Abstracts Tutorials - Karger Publishers

Cerebrovasc Dis 2013;35(suppl 2): 1-77

Abstracts

Tutorials

T1

Basic ultrasound principles

V. Oliveira

Department of Neurology, Santa Maria Hospital, Lisboa, Portugal

Ultrasound and the Doppler Effect were major achievements in physics and their application to medicine provided a number of advantages to investigate the vascular system. One should re-member the work of Christian Andreas Doppler (1803 – 1853), an Austrian mathematician from Salzburg, who was concerned about colour variation of the stars and stated that color change throughout time was due to the relationship between the veloc-ity of light and the speed of the moving stars. His work was con-firmed on the ground with the celebrated experience of musicians playing a single note on a moving train while trained observers listened on the ground and verified the change in intensity when the train passed: the “Doppler effect” was certified. Doppler may not have even imagined the use of his ideas regarding ultrasounds and the wide range of applications thereafter. Medical applica-tions in vascular medicine hit a milestone in the 1950’s when the Japanese scientists Shigeo Satomura and Ziro Kaneko produced the first ultrasound device able to register Doppler shift in blood vessels: the “Doppler Rheograph”. Since then, fast developments in technology have allowed a wide diffusion of a number of reliable devices along with the capability to depict and visualise vascular structures and, at the same time, to measure velocities of the blood flow. In 1980, another milestone occurred when Rune Aaslid in-troduced (1982) a device able to register Doppler signals through the intact skull. The use of ultrasounds in vascular medicine and in cerebral circulation in particular seems to have an endless field for pursuit. Continuous Doppler, pulsatile Doppler, transcranial colour coded Doppler, Doppler monitoring for diagnosis and also thrombolysis assisted ultrasound are some of their various mo-dalities. Nowadays ultrasound has gained a definitive role in the investigation of all vascular patients. Affordability, reliability (in experienced hands), user friendly, repeatability, without contra-indications are its main characteristics foreseeing a challenging and promising future.

T2

Ultrasonography of carotid stenosis

J. Klingelhöfer

Medical Center Chemnitz, Dept. of Neurology, Chemnitz, Germany

The classification of internal carotid artery stenosis is of great impact. The degree of stenosis is the main criterion for the de-cision between an invasive or non-invasive treatment of extrac-ranial internal carotid artery stenoses. By now the NASCET criteria have been internationally approved for radiological grad-ing. Accordingly to NASCET the stenosed lumen is compared with the lumen of the distal internal carotid artery. All ultrasound criteria do have limitations and can therefore cause pitfalls in de-termining the degree of stenosis using one criterion exclusively. Therefore a multi-parametric grading of stenoses should be fa-vored. The multi-parametric “DEGUM ultrasound criteria” have been revised and a novel differentiation between main (primary) and additional (secondary) criteria has been proposed (Ultraschall in Med 2010; 31:251-257). The differentiation between main and additional criteria is caused by their different reliability. Main criteria include the following: imaging of the stenosis in B-mode sonography; visualization of the stenosis by color-coded imaging of flow; measurement of the maximum systolic flow velocity in the area of greatest narrowing of the lumen; systolic flow veloc-ity measurement in the poststenotic segment; assessment of the collateral supply. Additional criteria include the following: indi-rect findings of an internal carotid artery stenosis in the common carotid artery; evidence of flow disturbances; end-diastolic flow velocity in the area of greatest narrowing of the lumen; the so-called confetti-sign; the carotid ratio. The main advantage of a multi-parametric grading of internal carotid artery stenoses is the synergetic effect of the different single criterion. Combining these ultrasound criteria, neurosonography allows reliable grading of carotid stenoses as a basis for decision making.

T3

Clinical impact of IMT measurement

M. Rodrigues

Department of Neurology, Garcia de Orta Hospital, Almada, Portugal The intima-media thickness (IMT) as measured by ultrasonog-

raphy of carotid arteries is an acknowledged non-invasive method for assessing the impact of vascular risk factors and the progression of cardiovascular disease risk over time. The average of the far wall IMT of the common carotid artery CCA (CIMT) from both right

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Cerebrovasc Dis 2013;35(suppl 2):1–772

and left sides is most frequently used. It correlates well with his-tology and it is a precursor phenotype of early atherosclerosis. Its increase is associated with vascular risk factors. Systematic reviews of longitudinal studies have quantified this risk, showing that an increase of 0.1 mm in the CIMT is associated with an increased relative risk of 15% of myocardial infarction and 18% of stroke. The evaluation of this parameter is simple, fast and inexpensive, when integrated into a routine cervical artery ultrasound exami-nation. However, CIMT also has applications in clinical research as an important study outcome, and then a standard measurement protocol should be applied to avoid information and measure-ment biases. The main consensus statements, both from Europe and North Americ, outline the technical conditions for IMT as-sessment and favor the use of automated edge detection software. The relation between CIMT and vascular risk factors or vascular events has been extensively reported. Nevertheless, the implica-tions of CIMT change observed in repeated measurements are not so thoroughly established in the available follow-up studies. The CIMT is an attractive method of measuring target organ damage. However, it will remain a structural evaluation only, a static photo-graph that does not capture the complex interplay between vessel inflammation and thrombogenic processes.

T4

Ultrasonography of vertebral arteries

G. M. von Reutern

Neurologische Praxis am Ambulanten Kardiologischen Zentrum, Bad Nauheim, Germany

Diagnostic interest: Understanding the cerebral circulation without a thorough examination of the vertebral a. (VA) system is impossible whether the prime interest is a carotid or posterior circulation problem. Therefore this aspect of vascular ultrasound should be one of the key competences of neurologists. It provides basic information in the emergency situation and adds functional information to MR-imaging. The message for the clinician de-pends highly on the presenting symptoms and signs respectively suspected site of occlusion e.g “herald hemiparesis” (Fisher) with signs of bilateral distal VA occlusion uncovers an emergency situ-ation. Technique of examination: Using Doppler- or Duplex-sonography the examination has to encompass 3 extracranial segments V0/1 (prevertebral), V2 (vertebral) and V3 (C2), each with advantages and limitations. To examine only V2 is insuffi-cient. With pathology it is of interest to examine cervical branches and the occipital a. as well. In addition the transoccipital approach (TCD, TCCS) and the transtemporal examination of the pos-terior cerebral aa. should be available. Diagnostic criteria for arteriosclerotic occlusive disease: Intrastenotic velocities are less reliable for grading occlusive disease than in carotid disease due to anatomical variations and the heavy impact of collateral flow. Collateralisation is frequently supported by the contralateral VA but also via ipsilateral branches of the thyreocervical trunk. Main criteria are (1) local intra and poststenotic disturbances, (2) pre- and postocclusive waveform alterations, (3) appearance of collateral flow allowing the differentiation of occlusion and

hemodynamically relevant (high degree) stenosis vs a moderate one. Uni- or bilateral intracranial VA occlusion (basilar A.) can be suspected taking in account the waveform at V3 (pulsatility) and vessel diameter. Steal phenomena: Typical wave form pat-terns allow the diagnosis of VA steal due to proximal occlusion of the subclavian a. Staging is possible observing the typical pattern of alternating flow direction during systole. Rare but important sources of error are occlusions of the brachiocephalic trunk with complex collateral flow involving the right carotid a. depending on the capacity of the circle of Willis. Conclusion: Careful examina-tion of the VA’s is demanding but rewarding.

T5

Non-atherosclerotic cervical arterial diseases

G. Baltgaile

Department of Neurology, P.Stradina University, Riga, Latvia

Approximately 3 to 4% of all strokes occur in patients between the ages of 15 and 45 years. Although atherosclerosis is the most common cause in older patients, causative disorders and condi-tions in younger patients often are uncommon or are reversible. Many from all non-atherosclerotic factors which could cause a stroke are associated with arterial damage. The most frequent pa-thology of cervical arteries is dissection which mostly occurs due to fibromuscular dysplasia or trauma, very rare during labor. Less frequently arterial circulation is disturbed by arterial tortuosity syndrome, vertebral artery compression in intravertebral or atlas segments, arteritis or angiopathy due to inflammatory diseases (SLE, GCA, polyarteritis nodosa), artery compression or irradia-tion damage caused by cancer. Very rare cervical arteries are af-fected by ‘vasculitis like arteriopathy caused by cocaine and heroin drug abuse. Carotid and vertebral aneurysm and arteriovenous fistula, glomus caroticus tumor is extremely rare. There are mor-phological and hemodynamic criteria of arterial lesions obtained by color-coded duplex sonography of cervical arteries. Typical ex-amples of different kinds of pathologic changes in arterial wall and blood circulation are given in a lecture.

T6

Transcranial Doppler/Duplex ultrasonography

E. Bartels

Center for Neurological Vascular Diagnostics, Munich, Germany

Using a pulsed Doppler system with low transmitter frequency, conventional transcranial Doppler sonography (TCD) allows blood flow velocities to be recorded from basal cerebral arteries through the intact skull. The Doppler signal obtained is assigned to a spe-cific artery on the basis of indirect parameters: depth of the sam-ple volume, position of the transducer, and direction of the blood flow. Since this method has no imaging component, the differ-entiation between individual vessels can be difficult. In addition,

Abstracts Tutorials Cerebrovasc Dis 2013;35(suppl 2):1–77 3

with use of the TCD method, the angle between the insonated vessel and the ultrasonic beam is not known. Because the posi-tion of the pulsed sample volume and the insonation angle cannot be visually controlled, the flow velocity within the artery can be underestimated. Transcranial color-coded duplex ultrasonography (TCCS), on the other hand, enables the visualization of basal cer-ebral arteries through color-coding the flow velocity information. The purpose of this lecture is to present typical sonographic path-ological findings in cerebrovascular occlusive disease, in vascular malformations, as well as in cerebral parenchyma disorders. Using TCCS the arteries of the circle of Willis can be identifid by their anatomic location with respect to the brain stem structures, and by determination of the flow direction. In cerebral occlusive disease, sonographic diagnosis of an occlusion of a cerebral artery can be made when a color-coded signal cannot be obtained at depths of insonation corresponding to that artery. In such a situation, it is important for further diagnostic steps and for therapy to be able to determine whether failure to visualize a cerebral vessel is due to methodological problems or to an occlusion of a cerebral artery. Color-coded duplex ultrasonography is increasingly accepted as a valuable method in neurovascular diagnostics. In the hands of an experienced examiner, it is a reliable tool in the evaluation of cerebrovascular diseases. The main limitation of TCCS, like that of conventional TCD, is the need for an adequate acoustic window which can be overcome with echo contrast agents.

T7

Transcranial imaging planes – advanced approach

using fusion imaging

S. Schreiber

Department of Neurology, University Hospital Charité, Berlin, Germany

Transcranial color-coded duplex ultrasound is increasingly used for diagnostics of intracranial vascular and parenchymal pa-thology. It is the sonographic method of choice as it gives a higher diagnostic yield compared to TCD. For orientation, different im-aging planes have been established. These are for the transtem-poral approach the midbrain plane, thalamic plane, cella media plane, upper and lower pontine plane and for the transforaminal approach a lower and higher axial plane. More recently, coronal and oblique imaging planes have come into use. However, land-marks for orientation in the latter are not well defined. Fusion im-aging is a new technique, permitting an online matching of live ultrasound images with pre-registered CT or MR images. In this technique, the patient’s head is positioned within an electromag-netic field which at the same time registers the exact position of the ultrasound probe. The resulting simultaneus visualisation of identical imaging planes from both imaging modalities consider-ably facilitates the three-dimensional orientation and may help to identify or match specific regions of interest. The tutorial will give insight into the ultrasound fusion imaging technique and poten-tial applications within the field of transcranial B-mode and vas-cular imaging.

T8

Sonothrombolysis and ultrasound monitoring in

acute stroke interventions

M. Rubiera

Stroke Unit, Hospital Vall D’ Hebron, Barcelona, Spain

Use of transcranial and carotid ultrasound in the acute stroke setting allows information of the vascular status in real time, which provides a tool for selecting patients for aggressive therapeutic approaches (even during endovascular reperfusion therapies). Furthermore, in vitro and animal models have demonstrated the efficacy of ultrasound (US) to enhance fibrinolysis. Mechanical pressure waves produced by ultrasound energy improve the de-livery and penetration of alteplase (tPA) inside the clot. In human stroke, the Combined Lysis of Thrombus in Brain ischemia using transcranial Ultrasound and Systemic tPA (CLOBUST) phase-II trial showed that the combination of tPA plus 2 hours of continu-ous transcranial Doppler (TCD) increased recanalization rates producing a trend towards better functional outcome compared with tPA alone. Other small clinical trials showed also an im-provement in clot lysis when transcranial color-coded sonogra-phy (TCCS) was combined with tPA. In contrast, low-frequency US increased symptomatic intracranial hemorrhage (SICH) rate in other clinical trial. Administration of microbubbles (MB) may further enhance the effect of US on thrombolysis by lowering the US energy threshold needed to induce acoustic cavitation. Initial clinical trials have been encouraging, and a multicenter inter-national study (TUCSON: Transcranial Ultrasound in Clinical Sonothrombolysis) determined a dose of newly developed MB that can be safely administered with tPA and TCD, but the higher dose increased the hemorrhage rate, and the study was stopped. The intra-arterial administration of US with the EKOS catheter is another US application for acute stroke. Operator-independent devices, different MB-related techniques or other US parameters for improving and spreading sonothrombolysis should be studied in future.

T9

Contrast agents: plaque risk and cerebral perfusion

R. Kern

Department of Neurology, University of Heidelberg, Mannheim, Germany

Second-generation echo-contrast agents consist of synthetical microbubbles who respond with non-linear behavior to acoustic waves. Modern ultrasound scanners offer contrast-specific im-aging modes and thus allow separation of signals arising from microbubbles and backscatter from tissue. In clinical and experi-mental neurosonology, echo-contrast agents are used not only for transcranial vascular imaging in patients with insufficient bone windows, but they can also be employed for semiquantitive anal-ysis of cerebral perfusion and for analysis of extracranial plaque



vulnerability. For transcranial perfusion imaging echo-contrast agent kinetics are most commonly evaluated after bolus injec-tion; newer protocols also allow analysis of the replenishment of microbubbles after complete destruction. It has been shown ex-perimentally that these replenishment kinetics correlate well with cerebral perfusion as measured with radiolabeled microspheres. Transcranial perfusion imaging can be used in the setting of acute stroke, subarachnoid and intracerebral hemorrhage, vascular mal-formations, and brain tumors. More recent studies were under-taken to use echo-contrast enhanced ultrasound for analysis of carotid plaque vulnerability. Morphological characteristics such as plaque neovascularization and ulceration can be assessed in a quick and non-invasive manner; such findings seem related to re-cently symptomatic carotid artery disease.

T10

Microemboli detection in different settings

D. Russell

Department of Neurology, Oslo University Hospital, Norway

Transcranial Doppler (TCD) may be used to detect asympto-matic cerebral microemboli in patient groups with an increased stroke risk and during invasive cardiovascular examinations and operations. This is possible because an embolus causes an in-crease in the amount of reflected ultrasound compared to that normally caused by red blood cells. Cerebral microemboli have been detected in patients with carotid stenosis, heart disease, during invasive cardiovascular examinations and cardiovascular surgery. Symptomatic carotid stenosis patients with microem-boli have been shown to be at high risk for developing ipsilateral stroke. Solid and gaseous microemboli are also increased in pa-tients with procedure-related ipsilateral ischemic strokes or new diffusion-weighted cerebral MRI lesions following CEA and ca-rotid angioplasty with stenting, which suggests that both solid and gaseous emboli may be harmful to the brain during these procedures. Solid cerebral microemboli were detected by multi-frequency transcranial Doppler ultrasonography in 35% of a me-chanical heart valve population, and their frequency was higher in patients who experienced cerebrovascular events during the first year after valve replacement. The results suggest that the detec-tion of solid cerebral microemboli may be helpful in predicting the risk of ischemic stroke in mechanical heart valve patients. Gaseous and solid microemboli are frequent during coronary artery bypass grafting (CABG) especially during manual manipulation, cannu-lation and clamping of the ascending aorta. Atheromatous disease of the thoracic aorta is therefore a crucial factor for the develop-ment of cerebral microemboli and postoperative lesions on DWI. Off-pump CABG surgery significantly decreases the number of emboli entering the brain but this may in part be counteracted by more unstable cerebral hemodynamics. Left heart catheterization also causes cerebral emboli due to mechanical fragmentation of atherosclerotic plaques or clots from the tip of the catheter.

T11

Extracranial and transcranial venous evaluation

J. Valdueza

Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany

Venous vessels of the cerebral outflow are involved in primarily venous disorders like cerebral sinus and venous thrombosis but also in a variety of primarily non venous pathologies, e.g. dural fis-tulas, transient global amnesia. And even arterial stroke. Recently the hypothesis of a chronic impaired cerebral venous outflow has claimed to be associated with multiple sclerosis pathology. This concept has not been reproduced by groups with a longstanding neurosonologic experience in venous duplex sonography. The de-bates, however, increased the scientific interest on the venous side of the cerebral circulation and its outflow. Aim of the lecture is 1) to present the main principles of the cerebral venous outflow (postural dependency, intraspinal venous system route, intrac-ranial valveless, extracranial internal jugular valve, right-sided predominance of venous outflow), 2) to give an overview about the ultrasound examination of the extracranial and intracranial venous vessels using color-coded duplex sonography, and, 3) to show its clinical usefulness focusing in cerebral sinus and venous thrombosis and multiple sclerosis.

T12

Cerebral parenchyma ultrasound imaging

U. Walter

Department of Neurology, University of Rostock, Rostock, Germany

Transcranial B-mode sonography (TCS) is a non-invasive, low-cost, short-duration neuroimaging method that allows high-resolution imaging of deep brain structures in patients with move-ment disorders. With contemporary high-end ultrasound systems, image resolution of echogenic deep brain structures can even be higher on TCS than on MRI. On TCS, about 90% of patients with idiopathic Parkinson’s disease (PD) exhibit abnormal hyperecho-genicity of the substantia nigra (SN). The TCS finding of SN hy-perechogenicity well discriminates PD from other Parkinsonian disorders such as multiple-system atrophy and welding-related Parkinsonism. In turn, normal SN echogenicity in combination with lenticular nucleus hyperechogenicity indicates an atypical Parkinsonian syndrome rather than PD with a specificity of more than 95%. TCS detects characteristic basal ganglia changes also in other movement disorders such as lenticular nucleus hypere-chogenicity in idiopathic dystonia and Wilson’s disease and cau-date nucleus hyperechogenicity in Huntington’s disease. Reduced echogenicity of midbrain raphe is frequent in depressive disorders and was found to correlate with responsivity to serotonin reuptake inhibitors. TCS reliably and safely displays deep brain stimulation electrodes in patients with movement disorders and allows post-operative monitoring of electrode location. Novel technologies

Abstracts Lectures Cerebrovasc Dis 2013;35(suppl 2):1–77 5

allowing automated image analysis and image fusion with MRI and CT will further enhance the application of TCS in neurode-generative brain disorders.

TS1

Multimodal Pressure-Flow Analysis to Assess

Dynamic Cerebral Autoregulation

A. Yang

National Yang-Ming University, Taiwan

Recently, we developed a new analysis tool, called multimodal -

-cal applications.

Lectures

L1

Cerebral autoregulation challenges

V. Novak

Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

Cerebral autoregulation (CA) is a complex mechanism that governs perfusion, brain volume and intracranial pressure in health and disease. A stable and optimal brain blood flow is essen-tial for normal brain function; therefore normal function of CA is crucial for brain health. Failure of CA has serious consequences across the lifespan and, in terms of prevalence, adverse outcomes related to failing CA are most prominent in older age. Decline in brain vascular reserve has been linked to age-related func-tional decline in older adults with diabetes, strokes and dementia. Therefore, the relationship between cerebral hemodynamics and cognitive performance has increasingly become recognized as a major challenge in clinical practice. Despite these clinical needs, and large body of scientific literature measuring CA, controversies exist between analytical and imaging methods, and their interpre-tation of CA. Therefore, there is a need to a large systematic study that would combine the existing analytical, modeling and imaging techniques and validate their sensitivity and specificity for predic-tion of CA impairment in a larger population.

L2

New insights into the physiology and pathology of

autoregulation

Y. C. Tzeng

University of Otago, Wellington, New Zealand

Although the identification and treatment of excessively high average blood pressure has dominated clinical management of chronic blood pressure disease, there is growing recognition that elevated blood pressure variability (BPV) across a wide range of timescales is also an adverse prognostic indicator. However, the focus on BPV belies the dependence of vital organs such as the brain on blood flow rather than blood pressure per se. Given that the brain has a high metabolic demand for oxygen, cerebral blood flow variability (CFV) and the integrity of flow-stabilizing mecha-nisms such as cerebral autoregulation may underlie the relation-ship between elevated BPV and end-organ disease at a population level. Unfortunately cerebral haemodynamic research has tradi-tionally focused on understanding within-individual physiology with comparatively little attention paid to inter-individual differ-ences in BPV and CFV. This lecture will present new data suggest-ing that the inter-individual relationships between BPV, CFV and control mechanisms such as arterial baroreflex function and cer-ebral autoregulation have important clinical implications from an epidemiological risk-stratification perspective. Specifically, it will be shown that cerebral perfusion regulation potentially involves the compensatory integration of arterial baroreflex function and mechanisms for cerebral blood flow control. The concept and implications that individuals may rely on either baroreflex vs. au-toregulation to achieve integrated cerebral perfusion homeostasis will be introduced and discussed. It will also be shown that across individuals BPV is not the sole determinant of CFV, and that ro-bust identification of vascular targets such as cerebral autoregu-lation have the potential to lead to better population based risk stratification and treatment strategies.

L3

Clinical applications of autoregulation assessment

J. Serrador

War Related Illness & Injury Study Center, New Jersey Medical School & Harvard Medical School, USA

Cerebral autoregulation is an important physiological mecha-nism that assists in maintaining cerebral blood flow relatively constant in the face of constantly changing blood pressure. The development of transcranial Doppler has allowed us to examine the response of cerebral flow velocity to beat by beat changes in blood pressure. This has resulted in significant advances in our understanding of autoregulation in the last thirty years. However, it remains unclear what role cerebral autoregulation may play clinically. This session will examine how autoregulation is affected in a number of pathological conditions including hypertension,



Parkinson’s disease and traumatic brain injury. Our previous work has found significant changes in autoregulation in conditions such as ischemic stroke, subarachnoid hemorrhage, intracerebral hem-orrhage, concussion, blast exposure, hypovolemia and intoxica-tion. The use of this information clinically may be important in informing us about blood pressure management in these condi-tions. If autoregulation is impaired, either allowing patients to be hypotensive or hypertensive may result in cerebral hypoperfusion, which could cause further ischemia, or hyperperfusion, which could increase chances of further bleeding. Future work is needed that will examine the role that impaired cerebral autoregulation in conjunction with blood pressure management plays in clinical outcomes.

L4

Non-invasive assessment of intracranial pressure

dynamics

R. Aaslid

Hemodynamics AG, Bern, Switzerland

Earlier attempts at non-invasive determination of ICP used ABP and TCD waveforms to estimate critical closing pressure (CCP). However, the CCP was found to be strongly influenced by vascular tone and a poor indicator of absolute ICP levels. An important effect of raised ICP is a decrease in intracranial com-pliance. This, in turn, causes the pulsations in the ICP waveform to increase. These pulsations are primarily caused by the changes in cerebral blood volume (CBV) throughout the heart cycle. We investigated a relatively simple model of the cerebral circulation where the relative changes in CBV were determined by integrating the difference between the arterial flow velocity (FV) waveform as recorded by TCD, and the venous outflow which we assumed to be non-pulsatile. In patients with good quality waveform record-ings, we found that this simple model gave a good representation of the ICP waveform; in particular it could predict the phase shift between the ABP and the ICP waveforms. We also hypothesized that the shape of the FV waveform was primarily determined by the difference between the ABP and ICP waveforms. The model was used to estimate the cerebrovascular pressure transmission (CPT) in a patient where the arterial pressure was measured in the brachial artery. We found a very good agreement between the esti-mated and the measured CPT. However, in patients with the low-er-quality radial ABP the method did not give reliable estimates. This problem can be resolved by using an accurate non-invasive brachial/axillary pressure waveform. We applied this method to a series of recordings in 10 normal subjects in whom the arterial pCO2 was manipulated. In all subjects we found that the model predicted a very low CPT. The estimates were not influenced by changes in vascular tone. Thus, this completely non-invasive ap-proach shows promise to assess intracranial pressure dynamics.

L5

Cerebral autoregulation measurement

M. Czosnyka

Academic Neurosurgical Unit, University of Cambridge Clinical School, Cambridge, UK

The methods for monitoring of cerebral autoregulation using correlation, phase shift, or transmission (either in time- or frequen-cy-domain) were introduced a decade ago. They express dynamic relationships between slow waves of transcranial Doppler (TCD), blood flow velocity (FV) and cerebral perfusion pressure (CPP), or arterial pressure (ABP). We review this methodology and its clini-cal application in various scenarios of neuro-critical care. Poor autoregulation and loss of pressure-reactivity are independent predictors of fatal outcome following head injury. Autoregulation is impaired by too low or too high CPP when compared to au-toregulation with normal CPP (usually between 60 and 85 mmHg; however, these limits are highly individual). Hemispheric asym-metry of the bi-laterally assessed autoregulation has been asso-ciated with asymmetry of CT scan findings: autoregulation was found to be worse ipsilateral to contusion or lateralized edema causing midline shift. Calculated indices are able to reflect tran-sient changes of autoregulation, as seen during plateau waves of ICP. However, minute-to-minute assessment of autoregulation has a poor signal-to-noise ratio. Averaging across time (30 min) or by combining with other relevant parameters improves the accuracy. It is debatable whether the TCD-based indices in head injured pa-tients can be calculated using ABP instead of CPP. Thresholds for functional and disturbed autoregulation dramatically depend on arterial tension of CO2—therefore, comparison between patients cannot be performed without comparing their PaCO2. We still do not know whether autoregulation-oriented therapy can be un-derstood as a consensus between CPP-directed protocols and the Lund-concept. What are the links between endothelial function and autoregulation indices? Can autoregulation after head injury be improved with statins or EPO, as in subarachnoid hemorrhage? In conclusion, monitoring cerebral autoregulation can be used in a variety of clinical scenarios and may be helpful in delineating optimal therapeutic strategies.

L6

Electroencephalography role in neurocritical care

F. Sales

Coimbra University and Hospital Center, Coimbra, Portugal

There is an increased awareness that continuous brain moni-toring might be beneficial to critical neurological patients, al-lowing for an earlier detection of brain dysfunction, in a possible reversible state. There is now a tendency to use a multimodal ap-proach in the neuromonitoring setting, which includes, among others, continuous electroencephalography (cEEG). The use of serial routine EEG examinations, in opposition to a continuous monitoring, might fail to pick up functional derangement during


this reversible period, which could last from minutes to hours. In a neurocritically ill patient there are several possible reasons for this aggravation of the mental status, including systemic hypotension with insufficient brain perfusion, intracranial hypertension, focal ischemia, bleeding, seizures and status, namely the nonconvulsive status epilepticus. The aim of this talk is to review the indications, limitations, and the possible added value of cEEG monitoring in the management of our patients. In this presentation, I will also address some clinical cases that may be representative of differ-ent pathologies commonly found in an intensive care unit, such as acute stroke, trauma, and encephalitis. I will more particularly stress the importance of recognizing subclinical seizures and sta-tus, both of which could contribute to an increase in morbidity and mortality.

L7

Multimodal monitoring in neurocritical care practice

M. C. Dias

São João Hospital Centre, Faculty of Medicine of University of Porto, Portugal

The management of severe neurological patients (head injury, subarachnoid haemorrhage and stroke) is a constant medical chal-lenge due to its complexity and dynamic evolution. Multimodal neuromonitoring is an important tool for clinical decision at bedside. The datasets collected by the several brain monitors help understand the physiological events of acute lesion and to define patient-specific therapeutic targets. We change from pure neurological clinical evaluation to the era of structure and image definition associated with instrumental monitoring of pressure, flow, oxygenation and metabolism. At each time we want to as-sure perfect coupling between energy deliver and consumption, in order to assure adequate cerebral blood flow and metabolism and to preserve normal tissue. Continuous monitoring of intrac-ranial pressure (ICP), cerebral perfusion pressure (CPP) and cer-ebrovascular reactivity with cerebrovascular index (Prx) or with transcranial Doppler (TCD) allows us to predict cerebral blood flow (CBF). However, adequate blood flow means not only quan-tity but also quality. To study and avoid tissue hypoxia we start to use methods for evaluation of oxygen extraction, such as oxy-gen jugular saturation (SjO2), cerebral transcutaneous oximetry (NIRS) or measurement of oxygen pressure with intraparenchy-mal probes (PbtO2). To better understand metabolic cascade we use cerebral microdialysis to monitor tissue metabolites such as glucose, lactate / pyruvate, glycerol or cytokines involved in the acute lesion. Multimodal brain monitoring in neurocritical care practice helps neurointensivists to better understand the patho-physiology of acute brain lesion and accomplish the challenge of healing the brain and rescue lives.

L8

Egas Moniz and cerebral hemodynamics: the man

behind the Nobel Prize

V. Oliveira

Department of Neurology, Santa Maria Hospital, Lisboa, Portugal

Egas Moniz (1874-1955) is the best known Portuguese neu-rologist. His name is associated with angiography and also with surgical attempts to treat some psychiatric manifestations - psy-cho-surgery. Moniz graduated at the University of Coimbra in 1899 and began his career in 1900 by obtaining an academic position at that University, and going on to have a seat in the Portuguese mo-narchic parliament. Soon after he directed his curiosity to neurol-ogy and psychiatry and during his summer holidays, he spared a couple of months every year visiting La Salpétrière where he met Babinski. A strong friendship began between them, becoming close friends throughout their lives. In 1910 republican regime was implemented in Portugal and the Universities of Lisbon and Porto were founded. A chair in Neurology was created in 1911 by his influence at the newborn Faculty of Medicine of Lisbon. This was the first neurological clinic in Portugal and he ran it until his re-tirement in 1945. The first ten years running his department were a tumultuous period coincident with the first turbulent years of the republic and the First World War. His political activity reached its pinnacle with him being a successful parliamentarian leader, ambassador in Madrid and finally president of the Portuguese del-egation at the Peace Conference in Versailles. Finally in 1919 he abandoned politics for good, with more sad than good memories as he later wrote. Nevertheless he maintained his interest by visit-ing Parisian clinics whenever an opportunity appeared. His main concern, at that time, was to identify brain tumors, their location and if possible, their type. Ventriculography introduced by Walter Dandy in 1918 was taking its first steps and Moniz pursued another thought: If one could inject an harmless product into the cerebral circulation, it might be possible to identify tumors by the displace-ment of normal circulation by the space occupying lesions. This idea of Moniz occurred in Paris after he had noticed that during a myelographical examination, some contrast media was incidental-ly injected into the spinal cord and a small vessel was then visual-ized. Henceforth, he developed experiments in order to identify an adequate contrast media and began experimenting on dogs. Only on the 13th animal was the procedure performed with it having survived. Then he tried the procedure on humans and after some setbacks he succeeded. The whole fascinating cerebral circulation bloomed before Egas Moniz’s eyes and of his co-workers and thus a new era of medicine was opened, normal circulation was bet-ter characterized. The Carotid Siphon and Sylvian Group were identified for the first time. Soon the Portuguese investigators un-derstood that brain vessels were not only useful to locate cerebral tumors, but the vessels themselves were worthy of investigation and then an entire new field of medicine was born: aneurysms, ar-teriovenous malformations, carotid and other arterial occlusions were identified. Encephalography as he initially coined it, grew steadily, worldwide and with permanent technical improvements continues today to be the golden standard for the study of cerebral circulation. Egas Moniz received worldwide recognition for their studies but he didn’t stop there, and in 1936 he developed a surgical



method to treat agitated, aggressive psychiatric patients. The idea was, for treating untreatable patients without hope, to produce selected lesions in the frontal white mater, the so called “leuco-tomy” in order to calm them down and allowing a better quality of life and even for some of them, to return to their families. He developed an instrument, the leucotome and about one hundred patients were treated. He published his results in “Tentatives opé-ratoires dans le traitement de certaines psychoses” (Masson-1936).This technique rapidly spread through Europe and the Americas, particularly in the United States, where Walter Freeman from the University of Washington DC, became an enthusiast of this proce-dure. Unfortunately, the misuse he made thrown Lobotomy as he called it, to the chamber of sad memories of medicine. One should remember that at the time when Egas Moniz developed his idea, no efficacious therapies existed to treat agitated and aggressive patients, as many of them were condemned to stay in psychiatric institutions for the rest of their lives. Chlorpromazine appeared a couple of years later (1950) and leucotomy practically disappeared in the following years. Curiously Egas Moniz didn’t perform any of the procedures that gave him international scientific recognition: at these initial times, angiography was a surgical procedure expos-ing the carotid artery and directly injecting a contrast. He had no interest in surgery so he needed the intervention of a surgeon. “He was the brain and the surgeon was his hands” he used to say. With 74 years of age he received the Nobel Prize for Medicine and Physiology shared with Walter Rudolf Hess, a Swiss Psychologist, for their work on both angiography and leucotomy. He dedicated his last years to writing his scientific memories and other books, giving conferences and keeping his private practice at 105 Rua do Alecrim, in Lisbon, never forgetting to visit his homeland, the small village of Avanca near the city of Aveiro, where he rebuilt his family mansion, nowadays a museum in his honor. In the field of medicine he published several books, namely the memories of his turbulent last year in politics (1918/19). A curious biography of the adventurer Abbot of Faria, a Portuguese XVIII century priest, magnetizer and hypnotist who lived in Paris for many years, as well as the extended biography, in two volumes, of the Portuguese romantic writer of the XIX century Júlio Diniz. Egas Moniz lived a comfortable life in his last years, praised by the international medical community, recognized by his co-citizens and ignored by the Salazar regime. He died unexpectedly in Lisbon on December 13, 1955, at the age of 81. His wife outlived him for 10 years, they had no children.

L9

Aging our arteries. A story about ADAM and EVA

E. B. Ringelstein

Department of Neurology, University Hospital Muenster, Germany

Between the classical vascular risk factors (RFs) and the final cardiovascular events, like MI or stroke, the “target organ dam-age” (TOD) is a mediating step, also called “intermediate pheno-type”. Early Vascular Aging (EVA) is charactarised by a cluster of tissue und circulating biomarkers in conjunction with classical

risk factors (RFs; hypertension, glycaemia, hyperlipidemia). New biomarker, also called “tissue biomarkers”, like arterial stiffness, central blood pressure and indicators of endothelial dysfunction, have an additional or even better predictive power of future car-diovascular events (CVE) than RFs. The logical answer to EVA is ADAM, i. e. Aggressive Decrease of Atherosclerosis Modifiers. Arterial stiffness in general, and aortic stiffness in particular, can be considered as measures of the cumulative influence of CV risk factors with aging on the arterial tree. Measuring only circulating biomarkers or peripheral blood pressure at a certain time may provide only a snapshot and not the entire history of arterial wall damage. This is why for a long time (up to the age of 50 years) the physician with his conventional view does not know about the amount of exposure to CV risk factors. There is clear evidence that arterial stiffness adds considerable predictive value, and it can directly be modified by preventive and therapeutic interventions. Patients considered at low risk by classic CV risk scores could, however, be at higher risk if their pulse wave velocity (indicating aortic stiffness) is excessively increased. A new intriguing marker of vascular aging is telomere length which was found to be clearly associated with hypertension, dyslipidemia, obesity, smoking, un-healthy lifestyle and increased arterial stiffness. It is a predictor of cardiovascular mortality in elderly, and an impressive example of genetic and environmental interactions. ADAM will counter-act EVA by the spectrum of lifestyle and medical interventions proven to improve arterial stiffness and wave reflection velocity. Preventive actions start in early life through maternal and child healthcare and improved lifestyle during adolescence.

L10

Can we identify the unstable carotid artery plaque ?

D. Russell

Department of Neurology, Oslo University Hospital, Norway

Several non-invasive imaging modalities have shown their potential to identify unstable carotid artery plaques. Echolucent plaques are thought to be more unstable than echo-rich plaques. Images can be evaluated either visually or by computer-assisted gray-scale median (GSM) measurements. Visual evaluation of plaque echogenicity has only fair reproducibility, whereas objec-tive characterization is more reliable and less observer dependent. However, even computer-assisted GSM measurement only assess-es the median brightness of the entire plaque; regional instability, such as hemorrhage, may exist within a plaque even with a high GSM value. Plaque irregularity on ultrasound has also been re-ported to be a risk factor for stroke in general. A relationship be-tween plaque irregularity and ipsilateral stroke alone has, however, not been demonstrated. Symptomatic patients with microembolic signals (MES), assessed by TCD, have been shown to be at high risk for developing ipsilateral stroke; these results should be fur-ther validated. Whether MES positive asymptomatic patients also are at increased risk has not been clarified; the number of ipsilat-eral strokes in studies to date was too small to achieve statistical significance. The use of microbubble-based ultrasound contrast agents may be helpful in determining plaque surface. Since the


microbubbles will also enter the microcirculation, information on plaque neovascularization may also be obtained. Multisequence MRI is able to quantify carotid plaque components. The use of a contrast agent improves quantification of total plaque burden, and contrast between fibrous cap and lipid core. Dynamic contrast-enhanced MRI allows assessment of plaque neovascularization. Larger prospective MRI studies are required to determine whether certain MRI assessed plaque components can predict the risk of ipsilateral stroke. Currently, there are few in vivo human stud-ies on functional imaging of carotid plaques: these initial studies have shown the potential of USPIO-enhanced MRI, 18F-FDG PET, IL2 scintigraphy, and low-density lipoprotein scintigraphy to identify inflammation, the potential of annexin A5 scintigraphy to identify cell death, and the potential of platelet scintigraphy to depict plaque thrombosis. More research is needed to determine their value in risk stratifying patients with carotid atherosclerosis. Biomarkers also hold out promise for discriminating the vulner-able patient, and some have been shown to improve prediction in-dependent of conventional risk factors. High sensitivity C-reactive protein (hs-CRP) and lipoprotein-phospholipase A2 (PLA2) are two such candidates. It is at present undecided whether one im-aging modality or a multimodality approach is most effective. Prospective clinical trials are needed to demonstrate if imaging methods do indeed result in an improvement in defining unstable plaques and if they can predict patient outcomes, particularly in asymptomatic subjects.

L11

Extra and intracranial ultrasound: risk assessment

and pharmacological interventions

L. Csiba

Department of Neurology, Debrecen University, Hungary

Carotid intima-media thickness (CIMT) is a noninvasive marker of atherosclerosis and can be assessed in a reproducible manner. The increased CIMT relates to the risk of vascular events and the results of CIMT trials is useful as a decision marker to predict the effect of drug therapies aimed on vascular events in trials using lipid-level modifying, antihypertensive and antidia-betic drugs with 1-5 years of follow-up. Intravenous injection of a contrast agent provides images about the plaque neovasculari-zation, that can be the early sign of an intraplaque hemorrhage. The contrast-enhanced carotid ultrasound is able to identify the presence of intraplaque neovascularization. Identification of an unstable vascularized carotid plaque using contrast-enhanced carotid ultrasound could improve the selection of patients for carotid endarterectomy. Recent observations found linear correla-tion between number of carotid ulcers and 3 year risk of stroke and death. Other follow up studies suggest that IMT, stenosis progres-sion and severity or juxtaluminal hypoechoic area should be con-sidered as risk factors for cerebrovascular events. The observation regarding impaired vasoreactivity and risk of stroke are contradic-tory. Some observations did not find relation between impaired cerebrovascular reactivity and the risk of vascular events but other observations and a metaanalysis suggested an association

between impaired CVR and future risk. Observations (includ-ing ACES study and metaanalysis) found correlations between microemboli positive patients, number of microemboli and risk of stroke and transient ischemic attack. The decrease of microemboli number could be detected by transcranial Doppler after pharma-cological interventions. Several studies have demonstrated that children with sickle cell disease should be monitored with serial TCD evaluations as TCD can be used to identify patients with in-creased risk of stroke.

L12

Is there a clinical value of plaque perfusion imaging?

H. Poppert

Department of Neurology, Technical University of Munich, Munich, Germany

Contrast-enhanced ultrasound (CEUS) has been shown to be a safe and valuable method in liver, breast and vascular applica-tions. The diagnostic benefit of luminal enhancement in extra- and transcranial examination of brain supplying arteries under diffi-cult conditions is obvious and its use is long established in daily clinical practice. Furthermore CEUS can be used to detect and roughly quantify intraplaque neovascularization of atheroscle-rotic plaques in carotid arteries, the accuracy of which has been reported in number of smaller studies. It is widely accepted that plaque vascularization reflects atherosclerotic inflammatory activ-ity and is associated with intraplaque hemorrhage finally promot-ing plaque rupture. Thus the detection of neovessels is a promising method to define rupture prone plaques and might serve as a sur-rogate marker to monitor response to plaque stabilizing therapy. However, large studies are still lacking. From experience a large part of obviously vulnerable, recently symptomatic plaques doesn‘t show any detectable neovascularization and in the remaining ones therapeutic consequences remain unclear. In this lecture the actual clinical value of this promising method will be critically discussed.

L13

Functional ultrasound imaging of brain activity :

from small animal imaging to clinical applications

M. Tanter1, B. Osmanski1, C. Demené1, M. Pernot1, J-L Gennisson, M. Fink1, V. Biran2, O. Baud2 , L-A Sieu3 and I. Cohen3 1Institut Langevin, ESPCI ParisTech, CNRS, INSERM, France2

3INSERM U739, CHU Pité Salpêtrière, UPMC

Functional imaging modalities such as fMRI or optical imaging identify regions of brain activity by measuring changes in blood flow thanks to the neurovascular coupling. Paradoxically, Ultrasound was not present in the field of Neuroscience till recently, whereas it is the



most used modality for blood flow imaging in clinics. The reason for this was the poor sensitivity of Doppler ultrasound limiting blood flow imaging to large arteries. Ultrafast Doppler imaging based on plane wave imaging breaks this barrier and enabled recently the emer-gence of fUltrasound (by analogy to fMRI). fUltrasound (fUS) is able to provide unique whole brain images of perfusion on small rodents with unprecedented resolutions (100 μm and 200 ms). Functional imaging of cerebral blood volume during epileptic seizures, whisker or odor stimulations, and drug injection emphasizes the potential of this new imaging modality to provide completely new information for the understanding of brain. As fUltrasound relies on ultrafast ultrasound acquisitions, it also enables the whole brain mapping of vascular indexes (such as resistivity, pulsatility or transient systolic time indexes) within a single cardiac cycle in addition to functional imaging of brain activity on longer time scales. fUS is a great tool for neuroimaging on small animals as it already helps both to answer unsolved questions and to observe the functional activity of to date unexplored brain regions. It should become a full-fledged imaging modality of neuroscience as it provides the first whole brain and portable neuroimaging modality for awake and freely moving animal studies. Beyond small animal imaging, clinical fUS should become an alternative to fMRI in particular applications, such as newborns or preterm infants, both for neona-tal seizure monitoring and cognitive science studies. It could also become a powerful portable tool for neuroimaging during preop-erative surgery on adults.

L14

Clinical applications of Functional Transcranial

Doppler

B. Rosengarten

University Clinics of Giessen and Marburg GmbH, Germany

Most cerebrovascular disease processes begin with an endothe-lial dysfunction before later on morphologic alterations occur. Conservative medical treatment regimes can reverse endothelial dysfunction whereas morphologic alterations mostly persist mak-ing invasive approaches necessary. Therefore, diagnostic instru-ments assessing the first steps in atherosclerosis are attractive in aiding clinical therapy. The functional Doppler sonography is a well established diagnostic tool to assess the vascular side of the neurovascular coupling by summing up the micro-vascular re-sponses in the upstream vessels. Several approaches such as stand-ardized carbogene gas inhalation or azetazolamid injection have been used to assess the vascular reactivity in different disease processes. Together with simultaneous EEG recording and use of appropriate functional stimuli, the electrical neuronal responses could also be obtained simultaneously allowing the assessment of both sides of the neurovascular coupling. Contrast based alter-nating visual pattern allow the investigation of the neurovascu-lar coupling in the visual cortex. Validation studies have shown a close correlation between early visual evoked potential amplitudes and hemodynamic responses. The constellation of a diminished vascular response but still intact evoked potential amplitude is typical for an early uncoupling and as animal experiments showed

indicative of inappropriate cerebral blood supply. Extending our own animal experiments we investigated the feasibility of the com-bined functional EEG-Doppler technique in several clinical dis-ease processes to detect early endothelial dysfunction.

L15

Cerebral hemodynamics and the aging brain

F. Sorond

Department of Neurology, Stroke Division, Brigham and Women’s Hospital, Women’s Hospital, Boston, USA

Aging is associated with a number of degenerative chang-es in the structure and function of blood vessels. Recent stud-ies have examined the impact of age on cerebral hemodynamics and brain structure and function. These studies have shown age related changes in resting cerebral blood, cerebral vasoreactivity, cerebral autoregulation and neurovascular coupling. Studies have also shown that aging is associated with cortical atrophy and cer-ebral white matter injury. More recent studies have also examined the relationship between age related cerebral hemodynamics and brain structure and function. Cross-sectional studies have shown that both cerebral vasoreactivity and pulsatility index are associ-ated with cerebral white matter injury. Similarly, cerebral vasore-activity has also been associated with impaired mobility which is known to be a clinical consequence of cerebral white matter injury in the elderly people. Neurovascular coupling has also been asso-ciated with slow gait and impaired executive function. Despite our advances in this field, our understanding of the relationship be-tween cerebral hemodynamics and structural changes in the aging brain is limited. We also know very little about the relationship between cerebral hemodynamics and clinical outcomes of struc-tural brain disease. A better understanding of these relationships is an essential step towards identifying therapeutic targets and preventive strategies for age related cerebrovascular disease. This review summarizes the available data from recent studies examin-ing cerebral hemodynamics and the aging brain.

L16

Why space flight is like aging: the vestibular-brain

blood flow link

J. Serrador

War Related Illness & Injury Study Center, New Jersey Medical School & Harvard Medical School, USA

Spaceflight is associated with a number of adaptations that are very similar to those seen with aging. For example, both space-flight and aging are associated with loss of muscle mass, loss of bone density and loss of balance. Both aging and spaceflight are also associated with increased incidence of orthostatic intolerance, or the inability to stay upright without fainting. One similarity in


both groups is the loss of balance function. In both conditions the vestibular system has a reduced ability to detect gravity through the otolith organs, one because of loss of hair cells with aging, and the other because of a retraining of the brain to ignore the otoliths for perception of gravity because of adaption to zero gravity. We hypothesized that otolith mediated vestibular inputs would pro-vide cues of position that would assist in maintaining brain blood flow when upright. To assess this we performed a series of experi-ments examining the role that the vestibular system may play in af-fecting cerebral blood flow. We found that direct stimulation of the vestibular system using centrifugation or tilt resulted in changes in cerebral blood flow that could not be explained either by changes in blood pressure or arterial CO2 levels. We further found that individuals with reduced otolith function demonstrated greater decreases in cerebral blood flow when upright. Finally, we used a new paradigm known as stochastic noise galvanic stimulation to improve vestibular function which resulted in enhanced cer-ebral blood flow during dynamic tilt with stimulation. These data demonstrate that reduced otolith function may be involved in or-thostatic intolerance and that stochastic noise may be a possible method of restoring impaired function.

L17

Peri-interventional diagnostic and therapeutic

ultrasound

G. Tsivgoulis

University of Athens, Greece

The present lecture will outline the role of neurosonology as an ideal screening tool for combined intravenous or intra-arterial reperfusion strategies in patients with acute cerebral ischemia, since it has the ability to identify and reject those patients who achieved early recanalization not yet accompanied with neurologi-cal recovery or to select patients with persistent occlusions that may be suitable candidates for further interventional reperfusion procedures. Moreover, ultrasound may be used for monitoring of intra-arterial reperfusion procedures to diminish the number of contrast injections that are thought to increase the risk of hem-orrhagic complications. TCD/TCCD can also yield accurate di-agnostic information regarding recanalization status at bedside in patients with contraindications to MRA or CTA or in centers with limited 24-hour availability to these neuroimaging modali-ties. Numerous groups have previously highlighted the potential of TCD in providing hemodynamic information, diagnosing air embolism, and detecting early reocclusion soon and immedi-ately after intra-arterial reperfusion procedures. Last and most important, data from small phase IIA-IIB studies and two recent meta-analyses indicate that sonothrombolysis (combination of high-frequency ultrasound and standard intravenous thromboly-sis) may enhance the lytic activity of tissue-plasminogen activator and thus increase the efficacy of systemic thrombolysis by achiev-ing higher recanalization rates.

L18

A new paradigm in acute stroke treatment: Should

neurologists become neurointerventionalists?

M. Ribó

Stroke Unit. Neurology Department, Hospital Vall d’Hebron, Barcelona, Spain.

Incorporating a stroke neurologist in a neurointerventional mul-tidisciplinary team may offer several advantages. In this collaborative scenario the neurologist should coordinate the therapeutic process that the patient will follow. The process includes initial evaluation in the emergency room and indication to initiate fibrinolytic therapy. At this point the possibility of performing endovascular revasculari-zation procedures will be discussed. The role of the stroke neurolo-gist should be not only to alert the interventionist and receive the patient at the door of the intervention room at the end of procedure. A joint assessment including neurologist and neuroradiologist opin-ions and the current clinical and neuroimaging condition will allow best selection of candidates. The neurologist, who had a close contact with the patients escorts since the beginning, is likely to be the best person to inform and consent in this stressful situation. From this moment until the start of the endovascular procedure, the neurolo-gist can continuously monitor with TCD the occluded artery so if an early recanalization occurs angiography may be avoided. A neu-rologist qualified to perform endovascular procedures will have a paramount role in the angio-suite. His presence will allow periodi-cal assessment of neurological status and decide on various issues that arise: intubation, analgesia, sedation, pressure management, glucose monitoring... Similarly the qualified neurologist’s opinion will help deciding the end of the procedure, integrating multiple factors: time from onset, state of occlusion, current neurological in-volvement, previous disabilities... The presence of a neurologist can add the benefit of intraprocedural TCD monitoring of the target artery providing real-time information on the status of the artery. Once the procedure is finished all professionals should agree on the best medical treatment for the next hours. The key issue is that the neurologist actively participated in the process and perfectly knows incidents: hypo-hypertension, vomiting, complete/partial/no reca-nalization, suspected dissection/perforation/stenting. A regular and close interaction between neurologists, neuroradiologists and nurse/technicians in the process allows better operation of the circuits and will certainly result in lower latency times and improved patient care.

L19

Usefulness of Doppler Ultrasound in “vertigo plus”

J. M. de Bray

Department of Neurology, University Hospital Angers, France

A vertigo is an illusion of movement from the environment. An isolated vertigo has mainly a peripheral origin. Ischemic “ver-tigo plus” has focal neurological symptoms which are sometimes discrete. Before an initial Doppler examination, a talk with the



patients permit to analyse voice, audition, gait and wave of the hands. Their diagnosis is an emergency: Stroke Unit. The main “vertigo plus” will be defined by a suggestive symptom: 1) Latero-bulbar infarction: vertigo with a nasal voice. Cause is atheroma of small branches coming from V4 or atheroma or dissection involv-ing V3V4. A Transcranial Doppler Sonography (TDS) can detect the stenoses. 2) Infarction in the PICA region: vertigo with a se-vere ataxia and/or clumsiness of one hand. Cause is atheroma in half of the cases involving PICA or V3 V4, lesions studied by TDS. 3) Progressive infarction of the brain stem with fluctuating symp-toms as fugax vertigo, diplopia, transient hemiparesia. An early diagnosis of basilar stenosis is needed. 4) Infarction in the distri-bution of AICA: vertigo with a common unilateral hearing. It is due to atheroma of basilar artery or occlusion of branche of AICA. TDS can show a basilar artery stenosis. A isolated Vertigo has ex-ceptionaly an ischemic cause. Its origin is atheroma involving me-dian branche of PICA not detected by TDS. In this case, the head trust test is normal. Conclusion: MRI with MRA is the best meth-od in emergency at the acute onset of a vertigo plus. Otherwise a CT SCAN with a brief Doppler Ultrasound is very useful. This examination could be completed later to quantify stenosis.

L20

How to refine the criteria for intracranial stenting

after SAMMPRIS

L. Wong

Prince of Wales Hospital, Chinese University of Hong Kong

In the SAMMPRIS study, luminal stenosis of 70-99% was used as one of the inclusion criteria for stenting. However, the event rate in the medical arm was lower than expected while the event rate in the stenting was higher than expected. There were many potential reasons for the disappointing results of SAMMPRIS. The use of just luminal stenosis might be one of them. Other than diameter stenosis as used in the WASID study, there are many factors in-volved. The status of the collateral circulation is also an impor-tant consideration. More recent works in the coronary circulation confirm the importance of computerized flow dynamics, which can be measured by CTA or MRA. TCD may have the potential in documenting the status of collateral circulation and flow pattern proximal/distal to stenosis before deciding on the need for stent-ing of intracranial atherosclerosis.

L21

Atrial fibrillation epidemics: a new era in stroke

prevention

L. Cunha

Coimbra University and Hospital Center, Coimbra, Portugal

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder and is associated with a 4- to 5-fold increase in the risk of stroke and systemic embolism. Altogether, this arrhyth-mia has been perceived as one of the major medical challenges in modern society and its clinical, social and economic aspects are all set to worsen over the coming decades, especially considering its increasing frequency with age. In fact, the fast and continuous epidemiological changes along with the increasing awareness of physicians has significantly raised the importance of AF in cur-rent cerebrovascular units. The pathological reasoning behind AF has been progressively deciphered with detailed physiologic and anatomical studies and the diagnostic strategies have evolved from pulse palpation to long-term implantable recordings and emboli detection. This evolution along with the knowledge of stroke mechanisms has allowed to gradually achieve the diagnosis from stroke to AF. Parallel to the increasing diagnostic and pathological comprehension, we have recently witnessed a dramatic improve-ment in treatment strategies of AF, which has mostly come from the field of antithrombotic medication. Despite the proven efficacy of vitamin K antagonists in primary and secondary prevention many doubts and obstacles remained on their adequate use. The main limitations were probably the debatable definition of “low risk” in this condition as well as the inconvenience, and in some occasions even impossibility, of periodic analytical control. The new generation of anticoagulants, with its distinct safety and com-modity profile is widely overcoming these obstacles and ultimately improving standard of care in these patients. These characteristics have generated a revolution in the medical paradigm of AF, with widespread recognition in treatment guidelines. The objective of this presentation is to discuss an updated approach to AF from diagnostic reasoning to therapeutic considerations.

L22

Prevention of stroke in atrial fibrillation: a new era on

detection devices

R. Dittrich

Department of Neurology, University Hospital Münster, Münster, Germany

Cryptogenic strokes account for 25% of all strokes and remain a challenge for doctors and patients. Among the different etiologies of cryptogenic strokes there are a significant proportion of patients with paroxysmal atrial fibrillation as long as these paroxysmal epi-sodes remain asymptomatic. The detection of atrial fibrillation has an impact for secondary prophylaxis because the most effective treatment is anticoagulation. However, the diagnostic work up on


dedicated stroke units with 24h holter ecg and transesophageal echocardiography have low detection rates for atrial fibrillation. Even with an extended holter ecg monitoring of seven days the de-tection rates remain low between 10-15%. Therefore, new strate-gies ecg monitoring are urgently needed to increase the sensitivity in detecting atrial fibrillation. Implantable devices are a promising technique. With these devices, a continuous long term monitoring is possible with a high reliability in detecting atrial fibrillation. In a pilot study with 60 patients an additional proportion of 17% with atrial fibrillation could be identified. Other innovative techniques are automated analysis tools of the bed side monitoring ecg with different algorithms. Sophisticated and even simple algorithms are also significantly more sensitive in the detection of atrial fi-brillation compared to the 24h holter ecg. These new techniques turn out to be more successful in the detection of atrial fibrillation compared to the existing strategies and their further development is warranted.

L23

Which ultrasound criteria require recanalisation of

carotid stenosis before cardiac surgery?

R. Dittrich

Department of Neurology, University Hospital of Muenster, Muenster, Germany

Stroke is the most feared complication of cardiac surgery and large artery atherothrombosis is a known risk factor of stroke. Concomitant high grade carotid stenosis in patients undergoing coronary bypass surgery is found in approximately 6-8%. Since years there is an ongoing debate whether the narrowed carotid artery should be operated simultaneously. The pathophysiological problem is that patients with carotid stenosis scheduled for bypass surgery often have additional stroke risk factors like atrial fibril-lation or aortic plaques. There are numerous retrospective obser-vational studies that the simultaneous revascularization is feasible but there is no randomized prospective study which addresses this issue and provide evidence that the patients have a benefit. To answer this question there is an ongoing randomized trial since 2010 comparing the simultaneous operation with isolated coronary bypass surgery (CABACS, Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis). Since results of this trial are to be expected there are no clear and well established criteria which require recanalisation of carotid stenosis before cardiac surgery. Analogous to the guidelines for patients with symptomatic and asymptomatic carotid stenosis it is worth to discuss whether high risk patients with high graded contralateral carotid stenosis or occlusion might benefit from a simultaneous operation.

L24

Cerebrovascular risk reduction with TCD monitoring

of cardiac and aortic interventions

Z. Garami

Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Texas

Objective: Thoracic Endograft placement (TEGP) and Transfemoral Aortic Valve Insertion (TAVI) has become an ac-ceptable treatment alternative to open surgical repairs. Cerebral embolization when manipulating the aortic arch during cardiac catheterization is well described. The influence of endograft and valve placement on cerebral embolization is not well studied. Our aim is to quantify the number of microembolic signals (MES) detected by Transcranial Doppler (TCD) during different stages of the endograft and valve placement and correlate them with. Methods: Imaging and medical parameters were entered into a combined database. Data was collected retrospectively. Results: TCD monitoring was successful in all the patients. The total num-ber of MES calculated for the diagnostic segment (DS) before TEGP/TAVI placement and during device placement (DP). The highest MES counts were generated by the pig tail catheter during the DS and by device/valve placement during DP. Embolic dis-tribution to right/left (Rt/Lt) sides was symmetrical in every case overall. In DS part of TEGP, an average of 9 MES were seen Rt/Lt during TEGP and average of 8 and 16 MES were detected during TAVI, while during DP in TAG, 45 and 43 MES were seen respec-tively for Rt and Lt, 474.2 and 530.2 during TAVI. There was no correlation between post-operative stroke, TIA, arch type, landing zone and number of MES. Conclusions: The ability of TCD to de-tect cerebral emboli is important in order to elucidate which steps of procedure are most likely to provoke emboli. Cerebral emboli-zation protection should be considered during TAVI procedures. It also has a potential to compare endografts, valves and their ca-pacity to generate emboli. We propose that further uses of TCD during TEGP and TAVI procedures to eliminate and learn about potential hazardous flow pattern changes not just the emboliza-tion rate.

L25

Predicting coronary artery disease (CAD) in stroke

patients

N. Bornstein

Department of Neurology, University Hospital, Tel Aviv, Israel

Atherosclerosis is a systemic inflammatory vascular disorder, involving multiple arterial beds. Although modern pharmaco-therapy and revascularization have markedly enhanced the prog-nosis of patients with atherosclerotic vascular disease, myocardial infarction (MI) and stroke remain leading causes of mortality and morbidity due to this disease. Concomitant atherosclerotic lesions of the extracranial internal carotid arteries (ICA) and the coronary



circulation portend an adverse prognosis in various clinical set-tings, including asymptomatic individuals, stroke patients, and patients undergoing coronary artery bypass surgery. Previous postmortem and clinical studies, often small in sample size, have reported a variable prevalence of concomitant carotid and coro-nary lesions in patients with or without clinically evident car-diovascular disease. Thus, the prevalence of clinically important, concomitant carotid artery stenosis (CAS) and coronary artery disease (CAD) requires further definition in larger populations. Concurrent CAD and CAS is frequently detected in clinical prac-tice and has important prognostic implications in symptomatic patients who are considered for revascularization of one or both of these vascular beds as well as in entirely asymptomatic individu-als. In patients with traditional atherosclerotic risk factors but not necessarily a prior cardiovascular event, the mere presence of a ca-rotid bruit predicts increased risk of MI and cardiac death. In fact, progression of CAS on sequential Doppler studies has been shown to stronger correlate with future MI events than with stroke. The presence of CAS has been shown in multiple, though not in all, studies to increase the risk of perioperative stroke in patients un-dergoing CABG. Conversely, the presence of CAD increases the risk of peripheral vascular surgery including carotid endarterec-tomy. Notwithstanding, the role of pre-emptive interventions on asymptomatic carotid or coronary lesions prior to coronary or carotid revascularization, respectively, is controversial, and guide-line recommendations regarding screening for asymptomatic CAS in patients with CAD are unsettled. The reported prevalence of asymptomatic CAS has ranged from 2% to 18% among screened populations, although in high-risk individuals, including those with coronary artery disease, the prevalence of significant CAS has been reported to be as high as 30%.

L26

Role of ultrasound in inflammatory and degenerative

brain diseases

U. Walter

Department of Neurology, University of Rostock, Rostock, Germany

Transcranial B-mode sonography (TCS) is a non-invasive, low-cost, short-duration neuroimaging method that allows high-resolution imaging of deep brain structures in patients with in-flammatory and degenerative brain diseases. Hyperechogenicity of the substantia nigra (SN), a TCS findings present in about 90% of patients with idiopathic Parkinson’s disease (PD), is already present in presymptomatic disease stages. SN hyperechogenicity has been demonstrated to correlate with iron accumulation in a number of brain disorders but also with microglia activation. The results of recent longitudinal studies suggest that TCS of SN may serve as a screening tool for detecting subjects at risk of later de-veloping PD. In a large study we could show in addition that the combination of TCS with simple olfaction and motor tests already at very early disease stages discriminates PD from other parkinso-nian disorders. In turn, normal SN echogenicity in combination with lenticular nucleus hyperechogenicity indicates an atypical

Parkinsonian syndrome rather than PD with a specificity of more than 95%. TCS detects characteristic basal ganglia changes also in other movement disorders such as lenticular nucleus hypere-chogenicity in idiopathic dystonia and Wilson’s disease and cau-date nucleus hyperechogenicity in Huntington’s disease. Reduced echogenicity of midbrain raphe is frequent in depressive disorders and was found to correlate with responsivity to serotonin reuptake inhibitors. An elegant application of TCS is the intra- and postop-erative localization of deep brain stimulation electrodes in patients with movement disorders. The detection of changes of deep brain structures on TCS in multiple sclerosis patients was found to have a predictive value for further disease progression.

L27

Tissue velocity imaging of muscle movements

M. Siebler

Mediclin /Essen Kettwig, Department of Neurorehabilitation / University of Dusseldorf, Germany

Background: By means of ultrasound (US) methods structur-al and functional properties of the muscle tissue could be detected in patients in real time and non-invasively. Since dynamic analysis in echocardiography is established in clinical routine myosonol-ogy is moving more and more in the focus of neurological inter-est. Using tissue velocity imaging (TVI) we are able to investigate the dynamics of movements in identified muscles. The US meth-od provides advantage compared to EMG or MRI/CT, since the muscle motion could be better detected and quantified in terms of velocity and accelerations as well as synchronicity of muscle contraction. We tested whether this method could be applied to measure the forearm muscle motions in order to monitor reha-bilitation therapies as well as pharmacological effects. Methods: The voluntary movement of hand opening (M.ext. digitorum) and closing (M.flexor digitorum) was analyzed in healthy subjects (n=30) and stroke patients (n= 31) using the B-mode and tissue velocity imaging (TVI). TVI is based on the Doppler effect to re-cord slow movements of the tissue and was adapted on a 6-8MHz probe (GE vivid 7). We recorded synergistic contractions or de-phasing (non-synchronous muscle activity) and quantified veloc-ity of contraction and relaxation as well as repetition frequency. Results: Normal subjects displayed a synchronous activation of the muscles with a contraction velocity of 4.1 cm/s, relaxation ve-locity of 4.3 cm/s and a repetition frequency of 4.5 / s, respectively (mean values). In stroke patients, a significant reduction of these parameters was found on the lesion side (1.1 cm/s; 1.2 cm/s; 1.2/sec; Fig). A significant decrease was also found on the contralateral “healthy” side (2.5 cm/s; 2.6 cm/s; 2.5/sec) which is also significant different to healthy controls. After 2 weeks rehabilitation exercises these parameters improved in a wide range (up to normal) on both sides. L-Dopa (n=3 patients) improved substantially the param-eters within 1 week. Conclusion: This US technique is a simple and bedside method which allows analyzing and quantifying the movement kinetic of identified muscles. This allows monitoring disease progression and treatment effects and may be thereby an appropriate tool for stroke rehabilitation.

Abstracts Orals Cerebrovasc Dis 2013;35(suppl 2):1–77 15

L28

Ultrasound in transient global amnesia, is it useful?

C. Baracchini

Department of Neuroscience, University of Padua School of Medicine, Italy

Background and Purpose: Several studies have suggested that Transient Global Amnesia (TGA) might be determined by cerebral venous congestion secondary to a reflux during a Valsalva-associated maneuver (VM) caused by internal jugular valve insufficiency (IJVI). These findings have led to the assump-tion of hemodynamic alterations in intracranial veins inducing focal hippocampal ischemia. This hypothesis has been recently investigated by different authors in TGA patients and controls. Methods: Extracranial and transcranial high resolution venous echo-color-Doppler sonography was performed in TGA patients and controls; in particular, IJVI was assessed during VM, while blood flow direction and velocities of the intracranial veins (main-ly the basal vein of Rosenthal) were recorded both at rest and dur-ing VM. These measurements were partly performed in the supine and in the sitting position, in the chronic and in the acute setting (i.e. while TGA patients were still symptomatic). Results: IJVI (left, right or bilateral) was found to be more frequent in TGA pa-tients than in controls; body position seemed to have no effect on the detection of IJVVI. Blood flow velocities in the deep cerebral veins of TGA patients did not differ from controls, both at rest and during VM. Intracranial venous reflux was neither observed in TGA patients nor in controls, in spite of unilateral or bilateral IJVI during prolonged and maximal VM. Conclusions: These stud-ies, though confirming the association between TGA and IJVI, shed doubts on a direct causative role of IJVVI in TGA patients. Routine examination of TGA patients by extracranial and intrac-ranial venous ultrasound is at this moment not advisable.

L29

CoSMo study results on CCSVI and MS

M. Del Sette

On behalf of Italian Association for Multiple Sclerosis (AISM)

Background: Chronic cerebro-spinal venous insufficiency (CCSVI), recently described as a condition related to malformation of the venous system, has been proposed as a possible mechanism important in the pathophysiology of multiple sclerosis (MS). Aim of the CoSMo study was to evaluate the association between CCSVI and MS. Methods: CoSMo was a multicenter, case-control, preva-lence study. The primary end-point was to compare the prevalence of CCSVI in MS patients versus patients with other neurodegen-erative diseases (OND) and healthy controls (HC). Colour-coded duplex (CCD) sonography was performed by a local sonologist and the images sent to one of three central sonologists for a second reading. Agreement between the local and central sonologist or, in case of disagreement, the report of the central readers was required for CCSVI diagnosis. Local and central readings, data collection

and statistical analyses were all blindly performed. Findings: 35 MS centres across Italy were involved, including 1874 adult sub-jects aged 18-55 years. 1767 (94%) were evaluable: 1165 patients with MS, 376 HC and 226 patients with OND. CCSVI prevalence was 3.26% for MS patients, 2.13% for HC and 3.10% for patients with ONDs. No statistically significant difference was found in CCSVI prevalence among the 3 groups (MS vs HC, OR=1.55 [95%CI=0.72-3.36], p=0.30; OND vs HC, OR=1.47 [95%CI=0.53-4.11], p=0.46; MS vs OND, OR=1.05 [95%CI=0.47-2.39], p=0.99). Negative agreement between the local and central reader was high while a low positive agreement was observed. Interpretation: The CoSMo study indicates that CCSVI prevalence is very low and not significantly associated with MS.

Oral Presentations

O1

Convergent cross mapping: a promising technique

for future cerebral autoregulation estimation

L. Heskamp1,2, A. Meel-van den Abeelen1, E. Katsogridakis3, R. Panerai3, D. Simpson4, J. Lagro1, J. Claassen1

1 Radboud University Nijmegen Medical Centre, Dept of Geriatric Medicine, Nijmegen, the Netherlands; 2 MIRA-Institute for Biomedical Technology and of Technical Medicine, of the Faculty of Science and Technology, University of Twente; 3 University of Leicester, UK; 4 University of Southampton, UK

Introduction: Dynamic cerebral autoregulation (CA) regu-lates cerebral blood flow velocity (CBFV) during changes in arterial blood pressure (ABP). Currently, transfer function analysis (TFA) is widely used to assess dynamic CA non-invasively. However, TFA is a linear approach and physiologically, CA is a non-linear process. Therefore this study has explored the use of convergent cross mapping (CCM) as a non-linear analysis technique to as-sess dynamic CA. Methods: CCM determines causality between variables by investigating if historical values of a time-series X(t) can be used to estimate the states of a time-series Y(t). X(t) and delayed versions of X(t), for example, X(t-tau) and X(t-2*tau) are used to reconstruct a so called shadow manifold. For each time-point i, the nearest neighbours of the point (X(i), X(i-tau), X(i-2tau)) are used to predict Y(i) using the nearest neighbour principle. This results in a prediction of the time-series Ypred(t). The Pearson correlation between Y(t) and Ypred(t) is determined and increases with increased time-series length to converge to a pla-teau. In case of CA, CBFV is used to predict ABP. With impaired CA, the influence of ABP on CBFV increases compared to normal CA. Therefore, CBFV data contain more information on ABP. As a consequence, the correlation between ABP and predicted ABP converges to a larger plateau. The CCM method was validated using artificial data for each autoregulatory index (ARI) value, and with data obtained in subjects under hypercapnic conditions



Results: CCM showed higher correlations for lower ARI values (more impaired CA), e.g. 0.97 ± 0.01 for ARI 2 vs. 0.61 ± 0.08 for ARI 5, p<0.01. Furthermore, in the hypercapnic data, CCM correlation was higher (p<0.01) during hypercapnia (0.65 ± 0.10) compared to measurements taken in these same subjects during normal breathing (0.34 ± 0.14). Conclusion: CCM is a promising technique for non-linear cerebral autoregulation estimation

O2

Between-centre variability in transfer function

analysis, a widely used method for linear

quantification of the dynamic pressure-flow relation:

the CARNet study

A. Meel-van den Abeelen1 and J. Claassen1 on behalf of the CARnet bootstrap network, The Nederlands1Radboud University Nijmegen Medical Centre, Dept of Geriatric Medicine, Nijmegen, the Netherlands

Cerebral autoregulation (CA) is the capability of the brain to maintain an adequate cerebral blood flow (CBF) during changes in blood pressure (BP). Transfer function analysis (TFA) is the most frequently used method to assess dynamic CA using spontane-ous oscillations in BP and CBF velocity (CBFV). However, there is considerable local, national, and international variation in how research groups utilize TFA, subsequently leading to high variabil-ity in outcomes measures. The objective of this study is to evalu-ate the effect of between-centre differences in performing TFA on related metric outcomes. 15 centres from Europe, North America, South America, and the South Pacific analyzed the same database that contained BP and CBFV data from healthy subjects (n = 50 baseline conditions; n = 20 during hypercapnia); 10 datasets were generated. Each centre used their own in-house transfer function estimation methods. We analyzed between-centre differences in TFA outcome metrics (gain, phase, coherence) during normo-capnia and during hypercapnia. The latter provides a means to ‘change’ CA and hence was used for discriminatory performance. Results were analyzed using the Mann-Whitney test and logistic regression. There was large variation in TFA gain, phase and co-herence between the 15 centres; however, variation was not ho-mogeneous, with a clustering of 9 centres exhibiting much smaller variation. Logistic regression demonstrated that 11 out of 15 cen-tres were able to distinguish between normal and impaired CA with an AUC higher than 0.85. Further analysis identified specific TFA settings that are associated with large variation in outcome measures, including sampling frequency, number of windows, window length, type of anti-leakage window, and the definition of frequency bands. These results indicate the need for standardiza-tion of TFA settings in order to reduce between-centre variability and to allow accurate comparison between studies. Suggestions on optimal signal processing methods are proposed.

O3

Can subcomponents analysis help with the

interpretation of the CBFv response to neural

activation after acute ischaemic stroke?

A. Salinet, T. Robinson, R. Panerai, UK

Department of Cardiovascular Sciences, University of Leicester, LE1 5WW, Leicester, United Kingdom

Introduction: Neurovascular coupling (NVC) is the mecha-nism for adapting cerebral blood flow (CBF) to underlying neu-ronal activity. However, simultaneous changes in peripheral physiological parameters add complexity to this cerebral response. We tested the hypotheses that neurovascular coupling (NVC) is impaired after acute ischaemic stroke (AIS) revealing signifi-cant differences between AIS and controls using subcomponents analysis of CBF velocity (CBFv) responses to neural activation. Method: NVC was measured in nineteen AIS and seventeen age/gender matched controls. Continuous recordings of bilateral CBFv, blood pressure (BP), heart rate and end-tidal CO2 were ob-tained during 60s of sequential passive elbow flexion (AIS with affected side and controls with the right arm). CBFv changes were decomposed into standardized subcomponents describing the relative contributions of BP (VBP), resistance area product (VRAP) and critical closing pressure (VCrCP). VRAP might reflect myogenic activity in response to BP changes, whereas VCrCP is more indica-tive of metabolic control. Results: The passive paradigm led to a bilateral CBFv increase in both groups, although the amplitude of CBFv in AIS was significantly lower. BP increases were shown to be an important contributor to CBFv response throughout the paradigm in both groups, with no significant difference between groups. The VCrCP contribution was not different between groups or hemispheres; its continuous rise during activation indicating a vasodilatory effect. On the other hand, the VRAP contribution showed significant differences (p=0.03) with bilateral positive peaks in controls, indicating vasodilatation which were lacking in AIS, thus suggesting myogenic impairment. Conclusion: CBFv responses to passive elbow flexion suggest an impairment of NVC in AIS. Subcomponent analysis can give greater insight into the different mechanisms contributing to the integrated neurovascu-lar response. Further research is needed to assess the clinical value of subcomponent analysis of NVC for management and follow up of patients with stroke and other cerebrovascular conditions.


O4

Random steps in lower-body-negative pressure

to augment blood pressure variability in the

measurement of cerebral autoregulation,

D. M. Simpson1, A. A. Birch2, H. Kouchakpour1, H. Lea-Banks1, R. B. Panerai3

1University of Southampton, ISVR, Southampton, UK; 2University Hospital Southampton Foundation Trust, Department of Medical Physics & Bioengineering, Southampton, UK; 3University of Leicester, Department of Cardiovascular Sciences, Leicester, UK

For the measurement of dynamic cerebral autoregulation many different experimental and signal analysis methods have been proposed, without a gold-standard having emerged. The exploitation of spontaneous variations in arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) is now perhaps most common, as it requires minimal interference with the pa-tients. However, low variability in arterial blood pressure has been associated with limited performance. We therefore investigated pseudorandom lower-body negative pressure (lbnp) as a means to provoke a small increase in blood pressure variability. We report on results from 12 healthy adult volunteers, during 5 minutes of lbnp, with random 5, 10 and 20 second plateaus. The mean ABP, CBFV and lbnp was calculated over the period from two to one second before each step on-set of lbnp, and also from one to two seconds after the transition, and then averaged for all transients in each subject. The pressure drop in the lbnp chamber was 80.4 +/- 2.0mmHg, with a mean baseline value of -15.0 +/- 1.2 mmHg (in order to accelerate the transition). The mean drop (across the cohort) in ABP was 4.9 +/- 3.7 mmHg (5.9 +/- 4.5%), with respect to baseline for each subject, and in velocity 5.3 +/- 2.3 cm/s (8.2 +/- 3.2%). The drop in ABP was significant in 9 and in CBFV in 11 of the 12 subjects (p<0.05, Wilcoxon). Autoregulation is signifi-cantly stronger during lbnp than at baseline (rest, 5 minutes), with a phase-lead of 0.90 +/- 0.35 and 0.60 +/- 0.14

O5

Non linear analysis does show impaired cerebral

autoregulation in human experimental endotoxemia

L. Heskamp1,2, A. Meel-van den Abeelen1, J. Lagro1, L. van Eijk3, C. Hoedemaekers3, J. Claassen1

1 Radboud University Nijmegen Medical Centre, Dept of Geriatric Medicine; 2 MIRA-Institute for Biomedical Technology and of Technical Medicine, of the Faculty of Science and Technology, University of Twente; 3 Radboud University Nijmegen Medical Centre, Intensive Care

Introduction: Sepsis, the host response to severe bacterial in-fection, is often accompanied by cerebral dysfunction. Impaired cerebral autoregulation (CA) may contribute to this sepsis related cerebral dysfunction, and as a consequence the brain might be more sensitive to hyper- or hypoperfusion. Currently, transfer

function analysis (TFA) is widely used to assess dynamic CA non-invasively. TFA is based on the assumption that CA is a linear process. However, in practice CA is a non-linear process. The goal of this study is to investigate if the non-linear analysis tech-nique convergent cross mapping (CCM) is able to detect changes in CA in a human experimental endotoxemia model of sepsis (Lipopolysaccharides; LPS). Results obtained by CCM were com-pared to those obtained by TFA. Methods: 16 healthy volunteers received an intravenous infusion of LPS. Arterial blood pressure and cerebral blood flow velocity were recorded over a five minute period using an arterial line and transcranial Doppler, respective-ly. Recordings were performed at 0, 2, 4, 6, and 8 hours after the start of LPS infusion. TFA was applied in the very low frequency (VLF: 0.02-0.07 Hz), low frequency (LF; 0.07-0.15Hz) and high frequency range (HF; 0.15-0.4 Hz). Results: TFA showed an in-creased phase at 2 hours after LPS infusion in the LF (p<0.01). CCM showed an decreased correlation at 4 hours after LPS infu-sion (p<0.05) and an increased correlation at 6 hours after LPS infusion (p<0.05). Conclusion: CCM was able to detect an im-proved CA (lower correlation) at 4 hours after LPS infusion and an impaired CA (higher CCM correlation) at 6 hours after LPS infusion. TFA was not able to detect the impaired CA 6 hours af-ter LPS infusion. A possible explanation is the presence of non-linearity in CA.

O6

Association of cerebral blood flow variability and

cerebral tissue oxygenation with tolerance to central

hypovolemia

C. Rickards1, V. Kay1, M. George2, K. Ryan3, C. Hinojosa-Laborde3, V. Convertino3

1University of North Texas Health Science Center, Fort Worth, TX, USA; 2ISS, Champaign, IL, USA; 3US Army Institute of Surgical Research, Fort Sam Houston, TX, USA

Background: We have previously shown that high toler-ance (HT) to central hypovolemia is associated with an increase in the low frequency (LF) oscillatory power of cerebral blood flow. We hypothesized that this increase in oscillatory cerebral blood flow improves cerebral oxygenation, leading to the delayed onset of presyncopal symptoms, and HT to lower body negative pressure (LBNP). Methods: 20 healthy human subjects were in-strumented for measurement of middle cerebral artery velocity (MCAv; via transcranial Doppler ultrasound), non-invasive ar-terial pressure (AP), end-tidal CO2 (etCO2), and cerebral oxygen saturation (ScO2; via near infra-red spectroscopy), and completed a step-wise LBNP test to presyncope. Subjects were classified as HT if they completed at least the -60 mmHg level of LBNP and low tolerant (LT) if they did not complete this level. Data are pre-sented up to -60 mmHg LBNP, the last common level between tol-erance groups. Results: The mean difference in LBNP tolerance time between HT and LT subjects was 482 s (P=0.004). In the HT group (N=12), while mean MCAv and etCO2 fell below baseline levels from -45 mmHg LBNP (P≤0.03), mean MCAv LF power in-creased above baseline levels at -60 mmHg LBNP (P=0.009), and



ScO2 did not fall below baseline (P≥0.26). In contrast, in the LT group (N=8), mean MCAv, etCO2, and ScO2 fell below baseline at -60 mmHg LBNP (P≤0.01), and MCAv LF power did not increase from baseline (P≥0.90). Conclusion: In support of our hypoth-esis, tolerance to central hypovolemia was associated with protec-tion of cerebral oxygenation and increased oscillatory power of cerebral blood flow, despite early reductions in absolute flow.

Source of Funding: US Army MRMC

O7

Improving the physiological interpretation of

cerebral critical closing pressure

C. Puppo1, J. Camacho2, G.V. Varsos3, B. Yelicich1, H. Gómez1, A. Biestro1, M. Czosnyka3

1Universidad de la República / Hospital de Clínicas / Emergency Department and Intensive Care Unit, Montevideo, UruguaySpanish National Research Council (CSIC); 2Ultrasound for Medical and Industrial Applications Group (UMEDIA) Madrid, Spain; 3Neurosurgical Unit, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK

Introduction: Cerebral critical closing pressure (CCP) is the level of arterial pressure at which brain small vessels close and circulation stops. It is a positive value and equal or higher than intracranial pressure (ICP). The difference between CCP and ICP is explained by the tone of the small arteries of the cerebral circula-tion (wall tension). The value of CCP is used in several models of dynamic cerebral autoregulation. Its correct calculation is there-fore important for correct autoregulation evaluation. However, the different models for calculation of CCP show frequent nega-tive values. There is no a clear physiologic interpretation for these findings. They are viewed as methodological limitations. We intended to study CCP with a new multiparameter mathemati-cal model, and compare it with the results already obtained with other methods in twelve severe traumatic brain injured patients. Patients and methods: 12 severe TBI patients, studied between September 2005 and May 2007. They were ten men, mean age 32 years old, range 16-61. Four patients (1/3) had decompressive craniectomies; three presented anisocoria. They were studied with transcranial Doppler cerebral blood flow velocity, invasive arte-rial blood pressure, and intracranial pressure. Data were acquired at a frequency of 50 Hz, with a data acquisition system made in our service. We compared 1) the results from the first harmon-ic method (M1), already studied, with 2) a new multiparameter method recently developed (M2). Results: With M1 seven values were negative, reaching -150 mm Hg. With M2 all the values were positive and only one was lower than ICP (ICP 60 mm Hg/ CCP 57 mm Hg). There was a significant difference between M1 and M2 values, and between ICP and M2. Conclusion: The results of posi-tive values higher than ICP are more accurate for the physiologic meaning of CCP.

O8

Effects of high altitude on dynamic cerebral

autoregulation

J. Smirl1, N. Lewis1, S. Lucas2, G. duManior3, N. Sherpa, K. Smith1, P. Ainslie1

1School of Health and Exercise Science, University of British Columbia Okanagan, Kelowna, B.C., Canada; 2Department of Physiology, University of Otago, Dunedin, New Zealand; 3Department of Human Kinetics, Okanagan College, Pentiction, B. C., Canada

We examined the following three hypothesis: 1) cerebral au-toregulation (CA) would be augmented upon initial arrival at high altitude (5050m) in both low-landers 2) upon acclimatization CA would not improve in low-landers and would be comparable with Sherpas and 3) returning to sea-level would restore CA metrics to normal values. Methods: we tested 32 subjects (16 low-landers at sea-level, 14 low-landers upon arrival, 12 acclimatized low-landers, 6 low-landers upon return and 16 Sherpas). Each test-ing session involved spontaneous (5-minutes seated rest), and driven (squat-stand manoeuvres at very low (VLF-0.05Hz) and low (LF-0.10Hz) frequencies) measures. The squat-stand manoeu-vres were performed to minimize the signal-to-noise ratio that can be present in spontaneous data. Beat-to-beat blood pressure (BP), cerebral blood flow (CBF) and end-tidal PCO2 were moni-tored. In order to establish how high-altitude may influence CA, transfer function analysis (TFA) between BP and CBF velocity was assessed in the anterior and posterior cerebral hemispheres. Dynamic CA was quantified using TFA in the VLF and LF (at rest and squat-stands) as these are the ranges where CA is most oper-ant. Results: The spontaneous measures of CA indicated an im-pairment upon arrival to high-altitude (-36% reduction in the VLF Phase, (p=0.045). With acclimatization to HA the impaired CA response was also noted with -60% and -34% reductions in VLF (p=0.001) and LF (p=0.002) Phase respectively, with the Sherpas reporting similar values to the acclimatized low-landers (p>0.05). When returning to sea-level, the augmented CA metrics were re-turned to normal (p>0.05). However, these results contradict the findings when the BP input was enhanced (squat-stands) as all groups (sea-level, initial arrival, acclimatized, Sherpas and return to sea-level) had comparable CA responses (p>0.05), indicating that all groups had an intact CA response. Conclusion: When the signal-to-noise ratio is minimized, CA (assessed via TFA) is not impaired at high-altitude.


O9

Cerebral autoregulation in hypertensive elderly

L. Wang1,3, A. Meel-van den Abeelen1,C. Slump3, A. van Beek1, J. Sijbesma1, M. Oudegeest-Sander1,2, J. Lagro1, J. Claassen1

Departments of Geriatric Medicine1 and Physiology2, Radboud University Nijmegen Medical Centre, the Netherlands; 3 MIRA-Institute for Biomedical Technology and Technical Medicine, Faculty of Science and Technology, University of Twente, the Netherlands

Introduction: Hypertension is a major problem among the elderly because of structural and functional changes in the cerebral arteriolar walls. These alterations may lead to an impaired cerebral autoregulation (CA). CA is a mechanism which controls cerebral blood flow during changes in blood pressure (BP). Impaired CA may contribute to cerebral dam-age due to insufficient or excessive cerebral blood flow. In this study, we investigate CA in hypertensive elderly. Method: Mean BP (MBP) and mean cerebral blood flow velocity (MCBFV) were measured using Finometer and transcranial Doppler, respec-tively, during baseline and a sit-stand test in 19 hypertensive el-derly (77±5 years, systolic BP>140 mmHg) and 19 healthy elderly (73±5 years, systolic BP≤140mmHg). The assessment of CA by spontaneous fluctuations in MBP and MCBFV was evaluated using transfer function analysis (TFA), resulting in calculations of phase (rad), gain (cm/s/mmHg) and coherence at three frequency bands (VLF 0.02-0.07Hz; LF 0.05-0.15Hz; HF 0.19-0.35Hz).The assess-ment of CA was also evaluated by the effect of sit-stand test. In this test MBP, MCBFV and cerebrovascular resistance (CVR) are expressed as the percentage difference between the time of maxi-mum reduction and the average value during baseline. Results: In hypertensive patients, phase was lower in the VLF and in the LF compared to controls (0.64±0.45rad vs 0.95±0.3rad, and 0.65±0.3rad vs 0.82±0.2rad, respectively, all p<0.05). Coherence was higher in hypertensive patients in VLF compared to controls (0.71±0.2 vs 0.54±0.07, respectively, p<0.05). During the sit-stand test, the hypertensive patients showed larger differences in MBP and CVR after standing compared to the controls (p<0.05); no dif-ference was found in MCBFV between the groups. Conclusion: In hypertensive elderly, TFA of CA shows reductions in phase and increases in coherence, consistent with less efficient (but not im-paired) CA. However, CA was still able to compensate for changes in BP evoked by standing up.

O10

Cerebral autoregulation indices are not significantly

different between the ‘on’ and ‘off’ states in

idiopathic Parkinson’s disease

V. Haunton1, N. Lo2, R. Panerai1,3, T. Robinson1,3

1Dept. of Cardiovascular Sciences, University of Leicester, Leicester, UK; 2University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK; 3National Institutes for Health Research (NIHR), Biomedical Research Unit in Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, Leicester, UK

Idiopathic Parkinson’s disease (IPD) is a common neurode-generative disorder but, to date, there have been very few studies exploring cerebral autoregulation (CA) in PD. This study aimed to evaluate CA indices in the on and off states of the disease us-ing transcranial Doppler (TCD) ultrasonography. 11 patients (male=8, median age 65) with a history of IPD treated with do-paminergic medications were recruited from the outpatient clinic at University Hospitals of Leicester. Exclusion criteria were a his-tory of diabetes, dementia, stroke, ischaemic heart disease, deep brain stimulation or peripheral neuropathy. Supine recordings of bilateral middle cerebral artery cerebral blood flow velocity, beat-to-beat blood pressure, electrocardiography and end-tidal CO2 were made for each patient at rest in both the on and off states, on two separate mornings no more than two weeks apart. On and off states were evaluated using the Unified Parkinson’s Disease Rating Scale (UPDRS). For the recordings made in the off state, patients were required to abstain from their anti-Parkinsonian medica-tions for either 12 hours (short-acting preparations) or 24 hours (long-acting preparations) before attending for the measurement. Patients were also requested to abstain from caffeine, smoking and large meals for the four hours prior to each measurement. The data were recorded onto a data acquisition system (PHYSIDAS) and analysed offline. The autoregulatory index for each recording was estimated using the Tieck’s model [1]. Median UPDRS scores for the on and off states were 28 (IQR 13) and 36 (IQR 12) respec-tively. Although individuals exhibited marked variability in their autoregulation indices, the differences in the values obtained for the on and off states were not statistically significant (p=0.832 at 0.05 significance). In this small study, no statistically significant, or consistent, difference was observed in CA indices between the on and off states in patients with IPD. [1] Tiecks, F. P., Lam, A. M., Aaslid, R. and Newell, D. W. (1995) Comparison of static and dynamic cerebral autoregulation measurements. Stroke 26, 1014–1019



O11

Dynamic cerebral autoregulation assessed by magnetic

resonance imaging and transcranial Doppler: a

comparative study in acute ischaemic stroke1N. P. Saeed, 1M. A. Horsfield, 2J. L Jara,1,3R. B. Panerai, 1,3T. G. Robinson1Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 2Departamento de Ingeniería Informática, Universidad de Santiago de Chile, Santiago, Chile; 3NIHR Biomedical Research Unit for Cardiovascular Sciences, The Glenfield Hospital, Leicester, UK

This study introduces a novel method for assessing Cerebral Autoregulation (CA) using magnetic resonance imaging (MRI), and the classical TCD ARI is compared to an MRI derived ARI. CA is known to be globally impaired in acute ischaemic stroke (AIS) patients. However, there is limited information about re-gional variations. Cerebral blood flow velocity changes in the mid-dle cerebral arteries were measured in subjects by Transcranial Doppler (TCD) ultrasound, and using the a thigh cuff (THC) ma-noeuvre, a transient decrease in blood pressure was provoked by a sudden release of inflated bilateral THC ARI was estimated using the Tiecks’ model ranging from 0 to 9, where normal (intact CA) was defined as 5±1. In addition an MRI scan where a gradient-echo echo-planar pulse sequence was used to scan the brains of subjects at a rate of 1 scan/second during the THC manoeuvre, and an MRI ARI index was constructed similar to the classical ARI [range 0 to 1.9], derived from fitting a function to signal intensity changes that models the return of signal intensity to baseline after the ini-tial drop. Sensitivity and specificity of CA impairment detection, was not different between the reference TCD ARI, and the new MRI ARI. The ARI for each technique was significantly different between populations: controls (n=9) and strokes (n=15) but there was no difference between affected (AH) and unaffected hemi-sphere (UH), TCD (5.9±1.4, 3.3±0.8, 4.2±1.3) and MRI (1.0±0.3, 0.5±0.2, 0.6±0.4). The area under the receiver-operator curve for controls and strokes was (AH: 0.93 and Controls: 0.93) and (UH: 0.83 and Controls: 0.82), implying, similar diagnostic accuracy of TCD and MRI. We conclude that TCD and MRI are comparable in identifying differences in dynamic CA between control and AIS populations, and this novel MRI method may have potential to investigate regional CA changes following AIS.

O12

Prx – a tool to evaluate autoregulation and decide

the optimal CPP management at bedside in a

neurocritical care unit

C. Dias1, E. Pereira1, A. Cerejo2, J. A. Paiva1, M. Czosnyka3

1 Intensive Care Department, Neurocritical Care Unit, Centro Hospitalar Sao Joao, Porto, Portugal; 2 Neurosurgery Department, Centro Hospitalar Sao Joao, Porto, Portugal; 3 Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK

Introduction: In acute brain injury cerebral blood flow (CBF) disturbances are detrimental to clinical and neurological outcome. Therefore, the role of monitoring of cerebral autoregulation, as a mechanism able to stabilize CBF is paramount. Direct measure-ment of CBF is not routinely used and treatment is most frequent-ly oriented by cerebral perfusion pressure (CPP) as a surrogate of CBF. Guidelines recommend CPP values of 50-70 mmHg for acute traumatic brain injury (TBI) management. However, opti-mal CPP is individual because patients have different perfusion thresholds based on types of TBI, patient characteristics and time course of the lesion. Objective: Assess the degree of medical and nursing compliance to a new CPP target based on pressure reac-tivity index (PRx) for management of TBI, after implementation in the Neurocritical Care Unit (NCCU) of bedside software tool - ICMplus® to evaluate cerebrovascular reactivity. Methods, Data Analysis: Prospective study of adult patients admitted in NCCU with severe TBI requiring intraparenchymal intracranial pressure (ICP) and CPP continuous monitoring. Local ethics committee approval was obtained. Optimal CPP (optCPP) defined as CPP at which PRx reaches minimum, using a moving 4hr time window, updated every minute[1] and the real-time CPP were recorded in ICMplus for offline analysis. Results, Conclusions: Eighteen pa-tients were enrolled with 89% male, mean age 42 yrs old, SAPS II score 44,65. Postresuscitation mean Glasgow Coma Score was 7 although CT Marshall classification was varied. Mean LOS in NCCU was 26±12 days. A total of 6028h of ICP and CPP were analysed. The mean recording time per patient after artefact re-moval was 335h (range 5–39 days). OptCPP curve was U-shaped in 12 (66%) patients, descending in 3 (16%) and in 2 patients (11%) autoregulation was severely impaired according to Prx. On average real CPP values stayed above optCPP suggesting potential hyperperfusion. 1. Aries, M.J., et al., Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med, 2012. 40(8): p. 2456-63.


O13

Screening of cerebrovascular diseases in a stroke

prevention centers in Latvia

G. Baltgaile 1, T. Timofejeva2, A. Raita3, Ž. Kovaldina4 1Medical Hospital “ARS”, Skolas 5, Riga, Latvia; 2Medical Centre ‘”VC-4”, Kr. Barona 117, Riga, Latvia; 3P. Stradina Clinical University Medical Hospital, Pilsonu 13, Riga, Latvia; 4Austrumu Clinical Hospital, Hipokrata 2, Riga, Latvia

Latvian Stroke Prevention Centres established in 2012 in Riga are based on two biggest out-patient clinics and two hospitals with stroke units and equipped with TCCD, CT Angiography and MRI machines. Analysis of clinical and diagnostic data of 1240 patients aged 7-89 years ( 65% female, 35 % male) had been performed in a 2 stroke prevention centres during Sept/2012 – Febr/2013. The most common diagnoses for patients sent to evaluation of precerebral and cerebral blood vessels by GP and specialists were: suspected oc-clusion or stenosis of precerebral and cerebral arteries (20, 4 %) and chronic cerebral ischemia (31, 8 %). Different degree stenotic lesions of precerebral and cerebral arteries have been found consequently in 66, 8% and in 23, 3 % of those cases. Less frequently (15,3 %) arterial pathology was defined in patients with chronic and acute headache (17, 2% of all patients), although AVM in posterior artery territory, venous sinus thrombosis and vertebral artery dissection were de-tected in this group. Surprisingly rare (in 17%) arterial pathology has been found in patients with suspected TIA in a vertebro-basilar artery territory (11 % of all patients). IMT increase and minor scle-rotic lesions in patients with arterial hypertension (11, 6 % from all patients) was found less then was expected (in 29, 7%), more prominent arterial lesions were detected in 21% of cases. The main complains of patients self-referred to centres were vertigo, tinnitus and headache. The percentage of defined vascular pathology was low whereas patients with arterial hypertension had atherosclerotic lesions in 24% of cases. Annual check of arterial status after carotid vascular operations and in cases of stenosis progression helped to detect negative dynamics in time. Comparative statistical analysis has been performed in all examined patients and age groups.

O14

Dynamic variations in the ultrasound greyscale

median of carotid artery plaques

B. Kanber1, T. C. Hartshorne1, M. Horsfield1, A. Naylor1, T. G. Robinson1,2, K. V. Ramnarine3 1 Department of Cardiovascular Sciences, University of Leicester, United Kingdom; 2 NIHR Biomedical Research Unit for Cardiovascular Sciences, University of Leicester, United Kingdom; 3 Department of Medical Physics, University Hospitals of Leicester, United Kingdom

Previous studies have found that the ultrasound greyscale medi-an (GSM) of carotid artery plaques may be useful for predicting the risk of cerebrovascular events. However, measurements of GSM are

typically performed on still ultrasound images ignoring any varia-tions that may be present on a frame-by-frame basis. Variations in the GSM of carotid artery plaques may occur due to deformation of the plaque during the cardiac cycle, and other confounding fac-tors such as out-of-plane plaque motion. The aim of this study was to investigate the nature and extent of these variations. Employing a novel method that enabled plaque boundaries to be tracked au-tomatically, variations in the plaque GSM were measured for 27 carotid artery plaques (19 patients, stenosis range 10%-80%) over image sequences of up to 10 seconds (average 4.4 seconds). The results showed a mean inter-frame coefficient of variation of 5.2% (s.d. 2.5%) for the GSM, and 4.2% (s.d. 2.9%) for the plaque area. Mean GSM differed significantly between the symptomatic and asymptomatic groups (p=0.002). Parameters based on the inter-frame variations in the GSM did not (p=0.48 for the inter-frame standard deviation of GSM and p=0.42 for the coefficient of vari-ation). Our investigation highlighted significant variations in the GSM and area of plaques when measured on a frame-by-frame ba-sis throughout ultrasound image sequences. Image normalisation did not reduce the extent of the GSM variations and in some cases resulted in greater amounts of variation. Substantial variations in the plaque GSM such as those found in this study have implica-tions on the reproducibility of GSM measurements and their clini-cal utility. Improved attempts to standardise GSM measurements and reduce variability between centres should account for these findings, for example, by performing GSM measurements at peak systolic/diastolic frames or by carrying out an assessment of the average GSM throughout the cardiac cycle.

O15

In-stent restenosis following carotid artery stenting:

Assessment by carotid duplex ultrasonography.

T. Rodrigues1, J. Domingos2, M. Milheiro3, R. Taipa2, J. Pereira1, V. Alves1, P. Pinto1, C. Correia2, J. Xavier1, G. Lopes2

1Centro Hospitalar do Porto/ Hospital de Santo António/ Neuroradiology department, Porto, Portugal; 2Centro Hospitalar do Porto/ Hospital de Santo António/ Neurology department, Porto, Portugal; 3Centro Hospitalar de Entre o Douro e Vouga/ Hospital de São Sebastião/ Neurology department, Santa Maria da Feira, Portugal

Background: Carotid artery stenting (CAS) has emerged as a valid alternative to endarterectomy in properly selected cases. Its ben-efits will be affected not only by the periprocedure complication rates, but also by the occurrence of an in-stent restenosis (ISR). Objective: The purpose of this study was to assess the incidence of ISR after CAS. Methods: Between January of 2000 and September of 2012 we performed 75 CAS in 66 patients, with a mean age of 71 years (50-87 years). The assessment of ISR rate was made with carotid duplex ultrasound imaging performed by two observers, using well defined duplex ultrasound velocity criteria. We evaluated 51 patients (77%), the equivalent to 57 CAS (76% of CAS), with a median interval of 14 month (mean of 22 month) from stenting. Twenty nine evaluations were made in the first 12 month after the procedure and 28 after this period. Of the remaining patients, 9 died and 6 were unreachable or



didn’t attend to the examination. Results: We have detected 7 ISR >50% (12%), 4 in the group of patients evaluated in the first 12 months (2 restenosis 50-60%; 1 restenosis 70-99% and 1 occlusion), and 3 in the group evaluated posteriorly (2 restenosis 50-60% and 1 between 70-99%). Only 2 patients developed ischemic strokes ipsilateral to the CAS, both with ISR. One patient died secondary to cerebral hyper-perfusion syndrome as a periprocedure complication, but none of the other deaths were related to cerebrovascular events at the same side of CAS. Conclusion: In our series, the rate of ISR is within the range reported in the literature, supporting its use in our center. The ISR seems to be related to a higher clinical complication rate, demanding a strict and long-term follow-up of all patients.

O16

Inter-individual variations in wall shear stress

distributions at the carotid artery bifurcation

L. Sousa*1,2, C. Castro1,2, C. António1,2, M. Ferreira2, R. Santos3, P. Castro3, E. Azevedo3

1Dept. of Mechanical Engineering, Faculty of Engineering, 2Institute of Mechanical Engineering (IDMEC), 3Dept. Neurology, Hospital São João and Faculty of Medicine of University of Porto, Portugal

Background: A long standing hypothesis that correlates fluid dynamic forces and atherosclerotic disease has led to numerous analytical, numerical, and experimental studies over the years. Stenosed regions are often localized at bifurcations, junctions and regions of high curvature, typically sites of complex hemodynam-ics. A patient specific study of mechanical parameters of interest such as wall shear stress (WSS), oscillatory shear index (OSI), wall shear stress space gradient (WSSSG) and wall shear stress tem-poral gradient (WSSTG) distributions in the common carotid bi-furcation based on ultrasound techniques is addressed. Methods: An in-house developed numerical simulation of blood flow by the finite element method was used to investigate inter-individual variations in flow biomechanics at the carotid artery bifurcation. Subject-specific studies were based on Doppler ultrasound im-ages of structural anatomy and measurements of flow velocities at the inlet (common carotid), and at the outlet (internal carotid). Data was obtained in Hospital de São João, a university hospital in Oporto, Portugal. Results: The hemodynamics of the stenosed carotid artery bifurcations of five individuals was compared with a case of another volunteer with no visible atherosclerotic plaque. For the stenosed carotid bifurcations high WSS gradients were observed not only in post-stenotic regions, but also within the stenosis. Maximum WSSTG values were found to be elevated at the carotid apex and the adjoining wall of the external-common carotid. Numerical simulations were able to capture areas of high OSI values lying within the areas of low WSS correlated to a fre-quently observed site of late atherosclerotic inflammation of the carotid bulb. Conclusion: Finite element model studies of arte-rial biomechanics and atherosclerosis have been performed with subject-specific in vivo imaging-based arterial geometries. A com-parison of fluid mechanic parameters of interest is addressed. The developed software improves diagnostic and assessment to treat-ment plans of the carotid bifurcation diseases.

O17

Quantitative assessment of carotid plaque surface

irregularities using ultrasound

B. Kanber1, T. Hartshorne1, M. Horsfield1, A. Naylor1, T. Robinson1,2, K. Ramnarine3 1 Department of Cardiovascular Sciences, University of Leicester, United Kingdom; 2 NIHR Biomedical Research Unit for Cardiovascular Sciences, University of Leicester, United Kingdom; 3 Department of Medical Physics, University Hospitals of Leicester, United Kingdom

There is growing interest in the assessment of carotid plaque surface irregularities as a surrogate marker of plaque ulceration and vulnerability. Studies investigated plaque surface irregularities using qualitative classification schemes (e.g. smooth vs. rough) or by using specific criteria for classifying ulceration. Quantitative assessments included the calculation of the bending energy of the plaque-arterial lumen boundary, and the measurement of Gaussian curvature in 3 dimensions. The aim of this study was to quantify plaque surface roughness using a novel parameter and evaluate its potential clinical value for identifying the vulnerable carotid plaque. Ultrasound greyscale cine-loop data were acquired from longitudinal sections of carotid plaques using a Philips iU22 ultrasound scanner and L9-3 probe. Thirty seven carotid plaques (25 patients, stenosis range 10%-80%) were analysed. Plaque sur-faces were tracked automatically using a novel surface tracking algorithm. Plaque surface roughness was quantified by measur-ing the average, unsigned, angulation of successive tangents on the discrete plaque surface (PSRmean) and results were compared with a qualitative classification scheme (smooth vs. rough). The average PSRmean of symptomatic plaques was significantly high-er than that of the asymptomatic plaques (6.68 vs. 5.91 degrees, p=0.018). Qualitatively, there were 13 smooth and 4 rough plaques in the asymptomatic group and 6 smooth and 14 rough plaques in the symptomatic group. Smooth plaques were more frequently observed in asymptomatic patients, while rough plaques occurred more frequently in symptomatic patients (p=0.005). The average PSRmean of the plaques qualitatively classified as irregular was 6.75 degrees while that of the regular plaques was 5.92 degrees. Our results showed that carotid plaque surface irregularities can be quantified in 2 dimensions using a novel plaque surface rough-ness parameter having good agreement with qualitative classifi-cation. The distinction between symptomatic and asymptomatic patient groups suggest potential clinical value to help improve identification of the vulnerable carotid plaque.


O18

Can neurovascular coupling predict the risk of

preeclampsia in pregnant women?

M. Reinhard1, R. Ehmann1, E. Ehlers1, A. Allignol2, S. Mayer3, B. Gabriel3, H. Prömpeler3, W. G. Janzarik1

1 Department of Neurology, University of Freiburg, Germany; 2

Freiburg Center for Data Analysis and Modeling, University of Freiburg, Germany; 3 Department of Obstetrics and Gynecology, University of Freiburg, Germany

Background: Preeclampsia and eclampsia is the severest ma-ternal complication during pregnancy affecting up to 5% of all pregnant women. Women with a history of previous preeclampsia may have abnormal parameters of neurovascular coupling. In this study, we examined whether a short testing protocol of neurovas-cular coupling during late mid-term pregnancy (within 25th to 28th week of gestation) is able to identify women with an increased risk for preeclampsia. Methods: Seventy-two women were pro-spectively studied. A bilateral uterine artery notch as a sign of disturbed uteroplacentar vasoregulation was assessed at baseline in all women. Cerebral blood flow velocity of the left posterior cerebral artery was recorded via transcranial Doppler sonography. Visual stimulation consisted of 10 cycles of 10 s checker-board stimulation and 10 s rest. The maximal visually evoked blood flow response (VEBF) and time to peak respone (TTP) during each cycle was analyzed and averaged thereafter. All women were fol-lowed until 6 weeks after delivery. The primary clinical endpoint was the occurence of preeclampsia or eclampsia. Results: At base-line, VEBF (p=0.005) and TTP (p=0.009) were significantly high-er in women with a positive notch sign. Nine women developed preeclampsia during follow-up, only one of them with neurologi-cal symptoms. Neither VEBF nor TTP were significantly associat-ed with the occurence of preeclampsia, while a positive notch sign reached a borderline significance for this association (p=0.052). A significant habituation of VEBF between the last 5 stimulation cy-cles compared with the first 5 cycles occurred (p=0.0045) but was not associated with a notch sign or occurrence of preeclampsia during follow-up. Conclusion: Neurovascular coupling shows an exaggerated blood flow response in late mid-term pregnant wom-en with uteroplacentar vasodysregulation. This suggests that with uteroplacentar vasodysregulation already alterations in cerebral endothelial function occur. Parameters of neurovascular coupling can, however, not predict the risk of preeclampsia at this stage.

O19

Non-Steroid anti-inflammatory drugs influence the

neurovascular coupling

K. Szabó¹, L. Oláh¹, B. Rosengarten², L. Csiba¹

¹Department of Neurology, University of Debrecen Medical and Health Science Center, Debrecen, Hungary, ²Department of Neurology, University of Giessen, Giessen, Germany

Introduction: Transcranial Doppler (TCD) can be applied to asses the neurovascular coupling (functional hyperemia). Increase of regional cerebral blood flow (rCBF) induced by neuronal acti-vation was shown in animal experiments to require the presence of functioning cyclo-oxygenase (COX). Our present study was designed to determine the effects of 2 widely used, non-selec-tive non-steroid anti-inflammatory drugs (NSAIDs) on visually evoked flow velocity changes in posterior cerebral arteries (PCAs). We sought the answer whether NSAIDs administered orally in therapeutic doses inhibit the neurovascular coupling in humans. Methods: By using a visual cortex stimulation paradigm, the flow velocity response was investigated in the P2 segment of both PCAs of young healthy adults (n=25) by TCD. The stimulation proto-col consisted of 10 cycles, each with a resting phase of 20 seconds (baseline) and a stimulating phase of 40 seconds. After the control examination, the same volunteers were given 3x25 mg indometha-cin (n=22) or 2x550 mg naproxen (n=25) for 2 consecutive days, and the investigation was repeated. Repeated-measures analysis of variance (ANOVA) was used to determine whether NSAIDs influ-ence the visually evoked flow velocity time course compared with the control phase. Results: The resting peak systolic flow veloci-ties were significantly lower under the effect of either indometha-cin or naproxen compared to the control phase (p<0.01). To allow comparisons between volunteers, absolute data were transformed into relative changes of flow velocity in relation to baseline. After NSAIDs treatment, repeated measures ANOVA revealed signifi-cant decrease (p=0,03) in the relative visually evoked flow velocity changes compared to the control period. Conclusion: Inhibition of COX by usual doses of NSAIDs resulted in decrease of the rest-ing flow velocity in the PCAs. Furthermore, NSAIDs decreased the measure of visually evoked flow velocity changes, indicating that COX plays an important role in the neurovascular coupling process in humans, too.



O20

Independent progression of cerebral and skin

microcirculatory dysfunction in type 1 diabetes

mellitus – preliminary report.

G.M. Kozera1, J. Neubauer-Geryk2, B. Wolnik3, S. Szczyrba1, W.M. Nyka1, L. Bieniaszewski2

1 Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland; 2 Department of Clinical Physiology, Medical University of Gdańsk, Gdańsk, Poland; 3 Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland

Background: Cerebral microcirculation may be assessed with the transcranial doppler (TCD) by the measurement of cerebral pulsatility index (PI). Skin microcirculation may be assessed with capillaroscopy by the determination of the distance between suc-cessive skin capillaries (DISTANCE) and the ratio between area of the capillaries and total area of determined skin (COVERAGE). However, little is known about the association between the cer-ebral and skin microvasculature function in patient with cerebral microangiopathy. Aims: Thus we aimed to assess PI of middle cer-ebral artery with TCD and the DISTANCE and the COVERAGE of the nailfold capillaries with quantitative capillaroscopy in middle aged subjects with DM1 and controls without diabetes and to as-sess the relationship between those parameters. Materials: Study group consisted of 48 patients with type 1 diabetes (26 women and 22 men; age 39,8 years) and 24 volunteers free of any chronic disease (13 women and 11 men; age 38,0 years). Results: Median of PI was higher in subjects with DM1 than in controls (0,82 vs. 0,75; p<0,01). Median of DISTANCE was lower in subjects with DM1 than in controls (221 μm vs. 240 μm; p=0,02), and median of COVERAGE was higher in subjects with DM1 than in con-trols (20,3% vs. 18,1%; p=0,02). No correlations between PI and DISTANCE or COVERAGE were found. Conclusions: In spite of simultaneous presence of cerebral microangiopathy, reflected by increased PI of MCA and skin microangiopathy, reflected by de-creased DISTANCE and increased COVERAGE of skin capillaries, we found no association between cerebral and skin microvascula-ture function. That may indicate the independent progression of microcirculatory injury in cerebral and peripheral vascular beds.

O21

Reduced pressure reactivity is related to lethal

outcome in brain injured patients

B. Schmidt, J. J. Schwarze, M. Weinhold, M. Czosnyka, J. Klingelhöfer

Chemnitz Medical Centre / Dept. of Neurology / Chemnitz / Germany; Addenbrooke’s Hospital / Academical Neurosurgical Unit / Cambridge / UK

Introduction: A pressure reactivity index (PRx) and autoregu-lation index (Mx) have been introduced formerly in order to assess the state of autoregulation during spontaneous changes of arterial

blood pressure (ABP) in patients with monitoring of intracranial pressure (ICP). In the current study a possible relationship be-tween lethal outcome during hospitalisation and index values was investigated. Patients and Methods. 41 patients (18-77 years, mean 52) with severe brain injuries were studied. FV in MCA, ABP and invasively assessed ICP were simultaneously recorded during 1 hour. Recording was repeated at days 2, 4 and 7. PRx and Mx were calculated offline, positive index values indicated impaired autoregulation. Results: Six of the patients died in the hospital. In this group PRx and Mx were higher (PRx=0.41, Mx=0.28) than in the survivor group (0.07, 0.06). In case of PRx this difference was significant (p < 0.005). Seven patients showed a PRx > 0.3, three of them died, while in 25 patients PRx was < 0.2, only one of them died. This association was significant (p < 0.05; Fisher’s exact test). Seven patients showed an Mx > 0.3, three of them died, in 28 patients Mx was < 0.2, two of them died. Again the classifica-tion (Mx>0.3, Mx<0.2) was significantly associated with classifi-cation (death, survival) (p<0.05; Fisher’s exact test). Conclusion. Increased PRx and Mx indicate impairment of autoregulation and are significantly associated with risk of death in patients with se-vere head injuries.

O22

Relationship between white matter lesions on magnetic

resonance imaging and cerebral hemodynamics

measured by transcranial color flow imaging

H. Mitsumura, K. Sakuta, R. Sengoku, Y. Kono, T. Kamiyama, H. Furuhata*, Y. Iguchi

Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan; *ME Laboratory, The Jikei University School of Medicine, Tokyo, Japan

Background and Purpose: Our aim is to evaluate the rela-tionship between white matter lesions as predictor of ischemic stroke on magnetic resonance imaging (MRI) and flow param-eters of middle cerebral artery (MCA) measured by transcranial color flow imaging (TC-CFI). Methods: Subjects were patients with acute ischemic stroke or transient ischemic attack who had patent temporal bone window after we performed MRI for them. Severity of periventicular hyperintensity (PVH) and deep and subcortical white matter hyperintensity (DSWMH) without acute ischemic lesion on MRI were divided into five grades according to the Japanese Brain dock Guidelines 2008, respectively. We de-fined severity of PVH-DSWMH as three groups; normal (grade 0), moderate (grade 1~2), severe (grade 3~4). We evaluated the relationship between severity of PVH-DSWMH and ultrasono-graphic flow parameters of MCA (peak systolic velocity; PSV, end diastolic velocity; EDV, time averaged maximum velocity; TAMV, resistance index; RI and pulsatility index; PI) among three groups. Results: We could measured MCA flow by TC-CFI at 203 temporal windows in 124 patients (103 Male, median age; 66 years). In moderate and severe PVH groups, PSV (median value (cm/s) of moderate/severe group: 86.75, p=0.009 / 90.55, p=0.03), EDV (32.65, p<0.001 / 30.65, p< 0.001) and TAMV (57.2, p=0.007 / 52.85, p=0.009) were significantly lower than normal group


(median value of PSV/EDV/TAMV: 97.7/44.8/60.6). RI (0.7, p=0.003 / 0.75, p=0.01) and PI (0.75, p=0.02 / 0.815, p=0.006) were significantly higher than normal group (0.65 / 0.65). The relation-ship between severity of DSWMH and flow parameters showed similar tendency to PVH. Conclusion: This ultrasonographic study showed that white matter lesions are relevant to low perfu-sion and high peripheral vascular resistance of intracranial artery.

O23

Treatment delay reduces recanalization after IV

Thrombolysis in acute stroke

M. Muchada, M. Rubiera, D. Rodriguez-Luna, J. Pagola, A. Flores, J. Kallas, E. Sanjuan, P. Meler, M. Ribó, J. Alvarez-Sabin, C. A. Molina

Stroke Unit, Vall d’Hebron University Hospital, Barcelona, Spain

Background: Although the efficacy of thrombolytic treatment depends on time, it is unknown if the effect of tPA on recanaliza-tion (RE) is also time dependent. As RE is only achieved in 30-40% of cases, patients selection based on accurate information is crucial. Therefore, we aimed to identify the impact of time-to-treatment (TTT) on tPA related RE in patients with acute ischemic stroke. Methods: Consecutive patients with intracranial acute occlusion treated with tPA were included. Transcranial Doppler examination was performed before and 1 hour after treatment, to identify occlusion location and RE. Patients were grouped accord-ing to occlusion´s location in proximal and distal occlusions. We sequentially analyzed RE according to TTT looking for significant 30-min cut-off points. Results: From 555 patients, 55.3% had proximal and 44.7% distal occlusion. Mean TTT was 171.6±64.6 and 6.3% were treated after 270min. RE occurred in 35.7% of all treated patients. We could not find a lineal association between TTT and RE, but the sequential analysis showed that patients treated after 270min had lower RE rate. After adjusting, glycemia and TTT≤270 emerged as independently predictors (OR 0.994; 95% CI 0.990-0.999; p=0.014) and (OR 0.280; 95% CI 0.095- 0.829; p=0.022) of RE, respectively. In patients with proximal occlusion, RE was observed in 40.5%. The cut-off point TTT>90 was associ-ated with lower RE in univariate analysis. However in the logistic regression only hyperglycemia (OR 0.993; 95% CI 0.987-0.999; p=0.028) and NIHSS (OR 0.923; 95% CI 0.866-0.983; p=0.013) predicted lack of RE.In distal occlusions, TTT≤270 emerged as the only independent predictor of RE(p<0.001). No patient recan-alized after 270min in this group. Conclusions: The effect of tPA on RE decreases with time. Treatment after 270min predicted lack of RE, especially in distal occlusions. Moreover, in proximal oc-clusions we observed a trend towards lower RE in patients treated after 90min.

O24

Ischemic stroke is associated with transiently

impaired autoregulation

P. Castro1, J.M. Serrador2,3,4, E. Azevedo1, I. Rocha5, M. Blatt2, B. Ghobreal2, F. Sorond4

1Dep. of Neurology, São João Hospital Center and Faculty of Medicine of University of Porto, Portugal; 2War Related Illness & Injury Study Center, NJ VA Health Care System, East Orange, NJ, USA & 3New Jersey Medical School, Newark, NJ, USA & 4Harvard Medical School, Boston, MA, USA; 5Faculty of Medicine & Institute of Molecular Medicine, Lisbon, Portugal

Introduction: Cerebral autoregulation is an important vascu-lar mechanism which serves to maintain relatively constant blood flow despite fluctuations in cerebral perfusions pressure. Whether cerebral autoregulation is impaired immediately following isch-emic stroke and if this impairment persists over time is unknown. Methods: Ten patients (5 females, 66.4 ± 11.9 years) were assessed within 6 hours of stroke symptoms. All ten patients had an infarct within the MCA territory (NIHSS 12.3±5.7). To assess autoregula-tion in the anterior (ACA) and middle (MCA) and posterior cere-bral arteries (PCA) we bilaterally measured cerebral flow velocity (transcranial Doppler), beat-by-beat blood pressure (Finapres) and end tidal CO2 via nasal cannula. Resting supine data was col-lected at 6, 12, 24 and 48 hours. Results: Examination of transfer functions between flow velocity and blood pressure waveforms showed that low frequency phase (0.04-0.15 Hz) was significantly reduced in the MCA on the infarct side within 6 hours post stroke (4.4±8.3 vs 41.3±7.7 deg, P=0.025) but returned to normal levels at 12, 24 and 48 hours. In contrast, phase was not significantly differ-ent at any time points in the ACA or PCA territories. Surprisingly gain values were lower on the infarct side in the MCA at all time points (P=0.05) but not different in the ACA or PCA. Discussion: These data show that cerebral autoregulation is transiently im-paired in the infarcted territory in the first 6 hours of symptom onset and returns to normal within 12 hours. Therefore, perfusion targeted blood pressure management may prevent further vascu-lar injury in acute stroke and improve clinical outcome. Further work in a larger number of patients is necessary to confirm these findings. Supported by Fundação para a Ciência e a Tecnologia Portugal, PTDC/SAU-ORG/113329/2009 (Rocha).



O25

Transcranial targeting low frequency ultrasound

thrombolysis system: in vitro sonothrombolysis

experiment and evaluation of blood flow monitoring

in human

J. Shimizu1, J. Kubota1, K. Ando2, Y. Tanifuji2, T. Azuma3,4, A. Arai5,

H. Mitsumura5, T. Ogawa6, H. Furuhata1

12Medical Engineering Laboratory and Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan; 3 Central Research Laboratory, Hitachi Ltd., Tokyo, Japan; 4Faculty of Engineering, University of Tokyo, Tokyo, Japan; 5Department of Neurology ; 6Emergency Medicine, The Jikei University School of Medicine, Tokyo, Japan

Background and Purpose: We developed the transcranial targeting low frequency ultrasound thrombolysis system (TCT-LoFUT) which will be used for an acute ischemic stroke (AIS). TCT-LoFUT can emit the T beam (500 kHz continuous wave-form, 0.72 W/cm2) for thrombolysis to a target thrombus with the D beam (2 MHz pulsed waveform, 0.72 W/cm2) for diagnostic TC-CFI. We report the in vitro thrombolytic efficacy by TCT-LoFUT and estimate the blood flow monitoring in human with a newly developed head-fixture for TCT-LoFUT using a same as-pect of commercial probe. Method: A) Sonothrombolysis experi-ment: The 1.25 ml of blood was extracted by the healthy volunteer. The blood in a syringe for 40 min and created a fresh thrombus with a centrifuge (4500 rotation / 5 min). The alteplase concen-tration in a syringe solution was made to be 358 IU/ml. The in-termittent T/D beams were applied under the 60 min of protocol which was described in our studies. The rt-PA independent group (rt-PA, n=39) and the rt-PA + TCT-LoFUT group (rt-PA+US, n=13) were compared. The sound intensity in a syringe was 0.05 W /cm2. B) Blood-flow monitoring evaluation: We evaluated the blood flow monitoring by middle cerebral artery (MCA) detection in 10 healthy volunteers for 30 min. We used the 2.5 MHz TC-CFI probe with the fixture which was developed for same aspect of the TCT-LoFUT. Results: A) Sonothrombolysis experiment: The recanalization rate of 60 min after were 64.1% in rt-PA group and 92.3% in rt-PA+US group. Average recanalization time was shortened from 27.2 min in rt-PA group to 21.4 min in rt-PA+ US group ( p < 0.01). B) Blood-flow monitoring evaluation: The MCA could be detected using the fixture for TCT-LoFUT. Conclusion: TCT-LoFUT has a function of the blood-flow monitoring simulta-neously with a thrombolysis accelerating effect which will be used for AIS patients.

O26

Prevalence of intracranial atherosclerotic stenosis in

Italian stroke patients: the ISIDE study

C. Baracchini1, G.P. Anzola2, M. Del Sette3, C. Gandolfo4, S. Ricci5, M. Diomedi6, R. Bella7, A. Tonon8, M. Braga9, G. Meneghetti1 for the ISIDE Study Group1Department of Neuroscience, University of Padua School of Medicine, Padua – Italy; 2Servizio di Neurologia Ospedale S. Orsola – Fondazione Poliambulanza Brescia – Italy; 3UO Neurologia, Ospedale S. Andrea La Spezia – Italy; 4Department of Neuroscience, Ophthalmology and Genetics, University of Genoa – Italy; 5UO Neurologia, ASL 1 Città di Castello – Italy; 6Department of Neurology University Tor Vergata, Rome – Italy; 7UO Neurologia Ospedale di Catania - Italy; 8UO Neurologia Hospital of Venice - Italy; 9Servizio di Neurologia Hospital of Vimercate - Italy

Introduction: Intracranial atherosclerotic disease (ICAD) represents a major cause of ischemic stroke in Asian populations (30-50%), however it has received comparatively little attention in Western countries. Here, estimates derive mainly from North American studies which have shown significant variabilities among different ethnic groups (11% in Hispanics, 6% in Blacks, 1% in Whites). Very few studies have so far addressed the true prevalence of ICAD in European patients, despite ICAD is bur-dened with a high annual risk of stroke recurrence (10-50%), hence posing a dramatic therapeutic challenge. The aim of the ISIDE study was to evaluate the prevalence of intracranial hemodynami-cally significant (>50%) atherosclerotic stenosis in stroke patients. Materials and Methods: Starting from January 2011, consecu-tive patients admitted with acute ischemic stroke in 8 participating Italian stroke centres underwent a systematic assessment of their intracranial circulation by repeat multi-modal imaging (TCCD and CTA/MRA/DSA) at admittance and at three months from dis-charge. This was necessary in order to exclude non-atherosclerotic causes of intracranial stenosis such as partial embolus recanali-zation, dissection, vasculitis, and vasospasm. According to a pre-specified protocol, all demographic clinical and instrumental data were recorded. Results: Among the first 761 patients enrolled into the ISIDE study (mean age, 71.9 ±13.7 years; males 442, M/F ratio 1.39), ICAD was found in 65 (8.5%) patients. Given its excellent negative predictive value (98%) but only modest positive predic-tive value, TCCD allows exclusion of ICAD with high certainty. ICAD was slightly more prevalent in the anterior circulation and was independently associated with extracranial vessel disease and BMI. Conclusions: The preliminary results of the ongoing ISIDE study indicate that ICAD is more frequent than expected in Italian stroke patients. A systematic assessment of intracranial vessels by ultrasound is useful in identifying patients at a higher risk of stroke recurrence with immediate therapeutic implications.


O27

Recurrence of cerebrovascular events in patients

with intracranial atherosclerotic disease

A. Gouveia1; J. Sargento-Freitas2; J. Penetra3; F. Silva2; C. Machado2; G. Cordeiro2; L. Cunha2

1Neurology Department and 2Stroke Unit, Coimbra University Hospital, and 3Faculty of Medicine of the University of Coimbra, Coimbra, Portugal

Background: Intracranial atherosclerotic disease is a com-mon etiology of stroke; its incidence and prevalence vary widely by ethnicity. In caucasians, it is estimated to cause 8-10% of is-chemic strokes. Objective: To study the recurrence of cerebrovas-cular events in patients with symptomatic (SIS) and asymptomatic intracranial stenosis (AIS). Methods: We conducted a historical cohort study including all patients seen in our hospital for stroke or TIA during 2011 with information on intracranial circulation (ultrasonography and/or CT angiography). We identified patients with SIS and AIS and studied the recurrence of cerebrovascular events (TIA or ischemic stroke within the territory of the stenosis) for a minimum period of one year after the diagnosis of intracra-nial stenosis. We calculated the rate of recurrence of cerebrovas-cular events, the median time to recurrence and investigated the mechanism of recurrence. Results: We investigated 498 patients, 357 (71.7%) were male and mean age was 63.93 years (SD: 13.41). We identified 90 intracranial stenosis, 43 (47.78%) were sympto-matic and 47 (52.22%) were asymptomatic. The recurrence rate of cerebrovascular events was 9.21 per 100 patient-years for SIS and 3.37 per 100 patient-years for AIS (p=0184). The median time to recurrence was 0.23 months (SD=0.43) for SIS and 9 months (SD: 8.49) for AIS (p=0.04). In most patients with SIS who had a recur-rence in the territory of the stenotic artery, the mechanism of the cerebrovascular events was similar. Conclusions: These results confirm the high risk of early recurrence of stroke in the territory of a SIS, highlighting the importance of its early diagnosis and ag-gressive treatment.

O28

Transcranial Doppler imaging in sickle cell disease

children: the “confounding” effect of age and anemia.

M. Diomedi1, I. Zivi1, A. Rocco1, C. Alfieri2, K. Paciaroni2

1Cerebrovascular Diseases Center and Neurosonology Laboratory, University of Rome Tor Vergata; 2Mediterranean Institute of Hemathology, University Polyclinic of Tor Vergata, Rome, Italy

Background: Transcranial Doppler ultrasound (TCD) is considered an important and useful test in children with sickle cell anemia (SCA) to detect increased risk of ischemic stroke. Current guidelines report TCD velocity criteria to define the risk (absent, conditional, high risk) on the basis of STOP trial results in children 2–16 years of age. Since cerebral blood flow velocity

is known to be age and anemia dependent, it is unclear whether the same cut-off for abnormal TCD velocity is pertinent to differ-ent age groups. The aim of the study was to determine significant differences between younger (2-7 y) and older (8-16 y) children. Methods: The study included patients with SCD selected from the Mediterranean Institute of Hematology at the Polyclinic of Rome Tor Vergata, screened for stroke risk with TCCDi. Time-averaged peak velocity (TAPV) and peak systolic velocity (PSV) were re-corded bilaterally in the dICA, the MCA, the ACA and PCA, the VA and in BA. Demographic and laboratory data (Hb, hematocrit and percentage of HbS) were recorded. Results: A complete angle-corrected TCCDi examination (Philips iU22) was performed in 35 patients (19F, 16M), mean age 9,1y (range 2-16). A significant correlation was found between TAPV and age (p=0.001; R-0.52), but not between TAPV and Hb (p=0.145). Significant differences in PSV and TAPV were recorded in all vessels except for dICA between the two age groups, independently from the hemoglobin levels. Conclusions: Age-related decline in flow velocity has been reported in TCD studies. Our results suggest that different velocity criteria should be considered in different age groups, even within the STOP trial population, to select SCD patients at risk for stroke.

O29

Ultrafast Doppler imaging of blood flow dynamics in

the myocardium

B. F. Osmanski1-4, M. Pernot1-4, G. Montaldo1-4, A. Bel5-6, E. Messas5-6, M. Tanter1-4

1Institut Langevin, CNRS UMR7587, 2ESPCI ParisTech, 3Inserm U979, 4Université Paris VII, 5INSERM U633, 6Hopital Européen Georges Pompidou. Paris, France.

Imaging intra-myocardial vascular flows in real-time could strongly help to achieve better diagnostic of cardiovascular dis-eases. The main limitation of conventional cardiac Doppler modes is that the blood flow in smaller arteries such small coronaries (50 to 200 μm) cannot be imaged because of a dramatic lack of sen-sitivity. To date, no standard imaging modality allows describing accurately myocardial blood flow dynamics with good spatial and temporal resolution. We recently introduced a novel ultrasonic Doppler imaging technique based on compounded plane waves transmissions at ultrafast frame rate (1500Hz). The high sensitivity of this ultrafast Doppler technique permits to image in two di-mensions the intramyocardial micro blood flow and its dynamics without any contrast agent. A dedicated demodulation-filtering process is implemented to compensate for the large tissue velocity of the myocardium during the cardiac cycle. A directional power Doppler processing provides the discrimination between arterial and venous flows. Experiments were performed in vivo in a large animal open chest model (N=5 sheep) using a conventional ultra-sonic probe placed at the surface of the heart. Results show the ca-pability of the technique to image intra-myocardial vascular flows in normal physiological conditions with good spatial (200μm) and temporal resolution (10ms). Flow dynamics over the cardiac cycle were investigated and the imaging method demonstrated a phase opposition of flow waveforms between arterial and venous flows.



Finally, Ultrafast Doppler combined with tissue motion compen-sation was found able to reveal vascular flow disruption in ischem-ic regions during occlusion of the main diagonal coronary artery.

O30

Carotid ultrasound and transesophageal

echocardiography – Complementary methods for

diagnosing atherosclerosis?

J. Chin, A. Camacho, P. Guilherme, A. Neves, P. Sousa, V. Marques, P. Gago, N. Tavares, R. Ferrinha, S. Cunha, A. Silva, I. Jesus

Hospital de Faro – Serviço de Cardiologia, Faro – Portugal

Background: carotid disease and atherosclerotic plaques in the aortic arch are important causes of stroke. Carotid ultra-sound (CU) is an established method to detect atherosclerotic disease. Transesophageal echocardiography (TEE) assesses the presence of plaques which may relate with cerebrovascular embo-lism. Purpose: to assess whether there is a relationship between the findings of the CU and of the TEE, regarding the presence of carotid plaques (Cp) and thoracic aorta plaques (Tp) and the common carotid intima-media (CIM) and the intima-media in the thoracic aorta (TIM). Methods: was performed a systematic study of the ascending aorta and aortic arch in 61 patients (P), who underwent TEE and CU with a gap of <1 month; were studied 61 patients (P), 57.4% were men; the mean age was 62.7 ± 14y; meas-urements of TIM were obtained at the level of the aortic arch, in telediastole; The CIM was obtained on the common carotid (CC), in the posterior wall 1cm below the bifurcation. Results: 37P had Cp and 18P had Tp, of the latter, 17P had concomitant Cp. Was found an association between the presence of Cp and Tp by χ2 test (p <0.001). In assessing the thickness of the intima-media was found a significant difference between TIM (1.44mm ± 0.38) and CIM (0.98mm ± 0.19) (p <0.001). Was found a positive relation-ship between CIM and TIM thickness (R²=0.18, 95% CI (0.38 to 1.28) p<0.001). Conclusion: 1- The presence of plaques in carotid artery might be a good indicator of the presence of plaques in the thoracic aorta. 2- There is a positive association between increas-ing CIM and TIM, the latter being significantly thicker. 3- A sys-tematic evaluation of the thoracic aorta when performing TEE is important, providing additional information about the extend of the atherosclerotic disease.

O31

Cerebral and systemic hemodynamics in patients

with hypertrophic cardiomyopathy and syncope.

I. Zivi1, R. Morgagni2, A. Rocco1, E. Bonelli3, M. Diomedi1

1 Division of Neurology; 2 Division of Cardiology; 3 Division of Neurophysiopathology; Department of Medicina dei Sistemi, Policlinico Tor Vergata, Rome, Italy.

Introduction: Syncope occurs in 15–25% of patients with Hypertrophic Cardiomyopathy (HCM), in which represents a known risk factor for sudden cardiac death (SCD). It is possibly due to cardiac arrhythmias or to altered hemodynamics. During exercise, episodes of inappropriate vasodilatation are frequently observed, predisposing to hypotension and syncope. Aim of our study was to investigate the vasomotor reactivity and cerebral au-toregulation in these patients. Patients and Methods: 14 HCM patients were submitted to a continuous monitoring of mean flow velocities (MFV) of Middle Cerebral Artery, blood pressure (BP) and heart rate (HR) during rest condition, Breath Holding (BH), Hyperventilation (HV) and Thigh Cuff Test (TCT). Patients were classified according to the presence (group 1, n.5 patients) or ab-sence (group 2, n.9 patients) of history of syncope. Results: At rest, there were no significant differences in all parameters be-tween the two groups. During BH, group 1 showed a higher in-crease in MFV (p=0.028), with a trend toward increased breath holding index (BHI, p=0.49) and slope (p=0.051). Range of vaso-motor reactivity (VMR) was wider (p=0.19) in group 1. In TCT, group 1 showed during cuff inflate a paradoxical decrease of HR and BP, followed by a faster and persistent reduction of MFV af-ter deflation (Slope, p=0.188). Discussion: HM patients show an adequate cerebral MFV responsiveness to variations in CO2 and BP. However, patients affected by syncope seem to have a faster and more pronounced vasomotor reactivity in response to CO2, suggesting a greater activity of endothelial Nitric Oxide Synthase. The paradoxical reduction in BP and HR during TCT could sug-gest a hypersensitivity of ventricular baroreceptors, that togeth-er with the MFV reduction could facilitate syncope occurrence. Conclusions: In patients affected by HM, hemodynamic studies during hypotensive stimuli can help to identify cases of reflex hy-potension, at high risk of syncope and SCD.


O32

The relationship between carotid atherosclerosis and

subclinical left ventricle longitudinal dysfunction

in asymptomatic subjects with cardiovascular risk

factors

A. C. Nechita ¹, V. Enache¹, F. Ciobanu¹, A. M. Stroi ²1St. Pantelimon Emergency Hospital, Cardiology Clinic, Bucharest, Romania; 2Colentina Clinical Hospital, Neurology Clinic, Bucharest, Romania

Purpose: Early diagnosis of left ventricular (LV) dysfunction represents a major challenge in asymptomatic subjects with car-diovascular (CV) risk factors. We analised whether early longi-tudinal LV systolic abnormalities in presence of normal ejection fraction (EF) is related primarily to increased intima-media thick-ness (IMT) or plaque disease in asymptomatic subjects with CV risk factors. Methods: We performed carotid ultrasonography and transthoracic echocardiography on 189 subjects(50.17± 14.14 years old) with CV risk factors from an ambulatory cardiology clinic. IMT,plaque scores,LVEF,Tissue Doppler Imaging param-eters were assessed. Results: Carotid atherosclerosis was asso-ciated with the presence of 2 or more CV risk factors (p<0,05), (OR=2.4, 95% CI, 1.2-4.5) and a more increased IMT in this group (p<0.001). We found an association between an IMT≥0.8 and the presence of longitudinal disfunction (LD) in both groups - less than two risk factors (p<0,05), (OR=5.7, 95%CI, 1.52 – 21.36) and ≥ 2 risk risk factors (p<0,05), (OR=2.55, 95% CI, 1.22 – 5.31). For the entire group, both carotid plaque (p<0,05, OR=2.2, 95%CI, 1.20 – 4.07) and IMT≥0.8 (p<0,001; OR=3.3, 95%CI, 1.76 – 6.15) were associated with LV LD. After multiple linear regression anal-ysis the carotid plaque (β = -0.183) and IMT (β = -0.180) remained independently predictor factors for LV LD. (p<0.001). The sensi-tivity, specificity, predictive positive value and negative predic-tive value of IMT≥0.8 (67%, 53%, 59%, 62%) and carotid plaque (52%, 75%, 67%, 62%) were assessed for the presence of LV LD. Conclusion: IMT and carotid artery atherosclerosis has been as-sociated with LV LD and the development of heart failure. These findings could be clinically relevant in identifying asymptomatic subjects who need an early individualized preventive treatment. These data support the extensive use of carotid ultrasonography as a safe and accurate method toghether with Tissue Doppler echo-cardiography for better risk stratification of the patients with CV risk factors.

O33

Transcranial sonography findings in spinocerebellar

ataxia type 3 (Machado-Joseph disease): a cross-

sectional study1J. L. Pedroso, 2E. Bor-Seng-Shu, 3 R. C. Nogueira, 2 F. Brambilla, 1A. C. Felicio, 1 P. Braga-Neto, 1 L. A. Dutra, 2 M. J. Teixeira, 1O. G. Barsottini1Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 3Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

Few studies on transcranial brain sonography have been per-formed in hereditary and non-hereditary ataxias. The objective of the present study was to report transcranial brain sonography find-ings in a sample of clinically and molecularly proven Machado-Joseph disease patients and to compare these data against those of an age- and gender-matched control group. A cross-sectional study on transcranial brain sonography was conducted in 30 Machado-Joseph disease patients. Transcranial brain sonography was performed by an experienced sonographer blinded to the clinical, genetic, and neuroimaging data. The results were com-pared with those of a control group of 44 healthy subjects matched for age and gender. The sonographic findings were also correlated with clinical features and genetic data in Machado-Joseph disease group. A significantly higher frequency of substantia nigra and lenticular nucleus hyperechogenicity was found in the Machado-Joseph disease group compared to an age- and gender-matched healthy control group (p<0.001). The substantia nigra echogenic area proved to be the best predictor for differentiating cases from controls. Third and lateral ventricles were significantly larger in the Machado-Joseph disease patients than in the control subjects. No significant correlations were found between transcranial brain sonography findings and Machado-Joseph disease demographic/clinical data. Transcranial brain sonography findings in Machado-Joseph disease patients differed significantly to those in age- and gender-matched controls. Substantia nigra hyperechogenicity oc-curred frequently in Machado-Joseph disease patients and was found to be the best predictor for differentiating cases from con-trols. Additionally, this data describes the occurrence of brain at-rophy in Machado-Joseph disease group.



O34

Optic nerve sheath diameter, hypobaric hypoxia and

acute mountain sickness: a prospective color study

P. Lochner1* T. Cappello2,G. Hofer 1, E. Procter2, H. Brugger2 L. Coppo 3, G. Strapazzon2

1Department of Neurology, General Hospital of Merano, Merano, Italy; 2EURAC Institute of Mountain Emergency Medicine, Bolzano, Italy; 3SCDU Neurologia, Head and Neck Department, AOU “Maggiore della Carità”, Novara, Italy

Objectives: Visitors to high altitude undergo a variety of acute and long term physiologic changes. Reproducible data on high-altitude adaptations are often lacking due to different patterns of acclimatization between studies and other confounding factors. Aim of the study was to investigate the effects of hypobaric hypox-ia on optic nerve sheath diameter (ONSD) in a group of 21 healthy lowlanders by B-scan ultrasound. Methods: Study variables, in-cluding ONSD, oxygen saturation (SpO2) and Lake Louise scor-ing system (AMS score), were assessed longitudinally at sea level (SL) before and during acute and subacute exposure (3, 9, 24, 48, 72 hours and 1 week) to hypobaric hypoxia at an altitude of 3,830 m (12,566 ft) without physical activity (HA) in the Eastern Alps. Ultrasound exams were performed and read by separate blinded observers. AMS score equal or above 3 in presence of headache defined acute mountain sickness. Results: Mean ONSD was 5.42 mm (95% confidence interval (CI) 5.26-5.75 mm) at baseline and increased significantly to 6.10 mm (95% CI 5.86-6.34 mm) after 3 hours of HA exposure (p<.0001). ONSD showed a parabolic pattern within the first 72 hours of HA exposure (partial eta squared=.84, p<.0001), followed by a trend to a further increase after 1 week of HA exposure. ONSD was significantly correlated with SpO2 (β=-.49, p<.001). Nevertheless, ONSD increased similarity in AMS+ and AMS- subjects (p=ns), whereas SpO2 increased differently in AMS+ and AMS- subjects (p<.05). Conclusion: Measurement of ONSD has a strong association with exposure to hypobaric hypox-ia in relation to time and early acclimatization, but it is not associ-ated with the development of acute mountain sickness symptoms in absence of physical activity in the current prospective study at a constant altitude. Further data will be required to assess ONSD in relation to long-term acclimatization.

O35

The effect of physical characteristics on reference nerve

sizes at multiple sites/levels of the arm and neck

T. Sugimoto1, K. Ochi1, N. Hosomi1, T. Mukai1, H. Ueno1, T. Nakamura1, T. Takahashi1, T. Ohtsuki1, T. Yamawaki1, T. Kohriyama2, M. Matsumoto1

1Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan; 2Department of Neurology, Hiroshima City Hospital, Hiroshima, Japan

Objective: The objective of this study was to identify ultrasono-graphic reference values of nerve sizes at multiple sites, including entrapment and nonentrapment sites along the median and ulnar nerves and among the cervical nerve roots, for practical use. We found associations between the reference nerve sizes and several physical characteristics (gender, dominant hand, age, height, weight, body mass index [BMI] and wrist circumference). In addition, we verified reliable sites and site-based differences between the reference values. Subjects and Methods: The nerve sizes were measured bilaterally at 26 sites/levels in 60 healthy Japanese adults (29 males, age 35.4±9.7 years, BMI 22.3±3.6 kg/m2 and wrist circumference 16.0±1.3 cm on the right side and 15.9±1.2 cm on the left side). Results: The mean reference nerve sizes were 5.6-9.1 mm2 along the median nerve, 4.1-6.7 mm2 along the ulnar nerve and 2.14-3.39 mm among the cervi-cal nerve roots. Multifactorial regression analyses showed that the physical characteristics most strongly associated with nerve size were age, BMI and wrist circumference at the entrapment sites (F = 7.6, p < 0.01 at the pisiform bone level of the carpal tunnel; F = 15.1, p < 0.001 at the level of Guyon’s canal), as well as wrist circumference and gender at the nonentrapment sites (F = 70.6, p < 0.001 along the median nerve; F = 24.7, p < 0.001 along the ulnar nerve). Site-based differences in nerve size were determined using one-way analyses of variance (p < 0.001). The intra- and interobserver reliabilities were the highest for the median nerve at both the distal wrist crease and mid-humerus, as well as at the arterial split along the ulnar nerve and at the fifth cervical nerve root. Conclusions: Our results suggest that the factors with the greatest influence on nerve size differed between the entrapment and nonentrapment sites.

O36

Cerebral venous outflow in children’s age. The

normal indicators, pathology and diagnostics

M. Abramova, I. Stepanova, S. Novoselova

Company: Russian State Medical University, Pediatric Faculty,Neurology, Neurosurgery and Medical Genetics Department, Laboratory of Child Cerebrovascular Disorders;Moscow, Russia

Investigation of cerebral venous hemodynamic in children is limited by the absence of diagnostics algorithm of venous outflow and normal indicators. These factors make difficulties in choice of


treatment of patients with cerebral venous disturbances. Purpose: Definition of normal indicators of venous cerebral blood flow in children’s age aspect. Method: We examined 600 patients from 3 till 18 years. Venous outflow in straight sinus (SS), great cer-ebral vein of Galen (VG) have been registered by TCD, TCCD un-der static conditions. Testing techniques of vasomotor reactivity (VMR) of static or dynamic cerebral autoregulation included the measuring changes in flow velocities in response to hemodynamic stimulus (Valsalva maneuver, orthostasis and head-down tilting).Results: Indicators of velocity maximum meanings of venous out-flow were determined in SS and VG at children in groups: 3-5, 5-7, 7-10, 10-12, 12-14, 14-18 years old. VMR tests have been modi-fied specially for children. The VMR dependence of cerebral ve-nous outflow in SS and VG on the children’s age is noted. Valsalva maneuver showed the increase of flow velocity in SS and VG in children 3-10-14 years old (50- 41 - 45%), 14-18 (29 - 34%). Under orthostasis flow velocity in SS and VG decreased at children: 5-10 years old ( 17-18%); 10 - 14 (20-21%), 14 -18 (11-12%). Under head-down tilting we noted the increase of flow velocity in SS and VG in children: 5 - 14 years old ( 50%) , 14 -18 (30-31%).Conclusion: Definition of cerebral venous hemodynamic normal indicators in children of different age groups is very important for identification and treatment of cerebral venous disturbances

O37

Scalp veins in outflow from cranium in patients with

parasagittal meningiomas

V. B. Semenyutin1, D. A Pechiborsch1, V. A. Aliev1, A. Patzak2, G. K. Panuntcev1, A. V. Kozlov1

1 Russian Polenov Neurosurgical Institute, St. Petersburg, Russia; 2 Johannes-Mueller Institute of Physiology University Hospital Charité, Humboldt-University of Berlin, Germany

Background: Invasion of parasagittal meningiomas (PSM) inside the superior sagittal sinus causes formation of collateral pathways of venous outflow (including scalp veins) from the cra-nial cavity. It could be presumed that in case of high significance of scalp veins in collateral outflow their damage during surgical approach for PSM removal may lead to serious complications.Purpose: Determine participation of scalp veins in formation of collateral outflow in patients with PSM. Material and methods: 8 patients with PSM (52−73 years) with invasion of the superior sagittal sinus (complete invasion in 4 cases) and four healthy vol-unteers were studied by bilateral transcranial Doppler-monitoring (MultiDop X, DWL) of blood flow velocity (BFV) in both middle cerebral arteries (MCA) and systemic blood pressure (BP) moni-toring by photoplethysmography (Ohmeda, Finapres 2300) in su-pine position. In patients circular compression of scalp veins with pneumatic cuff around glabella and inion during 3 minutes was used, while in volunteers – simultaneous transient (30 s) complete compression of both internal jugular veins controlled by ultra-sound in B-mode (Vivid E, GE). Results: Group-averaged BFV and pulsatility index (PI) on the side of PSM before compression were 45±13 cm/s and 0.88±0.15, BP − 101±31 mmHg. Significant changes of BFV, PI and BP were not detected during all period

of compression (3 min). These data indicate low significance of scalp veins in collateral venous outflow from the cranial cavity which was confirmed intraoperatively. Simultaneous compres-sion of both internal jugular veins in all 4 volunteers caused BFV decrease by 9±4% (p<0.05) and PI increase by 18±12% (p<0.05) associated presumably with intracranial hypertension and impair-ment of venous outflow from the cranial cavity. BP did not change significantly. There was a tendency to short-term increase of BP immediately after compression: from 91±18 to 99±20 mmHg (p>0.05). Conclusion: Temporary circular compression of scalp veins in patients with invasion inside the superior sagittal sinus does not cause significant impairment of venous outflow from the cranial cavity which presumably indicates their low significance in its formation.

O38

A rare case of familiar moyamoya disease presenting

with non-aneurysmal subarachnoid hemorrhage

(NASAH): hemodynamic features.

M. Toscano , F. Puledda , G. Guidetti , G. L. Lenzi , V. Di Piero, E. Vicenzini

Department of Neurology and Psychiatry, “Sapienza” Universityof Rome

Background: Moyamoya Disease (MMD) is a cerebrovas-cular condition that typically presents with ischemic or hemor-rhagic cerebral lesions. However, NASAH is very rare in MMD. Peculiar hemodynamic features both in intracranial and extrac-ranial vessels have been reported in MMD patients using Doppler ultrasound examination. We describe a patient presenting with NASAH studied with repeated TCD exams. Case Report: A 57 year old woman developed sudden headache followed by a par-tial seizure with rapid generalization. Her family history revealed two cousins with MMD. CT scan, cerebral angiography and TCD were performed upon admission. CT scans revealed SAH over the right frontal cortex and parieto-occipital cortex bilaterally. Cerebral angiography showed stenosis of the supraclinoid seg-ment of both ICAs, bilateral occlusion of the ACA, hypoplasia of the left MCA and multiple tortuous ‘moyamoya vessels’ branching from the right MCA. No cerebral aneurysms or vascular malfor-mations were found. Baseline TCD showed the typical hemody-namic pattern of MMD in terms of high flow velocity and low flow resistance in all monitored intracranial vessels but the R-MCA, which presented very high flow velocity and normal flow resist-ance; this was initially attributed to MCA vasospasm. NASAH in a patient with familial MMD was then diagnosed and nimodipine therapy was started immediately. Nonetheless, subsequent TCD controls showed a paradoxical increasing in blood flow velocity without any clinical or radiological signs of vasospasm, and a pro-gressive lowering of resistance indices. We therefore considered this alteration as a return to a previous abnormal pattern typical of MMD, more than a true vasospasm due to NASAH. Conclusions: This is, to our knowledge, only the second described case of fa-miliar MMD presenting with NASAH. It is also representative for the hemodynamic alterations in MMD peculiarly adapting to a



pathological condition such as subarachnoid bleeding, therefore resulting in a challenging diagnostic issue.

O39

Severe intracranial involvement in a case of giant cell

arteritis

J. Parra1, J. Domingues1, J. Sargento-Freitas1,2, R. Pina3, F. Silva1,2, G. Cunha4, I. Santana1

1Neurology Department; 2Neurosonology Laboratory; 3Internal Medicine Department and 4Neuroradiology Department, Coimbra University Hospital, Coimbra, Portugal

Introduction: Giant cell arteritis (GCA) is a chronic systemic granulomatous vasculitis envolving large and medium-sized ar-teries, typically affecting patients over the age of 50. Arteritic in-volvement of intracranial arteries is rare and appears to represent a subset of GCA with a fatal course. Clinical case: A 56-year-old man presented with apathy, weight loss, headache, articular pain and impaired gait progressing over 1 month. Initial neurological examination showed decreased processing speed, left central fa-cial palsy, and a mild spastic tetraparesis. He had a normocytic normochromic anemia, mild thrombocytosis and increased val-ues of C-reactive protein and Erithrocyte Sedimentation Rate (ESR). Initial cervical ultrasound indicated occlusion of left ver-tebral artery (VA) at V3 segment and hypoecogenic halo sign in both superficial temporal arteries. Despite early steroid initiation he continued to deteriorate. Follow-up neurosonologic evalua-tion at day three suggested occlusion of left VA and both inter-nal carotid arteries (ICA) in intracranial segments. Brain MRI indicated watershed infarcts and dissections of left VA and both ICA intracranially. Biopsy confirmed the diagnosis of GCA. After prednisolone at 2mg/Kg, Metotrexate (MTX) and oral anticoagu-lation the patient was stabilized. Two months later, control neu-rosonologic examination and MRI showed no signs of temporal artery inflammation, no new lesions and residual intracranial ar-terial stenosis. Two years after the initial presentation, the patient is neurologically asymptomatic and has an ESR value of 12mm/h. As a complication he had an aseptic necrosis of the femoral head that required hip replacement. After several unsuccessful attempts of steroid withdrawal he is still on 0.3mg/Kg daily of prednisolone plus 8mg per week of MTX. Conclusion: This is to our knowl-edge, the first reported clinical case with these characteristics. We stress the intracranial extent of vascular involvement with multiple dissections, and the need for early aggressive immune therapy to control the disease.

O40

Arteriovenous malformation in the carotid artery

bifurcation as a rare cause of syncope – case report

D. Sváčková1, J. Neumann1, F. Charvát2, J. Lacman2, D. Netuka3, P. Bodnárová1

1 Department of Neurology, Hospital Chomutov, Czech republic; 2 Department of Radiology, Military University Hospital, Prague, Czech republic; 3 Neurosurgical Clinic, Military University Hospital, Prague, Czech republic

Ateriovenous malformation (AVM) is defined as a convolute of abnormally connected arteries and veins, where capilar bed is missing. The most common localization of AVM is intracranial- brain malformations are about 20 times more frequent than ex-tracerebral ones. Clinical signs depend on the localization of the malformation, besides of local pain or bleeding, steal phenomenon often can be seen. In our case report, we present a case of 61-years old woman, who was admitted to the hospital because of recur-rent syncopes. During the neurosonologic examinaton we could see the acceleration of the flow in the left common carotid artery (133 cm/s), a huge convolute of the vessels in the area of the bifur-cation and accelerated, low resistant flow in the origin of external carotid artery with PSV 270 cm/s and low resistence index (0,3-0,4). The changes were seen also in the venous part - sings of arte-rial flow there. MR angiography was performed and confirmed a large malformation in the carotid artery bifurcation (about 8 cms). The patient was sent to the endovascular diagnostics and treat-ment, on digital subtraction angiography high-flow malformation of left lingual artery and the left half of the tongue was diagnosed. The selective embolization of the lingual artery by the coils was performed with very good radiologic and clinical outcome. We discuss the importance of the thorough neurosonologic examina-tion and present interesting ultrasound findings in this unusual localization of arteriovenous malformation.

O41

Prompt diagnosis of caroticocavernous fistula by

color coded sonography

J. Valaikienė¹, A. Širvinskas²

¹ Vilnius University, Faculty of Medicine, Clinic of Neurology and Neurosurgery, Lithuania; ² Republican Vilnius University Hospital, Department of Interventional Radiology, Lithuania

Background: Orbital color-coded duplex sonography (OCCS) is rarely used in every day neurological practice, but may be very useful as a diagnostic tool for vascular abnormalities. We presented a clinical case, using this non invasive ultrasound method to dif-ferentiate the cavernous sinus thrombosis from direct spontane-ous caroticocavernous fistula (CCF). Case presentation: 65 year old woman was urgently admitted to the hospital due to pulsatile tinnitus and ptosis in the left, double vision, chemosis and swelling of both eyes. Pulsatile tinnitus occurs 4 months ago, for unknown


reason. Then gradually developed chemosis, left proptosis and double vision. Family doctor, ophthalmologists, neurologists ex-amined the patient several times. 2,5 months later the patient was diagnosed with paresis of left eye oculomotor nerve. Magnetic res-onance angiography revealed a cavernous sinus and basilar plexus thrombosis. Non-septic intracranial venous system thrombosis was diagnosed. After 1 week of treatment with anticoagulants, computed tomography (CT) angiography showed normal venous flow. The patient condition worsened. Ophthalmoparesis and reti-nal venous thrombosis in the left eye and paresis of the abducens nerve in the right eye developed. Repeated CT scan detected no sudden pathology. However, OCCS detected a dilatation of the left superior ophthalmic vein and the diagnosis of CCF was made, confirmed by conventional angiography. Successful embolization of A type direct CCF was performed and pulsatile tinnitus with protosis and chemosis disappeared. Residual paresis of the left ab-ducens nerve was observed. At the 3-month follow-up, no CCA recurrence was detected in the control angiography. Conclusion: Prompt diagnosis of CCF remains a challenge for family doctors, ophthalmologists and neurologists. The orbital color coded sonog-raphy is fast and powerful diagnostic procedure for diagnosis of direct spontaneous caroticocavernous fistula.

O42

Vertebral artery dissection and acute right cerebellar

infarction in patient with coexisting transverse

vertebral foramen stenosis

J. Valaikiene¹, D. Jatuzis¹, J. Dementaviciene2

¹ Vilnius University, Faculty of Medicine, Clinic of Neurology and Neurosurgery, Lithuania; 2Vilnius University, Faculty of Medicine, Department of Radiology, Nuclear Medicine and Medical Physics, Lithuania

Background: Recent study showed that cerebellar infarctions are more frequently misdiagnosed in patients below 60 years and in cases of vertebral artery dissection. The pathogenesis of sponta-neous vertebral artery dissection may be multifactoral. Case pres-entation: 51 year old male was urgently admitted due to acute dizziness, loss of balance and gait ataxia. Three days ago acute diz-ziness, nausea and vomiting, loss of balance and gait ataxia occured after alcohol consumption. Neurological examination revealed bi-lateral nystagmus, ataxia, but no focal signs. Computed tomography showed low attenuation region in the right cerebellar hemisphere, posterior inferior cerebellar artery territory. Extracranial color du-plex ultrasound demonstrated dilation of V1 segment before en-tering into transverse foramina of the C6 and a double lumen of V1-V2 segments with unimpaired flow in the narrow true lumen. The dissection of the right vertebral artery was suspected. Magnetic resonance angiography confirmed the long dissection of the right vertebral artery with intramural hematoma. Cervical computed to-mography detected bilateral stenosis of the transverse foramina C3-7, especially in the right C3-4. Additionally alcoholic dehidration and secondary erythrocytosis was diagnosed. The patient recovered uneventfully. Conclusion: Acute cerebellar infarction without fo-cal neurological signs may be easily underdiagnosed, especially in

alcoholic intoxication. The possibillity of spontaneous vertebral dissection should be considered in younger patient with marked transverse vertebral foramen stenosis. Extracranial color duplex so-nography is useful tool for initial diagnosis of vertebral artery dis-section, even without evidence of flow impairment.

O43

Bilateral steno-occlusive disease of the middle

cerebral artery: a case report with clinical-

hemodynamic mismatch

H. Rocha1, R. Santos1, P. Castro1, A. Bastos-Leite2, E. Azevedo1, M. Carvalho1

1Department of Neurology, São João Hospital Centre, Faculty of Medicine of University of Porto, Porto, Portugal; 2Department of Medical Imaging, Faculty of Medicine of the University of Porto, Porto, Portugal

Background: Bilateral steno-occlusive disease of MCA in young adults is rare, and raises difficult issues regarding aetiology and prognosis. The potential concomitance of hypoperfusion in the affected territories is of particular clinical relevance, and war-rants the use of neuroimaging techniques that may demonstrate it. Case report: a 36-year-old Caucasian man was admitted for a right MCA transient ischaemic attack. He was smoker, obese, dyslipidaemic, binge drinker, with history of drug addiction to heroin, and B and C hepatitis virus infection reported as cured. Brain CT, electrocardiogram, and trans-oesophageal echocardio-gram were normal. Transcranial colour-coded Duplex (TCCD) showed >50% proximal right MCA stenosis and a possible distal left MCA stenosis/occlusion. Three-dimensional time-of-flight MRA did not accurately depict the corresponding arterial lu-mina. Treatment with aspirin and statin has been started. Two months later, TCCD revealed >70% right MCA stenosis, and oc-clusion of left MCA. Selective angiography confirmed the steno-occlusive disease, partial collateralization through branches of the external carotid arteries, without irregularities of other ves-sels. Cerebrospinal fluid analysis revealed increased protein levels, but a normal cell count. Despite lack of any particular evidence of vasculitis, corticotherapy has been started, but the patient did not comply. Bilateral occlusion of MCA was noticed on TCCD, two months later. Since the patient remained asymptomatic, MRI with pulsed arterial spin labelling (PASL) was performed to determine whether there was an associated pattern of brain hypoperfusion. PASL confirmed a severe decrease of cerebral blood flow in the distal part of the territory of both MCA. Discussion: serial TCCD plays a major role in the follow-up of intracranial stenosis. Apart from other neuroimaging modalities, arterial spin labelling can be additionally helpful, since it is a non-invasive method providing direct information on the status of brain perfusion and, hence, on the efficiency of collateral circulation.



Poster Sessions

P1

TCARNet: a pathway to translating cerebral

autoregulation research into patient benefit

V. Novak1, D. M. Simpson2, M. Czosnyka3, J. Pachter4, J. Ottesen5, M. Günther6, K. Hu7, A. De Gaetano8, I. Piper9, M. Shaw9, A. van Ravestijn10, J. Claassen11

1Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston-MA, USA; 2Institute of Sound and Vibration Research, University of Southampton, UK; 3Neurosurgical Unit, University of Cambridge, UK; 4Dept. of Cell Biology, University of Connecticut Health Centre, USA; 5Department of Science, Systems and Models, Roskilde University, Denmark; 6Fraunhofer MEVIS Institute for Medical Image Computing, Bremen, Germany; 7Harvard Medical School, USA; 8BioMatLab CNR-IASI, Università Cattolica del Sacro Cuore, Rome, Italy; 9Dept. of Clinical Physics, Southern General Hospital, Glasgow, UK; 10Radboud University, Nijmegen, The Netherlands; 11Dept. of Geriatric Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.

In spite of the extensive research into cerebral autoregulation (CA), patients have not yet benefitted greatly from the new knowledge and understanding acquired, from improved diagnostic techniques and associated interventions that could optimise their brain perfu-sion, brain health and long term outcomes. This paper outlines some current challenges in the field and the approach proposed in the re-cently submitted EU (FP7) multicenter project Translational Cerebral Autoregulation Network (T-CARnet). Although many different ex-perimental protocols, measurement and data analysis methods are available to assess CA, it is currently not known which method(s)perform(s) best. Moreover, methods available to investigators differ widely between centres. This absence of standardization makes it dif-ficult to compare results from published papers and establish a firm evidence-base to guide clinical interventions. Recommendations for ‘best’ methods, using large and varied datasets together with objec-tive criteria (robust estimates, sensitivity/specificity, clinical out-comes, patient comfort etc.), together with consensus among the CA research community are vital for the field to progress. The absence of a gold-standard, and only limited understanding of physiological mechanisms and their short and long-term stability, makes further research on mechanisms of autoregulation vital. Increased aware-ness of the importance of CA among all stakeholders (clinicians, car-ers, patients) is needed to ensure that CA research is fully exploited. Thus the following are the specific objectives of T-CARnet: i) Evaluate and compare current predictors of impaired CA in patients with car-diovascular and related diseases (e.g. diabetes), as well as patients following head trauma or surgery. ii) Provide validated tools and methodologies for detection of impaired CA, and inform patients, health care professionals, and policy makers when and how to use them. iii) Facilitate the translation of novel research findings on CA to clinical practice. This paper aims to stimulate further discussion of a roadmap for translating CA research into patient benefit.

P2

Doppler flow velocity and ICP: Responses to short-

term mild hypocapnia help to assess the intracranial

pressure-volume relationship after head injury

C. Haubrich12 , L.A. Steiner3, R.R.Diehl4, M. Kasprowicz15 , P. Smielewski1 , J.D. Pickard1, M.Czosnyka1

1Department of Academic Neurosurgery, Addenbrooke’s Hospital, Cambridge,UK; 2 Department of Neurology, University Hospital Aachen, Aachen, Germany; 3Department of Anesthesia, University Hospital of Basel, Switzerland; 4Department of Neurology, Alfried-Krupp-Krankenhaus Essen, Germany; 5Institute of Biomedical Engineering and Instrumentation, Wroclaw University of Technology, Poland

To anticipate an increase of intracranial pressure (ICP), informa-tion is required about the pressure-volume (p/v) compliance. ICP monitoring often fails this task after head injury. Could a test which transiently shifts intracranial blood volume produce consistent in-formation about the p/v relationship? Doppler flow velocities in the middle cerebral arteries (left:80.8± 34.7cm/s; right:65.9±28.0cm/s) and ICP (16.4±6.7mmHg) were measured in 29 head-injury patients before and during moderate hypocapnia (4.4±3.0kPa). The ratio between vasomotor responses and ICP changes was distinguish-able between high (left:14.8±6.9, right:14.4±6.6 cm/s/kPa/mmHg) and low intracranial compliances (left:1.8±0.6, right:2.2±0.9 cm/s/kPa/mmHg). Additionally, the ratio identified 12 patients deviating from the classical non-linear p/v curve (left: 5.7±1.3, right: 5.8±1.0 cm/s/kPa/mmHg). They exhibited an almost proportional rela-tionship between vasomotor and ICP responses (R=0.69; p<0.01). Results suggest that a test which combines responses of two intrac-ranial compartments may provide consistent information about the intracranial p/v compliance even if parameters derived from ICP monitoring are inconclusive.

P3

Differences in Cerebral Autoregulation between

Arterial Beds is Not Reflected in CO2 Reactivity

J. M. Serrador1,2,3, M.Blatt1, A. Acosta1, B. Ghobreal1 and M.J. Falvo1,2

1War Related Illness & Injury Study Center, NJ VA Health Care System, East Orange, NJ & 2New Jersey Medical School, Newark, NJ & 3Harvard Medical School, Boston, MA

Cerebral autoregulation represents the ability of cerebral ves-sels to adjust resistance in the face of changes in blood pressure. Cerebrovascular reactivity represents the responsiveness of cer-ebral vessels to change in response to changes in arterial CO2. The goal of this work was to determine if there were differences in cer-ebrovascular reactivity and/or autoregulation in different arterial beds. Twenty six participants (12 females, 35.8 ± 10.7 years) were assessed during a cerebrovascular reactivity protocol where they breathed normally for 3 min, 8% CO2, 21% O2, balance nitrogen for two min and hyperventilated for 2 min. To assess cerebrovascular

Abstracts Posters Cerebrovasc Dis 2013;35(suppl 2):1–77 35

reactivity in the anterior (ACA) and middle (MCA) and verte-bral arteries (VA) we measured cerebral flow velocity (transcra-nial Doppler), beat-by-beat blood pressure (Finapres) and end tidal CO2 via nasal cannula. End tidal CO2 changed from baseline (41.3±3.5), to hypercapnia (46.1±4.5), to hypocapnia (30.7±5.3 mmHg). Examining change in cerebral flow velocity, we were able to derive CO2 reactivities for each artery that were not significantly different (MCA: 1.8±1.0; ACA: 1.9±1.1; VA: 1.7±1.0 %/mmHg). In contrast, we previously found in these subjects that autoregula-tion was better in the VA than other arterial beds based on ARI values obtained from a sit to stand protocol (MCA: 2.6±1.7, ACA: 2.4±1.7; VA: 3.8±2.0). These data indicate that CO2 reactivity was not different between arterial beds. However, cerebral autoregula-tion was better in the VA than the MCA or ACA. Thus future work should consider examing cerebral autoregulation in multiple beds. These data also caution against the assumption that CO2 reactivity is related to autoregulation. Supported by the War Related Illness & Injury Study Center, Veterans Administration and NIH grant R21DC009900 (Serrador).

P4

Correlation of TCD blood flow velocity and ICP as a

new index of cerebral autoregulation. Do we need it?

M. Czosnyka1, P. Lewis2, P. Smielewski1, J. D. Pickard11Academic Neurosurgery, University of Cambridge Box 167, Addenbrooke’s Hospital, Cambridge; 2 Dept of Neurosurgery, Alfred Hospital, Prahran, Australia

Intro: Slow fluctuations (from 0.005 to 0.05Hz) in intracra-nial pressure (ICP) are believed to originate predominantly from changes in cerebral blood volume secondary to autoregulatory ad-justments in arteriolar diameter. These adjustments are reflected in the blood flow velocity (CBFV) recorded with transcranial Doppler ultrasound, which is a reliable measure of relative changes in cerebral blood flow (CBF) over short periods of time. Differing patterns of ICP change in response to specific patterns of varying CBF have previously been identified, and tey are likely to reflect differing states of cerebral autoregulation (CA). We investigated a continuous measure of CBFV/ICP association and its relation-ships to CA and outcome after severe traumatic brain injury (TBI). Materials and Methods: We retrospectively analysed recordings of ABP, CBFV and intracranial pressure (ICP) from 240 TBI patients treated at Addenbrooke’s Hospital, Cambridge, UK. Monitored data were recorded to a laptop computer using ICM+ software. A measure of CBFV/ICP association was derived as a moving continuous correlation coefficient between 10-seconds averaged CBFV and ICP waveforms over 5 minute periods (Flow-ICP in-dex or FIx). Previously published indices of CA were computed that included Mx and MxA. Statistical analysis was restricted to nonparametric tests. Key Results / Findings: FIx was significant-ly negatively associated with ICP (Spearman’s R=-0.40; p<0.01). Higher CPP was associated with a higher FIx (Spearman’s R=0.34, p<0.01. Kruskal-Wallis p<0.000001). FIx correlated significantly with TCD based indices of CA (Mx: R=-0.52, p<0.01. MxA: R=-0.19, p<0.01). FIx was significantly associated with outcome after

grouping into Glasgow Outcome Score fatal- non-fatal (Mann-Whitney p=0.009). Conclusions: The FIx index, a moving contin-uous correlation coefficient between averaged (10 sec) CBFV and ICP may be of value in identifying states of impaired autoregula-tion. FIx is associated with outcome after severe TBI.

P5

Cerebrovascular time constant in carotid artery

occlusive disease

M. Kasprowicz1,2 ,P. Smielewski1, J. D. Pickard1 and M. Czosnyka1

1Academic Neurosurgical Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom; 2Institute of Biomedical Engineering and Instrumentation, Wroclaw University of Technology, Poland

Intro: Cerebrovascular time constant theoretically approximates time needed for cerebral arterial blood to arrive during each heart cycle at hypothetical arteriole- capillary border. This parameter can be non-invasively assessed from TCD blood flow velocity waveform. Material and Methods: We studied 25 patients (20 males and 5 fe-males, median age: 62 years, range 47¸77) with occlusive disease of one or both internal carotid arteries demonstrated by angiography. The comparison was made with data from 11 volunteers (8 males, 3 females, median age 21 years, range: 20¸41). All patients and vol-unteers underwent simultaneous recording of middle cerebral artery blood flow velocity (CBFV) using TCD and arterial blood preassure (ABP) using Fianpress device during normo-, hyper-, and hypocap-nia. Time constant of cerebral blood inflow (t) was continuously calculated as resistance of cerebral vessels (CVR=mean ABP/mean CBFV) multiplied by cerebral arterial compliance (Ca=amplitude of cerebral arterial blood volume (CBV)/amplitude of ABP). Results: Substantial shortening of the time constant during normocapnia (p=0.01) was demonstrated in patients with both unilateral (ipsilat-eral side: t=0.18±0.04 s) and bilateral ICA stenosis (t=0.17±0.04 s) in comparison with healthy volunteers (t=0.22±0.06 s). The pCO2 challenge caused a significant shortening in t during hypercapnia (t=0.19±0.041 s) and prolongation during hypocapnia (t=0.25±0.07 s) in volunteers (p<0.001). However, no significant shortening of t were demonstrated in patients with carotid stenosis during hypercap-nia. The t significantly correlated with degree of stenosis (unilateral: r=-0.6, p=0.012, bilateral -0.5, p=0.023). Conclusion: Shortening of t in patients with ICA stenosis in comparison with volunteers might reflect the extend of vasodilatation in the territory distal to an oc-cluded ICA. Lack of further shortening in t to vasodilatory stimulus during hypercapnia in patients with ICA stenosis can suggest that the distal vessels had already achieved a state of maximal vasodilatation.



P6

Cerebral blood flow is reduced in the vascular

territory of ischemic stroke in the first 24 hours

J. M. Serrador1,2,3, P. Castro4, I. Rocha5, M. Blatt1, B. Ghobreal1, F. Sorond3, E. Azevedo4

1War Related Illness & Injury Study Center, NJ VA Health Care System, East Orange, NJ, USA & 2New Jersey Medical School, Newark, NJ, USA & 3Harvard Medical School, Boston, MA, USA; 4Dep. of Neurology, São João Hospital Center and Faculty of Medicine of University of Porto, Portugal; 5Faculty of Medicine & Institute of Molecular Medicine, Lisbon, Portugal

Introduction: Ischemic stroke is associated with neural damage in its vascular territory. However, it remains unclear how this damage may affect cerebral blood flow (CBF) and vascular resistance in other territories. Our goal was to examine changes in CBF and resistance in several arterial territories in the first 48 hours following an ischemic stroke. Methods: Ten patients (5 females, 66.4±11.9 years) were as-sessed within 6h of stroke symptoms. All ten patients had an infarct in MCA territory (NIHSS 12.3±5.7). To assess CBF we measured bilateral flow velocity (transcranial Doppler) in the anterior (ACA), middle (MCA) and posterior cerebral arteries (PCA), beat-by-beat blood pressure (Finapres) and end tidal CO2 via nasal cannula. Resting supine data was collected at 6, 12, 24 and 48h. Results: Mean arte-rial pressure was significantly higher at 6h (98.2±4.4) compared to 12 (87.2±4.1), 24h (77.4±4.3) and 48h (84.8±4.7 mmHg). Cerebral flow velocity in MCA territory was significantly lower on the infarct side at 6h (34.9±6.8 vs 50.1±5.9 cm/s) and remained lower at 12h and 24h un-til equalizing at 48h (52.5±7.4 vs 52.7±6.3 cm/s). This reduced flow was associated with a significantly greater cerebrovascular resistance at 6h (2.6±0.4 vs 1.7±0.4 mmHg/cm/s). In contrast there was no difference in flow or cerebrovascular resistance between hemispheres in either ACA or PCA territories. Discussion: These data show that CBF veloc-ity is reduced in the infarcted territory in the first 48h post stroke. The normalization of flow at 48h suggests that the initial reduction may be due to a possible distal occlusion which is subsequently reanalyzed or compensated by newly formed collaterals. The higher pressures at 6h may also be a compensatory response to maintain CBF in the face of higher cerebrovascular resistance. Other vascular territories do not ap-pear to be affected. Supported by Fundação para Ciência e Tecnologia Portugal, PTDC/SAU-ORG/113329/2009 (Rocha).

P7

Blast exposure is associated with impaired cerebral

blood flow regulation in US veterans

J. M. Serrador1,2,3, M.Blatt1, A. Acosta1, B. Ghobreal1 and M. J. Falvo1,2

1War Related Illness & Injury Study Center, NJ VA Health Care System, East Orange, NJ & 2New Jersey Medical School, Newark, NJ & 3Harvard Medical School, Boston, MA

Blast exposure is a significant problem for the current and re-cent military conflicts, however, data remains limited on the effects

of a pressure wave on cerebral blood flow regulation. The goal of this work was to determine if veterans with a blast exposure dem-onstrate impaired cerebral autoregulation. Ten veterans (males, 35.1 ± 9.3 years) participated. All ten endorsed blast exposure; seven reported a previous head injury. To assess autoregulation in both the anterior (ACA) and middle cerebral arteries (MCA) we had participants perform three sit to stand maneuvers while continuously monitoring beat-by-beat TCD and blood pressure. We also measured end tidal CO2 via nasal cannula. Examining vet-erans who had reported previous head injury, we found they had lower autoregulatory index values in both the ACA (Blast: 4.4±0.6; Blast+Head Injury: 3.8±0.6) and MCA (Blast: 5.3±0.7; Blast+Head Injury: 3.8±0.7). While blood pressure decreases when standing was similar between groups (Blast: -19.9±2.5; Blast+Head Injury: -21.2±1.6 mmHg), decreases in cerebral flow velocity were signifi-cantly greater in the Blast+Head Injury group (ACA: -22.1±3.2% ; MCA: -17.9±2.7%) compared to Blast only (ACA: : -13.7±4.1% ; MCA: -11.9±4.1%). These data indicate that veterans with blast ex-posure and previous head injury are more likely to show impaired cerebral autoregulation. This is consistent with our recent find-ings in which veterans with blast exposure and head injury dem-onstrated unilateral vestibular damage. However, further work is needed to confirm this initial finding. Supported by the War Related Illness & Injury Study Center, Veterans Administration and NIH grant R21DC009900 (Serrador).

P8

Carotid intima-media thickness in rheumatoid arthritis

T. Lepic, G. Ristic, D. Veljancic, B. Labovic, Z. Krsmanovic, M. Lepic, B. Glisic, M. Petronijevic, D. Stefanovic, R. Raicevic

Military Medical Academy/ Department of Neurology/ Department of Rheumatology and Clinical Immunology/ Belgrade/ Serbia

Objectives: Carotid intima-media thickness (IMT) of the ca-rotid arteries is marker of subclinical atherosclerosis in patients with rheumatoid arthritis (RA). Study intention was to determine factors associated with increased IMT and potential cardiovascular risk of RA patients. Methods: IMT was measured by ultrasonog-raphy in 42 non-diabetic, normotensive, female RA patients and 32 matched healthy controls (age 45.3±10.0 vs. 45.2±9.8 years) at com-mon carotid (CCA). Mean and maximal (max) IMT were calculated from 3 measurements at each site. Clinical work-up included labo-ratory analyses, determination of the disease activity and evaluation of treatment. Results: RA patients had increased IMT (mm) in comparison with controls (IMTmax: 0.764±0.148 vs. 0.703±0.100, IMTmean: 0.671±0.119 vs. 0.621±0.085. Parameters associated with IMT in RA patients were: age, body-mass index, smoking, rheuma-toid factor concentration, eritrocyte sedimentation rate, and dura-tion of methotrexate+chloroquine therapy (inverse correlation). Multivariate regression analysis revealed that RA is an independent risk factor for increased IMT. Factors correlating with IMT in the controls were: age, BMI, total cholesterol, LDL-cholesterol, total/HDL cholesterol, triglycerides and glycaemia. Conclusion: Despite a favourable risk profile, our female RA patients had significantly


enlarged carotid IMT than controls. RA itself was an independent risk factor for increased IMT. Impact of chronic inflammation on atherosclerosis was confirmed by negative correlation of IMT and duration of anti-inflammatory treatment.

P9

APOE gene polymorphism and symptomatic carotid

artery disease - An Egyptian study

S. El-Jaafary1, S. Ahmed1, M. Fathy2, F. Abd-Allah1

1 Neurology department Faculty of Medicine, Cairo University; 2Chemical pathology department, Faculty of Medicine, Cairo University

Background: The apolipoprotein E gene is a widely studied gene in atherosclerosis and development of stroke. Its relationship to ca-rotid artery disease is yet inconsistent some studies reported specific alleles to be associated with increased intima media thickness (IMT), others found no association to IMT, but showed positive association with plaque formation. Aim: studying the effect of APOE polymor-phism on carotid artery disease in a sample of Egyptian population being not studied before. Methods: 72 patients with ischemic stroke were examined by B-mode and color coded duplex ultrasound. APOE gene polymorphism assay was done using real time PCR technique. Results: APOE gene alleles distribution in the study group was as fol-low: E3 E3 (n=33, 45.8%), E4 E4 (n= 15, 20.8%), E3E4 (n=12, 6.6%), E2 E2 (n=5, 7%), E2 E4 (n=5, 7%) and E2E3 (n=2, 2.7%). Comparing different groups of alleles carriers using Chi square test showed no statistically significant difference regards the increased IMT or the presence of carotid artery stenosis in these patients with p value = 0.244 and p value = 0.521 respectively. Conclusion: Regards differ-ent APOE gene alleles, there was no specific allele showed associa-tion with development of symptomatic carotid artery disease either increasing the IMT or development of plaques in our study group. Key words: APOE gene polymorphism, carotid IMT, plaques.

P10

Arterial stiffness of the internal carotid artery does

not distinguish patients with stable unruptured

aneurysms from normal controls

F. Perren1; P Reymond2; E Fonck2 ; D Rüfenacht3; N Stergiopulos2

1HUG, University Hospital and Medical Faculty of Geneva, Dept. Clinical Neurosciences, Division of Neurology, Neurosonology Unit, Geneva, Switzerland; 2EPFL, Swiss Technical Insitute, Laboratory of Hemodynamics and Cardiovascular Technology, Lausanne, Switzerland; 3Hirslanden Clinic, Center of Neuroradiology, Zurich, Switzerland

Introduction: Today it is still impossible to image the aneu-rismal wall itself in vivo and to perform proper analysis of stress field within. This limits the assessment of the potential risk of

rupture, which remains subjective and mainly based on the loca-tion, geometry, patient’s age, health, family medical history, and size of the aneurysm. Since an underlying arteriopathy might contribute to the development and rupture of intracranial aneu-rysms, a rapid noninvasive inexpensive tool for the in vivo assess-ment of the biomechanical properties of the arterial wall and the changes associated with the risk of rupture is needed. Methods: Patients diagnosed (CTA/MRA,DSA) with unruptured (stable for >/= 6 months) intracranial aneurysms of the anterior circulation and their healthy (MRI/MRA, clinical data) matched controls have been compared. Noninvasive high-resolution ultrasound echo tracking system (Aloka) and blood pressure measurements have been used to assess the elastic properties of proximal con-duit arteries. Patients and controls suffering from cardiovascular risk factors or disease, or carotid vessel wall pathology have been excluded. Results: 18 subjects (9 patients and their controls; 12 women; mean age 54 years) were studied. Elastic properties were assessed in the proximal internal carotids. We compared the elastic modulus, stiffness parameter and arterial compliance computed with the ultrasound echo tracking system and found no signifi-cant difference (p= 0.24, 0.49 and 0.41 respectively). Conclusion: The aim of the present study was to show whether arterial stiffness of extracranial cerebral arteries could predict the development of intracranial aneurysms. We could not find significant differences in three arterial stiffness parameters between subjects with stable unruptured aneurysms and controls. Contrarily to a study which found increased arterial stiffness parameters in patients with rup-tured aneurysms this seem not to be true for patients with stable unruptured aneurysms.

P11

Assessing performance of shear wave elastography

using carotid artery stenosis phantoms.

J. Garrard1, K. Dexter2, S. Nduwayo1, T. Hartshorne2, A. Naylor2, T. Robinson1 and K. Ramnarine4

1Department of Cardiovascular Sciences, University of Leicester, UK; 2Department of Medical Physics, Department of Vascular and 3Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK

Shear Wave Elastography (SWE) is a novel ultrasound method, which has previously been researched in several larger, more stable tissues such as liver, breast and thyroid. This study assessed the suitability and reproducibility of SWE in carotid stenosis phan-toms. SWE imaging was performed using a SuperSonicImagine Aixplorer® system, to acquire cine-loop data and quantify Young’s Modulus (YM) in polyvinyl alcohol cryogel (PVA) stenosis vessel flow phantoms. Two phantoms were used; a homogeneous PVA phantom and an inhomogeneous phantom, which had a focal re-gion of stiffer PVA. In-vitro data were acquired by 2 observers, each performing 3 repeat measurements. Mean YM was quantified within 2mm regions of interest in 5 frames. The observed YM was significantly different in the region of stenosis compared to the vessel wall in both phantoms (p<0.05). The focal region of stiffer PVA was significantly higher than the homogeneous region of the



stenosis (p<0.05). There was no significant difference in values in either the steady or pulsatile flow for either phantom (p=0.70; p=0.82). Mean inter-frame CV for observer 1 and 2 in flow phan-toms simulating homogeneous and inhomogeneous plaques were: 0.12 and 0.17 under steady flow; 0.12 and 0.15 under pulsatile flow, respectively. Mean intra-observer intraclass correlation coef-ficient (ICC) over multiple acquisitions was 0.87 for steady and 0.88 for pulsatile flow. Mean difference between observers was 22% for both steady and pulsatile flow. Inter-operator ICC was 0.82 for steady and 0.84 for pulsatile flow. SWE can quantify ca-rotid plaque stiffness with good reproducibility and can quantify different tissue properties, even in the presence of pulsatile arterial tissue motion.

P12

Carotid atherosclerosis and metabolic syndrome

A. Arsovska, Z. Arsovski¹, A. Popovski ², S Popovska³

University Clinic of Neurology, Skopje, Macedonia; ¹University Clinic of Pulmonology and Allergy, Skopje, Macedonia²PHO Dr A. Popovski, Skopje, Macedonia³PHO Dr S. Popovska, Skopje, Macedonia

Background: Metabolic syndrome is a combination of disor-ders such as central obesity, dyslipidemia, hypertension and raised fasting plasma glucose levels. It is associated with increased risk for cerebrovascular diseases. Aim: to investigate the presence of carot-id atherosclerosis in patients with metabolic syndrome. Material and methods: Carotid color duplex ultrasound investigation was performed in 65 patients ( aged 25-44 years) who fulfilled criteria for metabolic syndrome (NCEP ATP III criteria) and in 40 age and sex matched control subjects. Results: Carotid atherosclerosis was present in 58 patients (89,2%) with metabolic syndrome. Of them, 50 patients( 86,2%%) had increased intima media thickness (IMT > 0,9 mm), 7 (12%) had low grade carotid stenosis and 1 (1,7%) had moderate carotid stenosis. The commonest risk fac-tor was increased level of triglycerides (> 1,7 mmol/l) found in 54 patients (93,1%). In the control group, only 2 patients (5%) had in-creased IMT >0.9 mm. Patients with metabolic syndrome had sig-nificantly higher percentage of carotid atherosclerosis compared to the control subjects (p<0.01). Conclusion: Carotid atheroscle-rosis is associated with metabolic syndrome, especially in patients with increased levels of triglycerides. Control examinations of blood triglyceride levels and color duplex examination of the ca-rotid arteries should be recommended in patients with metabolic syndrome to prevent occurrence of cerebrovascular diseases.

P13

Assessment of the unstable carotid plaque using

fluorine-18-labelled fluorodeoxyglucose (FDG) PET

K. Skagen1, K. Johnsrud2, M. Skjelland1, H. Scott3, A. Skretting4, J. Fjeld2, Russell D1

1Department of Neurology, Oslo University Hospital, Rikshospitalet, Norway; 2Department of Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Norway; 3Department of Pathology, Oslo University Hospital, Rikshospitalet, Norway; 4The Interventional Centre, Oslo University Hospital, Oslo, Norway

Introduction: A significant proportion of strokes are thrombo-embolic in nature, arising from the atherosclerotic plaques at the ca-rotid bifurcation. Such strokes are effectively preventable by carotid endarterectomy or carotid stenting. In current clinical practice pa-tient selection for revascularization primarily involves identification of the severity of luminal stenosis, measured using conventional im-aging modalities such as Doppler ultrasound and/or MR or CT angi-ography. It is, however; increasingly clear that the degree of luminal stenosis alone may not be the best predictor of risk. Inflammation is known to play a key part in all stages of atherosclerosis including initiation, progression and plaque rupture. The macrophage is one of the key mediators of this process, FDG uptake corresponds with macrophage rich areas of plaques. Higher degree of inflammation is thought associated with higher risk and there is therefore increasing interest in FDG-PET imaging for evaluating degree of inflammation in atherosclerotic carotid plaques. Aim/Methods: The aim of this study is to assess whether FDG PET can identify unstable carotid plaques. 25 consecutive patients with symptomatic high-grade ca-rotid artery stenosis scheduled for carotid endarterectomy are in-cluded. Patients with a history of transient ischemic attack or minor stroke due to carotid artery disease within 90 days of carotid en-darterectomy are considered symptomatic. All patients underwent a neurological examination, Doppler ultrasound, FDG PET and blood sampling before endarterectomy. Level of agreement between FDG PET findings and histological categorization of plaques is be-ing assessed. Conclusion: FDG PET imaging of carotid plaques may allow earlier and more specific diagnosis. This is important be-cause there are several groups in clinical practice, e.g. patients with symptomatic moderate or asymptomatic severe stenosis, for which decision-making based on stenosis severity alone is not optimal.

P14

Complications and restenosis after carotid

endarterectomy, outcomes of a Portuguese centre

J. Meireles, C. Ferreira, R. Santos, E. Azevedo

Dep. of Neurology, São João Hospital Center and Faculty of Medicine of University of Porto

Background: Significant carotid stenosis surgery reduce the risk of a subsequent stroke, but the benefit must overcome the morbi-mortality related to the intervention. On the other hand, it


is also important to evaluate the rate of recurrent stenosis after ca-rotid endarterectomy (CEA). Objective: We aimed to evaluate in our center the incidence of complications associated with CEA and of restenosis, as well as the influence of the surgical technique in these parameters. Methods: Duplex scans from 9342 consecutive patients routinely referred to our Neurosonology Unit from 2005 to 2011 were reviewed. We included cases of symptomatic (>50%) or asymptomatic (>70%) carotid stenosis submitted to CEA, who had at least one control of duplex scan after the surgery. We have evaluated local complications, post-surgical stroke or TIA, as well as mortality and its cause. In the survivors, restenosis was defined as a luminal narrowing >70%. Results: We have included a total of 92 CEA in 86 patients. 82% were male. 92% had symptomatic stenosis. The post-CEA evaluation was done over a variable pe-riod of time (mean time of 12 months ±11). Restenosis occurred in one patient (1%). 80% of the procedures were performed by the same surgeon. The majority of patients underwent loco-regional anaesthesia (98%) and CEA with patch (95%). Post-surgical com-plications were identified in seven patients. Three (3.3%) had local minor complications. Four (4.3%) had post-operatory strokes – 3 ischaemic and one hemorrhagic stroke – and 2 (2.2%) have died as a consequence of it. Discussion: In our series we had a low complication and restenosis rate after CEA. Although a correct selection of the patients is important, the persistence of an expe-rienced surgical team and the chosen technique with local anaes-thesia and use of patch for carotid enlargement may contribute to a good outcome.

P15

Evaluating the effect of carotid endarterectomy

on the cognitive functions of the patients having a

carotid stenosis more severe than 70%

A. Frendl1, A. Burainé Bojtor1, L. Kardos2, K. R. Kovács1, J. Borók1, S. Olvasztó3, K. Litauszky3, F. Bodnár3, L. Csiba1

1University of Debrecen MHSC Department of Neurology, Debrecen, Hungary; 2University of Debrecen MHSC Department of Preventive Medicine, Debrecen, Hungary; 2University of Debrecen MHSC Department of Vascular Surgery, Debrecen, Hungary

Objectives: We aimed to evaluate the changes of cognitive functions and the cerebrovascular reserve after carotid endarter-ectomy. Methods: 31 patients (22 men, 9 women, age: 62+/-8.8 years) with a carotid stenosis more severe than 70% were tested (17 asymptomatic, 14 symptomatic after TIA/minor stroke). Dementia was ruled out with MMSE test. They were examined before and 6-10 weeks after the carotid endarterectomy: cerebro-vascular reserve (breath holding index=BHI) was determined and 8 cognitive tests were done. We also compared the baseline cogni-tive functions of the asymptomatic patients with hypertensive con-trols without any severe disease and significant carotid stenosis. Neurological examination was repeated to discover any physical change after the surgery and control CT was performed to exclude new vascular lesions. Results: No patients had new neurologi-cal symptom or new vascular lesion on the CT after surgery. The

asymptomatic patients had significantly worse results according to reaction time (Choice Reaction Time, p=0.0083; Serial Reaction Time, p<0.001) and to the ability of analysis-synthesis (WAIS block design, p< 0.001; WAIS digit symbol, p=0.0001) compared to the controls. There was no significant change in the BHI after endarterectomy. After the surgery there was significant improve-ment in short term memory and world learning ability (REY AVLT, p=0.0015), in attention (Pieron test, p=0.0177), in the mo-tor functions driven by visual stimuli (Trail Making, p=0.0139), in the ability of analysis-synthesis (Waist Block design, p=0.0347), in the speed of thinking (Waist digit symbol, p=0.0438), in short and long term visual memory (Rey-Osterrieth, p=0.0042, p=0.0006). The standardized sum of the tests showed significant improvement as well (p<0.001). Conclusion: Based on our findings we suggest that indicated carotid endarterectomy can be beneficial not just by preventing an upcoming stroke but by achieving cognitive improvement.

P16

Intima-media thickness among Mediterranean

countries: inter-percentile comparison

L. Pereira1, M. Biscaia2, R. Guerreiro2, I. Palma3, M. Rodrigues1

1 Hospital Garcia de Orta, Neurology Department, Almada, Portugal; 2 Centro Hospitalar de Setúbal, Neurology Department, Setúbal, Portugal; 3 Clínica Girassol, Luanda, Angola

Background: Carotid intima-media thickness (IMT) is an ath-erosclerotic marker, predictive of cardiovascular events. Age, gender, hypertension and obesity influence it. Normative values have been published for different populations. Methods: Population-based, cross-sectional, observational study in individuals aged 50-70 years, randomly selected from a primary care setting. Demographics and vascular risk factors were collected. All subjects underwent stand-ardized carotid ultrasound with automated IMT measurement. We present rates and compare individual IMT values to gender and age-matched reference values from French, Italian and Spanish popula-tions, reporting descriptives, chi-square and kappa statistics. Results: We included 220 individuals (median age 59 years, 58.2% female). Hypertension was found in 79.1%, 73.6% had dyslipidemia, 35.0% smoked and 15.9% had diabetes. Mean body mass index was 28.1kg/m2. Common carotid median IMT was 0.653mm. The median IMT corresponds to percentile (P)25 of healthy French subjects, with 28.6% subjects >=P50 and 13.6% >=P75. Although there’s increased chance of multiple risk factors with IMT >=P50, it’s not statistically signifi-cant (p=0.43). Almost all subjects fall on lowest strata when com-pared to Italians. Only 4.1% have median IMT >=P25, and no risk factor or number of risk factors predicted these cases. Comparison with Spanish data shows median IMT on P25, with 33.6% >=P50 and 14.1% >=P75. Hypertension associates with IMT >=P50 (p=0.023) but number of risk factors doesn’t (p=0.252). Correlation between age and gender-adjusted percentiles was excellent with French and Spanish populations (κ=0.908 and κ=0.904 respectively), but moder-ate with Italians (κ=0.646). Conclusion: Our subjects’ IMT was lower than healthy French and cardiovascular disease free Spanish individ-uals. Nonetheless good concordance exists in percentile distribution



despite differences in risk factors. It was very low compared with Italians with 0-1 risk factors, but different IMT protocols were used. IMT normal values may differ by country. Further studies are needed to define IMT reference values in Portugal.

P17

Carotid stenosis in combination with other factors in

the development of stroke

B. Živadinović

Dept. of cerebrovascular disease Clinic of Neurology Clinical Center Nis,Serbia

Introduction: Stenosis of carotid arteries represents one of the most significant risk factors in the development of stroke. In case other risk factors are present (arterial hypertension, hyperlipidem-ia, diabetes mellitus, atrial fibrillation, weak heart, coagulopathies ..) the finding of carotid stenosis significantly increases the risk of stroke. Aims: 1 To determine the frequency of carotid stenosis in patients with cerebral infarction . 2 .To determine increased risk of stroke in patients with carotid stenosis combined with more than 2 risk factors. Material and methods: The retrospective research was conducted for a period of one year. The research included pa-tients treated for stroke at the Clinic of Neurology Clinical Center Nis. The used data were obtained from anamnesis, Color Doppler findings, ultrasound of the neck blood vessels. Results and dis-cussion: The research included 562 patients diagnosed with is-chemic stroke. A certain degree of carotid stenosis was found in 77% of patients (x2=30.80, p<0.01). The patients who had more than two risk factors in addition to carotid stenosis, had stroke more often (61.29%), compared to patients who had stenosis com-bined with one risk factors and patients without stenosis and with one or more risk factors (x2=73.41, p<0.01). Conclusion: Carotid artery stanosis presents with statistically significant percentages in patients with stroke. Carotid stanosis in combination with other risk factors significantly increases the incidence of stroke.

P18

Characterization of carotid disease: carotid

ultrasound vs carotid angiography

J. Chin, A. Camacho, P. Guilherme, A. Silva, A. Neves, N. Tavares, J. Amado, S. Marto, V. Brandão, I. Jesus

Hospital de Faro – Serviço de Cardiologia, Faro – Portugal

Background: the diagnosis of carotid artery disease is as important in the prevention of cerebrovascular accident, as in the stratification of patients with high cardiovascular risk, with known atherosclerotic disease. The carotid angiography (CA) remains the gold standard for determining the degree of carotid stenosis, however carotid ultrasound (CU) is a widely used test. Purpose: was evaluated the performance of CU, in comparison

with CA, in the diagnosis and characterization of cervical carot-id pathology. Methods: 55 consecutive patients (P) were retro-spectively evaluated; the P underwent assessment of carotids by both techniques, with a time interval between scans ≤ 3 months. In determining the degree of stenosis of the internal carotid ar-tery (ICA), both by CA and CU, was used the NASCET crite-ria; The ICA degree of stenosis, was categorized in four groups (G): G1 <50%; G2- 50-69%, G3- 70-99% and G4- occlusion. Results- the mean age of P was 72.6 ± 8.1y; 55 P (78.2%) were men. Were described the risk factors and the associated pathology. Was evaluated 110 carotid axis. The distribution by G, according to the evaluation made by AC and CU, and the corresponding sensitivity and specificity of CU are: G1(75/64) (82,6% /94,2%); G2 (4/16) (100%/88,6%) ; G3 (24/24) 87,5%/96,5%); G4 (7/6) (85,7%/100%). In the analysis of discordant cases, there was a ten-dency to CU overestimate the degree of stenosis in the less severe cases. Conclusion: 1– in our department, there is a good sensitiv-ity and specificity of the CU comparing to CA, with similar values to those described in other studies, between 82 and 100%. 2– In less severe injuries (<50%) there was a lower sensitivity (82.6%) of the CU, suggesting, that is appropriate to introduce other criteria to determine the degree of stenosis, which can improve the diag-nostic accuracy of the test.

P19

Shear wave elastography vs. grey-scale median in the

assessment of carotid artery disease: A comparison

with histology

J. Garrard1, B. Kanber1, S. Nduwayo1, T. Hartshorne2, K. West3, D. Moore3, A. Naylor2, T. Robinson1 and K. Ramnarine4

1Department of Cardiovascular Sciences, University of Leicester, UK; 2Department of Vascular and Endovascular Surgery; 3Department of Histopathology and 4Department of Medical Physics, University Hospitals of Leicester NHS Trust, Leicester, UK

Improved methods of identifying the unstable carotid plaque are required, in addition to current classification based on the per-centage stenosis and clinical history. Grey-Scale Median (GSM) and Shear Wave Elastography (SWE) are two techniques which may be of value in determining plaque risk stratification. SWE, which quantifies the Young’s Modulus to estimate tissue stiffness, has been researched in liver, breast, thyroid and prostate, but its use in carotid plaques is novel. The aim of this study was to assess the feasibility and potential clinical value of these two ultrasound techniques for the assessment of carotid plaques, with comparison to histological findings in a subset population. Fifty patients (32 male) were re-cruited, mean age 76 (SD=10.5). Patients underwent both clinical greyscale imaging using a Philips iU22 scanner and SWE scanning using a SuperSonicImagine Aixplorer® ultrasound system. GSM was averaged over a cardiac cycle. Mean Young’s Modulus (YM) was quantified in a 2mm region within the plaque across 5 frames. Histological features of stability were assessed in 15 patients follow-ing carotid endarterectomy excision. Fifty nine plaques of >30% ste-nosis were assessed. Both the Young’s Modulus (p= 0.025) and the GSM (p=0.001) correlated with subjective plaque appearance using


the Gray-Weale classification. Mean YM was also significantly lower (p=0.038) in the symptomatic patients (65Pa; 95% CI: 52-77kPa) compared to asymptomatic patients (88kPa; 95% CI: 69-107kPa), whereas there was no significant difference with GSM. Plaques clas-sified unstable on histology had a lower YM than stable plaques (mean 67kPa vs. 83kPa). Mean GSM was similar (56 unstable vs. 59 stable). Although studies suggest low GSM is associated with symp-tomatic patients our study highlights the benefit of SWE compared to GSM as an indicator of plaque stability. Further work is required to demonstrate the potential clinical benefit of incorporating SWE estimates to help identify the unstable plaque.

P20

The ratio of the dominant hemisphere

neuropsychological assessment and indicators of

cerebral blood flow

E. Lysenko1, Y. Mikadze2,A. Shakhovich3, S. Abuzaid4

1Moscow State University, Faculty of Psychology, Moscow, Russia; 2Moscow State University, Faculty of Psychology, Moscow, Russia; 3Burdenko Institute of Neurosurgery, Moscow, Russia; 4Burdenko Institute of Neurosurgery, Moscow, Russia

Currently reliably functional asymmetry of left and right hemi-spheres of the brain is established. Therefore, during medical pro-cedures (including surgery) a clear understanding of hemispheric dominance for verbal and perceptual functions is required. Recently in connection with inquiries neurological and neurosurgical prac-tice the method of functional transracial Doppler (fTCD) is often involved for these purposes as an alternative way for traditionally used invasive methods (eх., WADA-test). The study involved 36 healthy subjects (24 women) aged 17 to 58 years. Subjects were presented seven types of verbal and perceptual cognitive tasks in the auditory and visual modalities. The results of investigation were compared with the velocity of blood flow at rest. They showed changes in blood flow velocity during the solution of cognitive tasks. Depending on the quality of the presented stimulus material of dif-ferent tendency of speed changing of blood flow in the arteries of the brain different hemispheres is observed.

P21

A novel cerebral flow monitor for detecting

autoregulation – animal study

M. Kamar1 , A. Nini2, I. Breskin1, A. Ron1, L. Barkan1, Z. Silman1, M. Balberg1

1Ornim Medical Ltd; 2Kaplan hospital, Tel Aviv University, Israel

Background: Patients at risk for neurologic injury from an-esthesia, cardiopulmonary bypass, sepsis, and even intraoperative head-up positioning require scrupulous monitoring and support of their arterial blood pressure (ABP). Cerebral hypoperfusion

develops when cerebral autoregulation fails in the face of a severe reduction in BP. We tested a novel Cerebral Blood Flow (CBF) monitor, CerOx 3215F, that measures CBF non-invasively using ultrasound-tagged NIR, for the ability to continuously measure CBF together with ABP and delineate autoregulation and its lower limits in a swine model. Methods: We studied 6 piglets (20kg). Animals were anesthetized using either propofol or Isoflurane. ABP was measured via arterial line introduced to the Carotid Artery (CA) or Femoral Artery (FA). CBF was monitored using the CerOx monitor (Ornim Medical, Lod, Israel) with the probe placed on the animals forehead lateral to the sagital sinus. BP was raised using IV phenylephrine upto a Mean Arterial Pressure (MAP) of 180mmgH or double the baseline MAP. BP was de-creased using incremental dosage of IV Nitropruside targeting MAP of 30mmgH. Results: 4 piglets were anesthetized using propofol, two using isoflurane and two were anesthetized using both interchangeably. MAP was increased upto 180 ±20 mmHg and decreased to 30±10 mmHg. In 4 out of the six animals which were anesthetized using propofol autoregulation was detectable with a lower limit of 80±10mmHg. Conclusions: The CerOx flow monitoring device together with a continuous BP input may be a helpful tool in outlining autoregulation, its reactivity and bounda-ries. This may come as a handy tool for clinical practice for indi-vidualized management of BP in clinical settings where cerebral autoregulation and cerebral perfusion may be compromise.

P22

Cerebral autoregulation assessment in basilar artery

stenosis

X. Gong1, P. Dong1, P. Zhang2, X. Zhao1, Y. Wang1

1 Department of Neurology, Beijing Tiantan Hospital, affiliated to Capital Medical University, Beijing, China; 2 Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China

Background and Purpose: Previous studies showed cerebral autoregulation (CA) impaired in patients with Carotid and mid-dle cerebral artery stenosis/occlusion. Little information is known about CA in posterior circulation. We investigated CA within the posterior cerebral artery (PCA) in patients with Basilar artery (BAS) stenosis (>50%) identified by transcranial doppler using cross-spectrum analysis. Methods: We measured spontaneous oscillations of blood flow velocity (CBFV) in right PCA and left MCA and mean arterial pressure (ABP) continuously in 25 basi-lar artery stenosis patients (52 11 years) and 22 healthy volunteers (50±9 years) in supine position during 6cpm deep breath. Analysis was based on the “high-pass filter” model using phase shift an-gles and transfer function gains in both PCA and MCA. Results: Phase shift angles and transfer function gains between CBFV and ABP oscillations in MCA and PCA were similar in BAS moder-ate stenosis (50-69%) and healthy subjects. Phase shift angles in PCA were significant decreased in severe stenosis (≥70%) group compared to healthy (6.5±6.20 Vs 35.1±24.60, P<0.05). Poor phase shift angle values were observed in stroke patients with mRs>2 scores. Conclusion: Dynamic cerebral autoregulation in PCA



may be impaired in patients with severe BAS stenosis (≥70%) and in stroke patients who presented poor outcome (mRs>2 scores). Moderate stenosis seemed without negative impact on CA. The study was funded by Beijing Municipal Science & Technology Commission (No. D111107003111007)

P23

Cerebral perfusion pressure noninvasively in severe

head injury.

M.J. Dominguez1, A. Sanchez2

1ntensive care unit, Port Royal Hospital, and 2Intensive care unit, Sea Gate Hospital, Cadiz, Spain

Objetives: To determine the values of cerebral flow veloci-ties by transcranial Doppler (TCD), and to estimate cerebral per-fusion pressure (CHP) in patients with traumatic brain injury (TBI) severe, depending on the type of lesion on CT (TCDB) clas-sification). Methods: Prospective study of 43 patients admitted to the ICU for severe TBI (GCS ≤8). To sedation and VM. Stable, with invasive monitoring of BP, and intracranial pressure (ICP). Collection by DTC (p multidop DWL) and probe 2 mHz, through the transtemporal window, in the first 24 hours of admission: Average values of mean velocity (Vm) and diastolic (Vd) flow in both middle cerebral arteries (MCAs ). Estimation of the CFP by Czosnyka formula on both sides (CFP = TAM x Vd / Vm + 14). J Neurosurg 88:802-8, 1988. Statistical analysis: Comparison of means for independent samples and Pearson correlation coefficient. Results: Of the 43 patients 39 (90.69%) men, mean age 36.88 years (14-72). Mechanisms TEC: motorcycle accident 30% and pre-cipitation 30%. TAC Injuries: LED-I: 0 LED-II: 19 (44.1%) LED-III: 6 (13.9%) LED-IV: 3(6.9%) LOE-E: 10 (23 , 2%) LOE-NE: 5 (11.6%) Total 86 records of DTC made. LED-II: Vm (cm / s)-D-ACM ACM-I 65.63 66.42 and Vd (cm / s):D-ACM ACM-I 47.42 48.16. CFP: ACM-D 78.63 mmHg and 78.37 ACM-I LED-III: Vm: ACM-D 57.17 51.67 MCA-I and Vd: ACM-I ACM-D 39.67- 37. CFP: ACM 71 and ACM-D-I 76.5 LED-IV: Vm: ACM ACM-D 52-I and Vd 65.33: 34.67 ACM ACM-D-I 42. CFP: ACM 79 and ACM-D-I 76.67.LOE-E: Vm ACM ACM-D-I 72.67 65.5 and 44.6 Vd ACM ACM-D-I 47.89. CFP: ACM ACM-D-I 73.4 and 71.89. LOE-NE: Vm: ACM ACM-D 66-I 69.2 and Vd: ACM ACM-D 45-I 48.8. CFP: ACM 82 and ACM-D-I 84.6. Conclusions: No sta-tistically significant differences between the values of DTC in the first 24 hours of admission, according to the type of lesion on CT. The estimate of the CFP DTC is very reliable in the management of patients with severe head injury, with a Pearson coefficient above 0.8.

P24

Cerebrovascular reactivity to L-arginine in ischemic

leukoaraiosis

B. Žvan, M. Zupan , M. Zaletel, J. Pretnar- Oblak

Department of vascular Neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia

Background: The pathophysiology of ischemic leukoaraiosis (LA) is not fully understood. Thus, it is possible that cerebral en-dothelial dysfunction may play the essential role. To the best of our knowledge there are at present no published studies employing cer-ebrovascular reactivity to L-arginine (CVR-L-arg) to evaluate cer-ebral endothelial function in LA. Methods: To evaluate cerebral endothelial function in subjects with LA (group LA1) we examined CVR-L-arg and compared it to subjects with comparable risk factors without LA (LA0). Twenty-seven subjects with LA (57.6 ± 7.2 years) and 19 subjects with similar risk factors without LA (56.3 ± 5.5 years) were included. The mean arterial velocity in the middle cerebral ar-tery (vm) was measured by transcranial Doppler sonography before and after intravenous infusion of L-arginine, and CVR-L-arg was then calculated. Results: The vm at rest did not differ significantly between the groups (55.5 ± 14.8 cm/s vs. 61.6 ± 8.6 cm/s; p=0.144) but the vm after stimulation differed significantly (61.6 ± 17.4 cm/s vs. 70.0 ± 2.4 cm/s; p=0.040). In either group, the vm at rest and the vm after stimulation differed significantly (either group; p<0.001). Other parameters with an important influence on vm did not differ significantly between the groups: CVR-L-arg was significantly lower in subjects with LA compared to controls (10.7 ± 4.5 % vs. 14.0 ± 4.5 %, p=0.023). Regression analysis taking into account independ-ent parameters (LA, smoking, arterial hypertension, creatinine level and HDL) and the dependent parameter CVR-L-arg showed only an important influence of LA and additionally creatinine level on CVR-L-arg (p<0.05). Conclusions: Lower CVR-L-arg in subjects with LA compared to controls with comparable risk factors without LA reflects additional cerebral endothelial dysfunction in LA. This could possibly contribute to cerebral endothelial dysfunction being one of important aspects of pathophysiology of LA.

P25

Continuous monitoring of vertebrobasilar

hemodynamics utilizing TCDS transducer holder

Sonopod during postural changes

T. Shiogai1, M. Yamamoto1, Y. Arima1, D. Yamasaka2, K. Yoshikawa3, T. Mizuno4, M. Nakagawa4

Departments of 1Clinical Neurosciences and 2Radiology, Kyoto Takeda Hospital, Kyoto; 3Department of Stroke Medicine, Hoshigaoka Kouseinenkin Hospital, Osaka; 4Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan

Objective: To clarify the significance of continuous monitor-ing in the vertebrobasilar artery (VBA), utilizing the transducer holder Sonopod for transcranial color duplex sonography (TCDS),


vertebrobasilar hemodynamics and autoregulation were evaluated during postural changes. Methods: Subjects were five control adults (mean age 35) and six patients (mean age 66); two hyper-tension, two dizziness (hepatic cirrhosis and unknown origin), one lacunar infarction (LI) with diabetes mellitus, and one spi-no-cerebellar degeneration (SCD). TCDS with the Sonopod was monitored continuously in the intracranial VA or BA. Blood pres-sure (BP), heart and respiration rates, and oxyhemoglobin satura-tion were also monitored. During two series of postural changes (supine or sitting to/from standing), a) clinical symptoms, b) BP: systolic, mean, and diastolic pressures (SBP, MBP, and DBP), c) TCDS: Time-averaged maximum velocity (Vmax) and Pulsatility Index (PI), Estimated Cerebrovascular Resistance (eCVR) = MBP/Vmax, and Autoregulation Index (ARI) = (ΔeCVR/ΔMBP) were evaluated. Results: a) Symptoms: Dizziness resulted in an inability to remain standing in two (LI and SCD) patients. b) BP changes: 1) DBP>10mmHg in all cases. 2) SBP>20mmHg in 2 control subjects and all but one patient (CI), however hypotension during standing only in 1 SCD patient. c) TCDS: Tendencies of decreased eCVR/ARI and increased PI were observed in all patients. Conclusion: Continuous TCDS monitoring of vertebrobasilar hemodynamics utilizing the Sonopod during postural changes is useful for evalu-ating cerebral autoregulation in orthostatic dysregulation.

P26

Dynamic cerebral autoregulation changes during sub-maximal handgrip maneuver

R.C. Nogueira1, E. Bor-Seng-Shu2, M.R. Santos3, C.E. Negrão3, M.J. Teixeira2 and R. Panerai4,5

1Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 3Heart Institute (InCor), University of São Paulo Medical School, São Paulo; School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil; 4 Medical Physics Group, Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, England, LE1 5WW; 5 Biomedical Research Unit in Cardiovascular Science, Glenfield Hospital, Leicester, LE3 9QP

Purpose: we investigated the effect of handgrip (HG) maneu-ver on time-varying estimates of dynamic cerebral autoregulation (CA) using the autoregressive moving average (ARMA) technique. Methods: twelve healthy subjects were recruited to perform HG maneuver during 3 minutes with 30% of maximum contrac-tion force. Cerebral blood flow velocity, end-tidal CO2 pressure (PETCO2), and noninvasive arterial blood pressure (ABP) were continuously recorded during baseline, HG and recovery. Critical closing pressure (CrCP), resistance area-product (RAP), and time-varying autoregulation index (ARI) were obtained. Results: PETCO2 did not show significant changes during HG maneuver. Whilst ABP increased continuously during the maneuver, to reach 27% of its baseline value, CBFV raised to a plateau approximately 15% above baseline. This was sustained by a parallel increase in RAP, suggestive of myogenic vasoconstriction, and a reduction in

CrCP that could be associated with metabolic vasodilation. The time-varying ARI index dropped at the beginning and end of the maneuver (p<0.005), which could be related to corresponding alert reactions or to different time constants of the myogenic, met-abolic and/or neurogenic mechanisms. Conclusion: changes in dynamic CA during HG suggest a complex interplay of regulatory mechanisms during static exercise that should be considered when assessing the determinants of cerebral blood flow and metabolism

P27

Ultrasonographic study in Chronic migraine and relationship with endothelial damage biomarkers

V. González Quintanilla1, A. Rojo López1, A. González Suarez1, M. Toriello1, S. Gutiérrez González1, R. Viadero1, J. Fernández Fernández1, EJ. Palacio1, M. Rebollo1, J. Castillo2, A. Oterino1.1Service of Neurology. Hospital Universitario Marqués de Valdecilla, Santander, Spain; 2Centro Salud Camargo Costa, Camargo, Spain

Objects: Migraine has been considered a vascular risk factor. Although the intrinsic mechanism has not yet been fully elucidated, changes in vascular reactivity and endothelial disturbance are poten-tial pathways for vascular damage. We have studied the vascular risk in chronic migraine patients through the study of the cerebral vaso-motor reactivity by transcraneal Doppler and measuring the number of late endothelial precursor circulating cells (EPCs) as a surrogate marker of endothelial damage. Material and methods: Consecutive 36 patients with chronic migraine, having more than 15 days/month of headache being at least 8 of migraine type for at least 3 months, (30 women and 21 with aura) and 14 controls were recruited in outpa-tient clinic. We identified the “late” EPC those CD34+/KDR+/CD62+ (e-selectine +) in peripherical blood. At the same hour, all subjects underwent examination of flow velocity in the middle cerebral arter-ies using transcraneal Doppler by a blind explorer. The peak systolic velocity (PSV), the mean flow velocity (MFV) and pulsatile indices (PI) were studied in both middle cerebral arteries. The cerebral vaso-motor reactivity was assessed in all subjects by calculating the Breath Holding Index (BHI). Results: The BHI was higher in patients with chronic migraine (0,997) than in controls (1,496, p=0,019). The dif-ference remains after the correction including the age and the body mass index. (p=0,03). The number of late EPC showed an inverse re-lationship with BHI (r=-0,298, p=0,065). Conclusions: Patients with chronic migraine showed lower BHI than controls. The number of late EPC (e-selectine +) was higher in the subjects with lower BHI. This suggests the existence of endothelial persistence activation



P28

Usefulness of ultrasonology for monitoring the

posterior reversible encephalopathy syndrome

P. Lochner1, C. Mader1, R. Nardone1,F. Tezzon1, F. Brig12, G. Malferrari3, M. L. Zedde3

1Department of Neurology, General Hospital of Merano, Merano, Italy; 2Department of Neurological, Neuropsychological, Morphological and Movement Sciences.Section of Clinical Neurology, University of Verona, Italy; 3Neurology Department, Arcispedale S. Maria Nuova, Reggio Emilia, Italy

Objectives: To determine the value of ultrasound assessments in the diagnosis and follow-up of posterior reversible encephalopa-thy syndrome (PRES). Methods: Serial transorbital ultrasound as-sessments measuring the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE), as well as transcranial color-coded so-nography (TCCS) with evaluation of neurovascular coupling were performed in a 55 years-old woman with PRES both in the acute and follow-up stage. Results: In the acute stage, US showed a sig-nificantly enlarged ONSD (0,61cm) and an increased ODE (0,16 cm) associated with significantly high velocities of all the cerebral intracranial arteries. In the follow-up a normalization of MRI ab-normalities occurred, in concomitant with a decrease of ONSD to normal values (0,46 cm). A normalization of the velocities of the intracerebral arteries and of the vascular coupling occurred later, and ODE values required longer to normalize. Conclusion: Besides the typical MRI findings, the ultrasound studies proved to be use-ful to monitor the evolution of PRES. Ultrasound assessments may provide new insights in the pathophysiology of PRES.

P29

The correlation between attention, movement

coordination, cerebral hemodynamics and ethanol

concentration on healthy persons

M. Orosz1, K.R. Kovacs1, G. Hofgart1, L. Kardos2, L. Csiba1

1Department of Neurology, University of Debrecen Medical and Health Science Center, Debrecen, Hungary; 2Contract Medical Statistician, Kenézy Hospital, Debrecen, Hungary

Objectives and Aims: Previously the effects of ethanol on co-ordination and cerebral hemodynamic parameters were studied in detail. The present study aimed at testing the correlation be-tween attention, movement coordination, cerebral hemodynamics and ethanol concentration using The correlation between atten-tion, movement coordination, cerebral hemodynamics and etha-nol concentration and transcranial Doppler. Methods: 21 young healthy medical students (10 female and 11 male), between 21 and 26 years were included in the study. We examined the reaction time, coordination and cerebral hemodynamic parameters before and after ethanol consumption. Ethanol dose was calculated per kilogram of body weight. Blood samples for serum ethanol level were collected twice: after one hour of alcohol intake and at the

end of the examinations. The correlation between attention, movement coordination, cerebral hemodynamics was tested us-ing a reaction time meter and a touch screen game while coordi-nation by different clinical tests. We also used our self-developed movement measuring device. Cerebral and cardiac hemodynam-ic parameters were tested continuously, non-invasively and si-multaneously during head-up tilt table testing (HUTT). Results: After alcohol intake the reaction time significantly increased (0.431 ± 0.060 vs. 0.473 ± 0.058 seconds for choice reaction time before and after alcohol consumption, P:0.0002; 0.468 ± 0.051 vs. 0.529 ± 0.056 seconds for selective reaction time before and af-ter alcohol consumption, P<0.0001). Our movement data showed significantly greater scores in the coordination probe (1258.847 ± 582.951 vs. 1549.966 ± 667.054 for walking with raised up hands before and after alcohol consumption, P:0.0187), and significantly lower scores in the touch screen probe (3575.108 ± 1110.256 vs. 2888.707 ± 764.448 for before and after alcohol intake, P = 0.0045). After alcohol consumption during HUTT the heart rate values were significantly higher after tilt up (84.819 ± 8.678 vs. 89.714 ± 9.519, P:0.0012). Conclusion: Reaction time and coordination were altered after alcohol consumption. Ethanol induced changes of the reaction time and coordination were sensitively detected by our movement monitoring system.

P30

Clinical assessment of innovative intracranial

pressure and volume wave monitoring system

A. Ragauskas1, V. Petkus1, R. Chomskis1, R. Ferenets2, P. K. Eide3, A. G. Sorteberg3

1Kaunas University of Technology, Telematics Science Laboratory, Kaunas, Lithuania; 2Pera Technology, Tallinn, Estonia; 3Oslo University Hospital, Department of Neurosurgery, Oslo, Norway

Background: The research is performed as a part of EC FP7 DynICP project. The aim of the project is to develop an advanced prototype of a non-invasive intracranial dynamic pressure diag-nosing and monitoring device that would monitor the dynamic rather than static intracranial pressure (ICP). Methods: The estimation of brain compliance is possible by using a ultrasonic non-invasive time-of-flight (TOF) measurement technology. This innovative TOF technology is based on the ultrasonic measure-ment of the cerebral blood volume pulsation within brain paren-chyma. Non-invasively recorded TOF waves reflect the dynamics of intracranial blood volume and together with arterial blood pressure (ABP) pulse waves can be used to estimate brain com-pliance. Results: Intracranial pulse waves have been monitored in 7 patients at different pathological conditions by using invasive ICP, ABP and non-invasive TOF pulse wave monitoring technolo-gies. Recorded ICP, ABP and TOF pulse waves were processed and used to create a mathematical model allowing diagnosing of an intracraniospinal compliance changes . All waves were nor-malized in order to exclude the influence of heart rate variability and pulse waves’ amplitude changes. Conclusions: The presented model and preliminary study showed that the waveform of ICP pulse waves can be estimated by using ABP and non-invasively


measured TOF pulse waves. The differences between modelled in-tracranial waves and invasively measured ICP pulse waves is not exceeding a few percents. It is showed that the shape and area un-der curve of normalized TOF pulse waves reflect intracraniospinal compliance. Acknowledgements: The research has been funded by the European Commission’s FP7 R4SME Programme under the Grant Agreement No. 286610.

P31

Innovative method of cerebrovascular

autoregulation monitoring without ABP

V. Petkus1, A. Ragauskas1, A. Preiksaitis2, S. Rocka2, R. Chomskis1, L. Bartusis1

1 Kaunas University of Technology, Telematics ScienceLaboratory, Kaunas, Lithuania; 2 Vilnius University faculty of Medicine, Clinics of Neurology and Neurosurgery, Centre of Neuroangiosurgery, Vilnius, Lithuania

Background: The innovative method of real - time cerebrovas-cular autoregulation (CA) index monitoring without the arterial blood pressure (ABP) measurement line is presented. All necessary information about the CA status can be obtained by processing the intracranial waves only. It is not necessary to use the ABP line as a source of reference signal for CA estimation. Method: The present-ed method of CA estimation is based on the intracranial pressure wave measurements (slow, respiratory and pulse waves), extraction of informative and reference slow and respiratory intracranial waves and calculation of the pressure-reactivity index vPRx without using any additional ABP measurements. The reference slow and respira-tory waves are extracted from the demodulated intracranial pulse waves and used instead of ABP waves for real-time estimation of the CA status. Results: 6 traumatic brain injury patients were moni-tored with invasive ICP and ABP monitors. The measurement data were analyzed by exploring peculiarities of the novel CA estimation method. It is demonstrated that both slow and respiratory intrac-ranial waves with different weighting factors can be used for cal-culation of CA indexes depending on the amplitude and frequency of corresponding waves. The comparison of the CA status indexes calculated by using a novel methodology of ICP waves analysis and the PRx indexes calculated from the invasively measured ICP and ABP slow waves (ICM+) showed high coincidence between both methods in cases when TBI patient is mechanically ventilated (r = 0.73) and when ventilator is not needed (r=0.69). Conclusion: The proposed innovative CA real-time monitoring method without ABP line provides possibility to estimate the CA status from ICP waves only as well as to exclude ABP line’s errors and artifacts from vPRx monitoring results. Acknowledgements: This research has been funded by a grant MIP-118/2012 from the Research Council of Lithuania.

P32

Computer simulation of the cardiovascular system

A. Santos2, L. Sousa1, J. Tavares1, R. Santos2, P. Castro2, E. Azevedo2

1 Faculty of Engineering, University of Porto/ 2 Faculty of Medicine, University of Porto, São João Hospital Center / Porto, Portugal

Introduction: Disturbed flow conditions at the bifurcation of common carotid artery (CCA) plays an important role in the development of local atherosclerotic plaques, which may lead to stroke occurrence. As 3D models, built based on ultrasound imag-ing, can improve diagnostic assessment and support revasculariza-tion interventions, our aim was to develop a carotid segmentation algorithm that can detect CCA bifurcation contours used to build such 3D models. Methods: The algorithm is based on the hi-poechogenic characteristics of the lumen and the echogenic char-acteristics of the carotid bifurcation wall for the identification of their boundaries. Firstly, an ultrasound image in B-mode is ob-tained from a carotid bifurcation. Then the sonographer defines two initial contours in the image, one corresponding to the lumen and another to the bifurcation wall, for posterior application of the Chan-Vese level set model. This method provides the automatic segmentation of the arterial lumen and bifurcation boundaries of the carotid artery in longitudinal ultrasound images. The main ad-vantage of our method relies on the identification of the carotid lumen based on its hipoechogenic characteristics, overcoming the limitations of the usual methods with human intervention. Finally, a comparison is done between the contours obtained manually and automatically. Results: The results obtained, with a mean val-ue of area overlapped equal to 96.78%, and a maximum distance between the non-coincident points of the contours automatically and manually defined, of 9.85 pixels, confirm the good quality of our method. Regarding the distances between the non-coincident points of automatically and manually obtained contours, the over-all error is very low (maximum value equal to 1.42 pixels), proving that the contours resultant by the automatic segmentation are sim-ilar to the ones manually defined by the expert. Conclusion: Our method of segmentation has proven to be highly efficient, allowing an accurate computer simulation image of carotid bifurcation.

P33

Monitoring changes in cerebral blood flow using

ultrasound tagged near infrared spectroscopy – A

comparative study to 133Xe SPECT

H. W. Schytza, S. Guoa, L. T. Jensenb, M. Kamarc, A. Ninic, D. R. Gressd, M. Ashinaa

a Danish Headache Center and Departments of a Neurology & bClinical Physiology and Nuclear Medicine, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, Denmark; cOrnim medical Ltd, Israel. dDepartment of Neurology and Neurosurgery, University of Virginia, USA



Introduction: There is a need for real-time non-invasive, con-tinuous monitoring of cerebral blood flow (CBF) during surgery, in intensive care units and clinical research. We investigated a new non-invasive hybrid technology employing ultrasound tagged near infrared spectroscopy (UT-NIRS) that may estimate chang-es in CBF using a cerebral blood flow index (CFI). Methods: Changes over time for UT-NIRS CFI and 133Xenon single photon emission computer tomography (133XE-SPECT) CBF data were assessed in 10 healthy volunteers after an intravenous bolus of acetazolamide. UT-NIRS CFI was measured continuously and SPECT CBF was measured at baseline, 15 and 60 min after aceta-zolamide. Results: We found significant changes over time in CFI by UT-NIRS and CBF by SPECT after acetazolamide (P ≤ 0.001). Post-hoc tests showed a significant increase in CFI (P = 0.011) and SPECT CBF (P < 0.001) at 15 min after acetazolamide injection. There was a significant correlation between CFI and SPECT CBF values (r = 0.67 & P < 0.033) at 15 min. CFI, SPECT CBF values remained unchanged from 15 minutes to 60 min. No correlation in the mean change between the two modalities was observed at 60 min from baseline. Conclusion: UT-NIRS detected an increase in CFI following an acetazolamide bolus, which correlated with CBF measured with 133Xe-SPECT. The present study demonstrates that UT-NIRS technology may be a promising new technique for non-invasive and real-time bedside CBF monitoring.

P34

Web system for medical history management and

advanced data analysis

N. Barreira1, S. G. Vázquez1, C. Ferreira2, E. Azevedo2, J. Rouco3, R. Rocha3, A. Campilho3

1 VARPA, Dep.de Computación, Universidade da Coruña, A Coruña, Spain; 2 Dep. de Neurologia, Hospital São João, Porto, Portugal; 3 Instituto de Engenharía Biomédica – INEB, Porto, Portugal

Introduction: Computerized tools for data acquisition and management are widely used in health care services around the world. Patient details, laboratory test results or different image modalities are continually stored and retrieved for making a di-agnosis. Advances in computer science can be part of these tools in order to improve the diagnosis process, by embedding signal and image processing techniques to extract information in a fast and objective manner, or by including data mining techniques and statistical analyses to extract relevant information from the huge amounts of data acquired from different sources. Methods: We present a web application that provides an user-friendly medical history management system as well as several tools for automatic data analysis focused on vascular research. The system includes a semi-automatic procedure for the Intima-Media Thickness (IMT) measurement from B-mode ultrasonographies of the com-mon carotid artery. In addition, an automatic algorithm for the Arterio-Venous Ratio (AVR) computation from retinographies is included. The system is also able to analyze holter recordings and perform signal analysis. The information extracted is stored in the patient’s medical records in a centralized database server. The web

application is accessed by authorized users over a network, such as Internet or the Hospital’s intranet. Users only require a web brows-er to interact with the tools so no extra software is needed. Results: The proposed system is being used for research purposes in sev-eral units of Hospitals from Portugal and Spain. We had acquired clinical data from several patients and automatically measured IMT and AVR. Discussion: We propose a framework for com-puter-aided diagnosis focused on vascular research that integrates several tools for signal and image processing. The application is easily accessible and efficient, reducing the time requirements and efforts of the clinician, enabling collaborative work, and simplify-ing screening procedures as well as research activities

P35

Computational simulation of the movement of solids

and gasses in the cerebral arteries.

D. Marshall1, E. Chung1, J. Hague2, M. Horsfield1

1Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 2Department of Physics and Astronomy, Open University

Computational fluid simulations are an important research tool for haemodynamic investigations, but most methods have difficulty simulating the movement of solids and gasses in the flow, such as emboli, thrombus and bubbles, or the stretching of vessel walls. A technique which is largely used in astrophysics, but also in engineering and special effects, is smoothed-parti-cle hydrodynamics (SPH). This mesh-free Lagrangian method simulates flow using a large number of “virtual” particles, which makes it simple to include solids and gasses by adding particles with different properties. The technique is computationally in-tensive so generally simulations must be run on large computing clusters; however, recent advances in graphics chips mean that simulations can now be run on desktop computers. The benefits of SPH become clear when attempting to simulate conditions such as stroke and carotid artery disease which can involve the complex interactions between blood and, e.g., carotid plaques, emboli, bubbles. Particle trajectory within and the effect of ob-struction on cerebral blood flow is particularly interesting due to anatomical variation within the population. Simulation param-eters obtained using 3d models constructed using MR angiog-raphy and TCD monitoring of flows and embolic signals during surgery can be used to define the simulation, validate the model and perhaps even assess risk during procedures involving the re-lease of solids and gasses into the blood. This research involves the simulation of solids and bubbles within blood flow and ap-plying it to patient anatomy to hopefully reveal how the behav-iour may cause adverse effects and provide insight into how to combat these problems. The model will be validated using in-vivo measurements and anatomical replicas. The in-vivo data will come from research currently ongoing to assess neurocogni-tive decline during cardiac surgery in 100 patients using, among other methods, MRI and TCD monitoring of embolic signals.


P36

Carotid artery bifurcation modelling from patient CT

angiography and ultrasound technics

A. Santos1, J. Tavares2, L. Sousa2, C. Castro2, C. António2, R. Santos1, P. Castro1, E. Azevedo1

1 Faculty of Medicine, University of Porto, São João Hospital Center; 2 Faculty of Engineering, University of Porto/ Porto, Portugal

Background: Blood flow simulation of the common carotid artery bifurcation is an undergoing research project with topog-raphy based on CT angiography and velocity information given by ultrasound techniques. Methods: The segmentation algorithm is based on the echogenic characteristics of the left and right ca-rotid arteries for the identification of their boundaries, through all the slices acquired from a CT angiography. Initially, it requires the definition of two centroids, defining the region of the common ca-rotid artery (CCA). Through the application of morphological and segmentation operators, the structural information of the bound-ary walls of the CCA is saved and the algorithm proceeds with the calculation of two new centroids, based on the information resultant from the segmentation. The calculated centroids will be used in the definition of a new region in the next slice, proceed-ing with the same calculations for the posterior segmentation. In the separation of the CCA into the internal and external arteries (ICA and ECA), the algorithm calculates the centroids for each feature, resulting in a total of four centroids that will be used in the posterior slice. The calculations proceed till the last slice of the acquisition. Results: All the contours from each slice were saved and represented in a volume, obtaining a correct delineation of the bifurcation for both left and right carotid arteries in a total of 63 slices. Finally, the surface of the model of both left and right carotid arteries are built, by creating a Delaunay triangulation for all possible set of points considering from successive slices. After the meshing of the created volumes blood flow simulation is per-formed using a developed finite element code. Conclusion: The segmentation algorithm has proven to be highly efficient allowing an accurate topography necessary for the correct interpretation of the simulated carotid artery bifurcation hemodynamics.

P37

Carotid flow predictions based on artificial neural

network and Doppler signal

C. António1, C. Castro1, L. Sousa1, R. Santos2, P. Castro2, E. Azevedo2 1Mechanical Engineering Department of Faculty of Engineering and Institute of Mechanical Engineering, University of Porto, Portugal; 2Neurology Department, Faculty of Medicine and São João Hospital Center, University of Porto, Portugal

Background: Doppler ultrasound is widely used in the diag-nosis and monitoring of arterial diseases. A number of parameters related to blood flow may be extracted providing estimates of time-varying artery flows. The ability of an artificial neural network

(ANN) to accurately differentiate flow profiles has been addressed. Methods: A model based on ANN, Doppler signal and Finite Element Method (FEM) is developed aiming to investigate carotid arterial conditions. To achieve a good representation of the carotid flow behavior, six selected locations at the common carotid (CCA), internal (ICA) and external carotid (ECA) arteries are considered for Doppler flow measurements. Using supervised learning based on evolutionary search, the ANN can learn the mapping from one data space to another. The input data is defined by a set of position and time values and the corresponding output data contains the blood flow information collected with Doppler ultrasound signal. The ANN nonlinear behavior enables the analysis of blood flow at the carotid bifurcation. Results: The ANN with optimal configu-ration manages to simulate a bi-dimensional model of the carotid artery hemodynamics. The proposed model is validated compar-ing ANN results with experimental ones from Doppler measure-ments. Along the central axes of the carotid arteries similar flow velocity behavior is obtained with the ANN approach and Doppler observations. At ICA, the ANN manages to simulate high gradi-ents of blood flow velocity and the FEM results confirm a strongly skewed axial velocity in the carotid sinus. Conclusion: Doppler measurements of blood flow velocities are used as input values for ANN development based on supervised learning. The ANN is cross validated and tested with carotid arterial Doppler signal and FEM analysis. The use of ANN model for carotid arterial research has the potential to identify subtle changes induced by the onset of arterial stenosis or occlusion diseases.

P38

Hemodynamics in human carotid bifurcation based

on Doppler

L. Sousa*1,2, C. Castro1,2, C. António1,2, F. Sousa2, R. Santos3, P. Castro3, E. Azevedo3

1Dept. of Mechanical Engineering, Faculty of Engineering; 2Institute of Mechanical Engineering (IDMEC), 3Dept. Neurology, Hospital São João and Faculty of Medicine of University of Porto, Portugal

Background: Atherosclerotic lesions commonly develop at ar-terial branch sites. Disturbed flow conditions at the bifurcation of common carotid artery and proximal internal carotid artery play an important role in the development of local plaques. Non-invasive carotid artery ultrasound is a well-established and valid method which allows real-time images and measurements of flow velocities. A methodology for patient-specific computational 3D reconstruc-tion, structured meshing of the common carotid artery bifurca-tion and blood flow simulation based on ultrasound techniques is an undergoing research project. Methods: The acquisition of a set of longitudinal and sequential transverse Doppler images and velocity measurements at carotid artery bifurcation was performed at Hospital de São João, a university hospital in Oporto, Portugal. Computational 3D reconstruction and structured hexahedral meshing of the common carotid artery bifurcation together with finite element simulations of blood flow were used to investigate inter-individual variations in flow dynamics at the carotid artery



bifurcation. Subject-specific data were based on Doppler ultrasound images of structural anatomy and flow velocities at the common, in-ternal and external carotid arteries. Results: In order to validate the model systolic values given by Doppler ultrasound at six different locations were compared with obtained numerical velocities for six volunteers, showing good agreement with differences less than 10% at all positions. Comparing the hemodynamics of the stenosed ca-rotid artery bifurcations of five individuals with a case of a volunteer presenting no visible atherosclerotic plaque confirms the existence of significantly different biomechanical environments. Conclusion: Using patient-specific carotid artery bifurcation data collected in hospital practice we were able to demonstrate several complex flow features near stenosed regions associated with vessel geometry. This computational model will be important to help to understand the role of carotid biomechanics on plaque vulnerability.

P39

Assessment of the unstable carotid plaque using 3T

MRI

K. Skagen1, M. Skjelland1, H. Scott2, P. K. Hol3, D. Russell1

1Department of Neurology, Oslo University Hospital, Rikshospitalet, Norway; 2Department of Pathology, Oslo University Hospital, Rikshospitalet, Norway; 3The Interventional Centre, Oslo University Hospital, Rikshospitalet, Norway

Introduction: A significant proportion of strokes are throm-bo-embolic in nature, arising from atherosclerotic plaques at the carotid bifurcation. Such strokes are effectively preventable by carotid endarterectomy or carotid stenting. In current clinical practice patient selection for revascularization primarily involves identification of the severity of luminal stenosis, measured using conventional imaging modalities such as Doppler ultrasound and/or MR or CT angiography. It is, however; increasingly clear that the degree of luminal stenosis alone may not be best predictor of risk. There is therefore increasing interest in developing imaging modal-ities to identify morphological features (thin/ruptured fibrous cap, large necrotic core, intraplaque hemorrhage), which are thought to be associated with increased risk. Aim/Methods: The aim of this study is to assess whether carotid MRI can identify vulnerable carotid plaques. 25 consecutive patients with symptomatic high-grade carotid artery stenosis scheduled for carotid endarterectomy are included. Patients with a history of transient ischemic attack or minor stroke due to carotid artery disease within 90 days of carotid endarterectomy are considered symptomatic. All patients under-went a neurological examination, Doppler ultrasound, 3 T MRI with dedicated carotid coils and blood tests before endarterectomy. Level of agreement between MRI findings and histological catego-rization of plaque is being assessed. Conclusion: MR imaging of carotid plaques may allow an earlier and more specific diagnosis of unstable carotid plaques and consequently has the potential to aid in clinical decision -making when selecting patients for carotid endarterectomy. This is important because there are several groups in clinical practice, e.g. patients with symptomatic moderate or asymptomatic severe stenosis, for which decision-making based on stenosis severity alone is not optimal.

P40

Double inversion recovery imaging of cortical

damage in intracranial atherosclerosis

F. Farina, A. Palmieri A, M. Atzori, F. Viaro, M. Calabrese, P. Gallo, G. Meneghetti, C. Baracchini

Department of Neuroscience, University of Padua School of Medicine, Padua - Italy

Introduction: Intracranial atherosclerosis is an uncommon finding in European patients with cerebrovascular diseases, and the direct influence of hemodynamical changes in the develop-ment of cortical damage is only partially depicted by standard resonance sequences such as diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR). Double inver-sion recovery (DIR) is a Magnetic Resonance Imaging (MRI) technique used to demonstrate the cortical changes occurring in neurological conditions such as Multiple Sclerosis. The aim of this study was to analyse the presence and the extent of cortical damage in patients with symptomatic and asymptomatic intrac-ranial large artery atherosclerotic stenosis by applying MRI DIR sequences. Materials and Methods: We enrolled twelve consec-utive symptomatic patients with a first-ever stroke admitted to our Stroke Unit (8 males, 4 females) and ten asymptomatic patients referred to our Neurosonology Laboratory (6 males, 4 females) with a hemodynamically significant (>50%) atherosclerotic in-tracranial stenosis diagnosed by intracranial ultrasound and con-firmed by Magnetic Resonance Angiography/CT Angiography/Digital Subtraction Angiography. After three months the patients were re-examined with intracranial ultrasound and they under-went an MRI scan with DIR sequences. Results: DIR brain imag-ing allowed the identification of a more extensive involvement of the cortex of all stroke patients included in the study compared to conventional neuroimaging. In three symptomatic (3/12; 25%) and five asymptomatic patients (5/10; 50%), DIR sequences de-picted cortical changes that were not disclosed by conventional MRI sequences. Conclusions: According to our study, DIR brain imaging increases intra-cortical lesion detection in patients with symptomatic and asymptomatic intracranial artery stenosis. These results seem to suggest that a combined approach of ultrasound and innovative neuroimaging techniques should be considered in the diagnostic workup of patients with intracranial atherosclerosis.


P41

Arterial thrombus and stroke in a patient with

Crohn’s Disease

C. Duque1, F. Silva1, J. Sargento-Freitas1, P. Freire2, A. Gonçalves3, M. Fonseca3, G. Santo1, L. Cunha1

1Neurosonology Laboratory of Neurology Department; 2Gastroenterology Department and 4Surgery Department, Coimbra University Hospital, Coimbra, Portugal

Introduction: Thromboembolic phenomena may present as extra-intestinal complications of inflammatory intestinal diseases (IID), with an incidence varying from 1.2-7.1%. However, cerebro-vascular arterial events are particularly rare, especially in Crohn’s disease. Clinical case: 38-year-old male with previous history of Crohn’s disease, receiving treatment with adalimumab, presents to the emergency department with complaints of abdominal pain. Laboratory evaluation revealed a leukocytosis (20.7x10^9/L) with no other significant abnormalities. While in the emergency department, he had a sudden onset of dysarthria and moder-ate left hemiparesis with spontaneous recovery in approximately one hour. The brain CT did not show any cerebral lesions. In the first day as an inpatient, the supraaortic ultrasonographic study revealed an irregular, pedunculated and mobile thrombus at the level of the right common carotid artery, with a correspond-ing stenosis of 60%. The transcranial evaluation was unremark-able. The patient underwent urgent carotid endarterectomy in the same day, without any related complications. Complementary study with transesophageal echocardiogram (TEE) identified a thrombus in the descending aorta, confirmed with thoraco-ab-dominal angio-CT. Screening for infectious agents responsible for endothelitis was negative and prothrombotic risk study re-vealed an MTHFR C677T heterozygoty with normal homocyst-eine levels. Autoimmunity laboratory work-up showed positive antinuclear antibodies and anti-dsDNA. Anatomopathological ex-amination of the thrombus did not demonstrate any relevant data. Anticoagulation was started with enoxaparin followed by warfa-rin, with no recurrence of events or detection of new thrombus (in carotid ultrasound or TEE). Conclusion: IID is associated with a 3.6-fold increased risk of thromboembolic events, particularly with venous thrombosis. Arterial thrombus, although exception-ally rare, should not be forgotten. Decision on the therapeutic management - surgical approach, anti-aggregation or anticoagu-lation- should be individually tailored, given the fact that there are currently no evidence-based guidelines. The ultrasonographic features of the arterial thrombus are fundamental in the process of therapeutic decision.

P42

Cerebral embolic activity in a patient during acute

crisis of Takayasu’s arteritis

R.C. Nogueira1, E. Bor-Seng-Shu2, E. Santos2, M.J. Teixeira2

1Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

Takayasu’s arteritis is a disease that affects large vessels and may cause neurological symptoms either by stenoses/occlusions or em-bolisms from vessels with an inflammatory process. Transcranial Doppler (TCD) ultrasound can provide useful information for diagnosis and monitoring during the active phase of the disease. Cerebral embolic signals can be detected by TCD and have been considered a risk factor for vascular events. We report a patient in whom TCD ultrasound was used to monitor cerebral embolic signals during the active phase of the disease. This case report sug-gests that embolic activity in Takayasu’s arteritis may represent disease activity, and its monitoring may be useful for evaluating the response to therapy.

P43

Osler-Weber-Rendu disease with cervical – intracranial

and pulmonary arteriovenous malformations:

successful management of transient ischemic attacks

J. Valaikiene, D. Jatuzis

Vilnius University, Faculty of Medicine, Clinic of Neurology and Neurosurgery, Lithuania

Background: Osler-Weber-Rendu disease, or hereditary haemorrhagic telangiectasia (HHT), is a very rare vascular disor-der, characterized by arteriovenous malformations (AVM) of vari-ous types. HHT clinical symptoms depend on the AVM location and extent. Cerebral AVM occurs in about 10%, and spinal AVM presents in less than 1% of all HHT cases. We present 27 months follow-up of HHT patient with extremely rare cervical intradural extramedullar and intracranial AVM coexisting with pulmonary AVM. Case presentation: 42 year old female experienced five transient ischemic attacks (TIA) with left hemiparesis during 1,5 years. One year after diagnosis of HHT with cervical – intracranial AVM and pulmonary AVM an acute severe chest pain, dyspnea and cough occured. Conventional angiography confirmed a large pulmonary AVM. Left upper lobectomy was performed without complications. Pulmonary symptoms dissapeared. During 1 year follow up, no pulmonary AVM recurrence and no more TIA oc-cured. Repeated color coded sonography revealed high velocities in cervical and cerebral AVM, neurosonological imaging showed no worsening. Magnetic resonance imaging revealed no changes in size of the cervical-intracranial AVM. Single photon emission computed tomography showed slightly reduced perfusion in left temporal lobe and left cerebellar area. The patient does not have



any neurological symptoms until now. Management of cervical – intracranial AVM remains uncertain. Follow-up continues includ-ing periodical neurological examination and TCCS. Conclusion: The determination of etiology of transient brain ischemia may be problematic in case of coexisting cervical – intracranial and pul-monary AVMs. Removal of pulmonary AVM could successfully eliminate TIAs.

P44

Trigeminal neuralgia and TIAs in a patient with elongation and ectasia of the basilar artery

E. Vavrek

Medical university – Sofia, MDC Orion, Sofia, Bulgaria

The Vertebrobasilar dolichoectasia (VBD) is a rare pathology in the vertebro-basilar part of the cerebral circulation. Usually it is diagnosed when the the diameter of basilar artery is bigger than 45 mm (ectasia) and when the basilar artery passes laterally than the lateral end of the clivus or dorsum sellae or over the supra-sellar cysterna (elongation). This rare pathology can be associated mostly with compression of the trigeminal and/or facial nerves, cerebellar dysfunction, stroke or subarachnoid haemorrhage. Here is presented a case of a 71 years old man suffering trigeminal neuralgy (followed by surgery) and 2 TIAs in the vertebro-basilar system. His neurostatus was normal except the loss of the facial sensitivity in the right and slight asymmetry in the deep tendon re-flexes in the hands – weaker in the right hand. The Duplex sonog-raphy showed bilateral plaques in the left common and internal carotid arteries, and in the right internal carotid artery with less than 30% stenoses. MRI revealed elongation (basilar artery goes at the end of the clivus) and ectasia (diameter 43 mm), not sufficient to establish the diagnosis VBD, according to aforementioned crite-ria. In conclusion: in some cases clinical picture typical for VBD can be observed in patients with vessels changes not sufficient to establish the diagnosis VBD, so it can be speculated that in the future the diagnostic criteria for VBD will be expanded

P45

Extracranial color coded duplex sonography in a case with

recurrent intra-cerebral hematoma: is it a useful tool?

F. Abd-Allah1 , A. Esmail2, A. Hegazy3

1Director Neurosonology unit, Department of Neurology, Cairo university hospital, Egypt; 2Interventional Neuroradiology, Department of Radiodiagnosis, Cairo university hospital, Egypt; 3Department of Neurosurgery, Cairo university hospital, Egypt

A 50 years old male patient known to be diabetic and dysliped-imic presented 2 years ago by sudden onset of seizures followed by loss of conciseness for 48 hours. CT revealed RT fronto-parital hematoma; patient received anticonvulsant, dehydrating measures and recovered with some cognitive dysfunction. Patient discharged

upon request of his family without any further investigations. Six months ago, he developed a wake up stroke with Rt. Sided hemi-parsis and dysarthreia. Intial CT scan showed moderate intra-ventricular hemorrhage involving Lt Lateral and third ventricle. Intraventricular drain was placed at Neurosurgical emergency and Patient admitted to neurocritical care unit. We decided to perform a digital subtraction angiography to delineate any underlying vascu-lar malformation (aneurismal dilatation or A-V malformation) but surprisingly, the cerebral angiography showed the following: the left internal carotid artery is totally occluded through its extracranial course, ipsilateral LT MCA &ACA showed minimal filling via pial collaterals and hypoplastic RT ACA. We retrospectively performed extracranial color coded duplex sonography and reported the diag-nosis of Lt ICA atherosclerotic chronic total occlusion. We assumed recurrent intracerebral hemorrhage in such case due to over disten-sion and increase pressure inside the pial collaterals to support the intracranial circulation ipsilateral to carotid occlusion. Conclusion: We are reporting a case which raises 2 important questions: 1- Is extracranial duplex sonography should be a routine in every case of intracerebral hemorrhage?; 2- What is the postulated mechanism of intracerebral hemorrhage in a case with chronic atherosclerotic total internal carotid artery occlusion?

P46

Mild sensory aphasia after a stroke in the right

hemisphere in a rigth-handed man suffering stroke

E. Vavrek, N. Nicheva-Vavrek, E. Vassileva

University Hospital “Tzaritza Ioanna-ISUL”, Sofia, Bulgaria

Speech is lateralized in the left hemisphere in about 99% of the right handed men and about 60-70% of the left handed men. We present a case of a 65 years old right-handed man suffering stroke. The patient was admitted to our hospital with left hand plegia, left leg severe paresis, central lesions of the left facial and hypoglossal nerves, disarthria, mild sensory aphasia, left Babinski sign, weaker deep tendon reflexes in the right extremities. Initial NIHSS was 19 pts. The patient had history for arterial hypertension and diabetes mellitus. The Duplex sonography revealed thrombosis of the right internal carotid artery, 50% stenosis of the right external carotid artery, and more than 80% stenosis of the left internal carotid ar-tery. Speech therapist assessed the aphasia as mild sensory aphasia with fluctuations typical for thalamic aphasia. After 14 day the pa-tient was discharged with 11 pts on NIHSS. The patient was sent to surgery for endarterectomy. In our opinion it is more likely that the aphasia in this case was a consequence of some “steal” phe-nomenon, than to a rare localization of the speech functions in right hemisphere.


P47

The role of transcranial Doppler in reversible cerebral

vasospasm syndrome – a case report.

R. C. Nogueira1, L. Peraza2, M. de Oliveira2, K. James1, E. Bor-Seng-Shu2, M. J. Teixeira2

1Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache and focal neurologic defi-cits. RCVS is typically a transient condition with relatively good clinical outcomes. Diagnosis can be hampered by the dynamic na-ture of clinical and imaging features. Transcranial Doppler (TCD) has an essential role as a non-invasive method to diagnosis and follow-up. We describe a 66 years-old woman with hypertension and who was in use of 40mg of paroxetine daily. She complained of sudden onset headache and strength loss at her right body side. Her neurological exam disclosed right complete hemiparesis and right sensory loss. Cranial computadorized tomography showed a left frontal and parietal hemorrhage and cranial digital angiog-raphy showed multiple arterial spams of the anterior circulation. The first TCD exam disclosed cerebral vasospasm of both middle and anterior cerebral arteries, with improvement to normal ve-locities during the sequential exams. Supportive management was performed, a progressive improvement of symptoms was observed and the patient was discharged with no deficits. Although a com-plete understanding of the etiological and pathological features of RCVS has not yet been achieved, alterations in vascular tone lead to the observed transitory arterial changes. A clear association be-tween RCVS and anti-depressive drug use has been recognized. Transcranial Doppler has been proved to be a suitable method for diagnosis and follow-up after the suspicion of a RCVS syndrome.

P48

Aortic dissection cause of ischemic stroke

H. Nicolae, A. Popescu, G. Cioara, C. Panea

Elias Emergency University Hospital (Bucharest, Ro)

Background: Aortic dissection typically presents itself with severe chest or back pain and hypotension, often needing a dif-ferential diagnosis with myocardial infarction. Neurological symptoms may occur due to several factors and although in some studies they were associated with increased mortality, these results are not necessarily applicable when aortic dissection is recognized early. Case report: We present a 65 years old patient referred to the hospital for left hemiparesis. Anamnesis was poor and we not-ed that the patient was hypertensive and smoker. On initial evalua-tion he had regular pulse, hypotension, he could answer questions intermittently and follow simple commands, had a left hemiparesis with reduced reflexes and a Babinski sign and he accused diffuse

chest pressure which appeared during an effort similar to Valsalva maneuver. Laboratory studies showed mild anemia. Head MRI showed a right hemispheric stroke. Asking for further informa-tion, his family confirmed he was known with aortic aneurysm for the past three years. Based on the patient’s symptoms and history associated with persistent hypotension, we performed an abdomi-nal and chest CT scan that revealed dissection of the ascending aorta (type Stanford A). The patient, although with greater haz-ards, was considered a surgical candidate for aortic repair and was sent to vascular surgery. Discussion: Because aortic dissection is a rare cause of ischemic stroke and has varied presentations, the aggressiveness of screening for this entity is also questioned, but when stroke associates hypotension, even in pain-free forms, they should be considered. Chest CT scanning and echocardiography are sensitive for aortic dissection but in a certain way are time con-suming and expensive. When associated, neurological symptoms are often dramatic and may dominate the clinical picture with a tendency to mask the underlying condition.

P49

Bilateral internal carotid artery dissection in Behcet’s

disease patient; a case report

T. Mukai, N. Hosomi, A. Segawa, N. Kinoshita, J. Kitamura, S. Aoki, H. Ueno, K. Ochi, T. Yamawaki, M. Matsumoto1Hiroshima University Hospital, Department of Clinical Neuroscience and Therapeutics, Hiroshima, Japan

We report a rare case of bilateral internal carotid artery dissec-tion occurred in Behcet’s disease (BD) patient. Introduction: BD is a rare disorder that causes chronic inflammation in the whole body. It is considered as an autoimmune disease. The prevalence of BD is low in the U.S. and other Western countries, but is higher in Mediterranean, Middle east and Far east including Japan. BD is known as “Silk Road Disease”. Case report: A 49-year-old man was admitted to our department causing headache and visual im-pairment. He had a long history of BD with repeated oral ulcer and flank pain. Two years before his admission, ileocecum ulcer was revealed with colonoscopy. Ocular manifestation such as cho-rioretinitis was also observed. Based on the International Criteria for Behcet’s Disease, the diagnosis was confirmed. He was afebrile and had no other symptom. Carotid ultrasonography revealed that he had flap and reverse flow in the bilateral internal carotid artery. MRI demonstrated no fresh infarct in the brain. He was prescribed aspirin for the prevention of stroke. Two weeks later, the flap dis-appeared and normal flow was observed. We diagnosed bilateral internal carotid dissection. BD is known as an uncommon cause of stroke. BD’s vascular manifestation is known as superficial phle-bitis, deep vein thrombosis, large vein thrombosis, arterial throm-bosis and aneurysm. Venous thrombosis is the major vascular disorder represent in 7-33% of BD patients and 85-93% of vascu-lo-BD patients. Arterial disorder is rarely reported. Conclusion: We reported a rare case of BD patient presenting bilateral internal carotid artery dissection detected by ultrasonography.



P50

Pulmonary A-Vm closure by amplatzer device

B. Zamani, M. Rohani, S. Adibeig, A. Ghofraniha

TUMS rasoul akram hospital Tehran IRAN

40 year old lady had 3 attacks of transient biocular visual loss. MRI was normal. MRA, MRI TCD, cervical doppler, transtho-racic echocardiography was normal. In TCD with contrast there was shower of mes (curtain sign ). TEE showed PFO. Pfo closure with amplatzer performed. after few months he she had another episodes of TIA, again contrast TCD had shower of mes . Open surgery and pfo closure performed .again after few months had episodes of visual loss.in CT angiography there was pulmonary AV fistula .amplatzer device shown in chest xray inserted in av fistual after operation contrast TCD was normal .after 1 year she had no other attack .

P51

Carotid artery dissection with floating clot after

pulse therapy for optic neuritis

B. Zamani

Tehran university of medical sciences; Rasoul akram hospital

34 year old man known case of multiple sclerosis hospitalised because of rt side optic neuritis for pulse therapy with methyl prednisolon. After 10 gram methyl prednisolon he developed nonfluent aphasia. MRI was normal but in carotid dppler there was evidence of li ICA dissection with large floating clot at bifor-cation.he recieved full anticoagulation with heparin. Her situation improved completely after 3 months there was copmlete recanali-sation in cervical doppler.

P52

Orbital sonography in subarachnoid hemorrhage

J. Bäuerle1, N. Gross2, K.J. Buttler3, W. Lagrèze2, M. Reinhard1

1Department of Neurology, University Medical Center Freiburg, Germany; 2Department of Ophthalmology, University Medical Center Freiburg, Germany; 3Department of Neurosurgery, University Medical Center Freiburg, Germany

Purpose: Ocular bleedings (OB) are common complications in subarachnoid hemorrhage (SAH) and occur in 10-40% of patients with SAH. The presence of OB in SAH, especially sub-hyaloidal and vitreous hemorrhages, is associated with a higher mortality rate and a poor functional outcome. In contrast, reti-nal hemorrhages indicate a better prognosis. Furthermore, miss-ing the diagnosis of OB may impede the rehabilitation process due to visual impairment. Patients with SAH receive numerous

ultrasound examinations for the monitoring of arterial vasospasm. Our aim was to investigate the potential of orbital sonography, as an additional ultrasound monitoring tool in SAH, in detect-ing OB. Material and Methods: From June 2012 until February 2013 we examined 40 Patients (mean age 52 ± 11.9 years) with spontaneous SAH for OB and compared orbital B-mode sonogra-phy (3 to 9 MHz broadband linear array transducer, iU22, Philips Healthcare) with funduscopy as gold standard. Sonography was carried out by a neurologist, funduscopy by an experienced oph-thalmologist. Both examinations were done within 24 hours and the investigators were blinded to each other’s results. Results: 70% of patients suffered from an aneurysmal SAH and 45 % had a Hunt and Hess grade of III – V on admission. Sonography detected subhyaloidal and/or vitreous hemorrhages in 8 eyes of 6 patients, which were all confirmed by funduscopy. No further subhyaloi-dal or vitreous hemorrhages were found by the ophthalmological examination. Furthermore, retinal bleedings were disclosed by sonography in 3 eyes of 2 patients. These were verified by fun-duscopy, but the ophthalmologist identified 6 additional retinal bleedings. Conclusions: Orbital B-mode sonography is capable to detect SAH associated subhyaloidal and vitreous hemorrhages. Both represent indicators of poor prognosis in SAH. It does, how-ever, not reliably identify retinal bleedings. Furthermore, it pro-vides a screening tool for OB, which should be followed up and if necessary treated by ophthalmologists.

P53

Reproducibility and accuracy of optic nerve sheath

diameter assessment using ultrasound compared to

magnetic resonance imaging

J. Bäuerle1, F. Schuchardt1, L. Schroeder1, K. Egger2, M.s Weigel3, A. Harloff1

1Department of Neurology, University Medical Center Freiburg, Germany; 2Department of Neuroradiology, University Medical Center Freiburg, Germany; 3Department of Radiology, Medical Physics, University Medical Center Freiburg, Germany

Purpose: Quantification of the optic nerve sheath diameter (ONSD) by transbulbar sonography is a promising non-invasive technique for the detection of altered intracranial pressure. In or-der to establish this method as follow-up tool in diseases with in-tracranial hyper- or hypotension scan-rescan reproducibility and accuracy need to be systematically investigated. Material and Methods: Thirty optic nerve sheaths of 15 healthy volunteers (mean age 24.5 ± 0.8 years) were measured by both transbulbar sonography (9 – 3 MHz) and 3 Tesla MRI (half-Fourier acquisi-tion single-shot turbo spin-echo sequences, HASTE) 3 and 5 mm behind papilla. All volunteers underwent repeated ultrasound and MRI examinations in order to assess scan-rescan reproducibility and accuracy. Moreover, inter- and intra-observer variabilities were calculated for both techniques. Results: Scan-rescan re-producibility was robust for ONSD quantification by sonography and MRI at both depths (r > 0.73, p < 0.001, mean differences < 1%). Comparing ultrasound- and MRI-derived ONSD values, we found good agreement between both methods for measurements


at a depth of 3 mm (r > 0.70, p < 0.001, mean differences 5.5%). Further analyses revealed high inter- and intra-observer reliability for sonographic measurements 3 mm behind the papilla and for MRI at 3 and 5 mm (r > 0.84, p < 0.001, mean differences < 5.5%). Conclusions: Sonographic ONSD quantification 3 mm behind the papilla can be performed with good reproducibility, measure-ment accuracy and observer agreement. Thus, our findings em-phasize the feasibility of this technique as a non-invasive bedside tool for longitudinal ONSD measurements.

P54

Measurement of optic nerve sheath diameter

in egyptian females with idiopathic intracranial

hypertension

N. Kishk1 A. Hassanen1, H. Abdelhafez 2, N. Shalaby1, N. Abukresha1 M. Elsaed1

1Kaser Elaini Hospital Departments of Neurology; 2Radiodiagnosis, Cairo University; 3Neurology department Maadi millatry Hospital, Egypt

Background: The optic nerve sheath is anatomically continu-ous with the dura mater and has a trabeculated arachnoid space through which cerebrospinal fluid (CSF) slowly percolates. Optic nerve sheath diameter (ONSD) measurements may help to es-timate the degree of intracranial hypertension in patients with papilledema. Aim of work, To evaluate the use of orbital sonog-raphy in measuring ONSD in patients with idiopathic intracranial hypertension (IIH) and to correlate it with CSF pressure, and to compare its utility with orbital MRI. Methods: Ten female subjects with IIH and papilledema were compared with 10 normal controls age and sex matched. Measurements of ONSD were done using or-bital sonography (OS) and orbital MRI. OS was performed via a 10 MHz linear probe. The operator was blinded to the subjects. Two readings were taken in each eye and an average was taken then an average reading for both eyes was estimated. LP was done for all patients and the opening CSF pressure was measure. Results: The ONSD was higher in patients than controls when measured by OS (p<0.001), whereas no significant difference was found when was measured by MRI (0.7). The mean OSND measurement with OS was higher in patients than MRI orbit measures (<0.001). No correlation existed between the ONSD measured by OS or orbital MRI and CSF pressure. Conclusion: ONSD measurements via OS or orbital MRI cannot be an indirect tool to assess CSF pressure in IIH patients instead of LP. The OS seems to be a more accurate tool than MRI orbit in measuring ONSD. Key words: idiopathic intracranial hypertension, optic nerve sheath diameter, ocular so-nography, MRI orbit.

P55

Optical nerve diameter and echogenicity are

impaired in demyelinating diseases

J. Fernández-Domínguez, R. García-Rodríguez, V. Mateos

Neurology Department. Centro Médico de Asturias (, ES)

Background: Demyelinating diseases are a group of hetero-genic diseases in whom myeline is attacked. The optic nerve (ON) is usually impaired. Material and methods: An observational prospective case-control study with ON orbital echography was developed. Case group was formed by demyelinating diseases (multiple sclerosis and clinical isolated disease) patients and the control group was formed by healthy people. Results: 31 cases and 24 controls underwent transorbital echography. Mean age: cases: 48,3 ± 11,8 years old, controls 48,7 ± 9,9 years old. 46% of controls and 42% of cases were males. A previous study developed by our ultrasound laboratory showed no significant difference between left and right ON diameter. For that reason, we analyzed the 110 ON of these patients. There is a statistical significant difference in ON diameter, which is thinner in the cases group (3.79± 0,73 mm in control group vs 2.79±0.55 mm cases, p<0.001). Based in previ-ous analyses of the echogenicity of the carotid plaque, we made a variation of the GSM measurement and we applied it to the study of the ON echogenicity. And also, we find significant differences in the echogenicity of the ON, being significatively more echogenic in the case group (GSM median values in control group: 10.62 ± 7.61 vs 15.75±7.66 in the cases group, p=0.001). Conclusion: ON evaluation with transorbital echography is an easy, feasible, non invasive, useful and costless technique for the evaluation of the ON atrophy. Moreover, it seams to be useful to determine echo-genicity differences between healthy people and patients. We think that the higher values of the ON echogenicity could be related with the myeline loss that occurs in these diseases. More studies should corroborate our findings.

P56

Transorbital echography for assessment of optical

nerve damage in patients with multiple sclerosis

V. González Quintanilla1, A. Rojo López1, A. González Suarez1, S. Gutiérrez González1, M. Toriello1, R. Viadero1, J. Fernández Fernández1, EJ. Palacio1, M. Rebollo1, J. Castillo2, A. Oterino1

1Service of Neurology. Hospital Universitario Marqués de Valdecilla, Santander, Spain; 2Centro Salud Camargo Costa, Camargo, Spain

Objectives: There is a well-known relationship between Multiple Sclerosis (MS) and optic neuritis. Recent researches suggest that visual dysfunction is accumulated in MS patients even without prior optic neuritis. Our aim is to compare the optic nerve diameter and its correlation with ophthalmic ar-tery blood flow. Material and methods: At present 14 patients with MS (mean age 36,58 years, and Expanded Disability Status



Scale (EDSS) from 1.5 to 4.0) and 14 healthy people (mean age 34,92 years) have been included in the study. All subjects under-went noninvasive measurement of both optic nerve diameters by transorbital Doppler sonography. The blood flow of the ophthal-mic arteries was measured. The peak systolic velocity (PSV), the mean flow velocity (MFV) and pulsatile indices (PI) were studied in both ophthalmic arteries. Only two patients with MS had had clinic optic neuritis previously. Results: The preliminary results showed a reduced optic nerve diameter in MS patients vs. controls (Right optic nerve: controls 3.731±0.35 mm and MS 2.785±0.44 mm, p<0.01; Left optic nerve: controls 3.746±0.24 mm and MS 3.015±0.32 mm p<0.01) These results were age and EDSS inde-pendent. PSV (p= 0,27) MFV (p = 0,18) were higher in the MS group than in controls, although the PI was similar. Conclusions: Transorbital echography is an easy, noninvasive and useful tech-nique for the evaluation of the optic nerve damage. Although our results are provisional, the diameter of the optic nerve measured by transorbital Doppler could be useful for the diagnosis of unap-parent lesions in patients with MS.

P57

Space-time ultrasound imaging of calf muscle lesions

E. Titianova1,2, S. Karakaneva1, I. Tournev 3

1Clinic of Functional Diagnostics of Nervous System, Military Medical Academy - Sofia, 2Faculty of Medicine, Sofia University, 3Department of Neurology, Medical University – Sofia, Bulgaria

Aim: To present the ultrasound calf muscle architectonics in different disorders. Methods: Different types of calf muscle dis-turbances due to traumatic injury, genetic disorders, peripheral neuropathy and chronic spastic hemiparesis were imaged by mul-timodal 2D/3D/4D sonography in rest, during maximal plantar flexion and electrical stimulation. The results were compared to healthy myosonograms and the findings from other diagnostic methods. Results: A typical calf muscle architectonics was found in relation to the location, type and severity of triceps surae le-sions, muscle fibers contractility, degree of muscle atrophy, fat tissue infiltration and fibrosis. Conclusion: Space-time myosonol-ogy is superior to the standard ultrasound methods in imaging the structural and functional changes of calf muscles architectonics in normal and pathological conditions

P58

Transcranial Doppler ultrasonography with jugular

vein compression can detect impairment of

intracranial compliance

R. C. Nogueira1, M. F. Machado2, F. Paschoal2, E. Bor-Seng-Shu2, M. J. Teixeira2 1Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

The use of noninvasive techniques for assessing ICP has been a focus of discussion in recent years, particularly in situations where invasive measurement of ICP is contraindicated. Intracranial hy-pertension can result from an increase in volume of one or more intracranial compartments (brain parenchyma, cerebrospinal and intravascular fluid), without equivalent reduction of others (Monro-Kelly doctrine). We report two cases that had complaints of severe headache with features of intracranial hypertension. The first case was a 41-year-old male with meningeal signs and papilledema on neurological examination. The findings of labo-ratory and imaging tests included cerebrospinal fluid (CSF) with positive cytology, brain computed tomography (CT) with commu-nicating hydrocephalus and indirect signs of intracranial hyper-tension. The second case was a 59-year-old male with a Glasgow Coma Scale score of 8 and Hunt and Hess Scale score of 4 on neu-rological examination. Other tests disclosed hemorrhagic CSF, CT of the brain with bleeding grade IV on Fisher’s scale while brain angiography demonstrated anterior communicating artery aneu-rysm. Both patients showed no transcranial Doppler (TCD) signs of raised intracranial pressure (ICP. To better assess intracranial compliance status in clinically serious patients with suspected in-tracranial hypertension, ultrasound-guided compression of the internal jugular veins was carried out, and the behavior of cerebral blood flow (CBF) velocity and pulsatility index (PI) was evaluated using TCD ultrasonography. Physiological variables, such as mean arterial blood pressure, heart rate and ICP, were also recorded to supplement the cerebral hemodynamic assessment; ICP monitor-ing was only available in the second patient. In summary, TCD with jugular vein compression may be useful for identifying pa-tients with impaired intracranial compliance. The great merit of this method is that no direct measurements of ICP are required for evaluating the intracranial compliance. These ideas should be substantiated in larger clinical studies in terms of clinical safety and validity.


P59

Is plaque neovascularisation detected by contrast

enhanced ultrasound associated with symptomatic

carotid artery disease?

D. Artemi, L. Schall, M. Kablau, M.G. Hennerici, T. Riester, R. Kern

University of Heidelberg, Universitätsmedizin Mannheim, Neurology Department, Mannheim, Germany

Introduction: Among patients with carotid artery disease, it is very important to identify those with a particular high risk for stroke who may benefit from surgical or neuro-interventional therapy. Contrast enhanced ultrasound (CEUS) is a new diagnos-tic method that has been suggested to detect microbubbles within the plaque corresponding to plaque neovascularisation as a possible marker of “unstable”, vulnerable plaques. Methods: Native B-mode, color-coded and contrast enhanced carotid ultrasound examina-tions were performed in 50 symptomatic patients (mean age 69+/-4.9 years, 26 male) and 16 asymptomatic (mean age 73+/-8.5 years, 14 male) with significant (>50%) carotid artery stenosis. According to predefined criteria findings were evaluated for plaque echogenic-ity on B-mode, and for presence of plaque neovascularization or micro-ulcerations using CEUS. Results: Plaque neovascularisation was similarly distributed among symptomatic and asymptomatic carotid plaques (24% vs. 25% of the plaques (p=0,19.). The presence of plaque neovascularisation on CEUS was associated with arterial hypertension (p=0.04) but not with smoking (p=0.13), dyslipidae-mia (p=0.85) or diabetes mellitus (p=0.63). Symptomatic plaques had significantly more often components with low echogenicity on B-mode imaging (ρ=0.01). Conclusion: Symptomatic stenoses of the carotid artery mostly consisted of echolucent plaques. Whether or not this reflected a postembolic stage or a condition at risk dif-ferent from asymptomatic plaque remains uncertain. In the present analysis, however, plaque neovascularisation identified by CEUS was not associated with symptomatic carotid stenosis.

P60

Morphological changes of the internal carotid artery

and association with vascular risk factors and carotid

ischemic stroke

H. Martins1,2,3, P. Batista1, F. Soares1, V. Almeida1, A. Pedro4, V. Oliveira1,4,5

1Department of Neurosonoly, Hospital de Santa Maria-CHLN, Lisbon 2Department of Internal Medicine. Hospital de S. José-CHLC, Lisbon; 3Department of Anatomy, Faculty of Medical Science of Lisbon, Lisbon New University, Lisbon 4Department of Internal Medicine, Hospital de S. Maria-CHLN, Lisbon; 5Department of Neurology, Hospital de Santa Maria-CHLN, Lisbon

Objective: To assess the prevalence and characteristics of inter-nal carotid artery tortuosities: kinking, coiling or looping; identi-fied by carotid duplex scan and relating them to vascular risk factors

and carotid ischemic stroke in a series of patients investigated in an ultrasound laboratory. Methods: Retrospective analysis of 25,314 ultrasound cervical reports from Jan2000 to Jun2012 referred to our laboratory. Tortuosities were classified as: Kinking when an angular point on a vessel was find. Coiling: as an elongation (S or C-shaped) and Looping as a circular or elliptical shape. Carotid intima–media thickness (IMT) was assessed according the current methodology. History of vascular risk factors was collected: hypertension, diabe-tes mellitus and hyperlipidemia according to the European Society of Cardiology and Atherosclerosis guidelines. History of ischem-ic stroke in the carotid circulation was also collected. Statistical analysis was performed using Excel® 2007 and SPSS® 20 software programs calculating student t test, Хi2 and multivariable logistic regression. Statistical significance was accepted for p <0.05 and confidence intervals (CI) 95%. Results And Conclusions: From 21480 patients files reviewed, tortuosities were identified in 2785 (13.0%). They were unilateral in 66% and bilateral in the remain-ing 34%. Kinkings were found in 80% patients, Coilings in 18% and Looping in 1%. Prevalence of tortuosities increased with age (above 50-59 y) being higher in women. By multivariate logistic regression analysis, ICA tortuosities were associated with older age (64 ± 16 vs 71 ± 15 years p<0.01), female gender (1,85 CI 1.70-2,01 p<0.01), and hyperlipidemia (1.15 CI 1,05-1,26 p<0.01). Increased carotid IMT (1.37 CI 1.26-1,50 p<0,01) and hypertension - 1.11 CI 1.02-1,22 p<0.01). There was an association between kinking and ipsilateral cerebral ischemic events (2.04; IC 1.17-3, 55 p <0.05). Our results provide some data about clinical aspects associated ca-rotid tortuosities.

P61

Restenosis after carotid artery stenting: which

are the perfect velocity criteria? Example of an

ultrasonographic diagnostic protocol

P. Barros1, H. Felgueiras1, D. Pinheiro2, M. Guerra3, V. Gama4, M. Veloso1,2

1Department of Neurology; 2Stroke Unit, 3Department of Cardiothoracic Surgery, and 4Department of Cardiology, Vila Nova de Gaia/Espinho Hospital Center, Portugal

Background: Concerns have been raised that ultrasound velocity criteria designed for native carotid arteries could over-estimate stenosis in the presence of a stent, because the reduced compliance of the vessel wall could increase the peak systolic ve-locity. The optimal duplex ultrasound (DUS) velocity criteria to determine in-stent carotid restenosis are controversial. Our goal was to evaluate the restenosis rate in patients undergoing carotid angioplasty with stenting (CAS) at our institution over the past 5 years, using a pre-specified DUS protocol. Methods: Restenosis were assessed by DUS at 6, 12 months and yearly thereafter and were defined as a reduction in diameter of the target artery of 50%, diagnosed by a peak systolic velocity of at least 2·0 m/s. The cases in which restenosis was detected by DUS underwent carotid angio-CT. The frequency of restenosis was calculated by Kaplan-Meier survival estimates and was compared during a 2-year follow-up period. Results: 100 procedures were performed in 96 patients.



The mean age was 73.2 years. 76% of the carotid were monitored; 12 patients died and 11 were missed. The median follow-up was 29.2 months. Restenosis were detected in 6 carotid arteries (2 of them, >70%), all in-stent (estimated frequency of restenosis at 24 months – 6%). The carotid angio-CT confirmed all ultrasono-graphic detected restenosis. Discussion: The decision to use 2.0 m/s as the threshold velocity for restenosis diagnosis was based on the criteria used in several single-institution reports. In our institution, restenosis was infrequent and rates were similar to those previously published in other series, like CREST. We em-phasize the diagnostic agreement achieved between ultrasonogra-phy and angio-CT; in our ultrasonographic laboratory the 2.0 m/s peak systolic velocity threshold seems to be a good reference even though we know that only patients with high velocities underwent angio-CT for comparison, which may lead to potential bias.

P62

Internal carotid artery stenosis: validation of Doppler

velocimetric criteria

A. Monteiro, R. Santos, C. Ferreira, A. Costa, E. Azevedo

Neurossonology Unit – Department of Neurology, São João Hospital Centre, Faculty of Medicine of the University of Porto, Porto, Portugal

Background: Carotid endarterectomy is effective in reduc-ing recurrent stroke in patients with carotid stenosis. Duplex sonography is widely used for the diagnosis of internal carotid artery (ICA) stenosis and surgeons often base management de-cisions solely on this technique. Published velocimetric criteria for stenosis should be validated in each laboratory, considering that operator and device variation could interfere with stenosis measurement. Aim: Internal validation of Doppler velocimet-ric criteria for different grades of ICA stenosis and evaluation of possible intracranial collateralization circuits. Methods: Duplex scans from 10435 consecutive patients routinely referred to our Neurosonology Unit from January 2003 to December 2011 were reviewed. Cases with ICA stenosis ≥50% graded by morphologic criteria were selected. Groups were defined by percentage of steno-sis measured as diameter narrowing (ECST method): 50-59%, 60-69%, 70-79%, 80-89% and 90-99%. Mean ICA peak-systolic (PSV) and end-diastolic velocities (EDV) at the point of highest steno-sis, ICA/common carotid artery PSV ratio (CI) and the presence of collateral flow were recorded. The Coefficient of Pearson was used to correlate percentage of stenosis and velocity parameters. One-way ANOVA followed by Bonferroni’s post-hoc comparisons tests were performed for the presence of collateralization. Results: 977 ICA with stenosis ≥50% were identified. Mean velocities and CI for the different groups were, respectively, 111/36cm/s, CI:1,4; 161/51cm/s, CI 2,1; 218/78cm/s, CI:2,8; 377/152cm/s, CI:5,3 and 409/191cm/s, IC:7,3. Pearson’s correlation was R=0,802, p<0,001; R=0,724, p<0,001 and R=0,519, p<0,001 for the PSV, EDV and IC, respectively. The presence of collateral flow increased significantly for stenosis ≥70% (p<0,001). Conclusion: A positive correlation between velocimetric criteria and the degree of stenosis was found and there was increased intracranial collateral flow above 70%

stenosis. This work enabled the definition of velocimetric criteria for each stenosis range in our laboratory, allowing a better estima-tion of the stenosis when plaque characteristics prevent an accu-rate morphological measurement.

P63

Intracranial internal carotid artery dissection:

characteristics of early ultrasound diagnosis, follow-

up and early predictors of recanalization with

ultrasound contrast agents.

E. Vicenzini, M. Toscano, I. Maestrini, B. Petolicchio, F. Puledda, G. L. Lenzi, V. Di Piero

Department of Neurology and Psychiatry, Stroke Unit & Neurosonology, Sapienza University of Rome, Italy

Background: in the past, sole availability of invasive imaging for intracranial internal carotid artery dissection (IICD) detec-tion may have induced under-reporting, though this is a clinically significant condition that may cause severely disabling ischemic stroke. Consequently, there are few systematic published data and clinical studies have considered IICD as a rare occurrence, some-times coupling it with extracranial dissection. Aim of this work is to analyze early ultrasound findings and during a 4 years follow-up in 14 patients with IICD, and to describe timing and predictors of recanalization. Methods: patients with IICD diagnosis were submitted to carotid sonographic seriated monitoring with and without ultrasound contrast agents, from symptoms onset up to a 4 years follow-up. Results: Extracranial internal carotid patency was observed in 8 patients in the early stage: all these showed the complete recanalization within the first week and oral anticoag-ulants were withdrawn after 6 months. In 6 patients, retrograde internal carotid occlusion was soon observed: in 4 of these the intracranial occlusion persisted after 4 years while 2 had only a partial late recanalization, with evidences at contrast ultrasound of still late remodeling processes up to 2 years after onset. In these 2 patients anticoagulation was not discontinued, while in the 4 with persistent occlusion, therapy was suspended 1 year after the diagnosis. Conclusions: Carotid strict ultrasound surveillance, with the aid of ultrasound contrast agents, should be mandatory to monitor IICD patients. The identification of the site of dissec-tion – i.e. extra versus intracranial – is fundamental for progno-sis. Retrograde extracranial internal carotid thrombosis following IICD appears to be correlated with persistent occlusion and with only incomplete recanalization. The remodeling of thrombotic material in the internal carotid artery, detected with contrast ul-trasound, may though continue up to 2 years, thus supporting the decision to continue anticoagulation.


P64

Low ankle brachial index in acute ischemic stroke;

Does APOE gene polymorphism have a role?

S. El-Jaafary1, F. Abd-Allah1, M. Fathy2, H. Hosny1, M. El-Tamawy1

1Neurology department Faculty of Medicine, Cairo University; 2Chemical pathology department, Faculty of Medicine, Cairo University

Background: Presence of low ankle brachial index (ABI) as a marker of atherosclerosis in acute stroke patients has been docu-mented as well as its effect on stroke outcome and recurrence. The effect of different alleles of ApoE gene on acute ischemic stroke in patients with low ABI is not known. Aim: To study the com-bined effect of low ABI and Apo E gene polymorphism on stroke severity, outcome and recurrence. Methods: Patients with acute ischemic stroke were screened for the presence of a symptomatic peripheral arterial disease by estimating the ABI using a pocket Doppler ultrasound device. Assay of ApoE gene was done using the Real time PCR technique. Results: Low ABI was present in 31% of patients with acute ischemic stroke. Having OR= 8.7 with 95% CI (2.05-37.04), the chance of recurrence is 8.7 times more among cases with abnormal ABI than those with normal ABI. No significant difference between patients with normal ABI and those with abnormal ABI regarding the APOE gene polymorphism. No significant difference between patients with different APOE alleles regarding the recurrence of their symptoms. Conclusion: Results from this study showed that there was no significant relation be-tween APOE gene polymorphism in stroke patients with low ABI or normal ABI; patients with abnormal ABI didn’t show specific allele that could be linked to the increase risk for these patients either to develop ischemic stroke or to affect stroke outcome & recurrence. Key words: ABI, Acute ischemic stroke, ApoE gene polymorphism.

P65

Neurosonology versus neuroimaging in the

diagnosis of cerebrovascular disease: comparison

and diagnostic agreement

A. Tanzi¹, U. Scoditti¹, R. Silvano¹, M. Agosti², C. Zanferrari¹

¹ Neurological Unit, Department of Neurosciences, University-Hospital of Parma, Italy; ² Department of Rehabilitation, University-Hospital of Parma, Italy

Background: The routine use of digital subtraction angiogra-phy (DSA) in the diagnosis of extra and intracranial arteries dis-ease has known a progressive decline due to its limits of invasive, time consuming and expensive procedure. Duplex Ultrasound (DU), CT Angiography (CTA), Magnetic Resonance Angiography (MRA) have emerged as alternative investigations but there’s still controversy regarding the best non-invasive strategy. DU and Transcranial Colour Coded Sonography (TCCS) represent an ac-curate, repeteable, cost-effective diagnostic and decision-making

strategy. Aim of the study is to compare reproducibility of results and to evaluate diagnostic agreement between DU-TCCS and neuroradiologic techniques in patients with significative extra-in-tracranial arteries disease. Method: Among 657 patients submit-ted to DU-TCCS between 2010-2012 we enrolled those affected by occlusion, severe (≥ 70%) and moderate (50-69%) stenosis. CTA and/or MRA and/or DSA followed to confirm presence of occlu-sion and presence/degree of stenosis and results were compared. The diagnostic agreement in patients affected by extracranial arter-ies disease was quantified by the Kappa statistic (Cohen). Results: DU-TCCS showed significative artery disease in 20 (27,4%) fe-males e 53 (72,6%) males, mean age 66±11,8. Extracranial carotid arteries were involved in 34 patients (46,5%), vertebral arteries in 16 (22%), both in 7 (9,5%) and intracranial arteries in 16 (22%). CTA was performed in 32 patients (43,8%), MRA in 27 (36,9%) and DSA in 33 (45,2%).Diagnostic agreement in the carotid as in the vertebral extracranial district, was excellent towards DSA (K>0,85-1;IC 95%) and good/very good towards CTA (K>0,65-0,9) and MRA (K>0,69-09). Conclusions: Our study confirms reproducible results between ultrasound imaging and neuroradio-logic techniques, independently of degree of stenosis and vascular district. The excellent diagnostic agreement towards DSA suggests the adoption of a diagnostic algorithm based on DU-TCCS alone or followed by a further non-invasive confirmatory test. DSA should preserve a diagnostic role only in case of disagreement be-tween non-invasive techniques.

P66

The role of adhesion molecules (sICAM and sVCAM)

in atherosclerotic ischemic stroke

N. Kishk1 O. Elserafy1, H. Hosny1, N. Ghanem2, S. El-Shafee3, M. Nada1,

R. Shamlol1

1Kaser Elaini Hospital Departments of Neurology; 2Internal Medicine; 3Clinical Pathology, Cairo University, Egypt

Background: Adherence of leukocytes and their transen-dothelial migration mediated by soluble adhesive molecules in re-sponse to noxious stimuli as: ischemia may cause further vascular injury. Objective: To detect the relation between the Adhesion Molecules (sICAM and sVCAM) and various measures & degrees of atherosclerosis and to identify their relation to stroke severity to verify their role in ischemic atherosclerotic stroke. Methods: Thirty ischemic stroke patients and 30 controls were included. Patients were evaluated clinically by Barthel index & Modified Rankin scale. All subjects undergone laboratory levels for sICAM & sVCAM and U/S imaging (Doppler for ankle brachial index, Extra- and Trans cranial color coded duplex). Results: Levels of sICAM & sVCAM were higher in the patient group and correlated with carotid atherosclerotic plaques and stenosis. Conclusion: Elevations in sICAM reflect overt atherosclerosis while sVCAM is suggestive of advanced degree of atherosclerotic disease in is-chemic stroke patients. Key Words: Atherosclerosis, ICAM, VCAM, ischemic stroke, duplex studies.



P67

Reversal of ophthalmic artery flow and severe

ipsilateral carotid stenosis

M. Grilo, A. Monteiro, R. Santos, C. Ferreira, A. Costa, E. Azevedo

Neurosonology Unit - Department of Neurology, São João Hospital Centre and Faculty of Medicine of University of Porto, Porto, Portugal

Background: Duplex sonography has shown a >90% accu-racy, when compared to angiography, in establishing the degree of internal carotid artery stenosis. The examination of ophthalmic artery flow provides helpful information for the assessment of collateral circulation and can further evaluate the hemodynamic significance of high-grade internal carotid artery stenosis. Aim: Analyze our data regarding reversal of ophthalmic artery blood flow due to carotid stenosis. Methods: We reviewed 977 duplex scans performed in our Neurosonology Unit from January 2003 to December 2011 with internal carotid artery stenosis ≥50% graded by morphologic criteria. Groups were defined by estimated ste-nosis: 50-59%, 60-69%, 70-79%, 80-89% and 90-99%. One-way ANOVA followed by Bonferroni’s post-hoc comparisons tests were performed for the presence of reversed ophthalmic artery flow. Results: Reversal of ophthalmic artery flow was seen in 43% (62 cases) of carotid stenosis ≥80%. In the different groups, we ob-served, respectively, reversed flow in 1% (2); 1% (2); 6% (9); 36% (44) and 75% (18). There was no significant reversal in ophthalmic flow for stenosis <80%, but there was significant increase in colla-terization from this artery for stenosis 80-89% and 90-99%. In the cases with ophthalmic artery flow reversal we observed a sensitiv-ity of 43%, a specificity of 98%, a negative predictive value of 91%, and a positive predictive value of 83% for a high-grade stenosis of ≥80%. Conclusion: In our series, we found a significant associa-tion between reversed ophthalmic artery flow and carotid stenosis ≥80%. A positive correlation between the degree of stenosis and the presence of reversed ophthalmic artery flow was found. The latter is highly specific (98%) for severe ipsilateral carotid stenosis, with excellent positive predictive value, moderate negative predic-tive value, and limited sensitivity.

P68

Migraine as a risk factor for cranial artery dissection

A. Lovrencic-Huzjan, D. Sodec Simicevic, I. Martinic Popovic, M. Bosnar Puretic, V. Vukovic Cvetkovic, V. Basic Kes

University Hospital Center „Sestre milosrdnice“ / University Department of Neurology, Vinogradska 29/ 10 000 Zagreb/ Croatia

Cervical artery dissection (CAD) is at the most common single etiology of stroke in young adults. There is an association between migraine and stroke. Several small to medium sized studies indicated a link between CAD and migraine. The aim of the study was to assess the incidence of migraine and other risk

factors in consecutive patients with CAD. We analyzed the data of 20 consecutive patients with CAD diagnosed from January 1st to December 31st 2012. The neurosonological finding, clinical pic-ture, risk factors including migraine and recanalization rate and recurrence rate were analyzed. During one year 20 consecutive pa-tients (18/20 <40 years old) were diagnosed with CAD. Head and neck MR, MRA or CTA confirmed the diagnosis. Multivessel in-volvement was present in 4 patients, affection of one carotid artery in 9 and one vertebral artery in 7 patients. Hyperlipidemia was present in 11, hypertension and migraine in 7, diabetes mellitus in 3 patients. Head or neck pain was the dominant symptom in 19/20 patients, followed by ischemic symptomatology in 8/20, only one patient had intracranial hemorrhage. In 10/20 patients complete recanalization occurred within the first year. In this cohort there was no recurrence. In this cohort of patients with CAD migraine appears to be present as often as hypertension. The incidence of migraine was higher in patients with CAD than in the general population.

P69

Relationship between blood pressure control and

arterial stiffness, carotid artery and retina damages

in hypertensive patients with and without type 2

diabetes

E. Azevedo1, S. Penas2, C. Ferreira1, L. Martins2, A. Campilho3, J. Polonia4

Dep. of 1Neurology and of 2Ophthalmology, São João Hospital Center and Faculty of Medicine of University of Porto; 3Institute of Biomedical Engineering, University of Porto; 4Arterial Hypertension Clinic of Hospital Pedro Hispano and Faculty of Medicine of University of Porto

Introduction: Diabetes mellitus (DM) leads to accelerated pro-gression of arteriosclerosis in comparison to non-diabetic patients (non-DM). Retinopathy is a major microvascular complication of DM remaining a leading cause of blindness. Aortic stiffness and an increase in carotid artery intima-media thickness (IMT) are mac-rovascular complications that are associated with increased car-diovascular morbidity-mortality. It has been suggested that in DM blood pressure levels are more determinant than glycemic control of macrovascular lesions whereas retinopathy is more dependent on glycemic control. Methods: We compared the macrovascular damages – aortic stiffness by pulse wave velocity (PWV) and ca-rotid plaques and IMT by duplex ultrasound – and hypertensive retinopathy lesions (early and late stages) by fundus photograph between type 2 DM and non-DM hypertensive subjects with similar age and 24h-ambulatory BP values. Results: Hypertensive patients with DM (n=26, 10 female) and non-DM (n=33, 17 fe-male) did not differ for age (62±8 vs 58±13 yrs), BMI (29.6±4.0 vs 29.1±5.3 Kg/m2), 24h BP (144/84±15/11 vs 137/82±16/10 mm Hg) and for PWV (11.7±2.0 vs 11.1±1.7 m/s) and IMT max (0.92±0.16 vs 0.86±0.19 mm) IMT average (0.77±0.13 vs 0.72±0.17 mm) and presence of carotid plaques (73% vs 53%) (all p>0.19). In contrast DM showed a higher percentage of indices of late stage


hypertensive retinopathy than non-DM subjects (65.4% vs 33.4%, p<0.03). Significant correlations were found between PWV and 24h-SBP (0.330, p< 0.02) and between IMT and 24h pulse pres-sure (r=0.330, p<0.02) but no association was found between 24h BP values and retinopathy lesions. Conclusion: In DM macrovas-cular damage is particularly dependent on blood pressure levels, whereas the severity of hypertensive retinopathy is clearly related with DM condition.

P70

Transcranial brain parenchyma sonography in

Parkinson’s disease with glucocerebrosidase

mutations

M. Mijajlović, N. Kresojevic, S. Perić, A. Pavlović, M. Svetel, M. Janković, V. Dobričić, I. Novaković, M. Lakočević, V. Kostić

Clinic for Neurology CCS, School of Medicine, University of Belgrade, Serbia

Objectives: The aim of this study was to search for possi-ble differences in the findings of transcranial sonography (TCS) between groups of patients with glucocerebrosidase (GBA)-associated Parkinson’s disease (PD) (4 patients with Gaucher dis-ease type 1 and parkinsonism [GD+PD+] and 18 PD patients with heterozygous GBA mutations; [GBA+PD+]) and groups of 12 pa-tients with Gaucher disease type 1 and no signs of parkinsonism (GD+PD-), 9 asymptomatic carriers of heterozygous GBA muta-tions (GBA+PD-), 32 sporadic PD patients (sPD), and 49 healthy controls. Results: In all groups of patients, except asympto-matic carriers of heterozygous GBA mutations (mean ± SD: 0.16 ± 0.03 cm(2)), the maximal areas of substantia nigra hyper-echogenicity (aSN-max) was higher (GD+PD+: 0.28 ± 0.15 cm(2); GD+PD-: 0.18 ± 0.06 cm(2); GBA+PD+: 0.27 ± 0.06 cm(2); sPD: 0.28 ± 0.10 cm(2)) when compared to controls (0.11 ± 0.09 cm(2)) (p = 0.001). In GBA-associated PD (GD+PD+ and GBA+PD+) and sPD, aSNmax values were very similar. Moderate or marked SN hyperechogenicity was present in 87.5% of sPD patients and in 83% of PD patients with heterozygous GBA mutations, but in only 11.6% of controls, and in 22.2% and 33.3% of patients from GBA+PD- and GD+PD- groups, respectively (p < 0.001). The prevalence of interrupted or missing echogenicity of the brainstem raphe differed between the groups (p = 0.046), while no difference was observed in the diameter of the third ventricle. Conclusions: TCS findings in GBA-associated PD were very similar to those of patients with sporadic PD.

P71

Transcranial sonography of substantia nigra

echogenicity to predict therapy response in

idiopathic restless legs syndrome – a prospective

study

F. Doepp1, S. Schreiber1, P. Grosse1, E. Breuer1, F. Salih1

1Department of Neurology, University Hospital Charité, Berlin, Germany

Background: Substantia nigra (SN) hypoechogenicity is a com-mon finding in idiopathic restless legs syndrome (iRLS) probably indicating a nigral iron deficiency. However, its pathophysiologi-cal origin and possible clinical implications are still uncertain. For example, a potential relationship between SN echogenicity and re-sponse to dopaminergic therapy is not well studied. Objective: To prospectively analyse the response to dopaminergic treatment in iRLS patients with and without SN hypoechogenicity. Methods: 25 patients with iRLS (48 ± 15 years), were prospectively enrolled. A sum area of both sides <0.12 cm2 was defined as SN hypoechogenic-ity (values below mean minus one SD of 81 age matched healthy controls: 0.22 ± 0.10 cm2). SN echogenicity was assessed initially by an experienced investigator blinded for the clinical syndrome. Disease severity and concomitant sleep disorder were analyzed be-fore and after each treatment period (L-Dopa followed by Ropinirol, 8 weeks each) using the International Restless legs scale (IRLS) and Insomnia Severity Index (ISI), respectively. A reduction of ≥ 33% on one or both scales was defined as positive therapy response. Results: Mean SN echogenicity in iRLS was 0.15 ± 0.1 cm2. IRLS scores in patients with SN hypoechogenicity (n=10) were 25 ±7 (ini-tial), 17 ± 7 (8 weeks) and 18 ±8 (16 weeks) compared to 26 ± 5, 14 ± 12, 12 ± 8 in patients without SN hypoechogenicity (n=15). The corresponding ISI scores were 18 ± 7, 14 ± 6, 10 ± 5 and 18 ± 4, 14 ± 4, 12 ± 6. None of the differences were significant. The number of patients with positive response to therapy did not differ significantly between the two groups. Conclusion: SN hypoechogenicity is not associated with positive response to dopaminergic therapy in iRLS.

P72

Transcranial brain sonography findings in

neurosaroidosis

M. Mijajlović1, V. Vučinić2, N. Šternić1, J. Videnović2, M. Stjepanović2, M. Omčikus2, S. Filipović2

1Clinic for Neurology CCS, School of Medicine, University of Belgrade, Serbia; 2Clinic for Pulmonary Diseases CCS, School of Medicine, University of Belgrade, Serbia

Background: To date, transcranial sonography (TCS) is known to complement clinical findings in the diagnostic work up mostly of parkinsonian syndromes. However no investigation was performed to evaluate the TCS findings in neurosarcoidosis. In this study we wanted to elucidate the TCS findings and the cor-relation between the sensation of fatigue, depressive symptoms,



anxiety, restless legs syndrome (RLS) and sleep disorders in neu-rosarcoidosis patients. Methods: TCS was used to measure the echogenicity of substrantia nigra (SN, cm2),nucleus ruber (NR, cm2) and brainstem raphe on a two point scale (BR; normal echo-genicity grade 1, hypoechogeniscity/invisible BR grade 0) as well as diamter of the third ventricle (TV, mm). 47 biopsy positive neuro-sarcoidosis patients 27 female/ 20 male), mean age 49.9 ±9.6 years , were enroled into the study. Prior to TCS patients were evalu-ated for fatigue, depression and anxiety using : Fatigue Assessment Scale, (FAS), Beck Depression Inventory (BDI), Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD). RLS was evaluated using the Restless Legs Syndrome Rating Scale (RLRS) and the quality of sleep with the Pittsburgh Sleep Quality Index (PSQI). Results: Statistically significant correlation was found between PSQI mean score and FAS mean score (B=1.20; t=14.97 ;p<0.001; Rsquare=0.91); PSQI and BDI (B=0.83; t=9.80 ;p<0.001; Rsqare=0.82); PSQI and HAMA (B=0.75; t=15.38; p<0.001; Rsquare=0.92); PSQI and HAMD (B=0.71; t=13.13 ;p<0.001; Rsquare=0.89);and PSQI with RLRS (B=0.85; t=12.76 ;p<0.001; Rsqare=0.89).Hyperechogenicity of SN , with hyperechogenicity of NR coexisted in 43/47 neurosarcoidosis patients. BR echogenicity was normal-grade 1 in 28/47 sarcoidosis patients. Conclusions: The level of fatigue, depression, anxiety and movement disorders (RLS) significantly correlate with the quality of sleep in sarcoidosis patients. TCS showed the co existence of pathological findings of SN and NR in these patients.

P73

Transcranial sonography and tilt test in idiopathic

REM behaviour disorder: preliminary data

E. Guaschino1, N. Ghiotto1, D. Bosone1, A. Moglia2

1Neurovascular and Autonomic Nervous System Laboratory, IRCCS Neurological National Institute C. Mondino, Pavia, Italy; 2 Public Health and Neurosciences Department, IRCCS Neurological National Institute C. Mondino, Pavia, Italy

The neurochemical hallmark of Parkinson Disease (PD) is do-pamine loss in the nigrostriatal pathway. A large body of evidence suggests that PD-specific pathologic features antedate the onset of diagnostic clinical features, and the preclinical period of nigral cell loss has been estimated to last several years. In recent years, Transcranial Sonography (TCS) has been proven to be useful in detecting basal ganglia. Pathological hyperechogenic alterations are seen in the SN in patients with idiopathic REM behaviour disorders (IRBD). Data suggest that IRBD go on to develop PD/parkinsonism. There is also mounting evidence in the literature about IRBD that many of the non-motor symptoms that occur in PD also occur in IRBD. Recent reports support the presence of au-tonomic dysfunction, especially orthostatic hypotension in IRBD. The aim of our study is to assess autonomic function through tilt test examination, completed with Valsalva maneuver, in IRBD pa-tients versus healthy controls and correlate the findings with TCS images of basal ganglia, evaluating any changes in TCS findings in the two groups and their potential relationship with autonomic function. Five consecutive subjects referred to Sleep Center of

our Neurological Institute with clinical diagnosis of IRBD, con-firmed by video-polysomnographic study, will be enrolled in the study and will be compared with 5 healthy controls, age and sex matched. All the patient will undergo unified Parkinson‘s disease rating scale. To date we have studied 2 patients with IRBD, show-ing hyperechogenicity of SN without motor symptoms typical for extrapyramidal involvement. Of the two patients one had a positive tilt test for orthostatic hypotension. Identification of indi-viduals in premotor phase, using a non invasive and inexpensive method would allow testing disease-modifying drugs to prevent the onset of motor symptoms and thereby reduce direct and indi-rect medical costs. Follow-up studies are needed.

P74

Severity of restless legs syndrome is inversely

correlated with echogenicity of the substantia nigra

in different neurodegenerative movement disorders:

a preliminary observation

J.L. Pedroso1, E. Bor-Seng-Shu2, R. C. Nogueira3, M. F. Machado2, A. C. Felicio1, P. Braga-Neto 1, L. A. Dutra1, C. C. de Aquino1, H. B. Ferraz1, 1G.F. Do Prado, 2 M. J. Teixeira, 1 O. G. Barsottini1Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 3Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

Objectives: Hyperechogenicity of the substantia nigra is a fre-quent observation on transcranial sonography in Parkinson’s dis-ease and Machado-Joseph disease patients. Additionally, restless legs syndrome is a sleep disorder that is also frequently found in both diseases. Autopsy studies have demonstrated increased SN iron content in hyperechogenic substantia nigra. Iron storage is also known to be involved in restless legs syndrome. We formally compared echogenicity of the substantia nigra with restless legs syndrome in Parkinson’s disease and Machado-Joseph disease pa-tients. Methods: Transcranial brain sonography was performed in a sample of Parkinson’s disease and Machado-Joseph disease patients, and findings then correlated with the presence and sever-ity of restless legs syndrome. Results: There was a continuum of substantia nigra echogenicity among groups (Parkinson’s disease versus Machado-Joseph disease versus controls) and sub-groups (Parkinson’s disease with and without restless legs syndrome ver-sus Machado-Joseph disease with and without restless legs syn-drome) as well as a statistically significant negative correlation between restless legs syndrome severity and substantia nigra echo-genicity (p<0.001). Conclusions: These preliminary observations demonstrate that the severity of RLS may be influenced by nigral iron load reflected by substantia nigra echogenicity in different neurodegenerative movement disorders.


P75

Sickle cell disease task force – A new concept to

improve the number of children evaluated by

transcranial Doppler in high prevalent regions – Pilot

study in Brasilia, Brazil

M. C. Lange1, V. F. Zetola1, A. C. Leite3, C. Low2, D. L. Gomes4, C. Moro5, M. M. Alves4, A. R. Massaro6 to the Brazilian Task Force Group1Hospital de Clínicas, Curitiba; 2Hospital da Criança Jose de Alencar, Brasilia; 3Hemorio, Rio de Janeiro; 4 Hospital São Paulo, São Paulo; 5 Hospital São José, Joinville; 6Hospital Sírio Libanês, São Paulo, Brazil

Aim: To present the results of the first transcranial Doppler (TCD) task force to improve the early evaluation of patients with indication to chronic transfusion therapy in Brazil. Methods: Children between 2 and 16 years old without previous history of stroke were submitted to the TCD examination, this was done in a public hospital in Brasilia, two days before the 8th World Stroke Congress. All evaluations had a second neurosonologist observer. All the abnormal, conditional or inadequate evaluations (techni-cal difficulty, low velocity, absence of window) were reviewed by a second examiner. Results: During ten hours, 56 patients were evaluated, the mean age was 10.7 ± 3.69 years old, 28 (50%) were female. Only seven (12.5%) patients were submitted to a previ-ous TCD evaluation in their life. Forty nine (87.5%) patients had a normal TCD evaluation, four (7.14%) had a low conditional, one (1.79%) had a high conditional and two (3.57%) had an abnormal finding. Conclusion: This pilot study demonstrated that TCD task force was efficient to identify SCD patients at high risk to is-chemic stroke in Brazil. The project will be an example to improve TCD evaluation in areas with high prevalence of SCD in Brazil in the next years

P76

Stroke and disability predictors in patients with

intracranial atherosclerosis

A. Palmieri, F. Farina, G. Meneghetti, C. Baracchini

Department of Neuroscience, University of Padua School of Medicine, Padua – Italy

Introduction: Few data are available about stroke recurrence and disability in patients with intracranial atherosclerosis, al-though this condition is likely the most common cause of stroke worldwide. The aim of this study was to investigate the most im-portant predictors of stroke recurrence and disability in a group of patients with symptomatic or asymptomatic hemodynamically significant intracranial atherosclerotic stenosis. Materials and Methods: We enrolled twelve consecutive first-ever stroke patients with symptomatic intracranial atherosclerotic stenosis admitted to our Stroke Unit (8 males, 4 females) and eight patients with asymptomatic intracranial atherosclerotic stenosis referred to our Neurosonology Laboratory (6 males, 2 females). Atherosclerotic

intracranial stenosis was diagnosed and graded (50%-69%, 70%-99%) by ultrasound (TCCD) and confirmed by Magnetic Resonance Angiography/CT Angiography/Digital Subtraction Angiography. All patients were treated with best medical therapy following international guidelines and regularly followed clini-cally and instrumentally (TCCD/CTA/DIR-MRI). Results: After 2 years from diagnosis, two patients in the asymptomatic group (2/8; 25.0%) were dead: cardiac arrest, hemorrhagic stroke. In the symptomatic group, at 2 years from their first stroke, three patients (3/12; 25.0%) had a second ischemic stroke during this period: all strokes were in the same territory of the stenotic vessel. Moreover, considering both groups, seven patients (7/18; 38.9%) significantly worsened in terms of clinical disability, with a higher mRS score than at first visit/discharge; and five patients (5/18, 27.8%) had a mRS score of 3 or more. The most important predictors of stroke/stroke recurrence and disability were: degree of stenosis (>70%), stenosis progression, time from the initial event, more extensive cortical damage. Conclusions: With the limitations of our study sample, patients with asymptomatic and symptomatic severe (>70%) intracranial atherosclerosis and extensive cortical brain damage seem to have a worse prognosis regardless of optimal ag-gressive medical treatment and might represent a high-risk popu-lation eligible for endovascular intervention.

P77

Vertebrobasilar insufficiency and vascular screening:

the role of TCD

V. Zetola1, R. Mendes2, C. Adriano2, A. Mair2 M. Lange1, A. Caldart3, M. Oriques3, M Mocellin2

1Division of Neurology, Hospital de Clinicas, Universidade Federal do Parana, Brazil; 2Division of Otorhinolaryngology, Hospital de Clinicas, Universidade Federal do Parana, Brazil; 3Speech therapists, Universidade Federal do Parana, Brazil

Symptoms of vertebrobasilar insufficiency (VBI) are often non-specific and establish this diagnosis is a major clinical challenge. Transient ischemia of the vertebrobasilar territory requires a rapid and effective approach to avoid serious consequences. Embolism or hemodynamic insufficiency due to occlusion or compres-sive etiology should be investigated. We aimed to evaluated the contribution of combining transcranial Doppler (TCD) with carotid and vertebral duplex (CVD) in patients with suspected VBI. Background: TCD has a good sensitivity and specificity for hemodynamically significant stenosis, enables emboli detection and allows for hemodynamic monitoring during head movements. Method: During 3 years we selected 201 patients diagnosed clini-cally as VBI with normal otoscopy. We excluded from the study patients with labyrinthine crisis, benign paroxysmal positional vertigo, Meniere`s Syndrome, use of vestibular depressant medi-cation, traumatic brain injury history and stroke. We perfomed audiometry, tympanometry, vectoelectronystagmography, CVD and TCD in all. Results: the mean age was 63 years (+ 15) and 70.1% were female. TCD showed corroborative findings for VBI in 56 (28%): significant change in the flow during positional ma-neuvers, stenosis signs, reverse flow (vascular steal) and very low



mean velocity associated with a significant increase in pulsatility. Although not all patients undergo an image evaluation we could confirm all cases of stenosis and some flow reduction from ana-tomical variations. The CVD results were considering when any finding was described, even hypoplasia. 14 (26%) of the samples showed positive findings and in 90% were coincident with TCD. The principal clinical correlations were balance disorders, falls and vertigo. Conclusions: DTC should always be performed together with CVD because of the higher sensitivity. This combined ap-proached seems to be a suitable method to select patients to fur-ther investigation.

P78

hsCRP and PAI-1 level and its association with

ischemic stroke with underlying intracranial stenosis

using TCD for assessment intracranial stenosis at

RSUPNCM Jakarta

S. Harris1, I. Aprianti2, N. N. Rida Ariarini 3

1,3Department of Neurology Faculty of Medicine University ofIndonesia; 2National Brain Center Hospital, Indonesia

Introduction: Stroke is the leading cause of death in Indonesia. Most of stroke cases was ischemic stroke. The majority of ischemic stroke, especially in Asia, caused by intracranial ste-nosis. Intracranial stenosis is an iceberg phenomena in Indonesia. Pathophysiology mechanism of intracranial stenosis is based on atherosclerosis process, caused by inflammation and fibrinolytic impairment . hsCRP was the marker of inflammation respec-tivelly. The purpose of this study was to find out hsCRP level and its association with ischemic stroke with underlying intrac-ranial stenosis. Methodology: Cross sectional with consecutive non random sampling was conducted. Ischemic stroke patients at RSUPNCM, from June 2011 to November 2011 performed TCD for intracranial stenosis assessment. Subjects diagnosed intracranial stenosis performed serum hsCRP and PAI-1 level measurement. Result: Among 46 patients, mean age was 57.98 ± 8.09 years with 60.9 % over 60 years, and 35(76.1) % were men. hsCRP level was 2.6 (0.1-14.3) mg/L and PAI-1 was 39.72 (2.03) ng/ml. We found significant relationship between hsCRP level and degree of stenosis (p=0.04), but not for PAI-1 level . PAI-1 level showed significant relationship only if more than one abnormality identified (degree of stenosis, number of stenosis, or extracranial carotid abnormality) (p=0.026). Discussion: hsCRP level was as-sociated with degree of intracranial stenosis in our study as shown by other studies. PAI-1 level associated with all atherosclerotic le-sions, therefore degree of intracranial stenosis was not the only factor related to atherosclerotic lesions leading to increase PAI-1 level. Keyword: ischaemic stroke, intracranial stenosis, hsCRP, PAI-1,TCD.

P79

Neurosonologic study of cerebral vascular anomalies

(CVAs)

L. Pascazio1, C. Chiapparino1, P. Iaffaldano2, F. Federico1 1Stroke Unit, Neurology I, 2Neurophysiopathology Unit, Department of Neurosciences and Sense Organs, Bari, Italy

Objective: Assessing TCCD’s role in CVAs diagnosis and follow-up. Methods: 24 pts mainly with intra-parenchymal hem-orrhage prodromal signs received neuroimaging, angiography tests and TCCD. Results: CT/MRI supplemented by angiography (MRA-CTA), digital angiography (DSA) diagnostic and therapeu-tic in 16 pts., revealed 11 anterior circulation (AC), 5 posterior circulation (PC), 2 basilar artery (BA) and 3 vertebral artery (VA) aneurysms. Dimensions: 1 giant, 3 large, the others small; 4 large-sized and 4 small-sized arteriovenous malformations (AVMs). TCCD Aneurysm Findings: previously embolized and partially recanalized giant aneurysm seems to have a megadolicobasilar nature, relevant slight flow velocity increase, reduced Pulsatility Index(P.I.), in quite good compensation; one 7-mm VA aneurysm, two-color pattern and two ectasias, one of the BA and one of the VA with P.I. reduction, all newly diagnosed. TCCD was in line with angiographic findings in 4 cases, with PC malformations. TCCD AVM Findings. 1st case: basal region 6-to7mm AVM, AC flow velocity increase more pronounced on the left, Middle Cerebral Artery (MCA) VSP: 300cm/sec, P.I.: 0.40; VSP Straight Sinus (SS) and Rosenthal Vein: 53.3cm/sec, bilaterally. Post-embolization TCCD: AVM no longer visible, bilaterally reduced MCA VSP, normal P.I., reversed left SS, drain via pterigoideal plexuses. 2nd case: (CTA diagnosis of proliferative angiopathy) 1-cm AVM, with aliasing, right MCA VSP: 400 cm/sec, P.I.:0.35; flow velocity asymmetry greater on right than on left also in the extra-cranial carotid district. Stable follow-up. 3rd-4th case: post-embolization reduced AVM, right transverse sinus AV fistula with increased flow velocity indices. TCCD sensitivity and specificity in aneu-rysm diagnostic procedures is 31% and 43%, respectively, whereas for AVMs it stands to 57% and 69%. Discussion and conclu-sions: TCCD turns out to play a fairly good role in the diagnosis of AVMs, it fares poorly with aneurysms and small CVAs close to cortical regions, but excellently in AVMs follow-up.


P80

Transcranial color Doppler in adult patients with

sickle cell disease

F. M. Casoni1, G. Graziadei2, A. Marcon2, P. Ridolfi2, I. Gandolfi2, F. Annoni1, M.D. Cappellini2

1 Department of Pathophysiology and Transplantation, – Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – University of Milan; 2 Haereditary Anaemia Centre, Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Department of Clinical Sciences and Healthy Community – Italy

Background: the risk of stroke in patients with Sickle Cell Disease (SCD) is much higher than in the general population, with incidence of 11% by age 16 and of 24% by 45 age. In the Stroke Prevention Trial in Sickle Cell Anemia (STOP Trial) validity of the TransCranial Doppler and threshold velocity ≥200 cm/sec were demonstrated to be useful in the prevention of stroke in paediat-ric patients with SCD, but actually there is little knowledge about the adult patients with SCD. Aim: try to standardize the Doppler parameters in adult patients with SCD, using TransCranial Color Doppler (TCCD) with the correction of the angle of insonation. Material and methods: we enrolled 50 outpatients followed in the Congenital Anaemias Center in Milan, affected by SCD (15 with Sickle Cell Anaemia, SCA; 25 Sickle β-Thalassemia, HbS-Thal and 10 haemoglobinopathy SC disease), over the age of 16 years and 25 control subjects, matched for sex, ethnicity and age. Patients and control subjects were evaluated by TCCD. We evalu-ated haemoglobin (Hb) values, systolic and end diastolic peak, resistance and pulsatility index in the middle (MCA), anterior (ACA), posterior (PCA) cerebral arteries, carotid siphon, vertebral and basilar arteries. Results: mean Hb values of SCD and con-trols subjects were 9.9±1.5 and 14±1 g/dl; in SCA, HbS-Thal and SC were respectively 9.1±1, 9.5±1.4 and 11.9±1 g/dl. In all healthy adults TCCD was normal. Adults with SCD had a higher peak-systolic velocity (121 cm/sec ± 19) compared with healthy controls (110 cm/sec ± 15); in particular SCA patients had much higher velocities than the others (130 cm/sec ± 19), according with lower Hb values and worse clinical features. Conclusion: velocities in adults are lower than those provided by the STOP trial in children, confirming that the speeds disclose an age-related decline, how-ever are higher than in healthy controls.

P81

Dynamic cerebral autoregulation in acute

intracerebral hemorrhage

M. Oeinck1, F. Neunhöffer2, S. Meckel3, K.J. Buttler4, C. Weiller1, M. Reinhard1

1University of Freiburg / University Medical Center / Department of Neurology, Freiburg, Germany; 2Klinikum Augsburg / Department of Anesthesiology, Augsburg, Germany; 3University of Freiburg / University Medical Center / Department of Neuroradiology, Freiburg, Germany; 4University of Freiburg / University Medical Center / Department of Neurosurgery, Freiburg, Germany

Purpose: Blood pressure management in acute intracerebral hemorrhage (ICH) should be adapted to functioning cerebral au-toregulation (CA), which is not generally and early impaired in ICH. Rapid dynamic properties of CA are probably more vulner-able and important in counteracting short-term blood pressure fluctuations. They may be impaired in ICH, but their time course during the acute stage and relation to outcome is not known.Methods: 26 patients with spontaneous ICH were studied on days 1, 3 and 5 after onset. Dynamic autoregulation was measured from spontaneous fluctuations of blood pressure and middle cerebral artery flow (assessed by transcranial Doppler) by transfer function analysis in the low frequency range between 0.06-0.12 Hz (phase as a measure for rapid counter-regulation, gain as measure for rapid dynamic dampening of blood pressure fluctuations). Results were compared with 55 healthy controls and related with clinical fac-tors and 90-day outcome (modified Rankin scale, mRS). Results: Average phase values of all patients did not differ across days, be-tween ipsi- and contralateral sides and compared with controls. Lower ipsilateral phase on day 5 was significantly associated with higher mRS on day 90. In a multivariate analysis it showed in-dependence from other hemodynamic factors. On each day, low phase on lesion side was related with lower GCS. On day 1 low-er ipsilateral phase was associated with lower cerebral perfusion pressure. Gain was significantly higher in patients compared with controls across all days and on both ipsi- and contralateral sides. It showed, however, no significant relation to outcome or other clinical factors. Conclusions: Rapid temporal characteristics of CA (phase) are not generally altered in acute ICH. Individually poorer phase values are, however, associated with larger ICH volume, lower blood pressure and poorer outcome. Dampening characteristics (gain) are generally impaired in acute ICH but not related to clinical factors or outcome.



P82

The Norwegian Sonothrombolysis in Acute Stroke

study NOR-SASS

A Nacu, CE. Kvistad, U. Waje-Andreassen, H. Naess, L. Thomassen

Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, University of Bergen, Bergen, Norway

Background: Sonothrombolysis augments intravenous thrombolysis. Ultrasound promotes motion of fluid around the thrombus, stimulates arterial dilation, weakens fibrin cross-links, increases tPA concentration within the thrombus. Studies show that 2-MHz pulsed-wave ultrasound can double the chance of early complete recanalization without increasing the risk of symp-tomatic intracerebral haemorrhage. Contrast enhanced sono-thrombolysis (CEST), adding intravenous gaseous microspheres, may potentiate the effect of ultrasound. When exposed to ultra-sound, microspheres oscillate, expand and collapse, agitate sur-rounding fluid, erode thrombus surface and increase the surface area for thrombolytic action. Ultrasound in the absence of tPA accelerates clot break-up through mechanical mechanisms. These mechanisms are enhanced by echo contrast. Contrast enhanced sonolysis (CES) may therefore be clinically more effective than ul-trasound alone.

P83

Ultrasound-enhanced systemic thrombolysis for

acute ischemic stroke1R. C. Nogueira, 2K. A. Norremose, 2A. N. Esteves, 2M. L. Oliveira, 1K. .J. Almeida, 2E. Bor-Seng-Shu, 1F. I. Yamamoto, 1E. F. Evaristo, 2M. J. Teixeira1Department of Neurology, Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

Background and aims: It is supposed that Transcranial Doppler ultrasonography (TCD) during thrombolysis may help to expose thrombi to tissue plasminogen activator (t-PA). The aim of this study is to determine if TCD can safely enhance the throm-bolytic activity of t-PA. Methods: Patients with acute ischemic stroke which fufill current criteria to intravenous t-PA treatment were randomly assigned to receive continuous 2-MHz TCD (the target group) or placebo (the control group). In follow up analysis, outcomes are defined as good (as indicated by a score of 0 - 2 on the modified Rankin scale) or favorable (scores of 0 -1 on modified Rankin Scale). Results: A total of 108 patients were enrolled to re-ceive continuous ultrasonography waves (57 patients) or placebo (51 patients). The mean age was 64 in TCD group and 63 years in control group. Mean NIHSS score at admission was 13 in TCD group and 17 in control group. Good outcome was observed in 26 patients in the target group (45,6%) as compared with 19 patients in the control group (37,3%). A favorable outcome occurred in 25

patients in the target group (43.9%) as compared with 15 patients in control group (29.4%). Conclusion: In spite of results without significant statistical difference (p=0,136), a trend to better recov-ery was observed in the target group. TCD may have a role in the improvement of outcomes of patients submitted to thrombolytic approach.

P84

Early hemodynamic changes post intracranial

thrombectomy: a sign of vessel wall injury?

J. M. Pignat1, V. Mendes Pereira2, F. Perren1

1HUG, University Hospital and Medical Faculty of Geneva Department of Neurosciences, Division of NeurologyNeurosonology Unit; 2HUG, University Hospital and Medical Faculty of Geneva Department Radiology, Interventional Neuroradiology, Switzerland

Introduction: Stent retrievers are new devices for me-chanical thrombectomy. They have revolutionized endovascu-lar treatment of acute ischemic stroke with good recanalization and acceptable safety. However, previous animal studies have shown that mechanical thrombectomy may cause endothe-lial injury of the arterial wall leading to myointimal hyperplasia. METHODS: We studied ischemic stroke patients suffering from acute intracranial single large artery occlusion in whom me-chanical thrombectomy using stent retrievers was performed. Only those with complete vessel recanalization as assessed by post-procedural DSA and in whom MRA and transcranial du-plex sonography (TDS) were performed were retained. Complete revascularization was defined as modified TICI 2b or 3. Patients treated with intra-arterial thrombolysis or stenting of these ar-teries were excluded. Results: 9 acute ischemic stroke patients due to arterial occlusion (8 MCA (M1), 1 BA) showed complete recanalization post thrombectomy. All of them received acetyl-salicylic acid. Post acute MRA (mean 4.8 days) confirmed com-plete recanalization without residual stenosis or vasospasm. However, in all 9 patients transcranial duplex sonography (mean 3.4 days after thrombectomy) showed segmental acceleration of blood flow velocities in the affected arteries (MCA PSVmax at least > 35% as compared at same depth with the controlater-al side; BA PSVmax > 40% as compared to velocities measured in the same vessel). None showed clinical deterioration. TDS of control (mean 12 days) showed normalization in 2 /4 of them. Conclusion: This pilot study is the first showing with TDS early focal acceleration of blood flow velocities in intracranial arteries after thrombectomy with stent retrievers. In the absence of residu-al stenosis or vasospasms, this might be a sign of vessel wall i.e. in-timal injury in humans. Whether this is due to local inflammatory agents, neothrombosis or myointimal hyperplasia is not yet clear.


P85

Improvement of transcranial ultrasound uniformity by random modulation

O. Saito, H. Furuhata

Medical engineering laboratory, Research center for medical science, The Jikei university school of medicine, Tokyo, Japan

It is known that transcranial ultrasound irradiation can en-hance the effect of thrombolytic agent tissue plasminogen activa-tor (tPA). The ultrasound beam is inhomogeneous in the near-field region of the transducer and there are high-intensity (hot) spots of the ultrasound and low-intensity (cold) spots. The inhomogene-ous distribution can be problematic in the application to sono-thrombolysis, because risk of hemorrhage is higher at the hot spots and the effect of the tPA cannot be enhanced at the cold spots. In this work, we showed that the hot and cold spots problem can be resolved by modulation of the activating signal, which was first introduced in order to reduce the standing waves in the skull. In particular, we investigated the modulation method which inverts the phase of the sinusoidal wave at random intervals. We com-pared the random modulation method with sinusoidal one. In or-der to quantify the uniformity of the ultrasound field, we proposed a term Uniformity Index (UI) and gave a mathematical expression. The smaller value of UI means the more homogeneous field. We calculated the UI from the field distribution obtained by hydro-phone measurement. While the UI was 306 for sinusoidal wave in the free-field (without any obstacle) case, it was 213 for randomly modulated wave. In the case of passing through the temporal bone fragment, the UI was 566 for sinusoidal wave and 266 for random-ly modulated wave. It was shown that random modulation method can resolve hot and cold spots problem as well as standing wave problem. The present study is expected to play a role in developing safer and effective transcranial therapeutic equipment.

P86

Neuronosological monitoring during thrombolytic

therapy: TCCD’s role in diagnosis and selection of

therapeutic strategies

L. Pascazio1, C. Chiapparino1, P. Iaffaldano2, F. Federico1 1Stroke Unit, Neurology I, 2Neurophysiopathology Unit , Department of Neurosciences and Sense Organs, Bari, Italy

Objective: Assessing outcome and recanalization in patients undergoing thrombolytic therapy (TL) as a function of the kind of procedure (i.v. or i.a.). Methods: 44 pts, age range: 26-80, received pre- and post-TL neurosonological monitoring and angiography in 25 cases, in line with diagnostic ultrasound findings. Results: 5 pts with proximal occlusion respectively received i.a. TL (2 pts) and i.v. TL (3 pts), associated to sonothrombolysis in 1 pt. Good Outcome (G.O.) in 1 pt; Middle Outcome (M.O.) in 2; Poor Outcome (P.O.) in 2. Of 17 pts, 16 with Middle Cerebral Artery (MCA) and 1 with Basilar Artery occlusion/sub-occlusion,10 re-ceived i.v. TL (G.O. in 4 pts, M.O. in 2, P.O. in 4) and 7 i.a. TL (G.O.

in 6, M.O. in 1). 7 pts with M2-MCA occlusion/sub-occlusion re-ceived i.v. TL; G.O. in 4 cases, M.O. in 2, P.O. in 1. 15 pts exhibited collateral or terminal branches thrombosis: G.O. in 11 pts, M.O. in 3 and P.O. in 1. Statistical analysis: the outcome depends on pre-TL NIHSS severity, but not on TL (i.v./i.a.) type; it improves the more distal the occlusion is, P=0.001. G.O. correlates with early recanalization, P.O. with late recanalization, P:0.028; an associa-tion is observed between i.v. TL and late recanalization, P: 0.044. Discussion and Conclusions: G.O. was observed in 26 pts, 7 with underlying early total recanalization and the others with un-derlying early and efficient compensation. In patients treated with i.a. TL recanalization was more frequently earlier and complete, moreover the more proximal the occlusion was, the less likely was the possibility of a collateralization-induced efficient compensa-tion. In subjects with serious cardio-circulatory impairment and reduced likelihood of collateralization, TCCD plays a crucial role not only for diagnostic purposes, but also for informing therapeu-tic options alternative or complementary to i.v. TL, thus allowing for an improved outcome

P87

Sonothrombolysis in Araucanía, Chile: thrombolytic

treatment in acute ischemic stroke in a new stroke

center

R. Rivas 1,2, C. Klapp1, M. C. Abarca3, L. Bustos4, M. Manosalva4, C. Merino5, B. Cid5

1Department of Neurology, Stroke Unit, Clínica Alemana de Temuco, Temuco, Chile; 2Universidad de La Frontera, Department of Neurology, Temuco, Chile; 3Universidad Mayor, Faculty of Medicine, Temuco, Chile; 4Emergency Room, Clínica Alemana de Temuco, Temuco, Chile; 5Critical Care Unit, Clínica Alemana de Temuco, Temuco, Chile.

Background: Stroke is the first common cause of death in Chile, since 2008. The Araucanía region is the region with the worst indicators of outcome in stroke in our country. Object: Sonothrombolysis (ST) has recently been considered an emerging modality for the treatment of stroke. The purpose of the present study is to show the efficacy and the efficacy of ST associated with tissue plasminogen activator (tPA) on acute ischemic stroke in a center without previous experience. Methods: We conducted a retrospective review, in a middle size clinic (120 beds), in Clínica Alemana de Temuco, involving patients who underwent ST with a protocol of 2 hours, associated to tPA, between April 2010 to January 2013. The frequency of ultrasound waves was on 2 MHz (Spencer PMD 150). Data extraction was based on ultrasound vari-ables, patient characteristics, and outcome variables (rate of intrac-ranial hemorrhages and arterial recanalization). Informed consent forms were applied. Results: Of a total of 158 patients, 16 patients were included. The mean age was 61.5 (± 6.5) years, 56.8% were males. Median NIHSS score (baseline): 13 (5-24). Door - treatment time: 61.3 (± 23.2) minutes. Occluded artery symptoms: MCA: 75%. PCA, BA and VA: 25%.Onset treatment ≥3-4.5 hours: 43.8%. Symptomatic hemorrhage: 6.3%, mortality at 3 month 0%, com-plete recanalization 75.0%, partial recanalization 25%, mRS 0-1 (3



month): 81.3%, BI (3 month) ≥ 95: 87.5%. Proportion of patient that went to this procedure: 10.1%. Conclusions: Despite the little sample size, a standard protocol of ST associated to tPA in a newly and middle center in a development country is feasible and safety and is associated with a favorable outcome when it is applied by neurologists specifically trained in acute stroke management, even in patients of more than 3 hours.

P88

The relationship between the degree of

cerebral blood flow augmentation by external

counterpulsation and clinical outcomes after acute

ischemic stroke

L. Xiong, W. Hua-Lin, X. Yan-Chen, T. Leung, Y. Soo, K. Sing-Wong

Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, China

Background and Purpose:

-

Methods:

-

-

-

-

point. Results:

-

Conclusions: The study is under power to -

P89

Cerebral embolisation during catheter ablation of

atrial fibrillation

N. Patel1, C. Banahan2, J. D. Spiers1, J. Janus1, D. H. Evans1, G. A. Ng1, E. M. L. Chung1

1Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 2Department of Medical Physics, University Hospitals of Leicester NHS Trust, Leicester, UK

Aims: Radio frequency (RF) catheter ablation is curently an ac-cepted form of treatment for atrial fibrillation, a common heart ar-rhythmia. Despite the procedure’s high success rate, recent studies have found 14% of patients have silent cerebral lesions post-proce-dure. This pilot study aims to detect cerebral emboli during RF abla-tion using transcranial Doppler (TCD) ultrasound to determine the embolic load peri-procedure and to estimate embolus composition based on backscattered embolic signal intensity measured as an em-bolus-to-blood ratio, MEBR. In a previous study, 95% of ~850 throm-bus emboli detected post-carotid endarterectomy generated EBR values below 17.3 dB. Applying this as a threshold, emboli above this value were assumed to be gaseous. Methods: Intraoperative moni-toring of blood flow in the middle cerebral arteries was carried out using TCD (Doppler Box, Compumedics Germany) for 18 patients. The timing of microembolic signals was linked to possible origins of emboli transcribed during the procedure and their EBR values were measured offline using in-house software. Furthermore, the num-ber of microembolic signals were then compared between 3 differ-ent types of catheter used in the study: irrigated RF, robot-system and PVAC. Results: Patients experienced hundreds to thousands of emboli distributed throughout the procedure,1603±1419 (PVAC 3202±1324, Robot 1361±18, irrigated RF 768±486). The majority of signals occurred during energy application (86±22%). Of these only 6.2±11% were found to possess EBR values less than 17.3dB. The re-maining signals were observed during catheter manipulation 5±4%, mapping/trans-septal puncture 5±4% and contrast injection 3±3%. Conclusion: Of the 3 types of catheter, PVAC generates higher num-bers of embolic signals than irrigated RF or robot techniques. At least 94% of PVAC signals possessed intensities that were consistent with those of gaseous emboli. Further studies should be carried out to cor-relate embolic load with clinical symptoms, with the use of before/after MRI scans and neuropsychological tests.

P90

Modifying effect of aortic atheroma on ischemic

events recurrence in stroke patients with cervical and

intracranial steno-occlusive disease

L. Pereira, C. Fernandes, M. Rodrigues

Hospital Garcia de Orta, Neurology Department, Almada, Portugal

Background: Large artery atherosclerotic disease is a major cause of ischemic stroke (IS). Ultrasound techniques can access aortic, supra-aortic and intracranial vessels. Transesophageal


echocardiogram (TEE) evaluates aortic plaques. We describe recurrence rate and risk factors in patients with cervical/intrac-ranial disease (CIcDis) and aortic atheroma (AA). Methods: Retrospective observational study in patients admitted to a Neurology ward with IS or transient ischemic attack during 5 years. If TEE was done, clinical data, aortic/supra-aortic/intrac-ranial atherosclerotic disease and follow-up were collected. We report rates, compare groups with chi-square, and calculate recur-rence risk by Kaplan-Meyer curves with Log Rank (LR) and Cox regression with Hazard Ratio (HR), along with 95% confidence intervals (95%CI). Results: Of 1300 patients, 337 underwent TEE (25.9%; mean age 55.7 years; 62.9% male). Carotid non-obstruc-tive plaques were present in 42.5% and stenosis>50%/occlusion in 8.0%. Vertebral steno-occlusive disease occurred in 4.2% and intracranial changes in 14.2%. Aortic complex plaques (CP) were found in 18.2% and 28.3% had non-complex plaques. Diabetes loosely associated with CIcDis (p=0.082), other risk factors didn’t. Older age and smoking related to CP (p<0.001 and p=0.001). Recurrence rate was 10.3% (lethality 1.3%) in 604.7 days of mean follow-up. No difference was found between risk factors of pa-tients with/without recurrence. After 1 year of follow-up more new events were seen in CIcDis (11.7% vs 2.8%, LR p=0.006), even after adjustment for diabetes (HR=4.4, 95%CI 1.4-13.9). mHow-ever CIcDis isn’t predictive of recurrent events in patients without AA (LR p=0.607), while the association is strong if AA is present (LR p=0.013; HR=4.9 95%CI 1.2-19.5). In this last group of pa-tients women had more CIcDis (p=0.021), while other risk factors were balanced. Conclusion: In a group of stroke patients investi-gated with TEE, CIcDis had higher 1 year recurrence risk, but not in subjects without AA. Presence of AA slightly further increases recurrences.

P91

Segmental left ventricle hypokinesis is associated

with embolic signals in transcranial Doppler

A. Warsz-Wianecka, A. Lasek-Bal, P. Puz, Z. Kazibutowska

Department of Neurology, Medical University of Silesia Hospital No. 7, Upper Silesian Medical Centre, Katowice, Poland

Introduction: The significance of segmental left ventricle (LV) wall motion abnormalities for stroke is unknown. Objectives: Determination of the frequency of the embolic signals in the mid-dle cerebral artery in patients with segmental LV wall hypokinesis due to coronary artery disease (CAD) with and without stroke. Patients and methods: We examined: 68 patients (21-87 years) with segmental LV wall hypokinesis: 33 without stroke and 35 with stroke, 37 healthy volunteers and 30 patients from reference group. Clinical data, echocardiography, carotid and transcranial Doppler study with the detection of microembolic signals were performed in all subjects. Results: Embolic signals were detected in patients with segmental LV wall hypokinesis significantly more frequently than in the control and reference groups. At least 3 signals were detected more frequently in patients with CAD and stroke than in patients without stroke. Interventricular septum and apex hypoki-nesis were significantly associated with more frequent embolic signals. Conclusions: Segmental LV hypokinesis in patients with

CAD is associated with the occurrence of embolic signals in the middle cerebral artery that may have clinical importance as a risk factor for a stroke.

P92

Perioperative assessment of cerebral autoregulation

in patients with arteriovenous malformation

V. B. Semenyutin1, V. A. Aliev1, G. K. Panuntcev1, A. Patzak2, A. V. Kozlov1

1 Russian Polenov Neurosurgical Institute, St. Petersburg, Russia; 2Johannes-Mueller Institute of Physiology University Hospital Charité, Humboldt-University of Berlin, Germany

Background: It is established that cerebral autoregulation (CA) in the region of intracranial artery involved in blood supply of arteriovenous malformation (AVM) is impaired. This could be due either to pathologic shunting, disguising real state of CA, or the long-term steal of brain in perinidal cerebral area. But practi-cally it is quite difficult to define the influence of both factors on CA. Purpose: To assess dynamics of CA in patients with AVM in perioperative period. Methods and Materials: 47 patients with AVM were studied pre- and postoperatively. According to Spetzler & Martin classification 12 cases corresponded to I–II grade, 24 – to III, and 11 – to IV. AVMs were embolized either with hystoacryl or onyx through afferent vessels of middle cerebral artery (MCA). The radicality of embolzation was evaluated by calculation of in-tracranial shunting with cerebral angiography or blood flow in-dex in precerebral arteries with Vivid E (GE) prior to and after embolization. We monitored blood flow velocity (BFV) in MCA with Multi Dop X (DWL) and systemic blood pressure (BP) with Finapres-2300 (Ohmeda). CA was assessed with cuff test (autoreg-ulation index – ARI) and phase-shift (PS) between spontaneous oscillations of BP and BFV within the range of Mayer’s waves. Results: Preoperative values of ARI and PS on affected side in all patients were 1.80±0.71 and 0.29±0.17 rad, respectively. In 15 cases (12 – I–II, 3 – III grade) with total (75–100%) elimination significant (p<0.005) increase of rate of CA (ARI – 6.03±1.06, PS – 0.92±0.07 rad) was noted. In other two cases (III grade) with total elimination. CA didn’t change significantly after operation. In cases with subtotal (50–75%) elimination (14 – III grade) postop-erative ARI and PS were 3.61±0.48 and 0.67±0.08 rad, respectively (p<0.05), in cases with partial (up to 50%) elimination (5 – III, 11 – IV grade) – 2.12±0.62 and 0.38±0.06 rad (p>0.05). Conclusion: Elimination of AVM from circulation in majority of examined pa-tients was accompanied by increase of rate of CA. Nevertheless, in few patients with total embolization of AVM low values of rate of CA remained unchanged postoperatively, which testifies real im-pairment of CA in perinidal area caused by steal. This could be used in the management of surgical treatment of AVM and prog-nostication of postoperative neurologic complications.



P93

Perioperative assessment of cerebral autoregulation

in patients with hydrocephalus

V. B. Semenyutin1, V. A. Aliev1, V. P. Bersnev1, A. Patzak2, L. V. Rozhchenko1, A. V. Kozlov1, G. K. Panuntcev1, Sh. Sh. Ramazanov1

1 Russian Polenov Neurosurgical Institute, St. Petersburg, Russia; 2 Johannes-Mueller Institute of Physiology University Hospital Charité, Humboldt-University of Berlin, Germany

Background: It is still unclear the role of cerebral autoregulation (CA) in the pathogenesis of hydrocephalus. It was demonstrated the opportunity of CA evaluation for clarifying indications for surgery in patients with hydrocephalus. Data concerning the dynamics of CA in operated patients given in literature are contradictory. Purpose: To assess the dynamics of CA in patients with hydrocephalus in perio-perative period. Material and methods: 39 patients (aged 18-60) were studied pre- and postoperatively. There were 14 patients with occlusive hydrocephalus (OH) and 25 patients – with communicating hydrocephalus (CH). Cerebrospinal fluid (CSF) pressure was meas-ured in endolumbar (Becton Dickenson, USA) or subdural space (Codman, USA). We monitored blood flow velocity (BFV) in MCA with Multi Dop X (DWL) and systemic blood pressure (BP) with CNAP (Austria). CA was assessed with cuff test (autoregulation in-dex – ARI) and phase-shift (PS) between spontaneous oscillations of BP and BFV within the range of Mayer’s waves. Results: 13 patients with CH had normal values of ARI (6.27±1.16 on the right, 6.73±1.59 – on the left) and PS (1.09 ±0.35 and 1.06±0.30, respectively). Due to an absence of evident symptoms of hydrocephalus and intracranial hypertension (ICH) they didn’t underwent surgery and were recom-mended to conservative medication therapy and observation. The surgery which was aimed to restore normal CSF circulation has been performed in 26 cases (12 with CH and 14 – OH) manifested with apparent clinical symptoms of hydrocephalus and ICH. Niether post-operative clinical improvement nor significant increase of CA rate were observed in 7 cases. Preoperative values of ARI were 5.50±0.57 – on the right, 5.75±0.96 – on the left, PS – 0.96±0.15 and 0.97±0.14 rad, respectively. As for other 19 patients having had clinical improve-ment after surgery preoperative values of ARI (3.82±0.98 on the right, 3.90±0.99 – on the left) and PS (0.56±0.17 and 0.57±0.14 rad, respec-tively) were reliably lower (p<0.05). Postoperatively we noted signin-ficant (p<0.05) increase of ARI (5.12±0.97 – on the right, 5.13±0.96 – on the left) and PS (0.82±0.19 and 0.83±0.17 rad, respectively). Conclusion: Thus CA assessment in patients with hydrocephalus could be used not only for more precise determination indications for surgery but also for evaluation of surgical treatment efficiency in early and remote postoperative period.

P94

An observational study of cerebral blood flow

velocity during hypotensive epidural anesthesia

A. M. Bombardieri1,2,3, N.Sharrock3, G. Go3, J. Drummond4

1Department of Anesthesiology and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), UPMC, Palermo, Italy; 2Department of Anesthesiology, University of Florence, Italy; 3Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA; 4Department of Anesthesiology, University of California and Veterans Affairs Medical Center, San Diego, CA, USA

Background: Hypotensive epidural anesthesia (HEA), as practiced at our institution, employs sympathetic blockade to achieve mean arterial pressure (MAP) of ≤ 50 mmHg while ad-ministering epinephrine infusion to support the circulation (1). Despite MAPs below the commonly accepted lower limit of cerebral blood flow (CBF) autoregulation (LLA) (1), HEA has been associated with normal postoperative neurologic and cognitive function, suggesting maintenance of adequate CBF (3). We undertook this investigation to evaluate CBF veloc-ity (CBFV) with transcranial Doppler during HEA. Methods: Sixty-one patients undergoing hip replacement with HEA were enrolled in this prospective observational study. Following sedation, HEA was induced by lumbar epidural in-jection of local anesthetic to achieve an anesthetic level at T4 or above and infusion of epinephrine adjusted (1-8 mcg/min) to achieve a MAP ≤ 50 mmHg. CBFV in the middle cer-ebral artery was measured first with the patients awake, then at pre-HEA baseline (after administration of sedation and before ac-tivation of the epidural) and continuously during HEA. Results: Fifty-two patients completed the study. With epidural administra-tion of local anesthetic, MAP decreased by 40% of baseline values and was maintained at stable hypotensive levels throughout sur-gery (p<0.0001). On average, CBFVmean did not vary during HEA (p=0.6), CBFVsyst increased by approximately 15% (p=0.0003), and CBFVdiast decreased by 18% (p<0.0001) at all time points during HEA. Pulsatility Index increased during HEA (p<0.0001). There was no correlation between mean CBFV and MAP for MAP val-ues between 100 and 40 mmHg (R2=0.0015, p=0.44). Conclusion: In the setting of HEA, with infusion of epinephrine for circulatory support, CBFV was well maintained in spite of MAPs considered to be well below the commonly accepted LLA. References: 1. Sharrock NE, et al.: Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand 1996. 2. Lassen NA. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959. 3. Sharrock NE, et al. .The early recovery of cognitive function after total-hip replacement under hypotensive epidural anesthesia. Reg Anesth Pain Med 2005.


P95

Intraoperative ultrasonography for presumed brain

metastases: a case series study

H. Picarelli1, M. L. Oliveira1, E. Bor-Seng-Shu2, S. P. B. Lima1, R. C. Nogueira3, E. S. Ribas2, A. M. Santos2, M. J. Teixeira2

1Division of Neurological Surgery, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo SP, Brazil; 2Department of Neurosurgery, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil; 3Department of Neurology, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil

Brain metastases (BM) are one of the most common intracrani-al tumors and surgical treatment can improve both the functional outcomes and patient survival, particularly when systemic disease is controlled. Image-guided BM resection using intraoperative ex-ams, such as intraoperative ultrasound (IOUS), can lead to better surgical results. Methods: To evaluate the use of IOUS for BM resection, 20 consecutives patients were operated using IOUS to locate tumors, identify their anatomical relationships and surgical cavity after resection. Technical difficulties, complications, recur-rence and survival rates were noted. Results: IOUS proved effec-tive for locating, determining borders and defining the anatomical relationships of BM, as well as to identify incomplete tumor resec-tion. No complications related to IOUS were seen. Conclusion: IOUS is a practical supporting method for the resection of BM, but further studies comparing this method with other intraop-erative exams are needed to evaluate its actual contribution and reliability.

P96

Searching for a measure on collateral blood flow:

multimodal intraoperative monitoring during

temporary occlusion in middle cerebral artery

aneurysm surgery

P. A. Silva1, A. Vilarinho1, A. Cerejo1, C. Dias2, R. Vaz1

Departments of 1Neurosurgery and 1Neurocritical CareDepartments of 1Neurosurgery and 1Neurocritical Care, São João Hospital Center and Faculty of Medicine of University of Porto, Portugal

Backgrounds: Surgical clipping remains today a mainstay of treatment for ruptured and unruptured middle cerebral artery aneurysms. Temporary proximal arterial occlusion, a technique frequently applied to promote safer dissection and hemorrhage control, presents the risk of distal ischemia, depending on the time period of occlusion, local anatomy and, most importantly, collater-al blood flow. Intraoperative monitoring, with the use of multiple diverse techniques, has the potential to contribute to the surgeon’s immediate knowledge and aid in decision making. Methods: Consecutive patients submitted to middle cerebral artery aneurysm

surgery were enrolled. After standard pterional craniotomy, online assessment of ipsilateral medial gyrus tissue oxygenation (PbtO2) was performed, and indocyanine green videoangiography (ICG) was undertaken immediately after M1 temporary surgical clipping, dur-ing arterial occlusion, in an attempt to study retrograde blood flow. Results: Five patients (all females), aged 30 - 69 years were admit-ted to the study. In four cases, subarachnoid hemorrhage preceded the diagnosis; the other patient had no previous medical event suggestive of aneurysm rupture. Temporary proximal arterial oc-clusion resulted in reproducible decreases in brain tissue oxygena-tion. During the same period, evidence of retrograde blood flow through the distal middle cerebral artery complex in ICG videoan-giography, variable in extent, was recorded in all cases. Discussion: Collateral blood flow has the potential to rapidly refill the middle cerebral artery complex during temporary arterial occlusion, with functional and surgical implications. Differences in the amplitude of PbtO2 decrease and retrograde blood flow may vicariously rep-resent the available collateral network.

P97

Systemic blood flow and intracranial arterial

velocities changes in the early postoperative course

after cardiac surgery

A. Catalán, R. Sierra, R. Diaz

University Puerta del Mar Hospital, Cádiz/Spain

Objective: To characterize intracranial blood flow velocities (ICBFV) and systemic blood flow (SBF) changes that occur dur-ing the early postoperative course after cardiac surgery Methods: Middle cerebral artery (MCA) and internal carotid artery (ICA) velocities (vel) were measured by transcranial Doppler (TCD) ul-trasound (Multidop DWL, Germany). SBF was estimated by car-diac output which was measured by thermodilution. Data were collected at 2 times [ 2 hours (t1) and 20 hours (t2) after ICU admission ]. Data are expressed as mean values with 95% confi-dence intervals (CI95). Results: Twenty-eight patients who had undergone CS and immediately transferred to ICU afterwards, were prospectively included in this observational study. The types of CS were coronary bypass artery grafting (75%), and heart valve replacement or repair (25%). Mean age and APACHE II were 65.5 (62-69) years and 11.2 (8.6-13.7), respectively. The ICBFV and SBF values at t1 and t2 respectively were: Rigth MCA vel (cm/s), 40.7 (35.4-45.9) and 53 (46.2-59.9) (p<0.01). Left MCA vel (cm/s), 43.8 (38.6-49) and 60 (52.7-67.3) (p<0.01). Left ICA vel (cm/s), 36.8 (31.8-41.8) and 40.1 (36.5-43.8). Mean arterial pressure (mm Hg), 75.5 (72.5-78.5) and 80.5 (75.6-85.5) (p<0.05). Cardiac index, (L/min/m2), 2.51 (2.19-2.84) and 2.9 (2.5-3.3) (p<0.05). Stroke volume index (ml/beat/m2), 31.4 (28.2-34.6) and 35.2 (31.4-39) (p<0.05). Oxygen delivery (ml/min/m2), 695.9 (589.6-802) and 799.8 (674-925.6) (p<0.05). Conclusions: CS appeared to be as-sociated to transient decline of both ICBFV and SBF. The former may be related to alterations in cerebral autregulation



P98

TC Doppler and brain tissue oxygen pressure

monitoring in cerebral aneurysm surgery

A. Vilarinho1, P. A. Silva1,A. Cerejo1, C. Dias2, R. Vaz1

Departments of 1Neurosurgery and 1Neurocritical Care, São João Hospital Center and Faculty of Medicine of University of Porto, Portugal

Introduction: In neurocritically ill patients, particularly in SAH patients, neuromonitoring is essential for a better under-standing of the physiopathological mechanisms involved, en-hancing the possibilities of detection and potential treatment of complications. TC Doppler and monitoring of brain tissue oxygen pressure (PbtO2), are routinely used in patients operated on cer-ebral aneurysms in our Department. Material and methods: 52 patients underwent cerebral aneurysm surgery with intraoperative PbtO2 monitoring. The PtbO2 catheter was placed in the middle temporal gyrus, in cases of MCA and Pcom aneurysms, and in the inferior frontal gyrus, in cases of AcoA aneurysms. Post op-erative assessment of vasospasm with TC Doppler was performed in a daily basis. Initially the monitoring was made only during operation, but in the last 8 cases PbtO2 monitoring was carried out in the post operative period. Results: A significant correla-tion was found betwen low baseline levels of PtbO2 and the de-velopment of vasospasm in TC Doppler. PbtO2 monitoring values in the following days were not significantly different from those found during surgery. Conclusions: Low baseline levels of PtbO2 seem to correlate with the development of postoperative vasos-pasm. Although the limited number of cases precludes definitive conclusions, the evolution of PtbO2 values in the post operative period did not show changes that could indicate differences in the incidence of vasospasm. Decreased brain oxygenation in the first phases after SAH may have an important role in the development of post operative vasospasm

P99

The number and timing of cerebral emboli during

cardiac surgery in conjunction with post-operative

MRI scans and neuropsychological tests

N. Patel1, 2; J. Janus1; C. Banahan3; T. Spyt1, 2; D. H. Evans1; E. M. L. Chung1, 2

1Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; 2Leicester Biomedical Research Unit, National Institute of Health Research, Leicester, UK; 3Department of Medical physics, University Hospitals of Leicester NHS Trust, Leicester, UK

Background and aims: The purpose of this research was to analyse the incidence and timing of cerebral emboli during Coronary Artery Bypass Graft (CABG) surgery and cardiac valve surgery. A detailed understanding of the timing and impact of cer-ebral emboli may prove useful for understanding the relationship between embolisation, neurocognitive decline, and the appearance

of new ischaemic lesions in post-operative cerebral MRI scans. Methods: Bilateral Transcranial Doppler (TCD) ultrasound mon-itoring of the Middle Cerebral Artery was performed intra-oper-atively using a Doppler Box (Compumedics Germany) equipped with 2MHz transducers. Data from 21 patients (8 CABG, 8 valve and 5 combined procedures) were recorded and analysed offline for the presence of embolic signals. The timing of embolic signals was linked to possible origins of emboli transcribed during each procedure and related to the results of pre- and post-surgery MRI scans identified using ‘in-house’ subtraction software to detect new ischaemic lesions. Results: Patients undergoing surgery ex-perienced high rates of embolisation ranging from a few hundred to several thousand emboli during surgery. In all groups, patients experienced the longest periods of sustained embolisation during removal of the aortic cross-clamp and weaning from cardiopul-monary bypass. There was a trend showing highest number of emboli and longest period of sustained embolisation with patients undergoing valve surgery. New ischaemic lesions were identified in 10/21 patients (7 valve, 2 CABG and 1 combined). Conclusion: The use of TCD to establish the number and timing of emboli has potential to assist theatre staff in reducing neurological complica-tions and stroke following surgery. Our MRI scans suggest that solid emboli are more likely during valve surgery and atheroma avoidance or neuroprotective strategies may be warranted. In fu-ture work, it would be useful to develop methods for distinguish-ing solid and gaseous emboli using TCD.

P100

Preterm infant brain mapping of cerebral blood flow

indexes using Ultrafast Doppler imaging.

C. Demené1, M. Pernot1, V. Biran2, M. Alison3, M. Fink1, O. Baud2, M. Tanter1

1Institut Langevin, ESPCI ParisTech, CNRS UMR7587, Inserm U979, Paris, France; 2Réanimation et Pédiatrie Néonatales, Hôpital Robert Debré, Paris, France; 3Département d’imagerie médicale, Hôpital Robert Debré, Paris, France

Preterm infant are in a large extent subject to neurologi-cal disorders resulting from injuries during brain development. Among the most common lesions, intraventricular hemorrhage and hypoxia-ischemia involve the vascular network and can lead to severe complications, while ultrasound modalities encounter difficulties to give good prognostic parameters. Ultrafast Doppler imaging through the fontanel, used regularly during preterm in-fant monitoring, could give early insights on changes in Cerebral blood flow, and help to detect those incidents. In this study we investigate the use of this technique to build Pourcelot index (=Resistivity index) mapping over the entire vascular network in a single cardiac cycle. Ultrafast Doppler Imaging uses the recently introduced compound ultrasound plane wave imaging technique enabling both the detection of small vessels (~100 μm) and the acquisition of the complete blood flow speed profile over the entire field of view in a single cardiac cycle, which would not be pos-sible with a conventional focused Doppler sequence. Ultrafast Doppler images were obtained in parasagittal and coronal sections


for 10 preterm infants, using a dedicated ultrasound Plane Wave Compound sequence, enabling to acquire 3500 images in 1 sec. For each acquisition and in every pixel it is possible to compute a posteriori a pulse wave Doppler like spectral profile and to cal-culate the Pourcelot index. Results showed that the extraction of peak systolic and end diastolic flow speeds in every location of the imaged vascular network was possible, and that Pourcelot index mapping was practicable. Examples showed that this index map-ping was reflecting changes in preterm cerebral hemodynamics in agreement with what was observed on a pulse wave Doppler pro-file. Parametric mapping via Ultrafast Doppler imaging could be a very useful prognostic tool for preterm infant monitoring, but also a ground breaking tool for functional imaging of the infant brain activity.

P101

A longitudinal retrospective study on intracranial

arterial pulsatility index: its evolution in ten years’

time and how it relates to the occurrence of cerebral

and systemic ischemic disease.

M. Suarez-Pinilla, L. Benavente-Fernandez, S. Calleja-Puerta

Central University Hospital of Asturias/Department of Neurology, Oviedo, Spain

Background And Purpose: As a measure of distal vascular resistance, intracranial arterial pulsatility index (PI) has been re-lated to old age, hypertension, diabetes, small vessel disease and lacunar stroke. We sought to explore how this index changes through time, what conditions affect this evolution and whether or not it can predict the occurrence of future ischemic events. Material And Methods: 1288 patients underwent a transcra-nial Doppler evaluation at the Department of Neurology of the Central University Hospital of Asturias between the years 2001 and 2006. After exclusion of deceased patients and significant artery stenoses, there remained eighty-nine patients who agreed to be re-evaluated in 2012. Their clinical histories and neuro-imaging studies were reviewed, with special attention to vascu-lar risk factors and ischemic events. Results: Age was found to be related to both middle cerebral and basilar artery PI values, as well as sex (not significant), hypertension, peripheral arterial and ischemic heart disease, stroke and presence of ischemic le-sions in brain imaging studies. Higher PI values at baseline were significantly related to subsequent occurrence of coronary is-chemic events even after adjustment for previous heart disease. With respect to the longitudinal variation, only middle cerebral artery PI showed a significant positive change between the two evaluations performed, suggesting greater increases among pa-tients with a recent diagnosis of hypertension. Conclusions: Cerebral arterial pulsatility index works as a dynamic measure of both cerebral and systemic vascular disease thus being able to point subjects at higher risk of future ischemic events

P102

Clinical and analytical predictors of intracranial

pulsatility in cerebrovascular prevention

A. Gouveia1, J. Sargento-Freitas2, J. Madaleno3, J. Penetra4, F. Silva2, C. Machado2, G. Cordeiro2, L. Cunha2

1Neurology Department; 2Stroke Unit; 3Internal Medicine Department, Coimbra University Hospital; and 4Faculty of Medicine of the University of Coimbra, Coimbra, Portugal

Background: Transcranial Doppler pulsatility index (PI) has traditionally been interpreted as a descriptor of distal cerebrovascu-lar resistance. Many authors have investigated its usefulness in the context of traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) and hydrocephalus. Nonetheless, many doubts remain about its interpretation in cerebrovascular prevention. Objective: Identify the clinical and analytical predictors of increased PI. Methods: Analysis of a prospective database including all patients undergo-ing cerebrovascular ultrasonographic evaluation during 2011. We excluded patients with ≥ 70% stenosis or occlusion in any intra or extracranial artery, stenosis in Middle Cerebral Artery (MCA), atrial fibrillation, patients without transtemporal sonographic win-dow and all evaluations performed in context of TBI, SAH, acute ischemic stroke or intracranial hypertension. The mean PI of both MCA, measured in its middle third after a minimum of 10 min-utes of rest in the supine position were registered. Vascular risk factors and analytical parameters were analysed. Values of p<0.05 were regarded as significant. Results: We analyzed 947 patients, 446 were included, 287 (64.3%) were male and mean age was 62.7 years (SD: 14.92). Mean PI was 0.995 (SD = 0.240). In multivari-ate analysis, age (B:0.007, 95%CI: 0.005-0.009, p<0.001), hyperten-sion (B:0.056, 95%CI: 0.003-0.108, p=0037) and Diabetes-Mellitus (B:0.064, 95%CI: 0.006-0.121, p=0.030) were identified as predictors of increased PI. Conclusions: These results suggest that PI is as-sociated with vascular risk factors classically responsible for small vessel disease. We discuss the physiopathology of elevation of PI and its possible usefulness in cerebrovascular prevention. Longitudinal multicenter studies are needed to document its potential role as a prognostic cerebrovascular biomarker.



P103

Receiver operating characteristic analysis of

noninvasive intracranial pressure measurement

methods

A. Ragauskas1, L. Bartusis1, R. Zakelis1, G. Daubaris1, V. Matijosaitis2,

K. Petrikonis2, D. Rastenyte2

1Kaunas University of Technology / Telematics Science Laboratory, Kaunas, Lithuania; 2Lithuanian University of Health Sciences / Kaunas Clinics / Department of Neurology, Kaunas, Lithuania

Objectives: To assess the diagnostic accuracy of optic nerve sheath diameter (ONSD) ultrasonography for intracranial pres-sure (ICP) estimation and absolute ICP value measurement method based on two-depth TCD technology. Methods: Prospective clini-cal study of a non-invasive ICP estimation method, based on ONSD correlation with ICP has been conducted on 92 neurologic patients. Of this group, 85 patients were also investigated by simultaneous “gold standard“ invasive cerebrospinal fluid pressure measurement via lumbar puncture and noninvasive ICP absolute value measure-ment by the innovative technology which is based on two-depth TCD measurements in an ophthalmic artery. Receiver operating characteristic (ROC) analysis has been used to investigate the diag-nostic accuracy of these two methods. Results: Estimated sensitiv-ity, specificity and the area under the ROC curve (AUC) of ONSD method were 37.0 %, 58.5 % and 0.57, respectively. For detecting elevated ICP (critical threshold in neurology ICP > 14.7 mmHg) a cut-off point of ONSD 5.0 mm has been used. Diagnostic sensitiv-ity, specificity and AUC of noninvasive absolute ICP measurement method based on two-depth TCD were 68.0 %, 84.3 % and 0.87, respectively (cut-off point 14.7 mmHg). Conclusions: The results of this prospective clinical study show that noninvasive ICP abso-lute value measurement method based on two-depth TCD has bet-ter sensitivity, specificity and AUC for detecting elevated ICP (ICP > 14.7 mmHg) and can be used in clinical practice for treatment decision making in contrast with ICP estimation method which is based on intracranial pressure correlation with ONSD.

P104

Endothelial dysfunction and leukoaraiosis in patients

with obstructive sleep apnea syndrome

J. Pretnar-Oblak1, M. Zaletel1, A.Resman-Gašperšič1, L. Dolenc-Grošelj2, B. Žvan1, A. Koren3, M. Zaletel1

1Department for Vascular Neurology; 2Institute for Clinical Neurophysiology and 3Institute for Radiology, Ljubljana Medical Centre, Ljubljana, Slovenia

Objectives: Obstructive sleep apnea (OSA) patients have an increased risk of leukoaraiosis. In contradiction a recent study re-ported that OSA patients have similar extent of leukoaraiosis com-pared to patients with similar cerebrovascular risk factors (SRF).

Endothelial dysfunction is supposed to be an important mecha-nism causing complications in OSA. It is possible that cerebral en-dothelial function is specifically damaged in OSA patients. We used cerebrovascular reactivity to L-arginine (CVR-arg) to determine cerebral endothelial function and evaluated leukoaraiosis by MRI. We hypothesised that specific, marked cerebral endothelial dys-function resulting in leukoaraiosis is present in patients with OSA. Methods: CVR-arg was determined in 32 OSA patients (aged 54.1 ± 5.8 years) and 28 subjects (aged 48.7 ± 12.5 years) with SRF. The mean arterial velocity (vm) in both middle cerebral arteries was measured by TCD. CVR-arg was determined as a relative increase of vm during the ten-minute interval before and after L-arginine infusion. MAP, HR and Et-CO2 were calculated for the same inter-vals. MRI FLAIR sequences with Fazekas scale were used for evalu-ating the severity of leukoaraiosis. Results: Age (p ≤ 0,01) and BMI (OSA: 35,3 ± 4,1 vs. controls 31,1 ± 4,0; p ≤ 0,01) were significantly higher in OSA patients. CVR-arg was significantly lower in OSA patients (OSA: 7,9 ± 5,1 vs. controls 10,6 ± 5,9; p = 0,04). MAP and Et-CO2 did not change whereas HR increased significantly in all patients (p ≤ 0.01). Less OSA patients had Fazekas 0 (OSA: 43 % vs. controls 55 %) but the difference was not significant. Conclusions: Our results have shown that CVR-arg is impaired in patients with OSA compared to patients with SRF. MRI did not show significant differences between the two groups and is probably not sensitive enough. In conclusion OSA may be an independent risk factor for cerebral endothelial dysfunction.

P105

Role of endothelial function parameters in

evaluation of patients with Fabry disease

I. Zavoreo, M. J. Jurašić, L. Ćorić, M. Lisak, A. Lovrenčić-Huzjan, V. Bašić Kes

University Neurology Department, UHC Sestre milosrdnice, Zagreb, Croatia

Fabry disease (Anderson-Fabry disease) is an X-linked recessive lysosomal storage disorder resulting from the deficient activity of the lysosomal hydrolase, α-galactosidase A (α -Gal A) which leads to progressive accumulation of globotriaosylceramide (Gb3) in various cells, predominantly in endothelium and vascular smooth muscles, with clinical manifestations affecting major organs in-cluding the nervous system. Early initiation of therapy- prior to significant disease manifestations or complications may result in better outcomes for patients. In our study, we evaluated endothelial function parameters (beta stiffness-BS and intima-media thickness-IMT measured in common carotid artery in standardized manner) in 5 patients with confirmed Fabry disease after they suffered is-chemic stroke. There was no statistically significant increase in IMT in correlation with normal sex and age adjusted values ((right ACI 0.47±0.09 vs. 0,43±0.07, left ACI 0.54±0.07 vs. 0.46±0.09; p>0.05), while there was increase in BS values in Fabry population (right 6.48±2.4 vs. 5.18±2.12, left 6.78±2.18 vs. 5.27±2.03; p<0,05). Our results have shown that beta stiffness index is a good tool in recogni-tion of early endothelial dysfunction in Fabry patients, while IMT is more relevant marker for long term follow up of such patients.


P106

Effects of iodinated contrast media on vasospasm

due to subarachnoid hemorrhage

T.Nikitina1, V.B.Semenyutin2, V.P.Bersnev2, V.A.Aliev2, A.Patzak1, M.Sendeski1

1Institute for Vegetative Physiology, University Hospital Charite, Berlin, Germany; 2Russian Polenov Neurosurgical Institute, Saint-Petersburg, Russia

Introduction: Application of iodinated contrast media in pa-tients with vasospasm after subarachnoid haemorrhage (SAH) may influence vascular function of spastic brain vessels and in-crease morbidity and mortality. We developed an in vitro model of vasospasm post-SAH to investigate the effects of contrast media on vessel tone and myogenic response. Methods: Superior cer-ebellar arteries from rats were isolated and perfused isobarically. Coagulated blood was deposited into the perfusion chamber to simulate SAH. Either vehicle or iodixanol (23mg iodine/ml) was applied intraluminally. Vessel diameter was monitored in stable conditions and during changes of intraluminal pressure. The myo-genic response was quantified as the maximal change in diameter after each change in luminal pressure. Results: Vessels treated with blood developed a stronger tone compared to the control group (66+-2.0% vs. 77+-1.2% of initial diameter), as well as a decrease of both the dilatory and constrictor myogenic response. Contrast media did not influence the tone and the magnitude of the myogenic response, both in control as well as in blood treated vessels. During higher level changes in pressure, however, the my-ogenic response was less impaired in vessels exposed to blood and CM in comparison to blood alone, and also the variability of the myogenic response was decreased in the group receiving contrast. Conclusion: This in vitro model of vasospasm post-SAH reflects the clinical observation that the autoregulation of brain vessels may be impaired after SAH. Contrast media had small influence on vessel tone and myogenic responce in this model.

P107

Prognostic significant of cerebral blood flow volume

in vascular aphasia by duplex sonography

A. Hassanein1, N. Kishk1, K. Morsi1, N. Abokrysha1, M. Gerges2

1Department of Neurology, Cairo University; 2Elsahel Teaching Hospital, Cairo, Egypt

Background: The prognosis for language recovery varies de-pending on the size and nature of the lesion, level of education and the age. Most patients, even elderly ones, experience some recovery in post stroke aphasia, and some recover completely. Objective: The aim of this work is to study the relation between extra cranial vasculature and the recovery rate in different types of vascular aphasia. Methods: Thirty right handed patients with post ischemic stroke aphasia were included in this study. All pa-tients had CT brain confirming ischemic stroke diagnosis. The

patients were assessed using Kasr Al-Aini Aphasia Test (KAAT) and Extracranial duplex ultrasonography twice at three months interval to find a correlation between cerebral hemodynamics and recovery from aphasia. Results: The present study found a significant positive correlation between aphasia improvement per-cent with the initial left hemispheric cerebral blood flow volume (CBFV). The size of cerebral infarcts by CT brain showed a sig-nificant negative correlation with mean aphasia score both initially and after three months and also with Left hemispheric CBFV im-provement percent (after three months). Conclusions: Low cost, bed side availability and lack of invasiveness in particular, deserves consideration for extracranial duplex Ultrasonography in moni-toring CBFV in recovery of aphasic patients. Key Words: Aphasia; cerebral blood flow volume (CBFV); Duplex ultrasonography.

P108

Evaluation of cerebral hemodynamics and its impact

on cognitive screening test in SLE patients

N. Kishk1, A. E. L. Ghonamy1, A. Nabeel2, M. Farghaly1, Y. Zakaria1, N. Ramadan3, M. Raslan1

1Kaser Elaini Hospital Departments of Neurology; 2Rheumatology department; 3Internal Medicine, Cairo University, Egypt

Objective: The purpose of this study was to measure the Total Cerebral Blood Flow Volume (TCBFV) in patients with systemic lupus erythematosus (SLE) using Doppler ultrasonography to de-termine whether a relationship exists between cerebral perfusion changes with various clinical, laboratory and cognitive screen-ing tests. Subjects and Methods: This study was conducted on twenty-one (21) SLE female patients diagnosed according to the modified American College of Rheumatology (ACR) re-vised criteria of SLE. Ten age-matched female volunteers served as the control group.All subjects were assessed using Modified Mini-Mental State (3MS) as a Neuropsychological Screening test.Cerebral blood flow was assessed by extracranial duplex ultra-sonography to calculate total cerebral blood flow volume. Results: TCBFV was lower in patients’ group than in the control group but not reaching statistically significant difference. A significant lower CBFV in Left ICAwas observed in patients’ group compared to the control group (P =0.05). The cerebral perfusion was significantly lower in patients with active disease (p= 0.01). There was no sta-tistically significant difference between patients with neuropsychi-atric lupus (NPSLE) compared to Non NPSLEor between patients with antiphospholipid syndrome (APS) and without APS; regard-ing their TCBV SLE patients had subcortical pattern of cognitive impairment which is more obvious in SLE patients without APS. Conclusion: There is significant lower CBFV in active SLE pa-tients. SLE was associated with subcortical pattern of cognitive im-pairment. Key Words: Systemic Lupus erythematosus ,Cerebral blood flow volume, cognitive screening,extracrainal ultrasound.



P109

Infratemporal fossa - A window to insonation of

internal maxillary and meningeal arteries

M. Lepic1, T. Lepic2

1Military Medical Academy, Belgrade, Dpt. of Neurosurgery; 2Military Medical Academy, Belgrade, Dpt. of Neurology

Introduction: Insonation of middle meningeal artery (MMA) through infratemporal fossa returned satisfying results. As it branches off internal maxillary artery (IMA), we found trying to visualise both IMA and accesory meningeal artery (AMA) not su-perfluous. Aim: Aim of the study was to visualise and correctly differentiate the available arteries in the infratemporal fossa, which allows further exploration of the vessels. Methods & Approach: We have been using Toshiba PowerVision 6000, 7 - 11 MHz linear transducer in Color Dupplex-Doppler mode. Both vertical and horizontal positions of the transducer recorded parallel arterial flow. Clear differentiation between meningeal arteries (MMA and AMA) was not possible. Significance & Future Possibilities: Dopplersonographic examination of these arteries blood flow may be helpful in understanding the hemodynamic changes in mi-graine and other vascular phenomena, as well as pharmacologic treatment effects… Visualisation of the whole arterial tree must tell us more then just one branch, while it is easier visualise and understand.

P110

Diabetes Mellitus and Intracranial pulsatility index:

more than just elevated glucose

L. Almendra2, J. Sargento-Freitas1,2, J. Madaleno3, A. Gouveia2, F. Silva1,2, C. Machado2, G. Cordeiro1,2, L. Cunha1,2

1Neurosonology Laboratory; 2Neurology Department and 3Internal Medicine Department, Coimbra University Hospital, Coimbra, Portugal

Introduction: Vascular risk evaluation is part of the standard clinical care of diabetic patients. Cerebral microangiopathy is one of the most important complications in diabetes. Not only high glucose blood levels but also high insulin levels are recognized risk factors, since microvascular endothelium is more susceptible to metabolic and mitogenic insult than large vessel. Pulsatility index (PI) reflects the vascular resistance of intracranial arteries, how-ever its role in cerebrovascular prevention is not set. Objective: To study the role of Diabetes Mellitus (DM) and elevated blood glucose on PI. Method: We conducted a crossectional analysis to a prospective database. All patients undergoing transcranial dop-pler investigation in the year 2011 with blood metabolic panel per-formed within 30 days of the exam were included. We excluded patients with absent transtemporal bone window, intra or extrac-ranial artery stenosis greater than 70%, any stenosis in middle cer-ebral artery (MCA), atrial fibrillation and all exams performed in context of cranial trauma, subaracnoid hemorrhage, intracranial

hypertention and acute ischemic stroke. We registered the mean MCA PI read on the middle third of M1 segment after a minimum rest time of 10 minutes in supine. Results: We included 446 pa-tients out of the 947 analyzed, 287 (64,3%) were males, mean age was 62,7 (SD:14,92) years. The mean PI was 0,995 (SD: 0,240). On multivariate analysis the factors that showed a statistically signifi-cant association with increased PI were: age (p<0.001), presence of DM (p=0.030) and hypertension (p=0.037). Glycated hemoglobin was not an independent predictor of increased PI (p=0.504). Conclusion: Our study confirms the classical association of DM with increased PI. This association is not dependent on elevated blood glucose. These findings suggest that there might be alter-native physiopathological mechanisms. Longitudinal multicentre studies are necessary to confirm the role of PI as a cerebrovascular prognostic biomarker.

Aaslid, R. L4Abarca, M.C. P87Abd-Allah, F. P9, P45, P64Abdelhafez, H. P54Abokrysha, N. P107Abramova, M. O36Abukresha, N. P54Abuzaid, S. P20Acosta, A. P3, P7Adibeig, S. P50Adriano, C. P77Agosti, M. P65Ahmed, S. P9Ainslie, P. O8Alfieri, C. O28Aliev, V.A. O37, P92, P93,

P106Alison, M. P100Allignol, A. O18Almeida, K.J. P83Almeida, V. P60Almendra, L. P110Alvarez-Sabin, J. O23Alves, M.M. P75Alves, V. O15Amado, J. P18Ando, K. O25Annoni, F. P80António, C. O16, P36, P37, P38Anzola, G.P. O26Aoki, S. P49Aprianti-Putri, I. P78Aquino, C.C. P74Arai, A. O25Arima, Y. P25Arsovska, A. P12Arsovski, Z. P12Artemis, D. P59Ashina, M. P33Atzori, M. P40Azevedo, E. O16, O24, O43,

P6, P14, P32, P34, P36, P37, P38, P62, P67, P69

Azuma, T. O25Balberg, M. P21Baltgaile, G. T5, O13Banahan, C. P89, P99Baracchini, C. L28, 026, P40,

P76Barkan, L. P21Barreira-Rodríguez, N. P34Barros, P. P61Barsottini, O.G. O33, P74

Numbers refer to Abstract numbers

Author Index

Fax +41 61 306 12 34E-Mail [email protected]

© 2013 S. Karger AG, Basel

Accessible online at:www.karger.com/ced

Bartels, E. T6Bartusis, L. P31, P103Bašić-Kes, V. P68, P105Bastos-Leite, A. O43Batista, P. P60Baud, O. L13, P100Bäuerle, J. P52, P53Bel, A. O29Bella, R. O26Benavente-Fernández, L. P101Bersnev, V.P. P93, P106Bieniaszewski, L. O20Biestro, A. O7Biran, V. L13, P100Birch, A.A. O4Biscaia, M. P16Blatt, M. O24, P3, P6, P7Bodnár, F. P15Bodnárová, P. O40Bombardieri, A.M. P94Bonelli, E. O31Bornstein, N. L25Borók, J. P15Bor-Seng-Shu, E. O33, P26,

P42, P47, P58, P74, P83, P95Bosnar-Puretic, M. P68Bosone, D. P73Braga, M. O26Braga-Neto, P. O33, P74Brambilla, F. O33 Brandão, V. P18Breskin, I. P21Breuer, E. P71Brigo, F. P28Brugger, H. O34Burainé-Bojtor, A. P15Bustos, L. P87Buttler, K.J. P52, P81Calabrese, M. P40Caldart, A. P77Calleja-Puerta, S. P101Camacho, A. O30Camacho, J. O7, P18Campilho, A. P34, P69Cappellini, M.D. P80Cappello, T. O34Carvalho, M. O43Casoni, F.M. P80Castillo, J. P27, P56Castro, C. O16, P36, P37, P38Castro, P. O16, O24,O43, P6,

P32, P36, P37, P38Catalán, A. P97

Cerejo, A. O12, P96, P98Charvát, F. O40Chiapparino, C. P79, P86Chin, J. O30, P18Chomskis, R. P30, P31Chung, E.M.L. P35, P89, P99Cid, B. P87Cioara, G. P48Ciobanu, F. O32Claassen, J. O1, O2, O5, O9, P1Cohen, I. L13Convertino, V. O6Coppo, L. O34Cordeiro, G. O27, P102, P110Ćorić, L. P105Correia, C. O15Costa, A. P62, P67Csiba, L. L11, O19, P15, P29Cunha, G. O39Cunha, L. L21, O27, P41, P102,

P110Cunha, S. O30Czosnyka, M. L5, O7, O12, P1,

P2, P4, P5Daubaris, G. P103de Bray, J.M. L19De Gaetano, A. P1Del Sette, M. L29, O26Demené, C. L13, P100Dementaviciene, J. O42 Dexter, K. P11Di Piero, V. O38, P63Dias, C. L7, O12, P96, P98Diaz, R. P97Diehl, R.R. P2Diomedi, M. O26, O28, O31Dittrich, R. L22, L23Dobričić, V. P70Doepp, F. P71Dolenc-Grošelj, L. P104Domingos, J. O15Domingues, J. O39Domínguez, M.J. P23Dong, P. P22Drummond, J. P94duManior, G. O8Duque, C. P41Dutra, L.A. O33, P74Egger, K. P53Ehlers, E. O18Ehmann, R. O18Eide, P.K. P30El-Ghonamy, A. P108

El-Jaafary, S. P9, P64Elsaed, M. P54Elserafy, O. P66El-Shafee, S. P66El-Tamawy, M. P64Enache, V. O32Esmail, A. P45Esteves, A.N. P83Evans, D.H. P89, P99Evaristo, E.F. P83Falvo, M.J. P3, P7Farghaly, M. P108Farina, F. P40, P76Fathy, M. P9, P64Federico, F. P79, P86Felgueiras, H. P61Felicio, A.C. O33, P74Ferenets, R. P30Fernandes, C. P90Fernández-Domínguez, J. P55Fernández-Fernández, J. P27,

P56Ferraz, H.B. P74Ferreira, C. P14, P34, P62, P67,

P69Ferreira, M. O16Ferrinha, R. O30Filipović, S. P72Fink, M. L13, P100Fjeld, J. P13Flores, A. O23Fonck, E. P10Fonseca, M. P41Freire, P. P41Frendl, A. P15Furuhata, H. O22, O25, P85Gabriel, B. O18Gago, P. O30Gallo, P. P40Gama, V. P61Gandolfi, I. P80Gandolfo, C. O26Garami, Z. L24García-Rodríguez, R. P55Garrard, J. P11, P19Gennisson, J.L. L13George, M. O6Gerges, M. P107Ghanem, N. P66Ghiotto, N. P73Ghobreal, B. O24, P3, P6, P7Ghofraniha, A. P50Glisic, B. P8

Author IndexCerebrovasc Dis 2013;35(suppl 2):1–7776

Go, G. P94Gomes, D.L. P75Gómez, H. O7Gonçalves, A. P41Gong, X. P22González-Quintanilla, V. P27,

P56González-Suarez, A. P27, P56Gouveia, A. O27, P102, P110Graziadei, G. P80Gress, D.R. P33Grilo, M. P67Gross, N. P52Grosse, P. P71Guaschino, E. P73Guerra, M. P61Guerreiro, R. P16Guidetti, G. O38Guilherme, P. O30, P18Günther, M. P1Guoa, S. P33Gutiérrez-González, S. P27, P56Hague, J. P35Harloff, A. P53Harris, S. P78Hartshorne, T.C. O14, O17,

P11, P19Hassanen, A. P54, P107Haubrich, C. P2Haunton, V. O10Hegazy, A. P45Hennerici, M.G. P59Heskamp, L. O1, O5Hinojosa-Laborde, C. O6Hoedemaekers, C. O5Hofer, G. O34Hofgart, G. P29Hol, P.K. P39Horsfield, M.A. O11, O14,

O17, P35Hosny, H. P64, P66Hosomi, N. O35, P49Hu, K. P1Hua-Lin, W. P88Iaffaldano, P. P79, P86Iguchi, Y. O22James, K. P47Janković, M. P70Janus, J. P89, P99Janzarik, W.G. O18Jara, J.L. O11Jatuzis, D. O42, P43Jensen, L.T. P33Jesus, I. O30, P18Johnsrud, K. P13Jurašić, M.J. P105Kablau, M. P59Kallas, J. O23Kamar, M. P21, P33Kamiyama, T. O22

Kanber, B. O14, O17, P19Karakaneva, S. P57kardos, L. P15, P29Kasprowicz, M. P2, P5Katsogridakis, E. O1Kay, V. O6Kazibutowska, Z. P91Kern, R. T9, P59Kinoshita, N. P49Kishk, N. P54, P66, P107, P108Kitamura, J. P49Klapp, C. P87Klingelhöfer, J. T2, O21Kohriyama, T. O35, P49Kono, Y. O22Koren, A. P104Kostić, V. P70Kouchakpour, H. O4Kovács, K.R. P15, P29Kovaldina, Z. O13Kozera, G.M. O20Kozlov, A.V. O37, P92, P93Kresojevic, N. P70Krsmanovic, Z. P8Kubota, J. O25Kvistad, C.E. P82Labovic, B. P8Lacman, J. O40Lagrèze, W. P52Lagro, J. O1, O5, O9Lakočević, M. P70Lange, M. P75, P77Lasek-Bal, A. P91Lea-Banks, H. O4Leite, A.C. P75Lenzi, G.L. O38, P63Lepic, M. P8, P109Lepic, T. P8, P109Leung, T. P88Lewis, N. O8Lewis, P. P4Lima, S.P. P95Lisak, M. P105Litauszky, K. P15Lo, N. O10Lochner, P. O34, P28Lopes, G. O15Lovrencic-Huzjan, A. P68, P105Low, C. P75Lucas, S. O8Lysenko, E. P20Machado, C. O27, P102, P110Machado, M.F. P58, P74Madaleno, J. P102, P110Mader, C. P28Maestrini, I. P63Mair, A. P77Malferrari, G. P28Manosalva, M. P87Marcon, A. P80

Marques, V. O30Marshall, D. P35Martinic-Popovic, I. P68Martins, H. P60Martins, L. P69Marto, S. P18Massaro, A.R. P75Mateos, V. P55Matijosaitis, V. P103Matsumoto, M. O35, P49Mayer, S. O18Meckel, S. P81Meel-van den Abeelen, A. O1,

O2, O5, O9Meireles, J. P14Meler, P. O23Mendes, R. P77Mendes-Pereira, V. P84Meneghetti, G. O26, P40, P76Merino, C. P87Messas, E. O29Mijajlović, M. P70, P72Mikadze, Y. P20Milheiro, M. O15Mitsumura, H. O22, O25Mizuno, T. P25Mocellin, M. P77Moglia, A. P73Molina, C.A. O23Montaldo, G. O29Monteiro, A.M. P62, P67Moore, D. P19Morgagni, R. O31Moro, C. P75Morsi, K. P107Muchada-Lopez, M. O23Mukai, T. O35, P49Nabeel, A. P108Nacu, A. P82Nada, M. P66Naess, H. P82Nakagawa, M. P25Nakamura, T. O35, P49Nardone, R. P28Naylor, A. O14, O17, P11, P19Nduwayo, S. P11, P19Nechita, A.C. O32Negrão, C.E. P26Netuka, D. O40Neubauer-Geryk, J. O20Neumann, J. O40Neunhöffer, F. P81Neves, A. O30, P18Ng, G.A. P89Nicheva-Vavrek, N. P46Nicolae, H. P48Nikitina, T. P106Nini, A. P21, P33Nogueira, R.C. O33, P26, P42,

P47, P58, P74, P83, P95

Norremose, K.A. P83Novak, V. L1, P1Novaković, I. P70Novoselova, S. O36Nyka, W.M. O20Ochi, K. O35, P49Oeinck, M. P81Ogawa, T. O25Ohtsuki, T. O35, P49Oláh, L. O19Oliveira, M.L. P47, P83, P95Oliveira, V. T1, L8, P60Olvasztó, S. P15Omčikus, M. P72Oriques, M. P77Orosz, M. P29Osmanski, B.F. L13, O29Oterino, A. P27, P56Ottesen, J. P1Oudegeest-Sander, M. O9Pachter, J. P1Paciaroni, K. O28Pagola, J. O23Paiva, J.A. O12Palacio, E.J. P27, P56Palma, I. P16Palmieri, A. P40, P76Panea, C. P48Panerai, R.B. O1, O3, O4, O10,

O11, P26Panuntcev, G.K. O37, P92, P93Parra, J. O39Pascazio, L. P79, P86Paschoal, F. P58Patel, N. P89, P99Patzak, A. O37, P92, P93, P106Pavlović, A. P70Pechiborsch, D.A. O37Pedro, A. P60Pedroso, J.L. O33, P74Penas, S. P69Penetra, J. O27, P102Peraza, L. P47Pereira, E. O12Pereira, J. O15Pereira, L. P16, P90Perić, S. P70Pernot, M. L13, O29, P100Perren, F. P10, P84Petkus, V. P30, P31Petolicchio, B. P63Petrikonis, K. P103Petronijevic, M. P8Picarelli, H. P95Pickard, J.D. P2, P4, P5Pignat, J.M. P84Pina, R. O39Pinheiro, D. P61Pinto, P. O15Piper, I. P1

Author Index Cerebrovasc Dis 2013;35(suppl 2):1–77 77

Polónia, J. P69Popescu, A. P48Popovska, S. P12Popovski, A. P12Popper, H. L12Prado, G.F. P74Preiksaitis, A. P31Pretnar-Oblak, J. P24, P104Procter, E. O34Prömpeler, H. O18Puledda, F. O38, P63Puppo, C. O7Puz, P. P91Ragauskas, A. P30, P31, P103Raicevic, R. P8Raita, A. O13Ramadan, N. P108Ramazanov, S.S. P93Ramnarine, K.V. O14, O17,

P11, P19Raslan, M. P108Rastenyte, D. P103Rebollo, M. P27, P56Reinhhard, M. O18, P52, P81Resman-Gašperšič, A. P104Reymond, P. P10Ribas, E.S. P95Ribo, M. L18, O23Ricci, S. O26Rickards, C. O6Rida-Ariarini, N.N. P78Ridolfi, P. P80Riester, T. P59Ringelstein, E.B. L9Ristic, G. P8Rivas, R. P87Robinson, T.G. O3, O10, O11,

O14, O17, P11, P19Rocco, A. O28, O31Rocha, H. O43 Rocha, I. O24, P6Rocha, R. P34Rocka, S. P31Rodrigues, M. T3, P16, P90Rodrigues, T. O15Rodriguez-Luna, D. O23Rohani, M. P50Rojo-López, A. P27, P56Ron, A. P21Rosengarten, B. L14, O19Rouco, J. P34Rozhchenko, L.V. P93Rubiera, M. T8, O23Rüfenacht, D. P10Russel, D. T10, L10, P13, P39Ryan, K. O6Saeed, N. O11Saito, O. P85Sakuta, K. O22Sales, F. L6

Salih, F. P71Salinet, A. O3Sánchez, A. P23Sanjuan, E. O23Santana, I. O39Santo, G. P41Santos, A. P32, P36Santos, A.M. P95Santos, E. P42Santos, M.R. P26Santos, R. O16,O43, P14, P32,

P36, P37, P38, P62, P67Sargento-Freitas, J. O27, O39,

P41, P102, P110Schall, L. P59Schmidt, B. O21Schreiber, S. T7, P71Schroeder, L. P53Schuchardt, F. P53Schwarze, J.J. O21Schytza, H.W. P33Scoditti, U. P65Scott, H. P13, P39Segawa, A. P49Semenyutin, V.B. O37, P92,

P93, P106Sendeski. M. P106Sengoku, R. O22Serrador, J.M. L3, L16, O24,

P3, P6, P7Shakhovich, A. P20Shalaby, N. P54Shamlol, R. P66Sharrock, N. P94Shaw, M. P1Sherpa, N. O8Shimizu, J. O25Shiogai, T. P25Siebler, M. L27Sierra, R. P97Sieu, L.A. L13Sijbesma, J. O9Silman, Z. P21Silva, A. O30, P18Silva, F. O27, O39, P41, P102,

P110Silva, P.A. P96, P98Silvano, R. P65Simpson, D. O1, O4, P1Sing-Wong, K. P88Širvinskas, A. O41Skagen, K. P13, P39Skjelland, M. P13, P39Skretting, A. P13Slump, C. O9Smielewski, P. P2, P4, P5Smirl, J. O8Smith, K. O8Soares, F. P60Sodec-Simicevic, D. P68

Soo, Y. P88Sorond, F. L15, O24, P6Sorteberg, A.G. P30Sousa, F. P38Sousa, L. O16, P32, P36, P37,

P38Sousa, P. O30Spiers, J.D. P89Spyt, T. P99Stefanovic, D. P8Steiner, L.A. P2Stepanova, I. O36Stergiopulos, N. P10Šternić, N. P72Stjepanović, M. P72Strapazzon, G. O34Stroi, A.M. O32Suárez-Pinilla, M. P101Sugimoto, T. O35Sváčková, D. O40Svetel, M. P70Szabó, K. O19Szczyrba, S. O20Taipa, R. O15Takahashi, T. O35Tanifuji, Y. O25Tanter, M. L13, O29, P100Tanzi, A. P65Tavares, J. P32, P36Tavares, N. O30, P18Teixeira, M.J. O33, P26, P42,

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