José Bernardo Escribano Paredes

University Hospital of Geneva

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Emmanuel Carrera

University Hospital of Geneva

Jeremy J. Heit

Stanford University

Pierre Seners

Fondation de Rothschild

Gregory W. Albers

Stanford Medicine

Michael Mlynash

Stanford University

Maarten G. Lansberg

Stanford University

Nicole Yuen

Stanford University

Velina Nedkova-Hristova

Bellvitge University Hospital

Javier Martínez‐Poles

Hospital Universitario Rey Juan Carlos

Sebastián García‐Madrona

Instituto Ramón y Cajal de Investigación Sanitaria

Cooperative Institutions

Hospital Universitario Ramón y Cajal

Inserm

Instituto Cajal

Instituto Ramón y Cajal de Investigación Sanitaria

Universidad de Alcalá

Institut de Psychiatrie et Neurosciences de Paris

University of Geneva

Stanford University

University Hospital of Geneva

Université Toulouse III - Paul Sabatier

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Visual hallucinosis during hypoperfusion of the right occipito-temporal cortex

Journal of Neurology (2022)

Nicolae Sanda José Bernardo Escribano Paredes Victor Ferastraoaru

Positive visual phenomena, although reported in lesions of visual cortex, are often overlooked in patients with acute neurological conditions. Yet, their occurrence without structural abnormalities or other underlying neurological disorders represents a unique observation. This report aims to raise awareness of these phenomena, their implications for understanding visual consciousness and to propose a practical, structured algorithm for the clinical assessment of visual hallucinations related to neurological conditions.We describe the clinical presentation and imaging findings in two patients with isolated visual hallucinosis secondary to transitory hypoperfusion.One patient presented with subocclusion of the right posterior cerebral artery and the other with multifocal arterial abnormalities suggestive of reversible cerebral vasoconstriction syndrome (RCVS). Both presented isolated visual hallucinations and hypoperfusion of the right mesial occipito-temporal cortex. Hallucinated images exhibited peculiarities of certain attributes that were recognized only through guided perceptual analysis performed during their occurrence.Dysfunctions in the visual and attentional networks due to the uneven impact of hypoperfusion on the regions of the mesial occipito-temporal cortex likely contributed to the occurrence of visual hallucinations. The initial impaired awareness of certain image attributes obscured an altered, non-realistic rendering of the hallucinated images. Enhancement of awareness through clinical guidance indicates improved attentional deployment, modulation of visual information processing and hallucination-background integration. These features of the hallucinatory phenomena highlight the critical role of semiological analysis during their occurrence and question the validity of post hoc inquiries.

Hallucinating

Neuroradiology

10.1007/s00415-022-11346-x

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Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Stroke (2021)

José Bernardo Escribano Paredes Julian Klug Elisabeth Dirren Nicolae Sanda María Isabel Vargas

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Stroke

10.1161/str.52.suppl_1.p345

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¿Qué piensan los estudiantes de Medicina sobre los trastornos neurológicos funcionales?

Revista de Neurología (2023)

José Bernardo Escribano Paredes E Natera-Villalba J. Porta‐Etessam L Vela P García-Ruiz Espiga

Functional neurological disorders (FND) are a frequent reason for visits in neurology. However, specific training on these disorders during undergraduate and residency training is limited. This study assesses the knowledge, attitude and exposure of medical students to FNDs before completing their medical degree.We conducted a 15-item survey to explore understanding, exposure and attitudes towards FNDs among sixth-year medical students at four Spanish universities.A total of 118 students (mean age 23.6 ± 1.2 years; 71.2% female) returned the survey. Of these, 88 (74.6%) were aware of the concept of FNDs and 78 (66.1%) had studied them in psychiatry classes. The term 'psychosomatic' was chosen by 54.1% of the students as the most appropriate term to refer to these disorders, and 111 (94.1%) believed that a history of sexual or physical abuse was common among FND patients. Fifty-seven students (48.3%) assumed that the diagnosis of FND was mostly a clinical diagnosis of exclusion and 63 (53.4%) indicated that it is managed only by psychiatry. One hundred and one students (85.6%) considered that adequate training on FNDs is an important aspect of their medical training.Medical students are aware of the existence of FNDs, but their preferred terminology, as well as the perceived aetiological factors, reflect that the historical view of these disorders is still deeply rooted. Medical students feel that they should receive adequate education on FNDs from specialists in neurology and psychiatry as part of their training.¿Qué piensan los estudiantes de Medicina sobre los trastornos neurológicos funcionales?Introducción. Los trastornos neurológicos funcionales (TNF) son un motivo de consulta frecuente en neurología. Sin embargo, la formación específica sobre estos trastornos durante la formación universitaria y el período de residencia es limitada. En este estudio se evalúan los conocimientos, la actitud y la exposición de los estudiantes de Medicina a los TNF antes de terminar el grado de Medicina. Sujetos y métodos. Realizamos una encuesta de 15 ítems para explorar la comprensión, la exposición y las actitudes hacia los TNF entre los estudiantes de Medicina de sexto año en cuatro universidades españolas. Resultados. Devolvieron la encuesta 118 estudiantes (edad media 23,6 ± 1,2 años; 71,2%, mujeres). De ellos, 88 (74,6%) conocían el concepto de TNF y 78 (66,1%) los habían estudiado en las clases de psiquiatría. El 54,1% de los estudiantes eligió el término ‘psicosomático’ como el más adecuado para referirse a estos trastornos, y 111 (94,1%) creían que una historia de abuso sexual o físico era común entre los pacientes con TNF. Cincuenta y siete estudiantes (48,3%) asumieron que el diagnóstico de TNF era mayoritariamente un diagnóstico clínico de exclusión y 63 (53,4%) señalaron que el manejo se realiza únicamente desde psiquiatría. Ciento un estudiantes (85,6%) consideraron que una formación adecuada sobre los TNF es un aspecto importante de su formación médica. Conclusiones. Los estudiantes de Medicina son conscientes de la existencia de los TNF, pero la terminología preferida por ellos, así como los factores etiológicos percibidos, reflejan que la visión histórica acerca de estos trastornos está aún arraigada. Los estudiantes de Medicina consideran que deberían recibir una educación adecuada sobre los TNF como parte de su formación por parte de los especialistas en neurología y psiquiatría.

10.33588/rn.7608.2022409

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Stroke Incidence, Case Fatality, and Mortality Using the WHO International Classification of Diseases 11

Neurology (2025)

Elisabeth Dirren José Bernardo Escribano Paredes Julian Klug Maël Barthoulot Joël Fluss

In the field of stroke epidemiology, one of the major advances in the recently implemented International Classification of Diseases, 11th revision (ICD-11) relates to the definition of ischemic stroke, which now includes events shorter than 24 hours when ischemia can be proven on brain imaging. However, data are scarce to ascertain the incidence of strokes of short duration with tissue evidence of ischemia. In this study, we determined the incidence, 30-day case fatality, and mortality rate of stroke in the Geneva population using the new ICD-11 criteria, taking advantage of the organization of stroke service in the area. In this population-based observational cohort study, we used data from the Swiss Stroke Registry, supplemented by hospital records, outpatient medical files, and autopsy, to identify residents of the canton of Geneva, Switzerland, meeting the ICD-11 criteria for first-ever stroke, including ischemic strokes, nontraumatic intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH), from January 1, 2018, to December 31, 2019. We identified 1,186 first-ever strokes (75.8 years [interquartile range 63.4-84.5]; 571 women [48.1%]). MRI was performed in 90.9% of patients with ischemic strokes. The annual incidence of first-ever stroke, age-adjusted to the European Standard Population, was 127.0/100,000 (95% CI 119.8-134.3) (107.3 [100.7-114.0] for ischemic stroke, 13.2 [10.9-15.5] for ICH, and 6.0 [4.4-7.5] for SAH [3.1 {2.0-4.2} for aneurysmal SAH]). Overall, the 30-day case fatality was higher in ICH (32.5% [95% CI 19.7-38.8], compared with SAH (17.2% [6.6-27.9] and ischemic strokes 10.8% [8.4-12.4]). The incidence of ischemic stroke was 107.3 (100.7-114.0) according to ICD-11 and 90.4 (84.3-96.5) according to ICD-10 (excluding patients with radiologic infarct and symptoms lasting <24 hours). Compared with ICD-10, ICD-11 increased the number of ischemic stroke cases by 18.3%. Patients with ischemic strokes identified with ICD-11 but not under ICD-10 (i.e., patients with symptoms lasting <24 hours and a brain lesion) were younger and presented with a lower National Institutes of Health Stroke Scale (NIHSS) score on admission compared with those identified by ICD-10 and ICD-11. The new ICD-11 clinicoradiologic definition of ischemic stroke increased the number of ischemic stroke cases by 18.3% in our Western European population. Future studies will evaluate the impact of ICD-11 on the human, organizational, and economic needs allocated to the management of the disease.

Case fatality rate

Stroke

10.1212/wnl.0000000000213353

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Abstract 6: Relationship Between Hypoperfusion Intensity Ratio And Ischemic Core Growth Rate Is Similar On CT And MRI For Unselected Acute LVO Patients

Stroke (2023)

Pierre Seners Maarten G. Lansberg Jeremy J. Heit José Bernardo Escribano Paredes Emmanuel Carrera

Background: Predicting infarct growth rate (IGR) in acute stroke with large vessel occlusion (LVO) is important for treatment decision-making. IGR has typically been studied in patients treated with thrombectomy, which likely has underestimated the prevalence of ‘fast progressors’, as large core patients are less frequently treated. We aimed to study IGR in an unselected LVO population and study the association between Hypoperfusion Intensity Ratio (HIR, a surrogate marker of collaterals) and IGR as assessed by both CT and MRI. Methods: Retrospective study including ICA/M1 stroke patients with witnessed stroke onset and baseline perfusion imaging (MRI or CT) performed within 24hrs from symptoms onset. To avoid selection bias, patients were selected from (1) the registries of 3 centers with systematic use of MRI- or CT-perfusion and including both MT-treated and untreated patients, and (2) one trial where thrombectomy decisions were performed blinded from perfusion MRI results. IGR was defined as core volume/onset-to-imaging time, and fast progressors as IGR≥10mL/hr. HIR was defined as the proportion of Tmax>6s volume with Tmax>10s. Results: Overall, 423 and 215 patients were included in the MRI and CT cohorts. Median IGR was 6.4mL/hr (IQR 2.2-21.3) and 5.2mL/hr (0-25.2) in the MRI and CT cohorts, and median HIR was 0.44 (0.27-0.59) and 0.45 (0.25-0.60). 174 (41%) MRI patients and 86 (40%) CT patients were fast progressors. IGR was increasing with increase of HIR quartiles in both cohorts ( P <0.001, Figure). IGR≥10mL was found in 7%, 17%, 58%, and 83% of patients within respective increasing HIR quartiles in the MRI cohort ( P <0.001), and in 2%, 21%, 60% and 80% in the CT cohort ( P <0.001). Conclusion: In this unselected LVO population, 40% of patients were fast progressors regardless of imaging modality. HIR was a strong predictor of IGR in both CT and MRI-assessed patients, and may help for patient triage, e.g . for transfer decision from an outside hospital for thrombectomy.

Stroke

Quartile

Fluid-attenuated inversion recovery

10.1161/str.54.suppl_1.6

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Abstract WP104: Core/perfusion Mismatch Prevalence According To ASPECT Score In Acute Ischemic Stroke With Large Vessel Occlusion.

Stroke (2023)

Pierre Seners Nicole Yuen José Bernardo Escribano Paredes Sarah J Snyder Emmanuel Carrera

Background: In acute ischemic stroke (AIS) with large vessel occlusion (LVO), core/perfusion mismatch modifies the effect of mechanical thrombectomy (MT) on clinical outcome, MT appears to have greater benefit in patients with significant mismatch. We aimed to study the prevalence of core/perfusion mismatch according to ASPECT score in a large population of LVO-related AIS imaged either with MRI or CT. Methods: Retrospective study including AIS patients with ICA/M1 occlusion and baseline perfusion imaging (MRI or CT) performed within 24hrs from last seen well. To avoid selection bias, patients were selected from (1) the registries of 3 comprehensive centers with systematic use of MRI- or CT-perfusion imaging and including both MT-treated and untreated patients, and (2) one thrombectomy trial where MT decisions were performed blinded to the results of MRI perfusion imaging. Core/perfusion mismatch was defined as mismatch ratio (Tmax>6s volume/ core volume) >1.8 and volume (Tmax>6s - core volume) >15 mL. ASPECT score was rated on diffusion weighted imaging (DWI) or non-contrast CT blinded from the perfusion imaging. Results: Overall, 580 and 350 patients were included in the MRI and CT cohorts. Last-seen-well to imaging time was 4.8hrs (IQR 3.0-8.7) and 3.2hrs (1.3-8.0) in the MRI and CT cohorts, respectively, median ASPECT score was 7 (5-8) and 8 (7-9), and core/perfusion mismatch was present in 393/580 (68%) and 315/350 (90%) patients. In both cohorts, 75% of patients were treated with MT following imaging. In the MRI cohort, mismatch prevalence was 44% (75/170) and 92% (378/410) for DWI-ASPECTS 0-5 and 6-10, respectively. In the CT cohort, mismatch prevalence was 47% (15/32) and 94% (300/318) for ASPECTS 0-5 and 6-10, respectively. Conclusion: About 90% of patients with ASPECTS 6-10 have a core/perfusion mismatch regardless of imaging type. However, patients with ASPECTS ≤5 are heterogeneous in terms of mismatch status. Therefore, perfusion imaging may be particularly useful to select appropriate MT candidates with low ASPECT scores, regardless of imaging type, which has implications for large core trials.

Stroke

10.1161/str.54.suppl_1.wp104

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Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital

Neurología (English Edition) (2021)

Elena Natera‐Villalba Antonio Culebras Sebastián García‐Madrona Rocío Vera-Lechuga Alicia de Felipe

Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset.We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory.Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge.In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.

Stroke

Ischaemic stroke

Acute stroke

10.1016/j.nrleng.2020.08.013

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Larger ischemic cores and poor collaterals among large vessel occlusions presenting in the late evening

Journal of Stroke and Cerebrovascular Diseases (2023)

Anirudh Sreekrishnan Steffen Tiedt Pierre Seners Nicole Yuen Jean‐Marc Olivot

Stroke

10.1016/j.jstrokecerebrovasdis.2023.107352

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SUDDEN COMA FROM ACUTE BILATERAL INTERNAL CAROTID ARTERY OCCLUSION

José Bernardo Escribano Paredes

Coma (optics)

10.26226/morressier.5ab8f55fd462b8029238cca0

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Quand rechercher des causes rares de maladie des petits vaisseaux cérébraux ?

Revue Médicale Suisse (2023)

Nicolae Sanda Elisabeth Dirren José Bernardo Escribano Paredes Lukas Sveikata Emmanuel Carrera

The majority of small vessel diseases is related to vascular risk factors or sporadic amyloid angiopathy, but a minority is caused by genetic, immune, or infectious diseases. In this article, we propose a pragmatic approach for the diagnosis and treatment of rare causes of cerebral small vessel disease.La majorité des maladies des petits vaisseaux est liée à des facteurs de risque vasculaire ou à l’angiopathie amyloïde sporadique, mais une minorité est causée par des maladies génétiques, immunologiques ou infectieuses. Dans cet article, nous proposons une approche diagnostique et une prise en charge pragmatiques des maladies rares des petits vaisseaux cérébraux.

10.53738/revmed.2023.19.824.803

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