Patients and MethodsThis is a retrospective analysis of the CLOTBUST collaboration databank that includes patients with acute MCA occlusions treated with intravenous tissue plasminogen activator (tPA). 3 A sonographer performed transcranial Doppler (TCD) with a 2-MHz device (Ez-Dop, DWL; PMD 100, Spencer Technologies; Multigon, 500 mol/L, Multigon Industries). MCA occlusion and recanalization were identified using previously validated criteria before and during the first 2 hours after tPA bolus. 3 Before tPA bolus, we also performed carotid duplex (Sonosite 180 Plus), and previously validated diagnostic criteria for ICA occlusion were applied. 4 Tandem ICA/MCA lesions (tandem group) were defined as hemodynamically significant ICA obstruction (70% to 100% obstruction) with MCA occlusion, and isolated MCA occlusion was diagnosed when patients had abnormal TIBI (Thrombolysis In Brain Ischemia) flow grades without evidence of significant ICA obstruction on carotid duplex ultrasound and TCD.Neurological deficit was measured with the National Institutes of Health Stroke Scale (NIHSS) before, 30, 60, 90, and 120 minutes, and 24 hours after bolus. Modified Rankin scale (mRS) scores were obtained at 90 days after onset by a stroke neurologist blind to TCD findings. Early neurological improvement (ENI) was defined as reduction of NIHSS by Ն10 or decrease of total NIHSS to Յ4 within 24 hours after bolus. 5 Good outcome was defined by mRS Յ2. ResultsA total of 104 patients were included in our study. Seventytwo (69%) patients had isolated MCA occlusion and 32 (31%) patients had tandem lesions. Their demographic data and clinical parameters are summarized in the Table. Stroke subtypes in the isolated MCA group were: LVA 8.5%; CE 5.3%; LA 1%; and UE 37% of patients. In patients with tandem lesion, stroke subtypes were: LVA 62%; CE 22%; OE 6%; and UE 9% of patients.Complete recanalization rate increased with time after bolus in the isolated lesion group. It occurred in 26.4% of the isolated lesion group and 9.4% of the tandem group at 90 minutes after bolus (Pϭ0.05) and at 2 hours in 38.9% and 9.4%, respectively (Pϭ0.002; Figure 1). Complete recanalization rate was different according to the stroke subtype: LVA 14.4% and CE 39.1% (Pϭ0.02).ENI was achieved in 46% of the isolated lesion group and in 25% of the tandem group (Pϭ0.045; Table), and the median NIHSS score reduction was different between the 2 groups at 2 hours and 24 hours after bolus (Pϭ0.002 and Pϭ0.05, respectively; Figure 2). Good outcomes were similar in the 2 groups. DiscussionOur results showed that early complete recanalization and ENI are more common with the isolated lesion group compared with the tandem group despite similar baseline characteristics. MCA recanalization rate was lower with tandem than with isolated lesions in other studies at Ͼ24 hours after onset. 2,7 In our study, the isolated lesion group had faster and higher complete recanalization rate than the tandem group during the first 2 hours. Recanalization rate increased with time in the iso...

Backgound: Flow diversion (FD) can occur with an acute middle cerebral artery (MCA) occlusion. FD is thought to represent the collateral blood flow to the occluded MCA territory, but it is unclear whether or not FD lessens the stroke severity or leads to improved outcome. Methods: Patients with a proximal MCA occlusion were selected from the CLOTBUST trial data bank. FD to the anterior or posterior cerebral artery was determined using transcranial Doppler ultrasound. Stroke severity and clinical improvement were measured using the National Institutes of Health Stroke Scale (NIHSS) scores. Results: We evaluated 47 patients with an isolated M1 MCA occlusion who received intravenous tissue-type plasminogen activator (t-PA) within 3 h of symptom onset. FD was present in 83% of the patients. Median baseline NIHSS scores were 15.5 in the FD– group and 18 in the FD+ group (n.s.). Complete recanalization rates were 25 and 25.6% (n.s.). In 35 patients with a persistent occlusion, the average NIHSS score reduction was 22% (FD+) and 0.52% (FD–) during 90 min after t-PA bolus (p = 0.017), and 29 versus –25% during the first 24 h after the t-PA bolus, respectively (p = 0.01). Conclusions: In patients with persistent MCA occlusions after thrombolytic treatment, arterial blood flow diversion is associated with earlier and better neurological improvement. FD has protective effects on the ischemic brain tissue with persistent MCA occlusion.

CR was comparable between LTG + VPA and CBZ-CR, however, both SFR for 52-week MP and TTFS during MP were in favor of LTG + VPA than CBZ-CR. The study suggested that LTG + VPA can be an option as initial drug regimen for untreated patients with partial seizures and/or GTCS except for women of reproductive age.

Background and Purpose-An extremely low pulsatile cerebral perfusion can result in a massive cerebral infarction and poor outcome. We report a patient who had complete recovery from initial neurological deficits in spite of nonpulsatile perfusion in the middle cerebral artery. Methods-We used carotid duplex and transcranial Doppler to evaluate cerebral hemodynamics and the National Institutes of Health Stroke Scale (NIHSS) to score the neurological deficits. Results-A 62-year-old man had a sudden chest pain and right hemispheric symptoms with NIHSS score of 18 on arrival.Carotid duplex showed no blood flow in the right common carotid artery. Transcranial Doppler showed a nonpulsatile waveform with slow antegrade flow in right middle cerebral artery. Chest CT angiography revealed type A aortic dissection. After surgical repair for the aortic dissection with brain retroperfusion, the patient had dramatic recovery from the initial neurological deficit, and normal pulsatile cerebral perfusion in the right carotid territory. Conclusions-Nonpulsatile cerebral perfusion points to a proximal source of arterial flow obstruction that may necessitate interventional treatment or surgery in order to restore brain perfusion and potentially reverse impending stroke. Key Words: acute stroke Ⅲ ischemia Ⅲ nonpulsatile C erebral arterial blood flow has pulsatile pattern except for during cardiopulmonary bypass when direct heart contractions are replaced with continuous pump-induced flow. The pulsatility of cerebral perfusion is decreased when an arterial occlusion is present in a proximal segment and compensatory dilatation is induced in the distal vascular bed. Extremely low pulsatile cerebral perfusion was noted in patients with acute proximal internal carotid artery occlusion and impending infarctions 1,2 because it can lead to profound hypoperfusion, ischemia and poor clinical outcome.We would like to present a patient who achieved complete recovery from a severe initial neurological deficit after surgical correction of the nonpulsatile cerebral perfusion in the middle cerebral artery (MCA). Case ReportsA 60-year-old man was admitted after acute onset of the left-sided hemiparesis. He also had sudden chest pain and shortness of breath. He collapsed in his bathroom, and then was unable to move his left extremities. He had history of hypertension, myocardial infarction and cocaine abuse. He arrived at hospital within 1 hour after onset. His blood pressure was 110/80 mm Hg in the left arm. Arterial pulsation was good in the left radial artery, but it was not measured in the right side. Kim et al Nonpulsatile Cerebral Perfusion 1563by guest on May 12, 2018http://stroke.ahajournals.org/ Downloaded fromThe patient was transferred to cardiothoracic surgery, and at 3 hours after symptom onset an urgent surgical repair for the aortic dissection was initiated. Dissected ascending aorta and aortic arch were replaced with an artificial graft. Left CCA and right innominate artery were cleared of intimal flaps. Surgery was performed with...