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ObjectiveTo find early hemodynamic predictors of outcome and reperfusion injury in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) after endovascular treatment (EVT).MethodsSerial transcranial color-coded sonography examinations assessed the vessel status and cerebral hemodynamics of 185 (109 [58.9%] men, mean age 69.5 ± 12.3 years) consecutive patients with acute anterior circulation LAO soon after, at 48 hours after, and 1 week after EVT.ResultsSuccessful recanalization (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11–0.61) and normal peak systolic velocity (PSV) ratio (PSV of recanalized middle cerebral artery/PSV of contralateral middle cerebral artery) at 48 hours (OR 0.22, 95% CI 0.15–0.64) and after 1 week (OR 0.11, 95% CI 0.07–0.31) from EVT were independent predictors of good outcome at 3 months. Thrombectomy failure (OR 10.22, 95% CI 1.47–45.53) and pathologic PSV ratio at 1 week from EVT (OR 15.23, 95% CI 4.54–46.72) were associated with a worse 90-day outcome. Patients who subsequently developed postinterventional intracranial hemorrhage (ICH) showed a higher mean PSV ratio (3.5 ± 0.2 vs 2.4 ± 0.1, p < 0.0001) soon after successful recanalization. In multivariate analysis, early PSV ratio was independently associated with postprocedural ICH (OR 8.474, 95% CI 3.066–45.122, p < 0.01]. At 1 week from EVT, 15 of 21 (71.4%) patients with ICH who resumed normal PSV values had a better 90-day outcome (modified Rankin Scale score 0–2: 40% vs 0%).ConclusionPost-EVT ultrasound monitoring of stroke patients might be an effective bedside method for assessing treatment efficacy, shedding light on outcome variability and identifying patients at increased risk of ICH.

Background: The risk of stroke and the long-term prognosis of recurrent strokes in young patients with patent foramen ovale (PFO) are not well known. For this reason, the treatment of these patients remains empirical. An alternative treatment to prolonged antithrombotic therapy may be surgical closure of the PFO. Methods: Thirty patients (20 men and 10 women) with stroke and PFO were prospectively selected among 138 patients with stroke and PFO for a study of surgical closure of PFO at our center. Eligible patients were 50 microbubbles counted in the left atrium on contrast transesophageal echocardiography (TEE), and (4) Valsalva maneuver or cough preceding the stroke. Patients selected in this manner for surgery were considered to be a subgroup with a higher risk of stroke recurrence. Results: All patients had a direct suture of PFO while under cardiopulmonary bypass without recorded early or delayed significant complication. All patients underwent a new brain MRI and TEE simultaneous with transcranial Doppler ultrasonography after contrast injection at 8 +/- 3 months after surgery. After a mean follow-up of 2 years without antithrombotic treatment, no recurrent cerebrovascular event (stroke or transient ischemic attack [TIA]) and no new lesion on MRI had developed. Postoperative contrast TEE and transcranial Doppler ultrasonography showed that two patients had residual interatrial right-to-left shunting, although much smaller than before surgery, associated with single versus double continuous suture. Conclusions: Our study of 30 selected stroke patients with surgical suture of PFO showed a stroke recurrence rate of 0% and no significant complication. Residual right-to-left shunting may be avoided by double continuous suture of the PFO. In the absence of controlled studies to guide individual therapeutic decisions, our findings show that PFO closure can be done safely and may be considered to avoid recurrence in selected patients with long life expectancy and presumed paradoxic embolism.NEUROLOGY 1996;47: 1162-1166

Background: Sixty-two percent of all stroke deaths in the United States occur in women. We compared diagnostic evaluations by gender in ischemic stroke patients in a biethnic, population-based study. Methods: A random sample of patients with ischemic stroke identified between 2000 and 2002 by BASIC (Brain Attack Surveillance in Corpus Christi Project) were selected for this study (n = 381). Gender differences in the use of stroke diagnostic tests were assessed. Separate multivariable logistic regression models predicting diagnostic test use were constructed, adjusted for age, ethnicity, hypertension, atrial fibrillation, diabetes, history of stroke, coronary artery disease, having a primary care provider, discharge disposition, modified Rankin Scale score at discharge, and insurance status. Results: The study population consisted of 161 men and 220 women. Median age was 74.3 years. The respective proportions of males and females receiving any carotid artery evaluation were 71% and 62%; brain MRI, 43% and 41%; echocardiography, 57% and 48%; and EKG, 90% and 86%. Multivariable logistic models found that women were less likely to undergo echocardiography (odds ratio [OR] 0.64, CI: 0.42 to 0.98) and carotid evaluation (OR 0.57, CI: 0.36 to 0.91). There was no association of ischemic stroke subtype and gender to explain these results (p = 0.76). Conclusions: Despite controlling for explanatory variables, women with stroke were less likely to receive standard diagnostic tests vs men. Intervention is needed to increase access to quality stroke care for women.

To study the use of brain parenchyma sonography (BPS) in discriminating between patients with idiopathic PD (IPD) and atypical parkinsonian syndromes (APS).Twenty-five patients with APS, 9 with progressive supranuclear palsy (PSP) and 16 with multiple-system atrophy (MSA), and 25 age-matched patients with IPD were prospectively studied with BPS according to a standardized protocol.Twenty-four of the 25 (96%) IPD patients exhibited hyperechogenicity of the substantia nigra (SN) but only 2 of 23 (9%) APS patients (Mann-Whitney U test, p0.001). In those two APS patients, SN hyperechogenicity was moderate only, whereas the remaining 21 APS patients had normal SN echogenicity. The specificity of SN hyperechogenicity in detection of clinically diagnosed IPD patients was 96%, and the sensitivity was 91%. If SN hyperechogenicity was marked, APS could be excluded because of a positive predictive value of 100% for IPD. Nucleus lentiformis hyperechogenicity was found in 17 of 22 (77%) APS patients but in only 5 of 22 (23%) IPD patients (Mann-Whitney U test, p0.001). Nucleus caudatus and thalamus echogenicity and widths of the third ventricle and of the frontal horns of the lateral ventricles did not discriminate between IPD and APS. Two patients with PSP could not be assessed because of an insufficient bone window.BPS is a novel and noninvasive method to differentiate highly specifically between IPD and APS. Therefore, BPS might become a standard investigation in parkinsonian disorders.

A 12-year-old girl presented with headache, nausea, decreased level of consciousness, and diplopia. Brain MRI, arteriography (figure e-1 on the Neurology® Web site at www.neurology.org), vasculitic markers, and CSF were normal, as were EEGs and ECGs. Transcranial color-coded ultrasonography of the basilar artery revealed typical musical murmurs ("seagull cry") indicative of a hemodynamically significant stenosis (video).(1) Sumatriptan provided symptomatic relief; basilar flow normalized on ultrasonography (figure e-2). The clinical presentation suggested childhood migraine with aura; the ultrasound and normal arteriography suggested focal, transient vasospasm during a migraine attack. Topiramate was effective long-term. The high prevalence of childhood migraine (up to >20%)(2) suggests that ultrasound may be a useful diagnostic tool.

Each of the brain imaging techniques in common clinical use (skull radiography, midline ultrasonography, isotope scan, pneumoencephalography, angiography and computerized tomography) depicts some structural or functional characteristic of the brain. Each produces a correspondingly restricted concept of the status of the brain. Computerized tomography, which defines the radiodensity of head tissues, has a fundamental advantage over the other techniques in that it defines with quite good resolution a characteristic of brain tissue itself (radiodensity), rather than visualizing some anatomic compartment other than brain parenchyma. It provides an explicit image of the brain quite analogous to gross sections of the brain seen at autopsy. Computerized tomography has already substantially reshaped the practice of neurology wherever it has become available and probably will come to play a role as pivotal in clinical neurology as does bone radiography in orthopedics.

One hundred adult patients with headache, papilledema, and no localizing signs were evaluated prospectively and followed for up to 54 months. No patient with this syndrome who had a normal mental status, negative brain scan, and normal electroencephalogram was found subsequently to harbor a mass lesion. Benign intracranial hypertension was the final diagnosis in 71 percent of the patients studied. Lumbar puncture was a safe and helpful diagnostic procedure, and in no case was subsequent neurologic deterioration noted.

SUMMARYThe interpretations of 100 radiographically proved echoencephalograms by a group of readers with a wide spectrum of experience with echoencephalography were analyzed. The results suggest that when the examination is interpreted in the absence of any clinical clues and in accordance with relatively rigidly applied criteria, the process of interpretation assumes some degree of objectivity in that there is a high degree of interreader consistency. When these criteria are not precisely met, the more inexperienced reader will tend to call a study indeterminate rather than to offer an opinion as to the position of the midline structures. As experience with echoencephalography increases, the reader is more inclined to view the series of photographs taken as a composite and to give an opinion on certain additional studies. The overall accuracy for predictions actually made, however, appears to be quite constant under these circumstances, and in this study ranged from 93 to 95%. Our data further suggest that the accuracy of the results of midline echoencephalographic determinations by experienced, well-trained, and supervised technicians is not significantly different from that obtained when the entire examination is performed by a physician.

Variations in the amplitude of intracranial echoes that synchronize with systole are caused by movement of the reflecting interfaces. These movements result from propagation of the arterial pulse through the brain and vary with the arterial pulse pressure and the distance through the vascular tree for which the pulse propagates before being completely attenuated; this distance varies with the degree of arteriolar dilatation. The interpretation of such systolic fluctuations in echo amplitudes is subject to a number of limitations, and their recording is also subject to artifactual variations, usually resulting from the relative motion of the signal with respect to a fixed gate. Transient variations in the systolic fluctuations of echo amplitudes, as a result of various stimuli, can be recorded by a fixed gate but not simultaneously by a tracking gate. They would therefore appear to be artifactual and not indicative of regional changes in cerebral blood flow, which in any case would cause motion and amplitude changes in interfaces that were not confined to the region involved.

Currently accepted modes of clinical and radiologic evaluation were analyzed retrospectively in 55 patients with "normal-pressure" hydrocephalus on whom a cerebrospinal fluid shunting procedure was done. When applied alone, each criterion neither reliably differentiated normal-pressure hydrocephalus from cortical atrophy nor indicated in a significant number of cases which patients would benefit from shunting. Therefore, future prospective evaluations should include clinical history, physical and neurologic examination, skull radiography, echoencephalography, psychometric testing, brain scanning, lumbar puncture with cerebrospinal fluid laboratory analysis, isotope cisternography, pneumoencephalography, and constant-infusion manometric testing. Cerebral angiography may add optional support to the diagnosis of cortical atrophy but always should be done before lumbar puncture if there is evidence of intracranial mass and/or increased pressure is revealed on neurologic examination, skull radiographs, echograms, or brain scans. Patients with seizures should undergo electroencephalography. Postoperative improvement should be evaluated using serial neurologic and psychometric examinations. Echoencephalography may confirm postshunt reductions in ventricular size.

Automatic echoencephalography has been evaluated in 3,333 consecutive cases in which the positions of the cerebral midline structures were measured by the automatic midline computer. The great advantage of the technic appears to be the infrequency of false negative errors, although this advantage exists only so long as the transducer is kept correctly positioned. The technic appears to be capable of playing an important part in the early management of the acute head injury. In such cases its measurement of an undisplaced cerebral midline can be accepted with a high degree of confidence. We reaffirm our opinion that the development of automated technics for midline echoencephalography is the most significant advance since its discovery.