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Early Management of Stroke in France

Early Management of Stroke in France. Yves ALIMI Marseille - France. France: Annual incidence: 2 / 1000 pers., Mean age : 71 yrs (men) – 77 ( women ),. 140 000 stroke/ year  . Death : 15 – 20 %, . Funct . disorders : 75 %.

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Early Management of Stroke in France

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  1. Early Management of Strokein France Yves ALIMI Marseille - France

  2. France:Annual incidence: 2 / 1000 pers., Meanage: 71 yrs (men) – 77 (women), 140 000 stroke/year . Death: 15 – 20 %, . Funct. disorders: 75 %

  3. 2007, Lancet Rothwell

  4. Phone Call for a Stroke • Phone contact with the • Neuro Vascular Unit • atH2 • Medical transfert by helicopter

  5. Centre 15 Emergency department Neurovascular Unit Physiotherapy Orthophony Neuroradiology Cardiology Neurosurgery VascularSurgery Intensive care unit Rehabilitation Centres

  6. Emergent Management – NV. UnitTime < 3h : Thrombolytic Conditions Direct reception in the MRI room, Strict supine position, BP Control, Physical exam & neurological score: NIHSS, initial evaluation SUNV : simplified score fromNIHSS MRI: diffusion/perfusion, Flair, T2*, TOF MRI angiography

  7. Emergent Management – NV. UnitTime < 3h : Thrombolytic Conditions Immediate IV Thrombolysisif indicate, Cerebral TDM & AngioTDM of SupraAotrunks, after: Repermeation of intracranialvessels, Analysis of encephalicextracranialvessels.

  8. Strict supine position, BP Control, Cerebral TDM & Angio-TDM of SAoTrunks, IV Heparin & Aspirin, Physical exam & neurological score: SUNV : simplified score fromNIHSS Emergent Management – NV. UnitTime > 3h

  9. penumbra 24h CT-SCAN Stroke & Right Sylvian A Thrombosis INITIAL MRI AFTER THROMBOLYSIS

  10. The Prospective Study (2005) Between: - the neuro-vascular unit, - the department of vascularsurgery Goal: To Evaluate the results of earlycarotidsurgeryafter IV thombolysis in elected patients.

  11. Initial OperativeCriteria • Stable neurologicstatus, • 2. completerecanalization of intra cerebralvessels, • 3. No intra cerebralbleeding or oedema, • 4. Stroke involving < 1/3 sylvienarteryterritory,

  12. Results: 2005 => 2012 420 consecutives thrombolysis 39 carotidSurgery (9.3 %)

  13. Thrombolysed population: Characteristics • Meanage: 64 yrs, Men: 68%, Diabetics: 12 %, • MeanDelay = 156 min, Mean NIHSS = 11 • (normal = 0, contra-indication for thrombolysis > 22), • Isolatedprox. sylvianartery occlusion: 27%, • Extensive carotid & sylvianA. occlusion: 17%.

  14. Neurologic Evaluation NEURO.SCORE 3,3 0,6 * *p < 0,0001 Pré-op Admission

  15. Results 39 pts36 M, meanage: 67 yrs(49-82) NIHSS: 10 (0-21) Vesselsinvolved: % • CarotidOcclusion 7 • Sylvian Occlusion (M1 &/or M2) 39 • Carotid+ sylvian Occlusion 52 • Ant cerebral Occlusion 2 Meandelay stroke - surgery: 12.6 days(1 - 56)

  16. J-20 J-0 J-2 Stroke & Right CarotidThrombosis Admission 2 Hrs TL 20 Hrs TL

  17. Pre-op. BrainBleedingafter TL 9 pts (23%) Asympt. Delay after stroke: 2 days (1-9) NIHSS: 13 (8-18). Medical care:- stop aspirine, - decrease TA, - frequentangio-TDM. Delay stroke-surgery: 16 days(8-45) + 4 days

  18. NIHSS: Pre-op. brainbleeding * p<0,009 NIHSS

  19. Delay beforesurgery Number of patients

  20. SURGERY Meancarotidstenosis : 89 % • Surgical Technique • Eversion 28 • Meanclamping time:31 min • CAE with patch + shunt 10 • Bypass + shunt 1 No postoperativeredosurgery

  21. SurgicalResults • No death, • 1 brainbleeding, • 1 minor stroke, 5.1 % 39 pts : 22 dischargeat home (56 %)

  22. SurgicalResults Local complications (7.7 %): - Neck Haematoma 1 - Cranial nerves injury 2 General Complications (15 %): • Pneumopathy 4 • Others 2

  23. Follow-up at 3 months

  24. Mid-termResults MeanFw-up: 19 months • No death, • No other stroke, • Dupplex scanning: no redostenosis, • Contra-lateralcarotidsurgery: 4

  25. Literature:CEA afterthrombolysis n mean % Lysis Timing Postop pts agestenosisofCEAmorbidity Crozier 10 66 > 65 IV 8 3 (2010) Rathenborg 22 65 50-99 IV 11 0 (2012) Bartoli 39 67 50-99 IV 12 0 (2013)

  26. Conclusion Early & Midtermresults of emergentcarotidsurgeryafterthrombolysis are good. Operativecriteria are important: - Carotidsurgery: at least 48hrs afterthrombolysis (risk of bleeding), • If intra-cerabralbleedingafter TL: no carotidsurgery, untilangio-CT improvment, - Medical care by neurologistis important.

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