Notes depuis la première ligne de la prise en charge de l'AVC.

Même cas, mêmes chiffres, décisions différentes

L'étude des zones grises : où se situe votre propre jugement quand les preuves ne tranchent pas le cas ?

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Pourquoi les preuves ont besoin d'un dépositaire

Un argument, assemblé à partir des notes publiées de l'auteur.

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Là où les réponses se séparent

Deux systèmes s'accordent sur le cas qui a été randomisé et divergent sur celui qui se tient devant vous.

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When the system works, people stay (physician mobility / brain circulation)

I recently received a newsletter from the Athens Medical Association, emphasizing the migration of young physicians as a major threat to the health system ("loss of the most dynamic workforce", "need to fight to retain doctors", "brain drain as a national risk").

I couldn't disagree more with the framing.

Mobility is not a failure. It is one of the fundamental advantages of being a physician within the European Union.

Greece already ranks among the countries with the highest physician-to-population ratios globally. Movement means redistribution within a broader system, it is not a depletion problem.

Those who leave seek better conditions. Those who stay seek the same. The real issue is therefore not mobility but what systems have to offer.

In stroke care, this becomes particularly clear. Vascular neurologists in Greece have increased significantly in recent years. Yet, despite repeated announcements, the development of a reliable national stroke network remains limited. From 19 stroke units announced two years ago, only a small fraction received the promised support to become operational (hint: more than one and less than three).

This is a system design and implementation failure.

Health systems do not become fragile because physicians move. They become fragile when structures, networks, and processes are not in place to function consistently. If anything, mobility exposes these weaknesses.

The priority should not be to "retain" doctors as a static resource. It should be to build systems (ie networks, certification pathways, and functional care models) that can attract, integrate, and retain professionals because these systems work.

When the system works, people stay. And more importantly, they return.

#ESY #Stroke #StrokeCare #StrokeNetwork #HealthSystems #HealthPolicy #BrainCirculation #EuropeanHealthcare
Link: https://lnkd.in/ezMr7Gkn

Simple scans, saved brains

A colleague from Latin America recently reached out asking a very practical question: how should we organize reperfusion treatment for acute ischemic stroke in hospitals where only CT and CTA are available? No perfusion imaging. No advanced software. No luxury of prolonged deliberation. Just the reality faced by many stroke teams worldwide.

One barrier to expanding acute stroke treatment worldwide is the belief that advanced imaging is required to make treatment decisions. In reality, many effective reperfusion strategies can be safely implemented using CT and CTA–based pathways, provided that decisions are structured and protocols are clear.

This short video summarizes a simple but powerful idea: stroke systems should not wait for perfect technology before offering treatment. For many hospitals around the world, CT + CTA is already enough to enable intravenous thrombolysis and organize transfers for thrombectomy when appropriate.

The challenge is not technology alone. It is translating evidence into practical decision frameworks that clinicians can apply in real time.

Together with #kargiotisodysseas and colleagues, we recently reviewed the evidence supporting tailored reperfusion strategies based on imaging availability and thrombectomy access (see link in comments for free download).

The goal is simple: to expand access to life-saving and disability-sparing stroke treatments beyond highly specialized centers. Through Eurostrokes, we are working to translate this evidence into practical SOPs and workflows that stroke teams can adapt to their own systems.

Because in stroke care, the difference between disability and independence often begins with a simple scan and a clear decision.

#Stroke #Thrombectomy #StrokeSystems #GlobalHealth #StrokeCare #Eurostrokes

How Kepler killed the circle in Prague

For two thousand years, celestial motion was believed to be perfect: circular, harmonious, unquestionable. Faced with small but persistent discrepancies in planetary data, Johannes Kepler made a radical decision: he trusted observation over elegance. The ellipse replaced the perfect circle and science changed forever.

Arthur Koestler described these moments beautifully in The Sleepwalkers: progress rarely comes from linear certainty and building brick by brick. It comes from tolerating contradiction long enough to bring down and rebuild the framework.

Walking through Prague this year, I was reminded how often medicine faces similar moments. In stroke care, we rely on structured scores, thresholds, and algorithms. They bring order, enable trials, and support decisions. But reality is rarely circular.

As stroke systems evolve and AI tools become embedded in workflows, the challenge is no longer generating more metrics but integrating them into coherent, updated decision frameworks.

I'm sharing here a short audio reflection created using NotebookLM as an intellectual guide to Kepler's revolution and what it may teach us about updating our clinical paradigms.

Innovation in stroke will not come only from better devices or faster workflows. It will come from the courage to update our models when the data, quietly but persistently, ask us to.

If you visit Prague, consider this your alternative guide: find where certainty broke. That is where progress began.

#Prague #Kepler #StrokeCare #EVT #MedicalInnovation #DecisionMaking #SystemsThinking

EXMINT Prague: EVT decision-making in frail patients

Another great EXMINT course has just been completed in Prague!

As thrombectomy indications expand, the central question is no longer simply "Can we open the vessel?" It is: which patient truly benefits?

During my talk, we explored endovascular treatment (EVT) decision-making in frail stroke patients, a domain where binary algorithms fail. Biological salvageability alone is not enough. A structured decision must integrate:

• Extent and severity of ischemic injury
• Brain reserve (atrophy, SVD, prior infarcts)
• Systemic frailty and pre-stroke functional status
• Patient goals and care preferences

This multidimensional framework deliberately replaces simplistic yes/no trees with layered assessment. Because precision thrombectomy will depend not only on better devices but on better structured decisions embedded in real-world workflows.

As stroke systems evolve, decision complexity is increasing. The next frontier is not more data but better integration of data into coherent clinical pathways. This is where imaging biomarkers, workflow platforms, and system-level design intersect.

Grateful for the thoughtful challenges (and book suggestions) by Wim van Zwam and open debate by many participants that continue to push our field forward.

#Stroke #EVT #Neurointervention #StrokeSystems #DecisionFrameworks #EXMINT #eurostrokes

Low NIHSS stroke: are we under- or over-treating?

At XMINT in Prague, I will present a structured standard operational procedure (SOP) proposal for the management of acute ischemic stroke with low NIHSS.

This is an uncomfortable space in stroke care. We lack definitive randomized data. Yet decisions cannot wait for trials.

Every night, physicians are asked to decide:

• Mild deficit + LVO: treat or observe?
• "Non-disabling" symptoms: by whose definition?
• Imaging mismatch: should perfusion override clinical mildness?

In reality, most centers operate with unwritten rules and individual thresholds. Variation between clinicians even within the same hospital is often substantial. Absence of SOPs for either interventional or medical treatment. No critical follow-up of our decisions. Is this acceptable in 2026?

The expansion of imaging paradigms and endovascular capabilities has outpaced our formal decision frameworks. The result is predictable: noise and bias.

At XMINT, I will present a working SOP framework (not a guideline) aimed at: structuring escalation criteria, defining operational thresholds, reducing intra-center variability, supporting the physician making the decision at 3 a.m.

I expect disagreement and welcome it! Why low NIHSS with LVO should not lead systematically to thrombectomy? Are we being too conservative or aggressive? Hint: both, depends on...

Over the coming months, Eurostrokes will begin releasing editable, printable SOP templates for areas of persistent uncertainty in stroke care. Because in the absence of randomized certainty, structured thinking is not optional. We invite critical engagement.

#StrokeCare #lowNIHSS #AcuteStroke #ClinicalPathways #EXMINT #ESMINT #StrokeSystems

CHOICE-2: intra-arterial thrombolysis after thrombectomy

CHOICE-2 confirms the signal: intra-arterial thrombolysis (IAT) after successful thrombectomy improves outcomes without compromising safety.

The recently presented CHOICE-2 trial (ISC 2026) reinforces a critical shift in stroke care. Building on the original CHOICE trial and our study group's and collaborators' systematic review, the data demonstrates that adjunct intra-arterial alteplase addresses the "last mile" of treatment: persistent microvascular hypoperfusion.

The consolidated evidence (7 RCTs, n=2131). Our meta-analysis, recently published in the European Journal of Neurology, confirms the impact of this approach:

• Superior functional recovery: IAT is associated with a 23% higher likelihood of achieving an excellent functional outcome (mRS 0–1) at 3 months.
• Proven safety profile: no significant increase in symptomatic intracranial hemorrhage (sICH) or 3-month all-cause mortality across the pooled data.
• Alteplase efficacy: network meta-analysis identifies alteplase as the highest-ranking agent for efficacy (SUCRA 90%).

The implementation mandate. The evidence is converging: the limiting factor is no longer efficacy — but implementation. Using a reproducible dosing protocol (0.225 mg/kg alteplase), IAT offers a pragmatic strategy to address microvascular obstruction even after technically successful large-vessel recanalization.

The discussion should now focus on: standardizing cath lab workflows for IAT administration; auditable SOP integration within stroke systems; refining eligibility criteria based on tissue-level reperfusion.

Read the full meta-analysis here: https://lnkd.in/eGKujPc8

#StrokeCare #NeuroIntervention #Thrombectomy #ISC2026 #ClinicalPathways #Eurostrokes

A hidden gem in Paris: the Musée des Arts et Métiers

Just stumbled upon a hidden gem in Paris — the Musée des Arts et Métiers! If you're visiting, skip the touristy fine arts crowds (as amazing as they are) and dive into this treasure trove of human ingenuity.

This museum is a celebration of humanity's upward evolution — of trial, error, and the relentless curiosity that shaped our modern world. Some highlights:

• L'Obéissante, the first public transport vehicle to roll into Paris.
• A bat-like plane that almost flew — an adorable step toward aviation.
• Early motor vehicles with helices for propulsion (imagine trying to brake that thing!).
• A model of the Statue of Liberty, older than the real deal.
• And, of course, Foucault's Pendulum, immortalized in Umberto Eco's brilliant novel.

This museum captures the Cambrian period of modern science and technology from the late 19th century, a time when countless shapes, ideas, and inventions were being tested. Some worked, many didn't — but all contributed to the innovations we enjoy today.

Reflecting on this, I'm reminded of how modern neuroscience, cognitive science, and even machine learning teach us that knowledge isn't just about forming connections — it's about learning to inhibit wrong ones. Discarding false beliefs or ineffective pathways is often the key to progress. Umberto Eco's Foucault's Pendulum explores this concept beautifully, delving into humanity's tendency to crave deeper, hidden Truths — sometimes at the expense of the complex and demanding truths offered by science.

Even the great Newton, while uncovering the laws of planetary motion, spent years chasing the mystical secrets of the Pink Cross Knights. This human longing for clarity and simplicity amidst complexity is timeless — and endlessly fascinating.

So, here's my New Year wish: may 2025 bring you curiosity, wonder, and a thirst for knowledge. Go learn something new, explore the unexpected, and yes — read Eco! Happy New Year!

#Paris #MuséeDesArtsEtMétiers #FoucaultsPendulum #UmbertoEco #HistoryOfScience #Curiosity