Gaia Sirimarco

Monitoring After the Acute Stage of Stroke A Prospective Study

Background and Purposes— In the early stage of stroke, the occurrence of neurologic and medical complications is associated with clinical deterioration. Previous studies were focused on the first week after stroke onset. The aim of this study was to evaluate the impact of complications on clinical outcome in patients with stroke in the early subacute stage. Methods— We prospectively evaluated the influence on the outcome of complications feasible (MC) and not feasible for monitoring (NMC) in all patients with stroke admitted consecutively in our subacute stroke unit. Patients were divided into three classes according to stroke severity evaluated by the National Institutes of Health Stroke Scale score. A change in the National Institutes of Health Stroke Scale score group from admission to discharge was considered clinically significant. Results— We included 261 patients. Sixty percent of patients had complications (105 MC, 118 NMC). Hyperthermia (OR=14.12; 95% CI: 6.01 to 33.20), urinary infections (OR=4.92; 95% CI: 2.19 to 11.04), hypertension (OR=2.86; 95% CI: 1.21 to 6.76), hypoxia (OR=15.75; 95% CI: 6.73 to 36.84), and neuroradiologic damage progression (OR=58.31; 95% CI, 19.48 to 174.55) were associated with a change to a more severe class at discharge and with a higher risk of mortality. Conclusions— A high percentage of patients can develop both MC and NMC during this subacute stage of stroke. The occurrence of complications influences outcome and raises the question about the need for a prolonged stay in a dedicated ward for patients with stroke.

Extracranial and Intracranial Sonographic Findings in Vertebral Artery Diseases

Objective. The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases. Methods. We conducted a review of sonographic findings in VA diseases. Results. Various VA diseases are described, and sonographic techniques and features are discussed. Conclusions. Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra‐arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real‐time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation.

Transcranial Doppler for Brain Death in Infants: The Role of the Fontanelles

Objective: Transcranial Doppler (TCD) is a sensitive technique for circulatory arrest diagnosis in brain death when patterns such as reverberant flow and short systolic spikes are observed. In infants, the nonossified fontanelles compensate for intracranial hypertension. We describe TCD patterns in infants with brain death, different from adults, with the hemodynamic modifications induced by anterior fontanelle compression. Method: TCD was performed in 2 infants with diagnosed brain death admitted to the neonatal intensive care unit. Results: TCD showed a large peak ‘reverberant’ flow, with a high peak systolic velocity and a consistent retrograde component, away from the brain. Compression of the anterior fontanelle induced, at first, a reduction in systolic flow with the subsequent appearance of the characteristic short systolic spikes. Upon compression removal, a brief increase in the systolic flow was observed before the prompt reappearance of the reverberant flow. Conclusion: TCD for brain death diagnosis should be done cautiously in infants. In these cases, reverberating flow may be indicative of circulatory arrest even if with a large peak and with a high peak systolic velocity. Heavy fontanelle compression may reproduce the classical adult TCD patterns of brain death, thus supporting the diagnosis of cerebral circulatory arrest.

Noninvasive imaging of carotid arteries in stroke: emerging value of real-time high-resolution sonography in carotid occlusion due to cardiac embolism.

Objective. Comprehension of the pathophysiologic characteristics of atherosclerosis has focused its attention on the study of dynamic and metabolic processes involving the vessel wall as possible causes of stroke. When compared with conventional radiologic techniques, sonography has the main advantage of being a real‐time imaging modality. We report 2 acute stroke cases in which carotid sonography showed some dynamic features that could not be identified with computed tomography (CT) and magnetic resonance angiography (MRA). Methods. Carotid sonography with high‐resolution probes (9–14 MHz) was compared with CT and MRA findings showing carotid axis occlusion in 2 patients with acute stroke. Results. In case 1, the internal carotid artery occlusion observed on CT and MRA was interpreted as a dissection on a clinical basis, but sonography showed a mobile embolus originating from the heart in the internal carotid artery. In case 2, the occlusion of the whole carotid axis observed on CT and MRA was instead related to a heart‐originating embolus floating in the common carotid artery. Conclusions. The evaluation of dynamic aspects of atherosclerosis is fundamental to understanding the pathophysiologic characteristics of stroke. Sonography is fundamental in carotid artery imaging for its possibility of showing dynamic processes that could be misdiagnosed with “static” imaging. The correct identification of the pathophysiologic characteristics of stroke in these cases could have led to different diagnostic and therapeutic algorithms.

Transcranial Sonographic Findings in Wilson Disease

rogressive hepatolenticular degeneration or Wilson disease (WD) is an autosomal recessive inherited disorder of hepatic copper metabolism. The disease is associated with various mutations in the adenosine triphosphatase Cu++ transporting β polypeptide (ATP7B) gene that encodes a coppertransporting adenosine triphosphatase, leading to toxic copper accumulation in hepatocytes and extrahepatic tissues, including the cornea and basal ganglia of the brain. The worldwide prevalence is about 1 per 30,000, which may vary by population. The most frequent disease manifestations include a wide spectrum of liver disorders as well as neurologic and psychiatric abnormalities.1,2 Structural brain magnetic resonance imaging (MRI) studies show frequent bilateral involvement of the basal ganglia (particularly the putamen, the caudate head, the ventral thalamus, and the dentate nucleus), the brain stem, and the cerebellum, as well as atrophy of the cortex and the cerebral white matter.3–5 As a consequence of basal ganglia involvement, neurologic features of the disease include movement disorders such as a motor coordination deficit, slowness of voluntary limb movements, tremors, dystonia, dysarthria, writing tremors,6 and fine-motor disturbances.7 Diagnosis relies on typical neurologic symptoms, the presence of Kayser-Fleischer rings, and a reduced serum ceruloplasmin concentration. Recently, transcranial sonography (TCS) has been recognized as a reliable and sensitive tool in detecting basal ganglia abnormalities in several movement disorders, such as parkinsonism, corticobasal degeneration, and other kinds of extrapyramidal disorders.8 We report a case of WD in which TCS was able to easily identify altered basal ganglia echogenicity corresponding to MRI abnormalities. Furthermore, in this patient, we have identified peculiar hyperechogenicity of the dorsolateral periaqueductal gray matter that, to our knowledge, has never been described with this technique until now. Received January 28, 2010, from the Department of Neurological Sciences, University of Rome La Sapienza, Rome, Italy. Revision requested February 17, 2010. Revised manuscript accepted for publication March 2, 2010. Address correspondence to Maria Chiara Ricciardi, MD, Department of Neurological Sciences, University of Rome La Sapienza, Viale dell’Universita 30, 00185 Rome, Italy. E-mail: m.chiara78@libero.it Abbreviations LN, lenticular nucleus; MRI, magnetic resonance imaging; SN, substantia nigra; TCS, transcranial sonography; WD, Wilson disease

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.

Advantages and Pitfalls of Three-Dimensional Ultrasound Imaging of Carotid Bifurcation

Objectives: Several specialists use three-dimensional (3D) ultrasound as adjuvant imaging technique in their clinical practice. It has been applied to study carotid plaque morphology, surface and volume during atherosclerosis progression. Nonetheless, no papers have so far described the use of this technique in conditions different than carotid stenosis, such as bifurcation anatomy changes of the caliber and vessel course modifications. Methods: Patients admitted to our ultrasound laboratory for vascular screening were submitted to standard carotid duplex and to 3D ultrasound reconstruction of the carotid bifurcation. Results: Forty normal subjects, 7 patients with caliber alterations (4 carotid bulb ectasia and 3 internal carotid lumen narrowing), 45 patients with course variations (tortuosities and kinking) and 35 patients with internal carotid artery stenosis of various degrees have been investigated. Conclusions: 3D ultrasound is a feasible technique. It can improve carotid axis imaging through a better presentation of caliber variations and vessel course ‘at a glance’. 3D ultrasound from the inward flow can provide imaging of the stenosis, but stenosis quantification should always take into account the assessment of plaque morphology and vessel wall.

Effects of a Single Mannitol Bolus on Cerebral Hemodynamics in Intracerebral Hemorrhage: A Transcranial Doppler Study

Background: Mannitol infusion is widely used in clinical practice to reduce perilesional edema in intracerebral hemorrhage (ICH), though no controlled studies have yet provided evidence of its effects on clinical outcome or on cerebral blood flow impairment following the event. The aim of our study was to evaluate blood flow velocity changes in the middle cerebral arteries (MCA) after a mannitol bolus in patients with ICH. Methods: Transcranial Doppler bilateral monitoring was performed for 90 min in 20 patients with ICH, during 100 ml mannitol bolus i.v. administration. The MCA mean flow velocities (MFVs) and pulsatility index (PI) were recorded. Results: When the ‘healthy’ and the ‘affected’ hemispheres were compared, we observed higher MCA MFV and lower PI on the affected side than on the contralateral side, both at baseline and during the experiment. After the mannitol bolus, we observed a significant MFV increase, starting at the end of the infusion and lasting longer than 60 min in the MCA on the affected side alone. The PI increased after mannitol administration on the healthy side alone. Conclusions: A single bolus of mannitol modified cerebral hemodynamics in our patients with ICH, increasing flow velocities on the affected MCA. This effect may be a consequence of reduced edema in the perilesional areas. The increased PI on the unaffected side may be indicative of preserved pulsatility in the healthy hemisphere.

Acute subcortical stroke and early serotonergic modification: a IDAP study

The intensity dependence of the auditory‐evoked potentials (IDAP) is inversely related to serotonergic tone. Depression is frequently observed after stroke, associated with cognitive impairment and increased mortality. Aim of this study was to investigate the serotonergic tone in acute stroke patients by IDAP. Consecutive patients with an acute stroke admitted in our stroke unit were evaluated using clinical and instrumental examinations and compared with healthy controls. The IDAP was calculated as the linear amplitude/stimulus intensity function (ASF) slope, by measuring the peak‐to‐peak amplitude of Nl‐P2 on four blocks of different stimulus intensities. Twenty patients were enrolled; 11 had a right brain infarction; nine had depressive symptoms (DS). The ASF slope of the auditory‐evoked potentials was markedly increased in stroke patients compared with controls (P = 0.021). Stroke patients with DS had a significant steeper ASF slope than controls (P = 0.017). There was no statistical difference in ASF slope between stroke patients without DS and controls. Post‐stroke depression pathophysiology is still debated. Our study suggests that in acute stroke patients with DS, there is a direct involvement of the serotonergic system, regardless the degree of disability and the site of the lesion.