Background and Purpose-A cardiac right-to-left shunt (RLS) can be identified by transesophageal echocardiography and transcranial Doppler ultrasound (TCD) with contrast agents and a Valsalva maneuver (VM) as a provocation procedure. This article applies the modalities of these tests detailed in previous studies to a large patient cohort and compares 2 contrast agents (saline and Echovist-300). Methods-Eighty-one patients were investigated by both transesophageal echocardiography and bilateral TCD of the middle cerebral arteries. The following protocol with injections of 10 mL agitated saline was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, and (3) repetition of the test with VM if the first test with VM was negative. The VM was performed for 5 seconds starting exactly 5 seconds after the beginning of saline injection. Thereafter, the same protocol was repeated with 10 mL Echovist-300 instead of saline. Results-Thirty-one patients had a cardiac RLS. The Echovist-300 investigation disclosed all these 31 shunts, but saline disclosed only 29 of them. Twenty-two had an RLS only in at least 1 of the above TCD tests, some of them even with a considerable shunt volume. Conclusions-Contrast TCD performed with Echovist-300 but not with saline yields a 100% sensitivity to identify transesophageal echocardiography-proven cardiac RLSs. The TCD test should be repeated if negative the first time. This article gives detailed information for the optimization of the contrast TCD technique. Extracardiac shunts detected only during contrast TCD can have a considerable shunt volume and may allow for paradoxical embolism. Key Words: cerebral embolism Ⅲ cerebrovascular disorders Ⅲ foramen ovale, patent Ⅲ ultrasonography P aradoxical emboli of thrombotic material originating from the deep leg or pelvic veins via a cardiac or extracardiac right-to-left shunt (RLS) can cause ischemic stroke. 1,2 Prerequisites for the diagnosis of paradoxical brain embolism are the demonstration of such a shunt, the presence of an embolic pattern of infarction on cerebral imaging, and the absence of competing stroke origins. Other factors such as the performance of a mostly incidental Valsalva maneuver (VM) before the onset of infarction, the demonstration of remnants of the venous thrombosis during crural venous ultrasound or phlebography, concomitant pulmonary embolism, thrombophilia, and other factors predisposing to venous thrombosis additionally support the diagnosis. In very rare cases, echocardiography or autopsy discloses a thrombus trapped in the cardiac RLS and thus unequivocally proves the paradoxical embolism. 3,4 About 30% of the general population show a cardiac RLS, in most cases a patent foramen ovale. Juvenile patients with otherwise not explainable stroke have a much higher cardiac RLS prevalence of Ϸ50%. 5,6 This fact corroborates the importance of paradoxical embolism in stroke origin. Extracardiac shunts, mainly pulmonary ones, can also deliver a substantial...

A 30-year-old healthy woman was involved in a road trac accident. She sustained a fracture dislocation of T11/12 with a complete Frankel A paraplegia below T11. She had no associated injuries. High Dose Methylprednisolone was administered according to the NASCIS III protocol (48 h) together with low molecular weight Heparin and gastroprotected medication. Complete transection of the spinal cord and an anterior haematoma from T11 to T12 were con®rmed on X rays, CT's and MRI scans. Posterior surgical stabilisation was performed using Isola instrumentation, starting 8 h post injury. Her post surgical period was uneventful except for some episodes of low blood pressure (85/60 mmHg) from which she had no symptoms. On the 12th post operative day, while in the physiotherapy department, she complained of right scapular pain. This occurred every time she was sat up and was associated with paraesthesia of both upper limbs. Two days later she deteriorated neurologically and her level ascended initially to T8 and then to T3. MRI of the spine with and without gadolinium showed spinal cord oedema between C3 and T1. There was no evidence of haemorrhage or syringomyelia. The authors discussed this case making dierent hypotheses. They are mainly the following: (1) Gradually ascending ischaemia due to a vascular disorder; (2) Double spinal trauma; (3) Ischaemia related to repeated hypotensive episodes; (4) Low grade intramedullary tumour; and (5) Thrombus of the Radicularis Magna artery. The case has been recognised as being very rare and interesting. In the conclusions, the presenting author stresses the importance of adopting MRI-compatible instrumentation for the surgical stabilisation of the spine, and careful monitoring of blood pressure during the acute phase of spinal cord injury. Dr Aito agrees with Mr El Masry about the opportunity of forming a group of clinicians in order to discuss protocols to cope with this devastating complication.

In the vast majority of patients and healthy individuals, target blood pressure should be as high as or below 120/80 mmHg to minimize the occurrence of stroke and other cardiovascular complications.

Background and Purpose-With new CT technologies, including CT angiography (CTA), perfusion CT (PCT), and multidetector row technique, this method has regained interest for use in acute stroke assessment. We have developed a score system based on Multimodal Stroke Assessment Using CT (MOSAIC), which was evaluated in this prospective study. Methods-Forty-four acute stroke patients (mean age, 63.8 years) were enrolled within a mean of 3.0Ϯ1.9 hours after symptom onset. The MOSAIC score (0 to 8 points) was generated by results of the 3 sequential CT investigations: (1) presence and amount of early signs of infarction on noncontrast CT (NCCT; 0 to 2 points), (2) stenosis (Ͼ50%) or occlusion of the distal internal carotid or middle cerebral artery on CTA (0 to 2 points), and (3) presence and amount of reduced cerebral blood flow on 2 adjacent PCT slices (0 to 4 points). The predictive value of the MOSAIC score was compared with each single CT component with respect to the final size of infarction and the clinical outcome 3 months after stroke by use of the modified Rankin Scale (mRS) and the Barthel Index (BI). Results-Among the CT components, PCT showed the best correlation to infarction size (rϭ0.75) and clinical outcome (rϭ0.60 to 0.62) compared with NCCT (rϭ0.43 to 0.58) and CTA (rϭ0.47 to 0.71). The MOSAIC score showed consistently higher correlation factors (rϭ0.67 to 0.78) and higher predictive values (0.73 to 1.0) than all single CT components with respect to outcome measures. A MOSAIC score Ͻ4 predicted independence with 89% to 96% likelihood (mRS Յ2, BI Ն90); a MOSAIC score Ͻ5 predicted fair outcome with 96% to 100% likelihood (mRS Յ3, BI Ն60). Conclusions-The MOSAIC score based on multidetector row CT technology is superior to NCCT, CTA, and PCT in predicting infarction size and clinical outcome in hyperacute stroke.