Congenital vertebral duplication: a predisposing risk factor for dissection.

Spontaneous cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults. While their pathophysiology remains still poorly understood, CAD is considered today as a multifactorial disease determined by general and local predisposing factors; these predisposing factors being predominantly constitutional abnormalities of the arterial wall. Here, we report an MRI-confirmed dissection of a duplicated vertebral artery, in a patient with attacks of vertigo due to cerebellar infarction following a minor neck trauma. Knowing that another case of vertebrobasilar CAD on a duplicated vertebral artery has been reported, these rare anatomical variants probably predispose to vertebral CAD, via local histological defects or significant hemodynamics alterations, as reported for the classical local predisposing conditions for vertebral dissection, i.e.: fibromuscular dysplasias or carotid redundancies (including loops, kinks and coils).

[Atrial fibrillation in an acute stroke unit]. / La fibrillation atriale en unité de soins intensifs neuro- vasculaire (USINV).

Contrasting with the abundant literature dedicated to atrial fibrillation (AF) and to the use of new oral anticoagulants in this setting, very few recent studies have focused on patients with AF-associated stroke. From November 2010 to March 2011, we conducted a small prospective 4-month study in the stroke units of Lariboisière and Bicêtre hospitals. Fifty patients with FA and stroke were included (14% of all strokes), including 45 patients with cerebral infarcts (CI), 3 with transient ischemic attacks (TIA) and 2 with intracerebral hemorrhage (ICH). The results of this study, together with a review of the sparse relevant literature, underline the following points: these patients tend to be older and more frequently female than in recent clinical trials; TIAs are rare; these patients have numerous vascular risk factors and associated cerebrovascular diseases such as atheroma and leukoaraiosis; CI is often extensive and hemorrhagic; AF is discovered in a stroke unit in 40% of cases and is paroxystic in 33% of cases, with no consensus on the potential regulation; there is massive underuse of VKA in patients with known AF; rtPA intravenous thrombolysis is frequent; treatment difficulties arise in patients with AF-related CI and a history of ICH; the prognosis of VKA-related ICH is poor; the use of oral anticoagulants alone or combined with aspirin is controversial in case of AF associated with severe atheroma. Patients with AF seen in stroke units are therefore very different from those seen by cardiologists: they are older and have many vascular risk factors, stroke, and other cerebrovascular lesions, raising difficult treatment issues owing to the dual risk of embolic recurrence and symptomatic hemorrhagic transformation. In addition, contraindications to long-term VKA use are frequent. Many of these issues will again be raised with the arrival of new oral anticoagulants.