Cerebrovascular events during pregnancy and puerperium.

Though cerebrovascular complications of pregnancy remain relatively rare, they represent a potentially devastating event that necessitates prompt identification and treatment. Eighteen percent of strokes occurring in young women are linked to pregnancy. They occur mostly in the third trimester or during the post-partum period. Their biggest risk factors are hypertension, preeclampsia/eclampsia and migraine. Cerebrovascular events occurring during this period may involve specific pathophysiological processes that include embolic phenomena or endothelial dysfunction, but can also have common etiologies that are simply favored by the context of pregnancy. Thus, posterior encephalopathy and vasoconstriction cerebral syndrome are relatively frequently involved in cerebrovascular complications of pregnancy. Other very specific causes like amniotic fluid embolism or postpartum cardiomyopathy can also be responsible for such events. The management of stroke during pregnancy must be multidisciplinary and include a neurovascular expertise. Some conditions can lead to a long-life follow-up and modify the management of a future pregnancy.

Early neurological deterioration following thrombolysis for minor stroke with isolated internal carotid artery occlusion.

BACKGROUND AND PURPOSE: Better understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions. METHODS: From a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no-END patients were compared for (i) pre-treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow-up imaging. RESULTS: Seventy-four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre-treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3-12.2; P = 0.015). On follow-up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no-END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no-END, END was strongly associated with a poor 3-month outcome. CONCLUSIONS: Early neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site-largely a function of underlying stroke etiology-may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting.

Cerebral venous thrombosis at high altitude: A systematic review.

BACKGROUND AND OBJECTIVE: High altitude may be a factor associated with cerebral venous thrombosis (CVT). As our knowledge of CVT at high altitude is limited, it was decided to pool such information from the available case studies to determine whether high altitude can predispose to CVT. METHODS: A systematic review of the literature was performed for cases reporting CVT at high altitude. Searches of the PubMed database (up to July 2016) were performed for publications, using 'cerebral venous thrombosis' and 'high altitude' as keywords. Cross-referencing was also done to complete the search. RESULTS: Ultimately, 13 articles were included in our systematic review. The population consisted of 17 patients, predominately male (14/17), with a mean age of 32 (range: 19-47) years. Altitude range was 3000-8200m. Nine patients stayed at high altitude for>2 weeks; the duration of high altitude stay was unknown for the remainder. A hypercoagulable state was found in nine patients: secondary polycythemia in five; protein C deficiency in one; protein S deficiency in one; and factor V Leiden mutations in two. No comorbidities were found in any of these patients. CONCLUSION: Long-term stays at high altitude in association with a hypercoagulable state - in particular, congenital or acquired thrombophilia - appears to predispose to CVT. The association of CVT with a single exposure to high altitude seems low, but the risk cannot as yet be specifically estimated.

Triage practices in stroke units: Physicians' perceptions and ethical issues.

OBJECTIVE: We aimed to explore acute stroke admission decisions and to discuss ethical issues in triage practices in stroke units (SUs) in France. METHODS: In this study, 337 questionnaires were sent to physicians involved in acute admission to SUs in Île-de-France (neurologists and physicians from emergency medical services). The questionnaires comprised questions about physicians' perceptions of the reasonable allocation of SU beds and admission criteria for patients in SU in clinical vignettes illustrating complex situations. RESULTS: In total, 162 questionnaires were fully completed. There were some discrepancies in perceptions and reporting practices between emergency physicians and neurologists concerning patient admission criteria. Triage choices were more frequently declared by emergency physicians than by neurologists and were related to the difficulty of obtaining a positive response for the admission of certain complex patients (particularly those with comorbidities). CONCLUSIONS: Despite recommendations stating that all patients with stroke should be admitted to SUs, this study has shown that triage practices exist in stroke admission decisions. The triage depends on the role and perceptions of each physician in acute stroke management. These decisions suggest reflections on the applicability of distributive justice theories and on ethical issues in triage practices in medicine.

Acute headache at emergency department: reversible cerebral vasoconstriction syndrome complicated by subarachnoid haemorrhage and cerebral infarction.

Introduction. Reversible cerebral vasoconstriction syndrome is becoming widely accepted as a rare cause of both ischemic and haemorrhagic stroke and should be evocated in case of thunderclap headaches associated with stroke. We present the case of a patient with ischemic stroke associated with cortical subarachnoid haemorrhage (cSAH) and reversible diffuse arteries narrowing, leading to the diagnosis of reversible vasoconstriction syndrome. Case Report. A 48-year-old woman came to the emergency department because of an unusual thunderclap headache. The computed tomography of the brain completed by CT-angiography was unremarkable. Eleven days later, she was readmitted because of a left hemianopsia. One day after her admission, she developed a sudden left hemiparesis. The brain MRI showed ischemic lesions in the right frontal and occipital lobe and diffuse cSAH. The angiography showed vasoconstriction of the right anterior cerebral artery and stenosis of both middle cerebral arteries. Nimodipine treatment was initiated and vasoconstriction completely regressed on day 16 after the first headache. Conclusion. Our case shows a severe reversible cerebral vasoconstriction syndrome where both haemorrhagic and ischemic complications were present at the same time. The history we reported shows that reversible cerebral vasoconstriction syndrome is still underrecognized, in particular in general emergency departments.

[Contribution of arterial spin labeling to the diagnosis of sudden and transient neurological deficit]. / Apport de la séquence de marquage des spins artériels (ASL) devant un déficit neurologique brutal et transitoire.

MRI is the gold standard exploration for sudden transient neurological events. If diffusion MRI is negative, there may be a diagnostic doubt between transient ischemic attack and other causes of transient neurological deficit. We illustrate how sequence arterial spin labeling (ASL), which evaluates cerebral perfusion, contributes to the exploration of transient neurological events. An ASL sequence was performed in seven patients with a normal diffusion MRI explored for a transient deficit. Cortical hyperperfusion not systematized to an arterial territory was found in three and hypoperfusion systematized to an arterial territory in four. ASL helped guide early management of these patients.

Cerebral abscess due to an abnormal drainage of the superior vena cava.

INTRODUCTION: Causes of brain abscesses are multiple and often unclear. We present the case of a pregnant woman who developed a temporal brain abscess revealed by an epileptic seizure. OBSERVATION: Perfusion lung scan was performed because she had a mild hypoxemia: absence of contrast into the pulmonary arteries was suggestive of a massive intracardiac shunt or an anomalous drainage of the superior vena cava. Contrast-enhanced echography showed an abnormal drainage of the superior vena cava into the left atrium. CONCLUSION: Although rare, this anomaly can exist in adults. This report emphasizes the necessity of effective cardiologic investigations in case of unexplained brain abscess.

[Right subphrenic abscess and bronchial fistula from late trans-diaphragmatic migration of a postoperative abdominal foreign body.(author's transl)]. / Abcés inter-hépato-diaphramatique avec fistule bronchique par migration tardive trans-diaphragmatique d'un corps étranger abdominal post-opératoire.

Late trans-diaphragmatic migration of a postoperative abdominal foreign body followed a left hepatectomy for injury. Operative treatment, by means of the low posterior thoracic approach consisted of partial resection of the right inferior lobe with immediate closure of the diaphragm and subphrenic drainage. The natural history of the course taken by this abdominal foreign body is used as a basis for discussing diagnostic and therapeutic factors, particularly the surgical route of approach.