High efficiency and clinical relevance of exome sequencing in the daily practice of neurogenetics

OBJECTIVE

To assess the efficiency and relevance of clinical exome sequencing (cES) as a first-tier or second-tier test for the diagnosis of progressive neurological disorders in the daily practice of Neurology and Genetic Departments.

METHODS

Sixty-seven probands with various progressive neurological disorders (cerebellar ataxias, neuromuscular disorders, spastic paraplegias, movement disorders and individuals with complex phenotypes labelled 'other') were recruited over a 4-year period regardless of their age, gender, familial history and clinical framework. Individuals could have had prior genetic tests as long as it was not cES. cES was performed in a proband-only (60/67) or trio (7/67) strategy depending on available samples and was analysed with an in-house pipeline including software for CNV and mitochondrial-DNA variant detection.

RESULTS

In 29/67 individuals, cES identified clearly pathogenic variants leading to a 43% positive yield. When performed as a first-tier test, cES identified pathogenic variants for 53% of individuals (10/19). Difficult cases were solved including double diagnoses within a kindred or identification of a neurodegeneration with brain iron accumulation in a patient with encephalopathy of suspected mitochondrial origin.

CONCLUSION

This study shows that cES is a powerful tool for the daily practice of neurogenetics offering an efficient (43%) and appropriate approach for clinically and genetically complex and heterogeneous disorders.

Incidence of Acute Ischemic Stroke With Visible Arterial Occlusion

Background and Purpose:

Because of several methodological limitations, previous studies focusing on the prevalence of large vessel occlusion in ischemic stroke (IS) patients provided conflicting results. We evaluated the incidence of IS with a visible arterial occlusion using a comprehensive population-based registry.

Methods:

Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013–2017). All arterial imaging exams were reviewed to assess arterial occlusion. Annual incidence rates of IS (first-ever and recurrent events) and IS with a visible occlusion were calculated.

Results:

One thousand sixty cases of IS were recorded (mean age: 76.0±15.8 years, 53.9% women). Information about arterial imaging was available in 971 (91.6%) of them, and only preexisting dementia was independently associated with having missing information (odds ratio=0.34 [95% CI, 0.18–0.65], P =0.001). Among these patients, 284 (29.2%) had a visible arterial occlusion. Occlusion site was the anterior circulation in 226 patients (23.3% of overall patients with available data) and the posterior circulation in 58 patients (6.0%). A proximal occlusion of the anterior circulation was observed in 167 patients (17.2%). The crude annual incidence rate of total IS per 100 000 was 138 (95% CI, 129–146). Corresponding standardized rates were 66 (95% CI, 50–82) to the World Health Organization and 141 (95% CI, 118–164) to the 2013 European populations. The crude annual incidence rate of IS with a visible arterial occlusion per 100 000 was 37 (95% CI, 33–41) and that of IS with a proximal occlusion of the anterior circulation was 22 (95% CI, 18–25). Corresponding standardized rates were 18 (95% CI, 10–26) and 10 (95% CI, 8–13) to the World Health Organization population, and 38 (95% CI, 26–50) and 23 (95% CI, 19–26) to the 2013 European population, respectively.

Conclusions:

These results will be helpful to plan the need for thrombectomy-capable stroke center resources.

Association Between Fatigue and Cognitive Impairment at 6 Months in Patients With Ischemic Stroke Treated With Acute Revascularization Therapy

Background: Fatigue is a frequent symptom after stroke. We aimed to determine the association between fatigue and cognitive performance in patients with ischemic stroke who received acute revascularization therapy (IV thrombolysis and/or mechanical thrombectomy). Methods: Seventy patients were prospectively included in the stroke unit of the University Hospital of Dijon, France. A follow-up was performed at 6 months with clinical examination, fatigue assessment by the Fatigue Severity Scale (FSS), and a comprehensive neuropsychological evaluation. Patients with fatigue (FSS score >4) were compared with patients without fatigue. Neuropsychological factors associated with fatigue at 6 months were analyzed using multivariable logistic regression models. Results: Fatigue was reported by 34.3% of patients. Patients with fatigue were older, had more frequent residual handicap, depressive symptoms, and impaired quality of life. They had more frequently low score (<26) on the MoCA scale (79.2 vs. 47.8%, OR = 4.15; 95% CI: 1.32-13, p = 0.015), memory impairment (60 vs. 30.6%, OR = 3.41; 95% CI: 1.09-10.7, p = 0.035), and executive dysfunction (65 vs. 30.8%, OR = 4.18; 95% CI: 1.33-13.1, p = 0.014). In multivariable logistic regression analysis, only memory impairment was independently associated with fatigue (OR = 5.70; 95% CI: 1.09-29.6, p = 0.039). Further analyses restricted to non-depressed patients (n = 58, 84.1%) showed in multivariable models that a score < 26 on MoCA scale (OR 5.12; 95% CI: 1.00-26.2, p = 0.05), and a memory impairment (OR = 6.17; 95% CI: 1.06-35.9, p = 0.043) were associated with fatigue. There was also a non-significant trend toward an association between divided attention deficit and fatigue (OR = 6.79; 95% CI: 0.80-57.6, p = 0.079). Conclusion: The association between fatigue and subtle cognitive impairment including memory or attention deficits could be of interest in elaborating future interventional studies to evaluate the impact of therapeutic strategies, including cognitive rehabilitation, on fatigue.

Increasing early ambulation disability in spontaneous intracerebral hemorrhage survivors

Objective

To evaluate temporal trends in early ambulatory status in patients with spontaneous intracerebral hemorrhage (ICH).

Methods

All patients with ICH between 1985 and 2011 were prospectively registered in a population-based registry in Dijon, France, and included in the study. Outcomes of ICH survivors were assessed at discharge from their stay in an acute care ward with the use of a 4-grade ambulation scale. Time trends in ambulation disability and place of discharge were analyzed in 3 periods (1985–1993, 1994–2002, and 2003–2011). Multivariable ordinal and logistic regression models were applied.

Results

Five hundred thirty-one patients with ICH were registered, of whom 200 (37.7%) died in the acute care ward. While the proportion of deaths decreased over time, that of patients with ambulation disability increased (odds ratio [OR] 1.67, 95% confidence interval [CI] 0.87–3.23, p = 0.124 for 1994–2002; and OR 1.97, 95% CI, 1.08–3.60, p = 0.027 for 2003–2011 vs 1985–1993 in ordinal logistic regression). The proportion of patients dependent in walking rose (OR 2.11, 95% CI 1.16–3.82, p = 0.014 for 1994–2002; and OR 2.73; 95% CI 1.54–4.84, p = 0.001 for 2003–2011), and the proportion of patients discharged to home decreased (OR 0.49, 95% CI 0.24–0.99, p = 0.048 for 1994–2002; and OR 0.32, 95% CI 0.16–0.64, p = 0.001 for 2003–2011).

Conclusion

The decrease in in-hospital mortality of patients with ICH translated into a rising proportion of patients with ambulation disability at discharge. A lower proportion of patients returned home. These results have major implications for the organization of postacute ICH care.

Temporal trends in early case-fatality rates in patients with intracerebral hemorrhage

Objective:

To assess whether temporal trends in very early (within 48 hours) case-fatality rates may differ from those occurring between 48 hours and 30 days in patients with spontaneous intracerebral hemorrhage (ICH).

Methods:

All cases of ICH that occurred in Dijon, France (151,000 inhabitants), were prospectively collected between 1985 and 2011, using a population-based registry. Time trends in 30-day case fatality were analyzed in 3 periods: 1985–1993, 1994–2002, and 2003–2011. Cox regression models were used to evaluate associations between time periods and case fatality within 48 hours and between 48 hours and 30 days, after adjustments for demographics, risk factors, severity, and ICH location.

Results:

A total of 531 ICH cases were recorded (mean age 72.9 ± 15.8, 52.7% women). Thirty-day case fatality gradually decreased with time from 40.9% in 1985–1993 to 33.5% 1994–2002 and to 29.6% in 2003–2011 (adjusted hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.47–1.07, p = 0.106, for 1994–2002, and adjusted HR 0.49, 95% CI 0.32–0.73, p < 0.001, for 2003–2011). Over the whole study period, 43.6% of 1-month deaths occurred within the first 48 hours following ICH onset. There was no temporal change in case fatality occurring within the first 48 hours but a decrease in deaths occurring between 48 hours and 30 days was observed with time (HR 0.53, 95% CI 0.31–0.90, p = 0.02, for 1994–2002, and HR 0.32, 95% CI 0.32–0.55, p < 0.01, for 2003–2011, compared with 1985–1993).

Conclusion:

Although 30-day case fatality significantly decreased over the last 27 years, additional improvements in acute management of ICH are needed since very early case-fatality rates (within 48 hours) did not improve.

Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke

BACKGROUND

Several trials and meta-analyses have recently demonstrated the superiority of endovascular therapy over standard medical treatment in patients presenting with acute ischemic stroke. In order to offer the best possible treatment to a maximum number of patients, many stroke care networks probably have to be reorganized. After analyzing the reliability of data in the literature, an algorithm is suggested for a pre-hospital and in-hospital alert system to improve the timeliness of subsequent treatment: a drip-and-ship approach.

SUMMARY

Five recent well-designed randomized studies have demonstrated the benefit of endovascular therapy associated with intravenous fibrinolysis by recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke with confirmation by recent meta-analyses. The keys for success are a very short time to reperfusion, within 6 h, a moderate to severe pre-treatment deficit (National Institute of Health around 17), cerebral imaging able to identify proximal large vessel occlusion in the anterior circulation, a limited infarct core and a reversible penumbra, the use of the most recent devices (stent retriever) and a procedure that avoids general anesthesia, which reduces blood pressure. To meet these goals, every country must build a national stroke infrastructure plan to offer the best possible treatment to all patients eligible for intravenous fibrinolysis and endovascular therapy. The plan may include the following actions: inform the population about the first symptoms of stroke, provide the call number to improve the timeliness of treatment, increase the number of comprehensive stroke centers, link these to secondary and primary stroke centers by telemedicine, teach and train paramedics, emergency doctors and radiologists to identify the stroke infarct, proximal large vessel occlusion and the infarct core quickly, train a new generation of endovascular radiologists to improve access to this therapy.

KEY MESSAGE

After 20 years of rt-PA, this new evidence-based therapy is a revolution in stroke medicine that will benefit patients. However, a new robust and multi-disciplinary care strategy is necessary to transfer the scientific data into clinical practice. It will require reorganization of the stroke infrastructure, which will include comprehensive stroke centers and secondary and primary stroke centers. The winners will be patients with severe stroke.

Post-stroke cognitive impairment: high prevalence and determining factors in a cohort of mild stroke

BACKGROUND

Because of the aging population and a rise in the number of stroke survivors, the prevalence of post-stroke cognitive impairment (PSCI) is increasing.

OBJECTIVE

To identify the factors associated with 3-month PSCI.

METHODS

All consecutive stroke patients without pre-stroke dementia, mild cognitive disorders, or severe aphasia hospitalized in the Neurology Department of Dijon, University Hospital, France (November 2010 - February 2012) were included in this prospective cohort study. Demographics, vascular risk factors, and stroke data were collected. A first cognitive evaluation was performed during the hospitalization using the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MOCA). Patients assessable at 3 months were categorized as cognitively impaired if the MMSE score was ≤26/30 and MOCA <26/30 or if the neuropsychological battery confirmed PSCI when the MMSE and MOCA were discordant. Multivariable logistic models were used to determine factors associated with 3-month PSCI.

RESULTS

Among the 280 patients included, 220 were assessable at 3 months. The overall frequency of 3-month PSCI was 47.3%, whereas that of dementia was 7.7%. In multivariable analyses, 3-month PSCI was associated with age, low education level, a history of diabetes mellitus, acute confusion, silent infarcts, and functional handicap at discharge. MMSE and MOCA scores during hospitalization were associated with 3-month PSCI (OR = 0.63; 95% CI: 0.54-0.74; p < 0.0001 and OR = 0.67; 95% CI: 0.59-0.76; p < 0.0001, respectively).

CONCLUSION

Our study underlines the high frequency of PSCI in a cohort of mild stroke. The early cognitive diagnosis of stroke patients could be useful by helping physicians to identify those at a high risk of developing PSCI.

Trends in the incidence of ischaemic stroke in young adults between 1985 and 2011: the Dijon Stroke Registry

BACKGROUND

Recent data have suggested that stroke incidence in young people may be rising. In this population-based study, we aimed to determine whether the incidence of stroke in people aged <55 years old had changed over the last three decades.

METHODS

All cases of first-ever stroke (ischaemic stroke, spontaneous intracerebral haemorrhage, and undetermined stroke) occurring in Dijon, France, from 1985 to 2011 were prospectively collected from a population-based registry. Incidence rates were calculated and temporal trends were analysed by age groups and stroke subtypes using a Poisson regression to estimate incidence rate ratios (IRR). Risk factors and premorbid treatments were analysed.

RESULTS

Over the 27-year study period, 4506 patients were recorded (53% women, mean age 74.6±14.4, 10.1% aged <55 years). An increase in overall stroke incidence was noted, as was a rise in ischaemic stroke in individuals aged <55 years (IRR 1.308; 95% CI 0.982 to 1.741, p=0.066 for period 1994-2002 vs period 1985-1993, and IRR 1.697; 95% CI 1.340 to 2.150, p<0.001 for period 2003-2011 vs period 1994-2002), which was consistent for men and women. In these young patients, smoking was the most frequent risk factor (43%).

CONCLUSIONS

Multiple factors may account for the increased incidence of ischaemic stroke in people aged <55 years including changes in vascular risk factors, better awareness of the disease and treatment options in the population and among practitioners leading to more frequent referrals for specialised care, and improvements in stroke diagnosis. Stroke prevention must be encouraged even in young adults.

Secondary prevention in patients with vascular disease. A population based study on the underuse of recommended medications

OBJECTIVES

To investigate the premorbid use of secondary prevention medications in patients with recurrent vascular events.

DESIGN

Prospective, observational, population based study.

SETTING

The Dijon Stroke Registry and the registry of myocardial infarction of Dijon and Côte d'Or, France.

PATIENTS

All patients with cerebral ischaemia (ischaemic stroke or transient ischaemic attacks) or coronary artery disease (CAD) and a history of vascular disease (cerebral ischaemia, CAD or peripheral arterial disease (PAD)) in Dijon, France from 2006 to 2010.

MAIN OUTCOME MEASURES

Data on medical history and prior use of treatments were collected. Mutivariate analyses were performed to identify predictors of the use of medications.

RESULTS

867 patients (614 cerebral ischaemia and 253 CAD) were recorded including 448 (51.7%) with a history of cerebral ischaemia only, 191 (22.0%) with a history of CAD only, 68 (7.8%) with a history of PAD only and 160 (18.5%) with a history of polyvascular disease. In these 867 patients, 57.3% were on antithrombotic therapy, 61.2% were treated with antihypertensive drugs, 32.9% received statins and only 23.6% were on an optimal regimen, defined as a combination of the three therapies. Compared with patients with previous CAD only, those with previous cerebral ischaemia only were less likely to be receiving each of these treatments or to receive an optimal regimen (OR=0.17, 95% CI 0.14 to 0.26, p<0.001).

CONCLUSIONS

Our findings underline the fact that the underuse of secondary preventive therapies is common in patients with recurrent vascular events, especially those with previous cerebral ischaemia. This underuse could be targeted to reduce recurrent vascular events.

Prestroke antiplatelet therapy and early prognosis in stroke patients: the Dijon Stroke Registry

BACKGROUND AND PURPOSE

Previous antiplatelet therapy (APT) in cardiovascular prevention is common in patients with first-ever stroke. We aimed to evaluate the prognostic value of APT on early outcome in stroke patients.

METHODS

All first-ever strokes from 1985 to 2011 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, prestroke treatments and clinical information were recorded. Multivariate analyses were performed to evaluate the associations between pre-admission APT and both severe handicap at discharge, and mortality at 1 month and 1 year.

RESULTS

Among the 4275 patients, 870 (20.4%) were previously treated with APT. Severe handicap at discharge was noted in 233 (26.8%) APT users and in 974 (28.7%) non-users. Prestroke APT use was associated with lower odds of severe handicap at discharge [adjusted odds ratio (OR): 0.79; 95% confidence interval (CI): 063-1.00; P = 0.046], non-significant better survival at 1 month [adjusted hazard ratio (HR): 0.87; 95% CI: 0.70-1.09; P = 0.222] and no effect on 1-year mortality (HR: 0.94; 95% CI 0.80-1.10; P = 0.429). In stratum-specific analyses, APT was associated with a lower risk of 1-month mortality in patients with cardioembolic ischaemic stroke (HR: 0.65; 95% CI: 0.43-0.98; P = 0.040).

CONCLUSIONS

APT before stroke was associated with less severe handicap at discharge, with no significant protective effect for mortality at 1 month except in patients with cardioembolic stroke. No protective effect of APT was observed for mortality at 1 year. Further studies are needed to understand the mechanisms underlying the distinct effects of prior APT observed across the ischaemic stroke subtypes.

Diagnostic procedures in ischaemic stroke patients with dementia. a population-based study

BACKGROUND

Dementia is a frequent condition in stroke patients.

AIMS

To investigate the effect of dementia on access to diagnostic procedures in ischaemic stroke patients.

METHODS

All cases of ischaemic stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Patients' characteristics were recorded, as was the use of brain computed tomography scans, brain magnetic resonance imaging, electrocardiogram, echocardiography, and Doppler ultrasonography of the cervical arteries. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Logistic regression models were used to evaluate the associations between dementia and the use of the diagnostic procedures.

RESULTS

Of the 907 patients recorded, 104 were excluded because of death and inability to test cognition. Among the remaining 803 patients, 149 (18·5%) had dementia. Almost all of the patients underwent a brain computed tomography scan and an electrocardiogram during their stay. In contrast, the use of both Doppler ultrasonography of the cervical arteries (79·2% versus 90·2%, P < 0·001), echocardiography (32·9% versus 43·6%, P = 0·02), and brain magnetic resonance imaging (21·5% versus 34·4%, P < 0·001) were significantly lower in stroke patients with dementia than in those without. In multivariate logistic regression, dementia was associated with a lower use of both Doppler ultrasonography (odds ratio = 0·49; 95% confidence interval: 0·29-0·81, P = 0·005), echocardiography (odds ratio = 0·57; 95% confidence interval: 0·37-0·89, P = 0·012), brain magnetic resonance imaging (odds ratio = 0·55; 95% confidence interval: 0·34-0·89, P = 0·015), and a comprehensive assessment (odds ratio = 0·62; 95% confidence interval: 0·40-0·96, P = 0·033).

CONCLUSION

Demented patients were less likely to undergo diagnostic procedures after ischaemic stroke. Further studies are needed to determine whether this lower utilization could account for the reported excess in recurrent events in these patients.

[Epidemiology of stroke in the elderly : "the silver tsunami"]

Stroke in the elderly has more major differences compared to young people. The first cause remains the atherothrombosis disease associated to the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption. Lipohyalinosis of perforating arteries linked to blood hypertension inducing lacunar infarcts and atrial fibrillation are the 2nd and 3rd causes linked to age. The increase of the ageing population explains the rise of the number of stroke over 80 years. On a clinical point of view, the pseudo-bulbar syndrome is very frequent and explains the swallowing troubles and incontinence. Prognosis is characterized by a high risk of dementia (20 %). Primary and secondary prevention is very effective even in very old patients, on the risk of stroke. Fibrinolysis and stroke units have demonstrated their efficacy in stroke treatments over 80 years. We observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke of 5 years in men and 8 years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention. The elderly may be more often included in therapeutic trials.

The deleterious effect of admission hyperglycemia on survival and functional outcome in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

We aimed to evaluate the association between blood glucose (BG) levels at admission and both functional outcome at discharge and 1-month mortality after intracerebral hemorrhage (ICH).

METHODS

All cases of first-ever ICH were identified from the population-based Stroke Registry of Dijon, France from 1985 to 2009. Clinical and radiological information was recorded. BG was measured at admission. Multivariate analyses were performed using logistic and Cox regression models. Multiple imputation was used as a sensitivity analysis.

RESULTS

We recorded 465 first-ever ICH. BG at admission was obtained in 416 patients (89.5%) with a median value of 6.92 mmol/L. In multivariate analyses, BG in the highest tertile (≥8.6 mmol/L) was an independent predictor of functional handicap (odds ratio, 2.51; 95% CI, 1.43-4.40; P=0.01) and 1-month mortality (hazard ratio, 2.51; 95% CI, 1.23-2.43; P=0.002). The results were consistent with those obtained from multiple imputation analyses.

CONCLUSIONS

Admission hyperglycemia is associated with poor functional recovery at discharge and 1-month mortality after ICH. These results suggest a need for trials that evaluate strategies to lower BG in acute ICH.

Influence of prior transient ischaemic attack on stroke prognosis

BACKGROUND

To evaluate potential neuroprotection afforded by prior transient ischaemic attack (TIA) on functional and survival outcomes after ischaemic stroke.

METHODS

All cases of first-ever ischaemic strokes, diagnosed between 1985 and 2008, were identified from the Dijon Stroke Registry. Patients were analysed in three groups according to the time interval between prior TIA and stroke (<4 weeks, ≥ 4 weeks, no TIA) or the duration of TIA (≤ 30 min, >30 min, no TIA). Outcomes were severe functional handicap (unable to walk, bedridden or death) at hospital discharge or at outpatient consultation, and 1-month and 1-year any-cause mortality. Stratified analyses were performed by stroke subtypes (non-lacunar, lacunar). Generalised linear mixed models and Cox proportional hazard models with a sandwich covariance matrix accounting for the treatment centre as a random effect were used for multivariate analyses.

RESULTS

Among the 3015 patients with first-ever ischaemic stroke, 389 had had a prestroke TIA <4 weeks and 97 a prestroke TIA ≥ 4 weeks. Patients with TIAs had better ambulatory status (adjusted OR 0.61, 95% CI 0.45 to 0.81; p = 0.008) and better survival at 1 month (adjusted HR 0.76, 95% CI 0.65 to 0.89; p = 0.0006) and at 1 year (adjusted HR 0.72, 95% CI 0.67 to 0.76; p<0.0001) than those with no TIAs. Prestroke TIA <4 weeks and TIA duration ≤ 30 min also significantly improved the outcomes in overall, non-lacunar and lacunar strokes.

CONCLUSIONS

Recent prestroke TIA was associated with better functional outcome and lower 1-month and 1-year mortality after stroke, suggesting a neuroprotective effect.

Trends in Case-Fatality Rates in Hospitalized Nontraumatic Subarachnoid Hemorrhage: Results of a Population-Based Study in Dijon, France, From 1985 to 2006

BACKGROUND

Subarachnoid hemorrhage accounts for 2% to 5% of all strokes and is associated with high morbidity and mortality rates. Reports in the literature show that case-fatality rates vary with time and according to geographical area.

OBJECTIVE

The objective of the study was to evaluate the case-fatality rates in subarachnoid hemorrhage at 1 and 6 months and to determine trends in these rates over 22 years using a population-based registry.

METHODS

The Dijon Stroke Registry has enabled us to perform a comprehensive analysis of subarachnoid hemorrhage diagnosed in a population of &gt;150 000 inhabitants hospitalized between 1985 and 2006 in the Dijon University Hospital, which has both a neurosurgery unit and a neuroradiology unit. Diagnosis was based on clinical and neuroimaging features and, when necessary, on lumbar puncture.

RESULTS

Case-fatality rates for hospitalized subarachnoid hemorrhages at 1 and 6 months were 15.59% (95% confidence interval [CI], 9.37–25.34) and 16.84% (95% CI, 10.33–26.78), respectively. From 1985 to 1995, case-fatality rates for SAH at 1 and 6 months were 17.1% (95% CI, 8.1–34.2) and 17.7% (95% CI, 9.6–31.3), whereas from 1996 to 2006, they were 20.2% (95% CI, 10.2–37.8) and 19.7% (95% CI, 11.1–33.6), respectively.

CONCLUSION

Case-fatality rates for hospitalized subarachnoid hemorrhages in this population-based study remained stable over 22 years, suggesting that this stroke subtype is still a very severe disease despite early management. Most deaths occurred during the first 30 days. Further work is necessary to evaluate levels of prehospital case-fatality in our population-based registry.

Changes in risk factors and preventive treatments by stroke subtypes over 20 years: a population-based study

In order to evaluate progress in preventive therapeutic strategies, and to identify potential targets for improvement, it is essential to assess changes in the risk factors and preventive treatment of stroke over time. All of the strokes occurring within the population of Dijon, France (150,000 inhabitants), were prospectively ascertained from 1985 to 2004. Changes in stroke risk factors and preventive medications were analyzed by stroke subtypes. We recorded 725 lacunar infarcts (LI), 497 cardioembolic (CE) strokes, 2054 ischemic stroke from atheroma of large arteries or from other and undetermined causes (OIS), and 341 primary cerebral haemorrhages (PCH). Over the 20years, the prevalence of hypercholesterolemia increased whatever the stroke subtype (p<0.01) whereas that of diabetes only rose in LI and OIS stroke. The proportion of stroke patients on antiplatelet agents increased overall (p<0.01) and the proportion of patients on anticoagulants rose in CE stroke (p=0.01) and PCH (p<0.01). The proportion of patients on antihypertensive treatment only increased in CE stroke (p=0.01). The risk factor profile and the preventive treatments in stroke patients showed divergent variations over the 20years, according to the stroke subtype considered. These modifications certainly reflect changes in the therapeutic strategies for the preventive management of the population at risk.

[Stroke in elderly: what have we learned from stroke epidemiology in younger people]

Stroke in the elderly has more major differences compared to young people: it is the first complication of atherothrombosis disease associated with the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption and sleep apnea syndrome; AVC is the first consequence of atrial fibrillation; from a clinical point of view, seizure at the onset of the stroke is more frequent; prognosis is characterized by a high risk of dementia (20%); primary and secondary prevention is very efficacious even in very old patients, not only on the risk of stroke, but also on the risk of dementia; time trends at Dijon show a slight decrease of incidence rates of stroke only over 85 years, while prevention of stroke has taken advantage of real progress in precocious diagnosis and innovative treatments. In contrast, we observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke, reaching five years in men and eight years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention.

Trends in Incidence, Risk Factors, and Survival in Symptomatic Lacunar Stroke in Dijon, France, From 1989 to 2006

Background and Purpose— Lacunar infarcts are usually regarded as benign stroke, but population-based studies are required to assess the exact place of this stroke subtype in cerebrovascular pathology.

Methods— We evaluated trends in incidence rates, risk factor profiles, and survival rates in symptomatic lacunar stroke from a prospective population-based registry from 1989 to 2006.

Results— We recorded 2536 ischemic strokes. Among these, 715 (28%) were lacunar infarcts (354 men and 361 women). From 1989 to 2006, we observed a significant rise in the incidence of lacunar stroke in the 2 sexes considered together (relative risk, 1.02; 95% CI, 1.005 to 1.035; P =0.007), whereas the variation was not significant in either men or women when considered separately. Incidence rates significantly increased in young patients under 65 years old (relative risk, 1.049; 95% CI, 1.0175 to 1.0817; P =0.002). Concerning the distribution of cerebrovascular risk factors, lacunar stroke differed from nonlacunar stroke only with regard to the lower prevalence of a history of atrial fibrillation in the former ( P <0.001). For lacunar infarcts, survival rates were 96% at 1 month (95% CI, 0.94 to 0.97), 86% at 1 year (95% CI, 0.83 to 0.89), and 78% at 2 years (95% CI, 0.75 to 0.81) and were significantly higher than those for nonlacunar stroke (hazard ratio, 2.05; 95% CI, 1.70 to 2.47; P <0.001).

Conclusion— Our results suggest a significant increase in the incidence rates of lacunar stroke with a relatively good short-term prognosis in terms of survival. The association among hypertension, diabetes mellitus, and lacunar stroke was no stronger than the association between these 2 risk factors and nonlacunar stroke.

Épidémiologie des accidents vasculaires cérébraux

The development of several population stroke registries has improved our knowledge of the epidemiology of strokes, their natural history, and their trends over time and place. In Europe, stroke incidence decreases from east to west and from north to south. Incidence and mortality have also been decreasing regularly over time. The diagnostic tools created with the arrival of computed tomography (CT), magnetic resonance imaging (MRI), and other forms of vascular and cardiac imaging have improved the identification of risk factors for stroke according to its mechanism--hemorrhagic or ischemic--and according to the subtype of ischemic stroke. Hypertension is the leading risk factor for both ischemic and hemorrhagic strokes. New independent stroke risk factors have been confirmed, including elevated cholesterol and homocysteine levels. The regular decline of the incidence of some types of stroke and of mortality is partly due to the positive effects of prevention and confirms the usefulness of screening and early treatment of stroke risk factors. Development of new treatments during the acute phase and in the field of primary and secondary stroke prevention (such as statins) is necessary to improve prognosis, which remains too serious, especially in women.

Dépression après un accident vasculaire cérébral, un handicap supplémentaire

INTRODUCTION

Post-stroke depression is a severe complication affecting 30-50% of patients during the first year. Experienced medical and paramedical staff in stroke units, using validated scales, can now identify initial signs of depression in the first days after stroke onset.

METHODS

This review of the literature is based on a Medline search for the terms stroke, depression, and epidemiology. It discusses problems of pathophysiology, diagnosis, prognosis, and therapeutics.

RESULTS

Depression is an emergency in stroke patients because it impedes rehabilitation and family and social insertion. Early diagnosis is difficult, but possible with clinical somatic and cognitive symptoms. Post-stroke depression may also be a marker of pending cognitive decline. Management requires both antidepressants and psychotherapy.

CONCLUSION

There is a pressing need for further research to improve clinical practice in this area of stroke care.

Trends in the Incidence of Transient Ischemic Attacks, Premorbid Risk Factors and the Use of Preventive Treatments in the Population of Dijon, France from 1985 to 2004

BACKGROUND

We describe the epidemiological trends of transient ischemic attack (TIA) in a 20-year population-based pilot study.

METHODS

Trends in the incidence, risk factors and pre-TIA use of preventive treatments for TIA were observed from 1985 to 2004 according to the classic definition in the population of the city of Dijon, France (150,000 inhabitants).

RESULTS

The raw and standardized incidence of TIA were stable over time. We observed a significant increase in the mean age at TIA onset in women only. The prevalence of hypercholesterolemia and diastolic blood pressure > or =90 mm Hg among patients with TIA increased significantly. This contrasts with falls in smoking and in history of previous myocardial infarction.

CONCLUSION

The stability of classic TIA incidence, despite the rise in the proportion of elderly people, and the increase in the mean age at onset in women may be considered as a medical progress.

Apport de l’évaluation écologique des troubles exécutifs dans la sclérose en plaques

INTRODUCTION

Multiple sclerosis (MS) is a major cause of neurological disability among young adults. The cognitive disorders are the second cause of alteration of quality of life after physical handicap and are often responsible for loss of social-occupational adaptability. The prevalence of cognitive disorders is 40 to 65%. The alteration of executive functions predominates whereas instrumental functions are generally preserved. The assessment of these disorders is often underestimated by the usual battery of neuropsychological tests. However, the link between psychometric results and executive difficulties of daily life is uncertain.

OBJECTIVES

To evaluate the sensitivity of an ecological test compared to standard psychometric tests in assessment of executive disorders in MS.

METHODS

Twenty subjects with clinically definite MS were matched for age, sex and pre-morbid intellectual level with control subjects. A battery of neuropsychological and ecological tests was applied to all subjects. The performances on these tests formed a global score of executive function (SFE). The "paper and pencil" multiple errands test was used as the ecological test to examine planning and goal-oriented behavior. We also assessed fatigue and depression with the Fatigue Severity Scale and the Beck Depression Inventory.

RESULTS

There was no significant differences between MS patients and controls in neuropsychological executive tests, except for verbal fluencies (p=0.01). The performances were significantly decreased in the MS group for the multiple errands test (p=0.01). 75% of MS subjects have a pathological score for this test. There was a significant link between the performances with this test and SFE (p=0.009).

CONCLUSIONS

Executive disorders are underestimated in MS. However, we suggest that an ecological approach is more reliable than standard neuropsychological tests to estimate the cognitive difficulties in daily life in MS subjects. The results of our study favor further research to ascertain the usefulness of ecological assessment in MS.

Consultation après un infarctus ou un hématome cérébral

Hypertension is the principal risk factor for cerebral infarctions and intracerebral hematoma. The brain is the principal target of hypertension. The brain is the principal target of antihypertensive drugs. Controlling blood pressure and stopping smoking reduces the risk of cerebral infarction by 40%. Objectives of a consultation after cerebral infarction or intracerebral hematoma: validate diagnosis and cause, identify risk factors for recurrent cerebral infarction but also for myocardial infarction and lower limb arterial disease, begin treatment of the risk factors for recurrence, begin prevention of atherothrombotic complications and embolic heart disease, identify complications of cerebral infarction and intracerebral hematoma.

[Specificity of stroke in the elderly: clinical characteristics and impact on care]

Stroke in the elderly differs from stroke in younger adults in several points. It represents the most frequent consequence of atherothrombotic disease associated with hypertension, diabetes and hypercholesterolemia. It is also the main complication of cardiac arrhythmia. From a clinical point of view, epileptic seizure is frequently observed at the onset, and prognosis is darkened by a high risk of dementia occurrence (20%). Management of stroke in acute phase requires intensive care, which has been shown to decrease mortality and handicap by 20% in Stroke Units. Fibrinolysis with rt-PA can be carried out till 80 years. Primary and secondary prevention are still very efficacious in old patients and decrease not only the risk of stroke, but also the risk of dementia. Moreover, influenzae vaccination has been shown to decrease the risk of stroke in the following year in subjects over 65 years.

[Evaluation of care given by nurses during the acute stage of stroke]

INTRODUCTION

We report the results of a one-day survey of nursing care load in University Hospitals (UH), General Hospitals (GH) and Stroke Units (SU) regarding the acute stage of stroke.

METHODS

The type of care and the time devoted to care were compared by type of stroke (transient ischemic attack, ischemic stroke, hemorrhagic stroke, cerebral thrombophlebitis, sub-arachnoid hemorrhage), and degree of handicap (Barthel score).

RESULTS

Twenty-two hospitals (13 UH and 9 GH) participated in the study and provided care for 328 stroke victims (30 transient ischemic attacks, 247 ischemic strokes, 36 hemorrhagic strokes, 3 cerebral thrombophlebitis events and 11 strokes of unknown mechanism). Care was given in UHs for 63 percent of the patients and in GHs for 37 percent; in SUs for 40 percent (132 patients) and general neurology units for 60 percent (196 patients). Care involved physiotherapy for 70 percent, speech therapy for 42 percent, and care for cognitive decline for 36 percent. Mean time spent by nurses and nursing assistants peaked in the morning with a significant time not devoted to care. More than 3 hours of nurse care per day of care was significantly more frequent in SUs (p<0.001) and in GHs (p=0.02) for patients with Barthel score<40 or hemorrhagic stroke, irrespective of age. Patients older than 80 years, with a Barthel score<40, with hemorrhagic stroke, and who were admitted more than 15 days before the survey required more than two hours per day of nursing assistant care significantly more often. The probability of more than three hours per day of nurse care for stroke increased 2.8-fold for hemorrhagic stroke, 6.0-fold for Barthel Score<40, and 2.0-fold for care in a GH. The probability of more than two hours per day of nurse assistant care for stroke increased 3.0-fold for hemorrhagic stroke, 6.1-fold for Barthel score<40, 2.0-fold for patients older than 70 years, and 1.5-fold for stroke onset more than 14 days before the survey.

CONCLUSION

This survey enabled calculating the number of care givers required for 10 patients: 6 nurses and 5 nursing assistants, a level in line with recommended practices. These results emphasize the important role of nursing care for stroke victims, and points out that the type of hospital, the type of stroke, and the patient's age and degree of handicap have an effect on nursing load. This one-day survey enabled calculation of the number of nurses and nursing assistants needed for a 10-patient unit.

[Alien hand syndrome due to a corpus callosum infarct: a case report]

A 64-year-old man with alien hand syndrome presented with abnormal feelings in the left upper limb, associated with an intermanual conflict. There were no clinical signs of frontal or parietal apraxia. This syndrome was induced by an infarct localized in the right posterior area of the splenium, subsequent to a cardiogenic embolus. This observation enlightens the rising syndrome of callosal type alien syndrome due to a posterior callosal infarct.

Trends in utilization of antithrombotic therapy in patients with atrial fibrillation before stroke onset in a community-based study, from 1985 through 1997. From scientific evidence to practice

BACKGROUND

Despite the significant beneficial effects of antithrombotic therapy in primary prevention of stroke in patients with chronic nonvalvular atrial arrhythmia, this prevention therapy is underutilized. We conducted this population-based study to determine the rates and the trends of utilization of antithrombotic therapy for stroke patients with atrial fibrillation before stroke onset, and to evaluate indirectly the impact of medical recommendations on physician practice. Our aim was not to evaluate the efficacy of such prevention therapy.

METHODS

From 2,330 men and women of any age registered for a first-ever stroke from 1985 to 1997 in a community-based study, we selected 599 patients admitted for ischemic stroke or TIA, associated with prior atrial fibrillation. Previous antithrombotic treatment before stroke onset was recorded and we evaluated the ratio of stroke patients who had received antithrombotic treatment for atrial fibrillation, from 1985 through 1997.

RESULTS

Our study was performed to evaluate the practice of physicians in the prevention of stroke, and not to evaluate the efficacy of the anticoagulants in the prevention of stroke. Atrial fibrillation before stroke onset was identified in 599 patients. Of these, 222 (37%) received no antithrombotic therapy, 65 (10.8%) received an anticoagulant alone, 147 (24.5%) received an antiplatelet agent alone and 10 (1.7%) received both anticoagulation and antiplatelet treatment. From 1985 to 1988, the proportion of treated atrial fibrillation before stroke was small (14.6%). This increased to 21.5% within the period 1989-1991, to 40.3% within the period 1992-1994 and then to 47.6% within the period 1995-1997. It appears that the most significant change occurred within the period 1992-1994 (14.6% of treated atrial fibrillation within the period 1985-1987 constituted to 40.3% within the period 1992-1994) (P < 0.05), with a current rate of utilization of antithrombotic therapy close to 50%. The logistic regression analysis concerning anticoagulant therapy before stroke onset as a dependent variable, found that the factors independently associated with the use of anticoagulants before stroke were the lack of arterial hypertension and a history of smoking. The factors independently associated with the use of aspirin before stroke were arterial hypertension and lower limb peripheral vascular disease.

CONCLUSION

For primary prevention of stroke onset in patients with atrial fibrillation, therapeutic trials have changed medical practices although not to ideal levels because close to 50% of patients with atrial fibrillation experiencing an acute stroke or TIA received antithrombotic treatment. Therefore, clinical practice is inconsistent with the guidelines resulting from therapeutic trials. It is necessary to know the reasons for this inconsistency and to improve medical information about the cerebrovascular risk of atrial fibrillation and the efficacy of anticoagulants in stroke prevention in this condition.