impaired the myocardial expression of ADRB1 (adrenoceptor β1) and cardioprotective Survivor Activating Factor Enhancement signaling pathways. Conclusions— Our findings indicate that stroke not only impairs cardiac contractility but also worsens myocardial vulnerability to ischemia. The underlying molecular mechanisms of stroke-induced myocardial alterations after cerebral embolization remain to be established, insofar as they may involve the sympathetic nervous system and nitro-oxidative stress.

ObjectivesWe aimed to study trends in stroke unit (SU) admission during a period of their deployment in France and to assess whether this led to better and more equitable access to this specialised care.DesignAnalysis of records from the national hospital database.SettingAll acute care hospitals in metropolitan France for the period 2009–2014.ParticipantsOver 600 000 patients admitted in acute care with a main diagnosis of stroke.Main outcome measuresAdmission to a SU.ResultsBetween 2009 and 2014, the number of stroke admissions rose from 93 728 to 109 456, and the proportion of SU admission from 23% to 44%. Overall, characteristics associated with higher probability of SU admission were: male gender, younger age, ischaemic stroke type, medium level of comorbidity and larger size of town of residence. Although likelihood of SU admission increased in all patients’ categories during the study period, we identified steeper positive temporal trends among older patients, those with more comorbidities and those residing in medium or small towns (all p values ConclusionsAdmission to SU nearly doubled in France between 2009 and 2014. Faster trends observed for patients with lower admission to SU suggest that equity in access has improved over the period.

Background: We aimed to evaluate the impact of the ageing population on temporal trends in burden of stroke and to provide projections for the coming years. Methods: Stroke cases (ischemic strokes, spontaneous intracerebral hemorrhages, or undetermined strokes) were prospectively identified between 1987 and 2015 in Dijon, France, using a population-based registry. Age-standardized incidence rates of first-ever and recurrent stroke were calculated, and their temporal trends were assessed using age- and sex-adjusted annual incidence rate ratios (RR). Results: The population of Dijon increased by 3.8% over time, with an increase by 28% in the number of residents aged ≥75 years. We recorded 5,899 strokes including 5,101 patients with a first-ever event. Incidence of first-ever stroke was stable both in people < 75 and ≥75 years old, but an increase in standardized incidence rates of total strokes was noted due to a rise in the incidence of recurrent stroke (from 4.7/100,000/year in 1987–1994 to 12.3/100,000/year in 2009–2015 in people < 75 years old, RR 1.036; p < 0.001; from 74/100,000/year in 1987–1994 to 200/100,000/year in 2009–2015 in people ≥75 years, RR 1.040; p < 0.001). The absolute number of first-ever strokes increased by 43%, and that of total stroke events rose by 58% over time, with a more pronounced increase in people ≥75 years old (+47 and +65% respectively). The annual number of patients who survived > 90 days after a first-ever stroke increased by 90%. According to demographic projections, the total number of strokes will increase by 55% (+65% patients ≥75 years, and +25% patients < 75 years) by 2,030 in Dijon. Conclusions: Ageing and growth of the population led to a rise in the absolute number of strokes, especially in the elderly, that is expected to increase dramatically in the coming years. Improved stroke care was accompanied with an increase in stroke survivors that contributed to a rise in recurrent events. Urgent action is needed to meet this epidemiological challenge.

International audience; Objective: The aim of our study was to assess major cardiovascular event incidence, predictors, and mortality in ANCA-associated vasculitis (AAV).Methods: We conducted a retrospective cohort study of all GPA or MPA, according to Chapel Hill Consensus Conference classification criteria, diagnosed between 1981 and 2015. Major cardiovascular event was defined as acute coronary artery disease, or ischemic stroke, or peripheral vascular disease requiring a revascularization procedure. We calculated the comparative morbidity/mortality figure (CMF) and we used Cox proportional hazards regression models to assess the risk of coronary artery disease, ischemic stroke associated with AAV, after adjusting for covariates.Results: 125 patients, 99 GPA (79,2%) and 26 MPA (20,8%), were followed 88.4 ± 78.3 months. Ischemic stroke incidence was four times higher than in the general population (CMF 4,65; 95% CI 4,06-5,31). Coronary artery disease incidence was four times higher than in the general population (CMF 4,22; 95% CI 1,52-11,68). Smoking habits and history of coronary artery disease were strongly associated with coronary artery disease occurrence (adjusted HR 8.8; 95% CI 2.12-36.56, and adjusted HR 10.3; 95% CI 1.02-104.5, respectively). ENT flare-up was an independent protective factor for coronary artery disease occurrence. We did not identify factors significantly associated with stroke occurrence. The age-adjusted mortality rate was 22.5 per 1000 person-years. Mortality in AAV was 1.5 times higher than in the general population (CMF 1.56; 95% CI 1.34-1.83).Conclusion: AAV have a significantly increased risk of mortality, ischemic stroke, and coronary artery disease.

International audience; BACKGROUND: Many patients who receive intravenous (i.v.) recombinant tissue-plasminogen activator (rt-PA) for acute cerebral ischemia were under angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) at stroke onset. ACE-Is and ARBs have neuroprotective properties in animal models.OBJECTIVE: To evaluate whether the 3-month outcome of patients treated with i.v. rt-PA for cerebral ischemia was influenced by on-going therapy with ACE-Is or ARBs.METHODS: This study was observational, conducted in two prospective registries of stroke patients treated with i.v. rt-PA. We evaluated outcomes with the modified Rankin scale and symptomatic intracranial hemorrhages (s-ICH) according to the ECASS2 criteria. We compared outcomes between patients with and without ACE-Is/ARBs according to the modified Rankin scale (mRS) at month 3, using logistic regression analyses adjusted on propensity scores, and propensity-matched analyses.RESULTS: Of 1803 patients, 455 (25.2%) were under ACE-Is (259), ARBs (188) or both (8). At 3 months, patients under ACE-Is or ARBs were more likely to have an mRS 0-1, but did not differ for mRS 0-2, s-ICH and death. After adjustment on propensity scores, the association between ACE-Is/ARBs and mRS 0-1 disappeared. The propensity-matched analysis, performed in 397 pairs of patients, found no difference in outcomes between patients with and without ACE-Is or ARBs.CONCLUSIONS: In patients treated by intravenous thrombolytic therapy for ischemic stroke, on-going treatment with ACE-Is or ARBs does not influence on outcomes after adjustment on baseline characteristics and propensity scores.

To adapt the SS-QoL into French and test its psychometric properties.Seventy-seven patients from a population-based registry were enrolled 3 months after their stroke. SS-QoL, NIHSS score, Barthel index, HAD, FSS, SF-36 scales, and MMSE were administered at enrolment. SS-QoL was re-administered at 15 days and 2 months. Internal consistency was assessed by Cronbach's α coefficients, factorial validity by an exploratory factor analysis and external validity by Mann-Whitney test and Spearman's correlations (ρ), comparing SS-QoL scores with those obtained from established scales. Reliability was assessed by intra-class correlation coefficients (ICC) and responsiveness by standardized effect sizes (ES).Test-retest and inter-observer reliabilities were excellent (ICC 0.88). Internal consistency was acceptable (α= 0.65-0.91), except for the Personality domain (α= 0.58). Factor analysis individualized eight homogenous axes. SS-QoL scores were different between groups opposed by their modified Rankin score at enrolment or their overall quality of life compared with pre-stroke status (p 0.001). Ten of the twelve domains correlated moderately (ρ 0.35) to strongly (ρ 0.5) with established measures. Nine domains were mildly to moderately responsive to change (ES 0.3).The French version of the SS-QoL is a valid, reliable and moderately responsive instrument.

Summary Non-vitamin K antagonist oral anticoagulants (NOACs) – dabigatran, rivaroxaban, apixaban and edoxaban – are well established in terms of preventing stroke or systemic embolism in patients with non-valvular atrial fibrillation and high thromboembolism risk. When prescribed incorrectly, NOACs are associated with an increased risk of ischaemic events and bleeding. Current NOAC labels explicitly address dose adjustments according to age, body weight, renal function and concomitant treatment with P-glycoprotein inhibitors. The required dose adjustments vary significantly from molecule to molecule, thereby creating a complex dose adjustment environment. Furthermore, recommendations support assessment of individual risk using thromboembolic and bleeding risk scores. Evidence-based medicine also provides data about specific patient profiles. In particular, some patients who are at higher risk of bleeding, such as patients on polymedication, are often at higher risk of stroke. More and more patients are being treated with NOACs. The question of appropriate dosing has become important, as studies are starting to show that reduced doses are being prescribed at very high rates. Although these data have not been evaluated in light of individual risk assessments, in everyday practice, physicians are often more concerned about drug-related bleeding than about the spontaneous evolution of the disease (stroke/systemic embolism), leading to high rates of prescription of inadequately low doses. Recent results have shown that only certain risk criteria justify dose reduction. Thus, the right dose needs to be prescribed for the right patient in order to obtain, in real-life practice, the benefits of NOACs that have been demonstrated in randomized clinical trials.

Although secondary prevention in patients with arterial vascular diseases has improved, a gap between recommendations and clinical practice may exist.We aimed to evaluate temporal trends in the premorbid use of preventive treatments in patients with ischemic cerebrovascular events (ICVE) and prior vascular disease.Patients with acute ICVE (ischemic stroke/TIA) were identified through the population-based stroke registry of Dijon, France (1985-2010). Only those with history of arterial vascular disease were included and were classified into four groups: patients with previous coronary artery disease only (CAD), previous peripheral artery disease only (PAD), previous ICVE only, and patients with at least two different past vascular diseases (polyvascular group). We assessed trends in the proportion of patients who were treated with antihypertensive treatments and antithrombotics at the time of their ICVE using multivariable logistic regression models.Among the 5309 patients with acute ICVE, 2128 had a history of vascular disease (mean age 77.3±11.9, 51% men; 25.1% CAD 7.5% PAD, 39.8% ICVE, and 27.5% poylvascular). A total of 45.8% of them were on antithrombotics, 64.1% on antihypertensive treatment, and 34.4% on both. Compared with period 1985-1993, periods 1994-2002 and 2003-2010 were associated with a greater frequency of prior-to-ICVE use of antithrombotics (adjusted OR=5.94; 95% CI: 4.61-7.65, P0.01, and adjusted OR=6.92; 95% CI: 5.33-8.98, P0.01, respectively) but not of antihypertensive drugs. Consistent results were found when analyses were stratified according to the type of history of arterial vascular disease.Patients with ICVE and previous vascular disease were still undertreated with recommended preventive therapies.

Points essentiels La prise en charge des accidents vasculaires cerebraux (AVC) est desormais reconnue comme une urgence medicale au meme titre que l’infarctus du myocarde, car il existe un traitement medical, la fibrinolyse intraveineuse qui diminue le risque de deces immediat et de handicap moteur ou cognitif. Deuxieme caracteristique de l’AVC : sa tres grande frequence et son risque qui augmente chez les jeunes. Cette urgence medicale est structurante pour tout le systeme de soins car elle impose une « course contre la montre » pour le patient, sa famille et les professionnels de sante afin de pouvoir realiser la fibrinolyse intraveineuse dans les 3 premieres heures apres 80 ans, et dans les 4 h 30 avant 80 ans. Il est necessaire de debuter le traitement le plus rapidement possible lorsque l’indication est posee car il est plus efficace quand il est donne precocement. Plusieurs actions sont indispensables pour eviter toute perte de chance : sensibiliser le grand public sur les signes les plus pertinents pour suspecter un AVC, en diffusant le score FAST (paralysie de la face, du bras, du langage, en notant l’heure de debut) ; appeler le 15 devant toute suspicion d’AVC ; transferer le patient de preference par ambulance medicalisee, ou les pompiers ou une ambulance privee, vers le bon endroit (hopital ayant un service de neurologie avec imagerie) et au bon moment ; en l’absence de neurologue, utilisation de la tele-medecine afin de deleguer a l’urgentiste de l’hopital l’acte de fibrinolyse, apres imagerie cerebrale pour affirmer l’infarctus cerebral ; puis prise en charge du patient fibrinolyse ou non, dans une unite neuro-vasculaire au moins pendant 48 heures, delai pendant lequel se joue le pronostic vital et fonctionnel de l’AVC, et pendant lequel l’education therapeutique du patient est mise en place pour assurer une prevention secondaire optimale lors du retour a domicile. La prise en charge de l’AVC est ainsi devenue une urgence pluridisciplinaire mais centree autour du neurologue.

International audience; CASP specifically assesses post-stroke cognitive impairments. Its items are visual and as such can be administered to patients with severe expressive aphasia. We have previously shown that the CASP was more suitable than the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in aphasic patients. Our objective was to compare the above scales in non-aphasic stroke patients, and assess to what extent the solely visual items of the CASP were problematic in cases of neurovisual impairments.METHODS:Fifty non-aphasic patients admitted to Physical Medicine and Rehabilitation (PM&R) units after a recent left- or right-hemisphere stroke were evaluated with the CASP, MMSE and MoCA. We compared these three scales in terms of feasibility, concordance, and influence of neurovisual impairments on the total score.RESULTS:Twenty-nine men and 21 women were included (mean age 63 ± 14). For three patients, the MoCa was impossible to administer. It took significantly less time to administer the CASP (10 ± 5 min) than the MoCA (11 ± 5 min, P=0.02), yet it still took more time than MMSE administration (7 ± 3 min, P

Resume Introduction La maladie de Moyamoya est une atteinte vasculaire cerebrale chronique rare. L’objectif de cet article est de rapporter les differentes presentations cliniques, radiologiques, evolutives et therapeutiques de cette maladie. Methodes Nous avons recherche tous les cas de Moyamoya issus d’un centre hospitalo-universitaire francais. Le diagnostic fut porte en cas d’arteriographie confirmant une occlusion uni- ou bilaterale des terminaisons des arteres carotides internes ou sylviennes, associee a un reseau arteriel collateral typique. Nous avons analyse les donnees radiologiques et cliniques de patients identifies. Resultats Dix cas furent recueillis entre 2009 et 2014 dont un enfant et neuf adultes. Deux presenterent un accident vasculaire cerebral (AVC) hemorragique, six un AVC ischemique, et les deux derniers soit des accidents ischemiques transitoires ou soit des malaises a l’effort. Quatre patients presenterent une ou plusieurs recidives. Huit patients recurent un traitement medical et aucun un traitement chirurgical. Un Moyamoya secondaire fut evoque chez deux patients, les autres etaient idiopathiques. Conclusion Cette analyse retrouve une presentation plus frequente d’AVC ischemiques chez les adultes souffrant de cette maladie. Le diagnostic est toujours confirme par l’arteriographie et doit faire rechercher un Moyamoya secondaire. La recidive est frequente et fait donc considerer cette atteinte comme une maladie rare mais potentiellement grave.

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

Background and Purpose— This population-based study aimed to identify unplanned hospitalization within the first year after stroke to determine factors associated with it and consequences on survival. Methods— All first-ever acute strokes occurring in Dijon, France, from 2009 to 2011, were prospectively collected from a population-based registry. Demographics and clinical data, including stroke severity measured by the National Institutes of Health Stroke Scale and disability after stroke, were recorded. For each patient, the first unplanned hospitalization that occurred within 1 year after stroke was retrieved by linking data with the national French Hospital Discharge Database. Predictors of hospitalization and survival at 1 year were identified using logistic regression models. Results— Among the 613 patients recorded, 94 (15.3%) were excluded because of early death. Of the 519 remaining patients, 167 (32.2%) were hospitalized at 1 year. Subsequent hospitalization led to in-hospital death for 16 (9.6%) patients. In multivariable analyses, only a history of hypertension and atrial fibrillation were associated with hospitalization. In stratified analyses, the National Institutes of Health Stroke Scale score was associated with a higher risk of hospitalization (odds ratio, 1.13; 95% confidence interval, 1.03–1.22; P =0.006), whereas only a trend was noted for disability (odds ratio, 2.26; 95% confidence interval, 0.82–6.22; P =0.113) in patients who returned home after the index stroke. Hospitalization was negatively associated with being alive at 1 year (odds ratio, 0.36; 95% confidence interval, 0.19–0.66; P Conclusions— Stroke survivors are at high risk of hospitalization after the episode, and subsequent admission is associated with poor survival, thus highlighting the need for follow-up interventions after discharge to prevent readmission.

Background The greatest potential to reduce the burden of stroke is by primary prevention of first-ever stroke, which constitutes three quarters of all stroke. In addition to population-wide prevention strategies (the ‘mass’ approach), the ‘high risk’ approach aims to identify individuals at risk of stroke and to modify their risk factors, and risk, accordingly. Current methods of assessing and modifying stroke risk are difficult to access and implement by the general population, amongst whom most future strokes will arise. To help reduce the burden of stroke on individuals and the population a new app, the Stroke Riskometer™, has been developed. We aim to explore the validity of the app for predicting the risk of stroke compared with current best methods. Methods 752 stroke outcomes from a sample of 9501 individuals across three countries (New Zealand, Russia and the Netherlands) were utilized to investigate the performance of a novel stroke risk prediction tool algorithm (Stroke Riskometer™) compared with two established stroke risk score prediction algorithms (Framingham Stroke Risk Score [FSRS] and QStroke). We calculated the receiver operating characteristics (ROC) curves and area under the ROC curve (AUROC) with 95% confidence intervals, Harrels C-statistic and D-statistics for measure of discrimination, R2 statistics to indicate level of variability accounted for by each prediction algorithm, the Hosmer-Lemeshow statistic for calibration, and the sensitivity and specificity of each algorithm. Results The Stroke Riskometer™ performed well against the FSRS five-year AUROC for both males (FSRS = 75·0% (95% CI 72·3%–77·6%), Stroke Riskometer™ = 74·0(95% CI 71·3%–76·7%) and females [FSRS = 70·3% (95% CI 67·9%–72·8%, Stroke Riskometer™ = 71·5% (95% CI 69·0%–73·9%)], and better than QStroke [males–59·7% (95% CI 57·3%–62·0%) and comparable to females = 71·1% (95% CI 69·0%–73·1%)]. Discriminative ability of all algorithms was low (C-statistic ranging from 0·51–0·56, D-statistic ranging from 0·01–0·12). Hosmer-Lemeshow illustrated that all of the predicted risk scores were not well calibrated with the observed event data ( P < 0·006). Conclusions The Stroke Riskometer™ is comparable in performance for stroke prediction with FSRS and QStroke. All three algorithms performed equally poorly in predicting stroke events. The Stroke Riskometer™ will be continually developed and validated to address the need to improve the current stroke risk scoring systems to more accurately predict stroke, particularly by identifying robust ethnic/race ethnicity group and country specific risk factors.

Background— We explored the safety of intravenous thrombolysis (IVT) or intra-arterial treatment (IAT) in patients with ischemic stroke on non-vitamin K antagonist oral anticoagulants (NOACs, last intake Methods and Results— This is a multicenter cohort pilot study. Primary outcome measures were (1) occurrence of intracranial hemorrhage (ICH) in 3 categories: any ICH (ICH any ), symptomatic ICH according to the criteria of the European Cooperative Acute Stroke Study II (ECASS-II) (sICH ECASS-II ) and the National Institute of Neurological Disorders and Stroke (NINDS) thrombolysis trial (sICH NINDS ); and (2) death (at 3 months). Cohorts were compared by using propensity score matching. Our NOAC cohort comprised 78 patients treated with IVT/IAT and the comparison groups of 441 VKA patients and 8938 no-OAC patients. The median time from last NOAC intake to IVT/IAT was 13 hours (interquartile range, 8–22 hours). In VKA patients, median pre-IVT/IAT international normalized ratio was 1.3 (interquartile range, 1.1–1.6). ICH any was observed in 18.4% NOAC patients versus 26.8% in VKA patients and 17.4% in no-OAC patients. sICH ECASS-II and sICH NINDS occurred in 2.6%/3.9% NOAC patients, in comparison with 6.5%/9.3% of VKA patients and 5.0%/7.2% of no-OAC patients, respectively. At 3 months, 23.0% of NOAC patients in comparison with 26.9% of VKA patients and 13.9% of no-OAC patients had died. Propensity score matching revealed no statistically significant differences. Conclusions— IVT/IAT in selected patients with ischemic stroke under NOAC treatment has a safety profile similar to both IVT/IAT in patients on subtherapeutic VKA treatment or in those without previous anticoagulation. However, further prospective studies are needed, including the impact of specific coagulation tests.

The socioeconomic and health effect of stroke and other noncommunicable disorders (NCDs) that share many of the same risk factors with stroke, such as heart attack, dementia, and diabetes mellitus, is huge and increasing.1–4 Collectively, NCDs account for 34.5 million deaths (66% of deaths from all causes)3 and 1344 million disability-adjusted life years lost worldwide in 2010.2 The burden of NCDs is likely to burgeon given the aging of the world’s population and the epidemiological transition currently observed in many low- to middle-income countries (LMICs).5,6 In addition, there is low awareness in the population about these NCDs and their risk factors,7–10 particularly in LMICs.11 These factors, coupled with underuse of strategies for primary prevention of stroke/NCDs on an individual level and the lack of accurate data on the prevalence and effect of risk factors in different countries and populations have been implicated in the ever-increasing worldwide burden of the NCDs.12–15 Of particular concern is a significant increase in the number of young adults (aged

International audience; Background - Stroke units (SU) improve survival and decrease disability. Issued in 2010 the French national stroke plan recommended increasing access to SU and as a result their number rose from 87 to 117 between 2010 and 2012. Our objective was to analyze trends in care, case mix and early case fatality in a period of SU deployment. Methods - We used national hospital database to identify stroke patients discharged from hospitals between 2009 and 2014. We analyzed trends in SU admission and early (7 days) case fatality adjusting for age sex and comorbidy using logistic and Poisson regression.Results - Hospital stroke admissions rose from 93 728 in 2009 to 109 456 in 2014. The proportion of patients admitted in SU nearly doubled during the period (from 23 to 44%). This was mainly attributable to more admissions of patients residing inmedium and small towns. The mean age of ‘‘SU patients’’ remained below that of others but increased significantly fasterover the study period (+2.5 years compared to + 1; p < 10-3). After accounting for age, stroke type and comorbidity, womenremained less likely to be admitted to SU (OR for year 2014=0.89 95%CI: 0.87;0.92). Crude 7 days case fatality decreasedfrom 9.3% in 2009 to 8.1% in 2014 (annual trend= -2.37% 95%CI:-1.88;-2.85). Most of this trend was attributable to theincreasing proportion of patients admitted in SU for whom early case fatality was more than halved (adjusted rate ratio:0.44; 95% CI: 0.43-0.45). Conclusions - Although in 2014 less than half of stroke patients in France were admitted to SU, deployment of the latter has improved access to older patients and to those residing outside major urban areas. More work is required to explain the persisting gender gap in SU admission and to measure how much the reduction in early case fatality translates into longer term benefits to patients.

Background: We aimed to evaluate the epidemiological features of transient ischemic attack (TIA). Methods: All TIAs were prospectively collected in Dijon, France, using a population-based registry (2013–2015). TIAs were considered the first-ever in patients who had no previous cerebrovascular events (CVEs); otherwise they were considered recurrent TIAs. Annual incidence (first-ever TIAs) and attack rates (first-ever and recurrent TIAs) were calculated. Results: Four hundred twenty TIAs were registered (255 first-ever and 165 recurrent TIAs, mean age: 74.1 ± 15.7 years). The age-standardized incidence rate (to the 2013 European population) was 61 (95% CI 46–76) and the attack rate was 81 (95% CI 64–99) per 100,000/year. Patients with TIA as a recurrent event had a greater prevalence of risk factors and preventive treatments. However, one third of them were not receiving antithrombotic agents or antihypertensive treatments, and half were not treated with statins at the time of their recurrence. The mean ABCD2 score was 4.3 ± 1.3, and 72% of patients had a high risk of recurrence (score ≥4). In patients with available MRI (23%), an infarct lesion was seen in 15.5%. Conclusions: TIA is a frequent occurrence and a large proportion of patients have a high risk of recurrence, thus highlighting the need to establish dedicated emergency services to administer prompt secondary prevention.

ObjectiveTo examine factors contributing to the sex differences in functional outcomes and participation restriction after stroke.MethodsIndividual participant data on long-term functional outcome or participation restriction (i.e., handicap) were obtained from 11 stroke incidence studies (1993–2014). Multivariable log-binomial regression was used to estimate the female:male relative risk (RR) of poor functional outcome (modified Rankin Scale score >2 or Barthel Index score ResultsIn unadjusted analyses, women experienced worse functional outcomes after stroke than men (1 year: pooled RRunadjusted 1.32, 95% confidence interval [CI] 1.18–1.48; 5 years: RRunadjusted 1.31, 95% CI 1.16–1.47). However, this difference was greatly attenuated after adjustment for age, prestroke dependency, and stroke severity (1 year: RRadjusted 1.08, 95% CI 0.97–1.20; 5 years: RRadjusted 1.05, 95% CI 0.94–1.18). Women also had greater participation restriction than men (pooled MDunadjusted −5.55, 95% CI −8.47 to −2.63), but this difference was again attenuated after adjustment for the aforementioned factors (MDadjusted −2.48, 95% CI −4.99 to 0.03).ConclusionsWorse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.

International audience; Pain in amyotrophic lateral sclerosis (ALS) is paradoxical in this disease of the upper and lower motor neurons. As such, it remains an underestimated and neglected clinical problem because it is poorly identified by physicians, its mechanisms are numerous and its treatments are generally not effective. Pain may be primary in the form of cramps, spasticity and neuropathy, or secondary as nociceptive pain, and may arise before the first motor symptoms. It may also lead to depression and, in all cases, affect patients' daily activities and quality of life. Given the high frequency of pain in ALS, the use of analgesic or sedative drugs is necessary and should reduce the course of the disease. Nevertheless, it is important to understand the pathophysiological mechanisms of pain in ALS, and to train physicians how to detect ALS pain early on and provide dedicated treatments. In France, the implementation of ALS centers is a positive response to the public-health problem resulting from this disorder.

Stroke is a disease whose frequency is increasing especially in women and in the elderly, and that is associated with major functional impairment with adverse consequences in terms of quality of life. Implementation of a therapeutic education program is helpful for patients and their relatives so as to acquire skills to manage their own health, with the goal of reducing recurrences and improving personal experience of the disease.

Etude de cas; Introduction: Moyamoya syndrome is a rare progressive cerebrovascular occlusive disease for which several associated conditions have been described. Case Report: We report the case of a 76-year-old woman with a history of May-Hegglin anomaly who presented with an isolated unusual diffuse headache. Initial laboratory investigations showed only thrombocytopenia (platelet count 95000/mu L). Unenhanced brain computed tomography scan revealed a small subarachnoid hemorrhage in the left frontal lobe. Computed tomography angiography showed occlusion of the terminal portion of the left internal carotid artery (ICA) and narrowing of the terminal portion of the right ICA with abnormal collateral vessels. Conventional angiography confirmed the tight stenosis of the extremity of the right ICA, and the occlusion of the left ICA, associated with an extensive collateral network consistent with moyamoya syndrome. No aneurysm was identified. Conclusions: The rarity of these 2 diseases makes a fortuitous association very unlikely. We thus concluded that this observation could be the first reported case of May-Hegglin anomaly as a cause of moyamoya syndrome.

Pain after stroke (PAS) is a common clinical problem that is both underdiagnosed and undertreated. Yet, it induces depression and cognitive troubles, and impairs quality of life. To provide tools for practitioners, this report describes the most common PAS syndromes, including central post-stroke pain, spasticity and contractures, shoulder pain and complex regional pain syndromes, as well as headache and chondrocalcinosis, along with their risk factors, their prevention and their specific treatments. In addition, to ensure that the compulsory post-stroke clinical assessment in France is optimal, it is recommended that clinicians be trained in how to diagnose and treat PAS, and even to prevent it by early identification of at-risk patients, with the aim to improve patients' motor and cognitive functions and quality of life.

IF 3.988; International audience; BACKGROUND AND PURPOSE:Although there is growing and convincing evidence that socially deprived patients are at higher risk of stroke and worse outcomes, it remains controversial whether or not they suffer more severe stroke. This study aimed to evaluate the influence of social deprivation on initial clinical severity in patients with stroke.METHODS:A total of 1536 consecutive patients with an acute first-ever stroke (both ischaemic stroke and intracerebral hemorrhage) were prospectively enrolled from six French study centers. Stroke severity on admission was measured by the National Institutes of Health Stroke Scale score. Social deprivation was assessed at the individual level by the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examen de Santé (EPICES) score, a validated multidimensional questionnaire, and several additional single socioeconomic indicators. Polytomous logistic regression analyses were performed to evaluate the association between social deprivation and stroke severity.RESULTS:In univariate analysis, the EPICES score (P = 0.039) and level of education (P = 0.018) were the only two socioeconomic variables associated with stroke severity. Multivariate analysis of the association between EPICES and National Institutes of Health Stroke Scale scores showed that more deprived patients presented a significantly higher risk of both mild and moderate/severe stroke (odds ratio for mild versus minor stroke, 1.39; 95% confidence interval, 1.06-1.84; odds ratio for moderate/severe versus minor stroke, 1.44; 95% confidence interval, 1.09-1.92). A non-significant trend towards a higher risk of both mild and moderate/severe stroke in less educated patients was observed.CONCLUSIONS:Social deprivation was associated with a more severe clinical presentation in patients with stroke. These findings may contribute to the worse outcome after stroke in deprived patients, and underline the need for strategies to reduce social inequalities for stroke.© 2017 EAN.

Incidence of perinatal arterial stroke (ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage) occurring between 20 weeks of gestation and postnatal day 28 ranges between 20 and 65 cases per 100,000 living births. In children aged 29 days to 18 years old, the total incidence is 1.3 to 4.3 for 100,000 per year. In France, almost 450 children are hospitalized for a stroke each year, among them approximately half have an intracerebral hemorrhage.

Direct oral anticoagulants (DOACs) are indicated in the treatment and prevention of venous thromboembolism (VTE). However, the use of DOACs in unusual VTE, including cerebral venous thrombosis (CVT) and splanchnic venous thrombosis (SVT), and in patients with biological thrombophilia including minor thrombophilia (Factor V Leiden and prothrombin G20210A), major innate thrombophilia (protein C and S deficiency, and antithrombin) and major acquired thrombophilia (antiphospholipid syndrome [APS]), remains controversial due to the paucity of available data. There are some reports of DOACs use in the initial treatment or long-term maintenance of patients with either CVT or SVT, but their efficacy remains unclear. The efficacy of DOACs may be suitable in patients with biological minor or major thrombophilia. The use of DOACs for the long-term maintenance of patients with APS is more contentious. Randomized clinical trials, which are currently underway, should offer definitive insight into the efficacy and safety profiles of DOACs in these patient populations.

International audience; Introduction : L’accessibilite aux unités neuro-vasculaires (UNV) pour la prise en charge des accidents vasculaires cérébraux s’est considérablement développée en France grâce à la mise en œuvre du « Plan national d’action AVC 2010–2014 ». Dans ce contexte, l’objectif de notre étude est d’étudier l’évolution du profil des patients admis en UNV et celle de la létalite hospitalière précoce. Méthodes : Nous avons sélectionné les séjours relatifs à un AVC (codes I61, I63, I64 en diagnostic principal) dans la base PMSI-MCO de France métropolitaine pour la période 2009−2014. Nous avons examiné les évolutions du profil sociodémographique, de la comorbidité (index de comorbidité de Charlson, [ICC]) et de la létalite hospitalière jusqu’à sept jours en distinguant les patients admis de ceux non-admis en UNV. Résultats : Entre 2009 et 2014, le nombre d’AVC pris en charge en UNV a augmenté de 21 868 a 48 210. Bien que l’âge moyen des patients « UNV » soit resté toujours inférieur à celui des « non-UNV », son augmentation était plus importante chez les premiers (+2,5 ans contre +1 an chez les non-UNV, p Discussion/conclusion : Ces unités specialisées ont accueilli des patients plus âgés et présentant plus de comorbidités, sans que la létalite hospitalière précoce n’ait augmenté. Le devenir à moyen et long terme de ces patients mériterait d’être exploré notamment en termes de profil fonctionnel.

International audience; IntroductionAvez-vous déjà eu l’impression d’oublier quelque chose ? Le sentiment d’oubli est très commun dans la vie quotidienne mais a été très peu étudié expérimentalement.ObjectifsL’objectif de cette étude est d’évaluer les jugements d’oubli sur des tâches de mémoire sémantique et épisodique dans le vieillissement normal et dans la maladie d’Alzheimer.Patients et méthodesCinquante jeunes adultes, 35 personnes âgées et 33 patients Alzheimer ont été testés. Les participants effectuaient soit des jugements d’oubli, soit des jugements de rappel sur 2 tâches de mémoire. Pour la tâche de mémoire sémantique, les participants devaient rappeler toutes les régions de France et devaient ensuite estimer le nombre de régions qu’ils pensaient avoir oublié ou rappelé. Pour la tâche de mémoire épisodique, la même procédure était employée avec une liste de 22 mots.RésultatsLes résultats montrent que les jeunes adultes et les personnes âgées sont plus imprécis dans les jugements d’oubli que dans les jugements de rappel sur les deux tâches de mémoire. Dans la maladie d’Alzheimer, les précisions des jugements varient selon la mémoire sollicitée. Sur la tâche de mémoire sémantique, les patients sont aussi précis pour les jugements de rappel que pour les jugements d’oubli. En mémoire épisodique, seuls les jugements de rappel sont précis.DiscussionLes résultats montrent qu’il est plus difficile d’estimer l’oubli que le rappel. Juger l’oubli est plus complexe et nécessite de passer par un jugement de rappel (prise en compte du nombre de mots rappelés - le nombre total de mots présentés), mais l’inverse n’est pas nécessaire. Ce raisonnement peut donc expliquer le manque de précision des participants pour évaluer l’oubli.ConclusionCes résultats montrent qu’il est possible de mesurer l’oubli de manière expérimentale et que les patients présentent un pattern de résultats différents en fonction de la mémoire sollicitée.

Introduction: As women suffer worse functional outcomes of stroke than men, they may also face more challenges with community reintegration but data are scarce. We examined sex differences in participation after stroke and which factors might account for these disparities. Methods: INSTRUCT is an individual participant data pooling study of incident strokes obtained from 13 population-based cohorts worldwide. Two of the cohorts (Melbourne ’96-‘99 and Auckland ’02-‘03) included assessment of participation at 5 years after stroke using the London Handicap Scale (LHS). The LHS is used to assess the individual’s perspective of their involvement in life situations including orientation (person’s awareness of surroundings), physical independence, mobility, occupation, social interaction and economic self-efficiency. The total score ranges from 0 (worst disadvantage) to 100 (no disadvantage). Linear regression was used to compare LHS total scores and sub-domains for women compared to men. Study-specific multivariable models incorporated adjustment for socio-demographics, stroke-related factors, pre-stroke health and post-stroke factors were combined using random-effects meta-analysis. Results: At 5 years after stroke, there were data on participation for 351/592 (59%) of survivors in Melbourne and 266/881 (30%) of survivors in Auckland. Women suffered greater participation restriction than men (total LHS, pooled mean difference, MD -5.55 [95% CI -8.47, -2.63]). The magnitude of the difference attenuated after adjusting for covariates (pooled MD -2.48 [-4.99, 0.03]). Significant confounders in study-specific models included age, stroke severity, pre-stroke dependency and pre-stroke dementia for Melbourne; and age, stroke severity and pre-stroke dependency for Auckland. In sub-dimensions, women had greater restriction than men in mobility, physical independence and occupation. Additionally, women in Melbourne experienced poorer social integration and orientation than men. Conclusion: Greater restriction in participation after stroke among women than men was mostly attributable to their advanced age and greater pre-stroke dependency. Interventions targeting participation could reduce the impact of stroke in women.

Introduction Le GDF15 est un biomarqueur de mauvais pronostic dans certaines pathologies cardiovasculaires comme le syndrome coronarien aigu. Son interet dans le domaine de AVC n’a ete que peu etudie a ce jour. Objectifs Notre travail consistait a l’evaluation des taux de GDF15 chez des patients hospitalises a la phase aigue d’un AVC ischemique traites par fibrinolyse et/ou thrombectomie. L’objectif principal etait d’evaluer l’association entre les taux de GDF15 et la recuperation fonctionnelle a 3 mois. Methodes Au total, 174 patients ont ete inclus entre le 16/01 et le 30/09/2017. Le consentement etait recueilli oralement. Des prelevements biologiques ont ete realises a l’admission du patient (j0), a j1, j3 et j7. Les taux plasmatiques de GDF15 etaient mesures par methode Elisa. Les patients etaient recontactes par telephone a 3 mois afin d’evaluer le score de Rankin. Resultats Les moyennes des taux plasmatiques de GDF15 a j0, j1, j3 et j7 etaient significativement plus elevees chez les patients avec un score de Rankin ≥ 2 par rapport aux patients avec un score de Rankin a 0 ou 1. En analyse de regression logistique univariee, il a ete retrouve une augmentation significative de l’odd ratio (OR) concernant le risque d’avoir un score de Rankin ≥ 2 en ayant un taux de GDF15 situe dans le dernier tertile. Les taux de GDF15 etaient significativement plus eleves chez les patients traites par thrombectomie. Discussion Dans la litterature, seulement deux etudes se sont interessees au GDF15 en tant que biomarqueur pronostique apres la survenue d’un AVC ischemique. Notre travail est le premier a etudier l’evolution des taux de GDF15 dans un groupe defini de patients beneficiant d’un traitement de revascularisation. L’expression du GDF15 semble modifiee en fonction du traitement recu : fibrinolyse ou thrombectomie. Conclusion Ce travail montre des resultats concordants avec les quelques donnees actuellement disponibles dans la litterature. Le GDF15 apparait comme un biomarqueur de mauvais pronostic apres la survenue d’un AVC ischemique.

Background and Purpose— Stroke is the leading cause of death in women and the third leading cause in men in France. In young adults (ie, Methods— Hospitalization data were extracted from the French national hospital discharge databases and mortality data from the French national medical causes of death database. Time trends were tested using a Poisson regression model. Results— From 2008 to 2014, the age-standardized rates of patients hospitalized for ischemic stroke increased by 14.3% in patients Conclusions— An increase in cardiovascular risk factors and improved stroke management may explain the increase in the rates of patients hospitalized for ischemic stroke. The decrease observed for in-hospital stroke mortality may be because of recent improvements in acute-phase management.

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

IF 2.558; International audience; Stroke is a serious complication after acute myocardial infarction (AMI) and is associated with an increased risk of death. Though the pathophysiological mechanisms are not exactly known, increased inflammation and platelet reactivity could play an important role in the occurrence of stroke during AMI. We aimed to investigate the relationship between both mean platelet volume (MPV), a parameter of platelet function, and C-reactive protein (CRP) and the occurrence of in-hospital ischemic stroke (IHS) after AMI. Data were obtained from a French regional survey for AMI that included 5976 patients admitted to an intensive care unit (ICU) between 2001 and 2010. Patients were divided into two groups according to the occurrence of IHS. MPV, platelet count (PC), and CRP were routinely measured at admission to the ICU; 99 (1.6%) IHSs were recorded during hospitalization after admission for AMI. In multivariate analysis, IHS was independently associated with a history of stroke (OR: 1.99%, CI: 1.1-3.49, p = 0.01), impaired left ventricular ejection fraction 10 mg/l (OR: 2.19, 95% CI: 1.44-3.33, p < 0.001), and MPV/PC ratio (OR: 1.04, 95% CI: 1.01-1.08, p = 0.023). Compared with the first to fourth quintiles, the last quintile of the MPV/PC ratio was associated with higher rates of IHS on survival curve analysis (p = 0.014). At hospital admission, a high MPV/PC ratio and a high level of CRP might help to identify patients at increased risk of IHS. Moreover, these results provide new insights into the potential role played by increased inflammation and platelet reactivity in the occurrence of stroke after AMI.

Objectives: We investigated the incidence of stroke and stroke subtypes in a population-based cohort of patients in France treated with growth hormone (GH) for short stature in childhood. Methods: Adult morbidity data were obtained in 2008–2010 for 6,874 children with idiopathic isolated GH deficiency or short stature who started GH treatment between 1985 and 1996. Cerebrovascular events were validated using medical reports and imaging data and classified according to standard definitions of subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke. Case ascertainment completeness was estimated with capture-recapture methods. The incidence of stroke and of stroke subtypes was calculated and compared with population values extracted from registries in Dijon and Oxford, between 2000 and 2012. Results: Using both Dijon and Oxford population-based registries as references, there was a significantly higher risk of stroke among patients treated with GH in childhood. The excess risk of stroke was mainly attributable to a very substantially and significantly higher risk of hemorrhagic stroke (standardized incidence ratio from 3.5 to 7.0 according to the registry rates considered, and accounting or not accounting for missed cases), and particularly subarachnoid hemorrhage (standardized incidence ratio from 5.7 to 9.3). Conclusions: We report a strong relationship between hemorrhagic stroke and GH treatment in childhood for isolated growth hormone deficiency or childhood short stature. Patients treated with GH worldwide should be advised about this association and further studies should evaluate the potentially causal role of GH treatment in these findings.

BACKGROUND Because of the aging population and a rise in the number of stroke survivors, the prevalence of post-stroke cognitive impairment (PSCI) is increasing. OBJECTIVE To identify the factors associated with 3-month PSCI. METHODS All consecutive stroke patients without pre-stroke dementia, mild cognitive disorders, or severe aphasia hospitalized in the Neurology Department of Dijon, University Hospital, France (November 2010 - February 2012) were included in this prospective cohort study. Demographics, vascular risk factors, and stroke data were collected. A first cognitive evaluation was performed during the hospitalization using the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MOCA). Patients assessable at 3 months were categorized as cognitively impaired if the MMSE score was ≤26/30 and MOCA

We aimed to evaluate the influence of prestroke cognitive impairment (PSCI) on outcomes in stroke patients treated with IV recombinant tissue plasminogen activator (rtPA).OPHELIE-COG was a prospective observational multicenter study conducted in French and Japanese patients treated with IV rtPA for cerebral ischemia. The preexisting cognitive status was evaluated by the short version of the Informant Questionnaire on Cognitive Decline in the Elderly. PSCI was defined as a mean score3. The primary endpoint was a favorable outcome (modified Rankin Scale [mRS] score 0-1) after 3 months. Secondary endpoints were symptomatic intracerebral hemorrhage (sICH), mRS scores 0-2, and mortality at 3 months. We performed a pooled analysis with Biostroke and Strokdem.Of 205 patients, 62 (30.2%) met criteria for PSCI. They were 11 years older (p0.001). Although they had more sICH and were less frequently independent after 3 months, they did not differ for any endpoint after adjustment for age, baseline NIH Stroke Scale score, and onset-to-needle time: sICH (odds ratio [OR] 2.78; 95% confidence interval [CI] 0.65-11.86), mRS 0-1 (OR 0.82; 95% CI 0.41-1.65), mRS 0-2 (OR 0.62; 95% CI 0.28-1.37), death (OR 0.40; 95% CI 0.08-2.03). The pooled analysis found no association of PSCI with any endpoint.Ischemic stroke patients with PSCI should receive rtPA if they are eligible. This conclusion cannot be extended to severe cognitive impairment or severe strokes.This study provides Class IV evidence that in patients with PSCI presenting with acute ischemic stroke, IV rtPA improves outcomes.

Background Giant cell arteritis (GCA) is the most common vasculitis in people ≥50 years and can be associated with stroke. We aimed to evaluate the epidemiology and characteristics of stroke in patients with GCA. Methods All patients with a biopsy-proven diagnosis of GCA were identified among residents of the city of Dijon, France (152 000 inhabitants), between 2001 and 2012 using a prospective database. Among these, patients who suffered from stroke were retrieved by crossing data from the population-based Dijon Stroke Registry. Demographics and clinical features were recorded. We considered that the stroke was GCA-related if the stroke revealed GCA or occurred between the onset of symptoms and 4 weeks after the start of treatment. Results Among the 57 biopsy-proven patients with GCA (incidence rate 10.9/100 000/year in individuals ≥50 years), 4 (7.0%) experienced a GCA-related stroke. Three were men and all had ≥2 vascular risk factors and were ≥80 years. The stroke was vertebrobasilar for 3/4 patients and undetermined for the remaining one. The incidence rate of GCA-related stroke in patients ≥50 years was 0.76/100 000/year (95% CI 0 to 2.47), 1.36/100 000/year in men (95% CI 0 to 3.63) and 0.33/100 000/year (95% CI 0 to 1.45) in women. Conclusions This population-based study demonstrated that GCA-related stroke essentially affects the vertebrobasilar territory and mainly occurs in old men with associated vascular risk factors. Although rare, GCA symptoms must be searched for in elderly patients with stroke, and optimal vascular prevention must be conducted carefully in patients with GCA with a high vascular risk before initiating GCA treatment.

This study aimed to investigate the association between clinical and radiological markers of periodontal disease and ischemic stroke and to assess the potential influence of inflammatory response on the observed associations.A prospective case-control study including a series of 48 cases with a minor ischemic stroke and 47 controls was conducted at the University Hospital of Dijon. Vascular risk factors, clinical dental examination (plaque index, gingival index, percentage of pockets5 mm, percentage of bleeding on probing (BOP) sites), dental panoramic (bone loss) and biological parameters (CRP, total cholesterol, HDL, LDL, fasting glucose) were collected. Conditional regression analyses were performed to identify factors associated with ischemic stroke.The prevalence of hypertension, high CRP and glucose levels and overall odontological variables was higher in stroke patients. In multivariable analyses, hypertension (OR = 12.56; 95% CI = 2.29-69.96, p = 0.004), CRP levels5 mg/L (OR = 18.54; 95% CI = 2.01-171.17, p = 0.010), BOP (OR = 1.049; 95% CI = 1.012-1.88, p = 0.009) and bone loss20% (OR = 1.053; 95% CI = 1.017-1.091, p = 0.004) were associated with ischemic stroke. Among stroke patients, there was a non-significant trend towards higher CRP levels in patients with bone loss20% compared with those with bone loss20% (8.1 ± 1.27 mg/L vs 3.12 ± 3.14 mg/L, p = 0.25), whereas other biological parameters were very similar between the two groups.This case-control study demonstrates that periodontal disease, especially markers such as BOP and bone loss, is independently associated with ischemic stroke.

Background: Acute stress may trigger vascular events. We aimed to investigate whether important football competitions involving the French football team increased the occurrence of stroke. Methods: We retrospectively retrieved data of fatal and nonfatal stroke during 4 World Football Cups (1986, 1998, 2002, and 2006) and 4 European Championships (1992, 1996, 2000, and 2004), based on data from the population-based Stroke Registry of Dijon, France. One period of exposure was analyzed: the period of competition extended to 15 days before and after the competitions. The number of strokes was compared between exposed and unexposed corresponding periods of preceding and following years using Poisson regression. Results: A total of 175 strokes were observed during the exposed periods compared with 192 and 217 strokes in the unexposed preceding and following periods. Multivariate regression analyses showed an overall 30% significant decrease in stroke numbers between periods of competition and unexposed periods of following year (risk ratio (RR) 5 1.3; 95% confidence interval [CI] 5 1.0-1.6; P 5.029) but not with that of preceding year (RR 5 1.1; 95% CI 5 .9-1.3; P 5.367). This was mostly explained by a 40% decrease in stroke numbers during European Championships, compared with the unexposed following periods (RR 5 1.4; 95% CI 5 1.0-1.9; P 5.044) in stratified analyses by football competitions. Conclusions: Watching European football competitions had a positive impact in the city of Dijon with a decrease of stroke numbers. European championship is possibly associated with higher television audience and long-lasting euphoria although other factors may be involved. Further studies using nationwide data are recommended to vali