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Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.

Background and Purpose: Because of several methodological limitations, previous studies focusing on the prevalence of large vessel occlusion in ischemic stroke (IS) patients provided conflicting results. We evaluated the incidence of IS with a visible arterial occlusion using a comprehensive population-based registry. Methods: Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013–2017). All arterial imaging exams were reviewed to assess arterial occlusion. Annual incidence rates of IS (first-ever and recurrent events) and IS with a visible occlusion were calculated. Results: One thousand sixty cases of IS were recorded (mean age: 76.0±15.8 years, 53.9% women). Information about arterial imaging was available in 971 (91.6%) of them, and only preexisting dementia was independently associated with having missing information (odds ratio=0.34 [95% CI, 0.18–0.65], P =0.001). Among these patients, 284 (29.2%) had a visible arterial occlusion. Occlusion site was the anterior circulation in 226 patients (23.3% of overall patients with available data) and the posterior circulation in 58 patients (6.0%). A proximal occlusion of the anterior circulation was observed in 167 patients (17.2%). The crude annual incidence rate of total IS per 100 000 was 138 (95% CI, 129–146). Corresponding standardized rates were 66 (95% CI, 50–82) to the World Health Organization and 141 (95% CI, 118–164) to the 2013 European populations. The crude annual incidence rate of IS with a visible arterial occlusion per 100 000 was 37 (95% CI, 33–41) and that of IS with a proximal occlusion of the anterior circulation was 22 (95% CI, 18–25). Corresponding standardized rates were 18 (95% CI, 10–26) and 10 (95% CI, 8–13) to the World Health Organization population, and 38 (95% CI, 26–50) and 23 (95% CI, 19–26) to the 2013 European population, respectively. Conclusions: These results will be helpful to plan the need for thrombectomy-capable stroke center resources.

Introduction Moyamoya angiopathy (MMA) is a progressive steno-occlusive disease of the distal internal carotid arteries mainly described in Asia. It induces the development of collateral vascular networks to reduce chronic cerebral hypoperfusion. Symptoms depend on the patient's age in Asia: children are at greater risk of transient or constituted ischemic events, whereas adults are more exposed to hemorrhagic stroke . Data from the literature seem to show that the pattern of MMA in western countries differs from that in Asia. Material and methods A retrospective study of patients with MMA was conducted in Bourgogne-Franche-Comte (mid-eastern France). Clinical data (symptoms, risk factors, age at diagnosis, number and timing of recurrences, type of treatment) as well as radiological data (angiographic findings, Suzuki's grade) were analyzed. Results Seventeen adult patients (9 men, 53%) were followed at the university hospitals of Besancon and Dijon from 2009 to 2016. Fourteen patients (83%) had bilateral disease. The mean age at diagnosis was 49 years (± 16), 83% of the patients were Caucasian and 17% originated from Maghreb. Only 17% of the hemispheres had a hemorrhagic form. Ischemic form was more frequent before diagnosis with transient ischemic attack (24% of patients) and stroke (83% of patients). With medical treatment, 9 patients suffered from stroke recurrence (53% of patients) with an average delay of 22.7 ± 34 months. Three patients (18%) had combined surgical management by encephelo-synangiosis and superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis , without symptom recurrence after treatment with an average follow up of 14 months. Conclusion MMA remains a rare cerebrovascular disease in Europe and requires multidisciplinary care. Epidemiological analysis showed differences with the Asian population, especially the predominance of ischemic forms in adults.

Background The aim of this study was to characterize brain and orbital MRI features of patients with Leber hereditary optic neuropathy (LHON), with particular attention to the optic nerves and chiasm. Method We studied a patient cohort with genetically confirmed LHON followed at 2 ophthalmologic hospitals in France between 2013 and 2015. High-resolution brain and orbital MRI studies were analyzed for each patient during the first 12 months after the onset of visual loss was analyzed. Results Our study included 20 men and 8 women with a mean age of 38.3 years at diagnosis, and all had genetic mutations for LHON. Nineteen patients (67.9%) had T2 hyperintensity in the posterior portion of both optic nerves and in the optic chiasm, and enlargement of the chiasm was found in 16 patients (59.3%). No enhancement of the optic nerves or chiasm was detected. The T2 hyperintensity lesions were not associated with the time between symptom onset and obtaining MRI, the mutation type, or sex of the patient. Nonspecific T2 white matter lesions were found in MRI of 6 patients, but without the characteristics of those found in patients with multiple sclerosis. Conclusions Involvement of the posterior portions of the optic nerves has been described previously in case reports of patients with LHON. Our results support this observation with neuroimaging performed within 1 year of onset of visual loss. Enlargement of the optic chiasm also may occur in patients with LHON. The pathophysiology of the MRI changes is not yet understood.

Objective: We assessed the association between pre-stroke cognitive status and 90-day case-fatality. Methods: Patients with ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH) were prospectively identified among residents of Dijon, France, between 2013 and 2015, using a population-based registry. Association between pre-stroke cognitive status and case-fatality at 90 days was evaluated using Cox regression. Results: Seven hundred sixty-two patients were identified, and information about pre-stroke cognitive status was obtained for 716 (92.6%) of them, including 603 IS (84.2%) and 113 ICH (15.8%). Before stroke, 99 (13.8%) patients had mild cognitive impairment (MCI) and 98 (13.7%) had dementia. Patients with cognitive impairment were older, had a higher prevalence of several risk factors, more severe stroke, more frequent ICH, and less admission to stroke unit. Case-fatality rate at 90 days was 11.7% in patients without cognitive impairment, 32.3% in MCI patients, and 55.1% in patients with dementia. In multivariable analyses, pre-existing MCI (hazard ratio [HR] 2.22, 95% CI 1.21–4.05, p = 0.009) and dementia (HR 4.35, 95% CI 2.49–7.61, p < 0.001) were both associated with 90-day case-fatality. Conclusion: Pre-stroke MCI and dementia were both associated with increased mortality. These associations were not fully explained by baseline characteristics, pre-stroke dependency, stroke severity or patient management, and underlying reasons need to be investigated.

La Tele-fibrinolyse est reconnue comme outil incontournable pour permettre a tout citoyen de beneficier du 1er traitement curatif que represente la fibrinolyse dans les premieres heures d’un infarctus cerebral.Utilisee a grande echelle en Bourgogne avec 21 Hopitaux Generaux en lien avec le CHU de Dijon, une evaluation medicale et economique s’est imposee.Methodes : Nous exposons nos travaux menes sous la coordination du Registre Dijonnais des AVC qui evalue depuis plus de 30 ans les pratiques de soins et les innovations therapeutiques dediees a l’Accident Vasculaire Cerebral (AVC).Resultats : Il a ete demontre en Bourgogne que la Tele-fibrinolyse est aussi efficace et securisee que la fibrinolyse effectuee par le site expert.Sur le plan medico-economique, notre travail a montre 2 resultats :un cout de prise en charge legerement superieur pour les actes de fibrinolyse effectues a distance compares a la fibrinolyse effectuee dans le site expert, explique par le cout des transports.un cout moyen par patient significativement plus eleve que les recettes uniquement pour la fibrinolyse effectuee dans le site expert.En conclusion : La Tele-fibrinolyse est un acte efficace et securisee qui va devoir s’adapter avec les prochaines recommandations sur la selection des malades pouvant beneficier du 2e traitement efficace que represente la Thrombectomie Mecanique qui, pour l’instant, ne s’effectue que dans des sites experts.

Evidence from epidemiological studies has demonstrated that outdoor air pollution is now a well-known major problem of public health, mainly in low and middle income countries. Contrasting with myocardial infarction , there are few data on the association of air pollution and stroke. Methods We propose a narrative literature review of the effects and the underlying biological mechanisms of short- and long-term exposure to air pollutants on stroke risk and mortality, using the following key-words: stroke, cerebrovascular events, ischemic and haemorrhage stroke, transient ischaemic attack , mortality, air pollution and air pollutants. Results Twenty-one papers were selected. Air pollution, of which whose small particulate matter are the most toxic, contributes to about one-third of the global burden of stroke. We can identify vulnerable patients with classical neuro-vascular risk factors or a prior history of stroke or transient ischemic attack or persons living in low-income countries. Biological mechanisms of this new morbid association are discussed. Conclusion Air pollution should be recognized as a silent killer inducing stroke whose mortality rates remain elevated by its role as a new modifiable neurovascular risk factor, needing public health policies .

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted. Methods Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified. Results Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women. Conclusion This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Acute management of ischemic stroke is a burning topic in 2017 since stroke represents the leading cause of acquired handicap in adults. Over the last past years, major improvement took place, especially with the demonstration of the efficacy of mechanical thrombectomy, thus needing to better organize care pathways, and optimize access to neurologists and interventional neuroradiology platforms. Intensive care stroke units remain the pivotal place of patients' management. A multidisciplinary coordination is required, with continuous teaching of all the actors involved in stroke management, so as to increase the number of patients who could benefit from available active treatments.

ObjectiveTo evaluate temporal trends in early ambulatory status in patients with spontaneous intracerebral hemorrhage (ICH).MethodsAll patients with ICH between 1985 and 2011 were prospectively registered in a population-based registry in Dijon, France, and included in the study. Outcomes of ICH survivors were assessed at discharge from their stay in an acute care ward with the use of a 4-grade ambulation scale. Time trends in ambulation disability and place of discharge were analyzed in 3 periods (1985–1993, 1994–2002, and 2003–2011). Multivariable ordinal and logistic regression models were applied.ResultsFive hundred thirty-one patients with ICH were registered, of whom 200 (37.7%) died in the acute care ward. While the proportion of deaths decreased over time, that of patients with ambulation disability increased (odds ratio [OR] 1.67, 95% confidence interval [CI] 0.87–3.23,p= 0.124 for 1994–2002; and OR 1.97, 95% CI, 1.08–3.60,p= 0.027 for 2003–2011 vs 1985–1993 in ordinal logistic regression). The proportion of patients dependent in walking rose (OR 2.11, 95% CI 1.16–3.82,p= 0.014 for 1994–2002; and OR 2.73; 95% CI 1.54–4.84,p= 0.001 for 2003–2011), and the proportion of patients discharged to home decreased (OR 0.49, 95% CI 0.24–0.99,p= 0.048 for 1994–2002; and OR 0.32, 95% CI 0.16–0.64,p= 0.001 for 2003–2011).ConclusionThe decrease in in-hospital mortality of patients with ICH translated into a rising proportion of patients with ambulation disability at discharge. A lower proportion of patients returned home. These results have major implications for the organization of postacute ICH care.

Behcet's disease is a rare multisystemic vasculitis with an etiology that is still unknown. Neurological manifestations may be seen in approximately 5-15% of patients, and both parenchymal and extraparenchymal neurological involvement has been described. When cerebral venous thrombosis (CVT) is the main extraparenchymal manifestation of Behcet's disease, the condition is then dubbed "angio-Behcet's syndrome". However, arterial involvement is extremely rare, with only one reported case of vasculo-neuro-Behcet's disease, characterized by both venous and intracranial arterial involvement - until now. This report is of two patients diagnosed with Behcet's disease characterized by the concomitant presence of both cerebral arterial manifestations and CVT.

Background: We aimed to provide a representation of the global burden of stroke. Methods: All cases of stroke were prospectively identified through the population-based registry of Dijon, France (1987–2012). Attack rates and mortality rates (defined as stroke leading to death within 30 days) were standardized to the European standard. Sex differences and temporal trends were evaluated by calculating rate ratios (RRs). Results: In all, 5,285 stroke cases (52.7% women) were recorded. The standardized attack rate was 98.2/100,000/year and the mortality rate was 12/100,000/year, and both were lower in women than in men (RR 0.67, p < 0.001, and RR 0.70, p < 0.001, respectively). Attack rates increased over time (RR 1.016; 95% CI 1.013–1.020) irrespective of the stroke subtype. In contrast, mortality rates declined (RR 0.985; 95% CI 0.976–0.995) with decreasing rates for ischemic stroke but no change for intracerebral hemorrhage and subarachnoid hemorrhage. The sex gap in both attack and mortality rates remained stable. Between the first (1987–1991) and the last (2007–2012) study periods, the annual number of stroke patients who survived beyond 30 days rose by 55%, Conclusions: Increasing attack rates and decreasing mortality have led to a rise in the number of stroke survivors in the population, thus indicating a growing need for the implementation of dedicated services.

Une patiente de 42 ans est hospitalisee devant l’apparition progressive de cephalees, d’une instabilite a la marche et de mouvements oculaires anormaux. On note comme antecedent une neoplasie mammaire diagnostiquee en novembre 2018 sur des adenopathies axillaires gauche. Elle a beneficie entre janvier et avril 2019 d’une chimiotherapie neoadjuvante (epirubicine, cyclophosphamide, paclitaxel) associee a un curage ganglionnaire et une hormonotherapie. Une radiotherapie complementaire est egalement programmee. Le dernier PET scanner montrait une stabilite de la neoplasie. Elle n’a pas d’autre antecedent general ou ophtalmologique. Cliniquement, on note des cephalees holocrâniennes, des douleurs radiculaires de trajet L5-S1 bilaterales, une atteinte proprioceptive des membres inferieurs et une hypoesthesie corneenne bilaterale. L’examen neuro-ophtalmologique retrouve des mouvements oculaires anormaux a type d’intrusions saccadiques sans intervalle intersaccadique entre les saccades rapides a predominance horizontale mais pouvant prendre un aspect multidirectionnel. Il s’agit donc d’un flutter-opsoclonus sans myoclonie segmentaire associee. L’IRM cerebrale ne montre pas de rehaussement meninge ni anomalie parenchymateuse mais une prise de contraste des deux nerfs trijumeaux. Les quatre ponctions lombaires devoilent une meningite lymphocytaire s’aggravant, sans germe a l’examen direct (149 cellules a predominance mononuclee et une hyperproteinorachie a 0,7 g/L pour la derniere). Les analyses anatomopathologiques et les anticorps onconeuronaux sont negatifs. En revanche, la serologie sanguine Borrelia burgdorferi est positive en IgG et IgM comme la serologie du liquide cephalo-rachidien (taux d’IgG 84,5 UA/ML), confirmee en Western Blot (index de synthese intrathecale d’IgG anti-Borrelia burgdorferi 5,3). Apres un traitement adapte par ceftriaxone pendant 28 jours, les oscillopsies et les troubles de la marche disparaissent, l’examen neuro-ophtalmologique se normalise. Le flutter-opsoclonus est souvent apparente a un syndrome paraneoplasique, ce fut la premiere hypothese chez notre patiente. Cependant, il faut savoir evoquer d’autres etiologies plus rares, notamment infectieuses comme la neuroborreliose y compris en l’absence d’erytheme chronique migrant a l’interrogatoire.

Introduction : L’AVC reste une maladie frequente et grave en France (premiere cause de handicap, deuxieme cause de declin cognitif, troisieme cause de deces) malgre des avancees therapeutiques majeures, expliquant le role structurant de sa prise en charge sur le plan hospitalier et inter-hospitalier.Les filieres de soins pour AVC decloisonnees permettent au patient de beneficier d’une prise en charge optimale de son domicile juasqu’a l’Unite Neuro-Vasculaire (UNV).Les recommandations nationales ont preconise la mise en place de filieres pluridisciplinaires avec un numero telephonique unique (le 15), transfert par SAMU, prise en charge dans un Service d’Urgences assurant une imagerie cerebrale prioritaire puis passage en Unite Neuro-Vasculaire pour realisation d’une fibrinolyse et/ou d’une thrombectomie.L’objectif de cette revue est de rapporter les evaluations successives en pratique courante de la filiere AVC mise en place en Bourgogne depuis 2003, les reponses apportees aux attentes des patients et des tutelles, et leur transposition aux autres regions sanitaires.Methodes : Grâce a l’outil unique en France represente par le Registre Dijonnais des AVC, qui recense depuis 1985 les AVC des residents de la ville de Dijon intramuros de facon prospective, specifique et exhaustive, nous avons evalue le role du suivi telephonique des patients victimes d’un AVC par une infirmiere clinicienne sur l’evolution des taux de recidives et de re-hospitalisation, l’effet de la prise en charge des AVC en UNV sur la mortalite, l’efficacite de la prevention primaire sur l’evolution des taux d’incidence, le role des disparites medico-sociales sur les taux d’incidence et de mortalite des AVC, l’efficacite et la securite apportee par la tele-fibrinolyse, et les defis organisationnels face a l’augmentation du nombre d’AVC a traiter dans les annees a venir.Resultats : Il a ete demontre que le suivi telephonique par les infirmieres-cliniciennes permettait de diminuer le taux de recidives et de re-hospitalisation, l’UNV a fait disparaitre la surmortalite observee le week-end, la Tele-fibrinolyse etait aussi efficace et securitaire que la fibrinolyse effectuee dans l’UNV du CHU de Dijon, la prevention primaire permettait un allongement de l’esperance de vie sans AVC, l’incidence et la mortalite par AVC a trois mois etaient plus elevees dans la population a bas revenu, et le nombre d’AVC allait etre multiplie par 1.4 dans les dix ans a venir.Conclusion : L’organisation de filieres AVC a un cout humain et logistique qui restera a identifier, mais leur efficacite en pratique courante, sur le plan de la prevention et de la prise en charge aigue est reelle.Les methodes deployees en Bourgogne, et qui ont demontre leur efficacite, sont sans doute applicables dans les autres regions qui doivent planifier la prise en charge des AVC des la phase aigue jusqu’a la phase chronique.

Background and Purpose— We evaluated temporal trends in stroke incidence between men and women to determine whether changes in the distribution of vascular risk factors have influenced sex differences in stroke epidemiology. Methods— Patients with first-ever stroke including ischemic stroke, spontaneous intracerebral hemorrhage, subarachnoid hemorrhage, and undetermined stroke between 1987 and 2012 were identified through the population-based registry of Dijon, France. Incidence rates were calculated for age groups, sex, and stroke subtypes. Sex differences and temporal trends (according to 5-year time periods) were evaluated by calculating incidence rate ratios (IRRs) with Poisson regression. Results— Four thousand six hundred and fourteen patients with a first-ever stroke (53.1% women) were recorded. Incidence was lower in women than in men (112 versus 166 per 100 000/y; IRR, 0.68; P P =0.001) and women (IRR, 1.013; 95% confidence interval, 1.007–1.018; P =0.001). The sex gap in incidence remained unchanged in ischemic stroke and intracerebral hemorrhage. Conversely, the lower subarachnoid hemorrhage incidence in women vanished with time because of an increasing incidence. Conclusions— The sex gap in stroke incidence did not change with time except for subarachnoid hemorrhage. Despite lower rates, more women than men experience an incident stroke each year because of a longer life expectancy.

Background: Fatigue is a frequent symptom after stroke. We aimed to determine the association between fatigue and cognitive performance in patients with ischemic stroke who received acute revascularization therapy (IV thrombolysis and/or mechanical thrombectomy).Methods: Seventy patients were prospectively included in the stroke unit of the University Hospital of Dijon, France. A follow-up was performed at 6 months with clinical examination, fatigue assessment by the Fatigue Severity Scale (FSS), and a comprehensive neuropsychological evaluation. Patients with fatigue (FSS score >4) were compared with patients without fatigue. Neuropsychological factors associated with fatigue at 6 months were analyzed using multivariable logistic regression models.Results: Fatigue was reported by 34.3% of patients. Patients with fatigue were older, had more frequent residual handicap, depressive symptoms, and impaired quality of life. They had more frequently low score (

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.

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: 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.

We report the case of a woman who developed right third nerve dysfunction with synkinesis and ocular neuromyotonia secondary to a compressive arterial aneurysm. Surprisingly, our examination showed a downward drift of the right eye in sustained up-gaze resulting in transient hypotropia, suggesting either fatigability of the superior rectus or contraction of the inferior rectus. We believe this ocular motility pattern is secondary to a co-contraction of the inferior rectus in up-gaze caused by synkinesis (explaining the downward drift), followed by failure of the inferior rectus to relax upon return to primary position caused by ocular neuromyotonia (explaining the hypotropia).

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.

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.

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.

International audience

PURPOSE:The MNA (Mini Nutritional Assessment) is known as a prognosis factor in older population. We analyzed the prognostic value for one-year mortality of MNA items in older patients with cancer treated with chemotherapy as the basis of a simplified prognostic score. METHODS:The prospective derivation cohort included 606 patients older than 70 years with an indication of chemotherapy for cancers. The endpoint to predict was one-year mortality. The 18 items of the Full MNA, age, gender, weight loss, cancer origin, TNM, performance status and lymphocyte count were considered to construct the prognostic model. MNA items were analyzed with a backward step-by-step multivariate logistic regression and other items were added in a forward step-by-step regression. External validation was performed on an independent cohort of 229 patients. RESULTS:At one year 266 deaths had occurred. Decreased dietary intake (p = 0.0002), decreased protein-rich food intake (p = 0.025), 3 or more prescribed drugs (p = 0.023), calf circumference

fore, further studies are needed to assess the pathophysiological hypotheses. It appears to be crucial to consider patients from a global perspective, and one of the most significant illustrations is the link between the heart and the brain in the management of cerebrocardiovascular diseases. For example, a direct link between damage in specific regions of the brain, such as the insular cortex, and the incidence of cardiac death has been suggested [4] . In terms of perspectives, it would be interesting to study the clinical and preclinical inter-relation between the brain and heart in ischemic processes. To achieve this goal, we are currently developing a strong collaboration between reDear Sir, We thank Dr. Madias for his interest in our work [1] in which we tried to illustrate a clear relationship between neurologic and cardiologic fields of research. We totally agree that the brain and heart are linked in several affections, especially in Takotsubo syndrome (TTS). In this disease, stroke could be either the cause or the consequence of TTS. In our study published in European Neurology [2] , we assumed that ischemic stroke or epileptic events affecting specific brain regions could induce a massive catecholamine release, as suggested by other authors [3] . We acknowledge that we did not investigated blood catecholamine levels because of the retrospective nature of the study. ThereReceived: January 4, 2016 Accepted: January 4, 2016 Published online: February 2, 2016

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.

International audience; ObjectiveTakotsubo cardiomyopathy is characterized by a transient apical ventricular dysfunction typically induced by an acute stress. Acute cerebral events including ischemic stroke (IS) or Epileptic Event (EE) may both be associated with massive catecholamine release. We aimed to identify the characteristics and outcomes of patients who experienced Takotsubo syndrome complicating an IS or EE.MethodsBetween 2008 and 2013, 87 patients were admitted in our Intensive Care Unit for suspected Takotsubo syndrome, of whom 6 previously experienced acute cerebral symptoms with either IS or EE, within two days. Takotsubo syndrome was diagnosed on Cardiac Magnetic Resonance, echocardiographic, electrocardiographic, biological and coronary angiography data.ResultsFive women and one man were included. The mean age was 63.7±20.1 years old (range: 44-84). Four of them (67%) presented initially an acute IS and two (33%) had EE. The suspected culprit brain injury was the insular cortex for three patients or posterior fossa for two patients. Hemiparesis, aphasia and cerebellar symptoms were the main neurological signs. Abnormal ECG findings including ST segment elevation (33%) or T waves inversion (50%) developed between few hours and 48 hours after the onset of IS or EE. Troponin peak was at 1,8 (0,79-14,11) μg/L. A transient alteration of the left ventricular ejection fraction (46±12%) with apical hypokinesis was found at echocardiography. Two (33%) patients developed an acute heart failure. Coronary angiography confirmed the lack of significant coronary stenosis for all the patients.ConclusionTakotsubo cardiomyopathy can develop early within in the first days after an acute cerebral event, predominantly in women with insular or posterior fossa lesions and induced by possible vegetative reactions.The author hereby declares no conflict of interest

Les big data sont des outils epidemiologiques dont on commence a apprecier le degre de precision et de pertinence pour mesurer le poids des maladies dans une region, un pays ou un continent. Ce nouvel outil est applicable facilement pour les maladies tracantes comme les accidents vasculaires cerebraux (AVC). C’est ainsi que les donnees epidemiologiques mondiales les plus recentes portant sur une periode de 23 ans qui seront exposees, ont permis de montrer que 90 % des AVC sont secondaires a des facteurs de risques modifiables, et elles confirment la place insoupconnee de la pollution atmospherique dans la survenue des AVC qui approche 30 % des cas. La pollution atmospherique apparait ainsi comme un facteur de risque emergent pour les AVC qui contribue a aggraver le poids de cette pathologie, dans tous les pays mais particulierement dans les pays en voie de developpement. En conclusion, la reduction de la pollution atmospherique et a son exposition doit devenir une priorite de politique de sante publique, d’autant que l’AVC n’est pas la seule complication medicale des problemes environnementaux dont la pollution atmospherique.

International audience; OBJECTIVE: We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality. METHOD: We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1ratio1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17-23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes. RESULTS: Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4.9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p\textless0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups. CONCLUSION: Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect. TRIAL REGISTRATION: ClinicalTrials.gov NCT00459589.

Introduction La neuropathie optique hereditaire de Leber (NOHL) est une neuropathie liee a une mutation mitochondriale de penetrance incomplete. Elle touche surtout les hommes jeunes et conduit rapidement a une baisse d’acuite visuelle. Objectifs L’objectif de notre etude etait de recueillir les differents aspects retrouves sur les IRM cerebrales et orbitaires d’une cohorte de 26 patients souffrant de NOHL et ainsi de rechercher les images evocatrices de cette maladie. Methodes Les dossiers de 26 patients furent analyses. Le diagnostic de NOHL fut realise entre janvier 2013 et octobre 2014 dans deux centres medicaux d’ophtalmologie parisiens : Fondation ophtalmologique Adolphe-de-Rothschild et centre hospitalier des Quinze-Vingts. Pour chaque patient, l’IRM cerebrale et orbitaire initiale fut analysee avec une recherche systematique d’hypersignaux d’un ou des deux nerfs optiques (NO), du chiasma optique et de la substance blanche. Resultats L’âge moyen de diagnostic etait de 38,5 ans, avec une predominance masculine (73 %). La principale mutation etait la 11778 (73 %). Parmi les 26 patients, 23 IRM furent analysees et 3 IRM etaient manquantes. Le delai moyen entre les premiers symptomes et la realisation de l’IRM etait de plusieurs mois. Dix-sept IRM (74 %) retrouvaient des anomalies de signal de la portion posterieure (intracanalaire ou cisternale) d’un ou des deux NO, associees dans 82 % des cas a un hypersignal du chiasma et un aspect bombe de celui-ci. Discussion L’atteinte posterieure des NO a precedemment ete decrite chez des cas isoles de NOHL. C’est ce que nous retrouvons avec une extension au chiasma chez la majorite de nos patients. L’aspect elargi du chiasma est egalement fortement evocateur. Les 6 IRM normales peuvent s’expliquer soit par l’absence de sequences specifiques, soit par la realisation precoce de l’IRM initiale. Conclusion Un hypersignal de la portion posterieure des NO s’etendant jusqu’au chiasma avec un aspect elargi de celui-ci est retrouve dans la majorite des NOHL et doit donc faire evoquer le diagnostic.

Introduction La cardiomyopathie de Takotsubo est caracterisee par une dysfonction ventriculaire apicale transitoire typiquement induite par un stress. Les evenements neurologiques aigus comme les infarctus cerebraux (IC) ou les crises epileptiques (CE) peuvent etre associes avec un relargage massif de catecholamines. Objectifs Notre objectif etait d’identifier les caracteristiques et l’evolution des patients ayant presente un syndrome de Takotsubo compliquant un IC ou une CE. Methodes Entre 2008 et 2013, 87 patients furent admis dans notre unite de soins intensifs pour une suspicion de syndrome de Takotsubo. Parmi eux, 6 ont presente un IC ou une CE dans les deux jours precedents. Le syndrome de Takotsubo fut diagnostique a partir des donnees d’IRM myocardique, de l’electrocardiogramme, de l’echographie cardiaque, des donnees biologiques et de la coronarographie. Resultats Cinq femmes et un homme furent inclus. L’âge moyen etait de 63,7 ± 20,1 ans (44–84). Cinq d’entre eux (67 %) presenterent precedemment un IC et deux (33 %) eurent une CE. La lesion cerebrale responsable suspectee fut le cortex insulaire pour quatre patients, et la fosse cerebrale posterieure pour deux patients. Les principaux symptomes neurologiques etaient l’hemiparesie, l’aphasie et des signes cerebelleux. Les anomalies ECG incluant un sus decalage ST (33 %), ou des ondes T negatives (50 %) apparurent entre quelques heures et 48 heures apres le debut des signes neurologiques. Le pic de troponine fut de 1,8 (0,79–14,11) μg/L. L’echographie cardiaque revela une alteration transitoire de la fraction d’ejection ventriculaire gauche (46 ± 12 %) avec une hypokinesie apicale. Deux patients (33 %) presenterent une insuffisance cardiaque aigue. La coronarographie realisee chez tous les patients confirma l’absence de stenose coronaire significative. Conclusion La cardiomyopathie de Takotsubo peut survenir dans les premieres heures suivant un evenement cerebral aigue en particulier chez les femmes avec des lesions cerebrales insulaires ou de la fosse posterieure.

Objective Takotsubo cardiomyopathy is characterized by a transient apical ventricular dysfunction typically induced by an acute stress. Acute cerebral events including ischemic stroke (IS) or Epileptic Event (EE) may both be associated with massive catecholamine release. We aimed to identify the characteristics and outcomes of patients who experienced Takotsubo syndrome complicating an IS or EE. Methods Between 2008 and 2013, 87 patients were admitted in our Intensive Care Unit for suspected Takotsubo syndrome, of whom 6 previously experienced acute cerebral symptoms with either IS or EE, within two days. Takotsubo syndrome was diagnosed on Cardiac Magnetic Resonance, echocardiographic, electrocardiographic, biological and coronary angiography data. Results Five women and one man were included. The mean age was 63.7±20.1 years old (range: 44-84). Four of them (67%) presented initially an acute IS and two (33%) had EE. The suspected culprit brain injury was the insular cortex for three patients or posterior fossa for two patients. Hemiparesis, aphasia and cerebellar symptoms were the main neurological signs. Abnormal ECG findings including ST segment elevation (33%) or T waves inversion (50%) developed between few hours and 48 hours after the onset of IS or EE. Troponin peak was at 1,8 (0,79-14,11) µg/L. A transient alteration of the left ventricular ejection fraction (46±12%) with apical hypokinesis was found at echocardiography. Two (33%) patients developed an acute heart failure. Coronary angiography confirmed the lack of significant coronary stenosis for all the patients. Conclusion Takotsubo cardiomyopathy can develop early within in the first days after an acute cerebral event, predominantly in women with insular or posterior fossa lesions and induced by possible vegetative reactions.