Bony stroke is defined as a stroke caused by a conflict between the carotid or vertebral arteries and an osseous or fibrous structure. This conflict can be permanent or triggered by specific head positions. It represents an uncommon cause of stroke in young individuals. Diagnosis requires multimodal imaging with both static and dynamic vascular assessments. We report a retrospective case series of seven patients in whom a bony or structural anomaly was identified as the etiology of stroke after exclusion of other possible causes. The mean age was 50.5 years. Bony anomalies included vascular Eagle syndrome in five patients, with one case of bilateral internal carotid artery conflict with elongated styloid processes and two cases of carotid compression by the hyoid bone. Curative anticoagulation was prescribed in most patients, and surgical removal of the bony anomaly was performed in four cases. No stroke recurrence was observed in our series. One patient died from septic shock. This study highlights the importance of investigating structural abnormalities in young patients with stroke, particularly in cases of recurrence in the same arterial territory, since appropriate treatment can eliminate the risk of recurrence.

Introduction La rage paralytique (RB) représente un véritable défi diagnostique, étant fréquemment confondue avec un syndrome de Guillain-Barré (SGB). Nous rapportons un cas de RB survenant malgré l’administration de la prophylaxie antirabique. Observation Patient âgé de 44 ans, victime d’une morsure de chien grade III, ayant reçu le sérum antirabique et 4 doses du vaccin antirabique. Il est admis aux urgences 25jours après la morsure pour un tableau de quadriparésie fébrile descendante sur 24heures, débutant au niveau du membre mordu (membre supérieur droit), associé à des paresthésies au site de la morsure, puis s’étendant au membre supérieur controlatéral et, enfin, aux deux membres inférieurs, accompagnée d’une détresse respiratoire d’aggravation rapidement progressive. À son admission, le patient était conscient, calme, fébrile à 39,2° et en insuffisance ventilatoire. L’examen neurologique a trouvé une quadriparésie prédominante en proximal et aux membres supérieurs, associée une hyporéflexie/aréflexie ostéotendineux préservant les achilléens. Il n’y avait pas de raideur méningée ni d’aéro-hydrophobie, pas de signes pyramidaux, sensitifs ou encéphalitiques. Devant la suspicion d’un SGB post-vaccinal, l’étude du liquide céphalo-rachidien a montré une méningite lymphocytaire. L’IRM cérébrale a objectivé des lésions bilatérales symétriques en hyperT2 hypoT1 intéressant les noyaux gris centraux, le système limbique et le tronc cérébral. Cet aspect à l’imagerie est fortement évocateur de lésions cérébrales rabiques (Fig. 1). Discussion La RB, qui survient essentiellement chez les personnes vaccinées, représente 20 % des cas rabiques. Elle se manifeste par une quadriplégie flasque aréflexique, débutant souvent par le membre mordu sans hydroaérophobie. L’antécédent de morsure, les paresthésies au site d’inoculation, la quadriplégie atypique fébrile, la présence d’une méningite et les anomalies radiologiques nous ont orientés vers une RP plutôt qu’un SGB post-vaccinal. Conclusion Le diagnostic précoce de la rage est crucial pour la mise en place des mesures de contrôle infectieux. Ce cas illustre l’importance d’évoquer la RB comme diagnostic différentiel des SGB atypiques.

Ischemic strokes resulting from internal carotid artery (ICA) dissection are typically associated with trauma, connective tissue disorders, or spontaneous causes. However, rare mechanical factors-including well-documented compression by the styloid process and, more exceptionally, by the hyoid bone-have been identified as potential triggers of such injuries. The close proximity or elongation of the hyoid bone relative to the ICA may exert pressure on or cause injury to the arterial wall, leading to hemodynamic or embolic ischemia in the anterior cerebral circulation, or to a transient ischemic attack (TIA). Carotid dissection may also occur as a result of repeated or sudden microtrauma. We report the case of a 46-year-old woman with no significant medical history, admitted 2 hours after the onset of ischemic stroke symptoms, which included left-sided heaviness and facial paralysis. The remainder of the clinical examination was unremarkable. Radiological investigations revealed an acute right sylvian ischemic infarction with abrupt occlusion of the ipsilateral middle cerebral artery on CT angiography. Imaging of the supra-aortic trunks demonstrated a dissection of the right ICA in direct contact with the posterior horn of the hyoid bone.

Introduction « Wearing off phenomenon » chez les patients atteints de SEP désigne une aggravation de symptômes pré-existants sans impact sur l’évolution de la maladie, avant la dose suivante du traitement de fond, et qui s’améliorent généralement après la perfusion. Objectifs Préciser la prévalence et les facteurs prédictifs de survenue du « wearing off phenomenon » chez les patients atteints de SEP sous natalizumab. Méthodes Il s’agit d’une étude rétrospective à visée descriptive et analytique, incluant l’ensemble de patients suivis en hôpital de jour du service de neurologie du CHU Hassan II de Fès, pour une SEP forme rémittente récurrente, sous natalizumab. Au total, 30 patients sont sous le protocole « extended interval dosing » (EID) après une durée de traitement mensuel d’une année. Résultats Un total de 41 patients sont inclus (âge moyen 35 ans, sex-ratio F/H 2.15). Le poids moyen des patients est de 65kg. L’EDSS moyen est 3. La durée d’exposition moyenne des patients à natalizumab est de 35 mois. Un total de 16 patients décrivent ce phénomène « parfois » ou « souvent » avant les cures, dont 11 patients sous EID, dont les symptômes les plus fréquents sont : la fatigue, les difficultés à la marche et les troubles sensitifs. Ils apparaissent en moyenne 7.5j avant la cure et disparaissent en moyenne 2.6j après la perfusion. L’analyse statistique a montré que le sexe masculin (p<0.001) et le surpoids (p<0.01) sont les facteurs associés significativement à un risque élevé de survenue de ce phénomène (Figure 1) (Figure 2). Discussion « wearing off phenomenon » touche 37 à 67 % des patients SEP sous natalizumab. Il est plus fréquent chez les patients sous ocrélizumab. La fatigue est le symptôme principal. Aucun effet significatif n’a été observé selon le schéma posologique, l’EDSS ou la durée d’évolution. Un IMC élevé est un facteur prédictif. Il n’a pas d’effet sur l’activité de la maladie, mais peut altérer la qualité de vie et la satisfaction des patients du traitement. Conclusion « wearing off phenomenon » est fréquent chez les patients SEP sous traitements de haute efficacité. Il n’aggrave pas l’EDSS ni le pronostic, mais altère la qualité de vie, d’où l’importance d’en informer les patients pour favoriser une meilleure adhérence.

Posterior reversible encephalopathy syndrome (PRES) represents a neurological disorder with varied clinical presentation and typical imaging findings of predominant vasogenic edema in the parieto-occipital regions. The imaging abnormalities found in PRES are usually reversible. In some rare cases, it can lead to irreversible damage to the cerebral parenchyma, leading to cortical laminar necrosis, which is an atypical feature of PRES. We describe a unique case of a patient admitted for an atypical PRES presenting with generalized tonic-clonic seizures and imaging features of cortical laminar necrosis. To our knowledge, our case is only the third one reported of PRES carrying imaging features of cortical laminar necrosis.

The artery of Percheron (AOP) is a rare vascular variant that can cause bilateral paramedian thalamic infarctions when occluded. Due to its atypical clinical presentation and subtle imaging findings, this condition often leads to significant diagnostic challenges. The timely recognition of this condition is critical to implementing appropriate management strategies and improving patient outcomes. We report the case of a 76-year-old man with no prior medical history who presented to the emergency department with a sudden onset of impaired consciousness and vertical gaze palsy. On arrival, the patient was in a state of sleep-like coma. This clinical presentation, combined with the sudden onset of symptoms, was highly suggestive of an AOP infarction. The initial CT findings were unremarkable. Intravenous thrombolysis was administered due to clinical suspicion. The patient demonstrated rapid clinical improvement and regained consciousness in several hours. A follow-up CT scan 24 hours later confirmed bilateral paramedian thalamic infarction, establishing the diagnosis. Although the patient experienced moderate residual cognitive impairment and mild vertical gaze paresis, he regained functional independence within six months. AOP infarction is a rare but serious condition that can present with various symptoms. Its diagnosis can be challenging due to the nonspecific clinical presentation and limitations of conventional imaging techniques in the acute phase, especially in our local context. Early diagnosis and timely intervention, such as intravenous thrombolysis, are crucial to improving functional outcomes.

Introduction : L'accident vasculaire cérébral (AVC), qu'il soit ischémique ou hémorragique, constitue une des principales causes d'épilepsie chez les personnes âgées. Cette condition entraîne un risque accru de crises post-AVC, impactant à la fois la récupération fonctionnelle des patients et leur qualité de vie. (1,2) Objectif: Éclaircir et de simplifier la gestion de l'épilepsie vasculaire, en se basant sur les recommandations récentes d'experts. Cette étude cherche à répondre aux défis spécifiques liés à l'incidence des crises épileptiques post-AVC, en tenant compte des particularités cliniques et des besoins thérapeutiques des patients ayant subi un accident vasculaire cérébral. Méthodes : Une analyse des études disponibles a été effectuée, tenant compte des différents sous-types d'AVC, des délais d'apparition des crises et des facteurs de risque tels que l'âge, les comorbidités et la gravité de l'AVC. Les recommandations actuelles en matière de gestion de l'épilepsie vasculaire ont également été intégrées. Résultats : Les résultats montrent une variabilité de l'incidence des crises en fonction du sous-type d'AVC et du moment où elles surviennent après l'AVC. Ils mettent également en évidence le manque de consensus autour de certains facteurs de risque et des stratégies de gestion adaptées. Conclusion : Cette étude souligne la nécessité de lignes directrices claires pour la prise en charge de l'épilepsie post-AVC, en particulier pour les patients âgés à haut risque. Les recommandations actuelles apportent des éléments utiles, mais des recherches supplémentaires sont nécessaires pour mieux définir les facteurs de risque et optimiser les stratégies de prise en charge.

Vascular compression by osteocartilaginous structures, such as the hyoid bone, is an underrecognized cause of ischemic stroke, often referred to as "bony stroke." Due to its rarity, this condition presents a significant diagnostic challenge, requiring meticulous imaging to identify the underlying structural abnormalities. We report an intriguing case of a 40-year-old female presenting with an acute embolic ischemic stroke. Diagnostic imaging revealed compression of the right internal carotid artery by the greater horn of the hyoid bone, causing arterial stagnation in both neutral and rotated neck positions, which resolved after surgical decompression. Through this case, we emphasize the importance of a comprehensive evaluation of osteocartilaginous cervical structures surrounding the brain-supplying arteries, as they represent a rare yet treatable cause of ischemic stroke.

INTRODUCTION:Stroke (Cerebrovascular Accident, CVA), whether ischemic or hemorrhagic, is one of the main causes of epilepsy in the elderly. This condition leads to an increased risk of post-stroke seizures, affecting both patients' functional recovery and their quality of life. (1,2) Aim: To clarify and simplify the management of vascular epilepsy, based on recent expert recommendations. This study seeks to address the specific challenges related to the incidence of post-stroke seizures, considering the clinical characteristics and therapeutic needs of patients who have experienced a stroke. METHODS:An analysis of available studies was conducted, considering different stroke subtypes, timing of seizure onset, and risk factors such as age, comorbidities, and stroke severity. Current recommendations for managing vascular epilepsy were also included. RESULTS:The results show variability in the incidence of seizures depending on stroke subtype and timing post-stroke. They also highlight a lack of consensus regarding certain risk factors and suitable management strategies. CONCLUSION:This study emphasizes the need for clear guidelines for managing post-stroke epilepsy, especially for high-risk elderly patients. Current recommendations provide useful insights, but further research is needed to better define risk factors and optimize management strategies.

Eagle syndrome (ES), particularly its vascular variant known as stylocarotid artery syndrome (SAS), is characterized by an elongated styloid process (ESP) that impinges on the internal carotid artery (ICA), leading to vascular complications. We report a case of a 57-year-old man who presented with acute left-sided weakness. Imaging revealed right ICA dissection (ICAD), which was medically managed. Six years later, the patient presented with acute right-sided weakness, and imaging revealed a new left ICAD. Further review of the imaging findings identified bilateral ESP as the underlying cause of both dissections. The patient underwent a left-sided styloidectomy and had an uneventful recovery. This case report describes a patient with vascular ES who experienced bilateral ICADs separated by several years. This underscores the importance of recognizing vascular ES as a potential and treatable cause of stroke.

Background: Age increases the risk of mortality and poor prognosis following a stroke. The benefits of intravenous thrombolysis (IVT) in elderly patients have been well established. However, the outcomes in daily clinical practice may differ from those reported in other studies. The objectives of our study are to evaluate the effectiveness and safety of thrombolysis in elderly stroke patients and provide local data that can inform clinical practices in similar settings and raise awareness about specific challenges in treating elderly patients with ischemic stroke. Methods: We conducted a retrospective, cross-sectional, descriptive, and analytical study in the neurology department of Hassan II University Hospital in Fez, Morocco, from May 2015 to March 2021. All elderly patients aged ≥ 80 years within 6 h of onset who received intravenous thrombolysis were recruited. The primary outcomes were the rate of hemorrhagic transformation, NIHSS score at 24 h after IV thrombolysis and the rate of death within the first 7 days. Secondary outcomes were functional status at 3 months, assessed using the modified Rankin Scale (mRS). Our results were interpreted in light of the main studies in the literature. Results: 41 patients (58.5 % female, aged 84 ± 3.5 y.o) all received IV thrombolysis (tenecteplase 85.4% vs alteplase 14.6%) were included. The mean NIHSS score before IV thrombolysis was 13 (range, 3-20) and that 24 h after IV thrombolysis was 10 (rang, 1-19). Hemorrhagic transformations occurred in 31.7% of the patients within 7 days after onset (9.8% HI1, 9.8% HI2, 2.4% PH1, 9.8% PH2), and all of these cases were asymptomatic. The rate of death within the first 7 days was 22%. Among living patients, the median three months mRS was 3. The mortality rate at three months was 26.8% (n=11). However, there was no significant association between these outcomes and the occurrence of ICH after IVT. Conclusion: Despite the higher mortality rate in our sample, IV thrombolysis ...

Most anatomic features of the internal carotid artery (ICA) are described as a straight course to the skull base free of branches. In some cases, the excessive elongation of the internal carotid artery in a confined space results in a curvature showing a “C” or “S” shape, or in an abnormal vascular shape made of a single or double vessel loop. These anatomic variants are called dolichoarteriopathies of the internal carotid artery. The correlation between dolichoarteriopathy of the ICA and stroke is still questionable, however it is believed that it can be associated with cerebral ischemia with a clinical symptomatology that accompanies ischemic stroke. We report a case of a 41-year-old patient, with a history of hypertension, who was admitted for right hemiparesis with Broca's aphasia. The rest of the clinical examination was normal. Radiological investigations confirmed an acute left sylvian ischemic stroke with an abrupt occlusion of the posterior trunk of the left M2 segment on the CT angiogram, an excessive elongation of the ICA on both sides, describing a shape of coils or loops. Etiologic workup for ischemic stroke was negative.

Background and objective The rate of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is still low due to several absolute and relative contraindications, including admission time delay, which remains the main reason for exclusion from thrombolysis. In this study, we aimed to identify reasons for non-thrombolysis at our stroke center. Methods This retrospective study included all patients with a final diagnosis of AIS as per our stroke prospective register from 2014 to 2019. Reasons for non-thrombolysis were analyzed for all AIS and for patients admitted within 4.5 hours from symptom onset. From 2014 to 2016, a non-contrast CT scan was the unique imaging modality used to decide on performing IVT. In 2017, CT angiography was added to the imaging protocol. Results Among 3,562 patients with AIS, 3,365 (94.4%) were excluded from thrombolysis; 2,871 (80.6%) were admitted out of the IVT time window, which represents the main reason for exclusion from thrombolysis. Thrombolysis alert (TA) was triggered for 691 (19.4%) patients, and 197 patients had IVT (which represents 28.5% of TA and 5.5% of all AIS). Minor stroke and rapidly improving symptoms of stroke were also reasons for non-thrombolysis, which explain the high-average initial National Institutes of Health Stoke Scale (NIHSS) score of more than 12 in the thrombolysis group. CT angiography allows for the analysis of the supra-aortic trunks, the circle of Willis, and the collateral status. Therefore, during the period when a CT angiography scan was used, there were more IVTs for minor strokes, rapidly improving strokes, and AIS patients admitted beyond the IVT time window. Conclusions This study highlights the common reasons for exclusion from thrombolysis. Efforts should be undertaken to avoid admission time delays. Also, based on our findings, minor stroke and improving stroke no longer represent absolute contraindications for IVT in AIS.