Explore the vast range of titles available.

Cerebral infarction due to acute embolism in the large artery during pregnancy is a rare but severe condition threatening both the mother's and child's life. Physicians lack diagnostic and therapeutic guidance to manage this particular situation due to the paucity of published cases. Furthermore, the pathogeny is poorly known, rendering preventive strategies difficult. We describe the case of a young woman presenting cryptogenic acute cerebral infarction during the first trimester of pregnancy who was successfully treated with combined reperfusion therapy. We reviewed the literature to collect data about pathogeny and management. A 28-year-old pregnant woman was diagnosed with acute cerebral infarction due to left middle cerebral artery occlusion at 9 weeks of gestation. Endovascular thrombectomy combined with intravenous thrombolysis allowed cerebral reperfusion leading to a decrease in the National Institute of Health Stroke Score from 13 to 1 at 24 hours. Comprehensive etiological investigation was negative. Anticoagulation therapy with low-molecular-weight heparin was administered as preventive treatment during the pregnancy and postpartum. Neither the mother nor the child experienced any complications: the baby was born by normal vaginal delivery and the outcome was good at 1 year. We identified 21 other cases of patients treated with reperfusion therapies, four of which consisted of endovascular thrombectomy, and only one a combined strategy. Pregnant women with acute cerebral infarction due to arterial occlusion can benefit from combined reperfusion therapy. More cases should be collected to assess treatment in these patients, to understand pathogeny, and propose the best preventive strategy.

BackgroundThe effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT.PurposeTo compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)).MethodsWe performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis.ResultsEight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64).ConclusionsPatients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

BackgroundFor patients with stroke with large-vessel occlusion (LVO), study of factors predicting response to intravenous thrombolysis (IVT) would allow identifying subgroups with high expected gain, and those for whom it could be considered as futile, and even detrimental. From patients included in the Mechanical Thrombectomy After Intravenous Alteplase vs Alteplase Alone After Stroke trial, we investigated clinical-imaging factors associated with optimal response to IVT.MethodsWe included patients receiving IVT alone. Excellent outcome was defined by a 3-month modified Rankin Scale (mRS) score ≤1. Clinical-imaging predictors were assessed on multivariate analysis after multiple imputations. The predictive performance of the model was assessed with the C-statistic.ResultsAmong 247 patients with LVO treated with IVT alone, 77 (31%) showed 3-month mRS ≤1. Predictors of 3-month mRS ≤1 were no medical history of hypertension (OR 2.43; 95% CI 1.74 to 3.38; p=0.007); no current smoking (OR 2.76; 95% CI 1.79 to 4.26; p=0.02); onset-to-IVT time (OR 0.47 per hour increase; 95% CI 0.23 to 0.78; p=0.003); diffusion-weighted imaging (DWI) volume (OR 0.78 per 10 mL increase; 95% CI 0.68 to 0.89; p=0.0004); presence of susceptibility vessel sign (SVS) (OR 7.89; 95% CI 1.65 to 37.78; p=0.01) and SVS length (OR 0.87 per mm increase; 95% CI 0.80 to 0.94; p=0.001). The prediction models showed a C-statistic=0.79 (95% CI 0.79 to 0.80).ConclusionsIn patients with stroke with anterior-circulation LVO treated with IVT alone, predictors of excellent outcome at 3 months were no medical history of hypertension or current smoking, reduced onset-to-IVT time, small DWI volume, presence of SVS and short SVS length. These predictive factors could help practitioners in decision-making for IVT implementation in reperfusion strategies, all the more for the drip and ship paradigm.Trial registration number NCT01062698.

Anemia appears frequently in patients with alcoholic liver disease (ALD) but has never been linked to bilateral nonarteritic anterior ischemic optic neuropathy (NAION). A 65-year-old woman with a medical history of alcoholic cirrhosis was admitted for bilateral NAION. On admission, she was found to have a low arterial pressure and severe normocytic anemia (48 g/L). The anemia was related to chronic bleeding due to antral gastritis along with other factors associated with ALD. The applied treatment consisted of urgent transfusion followed by high doses of proton-pump inhibitors, iron and vitamin supplementation, and support in lifestyle measures. Her hemoglobin levels remained stable after 2 years but the patient still suffered from visual loss. This case highlights the link between anemia and bilateral NAION in ALD patients. The optic nerve head is prone to infarction in this context due to the vascularization characteristics of ALD. Hemoglobin levels should be monitored in ALD patients to avoid the severe complication of NAION.

Spontaneous cervical artery dissection (CAD) is a cerebrovascular disease typically considered to affect the young population. Literature reports cases in the elderly only as incidental findings, making the diagnosis unlikely in older patients. Incidence and pathogeny in this specific population remain to be assessed. We reviewed patients aged over 70 years admitted for spontaneous CAD in the Stroke Unit of the University Hospital of Nancy (northeastern France) over a period of 12 years as well as all reported cases in literature. During this period, only two patients aged over 70 years were diagnosed with internal carotid artery dissection in our center. The first patient was diagnosed with the typical radiological feature of long tapered stenosis due to mural hematoma. The second patient presented with the classic painful Horner syndrome. Literature review identified only two case reports and eight studies with an age range above 70 years. Headache was present in nearly all documented cases. Radiological features were the same as those usually described in younger patients. Even if spontaneous CAD in patients aged over 70 years would appear to be rare, it does occur with comparable clinical and radiological features as in the younger population. CAD is probably underdiagnosed in this population due to a higher prevalence of more common causes of stroke at this age. However, a simple investigation into headache or the Horner syndrome during the patient's diagnostic workup would lead to adapted exploration of cervical arteries and improve detection of CAD in the elderly.

Abstract Background and aims Endovascular therapy (EVT) is not recommended for acute stroke due to posterior cerebral artery (PCA) occlusion. Perfusion imaging may identify patients who could benefit from EVT. Methods We conducted a multicenter international observational study of consecutive acute stroke patients with isolated PCA occlusion (P1/P2), admitted ≤ 6 hours from symptom onset and with baseline perfusion imaging. Patients received best medical management (BMM) alone or combined with EVT. The primary outcome was good functional outcome (GFO), defined as 3-month modified Rankin Scale score 0–2 or return to baseline mRS. Propensity-score with overlap weighting (PSOW) was used to balance baseline characteristics. Interaction between treatment strategy and perfusion mismatch volume was tested. Results Overall, 295 patients were included (69 BMM + EVT, 226 BMM alone). Median age was 74 years (IQR 64-83), median NIHSS was 6 (3-10), occlusion site was P1 in 21% and P2 in 79%, intravenous thrombolysis used in 70%. Median core volume was 1.5 mL (0-8) and mismatch volume was 15 mL (4-32). The distribution of baseline variables was similar across the 2 groups following PSOW. EVT was not associated with GFO (PSOW-OR 0.99, 95%CI 0.54–1.83; P = 0.97). The association between EVT and GFO was not modified by mismatch volume (Pinteraction = 0.42). Similar results were observed for mRS 0-1. Conclusions In this cohort of acute strokes with PCA occlusion, EVT was not associated with GFO compared to BMM alone. Perfusion mismatch volume did not modify this association and may not be useful to select good EVT candidates in this patient group. Conflict of interest Sabben: Nothing to disclose/Turc reports lecture fees from Guerbert France and consultant services for AI-Stroke and Neurologica/Obadia: Nothing to disclose/Charbonneau: Nothing to disclose/Strambo: Nothing to disclose/Heldner reports grants from SITEM Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation/Ong: Nothing to disclose/Ter Schiphorst: Nothing to disclose/Sibon: Nothing to disclose/Legris: Nothing to disclose/Carrera: Nothing to disclose/Mione: Nothing to disclose/Bagan-Triquenot: Nothing to disclose/Mazighi reports consulting fees from Acticor Biotech, Boerhinger/Seners speaker fees from Acticor Biotech and Boerhinger-Ingelheim.

Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov , NCT04352296. Registered on 20th April 2020.

IntroductionWhile telestroke allows early intravenous thrombolysis (IVT) for ischemic strokes in spoke centers, mechanical thrombectomy (MT) for large vessel occlusion (LVO) is mainly performed at comprehensive stroke centers (CSCs). We aimed to compare 3 month outcome in patients with LVO after admission to a spoke center using telestroke compared with first CSC admission in our large regional stroke network, irrespective of final treatment decision.MethodsAll consecutive LVO patients who were admitted to one of six spoke centers or to the regional CSC within 6 hours of symptom onset were prospectively included from September 1, 2015 to August 31, 2017. All patients admitted to spoke centers were assessed on site with cerebral and vessel imaging. Primary outcome was 3 month favorable outcome (modified Rankin Scale score of 0–2).ResultsDistances between spoke centers and CSC ranged from 36 to 77 miles. Among 207 included patients, 132 (63.8%) were first admitted to CSCs and 75 (36.2%) to spoke centers. IVT was administered more in spoke centers (81.3% vs 53.8%, p<0.0001) while MT was performed less (26.7% vs 49.2%, p=0.001) and with a longer time from onset (303 vs 200 min, p<0.0001). No difference was found in 3 month favorable outcome between spoke centers compared with CSCs (32.0% and 35.1%, respectively; OR=0.68; 95% CI 0.42 to 1.10; p=0.12).ConclusionsDespite different distribution of reperfusion therapies for LVO patients managed by telemedicine, we could not demonstrate a difference in functional outcome according to admission location in a large area with long distances between centers.

Abstract Introduction Acute ischaemic strokes (AIS) due to proximal anterior cerebral artery (ACA) occlusions are rare. Their clinical outcomes following medical management alone have been scarcely described. Patients and methods We conducted a retrospective, multicentre, international study of consecutive AIS due to isolated proximal ACA occlusion (A1 or A2 segment) admitted within 6 h of symptom onset and treated with best medical management alone (ie, without endovascular therapy), across 23 centres in France and Switzerland. The primary outcome was poor functional outcome, defined as a mRS score > 2 at 3 months or failure to return to baseline mRS if the pre-stroke mRS was > 2. Associations between baseline clinical/radiological variables and outcome were evaluated in multivariable logistic regression analyses. Associations between outcome and key radiological follow-up variables such as recanalisation and haemorrhagic transformation were also analysed. Results Ninety-five patients were included in the study: median age was 76 (IQR, 66–87), baseline NIHSS score was 10 (IQR, 5–15) and occlusion site was A1 in 8 (8%) and A2 in 87 (92%). Intravenous thrombolysis was administered in 76 (80%) cases. Poor functional outcome was observed in 47 (49%) patients. Among baseline variables, older age (adjusted odds ratio [aOR] per 5-year increase = 1.25; 95% CI, 1.10–1.55; P = .028) and higher NIHSS score (aOR = 1.20, 95% CI, 1.07–1.34; P < .001) were independently associated with poor outcome. Lack of recanalisation at 24 h was also independently associated with poor outcome (aOR = 14.5, 95% CI, 1.1–188.7, P = .04). Poor outcome was higher in patients with than in those without haemorrhagic transformation (73% vs 42%, P = .03) in univariable analysis, but not in multivariable analysis adjusting for age and NIHSS score (aOR = 2.3, 95% CI, 0.5–11.5, P = .32). Discussion and conclusion Nearly half of AIS patients with isolated proximal ACA occlusion treated with medical management alone had poor 3-month functional outcomes. Older age, high NIHSS at admission and lack of recanalisation at 24 h were associated with poor outcome. These results underscore the need to investigate therapeutic strategies aimed at enhancing early arterial recanalisation to improve recovery in this population. Graphical Abstract Graphical Abstract

IntroductionPlasma biomarkers may be useful in diagnosing acute cerebral infarction requiring urgent reperfusion, but their performance remains to be confirmed. If confirmed, these molecules could be used to develop rapid and reliable decentralised measurement methods, making it possible to initiate reperfusion therapy before hospital admission. The FLAG-1 large prospective study will constitute a plasma bank to assess the diagnostic performance of two biomarkers: glutathione S-transferase-π and peroxiredoxin 1. These molecules are involved in the oxidative stress response and could identify cerebral infarction within a therapeutic window of less than 4.5 hours following the onset of symptoms. Secondary objectives include assessing performance of these biomarkers within 3-hour and 6-hour windows; identifying additional biomarkers diagnosing cerebral infarction and significant criteria guiding therapeutic decisions: ischaemic features of stroke, presence of diffusion/fluid-attenuated inversion recovery mismatch, volume of cerebral infarction and penumbra on cerebral MRI.Methods and analysisThe exploratory, prospective, multicentre FLAG-1 Study will include 945 patients with acute stroke symptoms (onset ≤12 hours, National Institute of Health Stroke Scale score ≥3). Each patient’s 25 mL blood sample will be associated with cerebral MRI data. Two patient groups will be defined based on the time of blood collection (before and after 4.5 hours following onset). Receiver operating characteristic analysis will determine the diagnostic performance of each biomarker, alone or in combination, for the identification of cerebral infarction <4.5 hours.Ethics and disseminationThe protocol has been approved by an independent ethics committee. Biological samples are retained in line with best practices and procedures, in accordance with French legislation. Anonymised data and cerebral imaging records are stored using electronic case report forms and a secure server, respectively, registered with the French Data Protection Authority (Commission Nationale de l\"Informatique et des Libertés (CNIL)). Results will be disseminated through scientific meetings and publication in peer-reviewed medical journals.Trial registration numberClinicalTrials.gov Registry (NCT03364296).