BACKGROUND There is an increasing number of transradial approach (TRA) for carotid artery stenting (CAS), however, similar techniques and materials as for femoral access are used. We report the results of TRA lower profile technique for CAS using a 7 F Simmons guiding catheter, especially in terms of feasibility and procedural safety in a single center. MATERIALS AND METHODS We retrospectively analyzed 68 consecutive patients with symptomatic extracranial carotid stenoses who underwent 75 CAS between January 2018 and December 2021. The success and crossover rate, procedural time, fluoroscopy, clinical outcomes, technical considerations, and procedural complications were analyzed. RESULTS TRA CAS with Simmons guiding catheter was successful in 67/75 (89.3%) cases, with a 7 (9.3%) crossover rate. Fluoroscopy mean time was 15.8 minutes. Two forearm hematomas were described. No ischemic or surgical site complications were reported. CONCLUSIONS In our experience frontline TRA with a 7 F Simmons guiding catheter is feasible with high procedural success and a low rate of access site complications.

Background and purpose. - Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice. Methods. - Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days. Results. - Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR = 0.90 [95%CI 0.46-1.77] P = 0.769) or mortality (OR = 0.75 [0.37-1.49] P = 0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR = 0.43 [0.16-1.16] P = 0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR = 1.08 [0.62-1.88] P = 0.767). Conclusions. - Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted. (C) 2022 Elsevier Masson SAS. All rights reserved.

Background/Introduction. - In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. Aim of the study. - The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. Methods. - A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. Results. - Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. Conclusions. - Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making. (C) 2018 Elsevier Masson SAS. All rights reserved.

In France, the law defines and prohibits “unreasonable obstinacy” and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons’ involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. The first aim of the study was to assess French neurosurgeons’ adherence to the law on patients’ rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making. En France, la loi définit et interdit «l'obstination déraisonnable » et encadre la décision qui en découle de limiter, voire d’arrêter les thérapeutiques. Elle accorde aussi au patient le droit de désigner une personne de confiance et de formuler des directives anticipées à cet égard. Peu d’études ont été réalisées sur les décisions de limitation thérapeutique chez les traumatisés crâniens sévères, et encore moins concernant le rôle et l’implication des neurochirurgiens. Le premier objectif de cette étude était d’évaluer l’observance de la loi n° 2005-370 du 22 avril 2005 relative aux droits des malades et à la fin de vie, qui encadre ces décisions. Le second objectif était d’estimer la fréquence des critères pronostiques et décisionnels utilisés par les neurochirurgiens. Une enquête de pratique par questionnaire envoyé par courriel aux neurochirurgiens membres de la Société française de neurochirurgie a été menée en France d’avril à juin 2016. Sur 197 neurochirurgiens contactés, 62 ont complété le questionnaire. Les discussions de limitation thérapeutique respectaient le principe de collégialité requis par la loi et incluaient le neurochirurgien référent du patient dans 100 % des cas. La personne de confiance et/ou la famille étaient toujours consultées, mais leur avis était pris en compte de façon variable. Les directives anticipées étaient le plus souvent inexistantes (68 %) [56 % ; 80 %] (27 %) ou inappropriées (27 %) [16 ; 38]. Les paramètres d’évaluation pronostique les plus utilisés étaient les paramètres cliniques, la pression intra-crânienne, la pression de perfusion cérébrale et l’imagerie cérébrale, avec toutefois une grande variabilité interindividuelle dans leur utilisation. Les critères décisionnels principaux étaient la qualité de vie et le handicap prévisibles, puis l’âge. On observe globalement une bonne observance de la loi par les neurochirurgiens, sauf concernant l’appel au consultant externe. Cette étude confirme l’hétérogénéité dans l’utilisation des critères d’évaluation pronostique et la nécessité de poursuivre la recherche clinique pour parvenir à des pratiques standardisées permettant de limiter au maximum la part de subjectivité dans le processus décisionnel.

Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Societe de reanimation de langue francaise [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Societe francaise d'anesthesie reanimation [SFAR]) with the participation of the French Emergency Medicine Association (Societe francaise de medecine d'urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe francophone de reanimation et urgences pediatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association nationale de neuro-anesthesie reanimation francaise [ANARLF]), and the French Neurovascular Society (Societe francaise neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.

BACKGROUND:Post-traumatic vasospasm (PTV) remains a poorly understood entity. Using a systematic review approach, we examined the incidence, mechanisms, risk factors, impact on outcome and potential therapies of PTV.METHODS:A search on Medline database up to 2015 performed with "traumatic brain injury" and "vasospasm" key-words retrieved 429 references. This systematic review was reported and analysed following the PRISMA criteria and according to the relevance in human clinical practice.RESULTS:The research retrieved 429 references of which 226 were excluded from analysis because of their irrelevance and 87 finally included in the review.CONCLUSION:Mechanical stretching, inflammation, calcium dysregulation, endotelin, contractile proteins, products of cerebral metabolism and cortical spreading depolarization have been involved in PTV pathophysiology. PTV occurs in up to 30-40% of the patients after severe traumatic brain injury. Usually, PTV starts within the first 3 days following head trauma and may last 5 to 10 days. Young age, low Glasgow Coma Score at admission and subarachnoid hemorrhage have been identified as risk factors of PTV. Suspected on transcranial Doppler, PTV diagnosis is best confirmed by angiography, CT angiography or MR angiography, and perfusion and ischaemic consequences by perfusion CT or MRI. Early PTV is associated with poor outcome. No PTV prevention strategy has proved efficient up to now. Regarding PTV treatment, only nimodipine and intra-arterial papaverine have been studied up to now. Treatment with milrinone has been described in a few cases reports and may represent a new therapeutic option.

La réaction anaphylactique aux curares est une complication qui peut concerner et préoccuper l'ensemble des anesthésistes car elle peut être sévère voire fatale. Le but de cette étude était d'évaluer son taux de mortalité en France, d'identifier les facteurs de risque de mortalité et de décrire la prise en charge thérapeutique des cas mortels. La base de données du système national de pharmacovigilance était analysée afin de selectionner les cas de réactions d'hypersensibilités aux curares survenus entre janvier 2000 et décembre 2011. Un questionnaire supplémentaire était envoyé aux centres régionaux afin d'améliorer l'information sur la gestion thérapeutique des cas à issue fatale. Les cas mortels étaient séparés en deux groupes : – « décès précoces » : issue fatale immédiate (arrêt cardiovasculaire non récupéré) ou après mise en place d'une assistance cardiocirculatoire ; – « décès tardifs » liées à une défaillance multiviscerale secondaire à l'arrêt cardiovasculaire récupéré. Une analyse multivariée était réalisée afin de déterminer les facteurs de risque indépendants de mortalité. Deux mille vingt-deux cas de réaction d'hypersensibilité à un curare étaient analysés dont 84 cas mortels (taux de mortalité moyen 4,1%). À partir des 1247 cas de réactions sévères (grade 3 et 4) ont pu être mis en évidence les facteurs de risques indépendants de mortalité reportés dans le Tableau 1. Le curare le plus souvent incriminé était le suxamethonium (n = 815, 65,4 %) suivi de l'atracrium (n = 181, 14,5 %), rocuronium (n = 105, 8,4 %), cisatracrium (n = 94, 7,5 %) et vecuronium (n = 23, 1,8 %). Aucun d'entre eux n'était identifier comme facteur de risque de surmortalité. Les détails de la prise en charge des réactions mortelles étaient obtenus pour 31 patients. Le délai moyen de survenu du premier symptome était de 2,1 minutes, le délai moyen d'injection du premier bolus d'adrénaline était de 3,4 minutes et la dose totale d'adrénaline injectée en bolus était de 15 mg. Il n'y avait aucune différence significative dans la prise en charge entre les groupes décès tardif et précoce. Aucun des patients placés sous assistance cardiocirculatoire ne survivait. Le sexe masculin, l'obésité, un antécédent de maladie cardiovasculaire, un traitement chronique par bêtabloquant et le contexte d'urgence sont des facteurs de risques indépendants de mortalité à une réaction d'hypersensibilité aux curares. Le taux de mortalité est de 4,1 %. La prise en charge des cas mortels était conforme aux recommandations internationales, avec un délai court de mise en œuvre des thérapeutiques spécifiques. On peut donc supposer qu'il existe des cas de résistance à l'adrénaline. Il est donc nécessaire de développer de nouvelles approches thérapeutiques.

Audibert, G.1; Charpentier, C.1; Crumière, P.-P.1; Cantais, E.2; Joly, L.-M.3; Mertes, P.-M.4 Author Information

Reitter, M.1; Petitpain, N.2; Latarche, C.3; Gillet, P.4; Audibert, G.1; Mertes, P. M.5 the French Network of Regional Pharmacovigilance Centers Author Information

OBJECTIVES:Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists. STUDY DESIGN:Prospective, transversal, single center study. MATERIALS AND METHODS:Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability. RESULTS:One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations. CONCLUSION:In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

The management of patients with central nervous system disorders such as brain tumours, hydrocephalus, intracranial hypertension, or subarachnoid hemorrhage has improved in recent years resulting in increased life expectancy. Consequently, the prevalence of patients with increased intracranial pressure or cerebrospinal fluid shunting devices presenting for non-neurological procedures has increased. These patients commonly receive a general anesthetic, as the safety profile of neuraxial anesthesia in this clinical setting remains uncertain. This article reviews literature on neuraxial anesthesia in patients with intracranial hypertension or cerebrospinal fluid shunting systems. It describes current knowledge, exposes and weighs the real benefits and risks of this technique in this setting. It provides several scenarios and anesthetic options to help the practitioner with choosing a tailored approach in this specific population.

Les deux principales complications du traitement endovasculaire des anévrysmes intra crâniens sont thromboemboliques et hémorragiques. La fréquence de survenue d'une complication thromboembolique est plus importante en cas d'hémorragie sous arachnoïdienne (HSA). Cette complication est prévenue par l'administration d'héparine non fractionnée (HNF). Les recommandations internationales proposent d'injecter un bolus de 50 à 100 UI/kg d'HNF, mais cette posologie est peu validée. L'objectif de ce travail était d'évaluer un nouveau protocole d'administration de l'HNF monitorée par l'ACT dans la prise en charge endovasculaire des anévrysmes intra crânien rompus. Vingt patients traités par technique endovasculaire pour HSA anévrysmale ont été inclus prospectivement. Ils étaient anticoagulés par l'injection d'un bolus d'HNF (70 UI/kg) suivie d'une perfusion continue d'HNF (18 UI/kg/h). La cible d'ACT était comprise entre 250 et 300 s. Ils ont été comparés à un groupe historique de 100 patients traités pour HSA de façon similaire, anticoagulés avec un bolus d'HNF (50 UI/Kg) suivi d'une perfusion continue d'HNF (25 UI/kg/h), sans monitorage. Les valeurs initiales d'ACT étaient de 117 ± 8 s. Après l'administration d'un bolus d'HNF de 67,3 UI/kg (IQR 70,4–61,5), l'ACT mesuré était de 225 ± 85s. La perfusion continue d'HNF dans le groupe ACT était de 17,9 UI/kg/h (IQR 19,8–16,5). Elle était significativement plus faible que dans le groupe non monitoré (26,8 UI/kg/h [IQR 30,7–19,9]) (p < 0,0001). L'ACT de contrôle, 30 min après le bolus, était de 182 ± 42s. Le bolus d'HNF, et la quantité totale d'HNF administrée étaient significativement plus élevés dans le groupe ACT : 67,3 UI/kg (IQR 70,4–61,5) versus 38,8 UI/kg (IQR 43,3–32,4), (p < 0,0001), et 68,5 UI/kg/h (IQR 87,4–54,4) versus 54,8 UI/kg/h (IQR 68,8–45,5) (p = 0,029). Le taux de complication était similaire dans les 2 groupes : complication thromboembolique 10 % versus 10 % (p = 1) ; complication hémorragique 9 % versus 5 % (groupe ACT) (p = 1) (Fig. 1). Ce travail montre que l'administration d'un bolus d'HNF de 70 UI/kg suivi d'une perfusion continue d'HNF de 18 UI/kg/h ne permet pas d'atteindre l'objectif d'ACT (250–300s). L'hypercoagulabilité induite par l'HSA peut partiellement expliquer cette résistance à l'HNF. Les doses d'HNF doivent probablement être augmentées dans la prise en charge endovasculaire des anévrysmes intra crâniens rompus.

Drug reaction with eosinophilia ans systemic symptoms (DRESS) is a severe medication-induced adverse reaction, which can threaten patient's life. Clinical symptoms and organ failures present wide variability. Furthermore, the latency period is long, so that diagnosis could be a real challenge in the intensive care unit. We report the case of a woman developing a DRESS after neurosurgery complicated by a nosocomial infection.

Corbonnois, G.1; Toussaint - Hacquard, M.2; Serge, B.3; Lecompte, T.4; Audibert, G.1 Author Information

Introduction : Malgre les progres des neurosciences ces dernieres annees, l'HSA reste une pathologie grave avec un taux de sequelles important. A l'heure actuelle, la litterature ne permet pas d'etablir precocement de maniere robuste le pronostic neurologique des patients victimes d'HSA « grave » par rupture d'anevrisme de la circulation anterieure. L'objectif principal de notre etude est d'essayer de definir des facteurs pronostiques a partir des caracteristiques initiales permettant d'une part, de proposer des strategies therapeutiques plus agressives pour certains patients et d'autre part, de detecter le plus vite possible les patients dont le pronostic neurologique est defavorable. Materiels et Methodes : Etude observationnelle retrospective preliminaire menee en service de reanimation sur une periode de 2 ans, incluant des hemorragies meningees anevrismale de la circulation anterieure. Analyses des donnees cliniques initiales, de la troponinemie Ic a l'admission en reanimation et des donnees scanographiques (scores de Fisher et Hijdra) apres relecture faite par un neuroradiologue. Une evaluation neurologique etait realisee a 6 mois pour l'ensemble des patients selon le score de Rankin modifie (evolution defavorable =Rankin 3-6). Resultats : Dans une cohorte de 73 patients analyses, 45 avaient une evolution defavorable a 6 mois.Le score WFNS et le score scanographique de Hijdra ventricules (mais non le score de Fisher) etaient des facteurs precoces associes a une evolution neurologique defavorable. L'age et le score de Fisher n'influencaient pas l'evolution. L'HIC diagnostiquee en reanimation multiplie par 5 la probabilite de mauvaise evolution.. La troponinemie Ic dosee a l'admission n'etait pas identifiee comme facteur predictif de mauvaise evolution neurologique a 6 mois. Conclusion : Outre la gravite clinique, l'importance du saignement ventriculaire (score d'Hijdra ventricules) est un facteur precoce de mauvaise evolution neurologique a 6 mois chez des patients admis en reanimation pour HSA de la circulation anterieure.

"Transfusion-related acute lung injury" (TRALI) is a post-transfusion lesional pulmonary edema, potentially severe, better defined since the conference of Toronto in 2004. The incidence of TRALI reported in France remains low in part because of its ignorance by physicians. The objective of our study was to evaluate retrospectively transfusion accidents with respiratory complications that occurred in Nancy University Hospital and reported to the haemovigilance between 1996 and 2006, from the software "Traceline" listing all the blood transfusion complications from signs observed. The analysis of the files has been performed by applying rigorously diagnostic criteria of Toronto. Forty-one cases of respiratory complications were found in 34,573 blood products. Ten cases of TRALI were diagnosed while only one case had been reported to the haemovigilance. The remaining nine cases were previously labeled transfusion-associated circulatory overload (TACO). No cases of TRALI have been identified in the ICU. Our work can find an incidence of TRALI 10 times greater than previously reported. Ignorance of TRALI and the lack of consensus definition before 2004 are not sufficient to explain these results. This study demonstrates the potential interest of database and computerized declaration system based on the symptoms observed. It highlights the vulnerability of the current haemovigilance too dependent on a single medical observer. Although TRALI are recognized as serious complications, sometimes requiring resuscitative care, our work was not isolated severe TRALI in ICU. Physician awareness of TRALI to the identification and to the declaration, including ICU should be continued. Finally, the diagnostic criteria for TRALI must be adapted to the ICU. (c) 2013 Elsevier Masson SAS. All rights reserved.

Anaphylactic shock is a rare, but potentially lethal complication, combining life-threatening circulatory failure and massive fluid shifts. Treatment guidelines rely on adrenaline and volume expansion by intravenous fluids, but there is no solid evidence for the choice of one specific type of fluid over another. Our purpose was to compare the time to achieve target mean arterial pressure upon resuscitation using adrenaline alone versus adrenaline with different resuscitation fluids in an animal model and to compare the tissue oxygen pressures (PtiO(2)) with the various strategies. Twenty-five ovalbumin-sensitised Brown Norway rats were allocated to five groups after anaphylactic shock induction: vehicle (CON), adrenaline alone (AD), or adrenaline with isotonic saline (AD+IS), hydroxyethyl starch (AD+HES) or hypertonic saline (AD+HS). Time to reach a target mean arterial pressure value of 75 mmHg, cardiac output, skeletal muscle PtiO(2), lactate/pyruvate ratio and cumulative doses of adrenaline were recorded. Non-treated rats died within 15 minutes. The target mean arterial pressure value was reached faster with AD+HES (median: 10 minutes, range: 7.5 to 12.5 minutes) and AD+IS (median: 17.5 minutes, range: 5 to 25 minutes) versus adrenaline alone (median: 25 minutes, range: 20-30 minutes). There were also reduced adrenaline requirements in these groups. The skeletal muscle PtiO(2) was restored only in the AD+HES group. Although direct extrapolation to humans should be made with caution, our results support the combined use of adrenaline and volume expansion for resuscitation from anaphylactic shock. When used with adrenaline the most effective fluid was hydroxyethyl starch, whereas hypertonic saline was the least effective.