Introducción y objetivos: El origen de los émbolos implicados en los episodios isquémicos relacionados con el foramen oval permeable (FOP) sigue estando poco documentado. El objetivo fue evaluar la enfermedad tromboembólica venosa (ETV) como posible fuente de episodios embólicos relacionados con el FOP.Métodos: Se sometió a los pacientes programados para el cierre del FOP como prevención secundaria de episodios embólicos arteriales relacionados con este a una evaluación sistemática del riesgo de ETV. Dicha evaluación incluyó: a) un cuestionario exhaustivo sobre antecedentes de ETV para identificar situaciones clínicas de alto riesgo en el momento del episodio embólico, y b) una resonancia magnética (RM) abdominopélvica con venografía para identificar enfermedades venosas abdominales o pélvicas.Resultados: Desde julio de 2020 hasta mayo de 2023, se incluyó prospectivamente a 366 pacientes consecutivos (edad media de 51 años [42-58], 42,9% mujeres). Un episodio previo de ETV, una situación de alto riesgo de ETV, un estado de hipercoagulabilidad o una anomalía venosa abdominal o pélvica en la RM estuvieron presentes en el 8,5% (IC95%, 6,0-11,8), el 22,7% (IC95%, 18,7-27,2), el 7,1% (IC95%, 4,9-10,2) y el 36,3% (IC95%, 31,6-41,4) de los pacientes, respectivamente, y el 58,5% (IC95%, 53,4-63,4) de ellos presentaron al menos 1 de estas condiciones. La RM identificó diversas anomalías venosas pélvicas no diagnosticadas previamente, con un 20,0% de varices pélvicas, un 9,8% de síndrome de May-Thurner/Cockett y un 7,4% de síndrome del cascanueces. Las anomalías en las imágenes fueron más frecuentes entre los pacientes más jóvenes (ORa = 1,02; IC95%, 1,00-1,04) y en mujeres (ORa = 1,94; IC95%, 1,25-3,02).Conclusiones: Un episodio previo de ETV, una situación de alto riesgo de ETV, un estado de hipercoagulabilidad o una anomalía venosa abdominal o pélvica en la RM pueden estar presentes en la mayoría de los pacientes con antecedentes de un episodio arterial relacionado con un FOP.

Importance Evidence regarding efficacy and safety of thrombectomy in acute ischemic stroke (AIS) due to medium or distal vessel occlusions (MDVOs) is lacking. Objective To evaluate the benefit of thrombectomy, in addition to medical treatment over medical treatment alone, in patients with an AIS related to a primary and isolated MDVO. Design, Setting, and Participants Randomized clinical trial conducted at 22 stroke centers in France from November 2021 to April 2025, with planned enrollment of 488 patients. The trial has been stopped after the planned interim analysis on the recommendation of the data and safety monitoring board for futility and increased rate of symptomatic intracranial hemorrhage with thrombectomy. Eligible adult patients had an AIS due to a primary MDVO within 8 hours of symptom onset or within 24 hours of last seen well if no hyperintense signal was present on fluid-attenuated inversion recovery imaging. Intervention Thrombectomy in addition to medical treatment (n = 123) or medical treatment alone (n = 121). Main Outcomes and Measures The primary end point was a good clinical outcome at 3 months, defined as a modified Rankin Scale score of 0 to 2, assessed by an independent, blinded assessor. Secondary end points included mortality rate at 3 months and adverse and serious adverse events. Results Of the 244 patients randomized (median age, 75 years [IQR, 67-81]; 56% male; median National Institutes of Health Stroke Scale score, 8 [IQR, 6-12]), 100 of the 123 patients in the thrombectomy group (81%) received thrombectomy and none of the 121 patients in the control group received thrombectomy; 217 (89%) completed follow-up. At 3 months, 72 of 116 patients (62%) in the thrombectomy group had a good clinical outcome vs 81 of 119 patients (68%) in the control group (odds ratio, 0.73 [95% CI, 0.40-1.31]; P = .29; adjusted absolute difference, −6.8% [95% CI, −19.4% to 5.7%]). The incidence of symptomatic intracranial hemorrhages was higher among the 100 patients who actually received thrombectomy than in those who did not (11% vs 3%, P = .008), as was incidence of subarachnoid hemorrhages (13% vs 2%, P < .001) and embolus migration (5% vs 1%, P = .04). Mortality rate did not significantly differ between the 2 groups (6% vs 8%; P = .49). Conclusions and Relevance Thrombectomy did not lead to a higher rate of good clinical outcome at 3 months compared with medical treatment alone in patients with acute ischemic stroke related to an MDVO. Hemorrhagic complications were more frequent after thrombectomy. Trial Registration ClinicalTrials.gov Identifier: NCT05030142

INTRODUCTION AND OBJECTIVES:The origin of emboli involved in patent foramen ovale (PFO)-related ischemic events remains poorly documented. Our objective was to evaluate venous thromboembolic (VTE) disease as a potential source of PFO-related embolic events. METHODS:Patients scheduled for PFO closure for secondary prevention of PFO-related arterial embolic events underwent a systematic VTE risk evaluation. This included: a) a detailed questionnaire on past VTE history to identify clinical situations associated with a high risk of VTE at the time of the embolic event, and b) abdominopelvic magnetic resonance imaging (MRI) with venography to identify abdominal or pelvic venous disease. RESULTS:From July 2020 to May 2023, 366 consecutive patients (median age 51 [range, 42-58] years; 42.9% female) were prospectively included. A prior VTE event, a high-risk VTE situation, a hyperthrombotic state, or an abdominal or pelvic venous anomaly on MRI were present in 8.5% (95%CI, 6.0-11.8), 22.7% (95%CI, 18.7-27.2), 7.1% (95%CI, 4.9-10.2), and 36.3% (95%CI, 31.6-41.4) of patients, respectively. Overall, 58.5% (95%CI, 53.4-63.4) of patients had at least 1 of these conditions. MRI identified several previously undiagnosed pelvic venous anomalies, including pelvic varices in 20.0%, May-Thurner/Cockett in 9.8%, and nutcracker syndrome in 7.4%. Imaging abnormalities were more frequent among younger patients (aOR, 1.02; 95%CI, 1.00-1.04) and women (aOR, 1.94; 95%CI, 1.25-3.02). CONCLUSIONS:A prior VTE event, a high-risk VTE situation, a hyperthrombotic state, or an abdominal or pelvic venous anomaly may be present in most patients with a history of a PFO-related arterial event.

To investigate short- and long-term post-stroke mortality in patients in a collaborative Stroke Pathway dedicated to the OLD patients (SPOLD). We observed longer 2-year survival in patients managed as part of a collaborative care pathway including neurologists and geriatricians, compared with those referred conventionally. This result was significant after reducing biases related to age, gender, stroke severity score, as well as disability, cognitive impairment and comorbidity levels, using cohort matched on propensity scores. This study suggests that collaboration between neurologists and geriatricians with a dedicated pathway may improve stroke survival in older patients. To compare the survival of stroke patients over 70 years old managed in the collaborative Stroke Pathway dedicated to the OLD patients (SPOLD) with those referred to conventional rehabilitation wards. This longitudinal observational retrospective cohort study involved over 70 years old patients referred from the same neurovascular emergency unit in a university hospital in France to a post-stroke geriatric unit within the SPOLD pathway, compared to patients referred to conventional rehabilitation ward during the same period. Initial stroke severity and comorbidities were assessed using the NIHSS score and the Charlson index, respectively. The primary endpoint was 2-year survival, analyzed using Cox models for both the entire cohort and a propensity score-matched cohort to control for referral bias. The study included 262 patients with a mean age of 84.5 ± 6.7 years, of whom 122 (46.6

Les accidents vasculaires cérébraux (AVC) sont la 3e cause de mortalité et la 1re cause de handicap acquis de l’adulte. Avec le vieillissement de la population et l’allongement de l’espérance de vie, les estimations pour 2050 sont d’une augmentation de 34 % des AVC. Leur prise en charge et leur prévention est donc un enjeu majeur de santé publique.Les traitements antithrombotiques représentent le socle des traitements de prévention des AVC ischémiques (AIC), avec en particulier les traitements anticoagulants oraux pour les AIC cardio-emboliques sur fibrillation auriculaire (cause cardio-embolique la plus fréquente) et les antiagrégants plaquettaires pour les AIC non cardio-emboliques.Toutefois, il existe un besoin de disposer d’anticoagulants plus efficaces, permettant de diminuer le risque ischémique résiduel sans augmenter le risque hémorragique. Dans cette perspective, plusieurs essais récents ont testé l’efficacité de nouveaux médicaments inhibant le facteur XI (FXI).Dans cette présentation, nous ferons le point sur leurs résultats et sur les perspectives qu’ils ouvrent au sein des options thérapeutiques de prévention secondaire des AIC cardio-emboliques et non cardio-emboliques.

ObjectivesA Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke.DesignA cohort observational study over a 4-year period.SettingHospitals Pitié-Salpêtrière and Charles Foix (Paris, France).ParticipantsWe studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017.InterventionPatients transferred in the PSGU were compared to those admitted in other rehabilitation units.MeasurementsThe primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson’s comorbidity score).ResultsAmong the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson’s comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88).ConclusionThe SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Abstract Objective The stroke risk for persons living with human immunodeficiency virus (PLHIVs) doubled compared to uninfected individuals. Stroke‐unit (SU)—access, acute reperfusion therapy—use and outcome data on PLHIVs admitted for acute ischemic stroke (AIS) are scarce. Methods AIS patients admitted (01 January 2017 to 31 January 2021) to 10 representative Paris‐area SUs were screened retrospectively from the National Hospitalization Database. PLHIVs were compared to age‐, initial NIHSS‐ and sex‐matched HIV‐uninfected controls (HUCs). Outcome was the 90‐day modified Rankin Scale score. Results Among 126 PLHIVs with confirmed first‐ever AIS, ~80% were admitted outside the thrombolysis‐administration window. Despite antiretrovirals, uncontrolled plasma HIV loads exceeded 50 copies/mL (26% of all PLHIVs; 38% of those ≤55 years). PLHIVs' stroke causes by decreasing frequency were large artery atherosclerosis (LAA), undetermined, other cause, cerebral small‐vessel disease (CSVD) or cardioembolism. No stroke etiology was associated with HIV duration or detectable HIVemia. MRI revealed previously unknown AIS in one in three PLHIVs, twice the HUC rate (p = 0.006). Neither group had optimally controlled modifiable cardiovascular risk factors (CVRFs): 20%–30% without specific hypertension, diabetes, and/or dyslipidemia treatments. Their stroke outcomes were comparable. Multivariable analyses retained good prognosis associated solely with initial NIHSS or reperfusion therapy. Older age and hypertension were associated with CSVD/LAA for all PLHIVs. Standard neurovascular care and reperfusion therapy were well‐tolerated. Interpretation The high uncontrolled HIV‐infection rate and suboptimal CVRF treatment support heightened vigilance to counter suboptimal HIV suppression and antiretroviral adherence, and improve CVRF prevention, mainly for younger PLHIVs. Those preventive, routine measures could lower PLHIVs' AIS risk.

Background Perfusion abnormalities after thrombolysis are frequent within and surrounding ischemic lesions, but their relative frequency is not well known. Objective To describe the different patterns of perfusion abnormalities observed at 24 hours and compare the characteristics of the patients according to their perfusion pattern. Methods From our thrombolysis registry, we included 226 consecutive patients with an available arterial spin labeling (ASL) perfusion sequence at day 1. We performed a blinded assessment of the perfusion status (hypoperfusion-h, hyperperfusion-H, or normal-N) in the ischemic lesion and in the surrounding tissue. We compared the time course of clinical recovery, the rate of arterial recanalization, and hemorrhagic transformations in the different perfusion profiles. Results We identified seven different perfusion profiles at day 1. Four of these (h/h, h/H, H/H, and H/N) represented the majority of the population (84.1%). The H/H profile was the most frequent (34.5%) and associated with 3-month good outcome (modified Rankin Scale (mRS): 63.5%). Patients with persistent hypoperfusion within and outside the lesion (h/h, 12.4%) exhibited worse outcomes after treatment (mRS score 0–2: 23.8%) than other patients, were less frequently recanalized (40.7%), and had more parenchymal hematoma (17.8%). The h/H profile had an intermediate clinical trajectory between the h/h profile and the hyperperfused profiles. Conclusion ASL hypoperfusion within the infarct and the surrounding tissue was associated with poor outcome. A more comprehensive view of the mechanisms in the hypoperfused surrounding tissue could help to design new therapeutic approaches during and after reperfusion therapies.

About two-thirds of patients with minor strokes are discharged home. However, these patients may have difficulties returning to their usual living activities. To investigate the factors associated with successful home discharge, our aim was to provide a decision tree (based on clinical data) that could identify if a patient discharged home could return to pre-stroke activities and to perform an external validation of this decision tree on an independent cohort. Two cohorts of patients with minor strokes gathered from stroke registries at the Hôpital Pitié-Salpêtrière and University Hospital Bern were included in this study (n = 105 for the construction cohort coming from France; n = 100 for the second cohort coming from Switzerland). The decision tree was built using the classification and regression tree (CART) analysis on the construction cohort. It was then applied to the validation cohort. Accuracy, sensitivity, specificity, false positive, and false-negative rates were reported for both cohorts. In the construction cohort, 60 patients (57%) returned to their usual, pre-stroke level of independence. The CART analysis produced a decision tree with the Montreal Cognitive Assessment (MoCA) as the first decision point, followed by discharge NIHSS score or age, and then by the occupational status. The overall prediction accuracy to the favorable outcome was 80% in the construction cohort and reached 72% accuracy in the validation cohort. This decision tree highlighted the role of cognitive function as a crucial factor for patients to return to their usual activities after a minor stroke. The algorithm may help clinicians to tailor planning of patients' discharge.

•We report a case of multiple dissections after Rituximab.•Accountability of Rituximab cannot be excluded.•The cytokine release after Rituximab infusion could be a trigger.

Objective. - To determine whether career development in academic medicine is more difficult for women than for men, and, if any, the nature and level of barriers to this progression. Methods. - Extraction of full-time medical staff in a Parisian hospital group, through the SIGAPS platform; an online questionnaire survey of career choices and barriers experienced by full-time male and female physicians. The study population comprises 181 hospital practitioners and 141 academic physicians (49 associate professors and 92 full professors). Results. - Women represent 49% of the medical staff but 15% of full professors. This underrepresentation of women is more important among intensivists/anesthesiologists than technique-based specialists (such as radiologists, biologists...). There is no difference in scientific output, marital status and parenthood between women and men. On the other hand, there is a difference in attitudes highlighted by the EVAR risk-taking scale as well as in the burden of familial involvement and the prejudices felt by women during the academic selection process. Conclusion. - The glass ceiling exists in one of the largest French hospital group. Career development principles promote merit, but should decrease the benefit of "masculine" attitudes in the competition for academic positions. Academic selection criteria should evolve to limit the disadvantage of women related to deeper familial involvement and less competitive strategies and risk-taking attitudes. (C) 2018 Societe Nationale Francaise de Medecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.

Background and Purpose- Early severity of stroke symptoms-especially in mild-to-severe stroke patients-are imperfect predictors of long-term motor and aphasia outcome. Motor function and language processing heavily rely on the preservation of important white matter fasciculi in the brain. Axial diffusivity (AD) from the diffusion tensor imaging model has repeatedly shown to accurately reflect acute axonal damage and is thus optimal to probe the integrity of important white matter bundles and their relationship with long-term outcome. Our aim was to investigate the independent prognostic value of the AD of white matter tracts in the motor and language network evaluated at 24 hours poststroke for motor and aphasia outcome at 3 months poststroke. Methods- Seventeen (motor cohort) and 28 (aphasia cohort) thrombolyzed patients with initial mild-to-severe stroke underwent a diffusion tensor imaging sequence at 24 hours poststroke. Motor and language outcome were evaluated at 3 months poststroke with a composite motor score and the aphasia handicap scale. We first used stepwise regression to determine which classic (age, initial motor or aphasia severity, and lesion volume) and imaging (ratio of affected/unaffected AD of motor and language fasciculi) factors were related to outcome. Second, to determine the specificity of our a priori choices of fasciculi, we performed voxel-based analyses to determine if the same, additional, or altogether new regions were associated with long-term outcome. Results- The ratio of AD in the corticospinal tract was the sole predictor of long-term motor outcome, and the ratio of AD in the arcuate fasciculus-along with age and initial aphasia severity-was an independent predictor of 3-month aphasia outcome. White matter regions overlapping with these fasciculi naturally emerged in the corresponding voxel-based analyses. Conclusions- AD of the corticospinal tract and arcuate fasciculus are effective biomarkers of long-term motor and aphasia outcome, respectively.

The outcome of aphasia at 3 months is variable in patients with moderate/severe stroke. The aim was to predict 3-month aphasia outcome using prediction models including initial severity in addition to the interaction between lesion size and location at the acute phase.

Giant cell arteritis (GCA) is associated with an increased risk of cardio- or cerebro-vascular death. The stroke rate in patients with GCA varies between 2.7 and 7.4%. The etiological diagnosis may be challenging between atherosclerotic stroke and stroke related to GCA. Case of an old woman who had ischemic stroke and concomitant diagnosis of GCA and brain imaging characteristics.

De nombreuses modalités d’imagerie ont été décrites pour le diagnostic et la surveillance de l’ostéoporose (OP), l’arthrose et les maladies rhumatismales inflammatoires. Ces dix dernières années, la recherche clinique a identifié le scanner périphérique à haute résolution (HRpQCT) comme une technique à la fois précise et non invasive pour l’étude des maladies ostéoarticulaires. Il permet notamment d’explorer la microarchitecture de l’os cortical et trabéculaire aux extrémités distales du tibia et du radius. D’autres applications ont été développées, comme l’étude des propriétés mécaniques par l’analyse en éléments finis. Dans des études cas témoin et transversales, les paramètres microarchitecturaux ont ainsi discriminé les sujets présentant des fractures indépendamment de la DMO surfacique (DMOs). Par ailleurs, les paramètres microstructurels permettent de prédire les fractures incidentes chez les femmes ménopausées. Dans les maladies métaboliques associées à une fragilité osseuse, le scanner HRpQCT peut également être utilisé pour explorer les changements osseux. Des études sur les maladies articulaires l’ont décrit comme un outil remarquable pour évaluer l’érosion osseuse et le pincement de l’interligne dans la main. Le présent article propose un aperçu de cette technique d’imagerie.

The Aphasia Rapid Test (ART) is a screening questionnaire used for examining language in acute stroke patients. The ART was initially developed and validated in French. The purpose of this study was to assess the inter-rater reliability of Italian ART.

Giant cell arteritis (GCA) is associated with an increased risk of cardio- or cerebro-vascular death. The stroke rate in patients with GCA varies between 2.7 and 7.4%. The etiological diagnosis may be challenging between atherosclerotic stroke and stroke related to GCA. Case of an old woman who had ischemic stroke and concomitant diagnosis of GCA and brain imaging characteristics.

Le « plafond de verre » désigne « les barrières invisibles, artificielles, créées par des préjugés comportementaux et organisationnels, qui empêchent les femmes d’accéder aux plus hautes responsabilités ». Malgré l’existence de concours censés garantir l’égalité des chances entre tous, de nombreuses inégalités persistent au sein de la fonction publique et notamment dans les progressions de carrière des femmes et des hommes au sein des universités. Notre objectif était de déterminer si la progression au sein des carrières hospitalo-universitaires est plus difficile pour les femmes que pour les hommes et, le cas échéant, la nature et le niveau des freins à cette progression. La liste exhaustive des praticiens en activité à temps plein a été extraite du Système d’Interrogation, de Gestion et d’Analyse des Publications Scientifiques (SIGAPS). Nous avons comptabilisé le pourcentage de femme à chaque échelon, en classant les spécialités en quatre domaines :. – médicales (incluant la psychiatrie) ; – chirurgicales ; – médicotechniques (médecins des laboratoires de biologie, de radiologie, de pharmacologie…) ; – anesthésie-réanimation (classée à part compte tenu du mode d’exercice très spécifique). Nous avons ensuite soumis un questionnaire à tous les médecins titulaires (PH, MCU-PH, PU-PH). L’enquête portait sur :. – les facteurs démographiques (âge, sexe, état civil, enfants ou non, profession des parents…) ; – le contexte du choix de carrière et de prise de poste ; – les freins ressentis au cours de la progression hiérarchique ; – le test EVAR (échelle évaluant la prise de risque en distinguant maîtrise de soi, le goût du danger, l’ardeur, l’impulsivité et le sentiment d’invincibilité). Résultats Les femmes représentent 49 % des effectifs médicaux et seulement 15 % des PU-PH. Cette sous-représentation des femmes PU-PH est plus importante en anesthésie-réanimation et moins dans les disciplines médicotechniques. L’enquête ne trouvait pas de différence en matière de production scientifique, de statut marital et de parentalité entre les femmes et les hommes hospitalo-universitaires. En revanche, il existe une différence d’attitude, mise en évidence par l’échelle EVAR, ainsi que dans le poids des obligations familiales et les préjugés ressentis par les femmes lors de la sélection universitaire. Le plafond de verre existe au sein de notre groupe hospitalier. La progression des femmes n’est pas ralentie à l’entrée des carrières universitaires en tant que MCU-PH mais à la nomination en tant que PU-PH. Les facteurs explicatifs sont complexes, allant de facteurs familiaux, comme la gestion des enfants, à des facteurs psychocomportementaux, comme la dévalorisation lors de la compétition. Les critères de sélection universitaire devraient évoluer pour limiter le désavantage des femmes lié à un engagement familial plus important et à des attitudes moins centrées sur la compétition et la prise de risque (Tableau 1).