Bernard Albat

Michel Brunel

Claude Humeau

Maurice Navarro

Yves Allieu

Bernard Canaud

Claude Jaffiol

Henri Navratil

Robert Alric

Paul-André Chaptal

Charles Janbon

Jacques Othoniel

Bernard Arnaud

Albert-Jean Ciurana

François Janbon

Michel Pages

Gérard Asencio

Jacques Clot

Daniel Jarry

Claude Peguret

Jacques Astruc

Pierre Costa

Jacques Jourdan

Jacques Pelissier

Charles Aussilloux

Françoise D'athis

Bernard Klein

Pierre Blanc

Gastroentérologie

Borie Frédéric

Arnaud Bourdin

Gilles Pneumologie

Pédiatrie

William Camu

Captier Neurologie

Anatomie Guillaume

Guillaume Cartron

Guillaume Hématologie

Chanques Cardiologie

Gérald

Christophe Dadure

Yves Physiologie Dauvilliers

Tayrac De

Renaud

Olivier Dereure

Droupy Dermatologie -Vénéréologie

Urologie Stéphane

Anne Ducros

Dupeyron Neurologie

Arnaud

Garrel Renaud

Oto-Rhino-Laryngologie Genevieve

David Génétique

Guillaume Sébastien

Hayot Maurice

Physiologie Houede

Nadine Cancérologie

Jung Boris

Médecine Intensive-Réanimation Kalfa

Nicolas Chirurgie

Klouche Kada

Laurence Lachaud

Thierry Parasitologie

embryologie Jean-Philippe Histologie

L E Bactériologie-Virologie ; Hygiène Hospitalière

Vincent Moing

Maladies

Florence Cardiologie

Matecki Stéfan

Physiologie Moranne

Olivier Néphrologie

Morel Jacques

Rhumatologie Navarro

Jean-Luc Pasquie

Perez Cardiologie

Antonia Martin

Perney Pascal

Michel Prudhomme

Pujol Anatomie

Louis Jean

Diane Pneumologie

Pascal Pédopsychiatrie

Tu-Anh Anatomie

Céline Bourgier

Cancérologie

Delphine Capdevielle

Adultes Psychiatrie D'

Pierre-Géraud Médecine

Pierre- Emmanuel Colombo

Vincent Ophtalmologie Daien

Anne Dorandeu

Florent Fuchs

Viala Gynécologie-Obstétrique

Rhumatologie Cécile

Sylvain Godreuil

Bactériologie-Virologie ; Hygiène Hospitalière

Venail Frédéric

Oto-Rhino-Laryngologie Villain

Max Ophtalmologie

Vincent Denis

Thierry Vincent

Immunologie

Lambert Philippe

Amouyal Michel

Clary Bernard

Garcia Marc

Bessis Didier

Pédiatrie Agathe Roubertie

PERSONNEL ENSEIGNANT Professeurs Honoraires

Je remercie mes parents, Florent, Clara et tous mes proches pour leur soutien tous au long de mes études.

Merci à Michaël, mon mari et meilleur ami, merci de toujours être à mes côtés et de me pousser à devenir chaque jour meilleur. Je suis fier du chemin que nous avons déjà parcouru et impatient de continuer tous nos projets ensemble.

Pour terminer j'ai une pensée pour tous les patients que j'ai rencontré au cours de ma formation, qui m'ont permis d'apprendre et de devenir un meilleur médecin. This retrospective observational study relates patients admitted for aneurysmal SAH in the year 2021. We conducted teleconsultations to evaluate the neurologic functional outcome and the prevalence of anxiety and depression symptoms at 6 months. We analyzed localization and volume of cortex infarction among patients with anxiety symptoms.

One hundred thirteen patients were included. Twenty-two patients died. We were able to carry out teleconsultation for 74 of the 91 survivors. Fifty-eight (60.4%) patients had good outcome. The prevalence of anxiety and depression symptoms were respectively 50% (95%CI 39-62%) and 36.5% (95%CI 31-49%). Twenty-one percent of patients resumed their professional activity without any change. Eleven anxious patients presented cerebral injuries on scans. Three patients showed lesions in areas potentially linked to anxiety.

This study shows that after SAH half of the patients presents anxiety symptoms and more than a third suffers from depression symptoms. These psychiatric disorders have a great negative impact on the return to professional activity. The presence of cerebral injuries on standard imaging does not seem to be linked to the onset of anxiety symptoms.

INTRODUCTION

Subarachnoid hemorrhage (SAH) is a rare type of stroke. It is a sudden irruption of blood into the spaces covering the brain and filled with cerebrospinal fluid [START_REF] Suarez | Aneurysmal Subarachnoid Hemorrhage[END_REF] . The leading cause of SAH is by far the rupture of an intracranial aneurysm, representing 80 percent of cases [START_REF] Van Gijn | Subarachnoid haemorrhage: diagnosis, causes and management[END_REF] . In France the incidence is around 9 cases for 100,000 inhabitants per year [START_REF] Rooij Nk De | Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends[END_REF] . The mean age of 55 years at presentation and the elevated death rate of 30 to 50 percent make it a dreadful affliction leading to prolonged stay in hospital [START_REF] Suarez | Aneurysmal Subarachnoid Hemorrhage[END_REF][START_REF] Rowland | Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm[END_REF][START_REF] Nieuwkamp | Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a metaanalysis[END_REF] .

Subarachnoid hemorrhage is an important cause of disability among survivors. According to recent French studies, around 30 percent of patients present at least a moderate disability (modified Rankin Scale ≥ 3) at one-year post ictus, this number increases to almost 70 percent for patients requiring mechanical ventilation [START_REF] Cinotti | Evolution of neurological recovery during the first year after subarachnoid haemorrhage in a French university centre[END_REF][START_REF] Chalard | Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation[END_REF] . Neurological impairments such as sensitivo-motor deficits, coordination disorders or sphincter disfunction have a considerable impact on the activity of daily living 8 but the large majority of patients suffer from less obvious impairments affecting the neuro-cognitive functions. Almost half of "recovered" patients presents memory disorder or behavioral disturbances and a third reports fatigue and sleep disorder with 40 to 60 percent of patients unable to resume their previous professional occupation one year after aneurysmal rupture [START_REF] Cinotti | Evolution of neurological recovery during the first year after subarachnoid haemorrhage in a French university centre[END_REF][START_REF] Al-Khindi | Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage[END_REF] .

One of the most common psychologic disorders after SAH is anxiety, described among 27 to 54 percent of patients and that can persist up to 7 years [START_REF] Morris | Anxiety and Depression after Spontaneous Subarachnoid Hemorrhage[END_REF][START_REF] Martinaud | Anatomy of executive deficit following ruptured anterior communicating artery aneurysm[END_REF][START_REF] Noble | POSTTRAUMATIC STRESS DISORDER EXPLAINS REDUCED QUALITY OF LIFE IN SUBARACHNOID HEMORRHAGE PATIENTS IN BOTH THE SHORT AND LONG TERM[END_REF][START_REF] Ogden | Neurological and Psychosocial Outcome 4 to 7 Years after Subarachnoid Hemorrhage[END_REF] . Depression, known to be common in neurological diseases and to worsen the global outcome, represents around 30 percent of patients and lasts for at least 5 years for 72 percent of patients [START_REF] Tang | Depression after Subarachnoid Hemorrhage: A Systematic Review[END_REF][START_REF] Ackermark | Longitudinal course of depressive symptoms and anxiety after aneurysmal subarachnoid hemorrhage[END_REF] .

Besides, it does not seem to exist any link between the development of psychologic disorders and the initial gravity of the SAH. Anxiety and depression also have a real negative impact on patients' life since they reduce the ability to return to work and the social activity [START_REF] Morris | Anxiety and Depression after Spontaneous Subarachnoid Hemorrhage[END_REF] .

Some studies show that anxiety and depression could be linked to specific brain regions like the amygdala and the insula [START_REF] Williams | Precision psychiatry: a neural circuit taxonomy for depression and anxiety[END_REF][START_REF] Fox | A Translational Neuroscience Approach to Understanding the Development of Social Anxiety Disorder and Its Pathophysiology[END_REF] . Thereby, left frontal strokes seem to generate more early onset depression than right frontal ones [START_REF] Robinson | MOOD DISORDERS IN STROKE PATIENTS: IMPORTANCE OF LOCATION OF LESION[END_REF] . Concerning SAH, which leads to more heterogenous lesions through several mechanisms, there is currently no evidence of a correlation between the topography of a central nervous lesion and the development of psychiatric disorders.

The aim of this study is to describe the prevalence of anxiety and depression 6 months after an aneurysmal SAH and to explore the link between the localization of cerebral lesions and the development of these neuro-cognitive symptoms.

MATERIAL AND METHODS

Study population

We conducted a retrospective monocentric cohort study of the patients admitted to the French University Hospital Center of Montpellier for aneurysmal SAH over 2021. Noninclusion criteria were according to the French law: patients under 18 years old, pregnant or breastfeeding women, patients under tutelage or curatorship, not registered in the social security system, or patients who refused to participate [START_REF] Toulouse | French legal approach to clinical research[END_REF] .

Patients' characteristics

We collected demographic data, medical history of anxiety or depression, habitus, weight and height from medical files. The data about SAH included the initial Glasgow Coma Scale (GCS), the World Federation of Neurological Surgeons score (WFNS), the simplified acute physiology score II (SAPS II), the type of aneurysm, the presence of intracranial or intraventricular hemorrhage and the modified Fisher scale [START_REF] Frontera | Prediction of Symptomatic Vasospasmafter Subarachnoid Hemorrhage: The Modified Fisher Scale[END_REF] .

Management protocol

Conventional management: Aneurysm exclusion was performed as soon as possible after the admission. Neuroradiologists and neurosurgeons decided collegially between endovascular coiling or surgical clipping. In case of hydrocephalus, an external ventricular drain (EVD) was placed. Surgical procedures including intracerebral hemorrhage (ICH) evacuation and/or decompressive craniectomy were performed when necessary. All patients were treated according to the international guidelines [START_REF] Connolly | Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association[END_REF] .

Patients requiring mechanical ventilation because of their critical state (GCS < 9) or to prevent secondary brain damage were admitted to the intensive care unit (ICU) while patients with less severe presentation were hospitalized in intermediate care unit.

Management of vasospasm and delayed cerebral ischemia: All patients received nimodipine. In case of suspicion of vasospasm or delayed cerebral ischemia computed tomography (CT) or magnetic resonance imaging (MRI) were used to diagnose angiographic vasospasm and/or delayed cerebral infarction [START_REF] Frontera | Defining Vasospasm After Subarachnoid Hemorrhage: What Is the Most Clinically Relevant Definition?[END_REF] . Most severe vasospasms were treated with continuous intravenous infusion of milrinone [START_REF] Lannes | Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol[END_REF] . Combined cerebral intra-arterial milrinone and nimodipine infusions were administered as a rescue therapy 23- 25 . As a last resort, percutaneous transluminal angioplasty was performed [START_REF] Hoh | Endovascular Treatment of Cerebral Vasospasm: Transluminal Balloon Angioplasty, Intra-Arterial Papaverine, and Intra-Arterial Nicardipine[END_REF] .

Long-term outcome

We carried out a teleconsultation at 6 months from the admission. A 30-minute videocall was performed by a senior intensivist following a semi-structured interview which can be found in annex.

The points of this interview were to:

-assess long-term functional neurological outcome using the modified Rankin Scale (mRS) [START_REF] Rankin | Cerebral Vascular Accidents in Patients over the Age of 60: II. Prognosis[END_REF][START_REF]Simplified Modified Rankin Scale Questionnaire[END_REF] and the Glasgow Outcome Scale Extended (GOSE) [START_REF] Wilson | Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use[END_REF][START_REF] Jennett | Disability after severe head injury: observations on the use of the Glasgow Outcome Scale[END_REF] .

-evaluate the level of disability through questions about the autonomy at home, the capacity to return to work, to resume hobbies and social activity, the presence of new relationship difficulties.

-search for neuropsychological symptoms such as fatigue, cephalalgia, motor or sensitive impairment, pain, vertigo, balance disorder, slowness, memory disorder, concentration disorder.

-detect symptoms of anxiety and depression as described in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) [START_REF]Diagnostic and Statistical Manual of Mental Disorders[END_REF] .

In addition, patients answered two self-assessment scales sent by mail or email, the Hospital Anxiety and Depression Scale (HADS) [START_REF] Zigmond | The Hospital Anxiety and Depression Scale[END_REF] and the EuroQol-5 Dimensions (EQ5D) [START_REF]EuroQol -a new facility for the measurement of health-related quality of life[END_REF][START_REF] Andrade | A French Value Set for the EQ-5D-5L[END_REF]

Infarction analysis

We focused on patients with anxiety symptoms for topographic analysis. We localized the cortex infarction according to the Atlas of the Human Brain from Mai et al [START_REF] Mai | Atlas of the human brain[END_REF] where Ai is the infarct area in mm 2 manually segmented on scan section i and H is the section thickness.

We differentiated the lesions pathogenesis:

-Early Brain Injury (EBI): presence, on a CT scan or MRI scan performed within 48-72 hours after the initial bleeding, of hypodensities or intraparenchymal hemorrhage caused either by initial aneurysm bleeding, intracranial pressure elevation, aneurysm-securing procedure or resulting from EVD placement [START_REF] Chalard | Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation[END_REF][START_REF] Schmidt | Cerebral infarction associated with acute subarachnoid hemorrhage[END_REF][START_REF] Gonçalves | Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis[END_REF][START_REF] Ayling | Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage[END_REF] .

-Delayed Cerebral Infarction: infarction on CT scan or MRI scans, absent from the scan performed between 24 and 48 hours after aneurysm occlusion, and not attributable to another cause: aneurysm-securing procedure or EVD placement [START_REF] Chalard | Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation[END_REF][START_REF] Vergouwen | Definition of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage as an Outcome Event in Clinical Trials and Observational Studies Proposal of a Multidisciplinary Research Group[END_REF] .

RESULTS

Demographics and clinical data

During the year 2021, 113 patients were admitted for aneurysmal SAH. The introduction of an antidepressant or an anxiolytic treatment were left to the decision of the intensivist. During their hospitalization, 18 patients received an antidepressant and 20 received an anxiolytic. The most common indication, when reported in the medical file, was insomnia.

Early brain injury, vasospasm and delayed cerebral ischemia

Forty-seven patients (41.6%) presented early brain injuries on the scans performed at

Survival and long-term functional outcome

The six-month patients' follow-up is summarized in Figure 1. Long term outcome is displayed in Figure 2 with GOSE and mRS. Twenty-two patients passed away at hospital.

We were able to carry out teleconsultations for 74 of 91 survivors (81.3%). Fifty-eight patients (60.4%) had good outcome (mRS<3). In detail, 7 (7.3%) had no symptoms (mRS=0), 20 (20.8%) had symptoms without disability (mRS=1), 31 (32.3%) had slight disability (mRS=2), 8 (8.3%) had moderate disability (mRS=3), 6 (6.2%) had moderately severe disability (mRS=4), 2 (2.1%) had severe disability (mRS=5). measures the degree of disability or dependence on a scale from 0 to 6: 0 -no symptom; 1 -no significant disability despite some symptoms; 2 -slight disability but no dependence; 3 -moderate disability but walking conserved without assistance; 4 -moderately severe disability; 5 -severe disability; 6 -death.

Daily living impairments

Data collected during the interviews are shown in Table 2. At 6 months, 85.1% of patients were living at home, 13.5% were still in rehab. Fifty-nine patients (79.7%) were able to live at home without any assistance. Among the fifty-one patients who worked before the hospitalization, 21.6% resumed their professional activity without any change, 15.7% returned to work with reduced responsibilities or working part-time and 62.7% were on sick leave. Fifty-three percent of patients could address their family responsibilities and 45.9% resumed their hobbies and social activities as before. Thirty-five percent of patients reported relationship issues. Finally, patients estimate their state of health at about 70 (± 20) out of 100.

Neurocognitive symptoms

The prevalence of anxiety and depression symptoms were respectively 50% (95%CI 39-62%) and 36.5% (95%CI 31-49%).

The large majority of patients reported neuropsychological symptoms at 6 months. The most common were fatigue (66.2%), anxiety symptoms (50%), depression symptoms (36.5%), memory disorder (51.4%), concentration disorder (47.3%) and cephalalgia (37.8%).

Patients with anxiety

Results collected with self-assessment scales are shown in Table 3

Infarction analysis

Two third of anxious patients did not have any lesion on imaging. Table 4 describes the cortex infarction localization and volume of the 11 remaining patients. Only two patients had significant cerebral infarction (>5 cm 3 ). One patient who suffered from intracranial hypertension presented an insular and amygdala lesion. Two patients who presented an intracranial hemorrhage of sylvian area were diagnosed with an insular injury. Among other analyzed patients, the volume and/or the topography do not seem to explain the development of anxiety symptoms. Fifty percent of assessed patients presented anxiety symptoms and around 40% presented depression symptoms. Though the prevalence of anxiety and depression symptoms suffers from a great variations depending on the method and the time of assessment, the rate of short term anxiety symptoms goes from 27 to 59% [START_REF] Al-Khindi | Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage[END_REF][START_REF] Morris | Anxiety and Depression after Spontaneous Subarachnoid Hemorrhage[END_REF][START_REF] Bartlett | Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis[END_REF] . As for depression symptoms, the prevalence in previous studies is in the range of 25 to 32% [START_REF] Tang | Depression after Subarachnoid Hemorrhage: A Systematic Review[END_REF][START_REF] Bartlett | Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis[END_REF] .

Concerning stroke, the prevalence of anxiety symptoms seems to be much lower with a rate between 18 to 25% while the prevalence of depression reported is 31% [START_REF] Burton | Frequency of Anxiety after Stroke: A Systematic Review and Meta-Analysis of Observational Studies[END_REF][START_REF] Hackett | Part I: Frequency of Depression after Stroke: An Updated Systematic Review and Meta-Analysis of Observational Studies[END_REF] . Among patients suffering from traumatic brain injury, a third of them presented depressive disorder and around 17% anxiety symptoms [START_REF] Jorge | Major Depression Following Traumatic Brain Injury[END_REF][START_REF] Max | Anxiety Disorders in Children and Adolescents in the First Six Months After Traumatic Brain Injury[END_REF] .

Only 21% of patients resumed their professional activity without any change. These findings seem to be in adequation with the recent study of Cinotti et al. who reported 37% of patients resuming professional activity at twelve months. Regarding non-visible symptoms, the large majority of patients reported at least one neuropsychological symptom, the most common being fatigue.

In our study, interviews conducted by untrained intensivists may cause interobserver variations in the evaluation of the level of disability or in the screening for neuropsychological symptoms. The use of a semi-structured interview limits greatly this heterogenicity but it is still up to the practician to insist, reformulate or maybe skip a question, leading to a different answer from the patient. Standardized questionnaires such as the HADS are not fit for diagnosing clinical anxiety or depression but allow us to detect significative symptoms of anxiety and depression. Moreover, we chose to use an eight-point threshold for HADS, to detect more patients at risk for anxiety and depression in order to address them to a specialist who can confirm the diagnosis and assure a treatment.

We know that patients hospitalized in ICU, even for a non-neurological disease, are at risk to develop neurocognitive symptoms defining the post intensive care syndrome [START_REF] Needham | Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference*[END_REF] .

Indeed, a third of ICU survivors experiences anxiety or depression symptoms during the first year after critical illness. Severity of illness and length of stay are not associated with these symptoms, only patients with psychiatric symptoms before or during the stay and with delusional experiences have a higher prevalence of anxiety and depression [START_REF] Nikayin | Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis[END_REF][START_REF] Rabiee | Depressive Symptoms After Critical Illness: A Systematic Review and Meta-Analysis[END_REF][START_REF] Davydow | Posttraumatic stress disorder in general intensive care unit survivors: a systematic review[END_REF] . In our study, 40% of patient were not hospitalized in ICU but in intermediate care unit due to a mild presentation and they presented as much psychiatric symptoms at 6 months as ICU patients. These patients endured less invasive interventions, they did not undergo mechanical ventilation nor sedation and only a few of them experienced delusional episode.

Some psychiatric studies report insula hypoconnectivity in depression, social anxiety and panic disorder leading to difficulties distinguishing relevant salient cues and avoidance of situations that could generate stimulus overload [START_REF] Williams | Precision psychiatry: a neural circuit taxonomy for depression and anxiety[END_REF] . Amygdala is also known to play a central part in anxiety. Indeed, functional MRI in inhibited adults shows a faster amygdala response with a prolonged and exaggerated reactivity, a decreased amygdala habituation and an increased amygdala volume. Moreover, hippocampus and orbitofrontal cortex have a regulatory role in presence of a stressful stimulus by providing contextual information to the amygdala [START_REF] Fox | A Translational Neuroscience Approach to Understanding the Development of Social Anxiety Disorder and Its Pathophysiology[END_REF][START_REF] Mizzi | Resting-state neuroimaging in social anxiety disorder: a systematic review[END_REF] . In this study, we did not find any link between the localization of brain injuries and the presence of anxiety symptoms at 6 months. Indeed, In conclusion, in our population, half of SAH survivors presents anxiety symptoms and more than a third of them depression symptoms. Considering the large proportions of patients suffering from these psychiatric disorders and the fact that their development seems unpredictable, every patient should receive a psychologic follow-up to assure the best care for them.

  Merci à toute l'équipe du DAR B de m'avoir appris l'importance de la rigueur dans une bonne prise en charge des patients de réanimation, merci pour vos encouragements qui m'ont poussé à m'améliorer. Merci beaucoup à l'incroyable équipe paramédicale, même si elle a un peu tendance a râler quand les nouveaux internes arrivent ! Merci à Marion, Virginie, Faustine, Valentine, Julien, Justine, Mathilde, Lucile, Mélissa, Nadège, Charlène, Laurène, c'était vraiment un plaisir de travailler avec vous ! Je remercie l'équipe du DAR A et leurs nerfs à toute épreuve. Merci à Hugues de m'avoir montré qu'on peut gérer des situations catastrophiques en restant calme, bienveillant et en pensant à commander des burgers. Merci à toi Camille pour ton énergie et ta bonne humeur même pendant les gardes les plus difficiles. Merci beaucoup à Pauline, la rigueur dans ta prise en charge des patients, l'attention que tu portes aux autres membres de l'équipe et la volonté que tu as de chaque jour apprendre quelque chose à tes étudiants font de toi un véritable exemple à suivre. Merci à Élie et Geoffrey pour ce que vous m'avez appris et pour ne pas m'avoir balancé quand j'allais chez le coiffeur sur les heures de boulot.Merci à toute l'équipe de la maternité et du bloc ortho de Nîmes pour votre gentillesse et votre volonté de voir les internes s'améliorer et s'épanouir.Un grand merci aux anesthésistes de pédiatrie. J'ai sincèrement adoré travailler avec chacun d'entre vous. Vous aimez votre travail et vous le faites aimer à vos internes. J'ai énormément appris au cours de ces six mois et grâce à vous, pas une fois je ne me suis fait peur alors que cette spécialité me terrorisait. J'espère de tout coeur pouvoir revenir et apprendre davantage au sein de votre équipe.Je remercie pour finir l'équipe du DAR C pour votre accueil chaleureux ce semestre, que ce soit côté bloc ou réa. Je me sens déjà à ma place parmi vous et je suis impatient de pouvoir m'investir dans cette équipe et tous ses projets. Un merci tout particulier à toi Flora, c'est un vrai plaisir de travailler avec toi, j'admire ta volonté de faire au mieux pour tes patients et leurs proches et je m'efforcerai de suivre ton exemple pour devenir aussi bon médecin que tu l'es. Un grand merci à Mélanie, j'attaque mes premières années de Docteur sereinement et avec joie en sachant que je les passerais aux côtés d'une amie sur qui je peux compter (et qui peut compter sur moi aussi !).Un grand merci à tous les copains qui m'ont accompagné pendant toutes années ! A Laurie, Morgane et Romain pour avoir partagé les galères du tout premier semestre ! Et à tous les copains de l'internat de Béziers. A la team du DAR B et leurs gros caractères (pire répartition de gardes EVER), merci pour les soirées au Fizz qui se sont changées en apéro dans le patio covid oblige, merci pour le barbeuc et l'olivier (il se porte bien rassurez-vous), bref merci à vous Anaelle, Shoushou, Clara, Joséphine, Marine, Maxime, Rim, Alexis, Marlène et Pirerre. Merci bien sûr à Lauriane, Sophie, Clément et Yassir de nous avoir préparer aux topos en nous payant des verres la veille. A la team du DAR A, merci pour ce semestre incroyable, ça me manque de partager ce bureau avec vous. Merci à Benjamin, Camille, Marlène, Simon, Guillaume et je crois que j'ai oublié personne… Je plaisante, merci Alice ! Aux petitous du DAR C, Sarah, Victoria, Imen, William, Simon, Nicolas, Louis, Emile, Rémi, Sybille, Julien.

Figure 1 .

 1 Figure 1. Six-month patients' follow-up. Poor outcome defined as mRS≥3 and good outcome as mRS<3.

Figure

  Figure2. Long-term functional outcome after subarachnoid hemorrhage. Patients were assessed during teleconsultation 6 months after the SAH. Glasgow Outcome Scale Extended (GOSE) measures the degree of disability or dependence on a scale from 8 to 1: 8 -good recovery upper level; 7 -good recovery lower level; 6 -moderate disability upper level; 5 -moderate disability lower level; 4 -severe disability upper level; 3 -severe disability lower level; 2 -vegetative state; 1 -death. Modified Rankin Scale (mRS) measures the degree of disability or dependence on a scale from 0 to 6: 0 -no symptom; 1 -no significant disability despite some symptoms; 2 -slight disability but no dependence; 3 -moderate disability but walking conserved without assistance; 4 -moderately severe disability; 5 -severe disability; 6 -death.

only 3

 3 patients over the 34 anxious patients had cerebral infarction in areas potentially involved in anxiety pathogenesis. These results participate to support the theory that neurocognitive disorders in SAH are not the direct consequences of cerebral injuries detected by standard MRI scans. Functional MRI or fluorodeoxyglucose-positron emission tomography (FDG-PET) may be useful to detect patients at risk to develop psychiatric symptoms after SAH.Anxiety among SAH patients may be explained by intrusive thoughts about a potential new rupture of the aneurysm which could lead to a far worse outcome. Besides, these patients had no medical history at all and are now considered sick by themselves, their families and their colleagues. They have life-long pharmacologic treatment, strict schedule of control scans and arteriography. A lot of the interviewed patients reported great difficulties to accept this new role.

Maîtres de Conférences des Universités -Praticiens Hospitaliers MCU-PH Hors classe -Echelon Exceptionnel

	IMMEDIATO DAIEN Claire MCU-PH de 2 éme classe	Rhumatologie
	JACOT William BARATEAU Lucie	Cancérologie ; Radiothérapie Physiologie
	JEZIORSKI Eric BERGOUGNOUX Anne	Pédiatrie Génétique
	LALLEMANT Benjamin MARTRILLE Laurent Médecine légale et droit de la santé Oto-rhino-laryngologie BOETTO Julien Neurochirurgie
	LATTUCA Benoît RICHARD Bruno CHIRIAC Anca	Cardiologie Médecine palliative Immunologie
	LE QUINTREC DONNETTE Moglie DE JONG Audrey	Néphrologie Anesthésiologie-réanimation et médecine péri-opératoire
	LETOUZEY Vincent MCU-PH Hors classe DESHAYES Emmanuel	Gynécologie-obstétrique ; gynécologie médicale Biophysique et médecine nucléaire
	LONJON Nicolas BADIOU Stéphanie DU THANH Aurélie	Neurochirurgie Biochimie et biologie moléculaire Dermato-vénéréologie
	LOPEZ CASTROMAN Jorge BOULLE Nathalie Biologie cellulaire Psychiatrie d'Adultes ; addictologie FITENI Frédéric Cancérologie ; radiothérapie
	LUKAS Cédric CACHEUX-RATABOUL Valère GATINOIS Vincent	Rhumatologie Génétique Histologie, embryologie et cytogénétique
	MENJOT de CHAMPFLEUR Nicolas CARRIERE Christian Bactériologie-virologie ; hygiène hospitalière Radiologie et imagerie médicale GOUZI Farès Physiologie
	MILLET Ingrid CHARACHON Sylvie HERBAUX Charles	Radiologie et imagerie médicale Bactériologie-virologie ; hygiène hospitalière Hématologie, transfusion
	MURA Thibault FABBRO-PERAY Pascale HUBERLANT Stéphanie	Biostatistiques, informatique médicale et technologies de la communication Epidémiologie, économie de la santé et prévention Gynécologie-obstétrique ; Gynécologie médicale
	NAGOT Nicolas GIANSILY-BLAIZOT Muriel Hématologie ; transfusion Biostatistiques, informatique médicale et technologies de la communication LEVEQUE Maude Parasitologie et mycologie
	OLIE Emilie MAKINSON Alain	Psychiatrie d'adultes; addictologie Maladies infectieuses, Maladies tropicales
	PARIS Françoise MCU-PH de 1 re classe MARIA Alexandre	Biologie et médecine du développement et de la reproduction ; gynécologie médicale Médecine interne ; gériatrie et biologie du vieillissement ; addictologie
	PELLESTOR Franck BERTRAND Martin PANTEL Alix	Histologie, embryologie et cytogénétique Anatomie Bactérologie-virologie ; hygiène hospitalière
	POUDEROUX Philippe BOUDOUSQ Vincent Biophysique et médecine nucléaire Gastroentérologie ; hépatologie ; addictologie PERS Yves-Marie Thérapeutique; addictologie
	RIGAU Valérie BRET Caroline ROUBILLE Camille	Anatomie et cytologie pathologiques Hématologie biologique Médecine interne ; gériatrie et biologie du vieillissement ; addictologie
	RIVIER François BROUILLET Sophie SZABLEWSKY	Pédiatrie Biologie et médecine du développement et de la reproduction ; gynécologie médicale Anatomie et cytologie pathologiques
	ROGER Claire COSSEE Mireille	Anesthésiologie-réanimation et médecine péri-opératoire Génétique
	ROSSI Jean François GIRARDET-BESSIS Anne	Hématologie ; transfusion Biochimie et biologie moléculaire
	ROUBILLE François HERRERO Astrid	Cardiologie Chirurgie viscérale et digestive
	SEBBANE Mustapha LAVIGNE Géraldine	Médecine d'urgence Hématologie ; transfusion
	SIRVENT Nicolas LESAGE François-Xavier Médecine et Santé au Travail Pédiatrie
	SOLASSOL Jérôme MATHIEU Olivier	Biologie cellulaire Pharmacologie fondamentale ; pharmacologie clinique ; addictologie
	STERKERS Yvon MOUZAT Kévin	Parasitologie et mycologie Biochimie et biologie moléculaire
	STOEBNER Pierre PANABIERES Catherine Biologie cellulaire Dermato-vénéréologie
	SULTAN Ariane RAVEL Christophe	Nutrition Parasitologie et mycologie
	THOUVENOT Éric SCHUSTER-BECK Iris	Neurologie Physiologie
	THURET Rodolphe THEVENIN-RENECéline Immunologie Urologie
	TUAILLON Edouard	Bactériologie-virologie; hygiène hospitalière

Maitres de Conférences des Universités Maîtres de Conférences hors classe

	LADRET Véronique	Mathématiques appliquées et applications des mathématiques
	LAINE Sébastien	Sciences du Médicament et autres produits de santé
	LE GALLIC Lionel	Sciences du médicament et autres produits de santé
	LOZZA Catherine	Sciences physico-chimiques et technologies pharmaceutiques
	MAIMOUN Laurent	Sciences physico-chimiques et ingénierie appliquée à la santé
	MOREAUX Jérôme	Science biologiques, fondamentales et cliniques
	MORITZ-GASSER Sylvie	Neurosciences
	MOUTOT Gilles	Philosophie
	PASSERIEUX Emilie	Physiologie
	RAMIREZ Jean-Marie	Histologie
	RAYNAUD Fabrice	Sciences du Médicament et autres produits de santé
	TAULAN Magali	Biologie Cellulaire
		Maîtres
	BERNEX Florence	Physiologie
	CHAZAL Nathalie	Biologie cellulaire
	Maîtres de Conférences de classe normale
	BECAMEL Carine	Neurosciences
	CHAUMONT-DUBEL Séverine	Sciences du médicament et des autres produits de santé
	DELABY Constance	Biochimie et biologie moléculaire
	GUGLIELMI Laurence	Sciences biologiques fondamentales et cliniques
	HENRY Laurent	Sciences biologiques fondamentales et cliniques
	HERBET Guillaume	Neurosciences

de Conférences des Universités -Médecine Générale MCU-MG de 1 re classe

	COSTA David
	OUDE ENGBERINK Agnès

MCU-MG de 2 éme classe

	PH chargés d'enseignements Je souhaite remercier toutes les personnes qui ont participé à ma formation au cours de REMERCIEMENTS
	Praticiens Hospitaliers Universitaires BRINGER-DEUTSCH Sop DJANIKIAN Flora LE MOINE DONY Marie-Christine ces dernières années. ABOUKRAT Patrick	RIDOLFO Jérôme
	CAZAUBON Yoann AGUILHON Sylvain BRINGUIER BRANCHERE Je tiens tout d'abord à remercier les membres du jury d'avoir accepté de lire et d'évaluer Pharmacologie fondamentale ; pharmacologie clinique ; addictologie DONNADIEU-RIGOLE Hélène LETERTRE Simon RIPART Sylvie Merci à de l'équipe de Réanimation de Béziers où j'ai fait mes premiers pas d'internes,
	DAGNEAUX Louis AKKARI Mohamed BRISOT Dominique FAIDHERBE Jacques Chirurgie orthopédique et traumatologique LOPEZ Régis ce travail qui conclut dix années d'études en Médecine. mes premières VVC posées en 2 heures, mes premières intubations (oesophagiennes), RONGIERES Michel
	DUFLOS Claire ALRIC Jérôme BRONER Jonathan FATTON Brigitte Biostatistiques, informatique médicale et technologies de la communication LUQUIENS Amandine ROULET Agnès
	Merci au Professeur Gérald Chanques, pour ce que vous m'avez appris au cours des mes premières gardes sans fermer l'oeil de peur d'être appelé. Je vous remercie pour
	GOULABCHAND Radjiv AMEDRO Pascal CADE Stéphane	Médecine interne ; gériatrie et biologie du vieillissement ; addictologie FAUCHERRE Vincent MANZANERA Cyril RUBENOVITCH Josh
	gardes rarement calmes du DAR B, pour vos paroles d'encouragement qui m'ont donné votre patience, votre bienveillance et votre soutien. Un énorme merci à toute l'équipe
	MIOT Stéphanie AMOUROUX Cyril CAIMMI Davide Paolo FAURE Elsa Médecine interne ; gériatrie et biologie du vieillissement ; addictologie MARGUERITTE SANTONI Fannie
	Emmanuel confiance en moi alors que je n'étais qu'un tout jeune interne, pour tout ce que vous paramédicale véritablement adorable sur laquelle les internes peuvent réellement
	ROCH Benoît ANTOINE Valéry CARR Julie partagez à vos étudiants, que ce soit à propos de la Médecine mais aussi de l'Histoire et Pneumologie, addictologie FILLERON Anne MARTIN Lucille SASSO Milène compter.
	SARRABAY Guillaume ARQUIZAN Caroline CARTIER César	Génétique FILLOLS Mélanie	MATTATIA Laurent	SCHULDINER Sophie
	SOUCHE François-Régis ATTALIN Vincent CASPER Thierry de la Culture. Cette phrase de Rabelais résonnera dans ma tête toute ma carrière : « Chirurgie viscérale et digestive FITENI Frédéric MEROUEH Fadi SEGURET Fabienne Je remercie l'équipe du bloc de Saint Eloi pour m'avoir appris les bases de l'anesthésie.
	AYRIGNAC Xavier Science sans conscience n'est que ruine de l'âme ». Je sais à quel point le bien-être CASSINOTTO FOURNIER Philippe MEYER Pierre SENESSE Pierre Merci à Daniel et Yvan pour votre envie de transmettre. Merci à Michaëla qui faisait
	Christophe psychologique des patients de réanimation vous tient à coeur et j'espère que ce travail
	BADR Maliha saura susciter votre intérêt. CATHALA Philippe	GAILLARD Nicolas	MICHEL Moïse	SERRE Jean-Emmanuel
	BAIS Céline	CAZABAN Michel	GALMICHE Sophie	MILESI Christophe	SKALLI El Medhi
	BARBAR Saber Davide CHARBIT Jonathan GENY Christian Merci au Professeur Pierre-François Perrigault, pour votre patience, votre bienveillance et MORAU Estelle SOLA Christelle
	BASSET Didier votre humilité, des qualités que j'espère pouvoir développer et savoir mettre au service CHEVALLIER Thierry GERONIMI Laetitia MORQUIN David SOULLIER Camille
	BATIFOL Dominique des patients et de mon équipe comme vous le faites. CHEVALLIER-GINIES Patrick MOSER Camille	SOUKSI MEDIONI Isabelle
		MICHAUD J
	BATTISTELLA Pascal COLIN Olivier Merci au Professeur Sébastien Guillaume d'avoir accepté de faire partie de ce jury. Bien GRECO Frédéric MOUSTY Eve STOEBNER DELBARRE Anne
	BAUCHET Luc que la réanimation et la psychiatrie soient deux spécialités très différentes, j'espère CONEJERO Ismael GUEDJ Anne Marie MOUTERDE Gaël TEOT Luc
	BELL Ariane réussir à illustrer avec ce travail à quel point il est bénéfique pour les patients de travailler CONSEIL Mathieu GROSSIN Delphine PANSARD Nicole THIRION Marina
	BENEZECH Jean-Pierre ensemble.	CORBEAU Catherine GUYON Gaël	PERNIN Vincent	TUNEZ Virginie
	BENNYS Karim Et bien sûr merci au Dr Kévin Chalard. Je suis très fier de travailler aux côtés d'un médecin COROIAN Flavia-Oana HEDON Christophe PERRIGAULT Pierre François VACHIERY-LAHAYE Florence
	FOLCO-LOGNOS Béatrice BERNARD Nathalie COUDRAY Sarah aussi passionné, investi et soucieux d'améliorer la prise en charge des patients. Merci de HENRY Vincent PEYRON Pierre-Antoine VERNES Eric
	CARBONNEL François BERTCHANSKY Ivan CRANSAC Fréderic JAMMET Patrick m'avoir toujours apporté ton soutien et tes encouragements au cours de ce projet alors PICARD Eric VIALA Maurice
	BIBOULET Philippe que je n'ai littéralement respecté aucune de tes dead lines (et j'en suis sincèrement CUNTZ Danielle JEDRYKA François PICOT Marie Christine VINCENT Laure
	Maîtres de Conférences associés -Médecine Générale DARDALHON Brigitte JREIGE Riad PIERONI Laurence WAGNER Laurent désolé). Ce sera un véritable plaisir de continuer de travailler avec toi. BIRON-ANDREANI Christine
	CAMPAGNAC Jérôme BLANC Brigitte DAVID Aurore	KINNE Mélanie	POQUET Hélène	WALTHER LOUVIER Ulrike
	LOPEZ Antonio BLANCHARD Sylvie Il y a une autre personne que je veux remercier, quelqu'un sans qui ce travail n'aurait DE BOUTRAY Marie LABARIAS Coralie PUJOL Sarah-Lise ZERKOWSKI Laetitia
	BLANCHET Catherine DE LA TRIBONNIÈRE pas été possible. Un grand merci à toi Océane, d'abord pour ton aide inestimable au cours LABORDE Caroline PUPIER Florence MILLION Elodie MINET Mathilde Xav BLATIERE Véronique DEBIEN Blaise LACAMBRE Mathieu QUANTIN Xavier de ce projet, ces heures passées aux archives ou à compléter de monstrueux tableurs,
	PAVAGEAU Sylvain BOBBIA Xavier DELPONT Marion mais aussi pour toutes les idées et les réflexions qu'on a pu partager au cours des derniers LANG Philippe RAFFARD Laurence
	REBOUL Marie-Catherine BOGE Gudrun DENIS Hélène mois, et surtout, merci pour l'amour que tu portes aux patients, pour toute l'empathie LAZERGES Cyril RAPIDO Francesca
	BOURRAIN Jean Luc DEVILLE de que tu as pour chacun d'eux et pour la volonté que tu as de mettre la recherche au LE GUILLOU Cédric RIBRAULT Alice SERAYET Philippe PERIERE Gil BOUYABRINE Hassan DI CASTRI Alberto LEGLISE Marie Suzanne RICHAUD-MOREL service de leur bien-être.
				Brigitte

semblant de me gronder parce que je ne mettais pas aiguille, guide, dilatateur et cathéter bien dans l'ordre sur ma table mais qui m'a quand même laissé faire ma première induction tout seul. Merci à toi Marie pour ton énergie, ta bienveillance et ta confiance.

Merci bien sûr à tous les IADE pour ce qu'ils m'ont appris et particulièrement à Muriel.

TABLE DES MATIERES

 DES ABREVIATIONS ..................................................................................................................................... ABSTRACT ............................................................................................................................................... INTRODUCTION ................................................................................................................................... MATERIAL AND METHODS ................................................................................................................ Study population .............................................................................................................................. Patients' characteristics ................................................................................................................ Management protocol .................................................................................................................... Long-term outcome ........................................................................................................................ Infarction analysis ..........................................................................................................................Aneurysmal subarachnoid hemorrhage has an elevated death rate and leads to severe disability. Anxiety and depression symptoms are often reported among patients and prevent them to resume their professional and social activities. Studies show that insula, amygdala and frontal cortex are involved in the development of anxiety but there is currently no link between cerebral injuries due to SAH and the development of psychiatric disorders.

	ABREVIATIONS ADAPT: Anxiety and Depression after Aneurysmal subarachnoid hemorrhage and
	correlation between Psychologic disorder and lesion Topography
	CT: computed tomography
	ABSTRACT
	EBI: early brain injury
	EQ-5D: EuroQol 5 Dimensions
	EVD: external ventricular drain
	GCS: Glasgow Coma Scale
	GOSE: Glasgow Outcome Scale Extended
	HADS: Hospital Anxiety and Depression Scale
	ICH: intracerebral hemorrhage
	ICU: intensive care unit
	SAPS II: simplified acute physiology score II
	MRI: magnetic resonance imaging
	mRS: modified Rankin Score
	SAH: subarachnoid hemorrhage
	WFNS: World Federation of Neurological Surgeons

Statistical analysis........................................................................................................................... Ethics and consent .......................................................................................................................... RESULTS .................................................................................................................................................. Demographics and clinical data ................................................................................................. Early brain injury, vasospasm and delayed cerebral ischemia ....................................... Survival and long-term functional outcome .......................................................................... Daily living impairments ............................................................................................................... Neurocognitive symptoms............................................................................................................ Patients with anxiety ..................................................................................................................... Infarction analysis .......................................................................................................................... REFERENCES .......................................................................................................................................... ANNEXES .................................................................................................................................................

Table 1

 1

	presents

The most frequent exclusion procedure was endovascular coiling (83.2%). Eleven patients (9.7%) were not treated due to a decision of withdrawal of care. Twelve patients (10.6%) underwent surgical evacuation of an intracranial hemorrhage and 54 (47.8%) presented hydrocephalus needing external ventricular drain. Seventy patients (61.9%) were admitted in ICU while 43 (32.3%) were hospitalized in intermediate care unit. Sixtythree patients (55.8%) requested mechanical ventilation and 53 (46.9%) were sedated representing respectively 90% and 75.7% of ICU patients. Mean length of mechanical ventilation was 16.6 days and mean length of sedation was 11.7 days.

Table 1 . Description of the 113 patients with subarachnoid hemorrhage.

 1 Data are expressed as means ± SD. BMI indicates Body Mass Index; SAH, Subarachnoid Hemorrhage; WFNS, World Federation of

	48-72 hours after the initial bleeding. During the stay, 74 patients (65.5%) presented
	angiographic vasospasm and 12 (10.6%) had delayed cerebral infarction. Twenty patients
	(17.7%) underwent intra-arterial treatment including milrinone and nimodipine infusions
	and/or angioplasty.

Neurological Surgeons; GCS, Glasgow Coma Scale; AComA, Anterior Communicating Artery; ACA, Anterior Cerebral Artery; IC, Internal Carotid; PComA, Posterior Communicating Artery; MCA, Middle Cerebral Artery; PCA, Posterior Cerebral Artery; PICA, Posterior Inferior Cerebellar Artery; BA, Basilar Artery; EVD, External Ventricular Drain; ICU, Intensive Care Unit.

Table 2 . Description of the type of disability and neuropsychological disorders among the 74 patients who participate to the teleconsultation 6 months after a subarachnoid hemorrhage.

 2

						GOSE
	N = 96
	0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
		GOSE 1	GOSE 2	GOSE 3	GOSE 4	GOSE 5	GOSE 6	GOSE 7	GOSE 8
						mRS
	N = 96
	0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
			mRS 6	mRS 5	mRS 4	mRS 3	mRS 2	mRS 1	mRS 0

Table 3 . Self-assessment of state of health, anxiety and depression symptoms.

 3 . Among the 74 patients interviewed in teleconsultation at 6 months, 34 (50%) presented anxiety symptoms and 6 patients could not be assessed due to lack of data. Anxious patients were young with Patients evaluated their state of health using the visual scale from 0 to 100 of the EuroQol 5 Dimensions questionnaire. Patients were screened for anxiety and depression symptoms using the Hospital Anxiety and Depression questionnaire. A score of 8 or more indicates a possible case of anxiety or depression and a score of 11 or more indicates a high probability of case.

	a mean age of 52 years old. One patient had history of anxiety disorder and 3 patients
	of depression. Sixteen anxious patients (47.1%) were hospitalized in ICU versus 18
	(52.9%) hospitalized in intermediate care unit only (p=0.808).
	Twenty-eight patients (82.4%) had a good functional outcome at 6 months (mRS < 3 or
	GOSE > 4). Twenty-nine patients (85.3%) were living at home at 6 months, 4 were still
	in rehab. Thirty patients (88.2%) were able to stay at home without any assistance. Six
	patients (17.6%) resumed their professional activity without any change and 6 (17.6%)
	returned to work with reduced responsibilities or at part-time.
	Nineteen patients (55.9%) reported relationship difficulties (mostly due to irritability).
	Nineteen patients (55.9%) reported depression symptoms and 23 (67.6%) complained
	about memory disorder.
	Self-assessment scales (n=62)	Score
	EQ-5D self-assessment of the state of health	70.4 ± 20.7
	HAD Anxiety	7.2 ± 4.6
	HAD Anxiety ≥ 8, n (%)	28 (45.2%)
	HAD Anxiety ≥ 11, n (%)	16 (25.8%)
	HAD Depression	5 ± 4.4
	HAD Depression ≥ 8, n (%)	20
		(32.25%)
	HAD Depression ≥ 11, n (%)	10 (16.1%)

Table 4 . Cortex infarction localization and volume quantification

 4 . WFNS indicates World Federation of Neurologic Surgeons; GOSE, Glasgow Outcome Scale Extended; mRS, modified Rankin Scale; HAD, Hospital Anxiety and Depression; MCA, Middle Cerebral Artery; SCA, Superior Cerebellar Artery; PCA, Posterior Cerebral Artery; IC, Internal Carotid; AComA, Anterior Communicating Artery; ACA, Anterior Cerebral Artery.

	Age Sex	Fisher scale	WFNS	Aneurysm localization	Infarction pathogenesis	Cortex infarction localization	Infarction (cm 3 ) volume	GOSE mRS	HAD score Anxiety
							Parietal Lobe	Left superior parietal lobule Left inferior parietal lobule	0,605 1,665
								Left precentral gyrus	1,36
	43 F	2	III	Left MCA	Embolic	Frontal Lobe	Left middle & inferior frontal gyri	2,2	6	2	12
							Occipital lobe	Left occipital gyrus	7,46
							Cerebellum	Left cerebellum	1,55
	64 F	4	IV	Right SCA	Embolic	Cerebellum	Right cerebellum	1,02	6	2	9
								Left straight gyrus	2,136
								Right straight gyrus	2,267
								Left cingular gyrus	3,468
								Right cingular gyrus	3,263
								Left orbital gyrus	6,862
							Frontal Lobes	Right orbital gyrus Left superior frontal gyrus	7,583 1,967
								Right superior frontal gyrus	2,751
								Right middle frontal gyrus	6,951
								Right precentral gyrus	1,817
	44 F	4	IV	Right PCA	Intracranial hypertension		Left precentral gyrus Right inferior frontal gyrus	0,449 5,188	4	3	12
							Insular Lobe	Right insula	8,837
								Right transverse temporal gyrus & planum temporal	3,401
								Right superior temporal gyrus	2,514
							Temporal Lobe	Right middle temporal gyrus Right amygdala	13,342 0,269
								Right hippocampus	0,231
								Right entorhinal and periamygldaloid cortex	0,34
							Parietal Lobe	Right postcentral gyrus	0,664
								Left precental gyrus	NA*
							Frontal Lobe	Left inferior frontal gyrus	NA*
	50 F	4	V	Left IC	Intrasylvian (12cm3) hematoma	Temporal lobe Parietal Lobe	Left operculum Left postcentral gyrus Left parietal operculum planum temporal Left transverse temporal gyrus &	NA* NA* NA* NA*	4	3	14
							Insular Lobe	Left insula	NA*
						Corpus
	64 M	4	IV	AComA	callosum haemorrhage (5cm3)	Corpus callosum dissection	NA*	4	3	4
						Left ACA compression	Frontal Lobe	Left cingular gyrus Left superior frontal gyrus	2,02125* 1,63375*
						Delayed		Left postcentral gyrus	1,625
	59 M	4	II	AComA	ischemia cerebral	Parietal Lobe	Left superior parietal gyrus	2,18	5	2	12
								Left precental gyrus	NA*
							Frontal Lobe	Left inferior frontal gyrus	NA*
						Intrasylvian		Left operculum	NA*
	52	F	4	III	Left MCA	hematoma		Left superior temporal gyrus	NA*	3	4	17
						(16cm3)	Temporal Lobe	Left middle temporal gyrus	NA*
								Left inferior temporal gyrus	NA*
							Insular Lobe	Left insula	NA*
	62 F	3	II	Left PCA	Embolic	Cerebellum	Right cerebellum	0,07	7	1	9
	45 F	3	I	Left MCA	Embolic	Frontal Lobe	Right middle frontal gyrus Left precental gyrus	0,028 0,014	6	2	21
	47 F	4	II	Left IC	Delayed cerebral	Parietal Lobe	Left postcentral gyrus Left superior parietal gyrus	2,23 0,27	5	2	14
	54 F	3	I	AComA	Bilateral ACA compression	Frontal Lobe	Left cingular gyrus Right cingular gyrus	1,488 2,196	6	2	6

SERMENT

En présence des Maîtres de cette école, de mes chers condisciples et devant l'effigie d'Hippocrate, je promets et je jure, au nom de l'Etre suprême, d'être fidèle aux lois de l'honneur et de la probité dans l'exercice de la médecine.

Je donnerai mes soins gratuits à l'indigent et n'exigerai jamais un salaire au-dessus de mon travail.

Admis dans l'intérieur des maisons, mes yeux ne verront pas ce qui s'y passe, ma langue taira les secrets qui me seront confiés, et mon état ne servira pas à corrompre les moeurs, ni à favoriser le crime.

Respectueux et reconnaissant envers mes Maîtres, je rendrai à leurs enfants l'instruction que j'ai reçue de leurs pères.

Que les hommes m'accordent leur estime si je suis fidèle à mes promesses. Que je sois couvert d'opprobre et méprisé de mes confrères si j'y manque.

Statistical analysis

Categorical variables were presented as numbers with percentage and compared using the chi square test when necessary. Prevalence of anxiety and depression symptoms was provided with its ninety-five-percent confidence interval (CI). Continuous variables were expressed as means ± standard deviation (SD). Statistical significance was set at 0.05.

Ethics and consent

This retrospective research was approved by the local Institutional Review Board of the University Hospital Center of Montpellier (IRB-MTP_2022_09_202201223). Since this research was non-interventional, information notes were sent to every patient or patient's relatives. Patients were allowed to refuse the use of their data, according to French law.


Dimitra Gaki
email: dimgaki@uth.gr

Serafim Felekis
email: sfelekis@engineer.com

George Vlahos
email: gvlahos@aua.gr

Irina Herzon
email: iryna.herzon@helsinki.fi

Maite Puig De Morales Fusté

Tristan Berchoux
email: berchoux@iamm.fr

Ruth Bennettcoady
email: ruth.bennettcoady@gmit.ie

Ionel Mugurel Jitea
email: mjitea@usamvcluj.ro

Yanka Kazakova
email: yanka.kazakova@gmail.com

Myriam Kessari
email: kessari@iamm.fr

Olgica Klepac
email: olgica.klepac@fazos.hr

Valentin Mihai
email: valentin.mihai@usamvcluj.ro

James Moran
email: james.moran@gmit.ie

Snježana Tolic
email: snjezana.tolic@fazos.hr

Marija Roglic
email: m.roglic@montpellier-bs.com

Innovative Education for Sustainable Development in Peripheral Rural Areas

Keywords: Sustainable rural development, peripheral rural areas, innovative education, participatory process

This paper aims to present the results of the Erasmus + RUR'UP project that developed educational tools for scientists, public managers, practitioners, and agricultural advisors living and working in peripheral rural areas. Based on the assessment of the educational needs and gaps for the sustainable development of the EU peripheral rural areas of Greece, Bulgaria, Romania, Croatia, Finland, Ireland and France via a participatory innovation process, we have developed: an asynchronous e-learning course and supporting educational materials. The objective was to provide educational tools that will help the professional competencies of the Higher Education (HE) institutions working with peripheral rural regions by answering to the labour market and societal needs in these regions, thereby strengthening the collaboration between higher education and regional and cross-regional employers. The project resulted in 50 students who attended the e-learning course and the development of Open-Access educational materials with pedagogically sound activities associated with them, which can be used by any actor interested in the sustainable development of peripheral rural areas, especially those with high natural values in the form of a Virtual Bank of Case studies that gathers 14 examples of case studies.

Introduction

EU peripheral rural areas cover almost 30% of the utilised agricultural area and nearly 15% of agricultural holdings [START_REF] Keenleyside | High Nature Value farming throughout EU-27 and its financial support under the CAP[END_REF]. They are of the most significant importance for rural livelihoods, cultural heritage, biodiversity, and ecosystem services such as carbon sequestration and water retention (SDG for United Nations Sustainable Development Goals: SDG8-Decent Work and Economic Growth, SDG15-Life on Land, SDG13-Climate Action). Additionally, these areas contain a vast part of the EU's biodiversity capital and a series of traditional farming practices. They contribute meaningfully to the local economy due to the small-scale production procedures they maintain and the unique geographical conditions. Depopulation, for instance, drains them of human capital and forces entrepreneurs to acquire various skills and competencies. Producers often face a complex dilemma in modernising production while avoiding potential wider social and environmental damage inflicted by the process. Despite their importance for rural livelihoods, cultural heritage, biodiversity, and ecosystem services such as carbon sequestration and water retention, these areas face social, political, and environmental pressures. Higher education is essential in achieving sustainable development goals (SDGs), specifically in peripheral rural areas that face isolation and often fall under the radar of mainstream education and development.

To answer these challenges, the Erasmus + RUR'UP project developed educational tools for scientists, public managers, practitioners and agricultural advisors living and working in these areas. Seven European universities and institutions commonly implemented them.

In what follows, we will present the research context, methodology and the key results of the Erasmus + project RUR'UP.

Research Context

RUR'UP project builds on the work carried on under HNV-Link project, an H2020 thematic network (2016-2019) that focused on the work with local actors in High Nature Value (HNV) farmland that aimed at demonstrating how so-called HNV brokers can be engaged with other regional actors for HNV conservation [START_REF] Poux | What is the relevant approach for engaging territorial actors in an HNV innovation project? A strategic perspectivefindings from HNV-Link H2020 Thematic Network[END_REF].

It uses local examples to show how innovations can be mobilised to conserve HNV farming systems. The work of this thematic network pointed out the importance of means and knowledge when dealing with high nature-value farmlands in peripheral rural areas [START_REF] Poux | What is the relevant approach for engaging territorial actors in an HNV innovation project? A strategic perspectivefindings from HNV-Link H2020 Thematic Network[END_REF]. The network identified two critical gaps in the HE fields in its innovation brokering work in 10 European HNV farming regions.

Firstly, interdisciplinary curriculum approaches commonly lack understanding and developing farming innovations. Secondly, the specific problems faced by farms in these regions (poor access to face-to-face advisory, lack of awareness of innovative marketing modes, absence of skilled human resources (including digital skills), lack of organisational and governance skills, etc.). Thirdly, the key target groups for HE are at the heart of the RUR'UP project. Students, teaching and training personnel, researchers and innovation actors such as farmers, agribusinesses, local action groups, NGOs and administrations work in and with peripheral rural areas. The work with this group of actors revealed their need to learn in a flexible and continuous (life-long learning) way, to work collaboratively and be able to work creatively with innovation in a problem-based context.

To sum up, the HNV-Link thematic network identified the necessity for non-members of the higher education institutions that engage in knowledge brokering to access educational materials they could use for self-learning and advisory needs. Therefore, Erasmus + RUR'UP developed educational materials to answer this "brokerage" need. The objectives of the RUR'UP project were:

1. To gain an understanding of the specific skills and competencies needed by the labour market and societal needs in the peripheral rural areas 2. To support curricula development that will ensure the attainment of critical skills and competencies 3. To strengthen the collaboration between HE and potential regional and cross-regional employers 4. To support the professional competencies of the higher education educators in such regions and working with such regions 5. To contribute to the international pool of open educational resources (OER)

We will proceed to present the methodology mobilised in developing our educational materials.

Methodology

To reach our objectives, we have adopted a stepwise approach. First, we have assessed the educational needs and gaps for the sustainable development of the EU peripheral rural areas to identify the learning gaps. Secondly, we have engaged in a transdisciplinary process to prepare the open educational resources (OER) and an adaptable curriculum. Thirdly we have built on the innovation processes identified within HNV-Link to develop a bank of case studies that will support the course. Thirdly we have engaged in a pilot implementation of the e-course via an online learning platform proposing it as an elective course within our universities. Fourthly, we have developed an open syllabus that addresses HE institutions and local actors. Lastly, we have developed a reflective report on the approach and the methodology adopted to reach the project objectives to evaluate the effectiveness with which the developed educational materials have answered the identified educational needs and gaps for sustainable development of the EU peripheral rural areas.

The Assessment of the Education Needs and Gaps for the Sustainable Development of the EU Peripheral Rural Areas

To identify the educational needs and gaps, we first conducted structured internet searches to review the current programs and curricula developed in the EU tertiary education systems for the sustainable development of the peripheral rural areas. We have focused on the bachelor's and master's programs designed in Bulgaria, Croatia, Greece, Finland, France, Ireland and Romania.

As there is no common understanding of what peripheral rural areas are, we have focused on investigating the curriculum that provides graduates and stakeholders working in mountain regions that are characterised as areas handicapped by a short growing season because of a high altitude or by steep slopes, or by a combination of the two at a lower altitude, HNV, natural park or Natura 2000 sites.

We have focused on the programs that provided education in disciplines relevant to the four HNV innovation types: regulatory, technical, social and the market, as identified by the HNV-Link thematic network as necessary for the sustainability of such areas.

This was complemented by the criteria established by the United Nations as Key sustainable development goals:

1. Decent work and economic growth 2. Life on Land

We have complemented these criteria with definitions used to identify the role of the peripheral rural areas in the geographical pool of students and the academic degree levels [START_REF] Jitea | The assessment of the education needs and gaps for the sustainable development of the EU peripheral rural areas[END_REF]. See figure 1. In the second step, with the scope to better understand the needs of professionals working in peripheral rural areas, we have used focus groups and surveys to develop an in-depth understanding of the knowledge and skills practitioners need. We have expanded on the existing community of practitioners developed at the local level within the HNV-Link thematic network. This ecosystem included farmers' associations, local action groups, AgroCusters, advisory services, educators, consultants and actors working in the public sector at the local and regional levels.

Using the focus group technique, we have investigated the needs in six cross-education themes:

Development of the RUR'UP e-Course "Sustainable Development in Peripheral Rural Areas in the EU"

Based on the assessment done in the previous step, we have developed a 6-module course, "Sustainable development in the peripheral rural areas in the EU" that was attended by 50 students from 7 countries in the spring semester of the academic year 2021/2022. The modules are presented in Figure 2.

During the course, the students have worked on real-life examples of innovation processes in Bulgaria, Croatia, Greece, Finland, France, Ireland and Romania. The scope was to engage in problemsolving as a way for students to broaden their understanding of peripheral rural areas' social, environmental, and economic characteristics. The students were asked to recognise the needs and opportunities for sustainable development and to engage in the participatory innovation process, with diverse innovations as potential solutions to the identified challenges.

All the course and learning activities took place on the CPD Learnonline.ie online platform run by GMIT, the Irish partner in the project. Activities were in English. A selection of students succeeding in the course attended RUR'UP Summer School in Greece during the summer of 2022.

The learners who completed the educational process were awarded with a total of 3 digital badges as a recognition of the knowledge and skills acquired: a Digital Badge after the completion of module 3 (explorer badge), a second Digital Badge after the full completion of the e-learning course (Graduate badge), and a digital Badge after the completion of the Summer School. The EPALE platform (online platform for adult education in Europe) was used to disseminate the produced content. In addition, the project has created a RUR'UP content under the UE platform EPALE (Electronic Platform for Adult Learning in Europe) for wider public dissemination of the course content, amongst other project content and productions, as the overall Virtual Bank of Case Studies.

Development of the Intensive Study Activity: RUR'UP Summer School in Greece

Building on the e-course, we have developed a 7-day intensive study activity during which the students have built upon and developed the skills acquired during the e-course:

1. Broad understanding of social, environmental, and economic characteristics of Peripheral Rural Areas in their regional contexts 2. Insights into the participatory innovation process 3. Awareness of the variety of existing innovations of relevance and their transferability across contexts 4. Practice international collaborative work, also with diverse stakeholders in English

We will proceed to present the results of the abovementioned approaches.

Results

To produce higher education tools for scientists, public managers, practitioners and agricultural advisors working and living in peripheral rural areas facing social, political and environmental pressures, we have joint upjoined actors from peripheral rural areas.

Firstly, we have produced a report that delineates the identified gaps in the HE relating to peripheral rural areas and the needs of the local actors (working on those areas). Figure 3 identified the gap between the knowledge and the skills that graduates acquired and the knowledge and skills required by local actors to work in such areas. Employers and practitioners from project peripheral rural areas pointed out as relevant a holistic and in-depth understanding of interactions between land use, environment, and economy related to the peripheral rural areas. This was an element we have already found in existing masters' programmes in the form of either technical knowledge or more focused on the socio-economic aspects. However, none of the programmes brings these two elements together.

What was judged as essential but missing from the HE curricula was the knowledge to use production techniques in a way that is respectful to the agrobiodiversity and work on diversification of agricultural products that will be supported by collective marketing actions, as well as the education of the existing public policies that will be followed with examples allowing the students to use it for problem-solving. Problem-solving is a way to find a gap representing an opportunity for developing multifunctional exploitation, agritourism business or handicraft.

Secondly, building on the identified gaps, we developed an e-course consisting of the following six modules:

In module one, students learnt about critical strategic issues in sustainable development and key particularities of those areas. The module provided links to educative tools on sustainable development strategies (e.g., Videos and papers)

In module two, the students learnt on baseline assessment and how to elaborate a territorial diagnosis. They were introduced to their peripheral rural area (PRA) case study. In this module, the students explored their case study's social, environmental, and economic characteristics and were taught how to identify the main weaknesses of PRAs. The students were asked to use mind mapping methodology to holistically explore a complex case study.

In module three, the students learnt the basics of the innovation and participatory innovation processes. The students were asked to recognize the role of participatory visioning and the importance of actors in territorial development. They were also asked to identify the innovation needs in their PRA case study.

In module four, the students learnt on the innovations of PRA and were requested to identify critical elements of an innovation process relevant to their case study area; to evaluate how a specific innovation case follows an innovation process and recognise the needs for innovation bundles.

In module five, the students were introduced to the innovation brokering process of a project. They learnt on the strategies and key points of the innovation transfer, dissemination and communication and capitalization elements and were requested to recognise the role of innovation transfer for the sustainable development of PRA. The objective was to make students aware that the process does not stop with an innovation implementation but continues through innovation exchange, transfer and dissemination.

In module six, the e-course student portfolio, the students submitted the e-cource overall portfolio where they should include own reflection linking the innovation process in their case study area to the EU policies and the UN Sustainable Development Goals, by writing a 400 words essay.

Thirdly, we have developed a Virtual Bank of Case Studies on innovative sustainable development for peripheral rural areas. These case studies were part of the e-course and are made available as an open source through the EPALE platform. We developed pedagogical RUR'UP Case study materials for advisors, practitioners and academia providing guidelines on territorial examples. Alongside we have also developed materials for teachers and trainers on how to deliver innovative education on sustainable development in peripheral rural area. This material is linked to the 7 RUR'UP Case studies and cover the following domains:

1. Analysis of the key points of a baseline assessment 2. Mind mapping tool 3. Organising and conducting an efficient farming demonstration event 4. Identifying vulnerabilities and adaptive capacities of a territory 5. Stakeholder analysis in participatory innovation process 6. Introducing Innovation types 7. Building participative projects in peripheral rural areas Fourthly, we have organised a Summer School in Greece (July 2022). This pilot in-field teaching and training course included collective work in groups, field research and presentation of results. Lastly, we have developed Digital Badges to recognise student's learning, knowledge and skills gains. Digital Open Badges provide unlimited ways of communicating knowledge, skills, and competencies. In the course of RUR'UP project, they were used to validate key milestones reached within the online course and skills the student has acquired in each stage of the course. The Digital Badge is in the form of an online certificate that contains the metadata which describes: the name of the badge, its description and criteria page. We have developed in total three digital badges, two for the ecourse and one for the completion of the summer school these were:

1. RUR'UP Explorer badgeawarded after module 3 2. RUP'UP Graduate badgeawarded upon the submission of the portfolio (module 6) and a completion of the course 3. RUR'UP Summer badgeawarded upon the completion of the summer school.

Conclusion

The results of the Erasmus RUR'UP project answer to the identified gap for educational materials for students and practitioners working with and in peripheral rural area.

The developed asynchronous learning course and supporting educational materials contribute to the educational materials for sustainable rural development within Europe, and beyond.

Figure 1 :

 1 Figure 1: Curricula analysis of the bachelor and master's programs (source: RUR'UP project from own data)

Figure 2 :

 2 Figure 2: E-course modules "Sustainable development of peripheral rural areas in the EU" (Source: RUR'UP e-course module's presentations, from CDP Leaning online platform)

Figure 3 :

 3 Figure 3: Identified skills needed by future graduates to improve the sustainability of the peripheral rural area (source: RUR'UP project, from own data)

Figure 4 :

 4 Figure 4: Summer school in Greece (source: pictures from RUR'UP consortium)

  1. Social and institutional innovation skills 2. Regulation and policy needs 3. Products and markets 4. Farming practices and management 5. Soft skills Due to the SARS-COV-2 lockdown, the partners who could not organize focus groups have sent an online survey to 11 to 20 stakeholders from 1. Farmers and small industry; 2. Local action groups or AgroClusters and farmers' associations' representatives; 3. Advisory services, educators, or training providers. 4. Employed or residents in peripheral rural areas; 5. NGO representatives; and 6. Governmental bodies.

Acknowledgements

This paper has received funding within the Erasmus + project RUR'UP. Project number 2020-1-EL01-KA203-079121.

The authors would like to thank all the local actors and practitioners that have participated in this project and the students that attended the e-learning course and the summer school in Greece of the project RUR'UP in the academic year 2021/2022.


Anliati Ahmed Abdallah

Esméralda Longépée

Matthieu Jeanson

Frédéric Bertrand

Claire Gollety

Esméralda Longepee

An interdisciplinary

Introduction

The loss of natural habitats is generally associated with a loss of biodiversity that will cause a change in the functioning of ecosystems and consequently in their capacity to provide ecosystem services. As ecosystem engineers, mangrove crabs fulfil key ecological roles in the structure of the mangrove ecosystem through burrowing and in the functioning through nutrient cycling and bioturbation. They are also of societal and economic interest for the populations.

Between 1950 and 2016, the mangroves of Mayotte have been affected by a moderate regression of 6%. This decrease is not very high, but it hides disparities with some mangroves relatively stable, other mangroves that have strongly decreased. This loss is likely to impact the distribution of crabs and consequently the structure and functioning of the ecosystem.

The objective of this study is to understand the impact of mangrove erosion on the distribution of crabs through an interdisciplinary approach combining methodologies in ecology, human geography and geomorphology.

Results

Abundances of crabs are lower in more eroded transects. At the Mzouazia site, the transect and stations interact, with a higher abundance of individuals at station 54 of transect 2. At the Dapani site, there is no effect of the transect on the stations.

Conclusion

Raesons given by responds to justify the stocks of crabs:

Aerial photographs have shown that the mangroves studied have decreased since 1950, with a retreat concentrated at the bottom of the foreshore. S. serrata, which lives seaward of the mangrove, does not seem to be disappearing according to interviewees, whereas species living within the forested portion seem to be more affected by habitat modification (data for Dapani only, not shown).

The top of the foreshore is not impacted by the retreat of the mangrove. Erosion does not seem to have an effect on C. carnifex, which lives at the landward end. At Mzouazia site, geomorphological measurements and sediment analysis show a higher concentration of sand on the beach ridge in the eroded area. Some interviewees believe the arrival of sand is a cause of crab mortality. They perceive the crab population decrease and link it with the mangrove erosion. Indeed, lower crab abundances and species richness were measured in the most eroded part of the mangrove.

Morphological changes in eroded sections

The analysis of aerial photographs shows that these two mangroves have experienced a regression of -64% for Dapani and -49% for Mzouazia between 1950 and 2020.

Distribution of sediments

Abundance of crabs in mangroves

The data are tested by nested ANOVAs with the factors transect and station nested within the factor site. The transect and station interaction is always significant. Muddy sediments prevail at the center of transects and decreases towards the top of the foreshore. At the Mzouazia site, the percentage of silt is higher on transect 2 than on transect 1, while at Dapani, the values are higher on transect 1 than on transect 2.

"

  de Mayotte (CUFR), 97660 Dembéni, Mayotte, France 2 PRODIG, CNRS, Univ Paris 1 Panthéon Sorbonne, AgroParisTech, Paris Sorbonne Université, IRD, Université de Paris, France 3 ESPACE-DEV, Univ Montpellier, IRD, Univ Antilles, Univ Guyane, Univ Réunion, Montpellier, France 4 MARBEC, Univ Montpellier, CNRS, IFREMER, IRD, Montpellier, France Geomorphology method  Analysis of vertical aerial photographs  Topographic surveys Aerial photography of one study site (IGN, 2016) This crab (S. serrata) lives hidden in the mud [...] The mangrove leaves, the mud stays there. As long as there is mud, there will always be crabs (EM3). C. carnifex 1, 2 Not affected by the presence or abscence of trees 3 Mangrove is decreasing but has not disappeared. The mud where the crabs live is still present 4, 5, 6 Where mangrove has disappeared 2 Constant

  Ecology survey  Measurement of abundance of crab species, identity of dominant mangrove trees, tree circumference, and grain size by using the Point-Centered Quarter Method (PCQM) in 10 sample stations ; height on the foreshore is provided by a digital elevation model.


Rudy Bahouth

Interaction of ultrasonic waves with damage by exploiting the transmission of digital data using guided waves

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

  Discipline, spécialité selon la liste des spécialités pour lesquelles l'École Doctorale est accréditée : Geneviève. Professeur. Université de Bordeaux -Bordeaux Rapporteurs -Mme. ABRAHAM Odile. Directrice de recherche. Université Gustave Eiffel -Nantes -M. FRANKLIN Hervé. Professeur. Université du Havre -Le Havre Examinateurs -M. HEBAZ Salah-Eddine. Maître de conférence. CY Cergy Paris Université -Paris Directeur de thèse : M. BENMEDDOUR Farouk. HDR, Maître de conférence. INSA Hauts-de-France -Valenciennes Co-directeur de thèse : M. ASSAAD Jamal. Professeur. Université Polytechnique Hauts-de-France -Valenciennes Co-encadrant : M. MOULIN Emmanuel. Professeur. INSA Hauts-de-France -Valenciennes (MHz.mm)