Sonothrombolysis is a therapeutic option to improve the outcomes in patients with acute ischemic stroke due to MCA occlusion.

Background Cerebral small vessel disease (SVD) is associated with acute events such as lacunar and hemorrhagic strokes, or chronic events such as cognitive deficit in the form of subcortical dementia, mood deficit in the form of late onset depression, sphincteric affection, and gait apraxia. Under conditions of moderate blood flow deficit, the inability of sclerotic vessels to dilate due to impairment of the cerebral autoregulation, renders the periventricular white matter seriously ischemic. Therefore, it is important to detect the implications of cerebral large artery disease on the severity of SVD, and the ability of transcranial duplex (TCD) to evaluate it in people at risk. Methods Fifty lacunar stroke patients were recruited, and evaluated using MRI brain to assess SVD score, carotid duplex and TCD to assess extracranial and intracranial stenoses, respectively. Results Both intracranial and extracranial stenoses showed significant relation to the severity of cerebral SVD. Moreover, there were significant relation between intracranial stenosis and presence of lacuna and EPVS. Conclusion Cerebral large artery disease contributes to the pathogenesis and severity of cerebral SVD. Therefore, TCD may be a useful tool for the prediction of occurrence of cerebral SVD in high-risk individuals, especially hypertensives.

Fontan procedure is a palliative surgery done for patients born with single ventricle physiology. An understanding of the hemodynamic alterations in such a patient is important for successful perioperative management. Added to this challenge is the Craniopharyngioma which constitute about 2-6% of all the intracranial tumors in pediatric age group. Management of craniopharyngiomas in children is very challenging for anesthesiologist, owing to the developing neurological and physiological status, handling of a growing brain, perioperative endocrinological complications, and the management of hydration. We discuss the anesthetic considerations for a 6 years old female with Fontan circulation going for craniopharyngioma resection under general anesthesia.

Background: Calcitonin-gene-related peptide (CGRP) and CGRP receptors are expressed in trigeminal nerve cells, and treatments targeting CGRP are effective in migraines. For headaches that do not respond to pharmacological treatment, minimally invasive techniques such as greater-occipital-nerve block (GONB) can help relieve the pain and reduce the frequency of headaches. Our study assessed the efficacy of ultrasound-guided greater-occipital-nerve block (USgGONB) in chronic migraines (CM) and its relationship to serum CGRP levels. Methods: Forty chronic migraineurs who underwent bilateral USgGONB using 40 mg triamcinolone and 1 mL lidocaine were recruited and interictal serum CGRP samples were collected immediately before and one month after GONB. The clinical response was evaluated using headache diaries before and one month after USgGONB. The patient response was determined after USgGONB according to the reduction in headache days as a good responder (>50% reduction), poor responder (<50%) or non-responder. Results: Monthly headache days after GONB showed a significant reduction (median, 10 days; range, 8–14.7) compared to before the block (median, 18 days; range, 17–22; p < 0.001). Across all patients, interictal serum CGRP levels after USgGONB were significantly lower than before the block (median, 40 pg/mL (range, 25–60) vs. 145 pg/mL (range, 60–380) (p = 0.001). The pre-treatment interictal CGRP levels showed a significant difference (p = 0.003), as their levels in non-responders (median, 310 pg/mL; interquartile range, 262–350) were significantly higher than those seen in responders, whether poor responders (median, 135 pg/mL; interquartile range, 100–200 pg/mL) or good responders (median, 140 pg/mL; interquartile range, 80–150 pg/mL). Conclusion: the study showed the beneficial effect of USgGONB in chronic migraines that was associated with lowering interictal CGRP levels, implying a potential role for CGRP in the mechanism of action of GONB in CM, and the interictal CGRP level may be used as a predictor for the response to GONB.

Background: The trigeminal ganglion plays a key role in primary headache pathophysiology. Calcitonin gene-related peptide (CGRP) and CGRP receptors are expressed in trigeminal neurons that form C-fibers and A-fibers, respectively. In migraine attacks, there is release of CGRP into the cranial venous outflow, in refractory headache to conventional pharmacologic management, minimally invasive techniques such as greater occipital nerve block (GONB) are feasible for pain relief, and help to decrease the frequency of the attacks, Studies on the ultrasound (US) guided GON injection technique have emphasized that this technique has a higher success rate and should allow for a more precise block of the nerve. Our study will be concerned by correlation of CGRP level as a biomarker for effectiveness and responders of us guided GON block in chronic migraine (CM). Methods: twenty patients diagnosed with chronic migraine were recruited in this study. All participants underwent ultrasound-guided bilat. GONB by 40 mg triamcinolone and 1 cc leidocaine using a portable ultrasound system with a 7 – 13 MHz multifrequency transducer, blood samples were collected from antecubital vein immediately before and three to five weeks after injection clinical response was evaluated using headache diaries Results: CGRP levels after ultrasound guided GONB (median, 40 pg/mL; range, 25-60) were significantly lower as compared with CGRP levels obtained before GONB (median, 145 pg/mL; range, 60-380; P =0.001). Pretreatment CGRP levels in non-responders (310 pg/mL) were significantly higher than those seen in responders being in poor responders less than 50% improvement (135 pg/ml) and good responders (140 pg/mL; P = 0.003). One month after treatment. A number of demographic factors, clinical features, and comorbidities were not different in responders as compared with those of nonresponders. Conclusion: These results suggests that interictal CGRP levels can be of help in predicting the response to GONB and suggest that the mechanism of action of GONB in CM is the reversal of sensitization as a result of the inhibition of CGRP release still more studies needed to highlight CGRP role with GONB