EMERGENCY TREATMENT OF ACUTE CEREBRAL ISCHEMIA. Five complementary strategies increase disability - and dependency - free survival after acute cerebral ischemia: - stroke unit care, independent on age, severity, type of stroke, and treatment; - aspirin prevents 7 ischemic recurrences and 9 deaths or stroke recurrences during hospitalisation for 1000 patients treated; - rt-PA allows 1 additional disability-free survivor at 3 months for 3 patients treated within 90 minutes, 7 within 3 hours and 14 within 4.5 hours; tenecteplase can be used in most cases where intravenous thrombolysis is required; - mechanical thrombectomy improves the chances of dependency-free survival in patients with proximal arterial occlusion; this benefit persists between 6 and 24 hours in few patients selected multimodal imaging; - decompressive surgery reduces mortality and disability in patients under 60 years of age who have a large middle cerebral artery territory infarct within 48 hours.

Objective. - To identify the benefit provided by antiplatelet agents at the acute stage of cerebral ischaemia, their risks, and perspectives in terms of efficacy and safety. Method. - Literature review. Results. - Platelet activation and aggregation play a central role in cerebral ischaemia due to atherosclerosis. Acute phase clinical trials have shown that: (i) aspirin given within 48 hours increases the proportion of independent survivors; (ii) dual antiplatelet therapy is superior to aspirin for the reduction of ischaemic risks; (iii) dual antiplatelet therapy is not inferior to intravenous thrombolysis in cerebral ischaemia with minor symptoms; (iv) antiplatelets agents increase the risk of cerebral and systemic haemorrhages; and (v) dual antiplatelet therapies are associated with a higher bleeding risk. This haemorrhagic risk limits the use of antiplatelet agents at the acute stage of cerebral ischaemia. This risk is low and does not overcome the benefit provided by the reduction in ischaemic events, except in patients with high bleeding risks (patients who received thrombolytic therapy or underwent mechanical thrombectomy in the first 24 hours, patients with large cerebral infarcts, and patients with recent stenting). Conclusion. - Antiplatelet agents reduce the risk of recurrent ischaemic event after a first ischaemic stroke, but at a price of increased bleeding risks. (c) 2024 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

ObjectifIdentifier le bénéfice apporté par les antiplaquettaires en phase aiguë de l’ischémie cérébrale, leurs risques, et les perspectives en termes d’efficacité et de sécurité.MéthodeRevue de la littérature.RésultatsL’activation et l’agrégation des plaquettes jouent un rôle central dans l’ischémie cérébrale due à l’athérosclérose. Les essais cliniques en phase aiguë ont montré que : (i) dans les 48 premières heures, l’aspirine augmente la proportion de survivants sans handicap ; (ii) l’association de 2 antiplaquettaires est supérieure à l’aspirine pour réduire le risque ischémique ; (iii) la bithérapie antiplaquettaire n’est pas inférieure à la thrombolyse i.v. dans les ischémies cérébrales à symptomatologie mineure ; (iv) les antiplaquettaires augmentent le risque d’hémorragie cérébrale ou systémique ; et (v) les associations d’antiplaquettaires exposent à un risque hémorragique plus élevé. Ce risque hémorragique limite l’utilisation des antiplaquettaires en phase aiguë de l’ischémie cérébrale. Il est faible et ne contrebalance pas le bénéfice apporté par la réduction des événements ischémiques, mais il est une limite chez des patients à haut risque hémorragique (patients ayant reçu un traitement thrombolytique ou une thrombectomie mécanique dans les 24 premières heures, ou ayant un infarctus cérébral étendu, ou un stent récent).ConclusionLes antiplaquettaire réduisent le risque de récidive ischémique après un premier épisode d’ischémie cérébral, mais leur utilisation est limitée par le risque hémorragique.

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

The authors declare that they have no conflicts of interest.

Identifier les pistes d’amélioration du traitement de l’ischémie cérébrale aiguë. Nous avons évalué : (i) l’accès en France aux traitements validés, et comparé à l’Allemagne et l’Italie ; (ii) les pistes d’amélioration des stratégies actuellement disponibles ; (iii) les stratégies nécessitant d’être évaluées. Nous avons identifié 4 pistes : augmenter la proportion de patients traités conformément aux évidences scientifiques. La France a (i) un déficit en lits de soins intensifs neurovasculaires par rapport à l’Allemagne et l’Italie (13,5 par million d’habitants vs 29,9 et 23,2), et en centres de thrombectomie (0,6 par million d’habitants vs 1,8 et 1,0) ; (ii) un déficit de thrombolyse intraveineuse (TIV) (203 par million d’habitants vs 402) et de thrombectomie mécanique (TM) (104 vs 194) par rapport à l’Allemagne ; et (iii) une hétérogénéité territoriale importante en lits de soins intensifs neurovasculaires, TIV et TM ; réduire les contre-indications à la TIV aux seuls patients à très haut risque hémorragique ; sélectionner les candidats à une reperfusion sur l’état du parenchyme plutôt que sur les délais ; explorer des stratégies nouvelles : (i) prise en charge préhospitalière (UNV mobiles, régulation) ; (ii) TIV par ténecteplase ou rt-PA à dose réduite ; (iii) amélioration de thrombectomie (indications et technique) ; (iv) neuroprotection, dont certaines pistes n’ont pas encore été explorées ; et (v) favoriser la récupération fonctionnelle précoce. Il existe une marge de progression importante dans le traitement de l’ischémie cérébrale aiguë, qui repose en partie sur des mesures déjà accessibles. To identify targets to improve the treatment of acute cerebral ischemia. We assessed (i) access to validated strategies in France and compared with Germany and Italy; (ii) avenues for improvement of currently available strategies; and (iii) strategies that still need to be evaluated. We identified 4 avenues: increase the proportion of patients treated according to current scientific evidence. France has (i) a deficit in neurovascular intensive care beds compared to Germany and Italy (13.5 per million inhabitants vs. 29.9 and 23.2), and in mechanical thrombectomy (MT) centres (0.6 per million inhabitants vs. 1.8 and 1.0); (ii) compared to Germany, a deficit in intravenous thrombolysis (IVT) (203 per million inhabitants vs. 402) and MT (104 vs. 194); and (iii) an important territorial heterogeneity for intensive neurovascular beds, IVT and MT; reduce contraindications to IVT only to those patients at very high bleeding risk; select candidates for reperfusion based on the cerebral criteria rather than on delays; explore new strategies: (i) pre-hospital management (mobile stroke units, regulation); (ii) thrombolysis with tenecteplase or with low dose rt-PA; (iii) improved thrombectomy (indications and technique); (iv) neuroprotection, some avenues of which have not yet been explored; and (vii) ptomoteearly functional recovery. There is significant room for improvement in the treatment of acute cerebral ischaemia, based in part on already available measures.

The Editors and Editorial Board Members of the European Journal of Neurology are deeply saddened to announce the recent death of our colleague and friend, Professor Hany Mohammed Aref, on 26 July 2023, at the age of only 62 years. [Professor Hany Mohammed Aref (with permission of his family).] Professor Aref was Head of the Department of Neurology at Ain Shams University, Cairo, Egypt. His main fields of interest were neurological education and research to improve the management of patients with neurological diseases, especially stroke and multiple sclerosis. He was the founder of the new stroke unit at Ain Shams University. This modern and comprehensive stroke unit was, unfortunately, inaugurated only a few days after his death. He had worked very hard for many years to raise the money required to establish this stroke service, and to organize it. Professor Aref was the General Secretary of the Egyptian Society of Neurology, Psychiatry and Neurosurgery, and was well known worldwide for his involvement with many neurology societies, including the European Academy of Neurology (EAN). He was a valued member of this Journal's Editorial Board, and played an important role in ensuring that our colleagues from Middle Eastern and North African countries were well represented as authors, readers, and reviewers for the Journal. Professor Aref was greatly appreciated by his colleagues. His positive attitude and great kindness made working with him a real pleasure. We would like to express our deepest condolences to his wife, Professor Nevine El Nahas, to their two sons, and to his colleagues and students in Cairo. Didier Leys, Editor-in-Chief Riadh Gouider, Member of the Editorial Board Didier Leys: Conceptualization; validation; writing – original draft; writing – review and editing. Riadh Gouider: Conceptualization; writing – review and editing; validation; writing – original draft.

Objective. - To identify targets to improve the treatment of acute cerebral ischemia. Method. - We assessed (i) access to validated strategies in France and compared with Germany and Italy; (ii) avenues for improvement of currently available strategies; and (iii) strategies that still need to be evaluated. Results. - We identified 4 avenues: increase the proportion of patients treated according to current scientific evidence. France has (i) a deficit in neurovascular intensive care beds com-pared to Germany and Italy (13.5 per million inhabitants vs. 29.9 and 23.2), and in mechanical thrombectomy (MT) centres (0.6 per million inhabitants vs. 1.8 and 1.0); (ii) compared to Ger-many, a deficit in intravenous thrombolysis (IVT) (203 per million inhabitants vs. 402) and MT (104 vs. 194); and (iii) an important territorial heterogeneity for intensive neurovascular beds, IVT and MT; reduce contraindications to IVT only to those patients at very high bleeding risk; select candidates for reperfusion based on the cerebral criteria rather than on delays; explore new strategies: (i) pre-hospital management (mobile stroke units, regulation); (ii) thrombo-lysis with tenecteplase or with low dose rt-PA; (iii) improved thrombectomy (indications and technique); (iv) neuroprotection, some avenues of which have not yet been explored; and (vii) ptomoteearly functional recovery. Conclusions. - There is significant room for improvement in the treatment of acute cerebral ischaemia, based in part on already available measures. (c) 2023 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights reserved.

BACKGROUND:The association between vascular risk factors and cervical artery dissections (CeADs), a leading cause of ischemic stroke (IS) in the young, remains controversial. OBJECTIVES:This study aimed to explore the causal relation of vascular risk factors with CeAD risk and recurrence and compare it to their relation with non-CeAD IS. METHODS:This study used 2-sample Mendelian randomization analyses to explore the association of blood pressure (BP), lipid levels, type 2 diabetes, waist-to-hip ratio, smoking, and body mass index with CeAD and non-CeAD IS. To simulate effects of the most frequently used BP-lowering drugs, this study constructed genetic proxies and tested their association with CeAD and non-CeAD IS. In analyses among patients with CeAD, the investigators studied the association between weighted genetic risk scores of vascular risk factors and the risk of multiple or early recurrent dissections. RESULTS:Genetically determined higher systolic BP (OR: 1.51; 95% CI: 1.32-1.72) and diastolic BP (OR: 2.40; 95% CI: 1.92-3.00) increased the risk of CeAD (P < 0.0001). Genetically determined higher body mass index was inconsistently associated with a lower risk of CeAD. Genetic proxies for β-blocker effects were associated with a lower risk of CeAD (OR: 0.65; 95% CI: 0.50-0.85), whereas calcium-channel blockers were associated with a lower risk of non-CeAD IS (OR: 0.75; 95% CI: 0.63-0.90). Weighted genetic risk scores for systolic BP and diastolic BP were associated with an increased risk of multiple or early recurrent CeAD. CONCLUSIONS:These results are supportive of a causal association between higher BP and increased CeAD risk and recurrence and provide genetic evidence for lower CeAD risk under β-blockers. This may inform secondary prevention strategies and trial design for CeAD.

Objective Neuropsychiatric (NP) symptoms are prominent features of cognitive decline, but they have been understudied in patients with spontaneous intracerebral haemorrhage (ICH). In ICH survivors, we aimed at assessing NP symptoms prevalence and profiles, and their influence on long-term outcomes. Methods We analysed data from consecutive 6-month ICH survivors enrolled in the Prognosis of Intracerebral Haemorrhage study. We performed NP evaluation using the Neuropsychiatric Inventory Questionnaire. Patients underwent long-term clinical follow-up after ICH (median follow-up time 7.2 years, IQR 4.8–8.2). Results Out of 560 patients with ICH, 265 survived at 6 months. NP evaluation 6 months after ICH was feasible in 202 patients. NP symptoms were present in 112 patients (55%), and in 36 out of 48 patients (75%) with post-ICH dementia. Affective symptoms were present in 77 patients (38%), followed by vegetative symptoms (52 patients, 26%) and hyperactivity (47 patients, 23%). Apathy and hyperactivity were associated with post-ICH dementia and cerebral amyloid angiopathy MRI profile (all p<0.05). Apathy and hyperactivity prevailing over affective symptoms at 6-month follow-up were associated with higher risks of developing new-onset dementia (HR 5.40; 95% CI 2.27 to 12.84), while presence or severity of NP symptoms were not. Conclusion NP symptoms were present in more than half of 6-month ICH survivors, with higher prevalence and severity in patients with post-ICH dementia. Distinctive NP profile might be associated to cognitive status and inform on long-term dementia risk.

Patients who are already in a stroke unit for a first cerebral event or a situation entailing high risk for stroke are treated with shorter delays, fewer missed treatment opportunities, and better outcomes compared to those who are in another type of medical ward or at home.

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BACKGROUND:According to the French regulation, stroke units (SU) include both an intensive (I-SU) and a non-intensive (NI-SU) component. Their standard operating procedures have been detailed in governmental directives in 2003 and 2007.OBJECTIVES:To evaluate (i) resources available in French SU, (ii) differences between regions, and between France and the 2 close European countries of similar size, and (iii) to identify avenues for improvement.METHODS:We performed a survey of all French SU, with an online questionnaire, to evaluate available resources and activity. We compared the 17 French regions, and France, with Germany and Italy. We used 2019 as year of reference.RESULTS:The 138 French SU, shared 911 I-SU beds; 123 SU (89.1%) answered the questionnaire. The number of I-SU beds per million inhabitants was 13.6 for the whole country, with important differences between regions, ranging from 7.0 (Reunion Island) to 20.9 (Occitanie region). Per million inhabitants, France had fewer I-SU beds than Germany and Italy (13.5 vs. 29.9 and 23.2 respectively), and fewer thrombectomy centres (0.6 vs. 1.8 and 1.0). Per million inhabitants, France had also lower thrombolysis (203 vs. 402) and thrombectomy (104 vs. 194) rates than Germany, but, compared with Italy, similar thrombolysis rates (203 vs. 202) and higher thrombectomy rates (104 vs. 81).CONCLUSION:There are still avenues for improvement in acute stroke care in France, especially concerning the number and regional repartition of I-SU beds, and access to reperfusion therapies.

Background: Although anxiety is common in several neurological conditions, it has been poorly investigated after spontaneous intracerebral hemorrhage (ICH). Aims: In consecutive ICH survivors, we assessed the long-term prevalence of anxiety and its clinical and radiological determinants. Methods: Using the Hospital Anxiety and Depression Scale (HADS), we evaluated ICH survivors enrolled in the prospective, single-center Prognosis of Intracerebral Hemorrhage (PITCH) study. The prevalence of anxiety (defined as a HADS-anxiety subscale score >7) was evaluated at three time points (1–2, 3–5, and 6–8 years after ICH), along with neurological symptoms severity, functional disability, and cognitive impairment scores. Clinical and radiological characteristics associated with anxiety were evaluated in univariate and multivariable models. Results: Of 560 patients with spontaneous ICH, 255 were alive 1 year later, 179 of whom completed the HADS questionnaire and were included in the study. Thirty-one patients (17%; 95% confidence interval (CI) = 12–23) had anxiety 1–2 years, 38 (27%; 95% CI = 19–34) 3–5 years, and 18 (21%; 95% CI = 12–30) 6–8 years after ICH. In patients with anxiety, the prevalence of associated depressive symptoms was 48% 1–2 years, 61% 3–5 years, and 56% 6–8 years after ICH. Among clinical and radiological baseline characteristics, only lobar ICH location was significantly associated with anxiety 1–2 years after ICH (odds ratio = 2.8; 95% CI = 1.2–6.5). Anxiety was not associated with concomitant neurological symptoms severity, functional disability, or cognitive impairment. Conclusion: Anxiety is frequent in ICH survivors, often in association with depressive symptoms, even many years after the index event.

Background. - Stroke units (SU) increase the proportion of independent survivors after stroke. Objectives. - to evaluate SU care, malfunctioning, and avenues for improvement.Methodology. - We (i) consulted the scientific literature, recommendations, previous reports and surveys, and regulatory texts; (ii) conducted a survey on the functioning of the French SU and compared regions with each other, and France with Germany and Italy; and (iii) interviewed qualified persons.Results. - We identified the following dysfunctions, leading to more than 5000 preventable deaths or dependencies per year: deficit in number of intensive neurovascular beds with inequa-lities between regions, frailty of many SU due to a lack of medical and nursing staff, deficit in the number of thrombectomy centres, frequent absence of standard operating procedures, lack of accreditation measures, existing facilities not readily available, excessive intra-hospital delays, insufficient or missing quality assessment.Recommendations. - (i) implementation of 75 new intensive neurovascular care beds; (ii) no overall increase in number of SU except in a few areas; (iii) territorial organisation with 3 SU (including 1 with thrombectomy) for 1.2 million inhabitants; (iii) increase the number of neurologists and neuro-interventionists in training to meet the 24/7 availability need; (v) adapt the number of nurses to the specificities of stroke care and (vi) implement an accreditation process of SU.(c) 2022 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights reserved.