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Les hemorragies cerebrales representent 10 a 20 % des accidents vasculaires cerebraux dans les pays occidentaux. En raison du vieillissement de la population et de l’augmentation de la prescription des agents anti-thrombotiques, un tiers des adultes victimes d’hemorragie cerebrale prennent un traitement antiagregant plaquettaire ou anticoagulant oral au moment ou l’accident hemorragique survient. Le risque annuel absolu d’hemorragie intracrânienne sous traitement anticoagulant oral est evalue entre 0,25 et 1,1 % (7 a 10 fois plus que l’incidence observee dans la population generale). Les facteurs de risque d’hemorragie cerebrale sous traitement anticoagulant sont l’âge, l’hypertension arterielle, l’intensite du traitement anticoagulant, l’existence d’antecedents d’accident vasculaire cerebral ou d’une micro-angiopathie cerebrale, l’association a un traitement antiagregant plaquettaire, et certains facteurs genetiques (alleles APOe2 et e4 en cas d’hematome lobaire). Le pronostic des hemorragies cerebrales survenant sous traitement anticoagulant oral est sombre avec un taux de mortalite eleve, notamment en raison du risque accru d’augmentation precoce du volume de l’hemorragie liee a la poursuite du saignement. Une reduction de 50 % de l’incidence des hemorragies cerebrales a ete observee chez les patients traites par anticoagulant oral direct en comparaison des patients traites par anti-vitamine K dans les essais randomises conduits dans la fibrillation atriale. Cependant, dans les meta-analyses recentes, le volume d’hemorragie cerebrale (principal facteur pronostique), le taux d’augmentation du volume d’hemorragie, la mortalite et le pronostic fonctionnel apparaissent similaires dans les hemorragies liees aux anticoagulants oraux directs et dans celles liees au traitement anti-vitamine K. Quand une hemorragie cerebrale survient sous traitement anticoagulant, les deux moyens therapeutiques visant a lutter contre l’augmentation du volume de l’hemorragie sont le controle de la pression arterielle et la reversion de l’action anticoagulante en urgence par l’administration de concentres de complexe prothrombinique ou d’un antidote specifique (idarucizumab pour le dabigatran). En cas d’hemorragie cerebrale survenant sous traitement antiagregant plaquettaire, il n’y a pas d’indication a realiser une transfusion de plaquettes, l’etude randomisee PATCH ayant montre une augmentation du risque de deces et de handicap en cas de transfusion de plaquettes.

Background Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County. Methods The four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006–7 and 2015–16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term. Results Between 2015–16 and 2006–7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p

Introduction Les patients de l’unite neuro-vasculaire de Bourg-en-Bresse sont transportes au CHU de Lyon pour une eventuelle thrombectomie en transfert infirmier inter-hospitalier (TIIH). Objectifs L’objectif est d’etudier la faisabilite et la securite du transfert infirmier inter-hospitalier en l’absence de medecin pendant le transport (infirmier + ambulancier). Patients et methodes Le travail a consiste en une etude retrospective des patients transferes par TIIH depuis le CHB vers le CHU de Lyon entre janvier 2016 et decembre 2018 en vue d’une thrombectomie. Les complications analysees pendant le transport sont l’hemorragie systemique, le trouble de conscience, l’angio-œdeme, l’instabilite hemodynamique ou respiratoire, l’arret cardio-respiratoire, la necessite d’appel a la regulation du SAMU, de renfort SMUR, d’administration de traitements pendant le transport et l’evolution defavorable du score NIHSS. Resultats 45 patients consecutifs ont ete etudies. Une thrombolyse IV est en cours pendant le transport chez 33 patients (73 %) et une thrombectomie a ete realisee chez 35 (78 %). La duree moyenne du transport est de 55 min. Il n’y a pas eu de complication sauf un trouble de conscience transitoire. Le centre 15 a ete appele a dix reprises sans declenchement de renfort medicalise. Il a ete necessaire d’instaurer un traitement dans onze cas (24 %). Discussion Le TIIH dans le cadre de la thrombectomie est peu developpe. Nous retrouvons un nombre tres faible de complications, meme chez les patients en cours de thrombolyse. Une medicalisation du transfert ne semble pas indispensable sous reserve d’une selection prealable des patients eligibles. La securite est renforcee par des protocoles pour le personnel paramedical et par teletransmission des parametres vitaux. Conclusion Notre etude montre la securite du TIIH dans le cadre de la thrombectomie. Il permet une economie de temps medical. Ces resultats doivent etre confortes par d’autres experiences similaires.

Introduction The management of stroke is a public health priority in France. Patients require emergency medical care and rapid implementation of reperfusion strategies to improve prognosis and reduce disability. Stroke is the leading cause of death in women, the third in men. We aimed to compare the management of stroke and outcome among women and men, in a cohort of acute ischaemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA). Methods We analysed data from a prospective AIS thrombolysis registry approved by ethical authorities. They are collected in standardized medical records and consistency is checked by clinical research associates. Data concern pre-hospital management, therapeutical decisions, management delays, complications, status at final discharge and follow-up at three months. A total of 2790 patients received tPA between 2010 and in the six stroke units of the RESUVal network (Rhone Valley, France); 1275 women (45.7%) and 15,152,016 men (54.3%). Results Women were older than men at admission time (median age: respectively 77 [66; 84] vs. 71 [61; 80] years old, P Conclusions Since the last years, the increasing use of technical reperfusion strategies - such as thrombectomy - and an organized access to the right pathway of care have tended to standardize treatment of AIS. Despite a later pre-hospital management and more severe presentation at admission, the comparison of the main key management of stroke does not differ among women and men and does not lead to excess mortality among women. For further investigation, we need to analyze the relationship between the pre-hospital delays and behavioral disparities.

New therapeutic strategies are under evaluation to improve the treatment of acute ischemic stroke (AIS). Approaches combining intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) and antithrombotic agents are currently evaluated. The combination of IV rt-PA and aspirin showed a high rate of intracranial hemorrhage whereas the association of rt-PA and eptifibatide seems more promising. The results of recent studies evaluating the administration of eptifibatide or argatroban in conjunction with conventional IV thrombolysis with rt-PA are expected to clarify the safety and efficacy of these treatments. More fibrin-specific plasminogen activators, tenecteplase and desmoteplase, are also investigated. These fibrinolytic agents showed a favorable safety profile but their efficacy in AIS remains uncertain. While phase III studies, DIAS-3 and DIAS-4, evaluating IV desmoteplase up to nine hours after stroke onset did not meet the primary endpoint, the results of studies comparing IV tenecteplase and IV rt-PA are expected.

Intravenous thrombolysis was the only proven effective reperfusion therapy for acute ischemic stroke within 4h30 until December 2014. Stroke management has been revolutionized after the publication of the recent positive trials, such as MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, and THRACE. Each of these demonstrates a clear benefit of stent retriever thrombectomy in association with thrombolysis in acute stroke patients with a documented occlusion of the distal internal carotid or the proximal middle cerebral artery within 6 h of symptoms onset. According to the initial selection, the number of patients to be treated by thrombectomy in order to have one independent patient varies from 3 to 8.To guarantee these results, thrombectomy should be performed by an interventional neuroradiologist within 60–90 min after imaging confirmation, which requires a very fast transfer of patients to hospitals, where interventional neuroradiology is available without delaying thrombolysis. Samu plays a key role in this. In case of contraindication to thrombolysis, early primary thrombectomy should also be considered within 6 h of last seen normal. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. A close cooperation between all the teams is crucial with the goal of gaining maximum time to the patient.

Background: Brain MRI may be helpful for selecting patients at higher risk of further bleeding after a first hemorrhagic stroke in patients with atrial fibrillation treated by oral anticoagulants. MRI may detect imaging markers consistent with an increased risk of further bleeding that could improve patient selection for left atrial appendage closure (LAAC). Method: We studied clinical and imaging data of patients with atrial fibrillation treated by oral anticoagulants who experienced hemorrhagic stroke. MRI was performed for the detection of small vessels disease abnormalities (cerebral amyloid angiopathy (AA) or severe hypertensive microangiopathy) suggesting a higher hemorrhagic risk thus supporting the choice of LAAC closure instead of anticoagulants to prevent thromboembolic events. Results: Between December 2013 and February 2016, 37 patients were included. Among them 25 patients experienced brain hemorrhage and underwent a cerebral MRI before LAAC. 16% (4/25) had severe white matter damage, 24% (6/25) exhibit MRI features consistent with hypertensive microangiopathy/or multiple cortical microbleeds (CMBs) and cortical superficial siderosis (CSS) consistent with AA. 16% (4/25) with mixed anomalies and 11 (44%) had undetermined small vessel disease. Conclusion: Brain MRI after a first hemorrhagic stroke may provide helpful information on the risk of bleeding recurrence before LAAC.

Background Echocardiographic evaluation is recommended in the acute phase of stroke mainly for etiological and therapeutic purpose but also for cardiovascular comorbidities assessment. Echocardiography (TTE) is known as an easy accessible tool. However facing an increasing incidence in strokes and TTE accessibility concerns due to organizational strains, TTE completion during hospital stay is often delayed and about to increase patient's length of stay (LOS). Purpose To evaluate the impact of the integration of TTE inside the acute neurovascular care unit (ANCU) for patients with an acute stroke on: – the percentage of in-hospital TTE; – the admission to in-hospital TTE delay; – the global LOS and specific LOS for patients having a TTE within the hospital stay. Methods We retrospectively compared period A, after TTE integration lasting from Oct 2017 to Feb 2018 to period B, before TTE integration lasting from Oct 2016 to Feb 2017. LOS was compared between periods and independent covariates were explored with TTE delay. Results Table 1 summarizes main characteristics. Proportions of total and in-hospital TTE completion were higher in period A but global LOS was not different. However TTE delay and LOS for the subgroup of patients having a TTE within the hospital stay were significantly lower in period A. Linear regression identified comorbidity index and TTE delay as independent factors influencing LOS in this subgroup. Increasing comorbidity index by 1000 and TTE delay by 1 day increased LOS by 1.2 days for both. Conclusion TTE integration in the ANCU improves quality of care and shortens TTE completion's delay as well as LOS. This calls for an early integration of cardiology in stroke care.

Background and Purpose— Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients. Methods— Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol. Results— Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%). Conclusions— Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies. Clinical Trial Registration Information— URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Resume Les mouvements periodiques des jambes (MPJ) sont des mouvements repetitifs des membres inferieurs survenant le plus souvent au sommeil. Les cas idiopathiques sont les plus frequents. Nous rapportons l’observation d’un patient presentant des mouvements periodiques, a la veille et au sommeil, du membre inferieur hemiplegique a la phase aigue d’un accident vasculaire cerebral. La lesion ischemique touchait le faisceau corticospinal. Une hypothese pouvant expliquer ces mouvements, et en particulier leur caractere permanent et diffusant, est celle d’un effet desinhibiteur supraspinal, a l’origine d’un renforcement de l’hyperexcitabilite d’une boucle sensorimotrice impliquant un relais medullaire. Chez notre patient, l’administration d’un agoniste dopaminergique a permis d’ameliorer significativement les mouvements.

New therapeutic strategies are under evaluation to improve the treatment of acute ischemic stroke (AIS). Approaches combining intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) and antithrombotic agents are currently evaluated. The combination of IV rt-PA and aspirin showed a high rate of intracranial hemorrhage whereas the association of rt-PA and eptifibatide seems more promising. The results of recent studies evaluating the administration of eptifibatide or argatroban in conjunction with conventional IV thrombolysis with rt-PA are expected to clarify the safety and efficacy of these treatments. More fibrin-specific plasminogen activators, tenecteplase and desmoteplase, are also investigated. These fibrinolytic agents showed a favorable safety profile but their efficacy in AIS remains uncertain. While phase III studies, DIAS-3 and DIAS-4, evaluating IV desmoteplase up to nine hours after stroke onset did not meet the primary endpoint, the results of studies comparing IV tenecteplase and IV rt-PA are expected.

Resume Introduction Les encephalopathies post-anoxiques surviennent parfois de maniere retardee, la semiologie etant alors celle d’une leucoencephalopathie rapidement progressive dont le diagnostic etiologique s’avere difficile lorsque l’anamnese est incomplete. Observation Nous rapportons l’observation d’une patiente presentant un tableau d’encephalopathie progressive a l’issue d’une tentative de suicide medicamenteuse associee a une detresse cardio-respiratoire. L’IRM montrait une atteinte diffuse de la substance blanche dont la nature anoxique fut documentee par la biopsie cerebrale stereotaxique. Conclusion L’encephalopathie post-anoxique d’apparition retardee est une affection rare de physiopathologie complexe dont le diagnostic etiologique reste difficile.

Resume Le delai d’admission des patients victimes d’accident vasculaire cerebral (AVC) demeure excessif. La reconnaissance precoce des symptomes peut raccourcir ce delai. L’etude prospective que nous rapportons visait a evaluer le niveau d’information concernant l’AVC des patients hospitalises dans une unite neurovasculaire francaise. Du 2 juillet 1998 au 2 juillet 1999, un questionnaire standardise visant a evaluer ce niveau d’information fut soumis a 166 patients consecutifs venant de presenter un AVC. Seuls 91 patients furent capables de repondre au questionnaire dans les 48 premieres heures. Parmi ceux-ci, seuls 19 patients (21 p. 100) avaient pense qu’ils etaient victimes d’une attaque cerebrale avant d’arriver a l’hopital, 38 patients (42 p. 100) ne pouvaient citer aucun symptome evocateur d’AVC et 33 patients (36 p. 100) ne pouvaient citer aucun facteur de risque d’AVC. Les facteurs de risque d’AVC les plus frequemment cites furent : le tabagisme cite par 31 patients (34 p. 100) et l’hypercholesterolemie citee par 19 patients (21 p. 100). Aucun patient n’a cite les antecedents personnels d’accident ischemique cerebral transitoire ou constitue. Les symptomes evocateurs d’AVC les plus souvent cites furent : la paralysie d’un hemicorps ou d’un membre citee par 40 patients (44 p. 100) et les troubles du langage cites par 15 patients (16 p. 100). En analyse multivariee, le sexe feminin et le fait de « connaitre quelqu’un ayant ete victime d’une attaque cerebrale » sont des facteurs independants influencant la capacite a citer un(des) symptome(s) evocateur(s) d’AVC. Des efforts d’information quant a la reconnaissance des symptomes et a la reaction appropriee doivent etre deployes dans l’espoir de reduire le delai d’admission. Une meilleure information du public concernant les facteurs de risque apparait egalement souhaitable afin d’ameliorer la qualite de la prevention des maladies vasculaires.

Resumen. Entre los accidentes cerebrovasculares (ACV) se distinguen los infartos cerebrales (el 80 % de los casos) y los hematomas intracerebrales (el 20 % de los casos). Las hemorragias meningeas forman parte de una entidad aparte. El tratamiento optimo de los accidentes cere-brovasculares establecidos deberia realizarse preferentemente en una unidad neurovascular. Diversos estudios aleatorizados han demostrado que el tratamiento en estos centros tiene efectos favorables sobre la mortalidad, el grado de invalidez 3 a 6 meses despues del ACV inicial, la duracion de la estancia en el hospital, el porcentaje de retornos al domicilio, y el indice de invalidez a mediano y largo plazo. Estas unidades tienen un impacto socioeconomico favorable indiscutible. Recientemente, el tratamiento especifico de los infartos cerebrales ha evolucionado considerablemente. El tratamiento mas eficaz es la trombolisis cerebral con rt-PA (recombinant tissue plasminogen activator) realizado en un lapso de 3 horas. La posologia puede ser de 0,9 mg·kg−1 (dosis preconizada por el National Institute of neurological Disorders and Stroke [NINDS]) administrada durante 60 minutos, o bien de 0,8 mg·kg−1 administrada durante 90 minutos (protocolo de Lyon). El beneficio de la trombolisis se basa en el aumento del 50 % de pacientes sin secuelas neurologicas a los 3 meses. La complicacion de este tratamiento es la aparicion de hematomas intracerebrales, que solo se manifiestan en el 7 % de los casos. La trombolisis intraarterial esta indicada, en particular, en las trombosis del tronco basilar y de la arteria vertebral intracraneal, puesto que la mortalidad, habitualmente del 95 %, disminuye con este tratamiento al 50 %. Otros metodos antitromboticos que utilizan principios activos como el acido acetilsalicilico, la heparina no fraccionada y las heparinas de bajo peso molecular (HBPM) tienen muy poca influencia en el pronostico. Sin embargo, la heparina forma parte del tratamiento preventivo de la enfermedad tromboembolica venosa. En los infartos malignos, debe considerarse la posibilidad de efectuar una ventana descompresiva. Se esta estudiando la eficacia del tratamiento hipotermico. El tratamiento basico de los hematomas intracerebrales no ha variado: consiste en el tratamiento antiedematoso con manitol y controlar la presion arterial. La metilprednisolona es relativamente eficaz, pero no existen estudios aleatorizados que lo demuestren. La evacuacion endoscopica de los hematomas de mas de 20 ml mediante trepanacion, efectuada en un lapso de 48 horas, parece dar buenos resultados. La craneotomia en caso de hematomas lobulares asi como la puncion-aspiracion-trombolisis por via estereotaxica (en el caso de hematomas profundos) pueden mejorar, en algunos casos, el pronostico si se realizan en un lapso de 24 horas. En la practica, el metodo mas eficaz parece ser la endoscopia.

Resume Nous rapportons les observations de deux patientes suivies depuis plusieurs annees pour une sclerose en plaques, ayant presente une symptomatologie neurologique dont la brutalite, l'evolution et les anomalies electroencephalographiques evoquent un etat de mal epileptique partiel non convulsif. L'une avait une presentation aphasique et deficitaire et l'autre psychiatrique. Ces observations soulignent l'importance d'evoquer de principe une etiologie epileptique devant un trouble de debut brutal, neurologique ou psychiatrique, chez un patient souffrant de sclerose en plaques. Le diagnostic precoce permet un traitement adapte rapide.

Amusia is defined as an auditory agnosia, specifically related to music, resulting from a cerebral lesion or being of congenital origin. Amusia is rarely associated to musical anhedonia. We report the case of a 43-year-old patient who suffered in January 2012 from a right ischemic lesion affecting the superior temporal cortex, in particular lateral Heschl Gyrus and the posterior part of the Superior Temporal Gyrus (Brodmann areas 21 and 22). Neuropsychological tests revealed an amusia combined to musical anhedonia. The specificity of this case is based on the combination of both syndromes highlighting the relation between neural networks involved in the processing of musical information in both its perceptual and emotional components.

Ischemic stroke is a very rare complication but classic ovarian hyperstimulation. We report the cases of three young women aged 35, 37 and 27 years. All three were victims of ischemic formed by proximal occlusion of the middle cerebral artery secondary to ovarian hyperstimulation. The first and the third had a proximal occlusion of the right middle cerebral artery occlusion and the second of the left middle cerebral artery. The last two have benefited from a patient intravenous thrombolysis. The first patient did not receive thrombolysis because it was out of time. Against by their evolution was different. The first has almost recovered its deficit, the second sequelae quite heavy after craniectomy and the third died despite her craniectomy.

Resume Les cephalees, associees aux autres symptomes de l’hypertension intracrânienne, constituent le mode de revelation le plus frequent des thrombophlebites cerebrales. Leur installation est le plus souvent subaigue et non soudaine comme dans les cephalees de l’hemorragie meningee. Nous rapportons un cas de thrombophlebite cerebrale du sinus longitudinal superieur et du sinus lateral droit revelee de facon exceptionnelle par une hemorragie sous-arachnoidienne. La regression complete des symptomes fut observee apres traitement precoce par heparine intraveineuse. L’hemorragie sous-arachnoidienne n’etait plus visible sur le scanner X de controle realise 48 heures apres le debut du traitement anticoagulant. A 2 mois, la patiente est indemne de tout deficit neurologique.

We describe a case of a 70-Year-old man who presented subacute pseudo-dementia due to a dural fistula. Neurological assessment and the reversibility of the symptoms after embolization support the originality of this observation.

β-thalassemia is a genetic hemoglobinopathy, which can cause hypercoagulability, vessel wall damages and thromboembolic events. Spontaneous subarachnoidal hemorrhages are not commonly described in this affection. We report subarachnoidal hemorrhage, observed during the post-partum period in a 27-year-old woman suffering from β-thalassemia major. Brain MRI revealed complex vascular abnormalities: intracranial carotid occlusion, carotid micro-aneurisms, abnormally developed deep perforators and cortical arteries.

The onset of post-anoxic encephalopathies can be delayed after the acute hypoxic injury.We present the case of a 45-year-old woman who achieved complete recovery from an episode of hypoxia related to a suicide attempt (ingestion of benzodiazepine). Three weeks later she developed a confusional state with akinetic mutism and parkinsonism. Brain CT-scan showed bilateral hemispheric white matter hypodensities. MRI showed extensive bilateral hyperintensities on T2-weighted and Flair sequences within the hemispheric white matter and the globus pallidus. EEG showed diffuse slow activity. All investigations for leukodystrophies were negative. Brain biopsy showed normal cortex and widespread demyelination with axonal sparing in the underlying white matter. The patient experienced a partial clinical recovery.The clinical course and the results of paraclinic investigations were consistent with the diagnosis of delayed post-anoxic leukoencephalopathy.

Headache of subacute onset, associated with other signs of increased intracranial pressure, represents the most frequent symptom of cerebral thrombophlebitis. We report a case of subarachnoid hemorrhage as a rare presentation of cerebral thrombophlebitis. Unfractionated intravenous heparin treatment resulted in resolution of subarachnoid hemorrhage on control brain CT scan and quick clinical recovery.

We describe a case of a 70-Year-old man who presented subacute pseudo-dementia due to a dural fistula. Neurological assessment and the reversibility of the symptoms after embolization support the originality of this observation.

Admission delay remains the main cause for stroke patient exclusion from urgent therapeutic protocols. Public lack of knowledge about stroke symptoms may result in delay in seeking medical care and late presentation at hospital. Lack of knowledge of risk factors for stroke may also hamper compliance with stroke prevention practices. The aim of this prospective study using a standardized questionnaire was to evaluate the stroke awareness of acute stroke patients in France. From July 2, 1998 to July 2, 1999, 166 consecutive stroke patients were admitted at our stroke unit. Among the 91 patients who were able to answer the questionnaire during the first 48 hours, only 19 patients (21 p.cent) thought they were having a stroke before their arrival at the hospital, 38 patients (42 p.cent) did not know a single sign of stroke and 33 patients (36 p.cent) did not know a single risk factor of stroke. The most common risk factors named by the patients were smoking and hypercholesterolemia (named by 31 patients (34 p.cent) and 19 patients (21 p.cent), respectively). The most common warning signs named by the patients were paralysis of one side of body or one limb and speech disturbance (named by 40 patients (44 p.cent) and 15 patients (16 p.cent), respectively). Female sex and "knowing somebody who had a stroke" were significantly associated with awareness of signs of stroke in multivariate analysis. Educational public programs regarding stroke awareness are needed in France. Educational campaigns must stress the risk factors and symptoms of stroke and the appropriate response in the hopes of reducing admission delay and improving stroke prevention.

BACKGROUND AND PURPOSE: Follow-up imaging data from stroke patients without angiographically apparent arterial occlusions at symptom onset are lacking. We reviewed our Emergency Management of Stroke (EMS) trial experience to determine the clinical and imaging outcomes of patients with ischemic stroke who showed no arterial occlusion on angiograms obtained within 4 hours of symptom onset. METHODS: All patients in this report were participants in the EMS trial that was designed to address the safety and potential efficacy of combined IV and intraarterial thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with acute ischemic stroke. RESULTS: Thirty-five patients were randomized to receive either IV rt-PA (n = 17) or placebo (n = 18), followed by cerebral angiography. No symptomatic arterial occlusion was evident in 10 (29%) of the 34 patients. Eight (80%) of 10 patients without angiographically apparent clot within 4 hours of symptom onset had a new cerebral infarction confirmed on follow-up brain imaging. The median 72-hour infarction volume was 2.4 cc (range, 1–30 cc). Four of the 10 “no-clot” patients had a favorable 3-month outcome as assessed by Barthel Index (score, 95 or 100) and modified Rankin Scale (score, 0 or 1). The six remaining patients had 3-month Rankin Scale scores of 1 (Barthel of 90), 2, 3, 4, or 5. CONCLUSION: Acute ischemic stroke patients with a neurologic deficit but a negative angiogram during the first 4 hours after symptom onset usually develop image-documented cerebral infarction, and approximately half suffer from long-term functional disability. The two most likely explanations for negative angiograms are very early irreversible ischemic damage despite recanalization or ongoing ischemia secondary to clot in non-visible penetrating arterioles or in the microvasculature.

Objective: To study the possible specific response to recombinant tissue plasminogen activator (rtPA) thrombolysis of anterior choroidal artery (AChA) stroke. Background: Outcome and response after rtPA thrombolysis are possibly better in small-vessel infarcts, but a specific study of AChA stroke has not yet been performed. Methods: The authors proposed an open trial of IV rtPA within 7 hours in patients age 20 and 81 years with all types of internal carotid artery territory stroke if the baseline Scandinavian Stroke Scale (SSS) score was less than 48. A dose of rtPA 0.8 mg/kg was infused over 90 minutes. Of 114 consecutive patients, 9 patients (7.9%) exhibited hypodensity in the AChA territory on day 1 brain CT. Results: Seven of nine patients with AChA infarct had a primary early recovery within 6 hours after the initiation of rtPA infusion. In addition, recovery was complete in five patients and partial in two patients. No intracerebral hematoma was observed. Three patients had a “reinfarct syndrome” at 12, 25, and 48 hours respectively. However, in the two latter patients treated with IV heparin, the deficit disappeared again with the increase of heparin dose in one patient and disappeared spontaneously in the other patient. The overall outcome at day 90 was six total recoveries in nine patients (66%). Patients with a final good outcome had a slight “unstructured” hypodensity in the AChA territory on day 1 brain CT, whereas patients with a bad outcome had the classic “structured” hypodensity of AChA territory stroke. Conclusion: These data support a specific quick response of AChA territory stroke to IV rtPA thrombolysis, probably due to the small size of the artery and of the “clot.” The high frequency of the reinfarct syndrome is a clinical fact that is difficult to explain. Efficient heparin treatment after 24 hours may control the reinfarct syndrome in some patients.

This report describes the observations of two patients with a several years' history of multiple sclerosis who presented sudden neurologic impairment. The symptomatology was suggestive of a non-convulsive partial status epilepsy. The clinical presentation was a paroxysmal dysphasic phenomenon in the first case without any consciousness impairment, associated with slight right hemiparesis. Electroencephalographic investigations revealed asymmetrical patterns, left-sided slow waves and periodic lateralized epileptiform discharges (PLEDs). Antiepileptic treatments were partially effective and intravenous steroids were needed for complete recovery. For the second patient, clinical presentation was acute psychiatric symptoms with disorientation, alternating manic symptomatology and mutism. Electroencephalography showed left fronto-central rhythmic continuous slow wave and spike wave activity. Intravenous antiepileptic treatment quickly improved the symptomatology. These observations draw attention to the fact that an epileptic cause should not be ruled out when a patient with multiple sclerosis presents sudden neurologic or psychiatric impairment. An early diagnosis allows immediate antiepileptic treatment. Intravenous steroids can be added to stop seizures.

Introduction La vascularisation des noyaux anterieur, ventro-lateral anterieur et ventro-lateral intermediaire du thalamus est principalement assuree par l’artere tubero-thalamique qui est une branche de l’artere communicante posterieure. Observation Nous rapportons le cas d’une patiente de 74 ans, hypertendue, dyslipidemique, porteuse d’une valvulopathie mitrale, sous traitement medicamenteux, admise dans notre service pour un ptosis gauche d’installation brutale et une desorientation temporo-spatiale. L’examen neurologique etait normal hormis ce ptosis isole, sans myosis ni autre anomalie de paires crâniennes associee. Il n’y avait ni ophtalmoplegie, ni paralysie faciale, ni deficit sensitivo-moteur des 4 membres, ni syndrome cerebello-vestibulaire, pas plus que de syndrome meninge, de trouble de vigilance ou de mouvements anormaux. L’IRM avec ARM montra un infarctus aigu et unique de la partie antero-laterale du thalamus gauche, correspondant au territoire de l’artere tubero-thalamique. Il n’y avait pas d’argument pour une dissection, une stenose arterielle ou une malformation vasculaire. La radio pulmonaire etait normale. Le test a la Neosynephrine a permis d’obtenir une correction transitoire du ptosis confirmant qu’il s’agissait bien d’un syndrome de Claude Bernard Horner (CBH) partiel. Un bilan neuropsychologique realise a J10 a trouve une perturbation moderee des capacites mnesiques et du langage. Discussion L’infarctus tubero-thalamique se manifeste classiquement par une semiologie frontale : apathie, euphorie, troubles attentionnels, perseverations etc. avec des signes de lateralisation selon l’hemisphere touche : aphasie, amnesie, troubles visuo-spatiaux, heminegligence, associes de maniere inconstante a une hemiparesie et/ou hemihypoesthesie d’evolution en general regressive. Quelques rares cas comportant un CBH sont rapportes dans la litterature. Conclusion Un syndrome de CBH peut etre satellite d’un infarctus de l’artere tubero-thalamique. Cette presentation clinique est certes rare mais doit etre evoquee devant tout CBH d’installation brutale chez un sujet a risque vasculaire.