ASSESSMENT OF NATURAL RADIOACTIVITY LEVELS AND RADIATION EXPOSURE IN NEW BUILDING MATERIALS IN SPAIN

Novel building materials were manufactured and analyzed for 226Ra, 232Th and 40K using an HPGe gamma-ray spectrometer. The results show that the highest value of 40K was 4530 Bq per kg which was measured in a sample containing fly ashes from olive stones. The highest values of 226Ra and 232Th activities were 181 and 185 Bq per kg, which were measured in a sample with fly ashes from the co-combustion of coal and coke, respectively. On the other hand, the lowest values of 40K, 226Ra and 232Th activities were obtained for samples incorporating mussel shells. The radiological health hazard parameters, such as radium equivalent activity (Raeq), activity concentration index (I), absorbed and effective dose rates, associated with these radionuclides were evaluated. These values are within the EU recommended limits in building materials, except for samples of concrete containing fly ashes from olive stones, coal and coke. This study has contributed to the inclusion of industrial wastes that have not been collected previously in the Naturally Occurring Radioactive Material (NORM) databases on radioactivity of building materials.

Clinical characteristics and outcomes of COMPASS eligible patients in France. An analysis from the REACH Registry

BACKGROUND

Following the publication of the COMPASS trial, the European Medicines Agency has approved a regimen of combination of rivaroxaban 2.5mg twice daily and a daily dose of 75-100mg acetylsalicylic acid (ASA) for patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischemic events. However, the applicability of such a therapeutic strategy in France is currently unknown.

AIMS

To describe the proportion of patients eligible to COMPASS in France, their baseline clinical characteristics and the rate of major adverse cardiovascular events, using the REACH registry.

METHODS

From the the REduction of Atherothrombosis for Continued Health (REACH) registry database, a large international registry of patients with, or at risk, of atherothrombosis, we analyzed patients included in France with either established CAD and/or PAD and fulfilling the inclusion and exclusion criteria of the COMPASS trial. The ischemic outcome was a composite of cardiovascular (CV) death, myocardial infarction (MI), or stroke, and serious bleeding were defined as haemorrhagic stroke or bleeding leading to hospitalization or transfusion.

RESULTS

Among more than 65000 patients enrolled in REACH, 2.012 patients were evaluable and enrolled in France. Among them, 1194 patients (59.3%) were eligible to COMPASS. The main reasons for exclusion of the COMPASS trial, were high bleeding risk (59.1%), anticoagulant use (43.4%), requirement for dual antiplatelet therapy within 1 year of an ACS or PCI (24.7%). In the "COMPASS eligible population", the rate of MACE (CV, MI and stroke) at 4 years follow-up was 13.4% [11.3-15.8], and serious bleeding was 2.5% at 4 years [1.6-3.4]. Patients with polyvascular disease (n=219) had the highest rate of MACE, compared with patients with CAD only and PAD only (19.1% [13.9-26.1] vs. 11.6% [9.1-14.8] vs 13.2% [9.2-18.8], P<0.0001, respectively).

CONCLUSION

The COMPASS therapeutic strategy in France appears to be applicable to more than half of CAD or PAD patients. This population appears at high residual risk of atherothrombotic events, and patients with polyvascular disease experienced the highest rate of events.

A sequential determination of 90Sr and 210Po in food samples

The latest EU Council Regulation 2016/52/Euratom updates the emergency limits on radionuclides in foods including ²¹⁰Po and ⁹⁰Sr, two of the most important radionuclides for radiological dose from the ingestion pathway. A novel and straightforward method has been developed for sequential determination of ⁹⁰Sr and ²¹⁰Po in food samples using ultra low-level liquid scintillation counting and alpha-particle spectrometry. For ⁹⁰Sr analysis, the method makes use of stable strontium as yield tracer, and ²¹⁰Po is determined through self-deposition using ²⁰⁹Po as a yield tracer. The quantification limit for this method is 25.0 and 2.0Bqkg^-1 for ⁹⁰Sr and ²¹⁰Po, respectively. The proposed radiochemical separation can be completed within 2days for a batch of 12 samples. The radiochemical procedure was validated by its application for the measurement of IAEA certified reference materials, and through participation in a national intercomparison exercise. Results are also presented in seafood from the Mediterranean coast.

New insights on the role of sea ice in intercepting atmospheric pollutants using (129)I

Measurements of (129)I carried out on sea ice samples collected in the central Arctic Ocean in 2007 revealed relatively high levels in the range of 100-1400×10(7) at L(-1) that are comparable to levels measured in the surface mixed layer of the ocean at the same time. The (129)I/(127)I ratio in sea ice is much greater than that in the underlying water, indicating that the (129)I inventory in sea ice cannot be supported by direct uptake from seawater or by iodine volatilization from proximal (nearby) oceanic regimes. Instead, it is proposed that most of the (129)I inventory in the sea ice is derived from direct atmospheric transport from European nuclear fuel reprocessing plants at Sellafield and Cap La Hague. This hypothesis is supported by back trajectory simulations indicating that volume elements of air originating in the Sellafield/La Hague regions would have been present at arctic sampling stations coincident with sampling collection.

Studying radon exhalation rates variability from phosphogypsum piles in the SW of Spain

Nearly 1.0 × 10(8) tonnes of phosphogypsum were accumulated during last 50 years on a 1,200 ha disposal site near Huelva town (SW of Spain). Previous measurements of exhalation rates offered very variable values, in such a way that a worst case scenario could not be established. Here, new experimental data coupled to numerical simulations show that increasing the moisture contents or the temperature reduces the exhalation rate whilst increasing the radon potential or porosity has the contrary effect. Once the relative effects are compared, it can be drawn that the most relevant parameters controlling the exhalation rate are radon potential (product of emanation factor by (226)Ra concentration) and moisture saturation of PG. From wastes management point of view, it can be concluded that piling up the waste increasing the height instead of the surface allows the reduction of the exhalation rate. Furthermore, a proposed cover here is expected to allow exhalation rates reductions up to 95%. We established that the worst case scenario corresponds to a situation of extremely dry winter. Under these conditions, the radon exhalation rate (0.508 Bqm(-2)s(-1)) would be below though close to the upper limit established by U.S.E.P.A. for inactive phopsphogypsum piles (0.722 Bqm(-2)s(-1)).

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a recently proposed cliniconeuroradiologic entity with several well-known causes, such as hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressive drugs, as well as some causes more recently described. PRES is characterized by neuroimaging findings of reversible vasogenic subcortical edema without infarction. The pathogenesis is incompletely understood. Two opposing hypotheses are commonly cited, but the issue is controversial: (1) the current more popular theory suggests that severe hypertension exceeds the limits of autoregulation, leading to breakthrough brain edema; (2) the earlier original theory suggests that hypertension leads to cerebral autoregulatory vasoconstriction, ischemia, and subsequent brain edema. The clinical syndrome of PRES typically involves headache, encephalopathy, visual symptoms, and seizures. The clinical presentation is often nonspecific, and therefore the diagnosis of PRES has come to increasingly rely on magnetic resonance imaging (MRI) abnormalities consistent with PRES with documented recovery clinically and on repeated neuroimaging. The diagnosis has important therapeutic and prognostic implications because the reversibility of the clinical and radiologic abnormalities is contingent on the prompt control of blood pressure and/or discontinuing the offending drug.

Radionuclide activities and metal concentrations in sediments of the Sebou Estuary, NW Morocco, following a flooding event

This study presents metal concentrations (Fe, Mg, Mn, Co, Cu, Zn, Pb, As, Sr and V) and radionuclide activities ((40)K, (137)Cs, (210)Pb, (226)Ra, (228)Ac, (234)Th and (212)Pb) in surface deposits and a sediment core from the Sebou Estuary, Northwest Morocco. Samples were collected in April 2009, about 2 months after a flooding event, and analysed using a well-type coaxial gamma-ray detector and inductively coupled plasma-quadrupole mass spectrometry. Activities of radionuclides and concentrations of almost all elements in surface samples displayed only moderate spatial variation, suggesting homogenous deposition of eroded local soil in response to intense precipitation. Excess (210)Pb displayed relatively constant activity throughout the sediment core, preventing dating and precluding determination of the historical accumulation rates of pollutants at the core site. Some elements showed non-systematic trends with depth and displayed local maxima and minima. Other elements presented relatively systematic concentration trends or relatively constant levels with discrete maxima and/or minima. Except for Mn, Sr and Cr, all metal concentrations in sediment were below levels typical of polluted systems, suggesting little human impact or losses of metals from sediment particles.

Determination of trace element concentrations and stable lead, uranium and thorium isotope ratios by quadrupole-ICP-MS in NORM and NORM-polluted sample leachates

This work focuses on the monitoring of the potential pollution in scenarios that involve NORM-related industrial activities (environmental or in-door scenarios). The objective was to develop a method to determine extent and origin of the contamination, suitable for monitoring (i.e. simple, fast and economical) and avoiding the use of too many different instruments. It is presented a radiochemical method that allows the determination of trace element concentrations and 206Pb/207Pb/208Pb, 238U/234U and 232Th/230Th isotope ratios using a single sample aliquot and a single instrument (ICP-QMS). Eichrom UTEVA® extraction chromatography minicolumns were used to separate uranium and thorium in sample leachates. Independent ICP-MS determinations of uranium and thorium isotope ratios were carried out afterwards. Previously a small aliquot of the leachate was used for the determination of trace element concentrations and lead isotope ratios. Several radiochemical arrangements were tested to get maximum performances and simplicity of the method. The performances of the method were studied in terms of chemical yields of uranium and thorium and removal of the potentially interfering elements. The established method was applied to samples from a chemical industry and sediments collected in a NORM-polluted scenario. The results obtained from our method allowed us to infer not only the extent, but also the sources of the contamination in the area.

Arctic Ocean sea ice drift origin derived from artificial radionuclides

Since the 1950s, nuclear weapon testing and releases from the nuclear industry have introduced anthropogenic radionuclides into the sea, and in many instances their ultimate fate are the bottom sediments. The Arctic Ocean is one of the most polluted in this respect, because, in addition to global fallout, it is impacted by regional fallout from nuclear weapon testing, and indirectly by releases from nuclear reprocessing facilities and nuclear accidents. Sea-ice formed in the shallow continental shelves incorporate sediments with variable concentrations of anthropogenic radionuclides that are transported through the Arctic Ocean and are finally released in the melting areas. In this work, we present the results of anthropogenic radionuclide analyses of sea-ice sediments (SIS) collected on five cruises from different Arctic regions and combine them with a database including prior measurements of these radionuclides in SIS. The distribution of (137)Cs and (239,240)Pu activities and the (240)Pu/(239)Pu atom ratio in SIS showed geographical differences, in agreement with the two main sea ice drift patterns derived from the mean field of sea-ice motion, the Transpolar Drift and Beaufort Gyre, with the Fram Strait as the main ablation area. A direct comparison of data measured in SIS samples against those reported for the potential source regions permits identification of the regions from which sea ice incorporates sediments. The (240)Pu/(239)Pu atom ratio in SIS may be used to discern the origin of sea ice from the Kara-Laptev Sea and the Alaskan shelf. However, if the (240)Pu/(239)Pu atom ratio is similar to global fallout, it does not provide a unique diagnostic indicator of the source area, and in such cases, the source of SIS can be constrained with a combination of the (137)Cs and (239,240)Pu activities. Therefore, these anthropogenic radionuclides can be used in many instances to determine the geographical source area of sea-ice.

Comparison of optimized and standard diffusion-weighted imaging at 1.5T for the detection of acute lesions in patients with transient ischemic attack

SUMMARY

The high rate of normal diffusion-weighted imaging (DWI) in patients with transient ischemic attack (TIA) raises the question as to its sensitivity for detecting small ischemic lesions. We compared standard and optimized DWI in 36 consecutive patients with TIA. Optimized DWI was positive in more patients than standard DWI (19 versus 16; P < .001) and showed more lesions (56 versus 42; P = .002). At 1.5T, optimizing DWI decreases the rate of false-negative DWI in patients with TIA.

Radioactivity levels in aerosol particles surrounding a large TENORM waste repository after application of preliminary restoration work

In this paper, (238)U-series radionuclides have been analysed in particulate matter samples collected at a phosphogypsum stack system located near the city of Huelva (SW Spain) during the course of 1 year. The results have been compared to those collected at a reference (background) site located a few km away, in order to establish if the stack system provokes an increase in radionuclide exposure due to inhalation with particulate matter. The (222)Rn progeny, which is considered a very important contributor to the internal dose rate received by the population, was collected for 6 months. The results indicate that for several types of radionuclides there is a significant increase in the radioactivity adsorbed by the aerosol particles collected at phosphogypsum stacks. The isotope analysis indicates that this increment could be affected by the water vapour emissions from the factory, which contain high concentrations of these radionuclides. However, the majority of these radionuclides could not be detected at the background location. The corresponding dose increment estimated at the sampling point is, however, negligible. This fact is a consequence of the very small radionuclide concentration increment, together with relatively conservative nature of the occupational factor applied. Regarding the Rn progeny, no significant differences between either the collecting sites has been registered due to of the dominant wind regime at the sampling locations.

An assay on the effect of preliminary restoration tasks applied to a large TENORM wastes disposal in the south-west of Spain

A large industrial wastes disposal site, where two phosphate rock processing plants release their wastes, located close to Huelva town (SW of Spain), has been partially submitted to restoration as a preliminary step in a possible decomissioning process. Due to the high natural radioactivity contents of these wastes, this repository is considered as a radiological anomaly, being actually considered as TENORM (technically enhanced naturally occurring radioactive materials). The efficiency of this restoration from the radiological point of view according to the new European regulatory framework was evaluated in this work. The results allow to conclude that, as a consequence of the partial restoration works, the external dose rate has been drastically reduced above the repository system. Nevertheless, special attention must be paid on the occupational factor to be applied to workers on the unrestored system. The application of a dosimetric model allows the prediction of the negative effects of using certain industrial wastes as a cover system in this restoration/mitigation task.

[Clinical evolution of patients following investigation of atrial vulnerability after a first cerebral ischaemic accident]

Atrial vulnerability reflects the ability of the atrium to fibrillate. ISAV (Ischemic stroke and atrial vulnerability) is a French epidemiological registry whose main goal is to assess the evolution modalities of patients in whom an electrophysiological study of the atrium has been performed. A group of 269 patients with a history of non elucidated ischemic stroke and an electrophysiological study of the atrium performed in a mean delay of 3 months after the stroke has been included. Their mean age at the time of the stroke was 55 +/- 15.8 years. The electrophysiological study has measured the effective refractory period of the atrium, the locoregional right intra-atrial conduction time, the index of latent atrial vulnerability and assessed the inductibility. The mean delay between the date of the stroke and the date of the last news was 4.4 +/- 2.8 years. We observed 12 deaths and 11 patients presented during the follow up a spontaneous atrial arrhythmia and 17 a recurrence of stroke. If we consider the occurrence of the 28 combined events (atrial arrhythmia and/or stroke), it is not correlated with the presence of an atrial septal defect nor with the existence of an atrial vulnerability. On the contrary this occurrence is correlated with tobacco consumption and/or arterial hypertension; 82% of patients have these risk factors versus 54% of patients without events (p = 0.004). This association is not significant in patients younger than 55 years.

Lack of validity of a French adaptation of a scale measuring attitudes towards clinical practice guidelines

BACKGROUND

Valid instruments to measure practitioners' attitudes towards clinical practice guidelines need to be developed. However, few of the available instruments have been thoroughly validated.

OBJECTIVE

To adapt into French and to test the reliability and validity of a scale for measurement of attitudes towards guidelines developed by Elovainio et al.

METHODS

A 27-item scale (divided into six dimensions) measuring attitudes towards guidelines was translated into French by two English native translators, reviewed and finalized by expert committee and administered to 314 practitioners who agreed to participate. Main practitioners' characteristics were collected. Item and dimension reproducibility were assessed for 62 practitioners by calculation of intraclass correlation coefficients. Internal construct validity was assessed by principal components analyses. Convergent and discriminant validity were analysed.

RESULTS

Item response rates ranged from 82 to 100%. In the test-retest procedure, intraclass correlation coefficients for separate items ranged from 0.1 to 0.7 and those for dimensions were 0.7 [95% confidence interval (CI): 0.5-0.8] for usefulness, 0.5 (0.3-0.6) for reliability, 0.4 (0.2-0.5) for individual competence, 0.5 (0.3-0.6) for organizational competence, 0.7 (0.5-0.8) for impracticality and 0.4 (0.3-0.6) for availability. The factorial structure after Varimax rotation showed that none of the different solutions obtained had a strictly comparable structure to that of the original scale. External construct validity was satisfactory.

CONCLUSION

This scale does not have satisfactory psychometric properties and therefore cannot confidently be used in future research assessing whether attitudes towards guidelines are a determining factor in physicians' compliance with guidelines. More research is needed to develop valid scales in a more rigorous procedure, involving qualitative and quantitative steps.

Accident vasculaire cérébral ischémique et tenseur de diffusion

PURPOSE

Diffusion-weighted imaging (3 directions) and diffusion tensor imaging (9 directions) were compared for their sensitivity to detect ischemic lesion.

MATERIALS AND METHODS

41 patients (18 supposed transient ischemic attacks, 23 arterial stroke, MRI<or=48h) presenting with stroke syndrome were imaged using two diffusion sequences (3 directions, 2 excitations, acquisition time: 40 seconds and 9 directions, 1 excitation, acquisition time: 50 seconds, other parameters being identical). The following variables were compared (Wilcoxon test): number and extent of lesions, MRI signal and absolute ADC values, relative signal intensity and ADC ratio. Fractional anisotropy was measured within the principal lesion on the 9 directions sequence.

RESULTS

24 patients presented a lesion on both sequences. Four of them (including one TIA) had more lesions (<5 mm) on the 9 directions sequence than on the 3 directions sequence. Both sequences were normal for the 17 remaining patients (TIA=4, differential diagnosis=7, indeterminate=6). No significant difference was found for the other study parameters between 3 vs 9 directions sequences. There was a 10% decrease of the mean fractional anisotropy in ischemic lesion.

CONCLUSION

By showing more lesions than standard diffusion-weighted imaging and providing quantitative anisotropy measurements, diffusion tensor imaging could replace the standard 3 directions diffusion-weighted sequence.

Diffusion-weighted MR imaging in transient ischaemic attacks

The purpose of this study was to determine frequency and the characteristics of diffusion-weighted imaging (DWI) abnormalities in patients with transient ischaemic attack (TIA). We analysed data of 98 consecutive patients (mean age: 60.6+/-15.4 years, 56 men) admitted between January 2003 and April 2004 for TIA. Age, gender, symptom type and duration, delay from onset to magnetic resonance imaging (MRI), probable or possible TIA and cause of TIA were compared in patients with (DWI+) and without (DWI-) lesions on DWI. Volume and apparent diffusion coefficient (ADC) values of DWI lesions were computed. DWI revealed ischaemic lesions in 34 patients (34.7%). Lesions were small (mean volume: 1.9 cm(3)+/-3.3), and ADC was moderately decreased (mean ADC ratio: 79.5%). The diagnosis of TIA was considered as probable in all DWI+ patients. A multiple logistic regression model demonstrated that TIA duration greater than or equal to 60 min (OR, 7.6; 95% CI, 2.3-25.7), aphasia (OR, 9.2; 95% CI, 2.7-31.4) and motor deficit (OR, 5.1; 95% CI, 1.5-17.8) were independent predictors of DWI lesions. Prolonged TIA duration, aphasia and motor deficits are associated with DWI lesions. More than half of TIA patients with symptoms lasting more than 60 min have DWI lesions.

[Diagnosis and follow-up of cervical arterial dissections--results of the SFNV-SFNR study]

INTRODUCTION

the objective of this study was to determine the role of radiological techniques in the diagnosis, assessment of severity and follow-up of cervical arterial dissections.

MATERIAL AND METHODS

from 1995 to 2001 a multicentre retrospective study was conducted in 24 hospital centers. A multiple-choice questionnaire was sent to each center in order to collect clinical information and imaging details regarding the diagnosis and follow-up of cervical arterial dissections.

RESULTS

information was gathered on 459 patients, comprising a total of 384 carotid artery dissections and 170 vertebral artery dissections. A mean of 4.85 diagnostic examinations per patient were conducted. Morphological imaging of the brain by CT or by MRI was performed on all except 3 patients. Cervical Doppler ultrasound examination was the most frequently performed test throughout the entire study period (performed in 87% of patients). Conventional arteriography was a routinely employed test in 1995 whereas by 2001 it comprised only 31.2% of requested examinations, having been progressively replaced by MRI and MRA scanning, which comprised 60% of all examinations performed by 2001. A combination of cervical Doppler ultrasonography, axial MRI and MRA of the neck vessels were performed in 39.6% of patients in 2001. Examination of the intracranial vessels was performed by transcranial Doppler ultrasound in 40% of cases and by MRA in 30% of cases. For the follow-up of arterial dissections, an average of 1.4 examinations was performed per patient. The majority of such follow-up examinations comprised Doppler ultrasound and/or MRA of the neck arteries.

CONCLUSION

The imaging diagnosis and follow-up of cervical arterial dissections will increasingly rely on non-invasive imaging techniques.

[Risk factors management in 5708 ambulatory patients suffering from peripheral vascular disease followed in urban practices]

STUDY OBJECTIVE

we examined the management of risk factors in patients suffering from obliterating peripheral arterial disease (OPAD), in urban medical practice.

METHODS

PRISMA, ECLAT1 and APRES are surveys based on urban medicine in France. These 3 studies have allowed a compilation of data pertaining to the control of risk factors in patients suffering from one or more clinical manifestations of atherothrombosis, including cerebral vascular accident, coronary insufficiency or OPAD. The study population was divided among patients with isolated OPAD, versus OPAD associated with coronary artery disease (CAD), versus OPAD associated with cerebral vascular disease.

RESULTS

a total of 5 708 patients with stable OPAD were included among the 3 studies. Risk factors were not managed in the majority of patients, including 62.6% of hypercholesterolemic patients, 71.1% of diabetics, and 77.4% of hypertensive patients. Overall, the control of risk factors was less satisfactory in patients with OPAD than in patients with CAD. Smoking (70.6% current or past smokers) remains a major risk factor in OPAD. The proportion of current smokers was significantly higher is the group with isolated OPAD than in the other 2 groups of patients (p < 0.0001).

CONCLUSIONS

The control of risk factors in patients with OPAD is suboptimal, mainly because of failure to reach the therapeutic goals, rather than because of poor medical management. It is important that recent recommendations be implemented in medical practice. Awareness of the primary physicians will be key in the optimisation of treatment prescriptions and, above all, in the achievement of a higher level of clinical performance.

[Prevalence of asymptomatic atherothrombotic lesions and risk of vascular events in patients with a stroke]

OBJECTIVE

To estimate the prevalence of asymptomatic atherothrombotic lesions and the absolute risk of vascular events in patients with ischemic stroke.

METHODS

We conducted a systematic review of studies published between 1980 and 2004 which allowed calculating prevalence of asymptomatic lesions and absolute risks of vascular events in stroke patients. Studies included in the review of absolute risks had to include at least 100 patients followed for at least 1 year and with less than 5% of lost to follow-up.

RESULTS

Coronarography was used in only one study which does not provide any precise estimation of the prevalence of asymptomatic coronary lesions. Depending on the population and the method used for the diagnosis of coronary disease, the prevalence of asymptomatic coronary artery disease ranged from 25 through 60%. Very few studies have been devoted to the prevalence of abdominal aortic disease in stroke patients. The prevalence of abdominal aortic aneurysm has been estimated to 1% and that of peripheral arterial disease to 10%. Thirty-six cohorts were identified. The absolute risk of myocardial infarction was about 2%/year and that of vascular death 2%/year.

CONCLUSION

Stroke patients carry a high risk of coronary and vascular events. Additional studies are required to better identify patients with a high prevalence of asymptomatic atherosclerotic lesions and with a high risk of vascular events.

[Screening strategies for the diagnosis of asymptomatic arterial lesions in patients with atherothrombosis]

Atherosclerosis is a ubiquitous inflammatory disease. Patients presenting an acute atherothrombotic event (acute coronary syndrom, stroke, aortic aneurysm, ...) have an increased risk of events in remote arterial territories affected by atherosclerosis. These patients could benefit from systematic screening of asymptomatic atherosclerotic lesions to avoid these complications. For each atherosclerotic territory (coronary artery, carotid artery, aorta, peripheral arteries including renal arteries), we review the methods for screening asymptomatic atherothrombotic lesions which could justify specific treatments: coronary artery stenosis > or = 50%, carotid artery stenosis > or = 60%, renal artery stenosis > or = 50%, and abdominal aortic aneurysm > or = 30 mm. This review shows that non invasive methods (ie, echography, tomodensitometry) are widely available for diagnosis of asymptomatic lesions in carotid and renal arteries, and in the aorta. Despite its invasive caracteristic, coronarory angiography remains the gold-standard for the diagnosis of coronary artery disease. However, cardiac multi-slices CT-scan appears a promising technique for asymptomatic patients.

Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome

BACKGROUND

Most studies on spinal cord infarction have been conducted in single centres; they usually consisted of case reports, or of larger series of patients recruited over a large period of time, with heterogeneous diagnostic procedures. Therefore, the clinical and radiological presentation of spinal cord infarcts and their short term outcome remain poorly understood.

OBJECTIVE

To define clinical and magnetic resonance imaging (MRI) findings, and short term outcome in patients with spinal cord infarcts.

METHODS

The authors prospectively included patients within 10 days of onset. An MRI scan was required and repeated when initially normal.

RESULTS

Twenty eight consecutive patients were included over a 24 month period in 16 neurological centres. The infarct was cervical in seven patients, thoracic in three, thoracolumbar in 15, and restricted to the conus in three. On axial MRI scans the infarct was located in the central territory of the anterior spinal artery in 21 patients, and in the peripheral arterial territory in three. At month two, 15 patients had a good outcome and 13 had a poor outcome, including three deaths. Patients who, at onset, could not walk, had bladder dysfunction, or proprioceptive deficits were more likely to have a poor outcome. At month two, pain had occurred in 10 of the 25 survivors and was associated neither with the initial severity, nor the extent of the infarct on MRI.

CONCLUSION

The two month outcome mainly depends on the initial severity of the neurological deficit; however, a few patients with a severe impairment at onset had a good outcome, especially when proprioception remained normal at onset. The study does not support the hypothesis that pain occurs more frequently in small spinal infarcts.

Spectroscopy and serial diffusion MR findings in hGH-Creutzfeldt-Jakob disease

This report describes the magnetic resonance imaging (MRI) findings in two patients fulfilling the diagnostic criteria for human growth hormone Creutzfeldt-Jakob disease, who initially had pronounced bilateral DWI/FLAIR (diffusion weighted imaging/fluid attenuated inversion recovery) hyperintensities in the basal ganglia, with decreased apparent diffusion coefficient (ADC) values (range, 58-82% of normal). MRI spectroscopy, obtained in one case, showed decreased N-acetyl aspartate/creatine (NAA/Cr) ratio in the atrophic vermis (0.79; normal: mean, 1.20; SD, 0.13), despite the lack of DWI/FLAIR signal changes, whereas NAA/Cr was normal in the putamina (1.6; normal: mean, 1.56; SD, 0.17), despite striking DWI signal changes and decreased ADC values (60% of normal). Serial DWI, obtained in the other case, showed a progressive disappearance of DWI hypersignal of the basal ganglia replaced by pronounced atrophy. Data from these two patients suggest that restricted diffusion associated with a normal NAA value might indicate spongiform changes of still viable cells, and that any subsequent regression of the DWI signal changes, atrophy, or decreased NAA values could be related to progressive neuronal death.

Neuroimaging in posterior reversible encephalopathy syndrome

The terms posterior reversible leukoencephalopathy, reversible posterior cerebral edema syndrome, and posterior reversible encephalopathy syndrome (PRES) all refer to a clinicoradiologic entity characterized by headaches, confusion, visual disturbances, seizures, and posterior transient changes on neuroimaging. Clinical findings are not sufficiently specific to readily establish the diagnosis; in contrast, magnetic resonance imaging pattern is often characteristic and represents an essential component of the diagnosis of PRES. Typical lesions predominate in the posterior white matter, with some involvement of the overlying cortex; are hyperintense on T2-weighted images; and are usually hypointense or isointense on diffusion-weighted images, with an increase of the apparent diffusion coefficient, indicating vasogenic edema. The pathogenesis is incompletely understood, although it seems to be related to the breakthrough of autoregulation and endothelial dysfunction. Since its initial description, this syndrome has been subsequently described in an increasing number of medical conditions, including hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressive drugs. The diagnosis has important therapeutic and prognostic implications because the reversibility of the clinical and radiologic abnormalities is contingent on the prompt control of blood pressure and/or discontinuing the offending drug. On the contrary, when unrecognized, conversion to irreversible cytotoxic edema may occur.

Carotid Angioplasty and Stenting With and Without Cerebral Protection

Background and Purpose— Whether cerebral protection during carotid angioplasty and stenting (CAS) is associated with a lower risk of periprocedural stroke or death remains to be established. We report on 80 patients randomized in the CAS arm of the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis trial comparing CAS (with or without cerebral protection) with carotid surgery in patients with recently symptomatic, severe carotid stenosis.

Summary of Report— The Safety Committee recommended stopping unprotected CAS, because the 30-day rate of stroke was 3.9 (0.9 to 16.7) times higher than that of CAS with cerebral protection (4/15 versus 5/58).

Conclusion— Although this result was not based on a randomized comparison of unprotected versus protected CAS, it suggests that the use of cerebral protection devices during CAS reduces periprocedural strokes.

[Prevalence and management of patients with a prior history of atherothrombotic disease in primary care in France. Results of the ECLAT1 survey]

This cross-sectional study assessed the prevalence of subjects with a previous history of atherothrombotic disease (myocardial infarction, ischemic stroke and/or lower limb arterial disease) among patients treated in general medicine. A random sample of 3,009 French general practitioners was recruited. Patients who consulted one of these general practitioners on December 7th 2000 were included. Those with a previous history of atherothrombotic disease were identified and further data on their cardiovascular risk factors and drug use were collected. The prevalence of patients with a previous history of atherothrombotic disease was 2% [95% confidence interval: 1.9-2-1] in subjects younger than 65, 13.4% [12.7-14.2] between 65 and 74 and 17.0% [16.2-17.8] in subjects older than 74. Arterial hypertension was found in 62.2% of the patients with a previous history of atherothrombotic disease, overweight or obesity in 59.4%, hypercholesterolaemia in 55%, current or past smoking in 48.3%, and diabetes mellitus in 20.1%. The last blood pressure and LDL-cholesterol measurements were respectively higher than or equal to 140/90 mmHg and 3 mmol/l in 70.6% of the patients suffering from arterial hypertension (missing data in 2.2%) and in 48.2% of the patients suffering from hypercholesterolaemia (missing data in 31.4%). Atherothrombosis represents a significant part of the primary care activity in France. Despite a widespread antihypertensive and hypocholesterolaemic drug prescription, the control of cardiovascular risk factors is insufficient. The high prevalence of overweight may contribute to this poor control.

Early asymptomatic recurrence of cervical artery dissection: three cases

Cervical artery dissection (CAD) recurrences are rare but the risk could be higher during the first month. Twenty-seven consecutive patients admitted for an acute CAD were investigated using a standardized imaging protocol. An early asymptomatic recurrence was observed in three patients 49 to 53 days after the initial diagnosis. Anticoagulation was maintained and the prognosis remained good. Early CAD recurrences may have been underestimated previously, because asymptomatic recurrences seem to be more frequent than symptomatic ones.

Early and late seizures after cryptogenic ischemic stroke in young adults

OBJECTIVES

To assess the incidence and predictive factors of early and late seizures after ischemic stroke in young adults.

METHODS

A total of 581 patients (aged 18 to 55 years) with recent cryptogenic ischemic stroke were prospectively enrolled at 30 neurology departments and followed for 37.8 +/- 9.7 months. Early seizures (occurring within 7 days of stroke) were assessed by chart review and late seizures were prospectively recorded at each follow-up visit. Clinical and brain imaging findings were reviewed by two neurologists and two neuroradiologists who were blinded to the occurrence of seizures.

RESULTS

Fourteen of the 581 patients (2.4%) developed early seizures, 71% of which occurred within the first 24 hours. Rankin scale >or=3 (odds ratio [OR] 3.9, 95% CI 1.2 to 12.7) and cortical involvement (OR 7.7, 95% CI 1.0 to 61.1) were independently associated with early seizures. Late seizures occurred only in patients with hemispheric stroke (n = 20). The risk of first late seizure was 3.1% (95% CI 1.4 to 4.8) within 1 year and 5.5% (95% CI 3.1 to 7.9) within 3 years. The mean delay between stroke and first late seizure was 12.9 months (0.3 to 33.9). Late seizures were associated with early seizure (hazard ratio [HR] 5.1, 95% CI 1.8 to 14.8), cortical signs (HR 4.5, 95% CI 1.6 to 13.1), and size of infarct superior to one-half hemisphere (HR 9.7, 95% CI 3.1 to 30.8). Eleven of the 20 patients with late seizure experienced recurrences (multiple in eight) on antiepileptic drug treatment. Most of them were seizure free at the end of the follow-up.

CONCLUSION

Epilepsy is rarely a major problem in young cryptogenic ischemic stroke survivors. Early seizures are associated with stroke disability and cortical involvement. Early seizures, cortical signs, and large infarct are independent risk factors for late seizures.

[Antithrombotic therapy for ischemic cerebrovascular accident]

Antithrombotic therapy should be considered in the acute phase of an ischaemic stroke in patients who are not candidates for thrombolysis. The recommended treatment is aspirin, 160 or 300 mg daily, associated in bed-ridden patients with prophylactic heparin therapy to avoid venous thromboembolic complications. Although not founded on scientific proof, high dose anticoagulants may be used instead of aspirin in special cases presumed to be at high risk of early recurrence of embolism or of extension of thrombosis. Secondary prevention in patients who have already suffered a non-embolic ischaemic stroke is based mainly on antiplatelet drugs. Aspirin, clopidogrel or the association of aspirin and dipyridamole are possible first the options. Ticlopidine is not recommended as treatment of first intention because of its secondary effects and the necessity of monitoring the blood count. Oral anticoagulants are not recommended after a non-cardio-embolic ischaemic stroke except in special cases (e.g. deficit in inhibitors of blood clotting). Secondary prevention in patients at high cardio-embolic risk (e.g. atrial fibrillation) should be based on oral anticoagulants. Cardiac disease carrying a low or uncertain risk (e.g. patent foramen ovale without an atrial septal aneurysm) is usually treated with platelet inhibitors.

Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystonia

OBJECTIVES

Botulinum toxin type A is a potent neuromuscular paralyzing agent used in various disorders including cervical dystonia. Two preparations of botulinum toxin are now commercially available ( Dysport and Botox), but much controversy remains about their respective potencies. The aim of the study was to compare the efficacy of Botox with two different ratios of Dysport.

METHODS

A double blind, randomised, three period cross over study involving 54 patients with cervical dystonia was performed. The patients received the following treatments in a randomised order: Botox at the usually effective dose, Dysport at a dose of 1:3 (conversion factor of 3 between Botox and Dysport units-that is, one Botox unit=three Dysport units) and at a dose of 1:4 (conversion factor of four). The improvement of the Tsui (primary outcome criteria) and of the TWSTRS pain scales between baseline and a control visit 1 month after each of the three injections, as well as the incidence of adverse events, were assessed.

RESULTS

Comparison of the Tsui scores and of the TWSTRS pain scores showed a better effect on impairment and pain with Dysport 1:3 (p=0.02 and 0.04, respectively) and 1:4 (p=0.01 and 0.02, respectively) than with Botox. The number of adverse events was higher with both Dysport treatments. The most frequent adverse event was dysphagia, found in 3%, 15.6%, and 17.3% (Botox, Dysport 1:3 and 1:4, respectively) of the patients. No adverse event required withdrawal of therapy or specific management.

CONCLUSIONS

Dysport 1:3 (and Dysport 1:4 to a greater extent) is more efficient than Botox for both impairment and pain in cervical dystonia although with a somewhat higher incidence of minor adverse effects. This strongly suggests that the most appropriate conversion factor between Botox and Dysport units is less than 3 in cervical dystonia.

Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm

BACKGROUND AND PURPOSE

Patent foramen ovale (PFO) has been identified as a potential risk factor for stroke, but the mechanisms of PFO-associated stroke remain unsettled. The aim of our study was to evaluate possible differences in stroke risk factors and stroke patterns between patients with and without PFO that may give clues to the mechanism of PFO-associated stroke.

METHODS

This prospective, multicentric study involved 581 young cryptogenic stroke patients. The presence of PFO and atrial septal aneurysm was assessed by transesophageal echocardiography and reviewed independently by 2 experienced sonographers. Clinical, brain, and vascular imaging findings were reviewed by 2 neurologists and 2 neuroradiologists.

RESULTS

Of the 581 stroke patients, 267 (45.9%) had PFO. Patients with PFO were younger (OR, 0.95; 95% CI, 0.93 to 0.97) and less likely to have traditional risk factors such as hypertension (OR, 0.49; 95% CI, 0.28 to 0.85), hypercholesterolemia (OR, 0.56; 95% CI, 0.34 to 0.93), or current smoking (OR, 0.67; 95% CI, 0.47 to 0.97). Features suggestive of paradoxical embolism, such as Valsalva-provoking activities or deep vein thrombosis, were not more frequent in patients with PFO. Migraine was more common in patients with PFO (27.3%) than in those without PFO (14.0%). PFO (OR, 1.75; 95% CI, 1.08 to 2.82), particularly when associated with atrial septal aneurysm (OR, 2.71; 95% CI, 1.36 to 5.41), was significantly associated with migraine after adjustment for age and sex.

CONCLUSIONS

Differences in stroke risk factors and stroke patterns suggest that different stroke mechanisms occur in patients with and without PFO. PFO is significantly and independently associated with migraine, and this association is even stronger in patients with PFO and atrial septal aneurysm.

Anticoagulant (fluindione)-aspirin combination in patients with high-risk atrial fibrillation. A randomized trial (Fluindione, Fibrillation Auriculaire, Aspirin et Contraste Spontané; FFAACS)

BACKGROUND

A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation.

OBJECTIVE

Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin (100 mg) in patients with high-risk atrial fibrillation.

METHODS

A multicenter, placebo-controlled, double-blind, randomized trial was conducted at 49 investigating centers in France. Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension, a recent episode of heart failure or decreased left ventricular function were included in the study. Patients were treated with fluindione plus placebo (i.e. anticoagulant alone) or fluindione plus aspirin (i.e. combination therapy), with an international normalized ratio target of between 2 and 2.6. The combined primary endpoint was stroke (ischemic or hemorrhagic), myocardial infarction, systemic arterial emboli or vascular death. The secondary endpoint was the incidence of hemorrhagic complications.

RESULTS

The 157 participants (average age 74 years; 52% women; 42% with paroxysmal atrial fibrillation) were followed for an average of 0.84 years. Three nonfatal thromboembolic events were observed (1 in the anticoagulation group, 2 in the combination group) and 6 patients died (3 in the anticoagulation group, 3 in the combination group), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe hemorrhagic complications (1 in the anticoagulation group, 2 in the combination group). Nonfatal hemorrhagic complications occurred more often in the combination group (n = 10, 13.1%) compared to the anticoagulation group (n = 1, 1.2%) (p = 0.003).

CONCLUSION

The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients. The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events.

Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both

BACKGROUND

Patent foramen ovale and atrial septal aneurysm have been identified as potential risk factors for stroke, but information about their effect on the risk of recurrent stroke is limited. We studied the risks of recurrent cerebrovascular events associated with these cardiac abnormalities.

METHODS

A total of 581 patients (age, 18 to 55 years) who had had an ischemic stroke of unknown origin within the preceding three months were consecutively enrolled at 30 neurology departments. All patients received aspirin (300 mg per day) for secondary prevention.

RESULTS

After four years, the risk of recurrent stroke was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent) among the patients with patent foramen ovale alone, 15.2 percent (95 percent confidence interval, 1.8 to 28.6 percent) among the patients with both patent foramen ovale and atrial septal aneurysm, and 4.2 percent (95 percent confidence interval, 1.8 to 6.6 percent) among the patients with neither of these cardiac abnormalities. There were no recurrences among the patients with an atrial septal aneurysm alone. The presence of both cardiac abnormalities was a significant predictor of an increased risk of recurrent stroke (hazard ratio for the comparison with the absence of these abnormalities, 4.17; 95 percent confidence interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether small or large, was not.

CONCLUSIONS

Patients with both patent foramen ovale and atrial septal aneurysm who have had a stroke constitute a subgroup at substantial risk for recurrent stroke, and preventive strategies other than aspirin should be considered.

Is patent foramen ovale a family trait? A transcranial Doppler sonographic study

BACKGROUND AND PURPOSE

Patent foramen ovale (PFO) is a frequent finding in young patients with stroke. The aim of this study was to assess whether PFO is a family trait.

METHODS

Sixty-two consecutive patients younger than 60 years of age with ischemic stroke and 62 age and gender-matched control siblings were examined by means of contrast transcranial Doppler (TCD) of the middle cerebral artery, using a standardized protocol. The reliability of TCD examination in our laboratory was assessed against transesophageal echocardiography (TEE). All TCD recordings were reviewed by a blinded experienced observer from another center. Disagreements between readers were resolved by unblinded consensus review.

RESULTS

Siblings of patients with PFO had a significantly higher prevalence of PFO than had siblings of patients without PFO (61.5% versus 30.6%; OR 3.64 [1.3 to 10.5]; P=0.015). The kappa statistics indicated that agreement of pairs (patients/control siblings) was not due to chance. The strength of the association was sex dependent. In women pairs, prevalence of a PFO was 76.5% in siblings of patients with PFO and 25% in siblings of patients without PFO, giving an OR of 9.8 (95% CI 2 to 47.9; P<0.01). In contrast, in men, no significant difference was observed in the prevalence of PFO between siblings of patients with or without PFO (respectively 33.3% and 35%), giving an OR of 0.9 (95% CI 0.2 to 4.9; P=0.9).

CONCLUSIONS

This study suggests that, in women, PFO is a family trait.

[Reversible posterior leukoencephalopathy. A new syndrome or a new name for an old syndrome?]

DEFINITION

Reversible posterior leucoencephalopathy syndrome is a recently proposed cliniconeuroradiologic category characterized by seizures, disorders of consciousness, visual abnormalities and headaches associated with predominantly posterior white matter abnormalities on CT and MRI examinations.

MECHANISMS AND CAUSES

Since the initial description, reversible posterior leucoencephalopathy has been recognized in an increasing number of medical conditions, including hypertensive encephalopathy, eclampsia, and immunosuppressive treatment. The rapid resolution of clinical and neuroradiologic abnormalities suggests cerebral edema which is thought to result from impaired cerebrovascular autoregulation and endothelial injury.

PROGNOSIS

Whereas reversibility of the posterior leucoencephalopathy is a characteristic of the disorder, this reversibility is contingent on prompt controlling blood pressure and discontinuing the offending immunosuppressive drug.

Aneurysmal forms of cervical artery dissection : associated factors and outcome

BACKGROUND AND PURPOSE

The natural history of aneurysmal forms of cervical artery dissection (CAD) is ill defined. The aims of this study were to assess (1) clinical and anatomic outcome of aneurysmal forms of extracranial internal carotid artery (ICA) and vertebral artery (VA) dissections and (2) factors associated with aneurysmal forms of CAD.

METHODS

Seventy-one consecutive patients with CAD were reviewed. Aneurysmal forms of CAD were identified from all available angiograms by 2 neuroradiologists. The frequency of arterial risk factors, of multiple vessel dissections, and of artery redundancies was compared in patients with and without aneurysm. Patients with aneurysm were invited by mail to undergo a final clinical and radiological evaluation.

RESULTS

Of the 71 patients, 35 (49.3%) had a total of 42 aneurysms. Thirty aneurysms were located on a symptomatic artery (ICA, 23; VA, 7) and 12 on an asymptomatic artery (ICA, 10; VA, 2). Patients with aneurysm had multiple dissections of cervical vessels (18/35 versus 7/36; P:=0.005) and arterial redundancies (20/35 versus 11/36; P:=0.02) more frequently than patients without aneurysm. They were also more often migrainous (odds ratio=2.7 [95% CI, 0.8 to 8.5]) and tobacco users (odds ratio=2.2 [95% CI, 0.7 to 6.3]). Clinical and anatomic follow-up information was available for 35 (100%) and 33 patients (94%), respectively. During a mean follow-up of >3 years, no patient had signs of cerebral ischemia, local compression, or rupture. At follow-up, 46% of the aneurysms involving symptomatic ICA were unchanged, 36% had disappeared, and 18% had decreased in size. Resolution was more common for VA than for ICA aneurysms (83% versus 36%). None of the aneurysms located on an asymptomatic ICA had disappeared.

CONCLUSIONS

Although aneurysms due to CAD frequently persist, patients carry a very low risk of clinical complications. This favorable clinical outcome should be kept in mind before potential harmful treatment is contemplated.

[Study of combined anticoagulant (fluindione)-aspirin therapy in patients with atrial fibrillation at high risk for thromboembolic complications. A randomized trial (FFAACS)]

BACKGROUND

A combination of low-dose aspirin (A) and anticoagulation (AC) may provide better protection against thromboembolic events compared with AC alone in high-risk patients with atrial fibrillation (AF).

METHODS

We performed a multicentric placebo-controlled double blind-trial to test the preventive efficacy against thromboembolic events of the addition of aspirin (A) (100 mg) or placebo (P) to anticoagulant treatment in patients with high-risk atrial fibrillation. A total of 157 patients were included, with atrial fibrillation and previous thromboembolic event or older than 65 years with either a history of hypertension, a recent episode of heart failure or a left ventricular dysfunction. All patients received fluindione (F) and P or F and A, with an INR target between 2 and 2.6. The primary endpoint was a combined endpoint of stroke (ischaemic or haemorrhagic), myocardial infarction, systemic arterial emboli or vascular death.

RESULTS

The study had to be stopped prematurely owing to a too low recruitment rate. During follow-up (0.84 years) 3 non-fatal thromboembolic events were recorded (1P, 2A) and 6 patients died (3P, 3A), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe haemorrhagic complications (1P, 2A). Non-fatal haemorrhagic complications occurred more often in group A (n = 10, 13.1 pour cent) compared with group P (n = 1, 1.2 pour cent), p = 0.003.

CONCLUSION

The FFAACS study was not able to show any therapeutic benefit from the addition of aspirin to anticoagulant in patients with high-risk AF. Such a combination increased the incidence rate of bleeding complications, which therefore greatly reduces its potential overall benefit.

Ischemic stroke in young women: risk of recurrence during subsequent pregnancies. French Study Group on Stroke in Pregnancy

OBJECTIVE

To assess whether subsequent pregnancies increase the risk of recurrent stroke and whether the occurrence of an ischemic stroke affects reproductive history.

METHODS

The authors identified 489 consecutive women aged 15 to 40 years with a first-ever arterial ischemic stroke or cerebral venous thrombosis from the record system of nine French neurologic centers. Information on stroke recurrence and reproductive history was obtained by means of chart review, written questionnaire, and telephone interview.

RESULTS

Data were analyzed from 441 women (373 with arterial ischemic stroke and 68 with cerebral venous thrombosis). During a mean follow-up of 5 years, 13 arterial recurrent ischemic strokes occurred. There were no cases of recurrent cerebral venous thrombosis. The overall risk of recurrence was 1% within 1 year and 2.3% within 5 years. The risk of recurrence was significantly higher in patients with stroke of definite cause. Eleven recurrent strokes occurred outside pregnancy (absolute risk of recurrence = 0.5%; 95% CI 0.3, 0.95) and two during pregnancy or the puerperium (absolute risk of recurrence = 1. 8%; 95% CI 0.5, 7.5). The relative risk of recurrence was significantly higher during the postpartum period (risk ratio = 9.7; 95% CI 1.2, 78.9) than during pregnancy (risk ratio = 2.2; 95% CI 0. 3, 17.5) itself. The outcome of the 187 subsequent pregnancies was similar to that expected from the general population. Thirty-four percent of women indicated that they would have desired more pregnancies after their initial stroke. The main reasons for not considering pregnancy were concern of a recurrent stroke, medical advice against pregnancy, and residual handicap.

CONCLUSION

Young women with a history of ischemic stroke have a low risk of recurrence during subsequent pregnancies. The postpartum period, not the pregnancy itself, is associated with an increased risk of recurrent stroke. The outcome of pregnancies in these women appears to be similar to that expected in the general population. A previous ischemic stroke is not a contraindication to a subsequent pregnancy.

Stroke and atrial fibrillation: is stroke prevention treatment appropriate beforehand? SAFE I Study Investigators

OBJECTIVE

To undertake a pilot study before conducting a large European multicentre prospective study, to determine the proportion of patients with atrial fibrillation who were not receiving antithrombotic treatment before stroke onset, and their characteristics.

DESIGN AND PATIENTS

The stroke in atrial fibrillation ensemble (SAFE) I study was an observational study conducted in 213 patients with atrial fibrillation consecutively admitted in 1997 to three European centres for an acute stroke or transient ischaemic attack (TIA). It was determined whether they were receiving prior antithrombotic treatment.

RESULTS

Atrial fibrillation was known before stroke in 148 patients (69.5%). Of 213 patients, 34 (16.0%) were receiving anticoagulation treatment before stroke, but only six had an international normalised ratio between 2. 0 and 3.5; 65 (30.5%) were receiving antiplatelet treatment; and three (1.4%) were receiving both anticoagulation and antiplatelet treatment. Of 137 patients eligible for oral anticoagulation, 108 (78.8%) did not receive treatment. Of 142 patients eligible for any antithrombotic treatment, 62 (43.7%) were not treated. The logistic regression analysis, assuming anticoagulation treatment as a dependent variable, found digoxin treatment, absence of arterial hypertension, mitral stenosis, and cardioversion as independent factors. Assuming any antithrombotic treatment as a dependent variable, previously known atrial fibrillation, lower age, being a non-smoker, and absence of arterial hypertension were found to be independent factors.

CONCLUSION

More than half of the patients with atrial fibrillation admitted for acute stroke or TIA were not receiving any antithrombotic treatment beforehand. New onset atrial fibrillation and contraindications account for a minority of non-prescriptions; thus, other reasons should be identified to improve stroke prevention in the community.

[Cardiopathies associated with a low embolic risk]

Advances in cardiac imaging techniques have resulted in the recognition of several potential cardioembolic sources (such as patent foramen ovale, atrial septal aneurysm, strands, mitral valve prolapse), but it is often not clear whether the findings, which often have a substantial prevalence in patients without stroke, are merely an associated abnormality or a direct cause of the stroke. Overall, these cardiopathies are associated with a low risk of stroke. Studies are needed to better define the risk and mechanisms of stroke associated with these cardiac abnormalities, to determine which patients are at increased risk of stroke and to assess the potential benefits from therapeutic interventions. Unless we can define strict indications for therapeutic interventions, we risk ending up with exposing some patients to unnecessary complications of treatment.

Angiitis of the central nervous system

Angiitis of the central nervous system is a rare disease which may result from numerous causes responsible for the presence of inflammatory lesions of the vascular wall. These inflammatory lesions may sometimes be associated with necrosis. Cerebral vessels of all sizes may be involved. The clinical presentation is highly variable, with focal to diffuse manifestations and acute to chronic evolution. Angiography is the cornerstone diagnostic procedure, showing multiple segmental stenoses of the cerebral arteries sometimes separated by fusiform dilatations. Although suggestive, this angiographical pattern is not unequivocal and other causes must be carefully ruled out. Only cerebral and/or leptomeningeal biopsy can provide a definite diagnosis of cerebral angiitis but this invasive diagnostic procedure is not performed in the majority of cases. Among the numerous causes of cerebral angiitis, one can individualize infectious diseases, primary systemic angiitis with cerebral involvement, angiitis secondary to various systemic diseases and other miscellaneous causes such as drug abuse or neoplasm.