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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.

Objectifs pedagogiques Illustrer les aspects caracteristiques de la Dysplasie FibroMusculaire (DFM) en imagerie (Scanner, IRM). Discuter l’apport des differentes techniques d’imagerie non invasive pour la recherche de DFM. Revoir les indications des explorations d’imagerie en cas de DFM renale ou cervicale, pour le diagnostic initial et le suivi. Messages a retenir La DFM est une des causes d’HTA reno-vasculaire du sujet jeune. Les methodes d’imagerie non invasive et notamment l’angio-scanner permettent de faire le diagnostic en montrant l’atteinte distale des arteres renales avec un aspect typique en « collier de perles ». Il faut chercher d’autres atteintes notamment des arteres viscerales et des arteres cervicales. L’imagerie non invasive par scanner ou IRM permet de faire le dignostic de la maladie et le bilan « d’extension » mais ne permet pas d’eliminer formellement une stenose serree notamment des arteres renales. Seule l’arteriographie numerisee selective permet d’eliminer sur des lesions distales en diaphragme une lesion serree.

Objectifs La presence d’infarctus d’âge different chez les candidats a la fhrombolyse pourrait accroitre le risque de transformation hemorragique. L’IRM permet de dater les lesions ischemiques aigues. Notre objectif est d’evaluer la frequence et les caracteristiques d’imagerie des infarctus cerebraux d’âge different chez les patients adresses pour infarctus Materiels et methodes Analyse retrospective de 65 patients consecutifs avec infarctus cerebral aigu, explores par IRM (FLAIR, diffusion) dans les 6 heures apres le debut des symptomes. Recherche d’infarctus d’âge different selon l’intensite des anomalies de signal en IRM. Comparaison aux donnees cliniques pour determiner le caractere symptomatique ou silencieux des lesions. Resultats Outre l’ischemie symptomatique, 7 (11%) patients avaient des lesions ischemiques supplementaires recentes d’âge different. Ces lesions avaient un hypersignal FLAIR/diffusion plus marque que l’ischemie symptomatique, etaient localisees dans un territoire arteriel different chez 3 patients et toutes cliniquement silencieuses. Deux de ces patients ont ete thrombolyses par voie intraveineuse dans les 3 heures, sans complication hemorragique. Conclusion Onze % des infarctus cerebraux de moins de 6 heures sont associes a des lesions ischemiques silencieuses semi recentes en IRM .

Introduction Il a ete suggere qu’une exposition transitoire a certains facteurs pourrait precipiter la survenue d’un AVC. Ces facteurs sont classiquement appeles « facteurs precipitants ». Objectifs Faire une revue systematique de la litterature sur les « facteurs precipitants » (definis par une exposition transitoire et une augmentation transitoire du risque de moins de 3 mois) des AVC. Methodes Les etudes (cohorte, cas-controle et cas-croisee), publiees en langue anglaise entre 1980 et 2006, analysant la relation entre « facteur precipitant » et AVC (a l’exclusion des hemorragies meningees) ont ete recherchees dans la base de donnees MEDLINE. Les odds ratio individuels, extraits des publications ou calcules, ont ete combines lorsque cela etait possible. Resultats Vingt etudes cas-controles et 7 cas-croisees identifierent 11 « facteurs precipitants ». Une association existait entre AVC ischemique et abus d’alcool > 120 g dans les 24 heures precedentes (2 etudes, OR = 5,7 ; IC 95 p. 100 : 2,7-12,1) ou > 300 g dans la semaine (4 etudes, OR = 4,1 ; 2,8-5,9) et infection dans la semaine (6 etudes, OR = 3,9 ; 2,8-5,4). Des etudes isolees montraient une association significative entre AVC et activite physique, emotions negatives, colere, chirurgie, arret de l’aspirine, pollution, changement de temperature. Discussion L’abus alcool et une infection sont bien documentes comme « facteurs precipitants ». La diversite de ces facteurs et des periodes d’augmentation du risque suggerent des mecanismes physiopathologiques varies. Bien que des similitudes existent avec la cardiologie, il existe des differences refletant probablement la variabilite dans le choix de la periode d’augmentation du risque. Conclusion Peu d’etudes ont ete menees sur les « facteurs precipitants » des AVC. De nouvelles etudes sont necessaires pour evaluer la causalite de l’association et mieux comprendre les mecanismes physiopathologiques sous-jacents.

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.

Pathophysiological mechanisms of ischaemic strokes occurring in patients with Rendu-Osler-Weber (ROW) disease remain unclear. We report on the case of a patient with ROW disease and pulmonary arteriovenous fistula thrombosis who suffered from recurrent strokes. In January 2005, a 38 year old woman was referred for the first time to our hospital for an ischaemic stroke fifteen days after undergoing a medically induced abortion. She reported recurrent epistaxis during her two pregnancies (1993 and 1994) and two familial cases of Rendu-Osler-Weber (ROW) disease. She also had experienced two episodes of ischaemic stroke (January 1996 and December 1997). Stroke workup had only revealed a patent foramen ovale with atrial septal aneurysm, which had been surgically closed after the second stroke. She had been receiving aspirin since closure of the foramen ovale. Eight years after the procedure, she presented with a new ischaemic stroke in the right middle …

Objectives The aim of our study was to evaluate, in acute ischemic stroke patients, the diagnostic accuracy of the MRI susceptibility vessel sign (SVS) against catheter angiography (DSA) for the detection of the clot and its value in predicting clot location and length. Materials and Methods We identified consecutive patients (2006–2012) admitted to our center, where 1.5 T MRI is systematically implemented as first-line diagnostic work-up, with: (1) pre-treatment 6-mm-thick multislice 2D T2* sequence; (2) delay from MRI-to-DSA 94%. Inter- and intra-observer ICC was excellent for clot length as measured on T2* (ĸ ≥0.97) and as measured on DSA (ĸ ≥0.94). Correlation between T2* and DSA for clot length was excellent (ICC: 0.88, 95%CI: 0.81–0.92; Bland & Altman: mean bias of 1.6% [95%CI: -4.7 to 7.8%], Passing & Bablok: 0.91). Conclusions SVS is a specific marker of clot location in the anterior and posterior circulation. Clot length greater than 6 mm can be reliably measured on T2*.

OBJECTIVE To compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection. DESIGN Systematic review with Bayesian meta-analysis. DATA SOURCES The reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors. STUDY SELECTION Studies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection. DATA EXTRACTION Data were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups. DATA SYNTHESIS Thirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ(2) = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30). CONCLUSION In view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.

Neurological complications are rare in trichinosis. We report a case with marked hypereosinophilia in which MRI showed multiple small subacute cortical infarcts with Gd-DTPA enhancement.

Background: Uncertainties about the frequency and the associated bleeding risk of recent silent ischemia (RSI), incidentally found on pretreatment MRI, in candidates for thrombolysis require clarification because exclusion from therapy is a serious consequence for patients with such MRI findings. Methods: We retrospectively analyzed the fluid-attenuated inversion recovery (FLAIR)/diffusion-weighted imaging (DWI) obtained before IV thrombolysis in 115 patients to search for MRI-defined RSI; these corresponded to well-developed FLAIR/DWI brain hyperintensities (RSI+), as distinct from the acute index ischemia, which typically lacked FLAIR changes. Patients without such findings were assigned to the RSI− group. Groups were compared for baseline characteristics and for rates of symptomatic and asymptomatic hemorrhagic transformation (HT) using odds ratios (OR) and their 95%confidence intervals (CI). Results: We observed RSI in 21 patients (18.3%). The mean (SD) volume of RSI was 6.5 (12) mL (interquartile range 0.6–9). None of the baseline parameters differed between groups. There was no significant difference in rates of any type of HT between groups. Parenchymal hemorrhage type 1 or type 2 according to European Cooperative Acute Stroke Study criteria occurred in 2 (10%) RSI+ patients and in 10 (11%) RSI− patients (OR 0.88; 95% CI 0.18–4.37). Symptomatic HT, defined according to National Institute of Neurological Disorders and Stroke criteria, occurred in 1 (5%) RSI+ patient and in 10 (11%) RSI− patients (OR 0.42; 95% CI 0.05–3.47). Conclusions: We found that 18.3% of patients with acute stroke treated by IV thrombolysis in a stroke unit had RSI on pretreatment MRI. However, the presence of RSI was not associated with an increased risk of asymptomatic or symptomatic HT.

In 1994, in accordance with WHO recommendations, the French health authorities decided to extend hepatitis B (HB) vaccination to newborns and preteenagers. Vaccination for adults at increased risk of HB infection (especially health care professionals) has been mandatory since 1991. In July 1996, about 200 cases of central nervous system demyelinating disorders (CDD) following HB vaccine injection were reported to the French pharmacovigilance system, raising the question as to whether this association was fortuitous or not. To explore this signal, the number of reported cases of CDD was compared with that expected under the hypothesis of no association, using Poisson cumulative probabilities [1]. The comparison considered spontaneous reports received by the French pharmacovigilance up to 31 December 1999. The analysis was restricted to subjects aged 20–44 years vaccinated in the period 1994–96. About 80% of CDD cases are expected to occur in this age group, and during the study period, HB vaccination was extensive in France. Between 1994 and 1996, 53 million doses of HB vaccine were distributed in France, 21.6 million to subjects aged 20–44 years. The most common immunization protocol used at the time of the study consisted of three injections of vaccine at 1 month intervals. On this basis, and assuming that all the doses were actually used, we estimated that 7.18 million subjects aged 20–44 years were vaccinated over the study period. As suggested by a panel of neurologists, we considered a time-window of excess risk of CDD of 2 months after a HB vaccine injection. A vaccinated subject is thus at increased risk for 4 months: one between the first and the second dose, one between the second and the third dose and two after the third and last dose. Background incidence rate was derived from data provided by several surveys of multiple sclerosis (MS) conducted in France before the start of vaccination [2]. Since about 80% of CDD episodes represent the onset of definite MS, we considered the highest incidence rate of MS available. The annual incidence rate for subjects aged 20–44 years was estimated to be 42.9 per million. During the chosen time-window, 102.7 cases were expected to occur in vaccinated subjects (Table 1). Two senior neurologists validated all CDD cases reported to the French National Pharmacovigilance System. Among the validated cases, we retained those that filled the following criteria: (i) received an HB vaccine injection between 1 January 1994 and 31 December 1996, (ii) aged 20–44 years, (iii) presented a first CDD episode within 2 months after a HB vaccine injection. Among the cases reported up to the end of December 1999, 108 matched the case definition. This reported number was not significantly different from that expected at the 5% level. However, a mere 1.12-fold increase would result in a level significantly higher than that expected. A capture-recapture study conducted in France with three independent sources estimated an underreporting coefficient of 2 for the period 1994–96 (French Medicine Agency, internal report). Background incidence rates used are consistent with epidemiological data on MS in other European countries [3]. By considering that all HB vaccine doses sold have been used for complete vaccination, we do not take into account isolated injections (incomplete first immunization or booster) for which the at-risk time-window is 2 months, as against 4 months for the three-dose scheme. This could underestimate the expected number of cases. This underestimation remains moderate, e.g. a factor of 1.1 for a proportion of 20% single injections could be considered as a maximum for this extensive first immunization campaign. Table 1 Comparison between reported and expected numbers of cases. The results of this study do not provide strong arguments for ruling out the possibility of an association, causal or otherwise, between HB vaccine and first episode of central nervous system demyelinating disorders. Since the observed number of cases would exceed significantly that expected with a modest under-reporting coefficient strongly supposes a signal.

Objectifs II est classique de considerer que l’hypersignal diffusion correspond a des lesions d’ischemie irreversibles. Pourtant, ces lesions pourraient regresser en cas de recanalisation precoce. Notre objectif est d’evaluer la frequence et les facteurs associes a la reversibilite des hypersignaux en diffusion post thrombolyse et ses corre-lats cliniques. Materiels et methodes Parmi les 38 patients consecutifs thrombolyses en intraveineux en 2008, 29 ayant une IRM pre et post thrombolyse ( Resultats Les hypersignaux diffusion regressaient partiellement ou totalement (64 + 25% du volume) (moyenne + DS) chez 6 patients (20,7% ; groupe A) et etaient stables ou augmentes chez 23 patients (groupe B). Les groupes etaient comparables pour le NIHSS a l’admission (13 ± 6 vs 13 + 6 ; N. S.), le delai symptomes-IRMcon-trole et le site d’occlusion. Les patients du groupe A etaient plus jeunes (P = 0,02), thrombolyses plus precocement (120 + 32 vs 158 ± 49 minutes ; P = 0,06) et plus frequemment recanalises (P = 0,04) que ceux du groupe B. Ils avaient un pronostic meilleur a 24 h (NIHSS = 2 + 2 vs 11,3 ± 7 ; P = 0,002) et a la sortie (Score Rankin 1 + 0,9 vs 3,22+ 1,6 ;P = 0,006). Conclusion La reversibilite des hypersignaux diffusion apres thrombolyse intraveineuse est observee chez plus d’un patient sur 5 et est associee a un excellent pronostic fonctionnel. La penombre ischemique s’etend donc a une partie de la zone en hypersignal diffusion.

Objectifs La presence d’infarctus d’âge different chez les candidats a la thrombolyse pourrait accroitre le risque de transformation hemorragique. L’IRM permet de dater les lesions ischemiques aigues. Notre objectif est d’evaluer la frequence et les caracteristiques d’imagerie des infarctus cerebraux d’âge different chez les patients adresses pour infarctus Materiels et methodes Analyse retrospective de 65 patients consecutifs avec infarctus cerebral aigu, explores par IRM (FLAIR, diffusion) dans les 6 heures apres le debut des symptomes. Recherche d’infarctus d’âge different selon l’intensite des anomalies de signal en IRM. Comparaison aux donnees cliniques pour determiner le caractere symptomatique ou silencieux des lesions. Resultats Outre l’ischemie symptomatique, 7 (11 %) patients avaient des lesions ischemiques supplementaires recentes d’âge different. Ces lesions avaient un hypersignal FLAIR/diffusion plus marque que l’ischemie symptomatique, etaient localisees dans un territoire arteriel different chez 3 patients et toutes cliniquement silencieuses. Deux de ces patients ont ete thrombolyses par voie intra-veineuse dans les 3 heures, sans complication hemorragique. Conclusion 11 % des infarctus cerebraux de moins de 6 heures sont associes a des lesions ischemiques silencieuses semi-recentes en IRM.

Objectifs Etudier les differences morphologiques en IRM entre les plaques d’atherosclerose carotidienne symptomatiques et asymptomatiques. Materiels et methodes Lecture en aveugle de 87 IRM Haute Resolution (HR) (46 carotides symptomatiques, 41 asymptomatiques) dans le cadre de l’etude HIRISC. Parametres analyses : degres de stenose (NASCET), volume de la plaque, presence/absence d’une zone hemorragique, calcifiee, rupture de chape, volume de chaque composant. Comparaison des groupes symptomatiques et asymptomatiques par tests de Student et Chi2. Resultats Les degres de stenose (58,8 % vs 60,9 %, N.S.) et le volume de la plaque (443 vs 430 mm 3 N.S.) etaient semblables dans les deux groupes. Comparativement aux plaques asymptomatiques, les plaques symptomatiques etaient moins frequemment calcifiees (30 % vs 61 %, p = 0,004) mais avaient une composante hemorragique plus frequente (41 % vs 22 %, p = 0,05) et plus volumineuse (222 vs 158 mm’ soit 15,2 % vs 7,8 % du volume de la plaque). Le volume du cœur lipidique (absolu ou rapporte au volume de la plaque) et la prevalence de rupture de chape (22 % vs 17 %, NS) etaient semblables dans les deux groupes. Toutefois, 63 % des plaques compliquees (hemorragiques ou rompues) etaient symptomatiques. Conclusion L’IRM HR montre des differences entre les plaques symptomatiques et asymptomatiques.

Objectifs Comprendre la place des differentes techniques d’imagerie pour l’analyse de la paroi. Comprendre comment realiser une IRM haute resolution (HR) des arteres carotides. Savoir analyser une plaque d’atherosclerose en IRM. Savoir comment distinguer les plaques stables des plaques instables. Points cles L’analyse de la plaque est possible en echographie, scanner ou IRM avec antenne de surface. L’IRM-HR permet de caracteriser les plaques d’atherosclerose. En routine clinique, l’IRM-HR permet de distinguer les stenoses/occlusions atherosclereuses d’autres etiologies plus rares. L’imagerie de la paroi a une valeur pronostique. Resume L’IRM-HR distingue les principaux composants de la plaque d’atherosclerose : cœur necrotico-lipidique, hemorragie intrapla-que, calcifications et chape fibeuse. Le volume global de la plaque et de ses principaux composants peut etre calcule. L’analyse de la structure de la plaque d’atherosclerose participe, avec la mesure du degre de stenose, a l’evaluation du risque d’evenement cerebrovasculaire. L’IRM-HR peut aussi etre un outil de suivi de l’efficacite des therapeutiques visant a stabiliser ou a reduire la progression de la plaque. Au-dela de la lumiere arterielle, l’etude directe de la paroi devrait dans les annees a venir modifier la prise en charge de l’atherosclerose.

High resolution MRI of the vessel wall and atherosclerotic plaque is an area of increasing development.1 In this issue of J Neurol Neurosurg Psychiatry , Harloff and colleagues2 assessed the accuracy of 3 T MRI to detect aortic sources of cerebral embolism in comparison with transoesophagal echocardiography (TOE) (see page 540) . They suggest that not only is MRI reliable in detecting aortic high risk plaques, but it is also potentially more accurate in investigating aortic segments that are not identified by TOE. Although there is little doubt that vessel MRI is a very promising technique, the authors’ enthusiasm needs to be qualified. Firstly, as underlined by the …

Objectifs Le diagnostic de dissection des arteres vertebrales (DAV) est difficile. L’etude ultrasonore peut etre negative lorsque l’hematome parietal siege au niveau d’un segment intertransversaire ou en V2 haut et V3. En scanner et en IRM, particulierement sur les coupes axiales avec saturation du signal de la graisse, un doute peut persister entre un hematome mural et un thrombus luminal ou des plexus veineux. L’objectif de ce travail est d’evaluer l’apport de l’IRM haute resolution (IRM-HR) pour le diagnostic de DAV. Materiels et methodes Analyse retrospective de 13 patients consecutifs (7 hommes, 38,7 ± 6,7 ans), porteurs de 15 DAV diagnostiquees en echographie et/ou IRM, ayant eu une IRM-HR entre novembre 2005 et novembre 2006. L’IRM-HR (antenne de surface posterieure, synchronisation cardiaque, 3 mm d’epaisseur, taille du voxel : 0,51 × 0,51 × 0,3 mm3 ) comportait des sequences ponderees en T2, DP FAT-SAT, T1 dans le plan axial ou oblique, et 3DTOF, permettant l’analyse simultanee des deux arteres vertebrales, sur 25 mm de hauteur. Resultats L’hematome mural etait visible dans tous les cas de DAV symptomatique, sous la forme d’un epaississement parietal en forme de croissant, en hypersignal en T2, DP et T1. Un aspect identique etait constate sur deux arteres vertebrales asymptomatiques, non vues sur le bilan d’imagerie standard. Dans les 17 cas de DAV, la lumiere et la paroi de l’artere vertebrale pouvaient etre distinguees des plexus veineux perivertebraux. On notait 14 dissections stenosantes et 3 occlusives, une augmentation de calibre du segment arteriel disseque dans Il cas, un aspect de double chenal dans 2 cas. Conclusion L’IRM-HR distingue aisement l’hematome mural des plexus veineux perivertebraux. L’IRM-HR ameliore la fiabilite diagnostique dans les suspicions de dissections des arteres vertebrales, et peut etre proposee en seconde intention, lorsque persiste un doute diagnostique apres l’imagerie standard.

Objectifs Tester la reproductibilite interobservateur des parametres d’analyse de la plaque d’atherosclerose carotidienne en IRM haute resolution (HR). Materiels et methodes Relecture en aveugle par deux observateurs de 64 IRM HR (antenne de surface, sequence en sang noir avec synchronisation cardiaque [Tl, densite protonique, T2] et sang blanc [TOF] acquises dans le cadre de l’etude HIRISC. Parametres analyses : volume de la plaque et de la lumiere arterielle ; presence d’une zone calcifiee, hemorragique, lipidique ; volume de la zone lipidique. Calcul de coefficients kappa (k) et coefficients de correlation intra classe (CCI). Resultats La reproductibilite est excellente pour les mesures de volume de la plaque (CCI = 0.94 [IC 95 % : 0.92-0.96]) et de la lumiere arterielle (CCI = 0.98 [IC 95% : 0.97-0.99]). Elle est bonne pour les mesures de volume de la composante lipidique (CCI = 0.74 [IC 95 % : 0.66-0.82]). La reproductibilite est raisonnable pour la detection de la composante calcique (k = 0.63 [IC 95 % : 0.44-0.83]) ou hemorragique (k = 0.62 [IC 95% : 0.39-0.84 Conclusion La reproductibilite des mesures en IRM HR confirme que c’est un outil fiable pour la quantification du volume de la plaque et de la composante lipidique. L’IRM HR peut donc etre utilisee comme critere de jugement lors d’essais therapeutiques

Objectifs Determiner si l’asymetrie de visualisation des arteres carotides internes (ACI) intracrâniennes en ARM 3D TOF est predictive d’une stenose carotidienne cervicale serree sous-jacente. Materiels et methodes Quatre vingt-quatre patients ont ete classes retrospectivement selon le degre NASCET de stenose carotidienne cervicale en 3 groupes : A 70 %, n = 26. Analyse en ARM 3D TOF intracrâniennes, en aveugle du degre de stenose, de l’asymetrie qualitative de signal et de taille des ACI, et mesure de leur signal et surface en C5. Resultats La visualisation d’une asymetrie de signal ou de taille des ACI intracrâniennes en 3DTOF permettait le depistage d’une stenose serree sous-jacente avec respectivement une sensibilite de 65 % [IC 95% = 45,8-84,7] et 78 % [61,4-95,1] et une specificite de 100 % et 95 % [89,7-100]. Les parametres quantitatifs de ratio d’intensite et de surface etaient significativement differents (p Conclusion L’existence d’une asymetrie de signal des ACI intracrâniennes oriente vers une stenose serree cervicale sous jacente, permettant son diagnostic precoce chez les patients suspects de pathologie vasculaire ou son depistage sur une IRM cerebrale realisee pour des symptomes a priori non vasculaires.

Objectifs Determiner si les hypersignaux en diffusion visibles apres un AIT sont reversibles ou correspondent a des infarctus cerebraux. Materiels et methodes Parmi les 79 patients consecutifs (52 hommes, âge 26-87 ans) admis pour un AIT en 2003, 28 (35,4 %) avaient un hypersignal en diffusion a l’admission. Vingt-six ont accepte un suivi IRM (FLAIR, T2, diffusion, 3D Tl-SPGR, delai AIT-IRM de controle : 3,5-22 mois, mediane 11 mois). Age, sexe, duree de l’AIT, delai AIT-IRM initiale, volume, ADC, nombre de lesions (unique, multiples) sur la diffusion initiale ont ete compares dans deux groupes : lesions reversibles et irreversibles. Resultats Sur le suivi IRM, 20/26 patients (77 %) avaient un infarctus correspondant aux hypersignaux sur la diffusion initiale. La presence d’un infarctus sur le suivi IRM etait associee a un volume initialement plus important (p = 0,02). Aucune des lesions initialement > 0,4 cm 3 (n = 11) n’etait reversible. Toutes les lesions reversibles etaient uniques alors que la moitie des patients avec sequelles avait des lesions initialement multiples (p = 0,05). Les autres parametres etaient identiques dans les deux groupes. Conclusion La plupart des hypersignaux en diffusion apres un AIT sont irreversibles. Seuls les petits hypersignaux uniques peuvent regresser, traduction possible d’une ischemie reversible. Ceci pourrait s’expliquer par le manque de sensibilite de l’IRM pour la detection des sequelles de petite taille.

Objectifs Evaluer l’apport de l’imagerie de diffusion chez les patients suspects d’accident ischemique transitoire (AIT). Materiels et methodes Les auteurs ont analyse retrospectivement les donnees cliniques et IRM de diffusion (delai IRM/symptoms : moy. 45 heures, min-max 3 heures-10 jours) de 81 patients consecutifs (âge : 59 ans, 67 % hommes) hospitalises pour un AIT en 2003. Le diagnostic d’AIT (criteres NINDS) a ete classe en probable (70 %) ou possible (30 %). Les variables âge, sexe, duree des symptomes, delai symptomes/IRM, probabilite clinique d’AIT, episodes multiples/unique ont ete comparees entre les groupes sans et avec lesions ischemiques en diffusion (Dif⊕). Resultats Trente sur quatre vingt un patients (37 %) avaient au moins une lesion recente en diffusion (multiples 43 %), compatible avec la symptomatologie chez 28. Les lesions etaient de petite taille (volume moyen : 1,8 ce, min-max 0,1-13), l’ADC moderement diminue (rADC moyen : 81 %). La probabilite d’observer une lesion en diffusion etait significativement plus importante si l’AIT etait cliniquement probable (probable : 46 % Dif⊕ ; possible : 9 % Dif⊕), d’une duree ≥60 minutes ( Conclusion L’imagerie de diffusion revele une lesion ischemique recente chez plus de la moitie des AIT dont le deficit persiste plus d’une heure.

Objectifs Grâce a une meilleure resolution angulaire, l’imagerie en tenseur de diffusion pourrait ameliorer la sensibilite de detection des lesions ischemiques arterielles. L’objectif est de comparer une sequence en tenseur (9 directions) avec une sequence de diffusion standard (3 directions) pour la visualisation de lesions ischemiques. Materiels et methodes 41 patients (19 deficits transitoires, 22 deficits persistants, IRM Resultats 24 patients avaient des lesions ischemiques sur les 2 sequences. Chez 4 d’entre eux, la sequence 9 directions montraient plus de lesions ( Conclusion La sequence en tenseur de diffusion montre davantage de lesions que la sequence de diffusion standard. La sequence a 9 directions, qui permet par ailleurs des mesures d’anisotropie, pourrait remplacer en routine clinique la sequence de diffusion a trois directions.

In clinical trials, assessing efficacy is based on validated scales, and the primary endpoint is usually based on a single scale. The aim of the review is to revisit the concepts and methods to design and analyze studies focused on restoration, recovery and or compensation. These studies are becoming more frequent with the development of restorative medicine. After discussing the definitions of recovery, we address the concept of recovery as the regain of lost capabilities, when the patient reaches a new equilibrium. Recovery is a dynamic process which assessment includes information from initial and final status, their difference, the difference between the final status of the patient and normality, and the speed of restoration. Finally, recovery can be assessed either for a specific function (focal restoration) or for a more global restoration. A single scale is not able to assess all the facets of a skill or a function, therefore complementary information should be collected and analyzed simultaneously to be tested in a single analysis. We are suggesting that recovery should be considered as a latent variable and therefore cannot be measured in pure form. We are also suggesting to customize the data collection and analysis according to the characteristics of the subjects, the mechanisms of action and consequences of the intervention. Moreover, recovery trials should benefit from latent variable analysis methods. Structural equation modeling is likely the best candidate for this approach applicable in pre-clinical and clinical studies.

Systemic thrombolysis with rt-PA is contraindicated in patients with acute ischemic stroke anticoagulated with dabigatran. This expert opinion provides guidance on the use of the specific reversal agent idarucizumab followed by rt-PA and/or thrombectomy in patients with ischemic stroke pre-treated with dabigatran. The use of idarucizumab followed by rt-PA is covered by the label of both drugs.

We report a unusual case of neuralgic amyotrophy (NA) occurring during the seroconversion stage of an HIV infection. Combined with previously published cases, our observation suggests that NA associated with HIV could belong to the group of early multiplex mononeuritis. Neurologists should be aware of HIV infection when managing a patient with NA.

BACKGROUND AND PURPOSE: Our aim was to determine whether diffusion-weighted imaging (DWI) changes associated with transient ischemic attack (TIA) are reversible or correspond to permanent tissue injury. METHODS: Among 103 consecutive patients admitted for TIA, 36 (34.9%) had abnormalities on initial DWI (delay from TIA = 30 ± 33 hours [mean ± SD]). Thirty-three patients (59 DWI lesions) had an MR imaging follow-up (delay from TIA = 10.6 ± 5 months) including fluid-attenuated inversion recovery, T2, DWI, and 3D T1-weighted sequences. For each lesion, we recorded the quantitative parameters on initial DWI (volume, apparent diffusion coefficient [ADC]) and performed a comparison between reversible and irreversible lesions. RESULTS: MR imaging failed to detect any permanent injury in 7 patients and identified subsequent infarct in regions corresponding to the original DWI abnormalities in 26 patients (79%). Of the 59 lesions initially identified on DWI, 45 (76.3%) were associated with permanent injury on follow-up MR imaging. The DWI volume was significantly larger (0.91 ± 1.7 versus 0.21 ± 0.21 cm(3), P = .003) and the ADC ratio values lower (79 ± 15% versus 91 ± 9%, P = .001) in lesions with subsequent infarct than in those that were fully reversible. CONCLUSION: By showing that most patients with DWI-positive TIAs share the same imaging outcome as stroke patients, our data provide additional support for the redefinition of TIA, which considers that all cases of transient deficit with characteristic neuroimaging abnormalities should be diagnosed as a stroke.