L Puybasset

Hôpitaux Universitaires La Pitié salpêtrière - Charles Foix, Lutetia Parisorum, Île-de-France, France

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Publications (203)561.16 Total impact

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    ABSTRACT: Severe traumatic brain injury (sTBI) is characterized by diffuse axonal injury (DAI). These lesions are difficult to observe in anatomical Magnetic resonance Imaging (MRI) and Computed Tomography (CT). Diffusion MRI (dMRI) has shown its ability to probe the white matter and its sensitivity to DAI. In this work, we use probabilistic tractography, a dMRI based-technique to highlight the DAI profile at the white/grey matter interface. Bayesian probabilistic tractography is thus used to reconstruct thalamo-cortical connectivity for 9 control subjects and 13 favorable outcome sTBI subjects. Parts of tractograms situated in the white/gray matter interface of the two groups, are compared each other, using a two-sample nonparametric permutation unpaired t-test in a general linear model (GLM) framework with randomization to reconstruct the DAI profile. sTBI subjects showed connectivity decrease, corresponding to DAI, in several cortical regions compared to control subjects: temporal, frontal, parietal and occipital regions and lesions in the left side are predominant. The control subjects didn’t show any decrease in connectivity when compared to sTBI subjects. We show that probabilistic tractography can faithfully reconstruct anatomical connectivity and above all highlights alterations of this connectivity, especially in complex areas, where fibers intersect or fan as in near gray matter (white/gray matter interface), an area known for extensive DAI, responsible for many cognitive deficits. ABREVIATIONS: DTI: Diffusion Tensor Imaging, TBI: Traumatic Brain Injury, MNI: Montreal Neurological Institute, DAI: Diffuse Axonal Injury, W/G interface: white/grey matter interface, CSF: Cerebro-Spinal Fluid, FA: Fractional Anisotropy, FAST: FMRIB's Automated Segmentation Tool
    Biomedical Engineering International Conference (BIOMEIC'14), Tlemcen, Algeria; 10/2014
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    ABSTRACT: Introduction Chez les malades atteints d’hémorragie sous-arachnoïdienne (HSA), le score WFNS est classiquement utilisé afin d’évaluer le pronostic neurologique à long terme, et de définir les malades dits WFNS bas grade (1-3) et WFNS haut grade (4-5). Pour les malades bas grade, il existe peu de critère permettant de discriminer ceux qui auront une mauvaise évolution. Récemment, des études de cohorte et des études expérimentales ont démontré que l’inflammation innée systémique est associée à une majoration des lésions cérébrales aiguës [1]. La néoptérine, impliquée dans la voie d’activation macrophagique est considérée comme un nouveau biomarqueur pertinent dans les pathologies inflammatoires [2]. Notre hypothèse est que le dosage de la néoptérine permettrait de prédire le pronostic à un an des HSA et en particulier chez les malades bas grade. Matériel et méthodes Dans cette étude pilote, un recueil prospectif des données cliniques, radiologiques et biologiques a été effectué pour 57 malades admis en réanimation pour HSA à partir d’une série consécutive de 198 malades (critères d’exclusion : saignement de plus de 48 h à l’admission, data cliniques et biologiques manquantes, absence d’exclusion anévrismale). Les dosages de néoptérine ont été réalisés du jour de l’admission au dixième jour de prise en charge. Une analyse statistique univariée sur la totalité de la cohorte puis sur les patients WFNS bas grade a été élaborée pour chacun des critères étudiés en cherchant leur association avec une mauvaise évolution à 1 an (GOS 1-3). Prenant en compte des comparaisons multiples sur 25 critères, le seuil de significativité était de 0,002. Résultats Les concentrations sériques de néoptérine des malades évoluant vers un GOS 1-3 sont statistiquement majorées de j5 à j10 par rapport aux malades GOS 4-5 (voir Fig. 1). Le score WFNS (p < 0,001), la PS100beta à l’admission (p < 0,001), le score ABC (p < 0,001) ainsi que la concentration de néoptérine à j5 (p = 0,001, OR : 1,40 IC95 % [1,14 ; 1,71]) sont statistiquement associés à une évolution vers un GOS 1-3, contrairement aux autres critères étudiés (âge, sexe, score Fisher, mise en place d’une DVE, vasospasme, épisode infectieux, existence d’un OAP ou de convulsions). Dans le sous-groupe WFNS bas grade (n = 38 dont 4 GOS 1-3), seule la néoptérine j5 présente une association statistique avec un mauvais pronostic (OR : 1,84 IC95 % (1,06 ; 3,22) sans atteindre le seuil de significativité (p = 0,03). Discussion Dans cette étude pilote portant sur un petit échantillon, la néoptérine, reflet de l’inflammation systémique, est un outil pronostique potentiel pour les malades porteur d’HSA et en particulier chez les malades WFNS bas grade. Ces résultats devront être complétés par une étude de plus grand effectif avant définir son utilité clinique.
    Annales francaises d'anesthesie et de reanimation 09/2014; 33:A31–A32. · 0.77 Impact Factor
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    ABSTRACT: Introduction Le pronostique neurologique après arrêt cardio-circulatoire ressuscité (ACC) est un enjeu majeur. L’évaluation pronostique repose sur l’examen clinique, les biomarqueurs et les examens électro-physiologiques. Ces techniques restent imprécises et ne sont pas validées après hypothermie thérapeutique. L’imagerie par résonance magnétique (IRM), en particulier les séquences en tenseur de diffusion (DTI), permettrait le diagnostic précoce de l’atteinte de la substance blanche par mesure de l’anisotropie fractionnelle (FA) [1]. Notre objectif était l’évaluation de la mesure de la FA de la substance blanche pour prédire l’évolution neurologique à long terme chez des patients victimes d’ACC ressuscité. Matériel et méthodes Étude observationnelle prospective multicentrique menée chez des adultes, victimes d’ACC, et non conscients après 7 jours de réanimation. Une IRM cérébrale était réalisée permettant la mesure de la FA globale de la substance blanche. Les valeurs de FA obtenues étaient normalisées par rapport à celles de volontaires sains et exprimées en pourcentage de la valeur des contrôles. L’évaluation du devenir neurologique était faite par le score de Cerebral Performance Category (CPC) à un an. La performance de la FA globale de la substance blanche pour prédire l’évolution neurologique était comparée à celle du coefficient de diffusion apparente (ADC) de la substance grise, de l’électro-encéphalogramme (EEG) par l’intermédiaire du score de Synek, de la protéine S100β et du score Glasgow à l’inclusion. Résultats De juillet 2009 à mars 2012, 119 patients ont pu être inclus dans l’étude ainsi que 116 volontaires sains. Parmi ces patients, 88 (74 %) ont eu une évolution neurologique défavorable (CPC 3-5) à un an et 31 (26 %) ont eu une évolution favorable (CPC 1-2). Les aires sous la courbe ROC pour prédire l’évolution neurologique défavorable à un an étaient respectivement de 0,94 (IC95 % : 0,88–0,98) pour la FA de l’ensemble de la substance blanche, de 0,65 (IC95 % : 0,56–0,74) pour l’ADC de la substance grise, de 0,80 (IC95 % : 0,70–0,87) pour le score de Synek, de 0,51 (IC 95 % : 0,41–0,61) pour le score de Glasgow et de 0,52 (IC95 % : 0,37–0,66) pour la protéine S100β. L’aire sous la courbe ROC de la FA était significativement supérieure à toutes les autres. Une valeur de FA inférieure à 86,3 % des contrôles prédisait une évolution défavorable avec spécificité de 100 % (IC95 % : 89 % > 100 %) et une sensibilité de 77 % (IC 95 % : 67 % > 86 %) (Fig. 1). Discussion La mesure de FA de la substance blanche permet de prédire avec précision l’évolution neurologique à long terme chez les patients comateux 7 jours après ACC ressuscité. Cette étude menée sur 10 centres de réanimation dans 3 pays confirme les résultats de notre étude pilote. La comparaison aux outils pronostiques conventionnels montre une supériorité de la mesure de la FA de la substance blanche.
    Annales francaises d'anesthesie et de reanimation 09/2014; 33:A29–A30. · 0.77 Impact Factor
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    ABSTRACT: Severe traumatic brain injury (TBI) is characterized mainly by diffuse axonal injuries (DAI).The cortico-subcortical disconnections induced by such fiber disruption play a central role in consciousness recovery. We hypothesized that these cortico-subcortical deafferentations inferred from diffusion MRI data could differentiate between TBI patients with favorable or unfavorable (death, vegetative state, or minimally conscious state) outcome one year after injury.
    Journal of Neuroradiology 06/2014; · 1.24 Impact Factor
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    ABSTRACT: Many patients admitted to the intensive care unit (ICU) have pre-existing or acquired neurological disorders which significantly affect their short-term and long-term outcomes. The ESICM NeuroIntensive Care Section convened an expert panel to establish a pragmatic approach to neurological examination (NE) of the critically ill patient. The group conducted a comprehensive review of published studies on the NE of patients with coma, delirium, seizures and neuromuscular weakness in critically ill patients. Quality of data was rated as high, moderate, low, or very low, and final recommendations as strong, weak, or best practice. The group made the following recommendations: (1) NE should be performed in all patients admitted to ICUs; (2) NE should include an assessment of consciousness and cognition, brainstem function, and motor function; (3) sedation should be managed to maximize the clinical detection of neurological dysfunction, except in patients with reduced intracranial compliance in whom withdrawal of sedation may be deleterious; (4) the need for additional tests, including neurophysiological and neuroradiological investigations, should be guided by the NE; (5) selected features of the NE have prognostic value which should be considered in well-defined patient populations.
    European Journal of Intensive Care Medicine 02/2014; · 5.17 Impact Factor
  • Robert D Stevens, Yousef Hannawi, Louis Puybasset
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    ABSTRACT: Data from MRI can be used to generate detailed maps of central nervous system anatomy and functional activation. Here, we review new research that integrates advanced MRI acquisition and analysis to predict and track recovery following severe traumatic brain injury (TBI) or anoxic ischemic encephalopathy (AIE) following cardiac arrest. Diffusion tensor MRI studies of comatose TBI patients demonstrate specific distributions of white matter damage that are robustly associated with long-term functional outcomes. In unconscious patients with AIE, whole brain diffusion restriction has prognostic significance, as do regional changes in diffusion restriction or anisotropy. Results using functional MRI suggest that coma following TBI and cardiac arrest is associated with disconnections within cerebral architectures associated with arousal and conscious perception. The relation between these disconnections and postinjury recovery is being explored in ongoing cohorts. MRI of the brain is feasible in critically ill patients following TBI or cardiac arrest, revealing patterns of structural damage and functional disconnection that can help predict outcome in the long term. Prospective studies are needed to validate these findings and to identify relationships between MRI-defined alterations and specific postinjury cognitive and behavioural phenotypes.
    Current opinion in critical care 02/2014; · 2.67 Impact Factor
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    ABSTRACT: Purpose To analyze white matter pathologic abnormalities by using diffusion-tensor (DT) imaging in a multicenter prospective cohort of comatose patients following cardiac arrest or traumatic brain injury (TBI). Materials and Methods Institutional review board approval and informed consent from proxies and control subjects were obtained. DT imaging was performed 5-57 days after insult in 49 cardiac arrest and 40 TBI patients. To control for DT imaging-processing variability, patients' values were normalized to those of 111 control subjects. Automated segmentation software calculated normalized axial diffusivity (λ1) and radial diffusivity (λ⊥) in 19 predefined white matter regions of interest (ROIs). DT imaging variables were compared by using general linear modeling, and side-to-side Pearson correlation coefficients were calculated. P values were corrected for multiple testing (Bonferroni). Results In central white matter, λ1 differed from that in control subjects in six of seven TBI ROIs and five of seven cardiac arrest ROIs (all P < .01). The λ⊥ differed from that in control subjects in all ROIs in both patient groups (P < .01). In hemispheres, λ1 was decreased compared with that in control subjects in three of 12 TBI ROIs (P < .05) and nine of 12 cardiac arrest ROIs (P < .01). The λ⊥ was increased in all TBI ROIs (P < .01) and in seven of 12 cardiac arrest ROIs (P < .05). Cerebral hemisphere λ1 was lower in cardiac arrest than in TBI in six of 12 ROIs (P < .01), while λ⊥ was higher in TBI than in cardiac arrest in eight of 12 ROIs (P < .01). Diffusivity values were symmetrically distributed in cardiac arrest (P < .001 for side-to-side correlation) but not in TBI patients. Conclusion DT imaging findings are consistent with the known predominance of cerebral hemisphere axonal injury in cardiac arrest and chiefly central myelin injury in TBI. This consistency supports the validity of DT imaging for differentiating axon and myelin damage in vivo in humans. © RSNA, 2013 Online supplemental material is available for this article.
    Radiology 02/2014; 270(2):506-16. · 6.34 Impact Factor
  • L Puybasset, R D Stevens
    Annales francaises d'anesthesie et de reanimation 01/2014; · 0.77 Impact Factor
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    ABSTRACT: PURPOSE Prediction of long-term neurocognitive outcome in patients with traumatic brain injury (TBI) is challenging. In this study, we evaluated the prognostic value of DTI, performed in acute-phase after TBI, for prediction of long-term neurocognitive sequelae. For this purpose, we tracked the changes in quantitative DTI parameters over a span of 5 years after the injury. METHOD AND MATERIALS Sixteen patients with severe TBI who were admitted to the intensive care unit were enrolled in this prospective study. A baseline MRI was acquired as soon as clinically feasible (within 6 weeks). The MRI scans were repeated at 2 and 5 years after the injury. Patients underwent a neuropsychological evaluation and we assessed the cognitive sequelae and the level of disability based on Glasgow outcome scale, the disability rating scale and the modified Rankin scale. Healthy controls (n=8) were scanned at baseline and at 2-year intervals. Automated segmentation software calculated axial/radial diffusivity and fractional anisotropy in 20 predefined white matter regions. The DTI parameters were normalized using a large set of DTI data from healthy controls. The association of DTI changes with patients’ clinical outcome was evaluated. RESULTS TBI patients had significantly lower fractional anisotropy and higher radial diffusivity in selected white matter tracts compared with healthy controls. Baseline changes in fractional anisotropy and radial diffusivity in the brain stem, corpus callosum and corona radiata were significantly (p<0.05) associated with cognitive sequelae, the score on disability rating scale and the modified Rankin scale at year 2 and 5. A normalized acute-phase fractional anisotropy of less than 0.86 in the body of the corpus callosum was more than 75% sensitive/specific in predicting a high disability score at 2 and 5 years. A normalized acute-phase radial diffusivity greater than 1.21 at the genu of the corpus callosum was more than 73% sensitive/specific in predicting a high disability score at 2 and 5 years. CONCLUSION Acute changes in fractional anisotropy and radial diffusivity after severe TBI can predict long-term neurological sequelae with high confidence. DTI changes in the body/genu of the corpus callosum provide the best long-term prognostic value for severe TBI. CLINICAL RELEVANCE/APPLICATION Quantitative DTI can be used as a prognostic tool for prediction of long-term neurocognitive outcome in severe traumatic brain injury.
    Radiological Society of North America 2013 Scientific Assembly and Annual Meeting; 12/2013
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    ABSTRACT: BACKGROUND AND PURPOSE:Extensive white matter damage has been documented in patients with severe traumatic brain injury, yet how this damage evolves in the long term is not well understood. We used DTI to study white matter changes at 5 years after traumatic brain injury.MATERIALS AND METHODS:There were 8 healthy control participants and 13 patients with severe traumatic brain injury who were enrolled in a prospective observational study, which included clinical assessment and brain MR imaging in the acute setting (< 6 weeks) and 2 years and 5 years after injury. Only subjects with mild to moderate disability or no disability at 1 year were included in this analysis. DTI parameters were measured in 20 different brain regions and were normalized to values obtained in an age-matched control group.RESULTS:In the acute setting, fractional anisotropy was significantly lower in the genu and body of the corpus callosum and in the bilateral corona radiata in patients compared with control participants, whereas radial diffusivity was significantly (P < .05) higher in these tracts. At 2 years, fractional anisotropy in these tracts had further decreased and radial diffusivity had increased. No significant changes were detected between 2 and 5 years after injury. The baseline radial diffusivity and fractional anisotropy values in the anterior aspect of the brain stem, genu and body of the corpus callosum, and the right and left corona radiata were significantly (P < .05) associated with neurocognitive sequelae (including amnesia, aphasia, and dyspraxia) at year 5.CONCLUSIONS:DTI changes in major white matter tracts persist up to 5 years after severe traumatic brain injury and are most pronounced in the corpus callosum and corona radiata. Limited structural change is noted in the interval between 2 and 5 years.
    American Journal of Neuroradiology 07/2013; · 3.17 Impact Factor
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    ABSTRACT: The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented.
    Journal of medical ethics 01/2013; · 1.42 Impact Factor
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    American Journal of Neuroradiology 01/2013; · 3.17 Impact Factor
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    ABSTRACT: Le traumatisme crânien sévère est une cause majeure de décès et d’incapacité, suite aux lésions axonales diffuses survenant au moment de l’accident, causées par les forces d’accélération-décélération associées à des rotations rapides de la tête, invisibles, toutefois en TDM et IRM anatomique. L’IRM de diffusion (IRMd), basée sur le modèle tensoriel, voit ses paramètres estimés utilisés pour construire des métriques telles que, l’Anisotropie Fractionnelle (FA), la Diffusion Moyenne (MD) et utilisées dans des études VBM après recalage, souvent imparfait, dans l’espace standard. Dans cette étude, regroupant des sujets de contrôle ainsi que des traumatismes crâniens sévères bon et mauvais pronostique, nous utilisons l’approche TBSS -robuste face aux problèmes du recalage et utilisant le squelette de la FA- pour localiser les lésions axonales diffuses et caractériser le profil de celles caractérisant le mauvais pronostique : elles sont bilatérales, impliquant des structures connues pour leur rôle dans la conscience. Keywords: IRM de diffusion, Lésions Axonales Diffuses, Traumatisme Crânien Sévère, Tractographie. Abréviations : TBSS : Tract Based Spatial Statistic, BP : Bon Pronostic, MP : Mauvais Pronostic, GOS : Glasgow Outcome Scale, FA : Fractional Anisotropy, VBM : Voxel Based Morphometry, SLA : Sclérose latérale Amyotrophique, Lésions Axonales Diffuses : LAD
    The third International Conference on the Image and Signal Processing and their Applications (ISPA'12); 12/2012
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    ABSTRACT: BACKGROUND:: Prognostication in comatose survivors of cardiac arrest is a major clinical challenge. The authors' objective was to determine whether an assessment with diffusion tensor imaging, a brain magnetic resonance imaging sequence, increases the accuracy of 1 yr functional outcome prediction in cardiac arrest survivors. METHODS:: Prospective, observational study in two intensive care units. Fifty-seven comatose survivors of cardiac arrest underwent brain magnetic resonance imaging. Fractional anisotropy (FA), a diffusion tensor imaging value, was measured in predefined white matter regions, and apparent diffusion coefficient was assessed in predefined grey matter regions. Prediction of unfavorable outcome at 1 yr was compared using four prognostic models: FA global, FA selected, apparent diffusion coefficient, and clinical classifiers. RESULTS:: Of the 57 patients included in the study, 49 had an unfavorable outcome at 12 months. Areas under the receiver operating characteristic curve (95% CI) to predict unfavorable outcome for the FA global, FA selected, clinical, and apparent diffusion coefficient models were 0.92 (0.82-0.98), 0.96 (0.87-0.99), 0.78 (0.65-0.88), and 0.86 (0.74-0.94), respectively. The FA selected model had the best overall accuracy for predicting outcome, with a score above 0.44 having 94% (95% CI, 83-99%) sensitivity and 100% (95% CI, 63-100%) specificity for the prediction of unfavorable outcome. CONCLUSION:: Quantitative diffusion tensor imaging indicates that white matter damage is widespread after cardiac arrest. A prognostic model based on FA values in selected white matter tracts seems to predict accurately 1 yr functional outcome. These preliminary results need to be confirmed in a larger population.
    Anesthesiology 11/2012; · 5.16 Impact Factor
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    ABSTRACT: BACKGROUND:: Existing methods to predict recovery after severe traumatic brain injury lack accuracy. The aim of this study is to determine the prognostic value of quantitative diffusion tensor imaging (DTI). METHODS:: In a multicenter study, the authors prospectively enrolled 105 patients who remained comatose at least 7 days after traumatic brain injury. Patients underwent brain magnetic resonance imaging, including DTI in 20 preselected white matter tracts. Patients were evaluated at 1 yr with a modified Glasgow Outcome Scale. A composite DTI score was constructed for outcome prognostication on this training database and then validated on an independent database (n = 38). DTI score was compared with the International Mission for Prognosis and Analysis of Clinical Trials Score. RESULTS:: Using the DTI score for prediction of unfavorable outcome on the training database, the area under the receiver operating characteristic curve was 0.84 (95% CI: 0.75-0.91). The DTI score had a sensitivity of 64% and a specificity of 95% for the prediction of unfavorable outcome. On the validation-independent database, the area under the receiver operating characteristic curve was 0.80 (95% CI: 0.54-0.94). On the training database, reclassification methods showed significant improvement of classification accuracy (P < 0.05) compared with the International Mission for Prognosis and Analysis of Clinical Trials score. Similar results were observed on the validation database. CONCLUSIONS:: White matter assessment with quantitative DTI increases the accuracy of long-term outcome prediction compared with the available clinical/radiographic prognostic score.
    Anesthesiology 11/2012; · 5.16 Impact Factor
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    ABSTRACT: Contexte La prise en charge de la fin de vie constitue un enjeu sociétal crucial auquel le législateur a répondu par la loi du 22 avril 2005. Néanmoins, un débat émerge de la société civile sur l’opportunité de dépénaliser/légaliser l’euthanasie et/ou le suicide assisté (E/SA). Cette question interroge directement les médecins, en particulier les anesthésistes-réanimateurs (AR). Objectif Mettre en perspective les concepts à partir d’une analyse de la littérature médicale et de l’expérience des pays qui ont légiféré sur E/SA. Résultats La loi du 22 avril 2005 constitue une réponse adaptée à l’essentiel des situations de fin de vie auxquelles est confronté l’AR. Sa force tient à l’obligation de dispenser des soins palliatifs quand les thérapeutiques devenues vaines sont interrompues. Néanmoins, les démarches d’accompagnement et de soins palliatifs sont introduites trop tard durant le cours des maladies fatales. Leur enseignement et des mesures incitatives fortes s’imposent. Les rares cas où E/SA sont demandés par les patients ou leurs proches résultent souvent de décisions non prises en amont et/ou de traitements qui ne considèrent pas le patient dans sa globalité. La mise en œuvre d’E/SA ne se résume pas à la simple affirmation d’un principe d’autonomie. Les procédures d’E/SA laissent entrevoir de réelles difficultés et des risques de dérives. Conclusion Nous formulons un message de prudence et de mesure. Peut-on répondre aux questions douloureuses de la fin de vie, de la souffrance morale, en supprimant le sujet lorsqu’une réelle démarche de soins palliatifs n’a pas été pleinement mise en œuvre ?
    Annales francaises d'anesthesie et de reanimation 09/2012; 31(9):694–703. · 0.77 Impact Factor
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    ABSTRACT: Management of the end of life is a major social issue which was addressed in France by law, on April 22nd 2005. Nevertheless, a debate has emerged within French society about the legalization of euthanasia and/or assisted suicide (E/AS). This issue raises questions for doctors and most especially for anesthetists and intensive care physicians. To highlight, dispassionately and without dogmatism, key points taken from the published literature and the experience of countries which have legislated for E/AS. The current French law addresses most of the end of life issues an intensive care physician might encounter. It is credited for imposing palliative care when therapies have become senseless and are withdrawn. However, this requirement for palliative care is generally applied too late in the course of a fatal illness. There is a great need for more education and stronger incentives for early action in this area. On the rare occasions when E/AS is requested, either by the patient or their loved-ones, it often results from a failure to consider that treatments have become senseless and conflict with patient's best interest. The implementation of E/AS cannot be reduced to a simple affirmation of the Principle of autonomy. Such procedures present genuine difficulties and the risk of drift. We deliver a message of prudence and caution. Should we address painful end of life and moral suffering issues, by suppressing the subject, i.e. ending the patient's life, when comprehensive palliative care has not first been fully granted to all patients in need of it ?
    Annales francaises d'anesthesie et de reanimation 08/2012; 31(9):694-703. · 0.77 Impact Factor
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    ABSTRACT: BACKGROUND:: Anincreasing number of elderly patients are treated for aneurysmal subarachnoid hemorrhage. Given that elderly age is associated with both poor outcome and an increased risk of hydrocephalus, we sought to investigate the interaction between age and hydrocephalus in outcome prediction. METHODS:: We enrolled 933 consecutive patients treated for subarachnoid hemorrhage between 2002 and 2010 and followed them for 1 yr after intensive care unit discharge. We first performed stepwise analyses to determine the relationship among neurologic events, elderly age (60 or more yr old), and 1-yr poor outcome (defined as Rankin 4-6). Within the most parsimonious model, we then tested for interaction between admission hydrocephalus and elderly age. Finally, we tested the association between age as a stratified variable and 1-yr poor outcome for each subgroup of patients with neurologic events. RESULTS:: 24.1% (n = 225) of subarachnoid hemorrhage patients were 60 yr old or more and 19.3% (n = 180) had 1-yr poor outcomes. In the most parsimonious model (area under the receiver operating characteristic curve, 0.84; 95% CI: 0.82 to 0.88; P < 0.001), elderly age and admission hydrocephalus were two independent predictors for 1-yr outcome (P < 0.001 and P = 0.004, respectively). Including the significant interaction between age and hydrocephalus (P = 0.04) improved the model's outcome prediction (P = 0.03), but elderly age was no longer a significant predictor. Finally, stratified age was associated with 1-yr poor outcome for hydrocephalus patients (P = 0.007), but not for patients without hydrocephalus (P = 0.87). CONCLUSION:: In this observational study, elderly age and admission hydrocephalus predicted poor outcome, but elderly age without hydrocephalus did not. An external validation, however, will be needed to generalize this finding.
    Anesthesiology 07/2012; · 5.16 Impact Factor
  • L. Abdennour, C. Zeghal, M. Dème, L. Puybasset
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    ABSTRACT: The brain and the lungs interact early and rapidly when hit by a disease process. Often well tolerated by the healthy brain, an impaired respiratory function may deteriorate further a “sick” brain. Hypoxemia is a prognostic factor in the brain-injured patients. At the opposite, an acute brain damage early impacts the lung function. Local brain inflammation spreads rapidly to the lung. It initiates an immunological process weakening the lungs and increasing its susceptibility to infection and mechanical ventilation. Sometimes this process is preceded by a swelling lesion, known as neurogenic pulmonary oedema, resulting from an sympathetic overstimulation which usually follows an intense and brutal surge of intracranial pressure. The management of brain-injured patients has to be directed toward the protection of both the brain and lung. Neuronal preservation is crucial, because of the lack of regenerative potential in the brain, unlike the lung. A compromise must be obtained between the cerebral and pulmonary treatments although they may conflict in some situations.
    Annales francaises d'anesthesie et de reanimation 06/2012; 31(6):e101–e107. · 0.77 Impact Factor
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    ABSTRACT: The aim of this study in patients with traumatic brain injury (TBI) was to assess the effectiveness of continuous cerebrospinal fluid (CSF) drainage in controlling intracranial pressure (ICP) and minimizing the use of other ICP-lowering interventions potentially associated with serious adverse events. We studied 20 TBI patients. In each patient, we compared four consecutive 12-hour periods covering the 24 hours before CSF drainage (NoDr1 and NoDr2) and the 24 first hours of drainage (Dr1 and Dr2). During each period, we recorded ICP, cerebral perfusion pressure (CPP), sedation, propofol infusion rate, and number of hypertonic saline boluses. With continuous CSF drainage, ICP decreased significantly from 18 ± 6 mmHg (NoDr1) and 19 ± 7 mmHg (NoDr2) to 11 ± 5 mmHg (Dr1) and 12 ± 7 mmHg (Dr2). CPP increased significantly with drainage. Drainage led to a significant decrease in the number of hypertonic saline boluses required for ICP elevation, from 35 in 16 patients (80%) (NoDr1/2) to eight in five patients (25%) (Dr3/4). Drainage was not associated with changes in the midazolam or sufentanil infusion rates. The propofol infusion rate was non-significantly lower with drainage. No significant differences in serum sodium, body temperature, or PaCO(2) occurred across the four 12-hour periods. CSF drainage may not only lower ICP levels, but also decreases treatment intensity during the 24 hours following EVD placement in TBI patients. Because EVD placement may be associated with adverse event, the exact role for each of the available ICP-lowering interventions remains open to discussion.
    Neurochirurgie 05/2012; 58(4):235-40. · 0.32 Impact Factor

Publication Stats

3k Citations
561.16 Total Impact Points

Institutions

  • 2002–2014
    • Hôpitaux Universitaires La Pitié salpêtrière - Charles Foix
      Lutetia Parisorum, Île-de-France, France
  • 2000–2014
    • Pierre and Marie Curie University - Paris 6
      • Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière
      Lutetia Parisorum, Île-de-France, France
    • Institut National des Télécommunications
      Évry-Petit-Bourg, Île-de-France, France
  • 1993–2014
    • Hôpital La Pitié Salpêtrière (Groupe Hospitalier "La Pitié Salpêtrière - Charles Foix")
      • Service de Neurochirurgie
      Lutetia Parisorum, Île-de-France, France
  • 2012
    • University of California, San Francisco
      • Department of Anesthesia and Perioperative Care
      San Francisco, CA, United States
  • 2005–2012
    • Centre Hospitalier Universitaire d'Angers
      Angers, Pays de la Loire, France
    • Assistance Publique Hôpitaux de Marseille
      • Service de neurochirurgie infantile
      Marseille, Provence-Alpes-Cote d'Azur, France
    • Hôpital Charles-Nicolle
      Tunis-Ville, Tūnis, Tunisia
  • 1997–2012
    • invivo-AFDIAR
      United States
  • 2011
    • Johns Hopkins Medicine
      • Division of Neurosciences Critical Care
      Baltimore, MD, United States
  • 2009–2011
    • Centre Hospitalier Universitaire de Nancy
      • Département Anesthésie Réanimation Cardiaque
      Nancy, Lorraine, France
    • Centre Hospitalier Universitaire Rouen
      Rouen, Upper Normandy, France
    • Centre Hospitalier Universitaire de Liège
      Luik, Walloon Region, Belgium
  • 2005–2009
    • Assistance Publique – Hôpitaux de Paris
      Lutetia Parisorum, Île-de-France, France