The management of stroke patients. Conference of experts with a public hearing. Mulhouse (France), 22 October 2008

Abstract The objective is to define as early as possible appropriate criteria for managing patients who have had a cerebrovascular accident (CVA), or stroke, beginning in the Neurovascular and Acute Care Services, in order to facilitate the patient's return home (or the equivalent of home) or continuing care in the most appropriate health care facility. Three clinical assessment tools are used in the initial care phase because they are robust and reproducible: – the National Institutes of Health Stroke Scale (NIHSS) score appears to be the best clinical assessment tool. It is the reference scale used during the acute phase of a stroke because it predicts the patient's chances of recovery and the medium-term functional recovery; – the Glasgow Coma Scale (GCS) is an initial assessment tool useful in predicting the medium-term evolution in terms of level of consciousness, essentially in cases of cerebral hemorrhage or severe cerebral infarction; – the Barthel Index (BI), scored from 0 – 100, is used during the first seven days after a stroke, and the index's progression over the following two weeks is a factor in predicting the functional recovery of stroke patients. The values of these tools must take the markers of clinical stability into account during the initial phase. These markers also have a predictive value: – the curve of the relationship between blood pressure (BP) and the prognosis of stroke patients would have a U-shape, with extreme BP values having a negative influence; – hyperthermia and hypoxia are also early predictive factors of poor functional and vital prognoses; – the presence and continuation of urinary incontinence and/or swallowing disorders are important predictive factors for a poor functional prognosis and a higher mortality rate in the medium term. Complementary examinations make it possible to approximate the anatomical, metabolic and physiological status of the injured cerebral parenchyma early on, when the processes of reparation and plasticity restoration have already begun. The reparation process is a complex multifactor phenomenon that can, at any moment, be called into question; it cannot be predicted with certainty by complementary examinations only, at least at the current level of knowledge. Two parameters seem decisive in using imaging to predict stroke recovery: MRI exploration of the cerebral parenchyma and the exploration of vascular permeability via perfusion imaging. Currently, the place of functional and molecular