mercredi 5 février 2020 

14h10 - 15h10


 
Espace Poster 9

Evaluation neurologique et pronostique

MODÉRATEUR(S) :  Alain CARIOU (PARIS), Stein SILVA (Toulouse)  
  

Velocity time integral in transcranial doppler (TCD) in healthy controls (C) versus ICU patients (P) for detection of cerebral blood flow (CBF) abnormalities.

Orateur(s) :   Jack RICHECOEUR (Beauvais) 

Auteur(s) :  Danièle COMBAUX (Beauvais)   Anne SAGNIER (Beauvais)   Romain MERCIER (Beauvais)   Nathalie VERRIER (Beauvais)   Romain DEBOCK (Beauvais)   Marie anais BASTIDE (Beauvais)   Cecile CAPLIN (Beauvais)   Chloe SOULIGNAC (Beauvais)   Jean-Louis DUBOST (Pontoise)   Bruno GELEE (Pontoise)   David LUIS (Beauvais)  

14h10 - 14h17
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Velocity time integral in transcranial doppler (TCD) in healthy controls (C) versus ICU patients (P) for detection of cerebral blood flow (CBF) abnormalities.

Introduction / Rationale :
Few studies report the relation between functionnal brain alterations during and after ICU stay and abnormalities of CBF displayed on TCD. Using VTI as hemodynamic parameter is unusual for evaluation of CBF.
The purpose of this preliminary study is to compare the values of VTI of healthy Controls (C) versus ICU (P) with usual parameters (i,e diastolic (Vd) and mean velocities (Vm), resistance (IR) and pulsatility index (IP)).

Méthodes / Patients and Methods :
38 C and 42 Pts are consecutively included during a 2 months period (August to September 2019). Brain damaged Pts and Pts with no temporal window were excluded segment M1middle cerebral artery (MCA) velocities and VTIMCA were sampled using TCD. Left ventricular out flow (VTIAo) was assessed by transthoracic echocardiography.
Demographics data, reason for admission in ICU, SAPS, sedative, vasopressor use and ventilator support were recorded as well MAP,Vs,Vd,Vm,IP,IR, arterial blood gaz
Data are shown as median (interquartile : 25-75).T.test or non parametric test (if appropriate) were use. P<0,05 was considered as significant.

Résultats / Results :
Age sex ratio are respectively 40y (30-51,75), sex ratio :1 for C and 58 y(50,0-64,5), sex ratio: 2,5 Pts group with SAPS II 52 (41-69). Reasons for admission were sepsis : 14, Cardiac arrests: 7, intoxications: 4, Cardiogenic shocks : 4, Others : 9.
All patients but 7 had MV, vasopressor support: 16 pts and sedative drugs : 33 Pts.
25 Pts had low VTIAMCA (range13,67 to 34cm) under the lowest value of 35 cm among C. 7 Pts among the 25 Pts had low Vd, below the cut-off of 25cm/s linked to CBF abnormalities. In addition, low VTIAo and Vd was significatly correlated to low VTIMCA but not Vm.

Discussion / Discussion :


Conclusion / Conclusion :
Pts versus C had dramatically collapsed VTIMCA.
Using VTIMCA cut-off of 35cm, more Pts (2/3) might have abnormal CBF compared Vd threshold of 25cm/s. Low VTIAo should prompt VTIMCA assessement.
 

Habituation to the auditory startle reflex is a new sign of minimally conscious state

Orateur(s) :   Bertrand HERMANN (Paris) 

Auteur(s) :  Amina BEN SALAH (Paris)   Mélanie VALENTE (Paris)   Lionel NACCACHE (Paris)  

14h17 - 14h24
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Habituation to the auditory startle reflex is a new sign of minimally conscious state

Introduction / Rationale :
Accurate diagnosis of the level of consciousness is a challenge and different states such as coma, vegetative state (VS) or minimally conscious state (MCS) are often confused while they convey meaningful prognostic information. This distinction rely on the Coma Recovery Scale – revised (CRS-R) gold-standard. However, this clinical scale is imperfect since unresponsive patients can exhibit genuine signs of consciousness using advance neuroimaging techniques. Expanding the range of behaviors indexing consciousness at bedside is thus of decisive importance.

Méthodes / Patients and Methods :
We designed and proposed a new clinical sign of MCS, the habituation to auditory startle reflex (ASR), based on the blink response to repeated sounds: either inhibition of the automatic ASR response (extinguishable) or no habituation (inextinguishable response). We prospectively tested this new sing in patients suffering from disorders of consciousness after severe brain injury and first compared its diagnostic performances with the current gold-standard (CRS-R) using standard discrimination metrics (AUC, sensitivity, specificity, likelihood ratios) and their 95% confidence interval. We then investigated the correlates of this new sign on two validated neuroimaging diagnostic procedures (multivariate EEG-based classification of the state of consciousness and FDG-PET metabolic index of the best preserved hemisphere) using an ANOVA with the state of consciousness and the ASR response as independent variable.

Résultats / Results :
96 patients were included between January 2014 and July 2019, mean age 44.2 +- 16.4 years, sex ratio 1.8, median delay since injury 58 [31-236] days, main etiologies anoxo-ischemic encephalopathy (41%) and traumatic brain injury (28%), with 51% patients under mechanical ventilation. Among the 48 VS patients 32 had an inextinguishable response and 16 an extinguishable one, while the reverse pattern was found in the 48 MCS patients with 16 and 36 patients respectively. The AUC of an extinguishable response to diagnose MCS was 0.71 [0.61-0.8] with 75% [60-86] sensitivity, 67% [50-80] specificity, 2.25 [1.46-3.47] positive and 0.38 [0.22-0.64] negative likelihood ratios, ranking second among all the CRS-R items defining MCS. Furthermore, patients with an extinguishable response had a significantly higher probability of being classified MCS on the EEG-based algorithm and higher metabolic index on the PET, independently of their clinical state of consciousness (main effect of ASR habituation, p=0.0002 and p=0.0391 respectively, Figure).

Discussion / Discussion :


Conclusion / Conclusion :
A successful inhibition of the automatic ASR response is a valid new sign of MCS compared with behavioral and neuroimaging validated procedures. This simple sign could be easily implemented at bedside as a screening tool or complement to the time-consuming CRS-R.
 

Teaching the Basics of Bedside Electroencephalography to Critical Care Staffs: a prospective multicentre study

Orateur(s) :   Stéphane LEGRIEL (Le Chesnay) 

Auteur(s) :  Gwenaëlle JACQ (Le Chesnay)   Amandine LALLOZ (Paris)   Guillaume GERI (Boulogne)   Pedro MAHAUX (Boulogne)   Cedric BRUEL (Paris)   Sandie BROCHON (Paris)   Benjamin ZUBER (Suresnes)   Cécile ANDRE (Suresnes)   Krystel DERVIN (Clichy)   Mathilde HOLLEVILLE (Clichy)   Alain CARIOU (Paris)  

14h24 - 14h31
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Teaching the Basics of Bedside Electroencephalography to Critical Care Staffs: a prospective multicentre study

Introduction / Rationale :
Although continuous electroencephalography (cEEG) is commonly recommended in neurocritical care patients, implementation of this monitoring in routine is facing the need for a specific training of professionals. We evaluated the effectiveness of a training program for the basic interpretation of cEEG to critical care staffs in a prospective multicentre study.

Méthodes / Patients and Methods :
After completion of a pre-test, participants (physicians and nurses) recruited in 6 French intensive care units (ICU) received a face-to-face EEG learning course, followed by additional e-learning sessions at day-1 (post-course), day-15, day-30 and day-90, based on training tests followed by illustrated and commented answers. Each test was designed in order to evaluate knowledge and skills through correct recognition of 10 predefined EEG sequences covering the most common normal and abnormal patterns. The primary objective was to achieve a success rate of more than 80% of correct answers at day-90 in at least 75% of participants.

Résultats / Results :
Among 250 participants, 108 (43.2%) completed the full training program and 77 of these 108 (71.3%) full-training participants achieved at least 80% of correct answers at day-90. Paired comparisons between scores obtained at each evaluation demonstrated a statistically significant increase over time. At day 90, rates of correct answers were greater than 80% for all predefined usual EEG sequences, excepted for the recognition of periodic and burst-suppression patterns and reactivity, which were identified in only 42.6 % (95% CI, 36.4-48.8) and 60.2 % (54.1-66.3) and 70.4 (64.7-76.1) tests, respectively.

Discussion / Discussion :
This multicentric prospective study, which evaluated a training program for the basics of electroencephalography offered to critical care teams, provides interesting information about the training process and its impact on learners according to their different characteristics. We believe that participants reflect the heterogeneity of the various use of cEEG in the critical care setting. Participants came from university and non-university ICUs, and whereas some of them used to monitor patients with cEEG, others were in an implementation process when the last monitored neurocritical care patients with intermittent EEG. In accordance with previous studies, we focused to the entire medical and nursing ICU staffs.

Conclusion / Conclusion :
A 3-months training program aiming to teach the basic interpretation of continuous EEG in the intensive care units was associated with a significant attrition in participation over time. However, participants who received the full training program were capable to accurately recognize the vast majority of EEG patterns that are encountered in critically ill patients.
 

Prognostic factors for stroke in CHUORAN emergency department

Orateur(s) :   Houria DJEBLI (Oran, ALGÉRIE) 

Auteur(s) :  Soumia BENBERNOU (Oran, ALGÉRIE)   Nabil GHOMARI (Oran, ALGÉRIE)  

14h31 - 14h38
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Prognostic factors for stroke in CHUORAN emergency department

Introduction / Rationale :
Introduction
Stroke is a real public health problem in the world is the second leading cause of death in Western countries. In Maghreb countries such as Algeria, few studies have addressed the issue. A study in this field had become necessary, thus making it possible to determine the frequency as well as the prognostic factors of this pathology.
Goal :
• Study the prognostic factors related to mortality at one month and one year.

Méthodes / Patients and Methods :
Prospective descriptive study for analytical and prognostic purpose carried out during the period from January 1, 2016 to December 31, 2017.
Any patient over the age of 15 with signs of a sudden loss of facility whose diagnosis of stroke is confirmed by the CT scan
Patients with recurrent stroke
The Cox regression model for uni-varied and multi-variate analyzes is designed to study the prognostic factors associated with 28-day mortality and one-year mortality following stroke.

Résultats / Results :
This is a study that has collected 1212 patients admitted to the Medical Emergencies of CHU Oran for
Stroke. Their prevalence was 61.7

Stroke accounts for 19.31% of all emergency room visits

55.3% are female, average age: 64.22 + or - 17.45
78% were ischemic stroke, 15% hemorrhagic, 4% cerebral venous thrombosis and 3% meningeal hemorrhage
Only 8.2% of patients arrive within a time frame for thrombolysis.

The final model of the one-year Cox model survival analysis retained three prognostic factors at a significance level α = 5%.
The age at which the risk of death is multiplied by 2.86 (HZa = 2.86, [1.89 - 4.34]).
The number of Comorbidities factors multiplies the risk of death by 2.25 times (HZa = 2.25; [1.33 - 3.80]). In hypertensive patients, the probability of survival at 6 months is 65.6% CI [60.4 - 70.8]; however, it is 73.1% CI [67.1 - 79.1] in non-hypertensive patients.
The survival rate of patients with no risk factor is 83.9% [76.9 - 90.9] whereas those with 4 or more risk factors are 65.4%. IC [52.2 - 78.6]; p = 0.039.
The Glasgow Coma Initial score where the risk of death is multiplied by 6 and a half times (HZa = 6.55; [4.68 - 9.17]).
Survival was 78.4% at 30 days compared with 63.2% at one year.

Discussion / Discussion :


Conclusion / Conclusion :
Stroke is a common pathology in emergencies, knowledge of their prevalence and prognostic factors can establish appropriate strategies for management.
 

The clinical and progressive aspects of cerebral venous thromboses at the Oran hospital and university center

Orateur(s) :   Mourad GOULMANE (Oran, ALGÉRIE) 

Auteur(s) : 

14h38 - 14h45
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
The clinical and progressive aspects of cerebral venous thromboses at the Oran hospital and university center

Introduction / Rationale :
Cerebral venous thrombosis (CVT) is a rare but very serious disease with various clinical and etiological aspects. Unlike ischemic arterial accidents, epidemiological studies are limited. Goals The aim of our work is to study the clinical, etiological and evolutionary features of TVC in the Algerian population from a sample of 28 patients.

Méthodes / Patients and Methods :
This is a retrospective observational study conducted in the neurology department of the CHU d'Oran between January 2016 and December 2017. In a clinical context suggestive of CVT, the diagnosis of certainty was provided by brain MRI coupled with MRA. . All subjects benefited from a complete etiological assessment. The anticoagulant treatment was based on the low molecular weight heparin relayed by the anti-vitamin K. The duration of the follow-up was 12 months.

Résultats / Results :
The mean age was 38.26 ± 13.59 years, the sex ratio was 6 (24F / 4H), the onset was subacute in 55% of cases. The main early signs were headache (88.8%), visual disturbances (50%), epileptic seizures (44.4%) and motor deficit (44.4%). Thrombosis predominated in the upper sagittal sinus and lateral sinuses; Parenchymal lesions were associated in 2/3 of the cases. Gynecologic obstetric causes were by far the most frequent. The evolution was favorable in 83,3% of the cases.

Discussion / Discussion :
TVC is characterized by its clinical polymorphism, its predominance in young women, and its most often favorable evolution. The causes are multiple and often intricate requiring the realization of a systematic etiological assessment even if the cause seems obvious. The treatment of choice remains early anticoagulation, based on heparinotherapy even in case of hemorrhagic softening.

Conclusion / Conclusion :
The characteristics of CVT in the Algerian population are distinguished by a high frequency of gynecological obstetric causes. Awareness campaigns for women of childbearing age are useful.
 

Analysis on prognostic factors of patients with ruptured intracranial aneurysm in intensive care unit

Orateur(s) :   Karim BADAOUI (Casablanca, MAROC) 

Auteur(s) :  Rachid CHERKAB (Casablanca)   Chafik EL KETTANI (Casablanca)   Barrou LAHOUCINE (Casablanca)  

14h45 - 14h52
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Analysis on prognostic factors of patients with ruptured intracranial aneurysm in intensive care unit

Introduction / Rationale :
Subarachnoid hemorrhage due to ruptured intracranial aneurysm (SAH) is a serious affection with a global mortality of 26% in France. The purpose of this work is to screen the prognostic factors of the aneurysms operated at the acute phase.

Méthodes / Patients and Methods :
Retrospective study spread over 7 years (from 1st January 2012 to 1st January2019), performed in the surgical emergency department (P17) Ibn Rochd ,including all patients operated for (SAH). All demographic, clinical, biological and therapeutic data werecollected. Univariate analysis used chi-square tests and Student's "t" test, while multivariate analysis wasperformed using the logistic regression model. The measurement of the scores discriminating power was based on the Receiver Operating Characteristic (ROC) curves and the comparison of the areas under the curves with the Hanley and McNeil method Survival is estimated by the Kaplan-Meier method followed by the Log-rank test for comparison of survival curves.

Résultats / Results :
132 patients were included with an average eage of 50 +/- 10 years. Mortality was 31.3%.Univariate analysis identified 12 prognostic factors that had an impact on mortality: poor Glasgow Coma scale (P <0.01), WFNS III and IV (P <0.01), Hunt and Hess IV (P: 0.005), hyperthermia (P = 0.02), Fisher III and IV (P: 0.003 and 0.02), ventricular inondation (P: 0.02), anterior aneurysmal location (P: 0.000), tracheotomy (P : 0.001), postoperative deficit (P: 0.03), prolonged ventilation (P: 0.003), dysnatremias (P: 0.037 and P: 0.019) and onset time of surgery (P: 0.000).
In multivariate analysis, the independent variables that appeared to be of poor prognosis were: a prolonged duration of ventilation (OR: 2.56), a prolonged duration of surgery (OR: 0.36), a WFNS IV score (OR: 0.65)

Discussion / Discussion :


Conclusion / Conclusion :
Mortality related to intracranial aneurysm remains high hence the interest of early and adapted management of any arachnoid hemorrhage by rupture of cerebral aneurysm.
 

Decompressive hemicraniectomy in malignant middle cerebral artery infarction about 20 cases

Orateur(s) :   Karama BOUCHAALA (Sfax, TUNISIE) 

Auteur(s) :  Rania AMMAR ZAYANI (Sfax, TUNISIE)   kamilia CHTARA (Sfax, TUNISIE)   Yousfi MOUNIR (Sfax)   Mabrouk BAHLOUL (Sfax, TUNISIE)   Chokri Ben Hamida (Sfax, TUNISIE)   Mounir BOUAZIZ (Sfax, TUNISIE)  

14h52 - 14h59
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Decompressive hemicraniectomy in malignant middle cerebral artery infarction about 20 cases

Introduction / Rationale :
Background:Malignant middle cerebral artery (MCA) infarction is associated with an up to 80% mortality rate due to ischemic edema and brain herniation.
Objective: To study the impact of decompressive hemicraniectomy (DC) in patients with MCA.

Méthodes / Patients and Methods :
Twenty patients with MCA treated with DC were studied during 5 years (2015-2019) in a Tunisian intensive care unit.

Résultats / Results :
Mean age was 59.3 ± 10.99 years. Sex ratio. Mean length of stay was 24 ± 18.79 days. Mean duration of mechanical ventilation was 19. 05 ± 17.19 days. Mean SAPSII was 41. 6 ± 11.35 points. Mean SOFA was 9.1 ± 4.5 points. Mean GCS was 8.5 ± 3.06. The etiology was arrytmia (23. 8%), hypertensive urgency (52. 4%) and atherosclerosis (42.9%). The affected artery was the left sylvian artery in 55%. The operative indications were deterioration of the state of consciousness in all cases (100%), pupillary modification (25%), mass effect and deviation of the median line> 5 mm (100%), brain herniation (50%) and hemorrhagic transformation (25%). Mean time of DC was 3.1 ± 2. 55 days. Tracheotomy was performed in 14 patients (66. 7%) with a mean at 11.5 ± 6.44 days. Osmotic treatment was initiated in 76, 2% of cases and antiepileptic treatment in 52.4%. The mortality rate was 57.1%. The functional prognosis was assessed by the modified Rankin Score (mRS): a good prognosis (mRS between 0-3) was found in one patient, a poor prognosis (mRS between 4-6) was found in 19 patients. The complications associated with DC were brain abscess (14. 3%), meningitis (19%), local infection (19%), hemorrhagic transformation (61.9%) and convulsion (42.9%). SAPSII score was significantly associated with mortality (p = 0.23). SAPSII ≥ 41.5 points had Se 70%, Sp 70% and an area under the curve (AUC) 0.807. SOFA score was significantly associated with mortality (p = 0.007). SOFA ≥ 6.5 points had Se 91.7%, Sp 75% and AUC 0.865.

Discussion / Discussion :


Conclusion / Conclusion :
Hemicranectomy decompressive in sylvian malignant infarction don’t improve good outcomes in severe critically ill patients.
 

Prediction of outcome after acute stroke: comparison of CT-DRAGON score and a simplified score

Orateur(s) :   Anouk LESENNE (Genk, BELGIQUE) 

Auteur(s) :  Jef GRIETEN (Genk, BELGIQUE)   Alain WIBAIL (Genk)   Ludovic ERNON (Genk)   Luc STOCKX (Genk)   Patrick WOUTERS (Gent)   Elly VANDERMEULEN (Genk, BELGIQUE)   Sam VAN BOXSTAEL (Genk)   Pascal VANELDEREN (Genk)   Sven VAN POUCKE (Genk, BELGIQUE)   Joris VUNDELINCKX (Genk)   Sofie VAN CAUTER (Genk)   Dieter MESOTTEN (Genk, BELGIQUE)  

14h59 - 15h06
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Prediction of outcome after acute stroke: comparison of CT-DRAGON score and a simplified score

Introduction / Rationale :
The CT-DRAGON score was developed to predict long-term functional outcome after acute stroke in the anterior circulation treated by thrombolysis. Its implementation in clinical practice is hampered by the plethora of variables included. In addition, the score has not been validated in important subgroups such as stroke patients undergoing thrombectomy. Given these limitations, the current study was designed to evaluate the use of a simplified score based on machine learning, as a possible alternative.

Méthodes / Patients and Methods :
This single-centre retrospective study included 564 patients treated for stroke, in the anterior and posterior cerebral circulation, between 01-2017 and 02-2019. At 90 days, favourable (modified Rankin Scale (mRS): 0-2) and miserable outcome (mRS: 5-6) were predicted by CT-DRAGON. Machine learning selected the features of the simplified score. Discrimination, calibration and misclassification of both models were tested.

Résultats / Results :
32% had proximal anterior stroke, 2% proximal posterior stroke and 50% lacunar infarcts in either circulation. In 16% no thrombus was objectivated. 13% of patients were treated with thrombectomy, 17% received thrombolysis and 9% underwent both thrombolysis and thrombectomy. 61% only received anti-platelet therapy.
The area under the receiver-operating-characteristic curve (AUC-ROC) for CT-DRAGON was 0.78 (95%CI 0.74-0.81) for favourable and 0.78 (95%CI 0.72-0.83) for miserable outcome. R2 of CT-DRAGON was 0.30 and 0.22 for favourable (lack of fit, p=0.75) and miserable (lack of fit, p=0.8) outcome respectively. Misclassification rate was 29% for favourable and 13% for miserable outcome with CT-DRAGON.

Selection of predictors from the CT-DRAGON was done by logistic regression, bootstrap forest and decision tree analysis. NIH Stroke Scale, pre-stroke mRS and age were identified as the strongest contributors to favourable and miserable outcome, and included in the simplified score. AUC-ROC was 0.83 (95CI% 0.79-0.86) and 0.83 (95CI% 0.77-0.87) for the prediction of favourable and miserable outcome respectively. R2 was 0.42 and 0.29 for the prediction of favourable (lack of fit p=0.34) and miserable (lack of fit p=1.0) outcome respectively. Misclassification rate was 26% for favourable and 14% for miserable outcome with the simplified score. The simplified score had better discriminative power than CT-DRAGON for both outcomes (both p<0.005).

Discussion / Discussion :


Conclusion / Conclusion :
The CT-DRAGON score revealed acceptable discrimination in our cohort of both anterior and posterior circulation strokes, receiving a variety of treatment modalities. The simplified score had a better discrimination, while maintaining comparable and good specificity and misclassification rate for miserable outcome. The simplified score needs further validation in a prospective, multi-centre study.