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

BACKGROUND:Mechanical thrombectomy (MT) for M2-segment occlusions of the middle cerebral artery can be an effective treatment for acute ischemic stroke but its effectiveness and the choice of the first line strategy remains unanswered questions. The angiographic shape of the occlusion has been suggested to impact the recanalization rates in M1-segment occlusions. We aimed to investigate whether the angiographic shape of the M2-segment impacts the outcomes of MT with stent retriever (SR) or contact aspiration (CA). METHODS:From January 2015 to December 2022, consecutive patients admitted to a single high-volume institution for acute ischemic stroke with an M2-segment occlusion treated by MT were included and retrospectively analyzed. Patients were classified into two groups, regular or irregular, according to the angiographic occlusion shape. Patients demographic, procedural, clinical and safety outcomes data were reviewed. RESULTS:A total of 214 MT procedures were included and categorized as regular (39 %) and irregular (61 %) shape occlusion groups. Interrater agreement was high (k = 94 %). There were no significant differences between the two groups as regard demographic, procedural, clinical and safety outcomes except for smoking (33.5 % vs 16.8 %, p = 0.01). Procedural outcomes, recanalization rates and clinical outcomes did not significantly differ between the regular and irregular occlusion groups. In subgroup analysis, for irregular occlusions SR as a first-line strategy was associated with higher rates of excellent recanalization (mTICI 2c - 3) after the first pass compared to CA±SR (44 % vs 27.16 %, p = 0.05), and also better clinical outcomes, with lower 24-hour NIHSS (p < 0.01) and lower 3-month mRS (p = 0.04). In regular occlusions, no significant differences were found in recanalization rates or clinical outcomes when using SR or CA±SR. CONCLUSION:Choosing SR as the first line strategy for irregular shape M2-segment occlusions is associated with higher rates of recanalization after the first pass and better clinical outcomes. Further prospective studies are needed to confirm our findings.

Introduction: Thrombolysis and endovascular thrombectomy (EVT) are standard treatments after stroke. We previously reported that these therapies benefit stroke patients over 80 years old. Now, we aimed to study reperfusion therapies specifically in nonagenarians, hypothesizing a poorer prognosis in this group. Methods: Nonagenarian stroke patients were identified from our prospective monocentric cohort, which included consecutive patients >= 80 years old treated with thrombolysis and/or EVT from 2015 to 2019. Baseline characteristics, treatments, and outcomes, as well as complications and mortality were analyzed. Results: Ninety-six nonagenarians were treated with thrombolysis (69.8%) and/or EVT (81.1%). A total of 51% had a pre-stroke modified Rankin score (mRS) <= 2. Cardioembolism was the most common etiology (67.7%). Age was associated with a higher mRS after stroke with a turning point at 90 years old: (90-99 years old: odds ratio [OR] = 0.33, 95% confidence interval [95% CI]: 0.13-0.83, p = 0.02) versus (85-89 years old: OR = 0.72, 95% CI: 0.34-1.50, p = 0.38), with 80- to 84-year-old patients as the reference. In nonagenarians, previous coronary artery disease (OR = 8.02, 95% CI: 1.66-38.68, p = 0.01), initial National Institute of Health Stroke Score (NIHSS) (OR = 1.11, 95% CI: 1.03-1.19, p = 0.01), pre stroke independence (OR = 0.25, 95% CI: 0.08-0.71, p = 0.01), and "drip-and-ship" status (OR = 3.35, 95% CI: 1.22-9.16, p = 0.02) were associated with 3-month mortality. Nonagenarians had more baseline comorbidities (p = 0.003) and lower levels of pre-stroke independence (p = 0.002) than octogenarians (n = 261). Despite no difference in the use of acute treatments, timelines, and rates of successful reperfusion, a good functional status at 3 months was less common in nonagenarians than octogenarians (14.3% vs. 34.0%, p < 0.001) with a higher mortality (60.2% vs. 16.4%, p < 0.001). A total of 9.5% of nonagenarians experienced a symptomatic intracranial hemorrhage. Conclusions: Age is a crucial factor affecting prognosis after stroke with a turning point at 90 years old. However, age alone should not be a limiting factor for treatment decision. Despite higher mortality and poorer functional prognosis overall, some nonagenarians may benefit from reperfusion therapies.

Stroke is not an uncommon way of revelation of Philadelphia-negative chronic myeloproliferative neoplasms (MPN). In a retrospective study, among 3318 patients with ischemic vascular cerebral events, 17 (0.5%) were diagnosed with MPN, and stroke was the revealing manifestation for 58% of them.1 Moreover, 29% of these patients had a history of repeated ischemic cerebral event preceding the diagnosis of MPN. Nevertheless, in this large cohort, another associated cause existed in all these stroke patients with MPN.1 In the emergency setting of a stroke, diagnosing underlying MPN can be difficult. First, MPN patients share common cardiovascular comorbidities that affects stroke risk in the same way than it does in general population.2 Moreover, erythrocytosis and thrombocytosis are common during acute vascular events, and can be linked to hemoconcentration.3 In a retrospective cohort of patients <60 years old presenting with stroke, 19% had high hematocrit levels, 3.1% had thrombocytosis, and according to authors 14% required further investigations for MPN diagnosis.4 On the other hand, proposing systematic JAK-2 V617F screening in stroke patients is costly and might lead to overdiagnosis, as the prevalence of JAK-2 V617F or calreticulin mutations has recently been estimated at 3.1% in the Danish population, among which only 2.5% had defined MPN.5 We report an institutional study based on a retrospective cohort of patients with ischemic stroke to describe MPN prevalence, clinical and radiological presentation, and outcome, and finally discuss accountability of MPN in stroke pathogeny and its therapeutic in acute and long-term management. We retrospectively collected data from patients hospitalized in the Bicêtre Hospital Stroke unit from 2009–2019. Local recommendations are to consider JAK-2 screening (i) in patients with elevated hemoglobin (>16 g/dL or > 16.5 g/dL in female or male patients respectively) and/or platelets (>450 G/L) and (ii) in patients younger than 55 years old in the setting of cryptogenic stroke. Patients were screened via computer search in the local discharge databases. Inclusion criteria were the association of cerebral infarction or TIA and MPN diagnosis. The diagnosis of MPN followed either 2008 or 2016 recommendations, depending on the date of stroke incidence, and patients with CML were excluded. For each patient, in the case of stroke recurrence in our institution, only the first stroke event was recorded. Stroke etiology was investigated using the TOAST score. Quantitative and qualitative data were reported as median [interquartile range, IQR], and n (%), respectively. For intergroup comparisons of quantitative data, the Wilcoxon-Mann–Whitney test was used. For intergroup comparisons of qualitative data, Fisher's exact test was used. Statistical significance was set to P < .05. All statistical analysis were performed on R-Studio software v1.3.1056. Among 8834 patients hospitalized from January 1, 2009 to January 1, 2019 for arterial stroke, 21 were retrospectively identified with MPN (0.2%): 11/21 (52%) with essential thrombocythemia (ET), 10/21 (48%) with polycythemia vera (PV). At the time of the recorded stroke event, MPN was previously diagnosed for 8/21 (38%), and revealed by stroke for 13/21 (62%). Median age was 70 years old [64–78], and sex-ratio was 1.33 women per men (Table 1). Median follow-up after stroke was 27 months [8–48]. 1 >1 N = 7 (33%) N = 11 (52%) N = 2 (25%) N = 5 (62%) N = 5 (38%) N = 6 (46%) .655 .659 Initial NIHSS (median [IQR]) NIHSS after 3 months Haemorrhagic transformation (with or without symptoms) Death from stroke Recurrent stroke Initial Rankin score (median [IQR]) Rankin score at 3 months (median [IQR]) 0 1 2 3 4 5 6 4 [1–10] 2 [1–4] N = 4 (19%) N = 1 (5%)§§§ N = 3 (14%) 0 [0–0] 1 [1–2.25] N = 4 (19%) N = 10 (48%) N = 1 (5%) N = 2 (10%) N = 2 (10%) N = 0 N = 1 (5%) 3 [0.75–5.25] 1.50 [0.75–4] N = 0 N = 0 N = 2 (25%) 0 [0–0.5] 1 [0.5–2] N = 2 (25%) N = 3 (38%) N = 1 (13%) N = 2 (25%) N = 0 N = 0 N = 0 4 [1–10] 2 [1–5] N = 4 (31%) N = 1 (8%) N = 1 (8%) 0 [0–0] 1 [1–2] N = 2 (15%) N = 7 (54%) N = 0 N = 0 N = 2 (15%) N = 0 N = 1 (8%) .635 .931 .131 .241 .530 .597 .580 Imputable exclusively to MPN Associated multiple causes Large artery atherosclerosis Cardioembolism N = 8 (38%) N = 13 (62%) N = 8a N = 4a N = 8 (100%) - - - - - N = 0 N = 13 (62%) N = 8a N = 4a N = 0 N = 2 Three patients (14%) presented with TIA, and 18 (86%) with cerebral infarction. Clinical presentation was severe for two patients (10%, NIHSS>16), moderate for seven (33%, NIHSS 5–15) and minor for 11 (52%, NIHSS 0–4). A total of 13/21 (62%) were not eligible for either thrombolysis or endovascular therapy, 10 because of delayed care, two because of TIA and one because of formal counter-indication to thrombolysis. After stroke, 10/21 (48%) received antiaggregant therapy, nine received anticoagulation therapy (43%) and one was treated by both. Median initial NIHSS and NIHSS at discharge were four [1–10] and two [1–4] respectively. Three patients experienced a stroke recurrence (two had a history of stroke, and one patient had a stroke recurrence 2 months after the recorded event), and one (5%) patient died from stroke. At 3 months, modified Rankin scale (mRS) scores were 0–1 (full autonomy) in 14/21 patients (67%) (Table 1). The median hemoglobin count was 14.3 g/dL [12.5–17.6], the platelet count 468 G/L [356–584], and the white blood cell count 10.1 G/L [8.3–11.8]. Seven (33.3%) patients presented with an elevated hemoglobin count, and 10 (48%) had elevated platelet counts at the time of stroke. After etiological workout, 13/21 (62%) had an additional stroke etiology: large artery atherosclerosis for 8/21 (38%), cardio-embolism for 4/21 (19%, mostly atrial fibrillation in 75%), and stroke of other determined etiology for 2/21 (10%, dissection for one patient and nephrotic syndrome for the other one)(Table 1). Interestingly, 8/21 (38%) patients (two with previously diagnosed MPN and six with stroke-revealed MPN) had no other determined stroke etiology than MPN (Table S1). Of the two patients with previously-diagnosed MPN and stroke without other determined etiology, one had PV and was not treated before stroke occurrence, and the other had TE and was under hydroxyurea. The only statistically significant difference between patients with MPN-related stroke (n = 8, 38%) and with multiple etiologies (n = 13, 62%) was the hemoglobin count, higher in the former group (median of 17.25 g/dL [15.57–18.52] vs 12.7 g/dL [12.5–14.3], P = .027). Among patients with MPN-related stroke, 75% were stroke-revealed MPN, whereas in patients with multiple etiologies, 64% were stroke-revealed MPN (P = .399). Five of them had PV, and three had ET (Table 1). No difference was observed between stroke-revealed and previously-known MPN in terms of age, gender, risk factors, TOAST score and hematological parameters. Interestingly, patients with stroke-revealed MPN had a higher frequency of middle cerebral artery involvement (P = .03) (Table S1). Over the eight patients with previously-diagnosed MPN, six were treated before the recorded stroke: one by JAK-inhibitors solely, five by hydroxyurea (combined with aspirin in 4/5), and one with anticoagulant therapy. Only one of eight untreated patients had an elevated hemoglobin count, while the seven others had normal hemoglobin and platelets counts at stroke occurrence. All of the 13 patients with stroke-revealed MPN were diagnosed with MPN shortly after the stroke event. After stroke, eight patients initiated hydroxyurea, and five started hydroxyurea and phlebotomy (Table S1). When comparing patients depending on their JAK-2 V617F mutational status, there were no significant differences regarding stroke presentation and severity, but patients with JAK-2 V617F mutation had a significantly higher platelet count at stroke occurrence (516 G/L vs 290 G/L, P = .029, Table S2). There were no statistically significant differences between patients with PV and ET regarding stroke characteristics (Table S3). Our study reports the clinical presentation and outcomes of MPN-associated strokes in a single institution retrospective cohort. Among 8834 patients hospitalized for stroke, we retrospectively identified 21 patients with MPN using diagnostic codes, for a prevalence of 0.2% over 10 years, similar to previously reported frequencies.1 Noticeably, this prevalence might be underestimated since only selected patients (ie, young or with suggestive biological alterations, as described in the methods) were screened for MPN. Arterial stroke revealed MPN in 62% patients, among which 15% had a previous history of thrombosis. The JAK-2 V617F mutation was found in 81% of the patients included. After a thorough etiological workup, up to 38% patients had no other imputable stroke etiology than MPN, contrarily to previous large series which reported additional etiologies in all stroke patients with MPN (atherosclerosis, atrial fibrillation, patent foramen ovale, dissection).1 These patients had a statistically significant higher hemoglobin count than patients with additional causes, providing arguments for the direct accountability of MPN to be the cause of stroke. In our study, 48% of the patients included (38% among patients with previously-diagnosed MPN) were not eligible for emergency stroke treatment because of delayed care, emphasizing the need for improvements in patients' education to stroke symptoms. Moreover, 14% of the patients (and 25% of the patients with MPN-related stroke) presented with recurrent stroke, enlightening the high risk in this population. Overall, our study identifies MPN as a rare cause of arterial stroke, and highlights the importance of an early diagnosis to prevent stroke recurrence. While systematic screening for MPN or JAK-2 V617F mutation would require cost/benefit evaluations from further studies, a thorough investigation should be considered in patients with cryptogenic stroke and/or abnormal blood counts. As stroke in the most frequent severe thrombotic manifestation among MPN patients and responsible for 7% of their long-term mortality,6 we believe that a close cooperation between neurologists and hematologists, both at stroke occurrence and during MPN follow-up, will improve MPN diagnosis at stroke occurrence and prevent recurrence. This study was not funded. The authors declare no conflict of interest. C.D. and L.P. designed the study. C.R., O.C., M.S., N.L. contributed clinical data. L.P., N.N. and C.D. analyzed the results. L.P., N.N. and C.D. wrote the manuscript. All authors read and agreed to the final version of the manuscript. All data are available from the corresponding author upon request. Appendix S1. Supporting information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Trissin was originally identified in silico from the transcriptomic analyses in the silkworm Bombyx mori. Trissin contains six cysteine residues within the conserved peptide sequence generally composed of 27 amino acids. Trissin-producing cells are colocalized with other neuropeptide-producing cells.

BACKGROUND:While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS. METHODS:Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed. RESULTS:Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20-0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11-9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81-0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83-0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19-0.93; p = 0.03; OR = 0.07, 95% CI: 0.01-0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01-0.61; p = 0.02). CONCLUSION:Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.

Background: Atypical fibromuscular dysplasia (AFMD), also known as carotid web, is a rare underdiagnosed shelf-like fibrous tissue arising from the posterior carotid artery bulb that is a cause of cryptogenic stroke of the anterior cerebral vascularization. Despite the recurrence and severity of strokes caused by embolization associated with AFMD, there are no recommendations on the best strategy to manage single and bilateral lesions, which have unsatisfactory outcomes when treated with medical treatment exclusively. Methods: From January 2016 to April 2019, 365 patients were operated on for a carotid stenosis in our institution. This cohort included 11 patients (3%), with a median age of 41 years (range, 39-51 years), referred by a stroke unit, treated for a symptomatic (10 strokes and 1 recurrent transient ischemic attack) AFMD lesion. Preoperative workup revealed a contralateral similar lesion in 45% of patients (5/11), which all also underwent surgery during a subsequent hospitalization. The diagnosis was confirmed by histologic examination when open surgery was performed. The 30-day and 1-year outcomes were retrospectively reviewed. Results: Of the 16 AFMD lesions operated, 13 were treated by open surgery (2 by classic endarterectomy and 11 by internal carotid resection-anastomosis) and 3 by carotid artery stenting, respectively, with a mean delay of 85.5 days and 20.5 days after the latest stroke. There was one complication after stenting (external iliac rupture) that was treated by a covered stent, and no perioperative complications after open surgery. The follow-ups at 30 days and 1 year were uneventful for all patients, without any deaths or stroke recurrences. Conclusions: Symptomatic AFMD is a rare cause of cryptogenic stroke. Bilateral lesions are frequent. Early intervention is associated with favorable perioperative and 1-year outcomes. Open surgery is the first-line therapeutic option in this young patient population.

Five trials published in 2015 showed the benefit of endovascular thrombectomy (ET) in patients with stroke and large vessel occlusion, extending the treatment window has become an obsession of all physicians. In 2018, the DAWN and DEFUSE-3 trials showed that, with careful selection of patients, the procedure could be carried out up to 24 hours after symptom onset with good outcomes. In addition, there have been cases where the DAWN criteria were met, and treatment occurred >24 hours after symptom onset. We present the case of a 68-year-old female whose groin puncture occurred 52 hours after the time last known well (TLKW), after neurological worsening of the initial situation, with a large mismatch ratio observed on magnetic resonance imaging, achieving TICI (the Thrombolysis in Cerebral Infarction scale) grade 3 recanalization. Five days after the procedure, the patient was discharged with NIHSS (National Institutes of Health Stroke Scale) score of 3. Some types of collateral circulation (slow progressors and “turtle” progressors, our term for very slow progressors) can extend the treatment window beyond 24 hours of the TLKW but can lead to a hyperperfusion-like syndrome immediately after the ET. Further studies are needed to evaluate the reproducibility of this hypothetical syndrome.

Symptomatic intracerebral hemorrhage (sICH) is a common complication of acute ischemic stroke (AIS) associated with limited treatments and poor outcomes. We aimed to identify predictive factors of sICH in patients with AIS following mechanical thrombectomy (MT) in a real-world setting. Patients with large vessel occlusion of the anterior circulation treated with MT were consecutively included in a prospective monocentric cohort. Clinical, biological, and radiological parameters were collected to identify pre-procedural predictors for sICH. 637 patients were included in our study. Magnetic resonance imaging was performed on most patients (86.7%). sICH occurred in 55 patients (8.6%). 428 patients (67.2%) were treated with intravenous thrombolysis. After multivariate analysis, prior use of antiplatelet therapies (odd ratio (OR) 1.84, 95% confidence interval (CI) 1.01–3.32), high C-reactive protein (OR per standard deviation (SD) increase 1.28, 95% 1.01–1.63), elevated mean arterial blood pressure (OR per 10 mmHg increase 1.22, 95% CI 1.03–1.44), hyperglycemia (OR per one SD-log increase 1.38, 95% CI 1.02–1.87), and low ASPECTS (OR per 1-point decrease 1.42, 95% CI 1.12–1.80) were found to be independent predictive factors of sICH. The pre-procedural predictors did not change when the absence of successful recanalization was considered as a covariate. Patients with strokes of unknown onset time were not especially vulnerable for sICH. sICH after MT was associated with several pre-procedural risk factors: prior use of antiplatelet therapies, high C-reactive protein and hyperglycemia at baseline, elevated mean arterial blood pressure, and low ASPECTS.

Type 2 heparin-induced thrombocytopenia (HIT 2) is a rare pro-thrombotic disorder occurring in patients treated with heparin. It is defined as a clinical-biological syndrome associating the sudden onset of a thrombocytopenia, characterized by a drop of more than 50% of the initial platelet count, and thrombosis. We report two cases of HIT 2 occurring in patients with major bleeding tendency. The first HIT occurred in a patient whose management, in accordance with current guidelines, made it possible to control the thrombocytopenia and the anticoagulation despite the complexity of adapting and monitoring treatments in the context of recent cerebral hemorrhage. The second refers to an autoimmune HIT, which occurred in a patient whose management required the use of alternative therapies to the standard treatments suggested for HIT 2, to correct the severe refractory thrombocytopenia.

Background The National Authority for Health (HAS) updated in 2018 its recommendations on the anticoagulation for vascular prevention after ischaemic stroke. Purpose The objective was to assess and compare oral anticoagulant (OAC) prescriptions to the guidelines in patients hospitalised for ischaemic stroke in a stroke unit. Material and methods This was an observational retrospective study of OACs prescriptions including Vitamin K antagonist (VKA) and direct-acting oral anticoagulant (DOAC) in patients admitted for ischaemic stroke in a comprehensive stroke centre. Data on prescribed OAC from January to August 2018 was collected from the electronic inpatient records. The prescriptions' evaluation was based on indication, dosage and drug interactions for DOAC, and indication and bridging anticoagulation for VKA. The thrombotic risk was quantified using the CHA2DS2-VASC score. Results The mean age of the 86 included patients was 72.8±14.5 years old (49% female). About 69% had an OAC initiation during hospitalisation and 31% was previously treated. At hospitalisation discharge DOAC were three times more prescribed than VKA (77% versus 23%). DOAC prescriptions of 92% conformed to the guidelines (dosage and no drug interaction). VKA prescriptions could not be evaluated because of ambulatory follow-up. The main OAC therapeutic indication was a confirmed atrial fibrillation (AF) in 62% patients (mean CHA2DS2-VASC=4.93±1.36). In 21%, AF was suspected, based on an association of factors such as: atrial hyperexcitability (59%), dilated left atrium (47%) and ischaemic stroke background in patients undergoing antiplatelet therapy (23%) (mean theoretical CHA2DS2-VASC=4.82±1.67). The remaining indications for OAC were: patent foramen ovale (PFO) before closure (7%, only DOAC), mechanical heart valve (5%, only VKA) and antiphospholipid syndrome (APS) (2%, only VKA). Conclusion Even though HAS gave no recommendation concerning OAC prescription in patients with an AF suspicion, neurologists prescribe it to prevent relapse stroke risk due to paroxysmal AF. A Holter monitoring is prescribed after discharge to decide upon the continuation of OAC at the neurologist's follow-up visit. This practice should be investigated further to prove its efficiency. Concerning mechanical heart valves, neurologists follow the HAS recommendations. For PFO, neurologists use DOAC regardless of the HAS recommendations. No recommendation has been given for APS. References and/or acknowledgements https://www.has-sante.fr/portail/jcms/c_1252051/fr/prevention-vasculaire-apres-un-infarctus-cerebral-ou-un-accident-ischemique-transitoire No conflict of interest.

Background: Randomized controlled trials for calcium antagonists therapy in patients with acute ischemic stroke have failed to show a benefit as a stand-alone therapy, due largely to the reduction of blood pressure, especially in the absence of early recanalization. Since mechanical thrombectomy (MT) has led to high successful recanalization rates, the effect of nimodipin as an adjuvant therapy during MT has not been evaluated. Materials and Methods: We retrospectively reviewed all consecutive cases of MT for which Nimodipin was used as an adjuvant therapy after at least one pass of any device. Clinical and angiographic characteristics, as well as immediate vessel caliber modifications, reperfusion status and early neurological improvement were collected between January 2016 and December 2017. Results: Procedural intra-arterial nimodipin infusion was administered in 10.3 % (58/559; 95%CI 7.8-12.8 %) of patients, after at least one pass of MT device. In 52/58 patients, < 3 manoeuvers of MT were performed. Angiographic vasospasm was identified on the carotid artery in 17/58 (29.3%) cases, on the middle cerebral artery in 35/58 (60.4%) cases and in vertebro-basilar artery in 6/58 (10.3%) cases. The vasospasm was responsible for an immediate reocclusion in 12% of the patients. Angiographic effect of nimodipin with the restauration of a normal vessel caliber and the improvement of the reperfusion without supplementary maneuver was observed in 77.5% % of the cases. Successful recanalization TICI 2b/3 was reached in 81% patients. Significant drop of blood pressure (BP) with need for additional vasopressive drugs was observed in 6 cases. Symptomatic hemorrhage occurred in 3 patients (5%). Concomitant fibrinolytic therapy did not influence the rate of intracranial hemorrhage rate after procedural nimodipin infusion (p=0.912). Early neurological improvement was reached in 46% and was not associated with a high initial systolic and diastolic BP at the admission (p=0.89) or with the modality of anesthesia (p =0.76). Conclusion: Nimodipin can be an efficient and safe adjuvant therapy in the setting of vasospasm due to MT, by normalizing the caliber of the recanalized artery and then, improving the reperfusion status without supplementary maneuver of MT.

Background and purpose: - To compare outcomes of minor stroke patients with intracranial vessel occlusions (IVO) underwent mechanical thrombectomy (MT) versus those treated with intravenous thrombolysis alone (IVT). Methods: - We retrospectively reviewed two large prospective stroke databases from two European centers searching for patients admitted with minor stroke (i.e. NIHSS Score <= 5), baseline mRS = 0 and occlusion of the M1-M2 segment of the middle cerebral artery (MCA). Groups receiving (A) IVT alone and (B) MT+/-IVT were compared. Primary outcome measures were MT safety, successful recanalization rate (mTICI 2b-3) and NIHSS shift (discharge NIHSS minus admission NIHSS); secondary outcomes included discharge rates and excellent outcome (mRS 0-1) at 3 months. Univariate and multivariate analyses were performed. Results: - Thirty-two patients were enrolled in Group B (19 MT alone; 13 MT + IVT) and 24 in Group A. Successful recanalization (mTICI 2b-3) was obtained in 100% of cases in Group B vs 38% in Group A. Symptomatic hemorrhagic transformation rate did not differ between the two groups. Multivariate analysis reported MT as the only predictor of early (< 12h) favorable NIHSS shift and lower NIHSS at discharge. Moreover, discharge at home and excellent outcome at 3-month follow-up were statistically associated with MT. Conclusions: - MT in patients with minor strokes and intracranial vessel occlusion (IVO) is safe and can determine a rapid improvement of NIHSS Score. MT seems also associated with a higher rate of patients discharged at home after hospitalization and better clinical outcome at 3-month follow-up. Larger randomized trials are warranted to confirm these results. (C) 2019 Elsevier Masson SAS. All rights reserved.

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy related to a severe deficiency of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13). In this article, we describe the first case of a young male adult suffering from a hereditary TTP revealed by recurrent strokes, relapsing despite antiplatelet and anticoagulant therapy. Because of the persistent moderate thrombocytopenia, plasmatic ADAMTS13 activity was investigated and was found lower than 5% in the absence of anti-ADAMTS13 IgG. Direct sequencing of ADAMTS13 gene led to the diagnosis of Upschaw-Schulman syndrome (USS). Inherited TTP or USS is a rare autosomal recessive inherited disease leading to a severe deficiency of ADAMTS13 mostly beginning in childhood or in young female adult during pregnancy. Our patient was treated with fresh frozen plasma every 2 weeks. One year after diagnosis, he was free of neurological symptoms. Around 12 cases of inherited TTP diagnosed in adults (outside pregnancy) are described in literature. Only 4 of them exhibited a stroke. This case is the first late onset genetic TTP revealed by recurrent strokes, moderate thrombocytopenia without anemia.

Au total, 85 % des patients avec un accident vasculaire cérébral (AVC) hémisphérique droit ont une NSU, qui constitue un facteur pronostic péjoratif. L'hétérogénéité du trouble rend son évaluation difficile et peu reproductible. Établir et valider une batterie d'évaluation rapide pour dépister la NSU en phase aiguë d'un AVC hémisphérique droit afin d'orienter précocement les patients vers une évaluation et une rééducation spécialisée. Notre batterie inclue 8 items explorant différents aspects cliniques de la NSU. La batterie a été testée initialement sur 70 sujets sains puis à tous les patients présentant un AVC hémisphérique droit hospitalisés en USINV (sauf démence ou lésion cérébrale focale antérieure préalables). L'existence d'une éventuelle NSU a été évaluée par la batterie rapide (par 2 médecins simultanément), puis avec le test de référence (BEN du GEREN) par un ergothérapeute, les évaluations étant réalisées en aveugle. Nos résultats intermédiaires montrent : un score moyen de 0,02/20 chez les sains, et après 42 patients inclus, 100 % d'acceptabilité et une variabilité inter-examinateur moyenne de 0,2 points. La NSU est sous-évaluée par le NIHSS comparativement à la BEN (33 % de faux négatifs). La passation de notre batterie est plus rapide (3,7 min vs 30,8 min, p < 0,001), avec une concordance entre la batterie rapide et la BEN chez 37 patients (88 %). Notre batterie constitue une approche acceptable et reproductible pour évaluer la NSU en USINV en aigu. Rapide et facile, elle devrait permettre de dépister la NSU afin de guider la prise en charge et de cibler la rééducation. Son utilisation pourrait s'étendre à d'autres domaines neurologiques. Le recrutement se poursuit en vue d'une imminente validation de la batterie. Cette batterie est un outil pertinent dans le dépistage rapide de la NSU en phase aiguë d'un AVC afin d'orienter les patients vers une rééducation précoce et adaptée.

The Extending the time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial using Tenecteplase (EXTEND-IA TNK) trial recently showed 2-fold higher early recanalization (ER) rate before mechanical thrombectomy (MT) following intravenous thrombolysis (IVT) with tenecteplase 0.25 mg/kg, as compared to alteplase 0.9 mg/kg. 1 However, most included patients were directly admitted to MT-capable centres ('mothership' paradigm), implying short IVT-to-MT delays.Tenecteplase may therefore be preferred in the mothership setting.Here, we assessed ER rate before MT following tenecteplase or alteplase in patients transferred for MT from a non-MT-capable centre ('drip-and-ship' paradigm), i.e., implying longer IVT-to-MT delays, currently the most frequent situation. 2nclusion criteria for the present retrospective study were (1) acute stroke with large vessel occlusion treated with IVT with tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg; and (2) ER evaluation ≤3 hours from IVT start on pre-MT first angiographic run or non-invasive vascular imaging.Tenecteplase patients were all from one large French non-MT-capable centre, which based on previous trials 3,4 and for practical convenience opted to use tenecteplase off-label before transfer for MT.Alteplase patients were from 23 other French non-MT-capable centres.ER

PRRT2 gene mutations cause paroxysmal kinesigenic dyskinesia (PKD), infantile convulsions, hemiplegic migraine, and episodic ataxia. A 21-year-old woman reported an episode of dizziness and ataxic gait occurring after swimming. Brain MRI showed a hyperintense cerebellar lesion on diffusion-weighted imaging (DWI) with decreased apparent diffusion coefficient. The clinical course was favorable. Both clinical and MRI abnormalities regressed. Her brother had presented PKD since adulthood. A C.649dupC PRRT2 truncating mutation was identified in both patients. To our knowledge, this is the first case of an acute cerebellar ataxia associated with heterozygous PRRT2 mutation and transient cerebellar hyperintensity on DWI. Among the clinical and genetic heterogeneities of familial paroxysmal disorders, PRRT2 mutation may be considered in patients with episodic cerebellar ataxia and diffusion restriction on neuroimaging.