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Basic Tutorial: Theory

T1Basic ultrasound principlesD. RussellDepartment of Neurology, Oslo University Hospital, Oslo,Norway

Clinical experience during more than three decades has shownthat diagnostic ultrasound has no serious side-effects. However, forcorrectly applying ultrasound with the lowest risk ultrasound physics,transducer technology and the most importantly the characteristicsof the instrumentation should be known especially during long-termmonitoring. The power output can be very different using modessuch as A-Scan, B-scan which can possibly increase the risk/benefitratio. The TIC-index (tissue heating by power output) should be aslow as possible using small sample volumes, low PRF and low burstamplitude etc. At present 2D-imaging of vascular diseases is carriedout using different ultrasound techniques. B-Mode imaging showstissue structure in a brightness grey-scale in real-time as cross-sectional pictures. For flow information colour-coded meanvelocities are added to the B-mode images to eliminate aliasingeffects in high flow situations. Combining these techniques withpower Doppler, spectral Doppler or with newer technology such asB-flow provides more reliable diagnoses. For detailed flowinformation during monitoring spectral Doppler instrumentation isnow established. Recently extended Doppler techniques such as M-Mode, power Doppler and neuronal networks have increased thereliability in monitoring cerebral microemboli. The use of more thanone transmitting frequency may allow differentiating between solidand gaseous emboli. Commercially available fixation devices forfixation of the ultrasound transducer at the temporal bone areavailable for long-term monitoring of the cerebral circulation butthese should be optimized. Robotic technology should lead to improvements in the near future which will establish automaticlong-term monitoring in the clinical routine e.g. stroke units.

T2Carotid and vertebral arteries: classification of stenosisJ. KlingelhoeferMedical Centre Chemnitz, Dept. of Neurology, Chemnitz,Germany

The classification of internal carotid artery and vertebral arterystenosis is of great impact. The degree of stenosis is the main criterion

for the decision between an invasive or non-invasive treatment ofextracranial internal carotid artery stenoses. By now the NASCETcriteria have been internationally approved for radiological grading.According to NASCET the stenosed lumen is compared with thelumen of the distal internal carotid artery. All ultrasound criteria dohave limitations and can therefore cause pitfalls in determining the degree of stenosis using one criterion exclusively. Therefore amulti-parametric grading of stenoses should be favored. The multi-parametric “DEGUM ultrasound criteria” have been revisedand a novel differentiation bet-ween main (primary) and additional(secondary) criteria has been proposed (Ultraschall in Med 2010;31:251-257). The differentiation between main and additionalcriteria is caused by their different reliability. Main criteria include thefollowing: Imaging of the stenosis in B-mode sono-graphy;visualization of the stenosis by color-coded imaging of flow;measurement of the maxi-mum systolic flow velocity in the area ofgreatest narrowing of the lumen; systolic flow velocity measurementin the poststenotic segment; assessment of the collateral supply.Additional criteria include the following: Indirect findings of aninternal carotid artery stenosis in the common carotid artery;evidence of flow disturbances; end-diastolic flow velocity in the areaof greatest narrowing of the lumen; the so-called confetti-sign; thecarotid ratio. The main advantage of a multi-parametric grading ofinternal carotid artery and vertebral artery stenoses is the synergeticeffect of the different single criterion. Combining these ultrasoundcriteria, neurosonography allows reliable grading of carotid andvertebral stenoses as a basis for decision making.

T3Non-atherosclerotic cervical arterial diseaseE. B. Ringelstein University Hospital Münster, Department of Neurology,Albert-Schweitzer-Campus 1, Münster, Germany

The two most important non-atherosclerotic disorders of thecervical and intracranial arteries (including the cephalad arteries)are cervical artery dissections (including the rare intradural arterydissections) and various forms of vasculitides. Spontaneouscervical artery dissections (sCADs) are among the most frequentcauses of stroke in the young. With the help of today’s imagingmachinery, dissections can reliably be diagnosed. Theirpathogenesis remains obscure. Modern diagnostic approachesshould preferably make use of magnetic resonance imaging (MRI)of both the cervical soft issue and the diseased arterial lumen inconjunction with color-coded duplex sonography. Amazinglydissections often occur in clusters involving more than one cervicalartery in rapid sequence or in a temporarily overlapping mode, astrong arguement for a generalized arteriopathy initiated by anunknown trigger. For the patient’s prognosis, very early diagnosis,

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Cerebrovasc Dis 2012;33(suppl 1): 1-88

Abstracts

or at least the suspicion, of dissection is decisive. This is a domainof Colour Coded Duplex. Careful history taking allows for thedetection of “local symptoms”, and subsequent comprehensiveneurosonological workup of the extracranial cerebral vasculatureis often diagnostic. By means of initial anticoagulation on the strokeunit, or even by means of induced hypertension on the ICU,catastrophic stroke can be prevented and long term prognosisappears benign. Vasculitides, mostly arteritis, are either “primary”,i. e. autoimmune disorders, or “secondary”, i. e. infectious, toxic orparaneoplastic diseases. The most frequently used classification ofarteritis considers the size of the affected arteries: (1) Large-sizedarteries: Takayasu disease, temporal arteritis (= Horton’s disease =giant cell arteritis, GCA). (2) Middle-sized arteries: Isolatedgranulomatous angiitis of the nervous system (= IGANS), pan-arteriitis nodosa (PAN), Kawasaki-Syndrome, or variousinfectious arteritides (syphilis, tuberculosis, borreliosis).Inflammatory lesions of large sized and middle sized arteries can bediagnosed by ultrasound techniques. This is not true for small sizedarteries. (3) Small-sized arteries: ANCA-positive vasculitides, likeWegener’s granulomatosis, Churg-Strauss-Syndrome, mPAN, andImmune-complex arteritis in SLE, M. Behcet, or rheumatoidarthritis. Clinical key features pointing to vasculitis are B-symtomatology (fever, weight loss, nocturnal sweating, malaise,musculoskeletal pain) and laboratory tests indicating inflammation(CRP, ESR), anaemia and leuco- or thrombocytosis. Typicalneurological symptoms are chronic headache, nocturnal headache,encephalopathy, recurring brain infarcts, recurring cerebralhaemorrhages, epilepsy, multiplex neuritis, amaurosis or myositis.Modern ultrasound techniques (like colour coded-Duplex) arediagnostically helpful, or even crucial in (1) Takayasu disease (= pulseless disease), (2) Moya-Moya-Syndromes, either idiopathicMoya-Moya disease, or symptomatic Moya-Moya-Syndrome dueto infectious arteritis of the basal arteries, (3) Temporal arteritis(pathognomonic halo-sign) and (4) the rare IGANS. In temporalarteritis, B-Mode-imaging is an ideal screening tool to identify theaffected segment(s) of the superficial temporal artery in order totarget the site of biopsy, and to monitor relapse duringglucocorticoid tapering. An important differential diagnosis isseptic arteritis from infectious brain emboli (“metastaticencephalitis”) due to bacterial endocarditis. Cerebrovascularultrasound may also play a diagnostic role in rare infections of thelarge brain arteries caused by syphilis, tuberculosis, zoster or fungi.Karahaliou et al. Arthritis Research & Therapy 2006; 8: R116, 1-8;Aschwanden et al. Ann Rheum Dis 2010; 69: 1356-9; Lowe et al.AJNR 2005; 26: 1698-701; Bakhru, Atlas. Arch Gynecol Obstet2011; 83: 663-8

T4Transcranial Duplex sonography: arteriesN. CarraroClinical Neurology-Stroke Unit, University Hospital,Department of Medical Sciences, University of Trieste, Italy

The blood supply to the human brain is provided by two pairsof arteries: the Internal Carotid and the Vertebral, right and left.Vertebral arteries join together giving rise to the Basilar Artery

which finishes dividing into the Cerebral Posterior arteries; thesetie up with the Internal Carotids through the PosteriorCommunicating Arteries. The Internal Carotids give origin to theMiddle and Anterior Cerebral arteries, the latter connectedbetween them by the Anterior Communicant artery. Ananastomotic ring placed to the floor of the brain, known as ThePolygon of Willis, is realized. From the polygon 3 pairs of arteriesstem from: the Anterior Cerebral, the Middle Cerebral and thePosterior Cerebral arteries, lying on the outer brain surface andprogressively dividing into smaller and smaller arteries whichpenetrate the parenchyma feeding specific regions. Arteries arisingfrom the Polygon of Willis can be explored with TCCD, byidentifying the signal of the blood flow, through 3 windows thatallow the ultrasound passing through: the Temporal, theOphthalmic and the Occipital window. The Temporal windowappear insufficient in about the 15-20% of the cases, especially theelderly women; only seldom the occipital window appearinsufficient and the difficulties to perform this insonation approachis more often related to the neck stiffness or to a poor collaborationby the patient. The use of contrast means almost completely removethe obstacle to the exploration, represented by the “hostile”window. TCCD is an useful and in some extent not replaceable toolto recognize the blood flow compensation for an extracranialcarotid severe stenosis or occlusion and to detect intracranialpathology like arterial stenoses or occlusions.

T5Extracranial and transcranial Duplex sonography: veinsS.J. Schreiber Dept. of Neurology, Charité, Universitätsmedizin Berlin,Germany

Until recently, the insonation of extra- and intracranial veinshas been the focus of only a limited number of sonographersaround the world and mainly in relation to classical venousdiseases, e.g. like sinus venous thrombosis. The recently postulatedhypothesis of venous obstructions in MS patients suddenlyincreased the scientific interest in cerebral veins. However theprecondition for drawing sensible conclusions in this field is a goodknowledge of the features and anatomical variants of the cerebralvenous system. The tutorial will give a systematic overview on theultrasound accessible extra- and intracranial veins in relation to thecerebral anatomy as well as in relation to the arterial cerebralsystem. Extracranially the jugular, vertebral and extravertebralvenous systems will be explained. Intracranially all currentlyaccessible veins, like the basal vein of Rosenthal, the cavernoussinus inflow region, the deep middle cerebral vein, the vein ofGalen, the straight sinus and the transverse sinus will bedemonstrated and discussed within the context of the knownphysiological anatomical variants.

20 Cerebrovasc Dis 2012;33(suppl 1); 1-88 17th Meeting of the European Society ofNeurosonology and Cerebral Hemodynamics

T6Contribution of ultrasound in the assessment of nervediseasesG. Granata1, L. Padua1, C. Martinoli2

1Università Cattolica del Sacro Cuore Roma, Istituto diNueurologia, Roma, Italy; 2Università di Genova Radiologia-DISC, Università di Genova, Genova, Italy

Recently, ultrasound (US) has been used to assess the peripheralnervous system. At US examination, nerves are poorly anisotropicstructures: therefore, different from tendons and muscles they donot need a perpendicular incidence of the US beam to be correctlyimaged. Around joints, nerves cross narrow osteofibrous tunnelsand may assume a more homogeneous hypoechoic appearance dueto a tighter package of fascicles and local reduction in the volumeof the epineurium. A careful scanning technique based on shortaxis planes is essential to recognize nerves throughout the limbsand extremities with US. Long-axis scans are less effective for thispurpose because the fascicles may be easily confused with echoesfrom muscles and tendons coursing along the same plane. Whendifficulties arise to distinguish small nerves from adjacent smallvessels, Doppler imaging may help the diagnosis. Although allnerves can be displayed in the extremities due to their superficialposition and absence of intervening bone, depiction of theperipheral nervous system is not possible everywhere with US. Infact, most cranial nerves, the nerve roots exiting the dorsal, lumbarand sacral spine, the sympathetic chains and the splanchnic nervesin the abdomen cannot be visualized due to a too deep course orinterposition of bony structures. When nerves lie deeply, as it oftenoccurs in obese patients, their evaluation can be more difficult. Thesuffering nerve exhibits a fusiform swelling which appears maximalin proximity to the compression point, where the nerve suddenlyflattens. Quantitative measurement of nerve thickening by meansof the ellipse formula to calculate the maximum cross-sectionalarea has proved to be the most consistent criterion for thediagnosis. In addition, the nerve echotexture may becomeuniformly hypoechoic with loss of the fascicular pattern due toswelling of the fascicles and reduced echogenicity of theepineurium.

Advanced Tutorial: Theory

T7Going beyond the Circle of WillisJ.M. Valdueza Neurologisches Zentrum der Segeberger Kliniken Gruppe,Bad Segeberg, Germany

The proximal parts of the Circle of Willis - the M1 of the middlecerebral artery (MCA), A1 of the anterior cerebral artery, distalinternal carotid artery (ICA), and the P1 and proximal P2 segment

of the posterior cerebral artery (PCA) can be examined either withTCD or transcranial color-coded duplexsonography (TCCS) withsimilar detection rates. The analysis of certain regions howeverrequires the use of TCCS to be confident of the vessel which isinsonated. Considering the transtemporal access one hot spot areais the carotid siphon of the ICA. Here the carotid siphon itself butalso the ophthalmic artery and the posterior communicating arteryhas to be distinguished. Considering MCA anatomy two variantsshould be mentioned which may lead to a misdiagnosis: Both, anearly temporal branch of the M1 segment as well as an earlybifurcation of the main stem of the MCA may be misinterpreted indistal M1 occlusion as a normal vessel status. Finally and lookingto the posterior circulation in the area of the basilar head thedifferentiation between the P1 segment of the PCA and thesuperior cerebellar artery may cause difficulties, especially in thecase of a hypoplastic P1 segment. A detailed visualization of thementioned vessel segments requires constant adaptation ofexamination techniques which include excellent knowledge and aparticular spatial sense of the intracranial anatomy. The anatomicdescriptions used should be as precise as possible. Adding thetranstemporal coronal approach to the conventional axial planesfurther helps to avoid misinterpretations of the vascular status atthe mentioned critical areas.

T8

T9Cardiac shuntsG. AnzolaServizio di Neurologia Ospedale S. Orsola, FondazionePoliambulanza Brescia, Brescia, Italy

The role of patent foramen ovale (PFO) in cryptogenic stroke isstill debated, but from recent follow-up studies it seems that theamount of right-to-left shunt (RLS) and the association with atrialseptal aneurysm are major determinants of stroke recurrence,especially so when stroke occurs on awakening. PFO and RLSthrough the atrial chambers have been recently studied in anumber of conditions not or marginally related to cerebrovasculardisease. Historically the first studies addressed the presence of RLSin scuba divers as a possible abnormality related to decompressionsickness of unknown aetiology. Despite initial dispute, there is nowrobust evidence to claim that patency of foramen ovale increasesthe risk of developing decompression sickness by 2.5 to 4 times.Recent reports suggest that divers with haemodynamicallysignificant RLS may have an increased risk of developing clinicallyasymptomatic multiple brain lesions. PFO has been found inpatients suffering from migraine with aura with approximately thesame frequency as that encountered in cryptogenic stroke patientsThis finding has prompted speculations on the possible role of RLSin increasing the stroke risk in migraineurs and in thepathophysiology of the aura. Recent experimental evidenceshowing that microembolism is able to trigger cortical spreading

21Cerebrovasc Dis 2012;33(suppl 1); 1-88Abstracts Tutorials

depression, the equivalent of aura in humans, in mice suggests thathumoral factors that reach the brain by escaping the pulmonaryfilter may indeed be causative. A right-to left shunt is involved in arare condition known as platypnea-orthodeoxia and perhapsunderlies an increased risk of cerebral complications after majororthopaedic surgery. Conditions that determine an increase inpulmonary pressure may facilitate the opening of the virtualinteratrial valve and thus promoting shunting of blood to the leftheart chambers which in turn might contribute to furtherdesaturation of arterial blood. It is therefore not surprising that RLShas been found in 70% of patients with chronic obstructivepulmonary disease and increased pulmonary pressure and in thesame proportion of patients with obstructive sleep apnoea, acondition that ultimately may result in pulmonary hypertension.In conclusion, from the evidence gathered so far the picture isemerging of an important role of PFO in a number of non-strokeconditions, either as causative factor or as associated conditionpredisposing to complications. The availability of simple diagnostictechniques such as transcranial Doppler to assess right-to-left shuntwill undoubtedly contribute a great deal of knowledge on therelevance in medicine of this hitherto neglected condition.

T10Ultrasound contrast agents: when and for whom?C. GreisBracco Imaging Deutschland, Global Marketing Ultrasound,Konstanz, Germany

Ultrasound contrast agents (UCA) where introduced in the '90sas signal enhancers. Weak Doppler signals (in the range or belowthe noise level) were quite common, in particular in case of lowflow volumes or slow flow velocities (or inappropriate flow angles),making it difficult to discriminate such situations from no flowconditions. Due to improved technical quality of recent ultrasoundscanners such situations of inappropriate Doppler flowrepresentation became more the exception than the rule. However,in transcranial color-coded sonography (TCCS) the penetration ofthe bone window still results in an inappropriate representation ofcerebral artery flow in about 10% of patients (Nedelmann etal,Consensus Recommendations for Transcranial Color-CodedDuplex Sonography, Stroke 40, 2009, 3238-3244). In that case,administration of an UCA can rescue the examination in mostcases. Demonstration of absence of cerebral arterial flow (i.e.cerebral artery occlusion) therefore always requires the use of anUCA, since otherwise absence of flow and weakness of signal cannot be discriminated (Allendörfer et al, Lancet Neurol 5, 2006, 835-840). On the other hand, a new use of UCA in vascularimaging became possible: the direct demonstration of contrastagent (independently from flow) in the vascular lumen usingcontrast-specific imaging modes. In the contrast-specific mode,scanners can detect minute amounts of UCA (even singlemicrobubbles) and display them separated from tissue signals. Thisallows a highly accurate demonstration of vascular geometry andstructure (angiography) in full spatial resolution and without anyblooming or movement artefacts. Vascular stenosis, plaques,dissections, pseudoaneurysms, fistulas, etc. can be imagaed with

high accuracy in 2D as well as in 3D imaging. The possibility fordynamic realtime imaging allows an easy quantitative measurementof UCA wash-in and wash-out. Contrast-specific imaging allowsalso the qualitative and quantitative assessment of blood flow inthe microcirculation, for example in parenchymal brain tissue orthe arterial wall (plaque vascularisation).

T11Cerebral parenchyma ultrasound imagingU. WalterUniversity of Rostock, Department of Neurology, Rostock,Germany

Transcranial B-mode sonography (TCS) is a non-invasive, low-cost, short-duration neuroimaging method that allowshigh-resolution imaging of deep brain structures in patients withmovement disorders. With contemporary high-end ultrasoundsystems, image resolution of echogenic deep brain structures caneven be higher on TCS than on MRI. On TCS, about 90% ofpatients with idiopathic Parkinson’s disease (PD) exhibit abnormalhyperechogenicity of the substantia nigra (SN). This finding isalready present in presymptomatic disease stages, suggesting TCSas a screening tool for populations at risk of later developing PD.Meanwhile, a number of independent TCS studies have shown thatSN hyperechogenicity well discriminates PD from otherParkinsonian disorders such as multiple-system atrophy andwelding-related Parkinsonism. In turn, normal SN echogenicity incombination with lenticular nucleus hyperechogenicity indicatesan atypical Parkinsonian syndrome rather than PD with aspecificity of more than 95%. In a recently published large studywe could show that the combination of TCS with simple olfactionand motor tests highly specifically discriminates early PD fromother parkinsonian disorders. TCS detects characteristic basalganglia changes also in other movement disorders such as lenticularnucleus hyperechogenicity in idiopathic dystonia and Wilson’sdisease and caudate nucleus hyperechogenicity in Huntington’sdisease. Reduced echogenicity of midbrain raphe is frequent indepressive disorders and was found to correlate with responsivityto serotonin reuptake inhibitors. Emerging applications of TCS arethe intra- and postoperative localization of deep brain stimulationelectrodes in patients with movement disorders, the detection ofchanges of deep brain structures in multiple sclerosis patients thatmay have a predictive value for further disease progression, as wellas the characterisation of basal ganglia alterations in children withneurobehavioral disorders.


Pre-Conference Symposium

S1

S2Phase shifts of the transcranial Doppler waveform: a new method to assess intracranial pressure dynamicsR. Aaslid, D.W. Newell Department of Neurological Surgery, University ofWashington School of Medicine, Harborview MedicalCenter, Seattle, Washington, USA

Background and Purpose: Patients with traumatic braininjury (TBI) frequently have increased ICP and decreasedintracranial compliance. This causes the pressure waveform of theABP to be transmitted to the ICP which in turn influences theshape of the flow velocity (FV) waveform. We hypothesized thatincreases in cerebrovascular pressure transmission (CPT) shifts thephase of the fundamental of the FV waveform relative to that of theABP. Methods: 17 patients with TBI were monitored for about 40minutes with simultaneous recording of the ABP, ICP and FVsignals. The fundamental amplitude and phase of the waveformswere determined by ensemble averaging and Fourier analysis. TheCPT and the phase shifts psICP and psFV of the fundamentalsICP1 and FV1 with respect to ABP1 were calculated. In a controlgroup of 10 normal subjects ABP (noninvasive) and FV wererecorded and only the psFV was calculated. Results: In TBIpatients we found a significant correlation between the CPT andthe psFV (r=-0.82). In the normal subjects, psFV was positive witha small S.D. (6.5±2.0 degrees, FV1 lagging ABP1). The increase inCPT correlated reasonably well with an increase in ICP (r=0.69).Conclusions: The phase of the FV is shifted by increased CPT. Thisphase shift can be determined noninvasively and may renderinformation about the intracranial dynamics useful in managementof patients with TBI.

Session I: Heart & Brain

L1Atrial fibrillation and strokeD. RussellDepartment of Neurology, Oslo University Hospital, Oslo,Norway

Atrial fibrillation (AF) is the most common sustained cardiacarrhythmia, affecting approximately six million Europeans.The

lifetime risk of developing AF is one in four men and women after theage of 40 years. The prevalence of AF increases dramatically with age,ranging from 1.5% in individuals aged 50–59 years to 23.5% in thoseaged 80–89 years. With an ageing population, the prevalence of AFis projected to double by 2030. Stroke is the most devastatingcomplication of AF. Atrial fibrillation causes 15–20% of ischemicstrokes and the overall risk of stroke in patients with nonvalvular AFis about 5% per year. Long-term studies have consistently shown thatpatients with AF have a 5-fold increased risk of stroke compared withindividuals without AF. One-third of patients who have atrialfibrillation and stroke were not known to have atrial fibrillation untiltheir stroke. Thrombogenesis in AF is due to the fact that it fulfils allthe components of Virchow’s triad- that is, abnormal changes invessel wall, blood flow and blood constituents leading to aprothrombotic or ‘hypercoagulable’state. The European Society ofCardiology (ESC) has recently extended the CHADS2 scheme byconsidering additional stroke risk factors that may influence adecision whether or not to anticoagulate. This risk factor-basedapproach for patients with non-valvular AF can also be expressed asan acronym, CHA2DS2-VASc [congestive heart failure,hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vasculardisease, age 65–74, and sex category (female)].This scheme is basedon a point system in which 2 points are assigned for a history ofstroke or TIA, or age ≥75; and 1 point each is assigned for age 65–74years, a history of hypertension, diabetes, recent cardiac failure,vascular disease (myocardial infarction, complex aortic plaque, andPAD, including prior revascularization, amputation due to PAD, orangiographic evidence of PAD, etc.), and female sex.

L2Cardiovascular TCD monitoringZ. GaramiDepartment of Cardiovascular Surgery, Methodist DeBakeyHeart & Vascular Center, The Methodist Hospital, Houston, TX,USA

Monitoring Carotid Endarterectomy (CEA). Non-invasivemonitoring of CEAs can identify the development of ischemia inpatients during surgery. Ultrasound can provide sensitivity equal toEEG in detecting cerebral ischemia, and demonstrates in real timethe mechanism by which the ischemia has developed, i.e.embolism, hypoperfusion, thrombosis, or hyperperfusion.Videotaped cases will be presented to demonstrate a variety ofpreviously reported typical transcranial Doppler (TCD) findingsduring CEA, their on-line interpretation, and responses to preventpossible complications. During CEA, no change in the flowvelocities after cross-clamping can be expected if the middlecerebral artery (MCA) unilateral to the severe carotid stenosis isnot dependent on the residual flow through the lesion, andcollateralization of flow occurs through the communicatingarteries. If the MCA flow waveform and velocity did not changeafter carotid clamping, the posterior cerebral artery (PCA) ismonitored. A potential unexpected change is the increased flowvelocity if it is needed by the collaterals. TCD velocity decrease isconsidered significant if it falls below 50% of the pre-clamp values,and shunt placement would be recommended. Shunt insertion

23Cerebrovasc Dis 2012;33(suppl 1); 1-88Abstracts Lectures

could result in flow velocity increase and improved systolic flowacceleration. A few embolic signals could be detected duringinsertion and removal of the shunt. However, after monitoring CEAwith TCD, the experienced TCD sonographer realizes that routineshunt placement in CEA exposes patients to embolization bothduring shunt insertion and removal. Nevertheless, there is noconsensus in the literature regarding selective versus routineshunting. Several normal flow velocity and waveform changes areexpected during CEA. Post-stenotic waveforms are seen at baselineat the start of the procedure. When an intact Circle of Willis is notpresent and there are insufficient collateral pathways to maintainadequate MCA flow, a significant mean flow velocity (MFV) dropis seen and can be accompanied by a dramatic decrease inpulsatility index (PI). In cases where sufficient collaterals exist, CEAwithout shunting can be performed. After the arterial clamp isapplied to the carotid artery, a minimal drop in MFV is seen. IfMFV remains >50% of baseline, shunt placement can be safelyavoided. After the clamp is removed, MFV and waveformsnormalize. It can be expected that several emboli (usually micro-bubbles) can be detected upon cross-clamp release. If thecontinuing presence of emboli is associated with re-establishmentof a blunted MCA waveform or a significant velocity decrease,surgical revision is warranted. If these TCD findings were obtainedafter wound closure, i.e. in the recovery room, a duplex ultrasoundexamination of the extracranial carotids can be performed to detectthe presence of a fresh thrombus in the internal carotid artery(ICA). Shortly after cross-clamprelease, TCD can show a spikyhigh-resistance signal in the MCA. This is an abnormal waveformthat indicates high resistance to flow at the site or just distal toinsonation depth. The abrupt appearance of this flow signal is rareand indicates thromboembolism in the MCA. In this situation,urgent angiography may be performed to visualize the site andextent of occlusion and this patient may be a candidate for anexperimental intra-arterial intervention, i.e. thrombolysis,mechanical clot disruption, or removal. Monitoring CarotidArtery Stenting (CAS). Since carotid artery stenting (CAS) wasapproved for clinical use in the United States, it has become anacceptable alternative to carotid endarterectomy (CEA) in selectedpatients. Strokes related to CAS are usually due to perioperativehypoperfusion, hyperperfusion, or, most commonly,thromboembolism. Published stroke rates range between 2-10%.In addition to symptomatic thromboembolic events, silentsubclinical cerebroembolism occurs at an even higher rate.Monitoring for such events is critical to prevent, diagnose, and treatprocedure-related embolism. With the increasing incidence ofcarotid stenting procedures, there is less histopathologicinformation usually attained during endarterectomy available tolink clinical events to cerebroembolism. Carotid Interventions (CIs)are sometimes performed without any neurophysiologicalmonitoring, which severely limits the clinician’s ability to intervenewhen complications arise. TCD is the only examination capable ofmonitoring intracranial blood flow in real time, thus detecting bothasymptomatic and symptomatic cerebrovascular events as theyactually occur. TCD shows the blood flow direction and velocityin the intracerebral vessels, adding physiologic information to theanatomical images obtained with other imaging modalities. TCDcan also detect potential collateral flow signals in the ophthalmic,anterior communicating, and posterior communicating arteriescaused by hemodynamically significant carotid stenosis.Understanding the collateral flow patterns can affect the

intervention, e.g. CEA vs. CAS, whether or not a shunt is placedduring CEA, and the decision as to which embolic protectionmethod is used during CAS based on the patient’s intracerebralflow patterns. Unlike CEA, sudden flow velocity and waveformchanges are not generally seen in CAS, except briefly duringballoon angioplasty. Since no arterial clamping is needed, flow isexpected to remain antegrade in the cerebral circulation.Contralateral ICA occlusion may be one of the indications toperform CAS over CEA. Acute hypoperfusion is less of a concern,since there is no arterial clamping. Hyperperfusion and, especially,thromboembolism are the major complications associated withCAS. Wires and catheters can dislodge atherosclerotic debris andthrombus in a diseased aortic arch and cause embolization to bothcerebral hemispheres. In recent studies, performing an aortic archangiogram was one of the worst embolic offenders. The incidenceof TCD-detected MCA microemboli increased with the frequencyof wire and catheter manipulation within the aortic arch. Inaddition to atherosclerotic emboli, contrast injections in the aorticarch and the carotid artery allow air bubbles to embolize to thebrain and are detected as MES by TCD. It is unclear how these airmicrobubbles affect the intracranial circulation and whether theycontribute to cerebral ischemia or cognitive dysfunction. There arecurrently several techniques to reduce embolization during CAS.The most prominent contenders are distal filter wire deploymentand reversal of carotid artery flow. Both techniques show MESwhen a wire is passed in the aortic arch, the carotid artery, and incrossing the lesion. Injection of contrast in the carotid systemappears on TCD as a bright reflection associated with MES. Evenwhen using a distal filter wire, stent deployment is still associatedwith distal embolic showers.The interest in using covered stents tocontain atheromatous debris waned due to higher in-stentrestenosis rates compared to bare metal stents. Nevertheless, fewerMES were detected by TCD with the use of covered stents. Flowreversal techniques are being developed to further reduce stentdeployment embolization. Early reports show significantreductions in MES during stent deployment with flow reversaltechniques. Depending on the exact flow reversal technique, flowreversal is commonly seen in the anterior cerebral artery (ACA)and terminal ICA by intraoperative TCD. Thromboembolism,hypoperfusion, and hyperperfusion are the primary causes ofstroke after CIs. TCD monitoring of the MCA during CIs is avaluable tool that quickly alerts clinicians to these complications.Because TCD monitors in real-time, the clinician can makeprocedural changes sooner than when using other monitoringmodalities. However, for intraoperative TCD to be effective, itrequires a team that is able to interpret and act on the TCDfindings. “The Doppler waveform never lies. It’s our own inabilityto understand its language that is the problem.” Merrill Spencer,MD; 1988


L3Cardiac arrhythmias: ablation, emboli monitoring andbrain imagingL. Csiba, E. Nagy-Balo, D. Tint, M. Clemens, I. Beke, R. KatalinKovacs, I. Edes, Z. CsanadiDept.Cardiology and Neurology, University of Debrecen,Hungary

The benefit of interventions in patients with cardiac diseasesis highly dependent on the perioperative stroke rate. Cerebralmonitoring plays an important role in reducing the perioperativecomplications as it makes possible to detect the embolism. Ourprevious study on coronary bypass patients proved, that cognitiveimpairment caused by cardiac surgery could be ameliorated bypharmacological intervention. The aim of this lecture is to providean overview of the result of emboli monitoring in some cardiacinterventions and present our observations (transcranial Dopplerstudies have revealed that cerebral microembolic signals could berecorded during interventions on cardiac patients (e.g. surgery, de-airing process, ablation) Transcranial Doppler can be used formonitoring of subclinical microemboli signals provocated bycardiac intervention. We compared the occurence of bubbleformation seen on intracardiac echocardiography (ICE) with theMES of AF patients (n=25 pts. 26 procedures) treated with threeinterventions: Group1, n=7 procedures:cryoballoon ablation and conventional anticoagulation with ACT>250 sec; Group 2, n=12 procedures: ablation using multipolar duty-cycledradiofrequency catheters (PVAC) and conventional intraproceduralanticoagulation regime with target ACT>250 sec; Group 3, n=7procedures:ablation with PVAC catheter using a more aggressiveanticoagulation protocol with ACT>350 sec. The MES in the threegroups of patients were detected in both middle cerebral arteriesby 2 MHz TCD with in-built programm to discriminate betweensolid and gaseous emboli. Significant correlation (r = 0.89) wasfound between the degree of bubble formation in the heart and thenumber of MES in all groups. Conclusion: bubble formation onICE showed a strong correlation with the number of MES duringablation regardless of the ablation technique and anticoagulationprotocol used. Duty-cycled RF ablation is associated withsignificantly higher number of MES even when a more agressiveanticoagulation is applied.

L4

Session III: Blood and Brain

L5Sickle cell disease: a clinical overview L. De FranceschiUniversity of Verona, AOUI, Policlinico GB Rossi, Dept. ofMedicine, Verona, Italy

Sickle cell disease (SCD; OMIM # 603903) is a worldwidedistributed autosomal recessive genetic red cell disorder, whichresults from a point mutation (bS, 6V) in codon 6 with the insertionof valine in place of glutamic acid leading to the production of adefective form of hemoglobin, the hemoglobin S (HbS). In theUnited States approximately 75,000 people suffer from SCD. InEurope, immigration from developing countries has increased theprevalence of SCD through the second half of the twentieth centuryand now almost 20,000–25,000 SCD patients have been registered.Sickle hemoglobin (HbS) shows peculiar biochemical properties, andpolymerizes when deoxygenated. Studies of the kinetics of HbSpolymerization following deoxygenation have shown that thekinetics of polymer formation is a high order exponential function ofhemoglobin concentration, thus demonstrating the crucial role ofcellular HbS concentration in sickling. Pathophysiological studieshave shown that the dense, dehydrated red cells play a central role inacute and chronic clinical manifestations of sickle cell disease, inwhich intravascular sickling in capillaries and small vessels leads tovaso-occlusion and impaired blood flow. However, the persistentmembrane damage associated with HbS polymerization also favorsthe generation of distorted rigid cells and further contributes to vaso-occlusive events and cell destruction in the peripheral circulation.Thus, the two main clinical manifestation of sickle cell disease arethe chronic hemolytic anemia and the acute vaso-occlusive events(VOCs). The VOCs in the microcirculation result from a complexand still partially known scenario involving the interactions betweendifferent cell types, including dense, dehydrated sickle cells,reticulocytes, abnormally activated endothelial cells, leukocytes,platelets and plasma factors as coagulation system cytokines andoxidized pro-inflammatory lipids. Musculosckeletal system, brian,lungs, spleen and kidney are target organs of SCD related vaso-occlusive events responsable for acute and chronic organ damage.Ischemic stroke is a dramatic clinical complication of SCD, especiallyin SCD pediatric population. Advances in managment of sickle cellcerebrovascular disease have been driven by the STOP study I and II(Stroke Prevention Trial in Sickle Cell Anemia). These studies showthat transcranial Doppler (TCD) blood flow velocity determinationis the major tool for identification of SCD children with high risk todevelop ischemic stroke and that SCD children on transfusiontherapy with the objective to maintain HbS < 30% have a significantreduction in SCD related cerebrovascular events. The growingnumber of patients with SCD in non-endemic areas requires theorganization of reference center with multidiscipinary teams, whichcan take care of both acute and chronic SCD related clinicalmanifestations to reduce organ damage and to ameliorate patients’quality of life and life expectancy.


L6Role of ultrasound in SCD: primary stroke preventionR.J. AdamsMedical University of South Carolina, Charleston, SC, USA

Primary stroke prevention in children was made possible by thedemonstration in 1992 that Transcranial Doppler Ultrasound (TCD)could identify children with SCD who have a high enough risk ofstroke to test treatments in a randomized trial, and, then after thepositive Stroke Prevention in Sickle Cell Anemia (STOP) trial results,gain traction in clinical practice. In 1985 regular blood transfusionwas commonly used after a child with SCD had stroke. It wasbelieved it would prevent first stroke but without focusing thetreatment it was impractical. Over 200 children with SCD would haveto be transfusion each month to prevent one stroke a year (based onthe unselected first stroke rate of .5%/year). After introducting ofTCD and applying a cutoff of > 200 cm/sec time averaged mean ofthe maximum velocity as a high risk selection criterion (associatedwith a 10%/year untreated risk of stroke), the NNT, “number neededto transfuse”, drops to 10. Using TCD selection, two randomizedcontrolled trials, STOP and STOP II confirmed the dramaticreduction in stroke (>90%) with TCD screening and regulartransfusion and also the pivotal role of TCD screening andmonitoring. Has this made a difference? Evidence now exists that,since STOP, US rates of first time stroke in children with SCD havedropped dramatically. Phase IV (post STOP trial) reports fromseveral clinics demonstrated that first strokes have become unusualif STOP criteria for screening and intervention are applied and oftenare seen in cases that were not regularly screened with TCD orrefused prophylactic transfusion. Now there are data from othersources. Data from the national inpatient sample indicate that SCDcomprised 8.7% of all pediatric strokes in 1997 but only 4.8% in 2006(p=.04). The comparable number for adults with SCD rose from .3%to .5% in this period. Recently it was reported that, based on datafrom the National Center for Health Statistics, the disparity (betweenblack and white children) in ischemic stroke related deaths in the USdropped by 74% since 1998. It was argued that the only plausiblereason for this was wide application of the STOP protocol because noother changes in care were introduced and the drop was not seen inhemorrhagic stroke against which the STOP protocol is not aseffective. This has had two other consequences that were not readilyapparent when I began the project at the age of 37 in 1986. The firstis that the number of children on transfusion has risen, probably bya lot, making the search for alternatives that much more important.The second is that the problem of stroke in adults with SCD, and theappalling lack of data and research “in the pipeline”, is becomingmore acute. In my opinion the need to initiate high impact researchis urgent. Two realizations have emerged. The first is that TCDdetects a “physiological lesion”, an aberrant response to anemiacausing increased cerebral blood flow and blood flow velocity wellbeyond what is predicted by the lower hemoglobin (the “normal SCDcompensated state” ), long before it detects a morphological one ; thesecond is that what I first thought we were doing in this work wasprevention of brain injury from stroke but, just as important, withearly screening and aggressive early intervention, we are providing“vascular protection”, protecting the only Circle of Willis thesepersons will ever have by preventing severe stenosis and moyamoya.The single most important predictor of regression of TCD and

stabilization of the angiographic appearance is the TCD velocity atthe time treatment is initiated. The role of TCD in current researchwill also be discussed.

Session IV: Atherosclerosis

L7-L8

L9Interrelations between carotid stenosis and coronarydiseaseN.M. BornsteinTel Aviv Souraski Medical Center, Tel Aviv, Israel

Atherosclerosis is a systemic inflammatory vascular disorder,involving multiple arterial beds. Although modern pharmacotherapyand revascularization have markedly enhanced the prognosis ofpatients with atherosclerotic vascular disease, myocardial infarction(MI) and stroke remain leading causes of mortality and morbidity dueto this disease. Concomitant atherosclerotic lesions of the extracranialinternal carotid arteries (ICA) and the coronary circulation portend anadverse prognosis in various clinical settings, including asymptomaticindividuals, stroke patients, and patients undergoing coronary arterybypass surgery. Previous postmortem and clinical studies, often smallin sample size, have reported a variable prevalence of concomitantcarotid and coronary lesions in patients with or without clinicallyevident cardiovascular disease. Thus, the prevalence of clinicallyimportant, concomitant carotid artery stenosis (CAS) and coronaryartery disease (CAD) requires further definition in larger populations.Concurrent CAD and CAS is frequently detected in clinical practiceand has important prognostic implications in symptomatic patientswho are considered for revascularization of one or both of thesevascular beds as well as in entirely asymptomatic individuals. Inpatients with traditional atherosclerotic risk factors but not necessarilya prior cardiovascular event, the mere presence of a carotid bruitpredicts increased risk of MI and cardiac death. In fact, progression ofCAS on sequential Doppler studies has been shown to be a strongercorrelate of future MI events than of stroke. The presence of CAS hasbeen shown in multiple, though not in all, studies to increase the riskof perioperative stroke in patients undergoing CABG. Conversely, thepresence of CAD increases the risk of peripheral vascular surgeryincluding carotid endarterectomy. Notwithstanding, the role of pre-emptive interventions on asymptomatic carotid or coronary lesionsprior to coronary or carotid revascularization, respectively, iscontroversial, and guideline recommendations regarding screeningfor asymptomatic CAS in patients with CAD are unsettled. Thereported 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 ofsignificant CAS has been reported to be as high as 30%.


L10Influence of genetic and environmental factors oncerebrovascular hemodynamics – a twin studyA. D. Tarnoki1, D.L. Tarnoki1, E. Medda2, M.A. Stazi2, C.Baracchini3, G. Meneghetti3, M.F. Giannoni4, G. Cardaioli5, R. Cotichini2, C. Fagnani2, L. Nisticò2, F. Fanelli6, G. Schillaci7, J. Osztovits8, K. Karlinger1, A. Lannert9, A. A. Molnar10,11,L. Littvay12, V. Berczi1, Z. Garami13

1Department of Radiology and Oncotherapy, SemmelweisUniversity, Budapest, Hungary; 2Genetic Epidemiology Unit,National Centre of Epidemiology, Istituto Superiore diSanità, Rome, Italy; 3Department of Neurological Sciences,University of Padua School of Medicine, Padua, Italy ;4Department “Paride Stefanini”, Vascular UltrasoundInvestigation Unit, Vascular Surgery, Sapienza University ofRome, Italy; 5Department of Neurology, Hospital “S. Mariadella Misericordia”, University of Perugia Medical School,Perugia, Italy; 6Vascular and Interventional Radiology Unit,Department of Radiological Sciences, La SapienzaUniversity of Rome, Rome, Italy; 7Unit of Internal Medicine,Angiology and Arteriosclerosis Disease, Department ofClinical and Experimental Medicine, University of Perugia,Perugia, Italy; 8Bajcsy Zsilinszky Hospital, III. Department ofInternal Medicine, Semmelweis University, Budapest,Hungary; 9Semmelweis University, Faculty of Pharmacy,Budapest, Hungary; 10Research Group for InflammationBiology and Immunogenomics of Hungarian Academy ofSciences and Semmelweis University, Budapest, Hungary;11Department of Cardiology, National Health Center,Budapest, Hungary; 12Central European University,Budapest, Hungary; 13The Methodist Hospital, MethodistDeBakey Heart and Vascular Center, Houston, TX, USA

Introduction: Cerebrovascular resistance is a pressuredependent mechanism due to the cerebral autoregulation definedas the normal buffering of changes in arterial blood pressure. Ourpurpose was to assess the heritability (A), shared (C) and unshared(E) environmental components of middle cerebral artery (MCA)mean flow velocities (MFV) and pulsatility indexes (PI). Patients(or Materials) and Methods: 175 Italian and American (90monozygotic /MZ/ and 85 dizygotic /DZ/) twin pairs (mean age53±13 years) underwent transcranial Doppler sonography (MFV,PI on left and right MCAs). Results: Heritability of right left andright MFV indicated 0.001 (95% CI, 0.000 to 0.287) and 0.107 (95%CI, 0.000 to 0.423), C was 0.724 (95% CI, 0.616 to 0.826) and0.577 (95% CI, 0.320 to 0.730), and E was 0.275 (95% CI, 0.201 to0.382) and 0.317 (95% CI, 0.219 to 0.457). Heritability of left andright PI values indicated 0.000 (95% CI, 0.000 to 0.094) and 0.049(95% CI, 0.000 to 0.332), C was 0.293 (95% CI, 0.105 to 0.459) and0.411 (95% CI, 0.210 to 0.566), and E was 0.707 (95% CI, 0.550 to0.889) and 0.540 (95% CI, 0.415 to 0.689), respectively.Conclusion: No genetic but common environmental factors(familiar socialization) seem to play a significant role on the onsetof MCA MFVs. Environmental factors related to individualexperience (e.g., smoking, diet, diabetes, physical activity) influencethe PIs.

Session V: The Unstable Carotid ArteryPlaque

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L12Evaluation of carotid plaque vascularization: useful instroke risk prediction?E. Vicenzini1, M.F. Giannoni2, G. Sirimarco1, M. Toscano1, I. Maestrini1, G.L. Lenzi1, V. Di Piero1

1Sapienza University of Rome, Department of Neurologyand Psychiatry, Rome, Italy; 2Department „Paride Stefanini“,Vascular Ultrasound Investigation, Vascular Surgery Unit,Rome, Italy

Background: Carotid plaque characterization with ultrasoundis a reliable diagnostic tool to identify echographic plaque featuesindicators of its composition and vulnerability. The role ofinflammation has also been identified as a fundamental factor foratherosclerosis progression, well established for coronary andcarotid artery diseases in clinical studies. In these regards,histological studies have indicated that neoangiogenesisdevelopment within atheromatic lesions is a predictor of unstability.Contrast enhanced ultrasound (CEUS) has proven a reliable toolto identify neoangiogenesis “in vivo” even in carotid arteries. Thistechnique and its clinical implications in cerebrovascular patientswork-up are discussed. Materials and Methods: Standard Duplexand CEUS have been performed both in symptomatic andasymptomatic plaques of different morphology and degree ofstenosis. In operated patients, vascularization observed at CEUSwas compared to post-operative histology. Results: Vascularizationwas detected with CEUS at the plaque shoulders, in the fibrous andin the fibrofatty tissues. A small vessel was constantly observedbelow surface ulcerations. Differently from plaque surfacefissuration, the diffusion of microbubbles appeared to be fromadventitial layers towards the inside of plaques. Vascularization wasnot detected in calcifications or in hemorrhagic areas. Acutesymptomatic plaques showed a different pattern of vascularizationin respect to asymptomatic ones, with a more diffuse contrastenhancement in localized areas of the lesions. Conclusions: CEUSis able to show different vascularization patterns in carotid plaques.In symptomatic and asymptomatic patients with surgicalindications, contrast examinations may add “in vivo” data on theevaluation of cerebrovascular risk, identifying more “unstable”plaques with a higher degree of vascularization. Future studies willshed light on the prognostic value of neoangiogenesis inasymptomatic patients with non-severe, non-surgical carotidstenosis. Possible effects of therapies aimed to plaque remodelingmay also be investigated in order to monitor plaque remodelling.


L13The European Unstable Carotid Artery Plaque Study(EUCAPS)O.M. Rønning1, D. Russell2

1Akershus University Hospital, Dept of Neurology; 2The National Hospital-Oslo University Hospital, Dept ofNeurology, Oslo, Norway

Background. Each year, there are 1 million strokes in theEuropean Union. The total incidence of stroke is projected toincrease by 50% the next 20 years because of the rapid increase inthe elderly population, and it is predicted that stroke will accountfor 6.2% of the total burden of illness in 2020.The prevention ofcerebrovascular disease and the development of new therapeuticoptions in this disorder is therefore a major goal in clinicalmedicine. The primary aim of this project is to establish a nationalresearch infrastructure in the field of cerebrovascular researchwhere the first goal is to register data which will enable theidentification of new markers of plaque instability in patients withatherosclerotic carotid stenosis. These markers may be used topredict the efficiency of therapeutic interventions and may lead tonew treatment modalities for this disorder. Methods. The projectwill establish a research infrastructure for registering and storingpatient data without the use of national identity numbers and withmechanisms to handle these conversions electronically with a highlevel of security. The first goal will be the registration of dataregarding patients with symptomatic (unstable) and asymptomaticcarotid artery plaques. The European Unstable Carotid PlaqueStudy (EUCAPS). This study will include clinical details, diffusion-weighted cerebral MRI findings,carotid ultrasound findings, CTangiography and where available imaging of macrophage activity(carotid 3Tesla MRI of ultra small super paramagnetic particles ofiron oxide) and imaging of metabolic activity (carotid 18Ffluorodeoxyglucose positron-emission tomography). The researchinfrastructure has the potential to address other major andimportant research problems in the field of cerebrovascular disease.The goal therefore of this research infrastructure is to establish arobust method for registering and storing patient data without theuse of national identity numbers and with mechanisms to handlethese conversions electronically with a high level of security.

L14Application of ultrasound contrast agents post-carotidsurgery/stentingS. HäfnerGerman Federal Armed Forces Hospital Ulm, Department ofAngiology, Ulm, Germany

Carotid entarterectomy (CEA) and carotid stenting (CAS) areestablished methods for revascularization of extra-cranial carotidocclusive disease. However restenosis is an unsolved problem andcan occur in up to 25 % of cases after both therapies. A high graderestenosis is associated with the risk of stroke related to the treatedartery. Therefore, post-carotid surgery/stenting surveillance for early-detection of restenosis is necessary. Color and spectral coded

ultrasound is an adequate tool for follow up surveillance of carotiddiseases, but there are several limiting factors for a full Dopplerultrasound examination of the extra cranial carotid artery: Heavilycalcified plaques, postoperative tissue calcifications or stents can limitthe visualization of the whole vessel, a deep-seated artery and vesseltortuosity can preclude a satisfactory Doppler angle for accuratevelocity measurements. After CAS the velocities obtained by duplexultrasonography are elevated for a given degree of stenosis due to astiffer vessel wall in the stented area. International standardized cutoff values for stented carotid arteries are not yet established. Thediagnostic capability of carotid Doppler ultrasound examinationpost-carotid surgery/stenting can be improved by use of an echo-enhancing blood pool agent. Contrast enhanced ultrasound providesa reduction in flow artifacts without aliasing. The visualization of theresidual lumen of multi-stented and heavily calcified vessels can beoptimized. Also, the full extension of an in-stent restenosis can bedetected. In aneurysmatic dilated arteries after CEA a betterdistinction between vessel wall and soft plaques can be reached.

Mini-Course in Neurosonology Sponsored by Toshiba: Live Session

MC1 – MC2 – MC3

Session VI: Intracranial Stenosis

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L18The prevalence of intracranial vascular disease in Italianstroke patients: the ISIDE StudyG.P. Anzola1, C. Baracchini2, M. Del Sette3, C. Gandolfo4, G. Meneghetti2, S. Ricci5, for the ISIDE Study Group1Servizio di Neurologia Ospedale S. Orsola – FondazionePoliambulanza Brescia, Italy; 2Clinica Neurologica Universitàdi Padova, Italy; 3UO Neurologia, Ospedale S. Andrea La Spezia, Italy; 4Dipartimento di Neuroscienze,

Oftalmologia e Genetica, Università di Genova, Italy; 5UONeurologia, ASL 1 Citta’ di Castello, Italy

Background and Objectives: Despite being largelyacknowledged as a major cause of ischemic stroke in Asianpopulations, intracranial atherosclerotic disease (ICAD) of brain


vessels has received comparatively little attention in Westerncountries. It is thus estimated that ICAD accounts for between 30and 50% of ischemic strokes in Chinese, Thai, Korean and SouthAsians, whereas in non Asians the estimates derive mainly fromstudies conducted in North America. Yet, in these studiesdifferences seem to emerge among ethnicities, with US Blacks andUS Hispanics showing an ICAD prevalence of 6% and 11%respectively as opposed to the 1% found in US White strokepatients. This is especially important inasmuch as ICAD iscommonly held as a malignant etiology of stroke with annual riskof recurrence between 10% and 50%, hence posing a dramatictherapeutic challenge. This notwithstanding, very few studies haveso far addressed the true prevalence if ICAD in European patients.Non-invasive assessment of large intracranial arteries is feasiblewith Magnetic Resonance and Computed TomographyAngiography (MRA-CTA) and with transcranial Doppler (TCD)and color coded Doppler (TCCD), but it has not yet become partof the routine assessment of stroke patients. Therefore the aim ofthe Intracranial Stenosis Investigated by Doppler Evaluation(ISIDE) study, a prospective multicentre observational study, wasto systematically assess the intracranial circulation of consecutivepatients admitted with acute ischemic stroke in order to evaluatethe prevalence of intracranial stenosis. Material and Methods:The study started in January 2011. Consecutive patients admittedfor acute ischemic stroke in the 6 participating Centres wereassessed during the study period according to a pre-specifiedprotocol . Demographic information, vascular risk factors androutine blood tests were recorded. The clinical and functionalassessments were performed with the NIH stroke scale and themodified Rankin scale respectively. The territorial distribution ofstroke were assessed with MRI/CT and with the Bamford scale.Both extracranial and intracranial vessels were scanned withultrasound as soon as possible after hospitalization, at dischargeand at three month follow up. Intracranial stenoses detected withTCD or TCCD were confirmed by CTA or MRA. Velocitythreshold values for intracranial stenosis were derived from theliterature. Results: The results of the first three hundred and fortyeight patients are reported. Mean age was 71 + 14. M/F ratio was203(58%)/145 (42%). Overall, ICAD was found in 34 (9.8%)patients: it involved the carotid territory in 18 (5.2%), the vertebral-basilar territory in 14 (4.0%) and both territories in 2 (0.6%). Onunivariate analysis, patients with ICAD , compared with thosewithout intracranial disease, had significantly higher plasma levelsof LDL cholesterol and triglycerides (114 vs 144 mg/dl and 124 vs161 mg/dl respectively), were significantly more likely to presentwith a non-lacunar Bamford syndrome (6% vs y20%) and with abrainstem infarction (19% vs. 7%), had a significantly higherfrequency of extracranial vertebral arteries abnormalities (33% vs8%) and severe carotid atheromatous disease – i.e.>70% orocclusion (26% vs 10%). On logistic regression only LDLcholesterol and extracranial vessel disease remained significantindependent predictors of ICAD. Conclusion: The preliminaryresults of the ongoing ISIDE study indicate that systematicassessment of intracranial vessels by means of ultrasound in acutestroke patients is not only feasible but also useful inasmuch as itmay disclose un unsuspected high prevalence of ICAD, the clinicalconsequences of which need not to be stressed.

Session VII: Acute Ischemic Stroke

L19-L20-L21

L22Neuromodulation in acute strokeF. Vernieri, P. Maggio, P. Palazzo, G. Assenza, R. Altavilla, C. AltamuraNeurology Unit, Policlinico Università Campus Bio-Medicodi Roma, Italy

Introduction: Repetitive transcranial magnetic stimulation(rTMS) and transcranial direct current stimulation (tDCS) havebeen recently proposed as a therapeutic tools in stroke. Highfrequency rTMS and anodal tDCS applied on primary motorcortex (M1) increase its excitability, while low frequency rTMS andcathodal tDCS produce opposite effects. Motor recovery afterstroke can be modulated by increasing excitability and brainplasticity on the affected hemisphere or by reducing the inhibitingeffect of the unaffected hemisphere on the damaged one.Objectives: Cortical neuromodulation influences cerebral bloodflow. Interestingly, rTMS and tDCS resulted to modify also cerebralvasomotor reactivity (VMR), that is the capability of the arteriolesto dilate in response to hypercapnia. It was demonstrated thatcerebral VMR is an independent risk factor for stroke occurrence.Methods and Results: We demonstrated that high frequencyrTMS applied on M1 induces a significant and long-lasting bilateraldecrease in cerebral VMR measured by transcranial Doppler(TCD) in healthy subjects and stroke patients. Conversely, lowfrequency rTMS applied on M1 increases cerebral VMR both inthe stimulated and in the contralateral hemisphere in healthysubjects, with a persistence of the effect for at least 2 hours.Moreover, tDCS exerts a polarity-specific and bi-hemisphericeffect on VMR: anodal tDCS applied on M1 produces a bilateralreduction of VMR, whereas cathodal produces its bilateral increase.Simultaneous and contrariwise autonomic parameters changes, aslow-frequency/high-frequency ratio of heart rate variability,suggest an autonomic system involvement in cerebralhemodynamics modulation induced by rTMS and tDCS.Conclusions: Cortical neuromodulation could be an importanttherapeutic strategy for stroke recovery. Its influence on cerebralhemodynamics and its interaction with autonomic nervous systemcontrol of cerebral blood flow should be taken into account intherapeutic trial design. References: Vernieri F, Maggio P, TibuzziF, Filippi MM, Pasqualetti P, Melgari JM, Altamura C, Palazzo P, Di Giorgio M, Rossini PM. High frequency repetitive transcranialmagnetic stimulation decreases cerebral vasomotor reactivity. Clin Neurophysiol. 2009;120:1188-94. Vernieri F, Assenza G, MaggioP, Tibuzzi F, Zappasodi F, Altamura C, Corbetto M, Trotta L, PalazzoP, Ercolani M, Tecchio F, Rossini PM. Cortical neuromodulationmodifies cerebral vasomotor reactivity. Stroke. 2010;41(9):2087-90.


Session VIII: Neuro-Myosonology

L23Contribution of US in diagnosing and therapeuticdecision making in peripheral nerve diseaseL. Padua1,2

1Dipartimento di Neuroscienze, Università Cattolica delSacro Cuore, Rome, Italy; 2Fondazione Don Carlo GnocchiOnlus, Milan, Italy

Electrodiagnosis is the main tool in assessing nerve function buta growing body of literature supports the use of Ultrasound (US) inthe assessment of nerve diseases. US has been used for nerveevaluation in entrapment neuropathies, traumatic nerve injuries and,in the last period, US is an emerging technique used as complementto pathophysiological studies in polyneuropathies (both dysimmuneand inherited). In 2007 we published a paper1 about the usefulness ofthe combination of electromyography (EMG) and US in diagnosingnerve involvement and we demonstrated that the combination ofthese two techniques if performed in the same session mayameliorate the diagnosis and address appropriate therapy. This studywas performed in patients with an atypical clinical andneurophysiological condition. In a recent article2 we prospectivelyevaluated 130 patients who underwent to our lab with clinical history,symptoms and neurological examination that suggest peripheralnerve diseases. We showed that US modified diagnostic andtherapeutic approach in 40.3% of cases, had a confirmatory role inthe 40.0%, and did not confirm clinical and neurophysiologicaldiagnosis in 17.7% of cases. US mainly helped to give surgicalindications, precisely identifying the site of nerve lesion, revealingiatrogenic findings (e.g. the presence of screws), pathologicalconditions (e.g. the presence of an accessory muscle or inflamatoryprocess) and dynamic abnormalities (ulnar nerve luxation).Furthermore, in cases of tumours and in the course of post-traumaticlesions, US provided useful information about the evolution of thepathologies. US can help us to the identification double crashsyndrome and, in some cases, to hypothesize the pathophysiologicalmechanism of nerve damage. In conclusion, our data suggest thatUS should be used, whenever possible, not only to improveassessment of nerve impairment, but above all, to assistneurologists/neurophysiologists in deciding on a therapeutic course.

L24Accurate targeting of botulinum toxin injections bymeans of ultrasoundU. WalterUniversity of Rostock, Department of Neurology, Rostock,Germany

Botulinum neurotoxin (BoNT) injection has been increasinglyused for treating muscular spasticity and dystonia. Unlike other

techniques of precision targeting such as electromyography orcomputed tomography that have been described to minimizeundesirable BoNT effects, B-mode ultrasound allows immediateand high-resolution imaging of the injection needle position withinthe target region. Visual identification of muscles and depth controlof needle placement are the key features of ultrasound-guidedinjection that lead to improved targeting and safety of BoNTinjections. Ultrasound may be helpful to validate alreadyestablished injection techniques or when learning the correctinjection technique. Ultrasound-guided BoNT injection has beenrecommended as a standard procedure in treatment of lower legspasticity in children with cerebral palsy. In recent years, thistechnique has been increasingly used also for the exact targeting ofBoNT injection in single forearm muscles (e.g. the flexor digitorumsuperficialis or the flexor digitorum profundus muscle of singlefingers) of patients with writers cramp or with mild post-strokespasticity. An emerging application is the ultrasound-guided BoNTinjection into deep cervical and nuchal muscles in patients withcervical dystonia, such as the scalene muscles and the obliquuscapitis inferior muscle. The upcoming MRI-ultrasound fusionimaging techniques that are available already today with advancedultrasound systems allow the ultrasound-guided targeting also ofsmall deep muscles such as the longus colli muscle in patients withantecollis, and the piriformis muscle in patients suffering from thepiriformis syndrome.

Session X: Veins

L25Hemodynamics of the cerebrospinal venous system:suggestions for a complete ultrasound studyE. Stolz Medizinische Fakultät Justus-Liebig-Universität Gießen,Medizinische Fakultät der Universität des Saarlands,Neurologische Klinik Caritasklinik St. Theresia, Saarbrücken,Germany

Until now no generally accepted consensus for the performanceof a complete venous ultrasound study exists. It is a difficult task todefine indispensable steps of such an examination because there isstill a lack of normative values for several parameters of the venoussystem in normal controls. Further, reproducibility has still to beestablished especially for the extracranial venous examination.Currently, intracranial venous examination is the most reliable partof the venous examination in terms of normal values andreproducibility. In this talk steps of the venous examination arediscussed in the light of evidence based criteria.


L26Blood flow in veins: a physicist’s perspective S. PascazioPhysics Department, University of Bari, Italy

The dynamics of blood flow in veins can be intricate, due to thesubtle interplay between the transmural pressure and thephenomenon of vein buckling. Scrutiny of steady and unsteadyflow in collapsible tubes enables one to draw analogies with bloodcirculations in veins. Vein buckling can be a consequence of avariety of natural factors, ranging from mechanical (and in thissense natural) to pathological ones. For instance, gravitysignificantly affects blood pressure (e.g., during standing) and thereare a number of physiological mechanisms that can compensate itseffects, minimizing or optimizing deformations and buckling. Afterconsidering a few examples and case-studies and some experimentsfrom elementary physics, we conclude that the familiar definitionof (artery) stenosis can be inappropriate when one applies the samenumerical figures to veins.

L27Optic nerve ultrasound evaluation in MS patientsN. Carraro1, G. Servillo1, A. Bignamini2, G. Pizzolato1, M. Zorzon1

1Clinical Neurology-Stroke Unit, University Hospital,Department of Medical Sciences, University of Trieste, Italy;2School of Specialization in Hospital Pharmacy, Departmentof Pharmaceutical Sciences “Piero Pratesi”, University of Milan,Italy

Background: Recent studies put forward the hypothesis thatalterations in the cerebrospinal venous system may have a causativerole in Multiple Sclerosis (MS) and that Chronic CerebrospinalVenous Insufficiency correlates with clinical features of MSpatients. Taking into account the peculiarity of the arterial-venoussystem supplying and draining the optic nerve, located in a closeenvironment, we have considered this as a representative site forstudying the relationship between veins and nervous parenchyma.Objectives: To evaluate the vascularisation of the Optic Nerve(ONe) by Duplex UltraSonography in Multiple Sclerosis patientswith and without previous Optic Neuritis (ONr) and test thepossibility to measure the ONe thickness by UltrasoundSonography. Subjects and Methods: We assessed the flowvariables in the Optic Artery (OA), Central Retinal Artery (CRA)and Central Retinal Vein (CRV) and measured the diameter of ONein 46 Relapsing-Remitting MS patients and 37 age- and gender-matched Healthy Controls (HC). Twenty-two MS patients hadprevious ONr and 24 MS patients did not. We examined andcompared 63 unaffected and 29 affected eyes of MS patients with 74control eyes. Results: Regarding OA, CRA, and CRV flow variableswe did not find any significant difference in any variable measuredbetween HC, MS affected, and MS unaffected eyes. ComparingONr diameters, we found a progressive significant thinning of theONr from HC to MS patients without and with past ONe.Conclusions: We failed to demonstrate, with Doppler

ultrasonography examination, significant alterations in the arterial-venous vascularization of both affected and unaffected ONrcompared with HC. We demonstrated the feasibility of themeasurement of ONr using ultrasound sonography. The analysisof the diameter of the ONrs showed that it is possible to detect ONratrophy in affected eyes and, at a lesser degree, also in unaffectedeyes of MS patients.

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L29The Italian multicenter study on venous hemodynamicsin multiple sclerosisG. Malferrari1, M. Del Sette2, M.L. Zedde1, S. Sanguigni3, N. Carraro4, C. Baracchini5, M. Mancini6, E. Stolz7

1ASMN, Neurology, Stroke Unit, Reggio Emilia, Italy;2Ospedale Sant’Andrea, Neurology, La Spezia, Italy;3Ospedale Madonna del Soccorso, Neurology, SanBenedetto del Tronto, Italy; 4Ospedale Cattinara, Neurology,Trieste, Italy; 5Ospedale di Padova, Neurology, Padova, Italy;6Consiglio Nazionale delle Ricerche, Istituto di Biostrutture eBioimmagini, Napoli, Italy; 7Giessen University, Neurology,Giessen, Germany

The COSMO study, promoted and sponsored by FISM, wasplanned in order to achieve a definite conclusion about the role ofvenous hemodynamic impairment in multiple sclerosis, because ofthe recently proposed hypothesis and the potential methodologicalpitfalls of these studies. A strict and controlled neurosonologicalprotocol was conceived, with the design of another smallermethodological study, ancillary to the COSMO study, formeasuring interoperator reliability in ultrasound examination andcomparing ultrasound data with MR findings. The aim of theadvanced protocol, designed for a subgroup of the COSMO study,is to collect data and analyze them concerning several items of theextracranial and intracranial venous hemodynamics. Study design:It is a multicenter, observational study, that will enrol 1200 adultpeople with MS, 400 healthy subjects and 400 subjects with otherneurodegenerative disorders (2000 subjects in total). A subgroup ofthese subject will be examinaed according to the advancedprotocol. The advanced protocol is on a voluntary basis and it isoptional. It includes, besides the basic one, measurements of bloodflow volumes in carotid and vertebral arteries and in jugular andvertebral veins (inflow and outflow), with the definition of thedrainage pattern. The blind ultrasound examination at eachclinical site will be followed by a second centralized blindedevaluation. The prevalence of CCSVI in MS will be estimated, withconfidence intervals at 95%, and compared with the prevalence inother groups. Moreover, multiple analysis will be done comparingvenous hemodynamics in the three different groups.


Session XII: Telemedicine

L30

L31Tele ultrasound during surgeryW.H. MessUniversity Hospital Maastricht, Department of ClinicalNeurophysiology, Maastricht, The Netherlands

Telemedicine has made a tremendous progress in the lastdecennia. This is predominantly attributable to the developmentin the field of information technology. Nowadays, signals acquiredat a given place can be transferred to another place withoutsubstantial quality loss, neither in terms of e.g. image quality nor interms of time delay. Neuromonitoring during carotidendarterectomy by means of transcranial Doppler (TCD)sonography can benefit in different ways when tele medicine isapplied. Transferring the TCD signal from the operating room(OR) to the office of the docter who is interpreting it makesphysical presence of this docter in the OR unnecessary. Especiallyif an experienced technician is performing the actual measurementthe amount of time the docter has to pay attention to themonitoring is well below 10 minutes. Furthermore, the same doctercan perform more than one TCD monitoring simultaneously. Ifappropriate soft- and hardware solutions are available, the latter hasnot to be restricted to one hospital. It goes without saying that bothaspects lead to a considerably improved efficiency as well as costeffectiveness yet without quality loss. In case an IT solution ischosen that allows for multiple viewers the setup can also be appliedfor educational purposes. An experienced TCD interpreter mightteach e.g. several residents at a distance. Taken together, telemedicine offers a new dimension to TCD monitoring duringcarotid endarterectomy and might stimulate its implementation ona larger scale.

L32Telementoring: ultrasound training and researchS. Castellani 1, G. Meneghetti 2

1Department of Cardiology and Internal Medicine,University of Florence, Italy; 2Department of Neurology,University of Padova , Italy

Remotely guided ultrasound scans can be applied to emergencyand rural care situations where access to a trained physician isdifficult. Emergency healthcare systems in rural communities oftenhave limited access to experienced trauma and emergency

physicians. Advanced telecommunication technologies may offeran opportunity to help meet this need. In pilot studies emergencymedical services (EMS) were supported via telemedicine guidance,using video ultrasonography, during vulnerable transport period.Physicians and technologists at a central workstation were linked toa telemedicine-equipped ambulance providing real-time audio andvisual communications during patient transport. The majority ofevaluators were able to telementor an abdominal and carotid vesselultrasound examination. Prehospital use of telemedicine for strokeis already being piloted, linking patients in the ambulance to theemergency department. Therefore in a similar fashiontelementoring US examinations can enable non expert physiciansto detect extracranial and intracranial arterial obstructions inacute ischemic stroke for improving acute stroke care of inhabitantsin underserved regions. As technology’s impact on everyday lifebecomes more and more extensive, its impact on mentoring is alsobecoming more widely acknowledged. Telementoring is becomingan increasingly widespread mode for providing mentoring services.With the advance of new technologies such as universal wirelessaccess and communication, telementoring may take many new formsand go in new directions, increasingly opening up the possibilitiesfor communication across time and space. Telementoring programsmay have a deep impact in neurosonological education linkingprofessionals with students and providing an expert guidance or advanced informations on diagnosis and treatment ofcerebrovascular diseases.

Oral PresentationsSession II: New Frontiers

O1Verification of the safety in transcranialsonothrombolysis: the neuropathological evaluation bythe 400 kHz burst waveform ultrasound in rabbit brainJ. Shimizu1, T. Fukuda2, T. Azuma3,5, K. Sasaki4, M. Ogihara6, J. Kubota6, A. Sasaki6, S. Umemura7, H. Furuhata1

1Medical Engineering Laboratory,2 Division ofNeuropathology, Department of Neuroscience, JikeiUniversity School of Medicine, Tokyo, Japan; 3School ofEngineering, The University of Tokyo, Tokyo, Japan; 4Faculty of Agriculture, Tokyo University of Agriculture andTechnology, Tokyo, Japan; 5Life Science Research Center,Central Research Laboratory, Hitachi Ltd., Tokyo, Japan;6Hitachi Medical Corporation, Tokyo, Japan;7 GraduateSchool of Biomedical Engineering, Tohoku University,Sendai, Japan

Background and Purpose: Sonothrombolysis usingdiagnostic ultrasound (US) in combination with rt-PA ormicrobubble contrast agents is a current therapy in acute ischemicstroke. And we have been developing a sonothrombolysis methodby 500 kHz mid-frequency continuous waveform US. However,the TRUMBI trial with rt-PA using 300 kHz burst waveform US


(BW-US) presented high rate of intracranial hemorrhage inpatients, and its pathological mechanism have never been fullyunderstood. We performed a neuropathological evaluation of 400kHz BW-US for rabbit brain using craniotomy model. Method:Three male rabbits (3.27±0.16kg) were made a 2.5 cm ofcraniotomy window under general anesthesia. Ten days aftersurgery, they received the 15-min duration of transcutaneousburst waveform US (400 kHz, duty cycle 20%, Ispta 0.70 W/cm2)from the craniotomy window. Brains were harvested 7 days aftereuthanasia and examined immunohistochemically by lightmicroscopy. Results: There was no heat shock protein express insonicated brain. However, amyloid precursor protein positiveaxons in white matter and alpha-B crystallin positive astrocytes incortex were observed. These findings were similar to histologicaldamage like a diffuse axonal injury (DAI) in brain trauma.Discussions: The problems of the TRUMBI trial are follows; 1)high effective mechanical index (eMI) over 2.0, 2) evolution ofintracranial bubbles and standing wave, 3) bubble trapping bystanding wave, 4) multi-reflection at the opposite side innercranium. According to McDannold et al., the eMI threshold ofthe disruption in rabbit blood brain barrier (BBB) by of BW-USis 1.38. In our rabbit study, the similar traumatic change appearedat the eMI value of 1.56 by BW-US. Conclusions: The similarDAI change by 400 kHz BW-US was shown neuropathologically.As one of the causes of the bleeding in TRUMBI trial, thetraumatic action exceeding the BBB disruption by unsuitable USconditions was considered.

O2Improved parameterization of the transcranial DopplersignalA. SchaafsmaMartini Ziekenhuis Groningen, the Netherlands

Transcranial Doppler (TCD) does not live up to its promise asa tool for neuromonitoring. Partially this is due to the currentparameterization of the signal. A new set of parameters is proposedto more accurately represent the shape of the waveform andeliminate a number of confounding factors. These parameters weretested in 227 patients with carotid stenosis versus 31 normalcontrols. On a beat-to-beat basis we calculated the maximal changein flow velocity at stroke onset (acceleration or acc), the maximalflow velocity during the first 100ms of systole (sys1) and during theremaining part of systole (sys2). All data were normalized relativeto the diastolic flow velocity at 560ms after stroke onset (dias@560).Comparing the carotid stenosis group with the normal controls,the average ± SD for acc (20.2 ± 9.5 versus 20.2 ± 6.7; p=0.98) andsys1 (1.82 ± 0.38 versus 1.77 ± 0.56; p=0.35) did not differsignificantly. The average ± SD for sys2 (1.94 ± 0.33 versus 1.50 ±0.12; p<0.001), however, was significantly higher in the group withcarotid stenosis than in the group of controls. The differencebetween sys1 and sys2 (‘sys1-sys2’) was lower in the patient groupthan in controls (-0.12 ± 0.16 versus 0.27 ± 0.22; p<0.001). Of theold parameters, the beat-to-beat mean (37.0 ± 13.1 versus 41.3 ±15.9; p=0.17) and the pulsatility index (PI; 1.00 ± 0.26 versus 0.91± 0.23; p=0.06)) were not significantly different between groups.

Graphed together the acc and ‘sys1-sys2’ parameters allowed a cleardemarcation of both groups whereas both groups overlappedconsiderably in a graph of mean and PI. The theoretical andpractical benefits of the new set of parameters facilitate TCDinterpretation and will make TCD a more powerful tool forneuromonitoring at the bedside.

O3Cerebral vasoreactivity evaluation in brain tissue andmajor cerebral arteriesT. Shiogai1, M. Yamamoto1, M. Koyama1, K. Yoshikawa2, M. Nakagawa3, H. Furuhata4

1Kyoto Takeda Hospital, Department of ClinicalNeurosciences, Kyoto, Japan; 2Hoshigaoka KouseinenkinHospital, Department of Stroke Medicine, Osaka, Japan;3Kyoto Prefectural University of Medicine/ Department ofNeurology, Kyoto, Japan; 4Tokyo Jikei University School ofMedicine/ Medical Engineering Laboratory, Tokyo, Japan

Objective: Time-dependant parameters rather than intensity-dependant parameters have been believed suitable for quantitativeevaluation of transcranial ultrasound perfusion imaging. Toovercome depth-dependent ultrasound attenuation problems, wehave introduced Acetazolamide (ACZ) cerebrovascular reactivity(CVR) evaluation in the brain tissue utilizing power modulationimaging (PMI). This has shown some correlation with CVR in themajor cerebral arteries, as measured by transcranial color duplexsonography (TCDS). Furthermore, to improve quantitative datareproducibility, we have introduced a transducer holder (Sonopod).ACZ CVR utilizing both time- and intensity- dependantparameters in the brain tissue with/without the Sonopod wasevaluated and correlated with TCDS observed CVR in the majorarteries. Methods: Time-averaged maximum velocity (Vmax) inthe middle/posterior cerebral arteries (MCA/PCA) was measuredbefore/after ACZ. After a bolus intravenous Levovist®, transcranialPMI was evaluated via temporal windows in 11 patients withoutand 10 patients with the Sonopod. Peak intensity (PI) and time toPI (TPI) before/ after ACZ were measured and CVR calculated onthe basis of time-intensity curves in five regions of interest; bilateralbasal ganglia (BG) and thalamus (Th), and contra-lateral temporallobe (TL). Correlations between Vmax and PI/TPI in thecorresponding vascular territories were evaluated before/after ACZand in CVR. Results: 1) Both before/after ACZ, Vmax in theipsilateral MCA and PCA correlated closely with PI/TPI in theipsilateral BG/TL and Th, respectively. 2) Easily disrupted PI/TPICVR resulted in poor correlations with Vmax CVR. 3) Much closerCVR correlations were not always identifiable, despite utilization ofthe Sonopod. Conclusions: 1) Regardless of the use of time- orintensity- dependant parameters or a transducer holder, thetendency of close ACZ relationships between brain tissue perfusionand velocity changes in the major arteries remains unchanged. 2)Easily disrupted CVR in the brain tissue resulted in poorcorrelation with CVR in the major arteries.

33Cerebrovasc Dis 2012;33(suppl 1); 1-88Abstracts Orals

O4Standing wave suppression in human skull by randomlymodulated ultrasoundO. Saito, J. Shimizu, H. FuruhataMedical Engineering Laboratory, Research Center forMedical Science, The Jikei University School of Medicine,Tokyo, Japan

Various transcranial sonotherapeutic technologies havecertain risks such as hemorrhage and undesired cell damagesoutside the target region, related to standing waves in the skull. Inorder to suppress standing waves, we investigated an activationsignal of transducer with random modulation. In particular, weapplied frequency modulation by noise (FMN) (deviation±50kHz) and periodic selection of random frequency (PSRF)(deviation ±50kHz) methods using the continuous wave around500kHz. Using schlieren method, we experimentally observedstanding waves produced by reflection with human skull in awater tank. An index of standing wave formation SWR , which isdefined by the difference of brightness between nodes andantinodes divided by the average of brightness, was calculatedfrom schlieren images. SWR was 23 for sinusoidal case,12 forFMN, and 9 for PSRF. The suppression ratio of standing wave isvery high in PSRF with narrow frequency band and high potentialto apply not only continuous wave but also burst wave. Thepresent study is expected to play a role in developing safertranscranial therapeutic equipment such as high intensity focusedultrasound, ultrasonic drug delivery and sonothrombolysis.

O5Feasibility and validation of spinal cord vasculatureimaging using high resolution ultrasoundF. Abd Allah1, S. Majidi2, M. Watanabe2, S.A. Chaudhry2, A.I. Qureshi2

1Cairo University, Cairo, Egypt; 2Zeenat Qureshi StrokeResearch Center, University of Minnesota, USA

Background: A non invasive method of visualization of theanterior spinal artery such as ultrasound that can be utilized inemergent or intra-operative settings can reduce the risk of spinalcord ischemia. Objectives: We assessed the feasibility of imagingand characterizing blood flow in the anterior spinal artery usingultrasound with concurrent validation using a cadaveric model.Methods: We developed a protocol for ultrasonographicassessment of anterior spinal artery based on anatomical,morphological and physiological characteristics of anterior spinalartery and determined the feasibility in 24 healthy subjects usinghigh frequency probe (3-9)MHZ through the left lateralparamedian approach in the area between T8-T12. We ascertainedthe detection rate, depth of insonation, and flow parametersincluding peak systolic velocity (PSV), end diastolic velocity (EDV)and resistivity indices for both segmental arteries and anteriorspinal artery within the field of insonation. We validated theanatomical landmarks using simultaneous spinal angiography andsimulated anterior spinal artery flow in a cadaveric set-up.

Results: We detected flow in all segmental arteries at differentlevels of our field of insonation with mean depth (±SD)ofinsonation at 3.9±0.7cm identified by characteristic high resistanceflow pattern. Anterior spinal artery was detected in 15 (62.5%)subjects at mean depth (±SD) of 6.4±1.2cm identified bycharacteristic low resistance bidirectional flow. Age, sex, and body-mass index were not correlated with either the detection rate ordepth of insonation for anterior spinal artery. Simultaneous spinalangiography and simulated anterior spinal artery flow in acadaveric set-up confirmed the validity of the anatomic landmarksby demonstrating concordance with results obtained fromvolunteer subjects. Conclusion: The current study describes atechnique for non invasive imaging of spinal vasculature usingultrasound which may enhance our diagnostic capabilities inemergent and intra-operative settings.

Oral PresentationsSession III: Blood and Brain

O6A two-center survey of psycho-social aspects in sicklecell disease African immigrant children living in Italy: a preliminary analysisR. Colombatti1, M. Montanaro1, M. Pugliese2, C. Migliozzi2,F. Zani2, M. E. Guerzoni2, S. Manoli1, G. Palazzi2, P. Rampazzo3,G. Meneghetti3, R. Manara4, L. Sainati1

1Sickle Cell Group, Clinic of Pediatric Hematology-Oncology, Department of Pediatrics, University Hospital ofPadova, Italy; 2Clinic of Pediatric Hematology-Oncology,Department of Pediatrics, University Hospital of Modena,Italy; 3Dept. of Neurosciences, University of Padova, Italy;4Neuroradiologic Unit, University Hospital of Padova, Italy

Background: Sickle Cell Disease (SCD) is associated withgeneral cognitive impairment and/or impairment of specificneurocognitive domains. Most studies on neurocognitive deficitshave been performed in the USA. Few studies were replicated inWestern-Europe where the healthcare and educational systems andthe origins of the patient population are different. SCD is animportant health condition in Italy due to immigration. Socio-demographic-linguistic factors might impact the evaluation ofcognitive impairment. Methods: Cognitive evaluation wasperformed in Padova and Modena. The Wechsler scales,standardized and age adjusted for the Italian population, were used.WIPSSI for children 4-6 yrs, WISC-III for older ones. Results: 68children (54 SS, 3 SB0, 11 SC), mean age 8,95 years (4 yrs-15 yrs 6mo) were evaluated, 47 in Padova, 21 in Modena. M 32 F 36. 67/68were first generation immigrants (47 from English speakingcountries, 14 from French, 3 Portuguese, 3 Albanian); 4 children wereadopted. 66,2% were born in Italy. 72% spoke three languages, 21% two and 7% one. Cognitive evaluation: Mean FSIQ was 86,9(WISC-III patients) and 89,6 (WPSSI patients). FSIQ indicatedlow/medium cognitive impairment for 13,2%, low/borderline for


41,1%, within the mean/above the mean for 46,3 %. Mean VIQ was84,5 (WISC-III patients) and 83,8 (WPSSI patients). Mean PIQ was91,7 (WISC-III patients) and 98,0 (WPSSI patients). VIQ was lowerthan PIQ in 46 patients (76,5%). 83% displayed behavioral problems:slowness in performing the test (19), low self-esteem (18),performance anxiety (10), difficulties in understanding the tasks (10),impulsivity (10), oppositional behaviour (5), attention deficiency (4),and hyperactivity (4). All families accepted to discuss the results andasked for support in dealing with school teachers. Conclusion:Cognitive assessment is feasible among vulnerable groups such asimmigrants and reveals a certain degree of cognitive impairment,mainly in the verbal domain (VIQ).

O7Parenchymal brain abnormalities in children with sicklecell disease: a magnetic resonance imaging studyM.G. Zanatti1, R. Manara1, V. Citton1, M. Grumolato1, G. Bommarito1, C. Baracchini2, P. Rampazzo2, G. Meneghetti2,G. Palazzi3, F. Cavalleri3, V.Munaretto4, G. Basso4, R. Colombatti4, L. Sainati4

1Neuroradiologic Unit, University Hospital of Padua, Italy;2Dept of Neurosciences, University of Padua, Italy; 3Dept ofPediatrics, Hospital of Modena, Italy; 4Clinic of PediatricHaemathology Oncology, Dept of Pediatrics, University ofPadua, Italy

Background: Sickle cell disease (SCD) is one of the mostcommon cause of stroke in pediatric patients. Silent infarcts (ISC)occur even more frequently in SCD patients and might impairtheir cognitive functions. Materials and methods: Weconsidered 47 patients (mean-age 8 years, age-range 2-18, 24females) affected by SCD (HbS/HbS in 40 cases, HbS/HbC in 6cases, HbS/βthal in one case); 39 of them had intracranialvascular stenosis. Twenty-three age-matched controls (mean-age10 years, age-range 4-18, 14 females) underwent brain MRIbecause of headache. The study protocol included FluidAttenuated Inversion Recovery (FLAIR; TR: 10000ms, effectiveTE: 140ms; TI: 2100ms; matrix 256X320) and diffusion weightedimaging (DWI; TR: 3948 ms, TE: 96 ms, matrix: 192X153, b-value: 1000s/mm2) with identical position, field of view(230mm), slice thickness (5mm) and gap (0.5mm). Volume ofischemic lesions was calculated after manually drawing the signalabnormalities on FLAIR images [Σ Area lesions x (slice thickness+ interslice gap)] using a dedicated software (MedStation).Results: 22 patients (46.1%) had parenchymal lesions (1 territorial infarct, 1 area of atrophy, 2 lacunar infarcts andwatershed lesions in 20 patients), while only 2 healthy subjectspresented non-specific punctuate white matter lesions (p<0.001,X-square test). Mean lesion volume was 987.9 mm3 ± 1589.6 anddid not correlate with patients’ age; 5 patients had a lesion volumegreater than 1000 mm3. No acute ischemic lesion was found.Parenchymal lesions did not correlate with the presence ofvascular abnormalities. Conclusions: Parenchymal ischemiclesions are frequent in SCD children, especially in the vascularborderzone; nontheless, lesions do not seem to correlate with thepresence of vascular abnormalities. The clinical impact of thesefindings needs to be elucidated further.

O8High incidence of intracranial artery stenosis in childrenwith sickle cell disease: a magnetic resonanceangiography studyR. Manara1, M.G. Zanatti1, M. Grumolato1, V. Citton1, G. Bommarito1, C. Baracchini2, P. Rampazzo2, G. Meneghetti2,G. Palazzi3, F. Cavalleri3, V.Munaretto4, G. Basso4, R. Colombatti4, L. Sainati4

1Neuroradiologic Unit, University Hospital of Padova, Italy;2Dept of Neurosciences, University of Padova, Italy; 3Dept ofPediatrics, Hospital of Modena, Italy; 4Clinic of PediatricHaemathology Oncology, Dept of Pediatrics, University ofPadova, Italy

Background: Moya-Moya disease is an unremittingcerebrovascular intracranial occlusive disorder that can lead topermanent neurological disability. It is characterized by the appearanceof basal arterial collateral vessels and may be idiopathic or occur inassociation with other syndromes like Sickle Cell Disease (SCD).Magnetic resonance angiography (MRA) is a noninvasive diagnostictool for Moya-Moya disease; the purpose of this study was to establishprevalence and severity of intracranial stenosis in children with SCD.Methods: We considered 47 patients (mean-age 8 years, range 2-18,24 females) affected by SCD (40 HbS/HbS , 6 HbS/HbC, 1 HbS/βthal)and 22 age-matched controls (mean-age 10, range 4-18, 14 females).MRA was obtained on a 1.5-Tesla scanner (Achieva, Philips, Best, theNederland) using a three-dimensional time of flight technique (flipangle: 20°, repetition time: 25ms, echo time: 6.9ms, field of view: 160x 160mm, slice thickness: 0.5mm, matrix: 320 x 183). Severity ofocclusive changes of the internal carotid artery siphon (s-ICA), of themain segments of the anterior (A1-, A2-ACA), middle (M1- , M2-MCA) and posterior (P1-, P2-PCA) cerebral arteries was scored asfollows: 0 (normal), 1 (mild stenosis), 2 (severe stenosis), 3 (occlusion).Results: No healthy subject presented intracranial stenosis, while39/47 patients (81.25%) had at least one intracranial stenosis; stenosiswere found in 35.1% of s-ICA, 48.9% of A1-ACA, 22.3% of M1-MCA,29.7% of M2-MCA, 2.1% of P1-PCA and 6.3% o f P2-PCA. In 15.6%of cases the stenosis was graded 2; no complete occlusion were found.Multiple stenosis were detected in 32 patients (68%). Patients withoutstenosis (8 patients) and with single (7 patients) or multiple (32patients) intracranial stenosis had comparable age (9.6, 9.6 and 8.8years, respectively). Conclusions: Intracranial stenosis are frequentin SCD patients even at a young age and mostly involve the anteriorcirculation.

O9Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients withantiphospholipid syndrome and stroke?V. Flumignan Zetola, L. Zanproni, M. LangeHospital de Clinicas, Neurology Departament, FederalUniversity of Parana, Curitiba, Brazil

Patent foramen ovale is associated with paradoxical embolism(PE)and stroke. Hypercoagulable states, such as antiphospholipid syndrome


(APS), can exacerbate PE by increasing clot formation. The aim of thisstudy was to verify whether patients with APS and stroke present aright-to-left shunt (RLS) with greater frequency than patients with APSbut without stroke. Methods: Fifty-three patients with APS were testedfor RLS using contrast-enhanced transcranial Doppler (cTCD).Results: Twenty-three patients had a history of stroke (Stroke Group)and 30 had no history of stroke (No-Stroke Group). cTCD was positivein 15 patients (65%) from the Stroke Group and in 16 patients (53%)in the No-Stroke Group (p =0.56). The proportion of patients with asmall RLS (≤ 10 high-intensity transient sign or HITS) and a large RLS(> 10 HITS) was similar between the groups. There was no significantdifference between the groups. Conclusions: Our data do not supportthe theory that paradoxical embolism may play an important role instroke in APS patients.

Oral PresentationsSession IV: Atherosclerosis

O10Carotid intima-media thickness and peripheral vascularendothelial dysfunction with tonometry in HIV infectedpatientsE. Azevedo1, C. Ferreira1, P. Castro1, F. Salgueiro2, P. Andrade2, I. Ferreira3, T. Guimarães4, C. Costa-Santos5, A. Costa-Pereira5, M. Pestana3, A. Sarmento2

1Neurology Department, Faculty of Medicine and São JoãoHospital Center, Porto, Portugal; 2Infectious DiseasesDepartment, Faculty of Medicine and São João HospitalCenter, Porto, Portugal; 3Nephrology RID Unit, Faculty ofMedicine and São João Hospital Center, Porto, Portugal;4Clinical Pathology Department, Faculty of Medicine andSão João Hospital Center, Porto, Portugal; 5HealthInformation and Decision Sciences Department, Faculty ofMedicine and University of Porto, Portugal

Introduction: HIV infected patients (HIV pts) have a highincidence of cardiovascular disease that cannot be accounted only byclassic vascular risk factors. It has been suggested that that some anti-retroviral drugs (mainly some protease inhibitors) can promoteatherosclerosis and endothelium dysfunction (ED), both potentialmarkers of preclinical vascular disease. We aimed to compare the effectof highly active anti-retroviral therapy (HAART) on ED and intima-media thickness (IMT) in HIV patients. Methods: We measuredreactive hyperaemia ratio (RH) by peripheral arterial tonometry(EndoPAT) and mean bilateral carotid IMT (M’Ath software) in HIVpatients of our outpatient clinic. Other analysed parameters weredemographic data, classical vascular risk factors, serum asymmetricaldimethylarginine (ADMA), cystatin C, hsPCR, renal function,proteinuria, lipid profile, follow-up time, time on HAART, drug classand viral load. Pearson correlations, multivariate logistic and linearregression analysis were used to evaluate significant results for RH andIMT. Results: Eighty men and 31 women with mean age of 44 ± 11

years were included. Mean follow-up time and time on HAART were102 ± 62 and 72 months, respectively. Mean RH was 2,1±0,5, maximaland mean IMT were 0,72±0,16 and 0,60±0,14 mm; ADMA blood levelswere 0.5±0.1mmol/L, cystatin C blood levels were 0,8±0,1mg/L,triglyceride, HDL and LDL blood levels were 149±75, 49±13 and126±37mg/dL; GFR was 90±16 mL/min and median proteinuria levelswere 71mg/day (0-960). Time on HAART (OR=1.011, p=0.013) andprotease inhibitor treatment (OR=2.856, p=0.038) were independentlyassociated with ED, but not with IMT, after multivariate adjustment.Discussion: Although ED and IMT are both markers of preclinicalvascular disease, in this study time on HAART was correlated with ED,but not with carotid IMT. In a prospective study, it will be interestingto evaluate which of these markers will be a better predictor ofcardiovascular events in HIV patients.

O11Rheumatoid arthritis and atherosclerosisG. Baltgaile, E. Stumbra, H. Mikazane, R. Erts Health Center ARS, Neurosonology Dept, Health Center 4,Neurosonology Dept, Clinic Orto, Rheumatology Dept, Riga Stradins University, Physics Dept, Riga, Latvia

Background and aims: It is widely accepted that patients withrheumatoid arthritis (RA) have increased mortality and morbidityfrom premature cardiovascular disease. Up to 50% of this excessmortality is secondary to ischaemic heart disease closely followedby cerebrovascular disease. The aim of this study was to investigatechanges in arterial wall elastic properties, intima-media thickness(IMT) and plaque formation with relation to age, disease durationand inflammation markers in patients with RA in order to detectand estimate cerebrovascular risk factors. Methods: 20 patientswith confirmed RA and 27 sex and age matched healthy controls(aged 27-70) were recruited. Carotid arteries haemodynamicparameters, elastic properties, IMT and plaques were measuredusing high resolution B-mode, M-mode and Doppler–modeultrasound to calculate arterial wall distensibility and stiffnessindices, blood flow velocities and resistance indices, maximal IMT,size of atherosclerotic plaques. Subjects with arterial hypertensionand smoking had been excluded from trial. C-reactive protein wasused to measure systemic inflammation. The correlations betweenbrachial arterial blood pressure, carotid haemodynamic , wallelastic indices and patients age, stage of disease, inflammationmarkers were calculated separately and in comparison withcontrols. Results: Statistically, patients with RA had mean valuesof IMT higher than healthy subjects (+-SD 1,02+-0,21 vs 0,85+-0,22, t=2,45, p=0,19; sin 1,01+-0,28 vs. 0,82+-0,19, t=2,47, p=0,18).This difference was more pronounced in a group of thirty-year. Nostatistically proved correlations between carotid stiffnessparameters, IMT and duration of disease was found. The presenceof carotid plaque correlated with the period of rheumatoid arthritisand markers of RA seropositivity - RF and anti CCP, although thechanges in IMT and carotid elastic indices did not differsignificantly according to seropositivity. These preliminaryobservations can indicate the need of further investigation with therecruitment of larger number of patients with RA to prove the roleof systemic inflammation in the atherosclerotic process.


O12Carotid artery elasticity and intracranial atherosclerosisF. Viaro, F.M. Farina, M. Atzori, G. Meneghetti, C. BaracchiniDepartment of Neuroscience, University of Padua School ofMedicine, Padua, Italy

Background: Intracranial artery disease is a major cause ofstroke worldwide, but presently there is no biomarker available for it.Carotid artery elasticity is a simple non-invasive measure of arterialwall function, which can be easily determined by high-resolution B-mode ultrasound and is a potential surrogate marker ofcardiovascular risk. The aim of this study was to investigate carotidartery wall dynamics in patients with intracranial atherosclerosisversus patients with extracranial artery disease. Subjects andMethods: We enrolled a group of 20 patients (16 males, mean age74.0±7.4yrs) with a recent minor ischemic stroke and a >50%intracranial symptomatic atherosclerotic stenosis detected by TCCDand confirmed by MRA/CTA/DSA. The control group wasrepresented by 20 gender- and age- matched patients withatherosclerotic disease of the cervical arteries but no TCCD evidenceof intracranial vessel disease. Every patient underwent a completebilateral assessment of common carotid wall dynamics: strain,stiffness and distensibility adjusted for IMT. Results: In theintracranial stenoses group, mean carotid stiffness was significantlyhigher [6.38±0.30 vs 5.89±0.27; p<0.01], while mean carotiddistensibility was significantly lower [15.69±0.74 vs 17.14±0.78;p<0.01] when compared with the control group. No significantdifferences were found in common vascular risk factors,statin/antithrombotic treatment and mean IMT values between thetwo groups. Conclusions: According to this study, carotid stiffnessseems to be more strongly associated with intracranial thanextracranial atherosclerosis; therefore, carotid elasticity may serve asa surrogate marker for cerebrovascular risk with potentialapplications in both research and clinical settings.

Oral PresentationsSession V: The Unstable Carotid ArteryPlaque

O13Plasma homocysteine levels are associated with carotidplaque echolucency in ischemic stroke patientsJ. Fernández-Domínguez, P. Martínez-Sánchez, E. Díez-TejedorDepartment of Neurology and Stroke Center. IdiPAZ HealthResearch Institute, Hospital Universitario La Paz,Universidad Autónoma de Madrid, Spain

Homocysteine (Hcy) is a natural metabolite of methionine, ancompound for intracellular metabolism. Epidemiologic studies

have proved that total plasma Hcy (tHcy) levels are anindependent risk factor for atherosclerotic disease, includingcerebrovascular disease, coronary artery disease, peripheral arterydisease and aortic plaque thickness. Carotid plaque echogenicityis correlated with its histological composition, so a lowerechogenictiy, is associated with higher stroke risk. Objectives:To determine whether there is a relation between tHcy andcarotid plaque echogenicity measured by the Gray-Scale Mediansystem (GSM). Methods: Prospective observational study ofconsecutive acute ischemic stroke patients with atheromatouscarotid plaques admitted to our Stroke Unit from October-2007to October-2009. Sympthomatic plaques and/or symptomaticlateral plaque are considered. Demographical data, vascular riskfactors and treatments are analyzed. Results: 289 patients withathero-thrombotic or lacunar cerebral infarction underwent acarotid color Doppler ultrasound. Of them, in 74 cases was possible to measure carotid plaque echogenicity and to determine tHcy plasma levels. The mean value of t-Hcy was12,2± 3,65μmol/l. tHcy higher than 10 μmol/l are related withlower GSM carotid plaque. Moreover, carotid plaque GSM andtHcy were inversely correlated. Conclusion: Higher levels of tHcyare correlated with lower GSM plaques, which could mean thatunestable plaques are somewhat related with tHcy levels.

O14Detection of micro embolic signals and impedanceaggregometry in patients with acute symptomaticcarotid disease. Is an insufficient inhibition of plateletfunction associated with an increased risk forpreoperative embolism?A. Kerasnoudis1, S.H. Meves1, A. Mumme2, R. Gold1, C. Krogias1

1Neurological Department, St. Josef Hospital, RuhrUniversity, Bochum, Germany; 2Vascular SurgeryDepartment, St. Josef Hospital, Ruhr University, Bochum,Germany

Introduction: The detection of microembolic signals (MES)with doppler sonography in symptomatic carotid stenosis isassociated with an increased risk of reinfarction. The impedanceaggregometry provides in vitro evidence on the effectiveness ofinhibition of platelet function. In this study, we examined therelationship between in vivo occurrence of MES and the in vitromeasured inhibition of platelet function. Methods: We includedin the study 32 patients (26 male, mean age 70) with severesymptomatic stenosis of the internal carotid artery (> 50%,NASCET graduation) before performing a carotid endaterectomy(CEA). The ischemic event (20 infarcts, 12 TIA) was back to tendays.We performed a 30-minute MES detection with dopplersonography in the ipsilateral middle cerebral artery, as well as ameasurement of the inhibition of platelet function induced bywhole blood impendance aggregometry. Results: In the dopplerexamination of the study group, at least one MES was detected in21 patients (65.6%). In the impendance aggregometry 24 patients(75.9%) showed a sufficient inhibiton. In 23 patients theaggregometry was performed under acetylsalicylic acid (ASA)


medication (19 showed sufficient inhibition and 4 insufficientinhibition), while in 9 patients the aggregometry was carried outunder clopidogrel medication (5 showed sufficient inhibition and4 insufficient). The probability of detecting more than one MESwas 75.0% in the case of an insufficient aggregation. Thisproprability was significantly higher than in patients withsufficient aggregation (only 29.2% with detection of more thanone MES, fisher exact test: p = 0.038). Discussion: Thepreoperative MES detection and the impedance aggregometry arereliable and rapidly applicable methods in patients withsymptomatic carotid stenosis. These studies could help identifypatients who are at risk of reinfarction, and thus contribute to thedetermination of preoperative treatment strategies.

O15Isolated parietal internal carotid artery thrombusJ. Meireles, R. Santos, P. Abreu, E. AzevedoDept. Neurology, Hospital São João and Faculty of Medicineof University of Porto, Portugal

Introduction: Strokes secondary to isolated parietal carotidartery thrombus are believed to be rare and often misdiagnosed.Risk factors and etiology in these particular cases remains mostlyto be established. Our aim was to review a patient series in orderto characterize and identify possible etiologies. Patients andMethods: A retrospective study of clinical and ultrasound datawas performed using information from stroke or TIA patientsregistered in our neurosonology unit. We selected cases ofisolated non-occlusive focal parietal internal carotid arterythrombus, excluding those with thrombus in other carotidsegments, those associated to atheromatous plaques or to carotidartery dissection. Results: Thirteen patients (9 women, mean age46, ranging 20-68 years old) admitted due to ischaemic stroke(n=12) and TIA (n=1) and with an isolated focal internal carotidartery thrombus in ultrasound examination were identified. Fivepatients also had CT or MRI angiography. In six cases (46%) nopossible aetiology was found, despite thorough investigation. Inthe remaining patients we identified some prothromboticconditions that could possibly be responsible for the thrombus: 3patients had iron deficiency anaemia, 1 patient had polycythemiavera, 1 patient suffered from Henoch–Schönlein purpura and hadpolyglobulia, 1 patient had a previous history of breast cancer andwas under treatment with tamoxifen, and 1 patient had an adultVaricella Zoster infection. Re-evaluation within the first monthshowed complete recanalization in 77% of the cases, decreasedstenosis in 15%, and one patient (8%) maintained the stenosis.Conclusion: The most common possible underlying cause forisolated focal internal carotid artery thrombus was ahaematological disorder. In the majority of cases a completerecanalization has occurred during the first month of follow-up.Further studies are needed to better characterize thisphenomenon and to gather data to support a possiblerecommendation for the treatment approach.

O16Risk reduction of brain infarction during carotidendarterectomy or stenting using sonolysis. Aprospective randomized studyE. Hurtíková1, D. Školoudík1,2, M. Kuliha1,2, M. Roubec1, R. Herzig2, V. Procházka3, T. Jonszta3, J. Krajča3, D. Czerný3, T. Hrbáč4, D. Otáhal4, K. Langová5

1Comprehensive Stroke Center, Dept. of Neurology,University Hospital Ostrava, Czech Republic;2Comprehensive Stroke Center, Dept. of Neurology, PalackyUniversity and University Hospital Olomouc, CzechRepublic; 3Comprehensive Stroke Center, Dept. ofRadiology, University Hospital Ostrava, Czech Republic;4Comprehensive Stroke Center, Dept. of Neurosurgery,University Hospital Ostrava, Czech Republic; 5Dept. ofBiophysics, Palacky University Olomouc, Czech Republic

Background: Sonolysis is a new therapeutic option for theacceleration of artery recanalization. The aim was to confirm therisk reduction of brain infarction during carotid endarterectomy(CEA) and carotid stenting (CAS) using sonolysis with continuoustranscranial Doppler (TCD) monitoring by diagnostic 2 MHzprobe. Methods: All consecutive patients 1/ presenting with >70%stenosis of the internal carotid artery, 2/ indicated to CEA or CASwere enrolled to the study. Patients were randomized into: Group1 with sonolysis performed during the intervention usingcontinuous TCD monitoring with diagnostic 2 MHz probe; andGroup 2 without continuous TCD monitoring. Neurologicalexamination and brain magnetic resonance imaging (MRI) wereperformed in all patients before and 24 hours after intervention.The number and volume of new brain ischemic lesions wasassessed, including statistical evaluation using t-test. Results:Ninety-seven patients (63 males, mean age 65.3±8.2 years) wereincluded in the study. Out of the 47 patients randomized to Group1 (35 males, mean age 65.2±8.1 years), 25 underwent CEA (Group1a) and 22 CAS (Group 1b). Out of the 50 patients randomized toGroup 2 (28 males, mean age 65.3±8.4 years), 22 underwent CEA(Group 2a) and 28 CAS (Group 2b). New brain infarctions onfollow up MRI were found in 14 (29.8%) patients in Group 1 (4/25Group 1a,10/22 Group 1b); in Group 2, new brain infarctions werefound in 18 (36.0%) patients (6/22 Group 2a, 12/28 Group 2b)(p>0.05 in all cases). Significant difference was detected in numberof brain infarctions with volume > 0.5 cm3 (4 in Group 1 vs. 12 inGroup 2; p=0.02). Conclusion: The study demonstrated thereduction of brain infarction volume and an apparent trend for theinfarction risk reduction during CEA and CAS using sonolysis.Supported by grants IGAMHCR NT/11386-5/2010 and NT/11046-6/2010.


O17Assessment of vulnerable carotid plaques using 3T MRIand carotid coilsSkagen K, Skjelland M, Scott H, Hol PK, Russell DOslo University Hospital, Rikshospitalet, University of Oslo,Faculty of Medicine, Oslo, Norway

A significant proportion of strokes are thrombo-embolic innature, arising from atherosclerotic plaques at the carotidbifurcation. Such strokes are effectively preventable by carotidendarterectomy or carotid stenting. In current clinical practicepatient selection for revascularization primarily involvesidentification of the severity of luminal stenosis, measured usingconventional imaging modalities such as Doppler ultrasoundand/or MR or CT angiography. It is however; increasingly clear thatthe degree of luminal stenosis alone may not be best predictor ofrisk. There is therefore increasing interest in developing imagingmodalities to identify in vivo morphological features (thin/ruptured fibrous cap, large necrotic lipid core, intraplaquehaemorrhage/thrombus) which are thought to be associated withincreased risk. The concept “vulnerable plaque” is increasinglybeing accepted in the carotid circulation. The aim of this study is toassess whether carotid MRI can identify vulnerable carotid plaques.Thirty consecutive patients with symptomatic high-grade carotidartery stenosis scheduled for carotid endarterectomy and 30consecutive patients with asymptomatic high-grade stenoses areincluded. Patients with a history of transient ischemic attacks orminor strokes due to carotid artery disease within 90 days of carotidendarterectomy are considered symptomatic. Neurologicalexamination, Doppler ultrasound, MR with carotid coils (3T MRI)and blood tests are performed before endarterectomy.Morphological status assessed by MRI in symptomatic andasymptomatic patients is compared, and the level of agreementbetween the MRI findings and histological categorization of plaqueassessed. MR Imaging of carotid plaques may allow earlier andmore specific diagnosis which may lead to the development ofmore individualized patient therapy. This is important becausethere are several groups in clinical practice, e.g. patients withsymptomatic moderate or asymptomatic severe stenosis, for whichdecision-making based on stenosis severity alone is not optimal.

O18The calgranulin S100A12 is increased in patients withsymptomatic carotid artery stenosisA. Abbas1, P. Aukrust2, D. Russell1, B. Halvorsen2, M. Skjelland1

1Department of Neurology, 2Research Institute of InternalMedicine, Oslo University Hospital, Rikshospitalet, Norway

Background and purpose: The calcium-binding proteinscalgranulins, including S100A8, S100A9 and S100A12 are involvedin many cellular activities and pathological processes includinginflammation. Atherosclerosis is one of the major causes ofischemic stroke and it is increasingly clear that inflammation plays

a major role in this disease. In this study we hypothesized thatcalgranulins may be markers of plaque instability in patients withcarotid artery atherosclerosis. Methods: Plasma levels ofS100A8/A9 and S100A10 were measured in 159 consecutivepatients with high-grade carotid stenosis and in 22 healthy controls.The mRNA levels of calgranulins were also measured in theatherosclerotic carotid plaques following endarterectomy, and theirregulation analyzed in vitro in monocytes. Results: Plasma levelsof S100A12 were significantly higher in patients with carotidatherosclerosis compared with healthy controls. The levels werehighest in patients with the most recent symptoms (i.e. within 2months). Plasma levels of S100A8/S100A9 showed a modestincrease in patients who had symptoms in the previous 2-6months, but not in the other patients. mRNA levels of S100A8,S100A9, and S100A12 showed increased expression inatherosclerotic carotid plaques from patients with the most recentsymptoms compared with the remaining patients. Conclusion:These findings support a link between calgranulins andatherogenesis and suggest that these mediators, and in particularS100A12, may be related to plaque instability.

Oral PresentationsSession VI: Intracranial Stenosis

O19Ultrasound enhanced thrombolysis with TCCS. Safetydata from a single center experience G. Malferrari1, M.L. Zedde1, R. Pascarella2, M. Maggi2, N. Marcello3

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Dept. of Medical Imaging,Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy;3Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy

Ultrasound enhanced thrombolysis is a useful and promisingtechnique for trying to increase the recanalization rate of patientswith ischemic stroke and large intracranial arteries occlusion.TCD demonstrated his safety concerning this application, but lessdata are available about TCCS. We reviewed the data of a smallsample of patients treated by thrombolysis with ultrasound+rtPAwas chosen, regardless UCA use. The recanalization wasmonitored by the continuous application of ultrasound during 60minutes, and then at 24 hours. 23 patients (8 female, 15 males;age 75.75+7.86 years) were treated within 3 hours from symptomonset, with MCA occlusion (TIBI 0-1) and a good temporal bonewindow. ASPECTS score of the baseline CT was 8.52+1.34. 5patients had a T occlusion and 18 patients a M1 MCA occlusion,in the left side in 14 patients. The NIHSS at the onset is15.56+4.58, at 24 hours 11.77+9.99, at 90 days 5.29+6.69. mRS at


90 days was 3.21+2.54. Only 3 patients had a parenchymalhemorrhage (and one of these because of a very late reperfusion).6 patients had a mRS 6 at 90 days and the causes of death wereintracranial hypertension (4 patients: 2 because of hemorrhagePH2 and 2 because of the hemispheric infarction), severerefractory heart failure (1) and pneumonia (1). The etiologicalclassification of intracranial occlusion was parted among acardioembolic one (14 patients) and large artery atherosclerosis (9patients). 8 patients (34.78%) had a complete recanalization (TIBI4-5) at 1 hour and 12 patients (52.17%) at 24 hours. 6 patients(26.09%) had a lack of recanalization at 24 hours (TIBI 0-1). 10patients (43.48%) had a good functional outcome at 3 months(mRS 0-1). The TIBI scores at 0, 20 min, 40 min, 60 min and 24hours were compared with test t and a statistically significantdifference arises between 0 and 20 min (p=0.0003), 60 min and 24hours (p=0.0104) and 0 min and 24 hours (p= 0.000151). In oursmall series of patients treated by iv rtPA and ultrasoundmonitoring with TCCS, there is not an increased rate of cerebralhemorrhage and the combined strategy was associated with animproved recanalization rate at 60 min and a 24 hours (completerecanalization 34.78% and 52.17% respectively; partialrecanalization 8.69% and 17.39%, respectively). The functionaloutcome was similar to the other literature reports.

O20Effect of microbubble contrast on intracranial bloodflow velocity assessed by transcranial DopplerN. Logallo, A. Fromm, U. Waje-Andreassen, L. ThomassenCenter for Neurovascular Disease, Haukeland UniversityHospital, Bergen, Norway

Purpose: Ultrasound Contrast Agent (UCA) bolus injectionleads to an increase in measured peak systolic velocity (PSV). Theeffect of UCA continuous infusion on measured PSV has not beeninvestigated. Gain reduction during UCA infusion may alsoinfluence measured PSV, but it has not been investigated in a clinicalsetting. This study aimed to investigate 1) the effect of UCAcontinuous infusion on PSV measured by TCD and 2) the influenceof gain reduction on these measurements. Materials and Methods:All study subjects had a good temporal bone window. The rightmiddle cerebral artery was insonated using a 2-MHz probe securedto patient’s head with a head band. UCA was administered using aninfusion pump via antecubital fossa venous access. PSV wasmeasured 1) at baseline; 2) during UCA infusion; and 3) during UCAinfusion and gain reduction. Two neurosonographers agreed on thedegree of gain reduction necessary to restore baseline Doppler signalintensity. Results: Ten patients were included (8 male; median age56.5 years; age range, 35-67 y). PSV measured during UCA infusionand no gain adjustment was significantly higher than baseline PSV(85.1 ± 19.7 vs. 74.4 ± 19.7 cm/s, p < 0.0001). The percent increasein measured PSV was 16 ± 9 (range 6-33). PSV measured duringUCA infusion and gain reduction was not significantly higher thanbaseline PSV (74.3 ± 18.9 vs. 74.4 ± 19.4 cm/s, p < 0.0001).Conclusions: UCA infusion leads to increase in measured PSV. TheUCA-related increase on PSV may be counteracted by gain reductionrestoring pre-contrast DSI.

Oral PresentationsSession VII: Acute Ischemic Stroke

O21Transcranial low mechanical index imaging with codedcontrast harmonics and microvascular imaging for real-time assessment of cerebral perfusionR. Kern1, A. Alonso1, M. Bolognese1, D. Artemis1, J. Powers2, M.G. Hennerici1, S. Meairs1

1Department of Neurology, Universitätsmedizin Mannheim,University of Heidelberg, Mannheim, Germany; 2PhilipsUltrasound, Bothell, USA

Background: In the past, transcranial ultrasound perfusionimaging has commonly been performed by using triggered highmechanical index (MI) scanning. Recent technologicalimprovements of contrast-specific imaging techniques now enablelow MI imaging in real-time. Coded contrast harmonics (CCH)describe a new pulse compression method which avoidsmicrobubble destruction by transmission of more power despitelow voltage of the transmitted signals. We evaluated whether CCHimproves image quality and contrast stability of low MI perfusionimaging with post-processing (“microvascular imaging”, MVI).Methods: Five patients with acute middle cerebral artery strokeand 5 control subjects were included. All ultrasound examinationswere performed with a Philips iU22 system; power-modulationimaging with and without CCH was used for transcranial perfusionimaging. Contrast stability was measured as the time between firstappearance and disappearance of contrast signals on MVI afterinjection of 2.5 mL of the echo-contrast agent Sonovue. Imagequality and detection rates of ischaemic lesions were rated by 2independent investigators and compared between CCH andconventional imaging. Results: By using CCH, contrast stabilitywas significantly better with a contrast detection time of up to 6minutes at an MI of <0.2. Image quality was rated superior in allsubjects while the detection rate of ischaemic lesions was similarbetween the two methods. Conclusions: CCH together with MVIpost-processing significantly improves contrast stability and imagequality of low MI transcranial perfusion imaging. This may furtherincrease the success rate of ultrasound perfusion studies in acutestroke, particular in patients with moderate temporal bonewindows.


O22Ultrasound analysis of cerebral blood flow duringinduced hypertension in acute stroke J. List1,2, J.E. Röhl3, M. Köhnlein1, F. Scheibe1, F. Doepp1, J.M.Valdueza4, S.J. Schreiber1

1Dept. of Neurology, Charité, Universitätsmedizin Berlin,Germany; 2Center for Stroke Research Berlin, Charité,Universitätsmedizin Berlin, Germany; 3Dept. of Neurology,St. Josefs Krankenhaus, Potsdam, Germany; 4Dept. ofNeurology, Segeberger Kliniken, Bad Segeberg, Germany

Background: In healthy individuals, cerebral autoregulation(CA) refers to the ability of the brain to keep cerebral blood flow(CBF) constant over a wide range of systemic blood pressure. Inischemic stroke, failure of CA is assumed, leading to currenttreatment guidelines of controlled hypertension in the hyperacutephase. However, the direct effect of blood pressure on CBF in acutestroke is poorly investigated. Here we report an observational studyof transcranial ultrasound blood flow analysis in a subgroup of strokepatients with occlusive disease of the internal carotid artery (ICA).Methods: Five patients were included, 3 with ICA occlusion and 2with high-grade ICA stenosis, demonstrating acute watershedinfarction and marked poststenotic middle cerebral artery (MCA)flow profiles and were therfore treated by catecholamine-inducedhypertension. Results: Stepwise increase of blood pressure was co-registered by TCCS analysis of blood flow in the ipsilateral MCAand ipsilateral posterior cerebral artery (PCA). Norepinephrinetherapy resulted in a significant flow velocity increase in both vessels(mean MCA increase: 0.27% per mmHg, mean PCA increase: 0.53%per mmHg). Conclusion: Our results show a clear relationshipbetween arterial blood pressure and MCA/PCA blood flow velocityin our group of stroke patients with hemodynamic pattern. The dataare giving functional evidence for CA failure and hypertensioninduced improvement of cerebral blood flow. Interestingly, thisoccurs via improved ipsilateral MCA flow but even more via theleptomeningeal activation of the PCA. Using TCCS offers anopportunity to directly perform a bedside online assessment of thehemodynamic effects caused by active blood pressure management.It has therefore the potential to become a therapy guiding tool inpatients with acute ischemic stroke.

O23Acute hyperglycemia reduces cerebral vasomotorreactivityP. Palazzo1,2, R. Altavilla1, P. Maggio1, C. Altamura1, I. Giordani3,I. Malandrucco3, F. Picconi3, F. Vernieri1, F. Passarelli2

1Neurologia Clinica, Università Campus Bio-Medico, Rome,Italy; 2Dipartimento di Neuroscienze, Ospedale “S. GiovanniCalibita” Fatebenefratelli, Rome, Italy; 3Dipartimento diEndocrinologia, Ospedale “S. Giovanni Calibita”Fatebenefratelli, Rome, Italy

Background: Cerebral Vasomotor Reactivity (CVR), a reliablemethod to evaluate cerebral hemodynamics, is impaired in type 2

diabetic patients, thus contributing to cerebrovascular morbilityand mortality. This study aimed to investigate the impact of acutehyperglycemia on cerebral reactivity, mainly in a condition ofinsulin-resistance. Methods: Seventeen patients with metabolicsyndrome (MS) and 3 age-matched controls, without a medicalhistory of vascular events, were evaluated. Metabolic syndrome wasdefined according to the International Diabetes Federation criteria.All subjects underwent a 2-hour hyperglycaemic clamp (HC), at ablood glucose level of 13.9 mmol/l. In order to avoid the possibleconfounding effect of hyperinsulinemia, endogenous insulinsecretion was inhibited by octreotide. At baseline, 60 and 120 minof the HC, and 2 hours, after the end, CVR was evaluated, by meansof bilateral transcranial Doppler measurement of middle cerebralartery mean flow velocity, and expressed as percentage changeduring inhalation of a mixture of air and 7% CO2. Results: In MSpatients, but not in controls, CVR was significantly reduced after 1hour and 2 hours of stable hyperglycemia vs. baseline (50.23% vs.62.38%, p=0.002 and 54.27% vs. 62.38%, p=0.015 respectively). 2hours after the end of HC, CVR value returned to baseline.Discussion: The finding that acute hyperglycemia worsened CVRcould contribute to explain its negative prognostic role in patientswith cerebrovascular disease. Considering that this effect wasobserved only in patients with metabolic syndrome, we canhypothesise that insulin resistance per se plays a rolein cerebrovascular response to acute hyperglycemia, before the onset of diabetes. This observation has many clinicalimplications, particularly on the possible prognostic meaning ofthe stress-induced hyperglycemia, in terms of cerebrovasculardisease in patients with metabolic syndrome.

Oral Presentations Session VIII: Neuro-Myosonology

O24Can neuro-myosonology help for differentiation of thetype and the severity of triceps surae muscle lesionsE. Titianova1, S. Karakaneva1, S. Chamova2, I. Tournev2

1Clinic of Functional Diagnostics of Nervous System,Military Medical Academy, Sofia, Bulgaria; 2Department ofNeurology, Medical University, Sofia, Bulgaria

Aim: To present the ultrasound calf muscle myoarchitectonicsin patients with different disorders. Methods: The study wasperformed in patients with different types of calf muscledisturbances: traumatic injury, genetically verified distalmyopathies, diabetic polyneuropathy and chronic post-strokespastic hemiparesis. Ultrasonic characteristics of the calf muscleswere assessed in rest, during maximal plantar flexion and electricalstimulation using multimodal color-duplex 2D/3D/4D sonography.The results were compared to the myosonograms of healthycontrols. Results: Compared to controls all patients had anabnormal calf muscle architectonics. The volume ultrasound


patterns depended on the location, type and severity of tricepssurae lesion, muscle fibers contractility, degree of muscle atrophy,fat tissue infiltration and fibrosis. Conclusion: Neuro-myosonology helps the noninvasive imaging of the structural andfunctional changes in muscle architectonics in patients with normaland pathological conditions and contributes for differentiation ofthe type and the severity of triceps surae lesions.

O25Ultrasound evaluation of patients with hereditaryneuropathy with liability to pressure palsies C. Dalla Torre1, M. Lucchetta1, M. Campagnolo1, G. Granata2,3,L. Padua2,3, C. Briani1

1Dept. of Neurosciences, University of Padova, Italy; 2Dept. of Neurosciences, Catholic University of Roma, Italy;3Don Gnocchi Foundation, Milano, Italy

Background: the diagnosis of hereditary neuropathy withliability to pressure palsies (HNPP) is often challenging due to thepoor clinical and electrophysiological picture. High resolutionultrasound (US) has been proven to be useful in the diagnosis ofperipheral neuropathies, especially of entrapment syndromes, andit may play a role also in the diagnosis of HNPP. Three patients,with confirmed or suspected diagnosis of HNPP underwent nerveUS evaluation at four limbs. Case report: Patient n.1 was a 29-year-old man with a history of recurring mononeuropathiesresulting in a right foot dorsal flexion hypostenia with confirmedHNPP. US showed ulnar nerve enlargement at elbows and also atleft forearm and at right arm. Median nerve enlargement was foundat wrists and at left arm and axilla and at right elbow and arm. Theright peroneal nerve presented enlargement at fibular head. Patientn.2 was a 56-year-old man with a history suggestive of HNNP. Hisneurological evaluation was unremarkable apart from dysphagiasecondary to achalasia. US revealed enlargement at ulnar nerve atelbows and of left peroneal nerve at popliteal cavus. The USfindings prompted us to perform the genetic analysis whichconfirmed the suspicion of HNPP. Patient n.3 was a 51-year-oldman with HNPP and a history of left peroneal nerve palsy. Clinicalexamination showed also mild hands weakness. US showedbilateral enlargement at entrapment sites of median and ulnarnerve. A median nerve enlargement was also present at right arm.Patients affected with HNPP may present nerve enlargement bothat entrapment sites and outside. Widespread US nerve evaluationshould therefore be performed in patients with entrapmentsyndromes and a history of recurring mononeuropathies toevaluate the presence of nerve abnormalities also outside theentrapment sites to help diagnose possible overlooked HNPP.

Oral Presentations Session IX: Parenchyma, Veins, Vasomotor Reactivity

O26Transcranial sonography and diffusion tensor imagingchanges of the brainstem raphe in depressionassociated with Parkinson’s disease M. Mijajlovic, M. Svetel, E. Stefanova, I. Petrovic, A. Pavlovic, V. KosticNeurology Clinic, Clinical Center of Serbia and School ofMedicine, University of Belgrade, Serbia

Objectives: Transcranial brain parenchyma sonography (TCS)showed decreased echogenicity of the brainstem raphe (BR) indepression associated with Parkinson´s disease (PD). Magneticresonance imaging and histopathological studies confirmed thehypothesis of a structural changes of the BR in depression in PD. Wecompared fractional anisotropy (FA) values and apparent diffusioncoefficients (ADC) of the BR in depressed and non-depressed PDpatients, in comparison to TCS findings, to investigate possiblestructural disruption of the BR. Methods: 40 PD patients withdepression (PD+ D+), 41 PD patients without depression (PD+ D-)and 30 healthy individuals (PD- D-) were included. PD patients withand without depression were matched for age and disease stage andduration. Echogenicity of BR was rated using TCS with a two pointscale (grade 1:normal BR echogenicity same as red nuclei, grade 0:hypoechogenic, invisible or interrupted BR). ADC and FA valueswere calculated using SPM7 software. Results: Significant increaseof mean ADC (t-test, each, P<0.0001) and significant decrease ofmean FA values (t-test, each, P<0.0001) were found in patients withhypoechogenic BR compared with patients with normal rapheechogenicity. Mean FA values were significantly decreased in dorsaland ventral part of the BR in PD+ D+ patients but only in ventralpart of the BR in PD+ without depression in comparison with healthysubjects ( t-test, each, P<0.0001). Conclusion: Our findings confirmstructural changes of the BR in depression associated with PD whichmay reflect the pathogenic role of the basal limbic system and itsprojections in the pathogenesis of depression in PD.

O27Transcranial sonography in bipolar disorder C. Krogias1, K. Hoffmann2, C. Norra2, J. Eyding1, R. Gold1, G. Juckel2, H.J. Assion2

1Ruhr University Bochum, St. Josef-Hospital, Dept. ofNeurology, Bochum, Germany; 2Ruhr University Bochum,LWL, Dept. of Psychiatry, Bochum, Germany

Introduction: Transcranial brain sonography (TCS) hasbecome a reliable and sensitive diagnostic tool in the evaluation ofextrapyramidal movement disorders. Alterations of brainstem


raphe (BR) have been depicted by TCS in major depression but notin bipolar disorder. The aim of our study was to evaluate BRechogenicity depending on the different conditions of bipolarpatients. Echogenicities of dopaminergic basal ganglia structureswere assessed for the first time in bipolar disorder. Methods:Thirty-six patients with bipolar I disorder (14 depressed, 8 manic,14 euthymic) were compared to 35 healthy controls. Echogenicitieswere investigated according to the examination protocol forextrapyramidal disorders using a Siemens Sonoline® Elegra system.The sonography examiner was blinded for clinical rating scores.Results: Six patients (16.7%) showed hyperechogenicity of thesubstantia nigra. The raphe was hypoechogenic in 13 (36.1%) ofthe patients. No significant differences were seen between thesubgroups. Compared to the control group, frequency of alteredechogenicities did not reach statistical significance. The width ofthird ventricle was significantly larger in the patient group (3.8±-2.1 mm vs. 2.7±1.2 mm). Depressed bipolar patients with reducedBR echogenicity showed significantly higher scores on theHamilton Depression Rating Scale as well as the Montgomery-Åsberg Depression Rating Scale. Conclusion: In contrast tounipolar depression, sonographic findings of bipolar patients maygenerally indicate structural integrity of mesencephalic raphestructures. If bipolar disorder coexists with hypoechogenic raphestructure, depressive symptoms are more severe.

O28Usefulness of transcranial brain parenchymasonography in discrimination between hepatic andneurologic forms of Wilson’s disease M. Mijajlovic, M. Svetel, A. Tomic, N. Kresojevic, T. Pekmezovic,A. Pavlovic, V. KosticNeurology Clinic, Clinical Center of Serbia and School ofMedicine, University of Belgrade, Serbia

Aim: To determine usefulness of the transcranial brainparenchyma sonography (TCS) in detection of potentially patternedfinding in Wilson disease (WD) with and without neurologicalinvolvement and its correlation with disease duration and severity.Patients and Methods: 54 patients with WD (33 with neurologic,16 with hepatic, 5 with mixed form) and 60 age-and sex matchedsubjects without any psychiatric or neurodegenerative disease wereinvestigated. TCS was carried out by 2.5-MHz transducer (Aloka,Alpha 10) by one investigator who was not aware of the group of thesubject. Echogenicity of substantia nigra (SN), thalami, thelenticular nuclei (LN), and the heads of the caudate nuclei wasinvestigated and classified as hyperechogenic when it was moreintense than the surrounding white matter. The hyperechogenicareas were calculated planimetrically and given in cm2.Echogenicity of the brainstem raphe was rated semiquantitativelyon a two point scale, and the diameter of the ventricular systemwas measured on diencephalic plane. Results: In comparison withcontrols, WD patients had significantly increased SN- (p=0.007)and LN-echogenicity (p=0.001). Patients with neurologic form hadsignificantly increased SN echogenicity (p=0.025) and the thirdventricle diameter (p=0.002) compared with hepatic form. Diseaseseverity correlated with SN and LN echogenicity (r=0.303; p=0.029,

respectively) and with the third ventricle diameter (r=0.351;p=0.011), while there were no correlation between disease durationand any of the brain structures studied. Conclusion: TCSdifferentiate WD from healthy individuals, but also neurologic-from hepatic-form of WD. It allows correlation between diseaseseverity and hiperechogenicity of certain basal ganglia structures.

O29Musical murmurs in intracranial veins: a never reportedfinding with a different meaning than in the intracranialarteries M.L. Zedde1, G. Malferrari1, S. Sanguigni2, R. Pascarella3, M. Maggi3

1Neurology Unit, Stroke Unit, Dpt. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Neurology Unit, Ospedale Madonna delSoccorso, San Benedetto del Tronto, Italy; 3Radiology Unit,Department of Medical Imaging, Arcispedale Santa MariaNuova IRCCS, Reggio Emilia, Italy

Musical murmurs (MM) are periodic sounds of short duration,sometimes reported in extracranial and mainly in intracranialarteries, as associated to an anatomic stenosis or a hyperdynamiccirculation, as in arterovenous malformations and fistulas or inactivated collateral routes of patients with wide steno-occlusivedisease. It has been postulated that they can derive from vibrationsof vessel walls in high flow conditions, as those described for thearterial circulation. At our knowledge, until now MM have notbeen reported in intracranial veins or sinuses. We reported a singlecenter experience of incidental findings of MM in intracranialveins, among patients referred to the Neurosonology Lab for TCCS.The majority of patients underwent TCCS for studying the arterialside of intracranial circulation and the identification of venous MMwas reported as incidental finding and suggested by an anomalousspreading of Power-mode signal along the course of veins. In a 2years period 1556 patients were examined with along the course ofGalen vein, mainly in his distal segment, near the junction with thestraight sinus. All patients underwent brain MRI and MRA forexcluding intracranial venous disease, as partial thrombosis andartero-venous malformations, but findings were unremarkable.One patient underwent also a digital subtraction angiography,because the previous occurrence of a brain hemorrhage in anatypical site, but a vascular malformation or fistula was excluded.One patient presented MM only during Valsalva maneuver and hehas an history of transient global amnesia. The extracranial venouscirculation of these subjects did not show significant abnormalities;two subjects have an internal jugular vein valve incontinence. MMcan be found not only in intracranial arteries but also in intracranialveins. In this last situation their significance could be more benignand they could not be associated to a pathological condition.


O30Early and direct interaction between ICP and cerebralblood flow after head injuryC. Haubrich1, D.J. Kim2, M. Kasprowicz3, R. R.Diehl4, K.Budohoski5, E. Sorrentino5, P. Smielewski5, M. Czosnyka5

1Dept of Neurology, University Hospital Aachen, Aachen,Germany; 2Dept of Neurosurgery, University HospitalToronto, Toronto, Canada; 3Institute of BiomedicalEngineering and Instrumentation, Wroclaw University ofTechnology, Poland; 4Department of Neurology, Alfried-Krupp-Krankenhaus Essen, Germany; 5Dept of AcademicNeurosurgery, Addenbrooke’s Hospital, Cambridge, UK

Introduction: Literature has suggested that the interactionbetween intracranial compartments under closed box conditionsmay alter the transmission of respiratory oscillations to blood floweven before the intracranial pressure increases. May these oscillationsprovide early evidence for increasing ICP after head injury (HI)?Does the multimodal monitoring help to elucidate compartmentalinteraction? Methods: 22 sedated and ventilated patients weremonitored on days 1 to 4 after traumatic HI. Monitoring includedintracranial pressure (ICP), bilateral transcranial Doppler of themiddle cerebral arteries (MCA), and invasive arterial blood pressure(ABP) which was analysed for the transfer of oscillations in therespiratory frequency range (R waves 9-20 cpm) from blood pressureto cerebral blood flow velocity (Fv), as well as indices of pressure –volume reserve (RAP), and autoregulation (Mx). Results:.Rising ICPhas dampened R wave gains from day 1 to day 4 after HI. Its impacton R wave gain was measured as ΔGain /ΔICP and depended onpressure-volume reserve (R2 right: 0.75; R2 left: 0.72, p<0.05). Largeimpact on R wave gains (ΔGain/ΔICP right: 0.14±0.06; left:0.18±0.08) was found associated with moderate ICP increase(9.02±4.73 mmHg) but a complete exhaustion of the pressure-volume reserve (RAP≥0.9). Steep increases in ICP (20.19±13.22mmHg) had lower impact on R wave gains (ΔGain /ΔICP right:0.05±0.02; left: 0.06±0.04; p<0.05) but increased the Fv pulsatilityand the Mx autoregulatory indices (left: 0.27±0.35; right: 0.30±0.40,p<0.05). Conclusion: Study suggested that rising ICP after HI hasimpact on cerebral blood flow by two different routes: 1. Through avascular route, resulting in a pulsatility increase and alteredautoregulation. 2. By direct compartmental interaction at the stage ofexhausted reserve. Here, R wave gains may provide early indicationfor increasing ICP before autoegulation is impaired.

O31Is hemifacial spasm accompanied by hemodynamicchanges detectable by ultrasound? F. Perren, M. MagistrisHUG, University Hospital and Medical Faculty of Geneva,Switzerland; Department of Neurology, Neurosonology andElectroneuromyography Units, Geneva, Switzerland

Background: Hemifacial spasm is characterized by weakness,synkinesis and involuntary, intermittent, spasmodic contractions

of hemifacial muscles innervated by the facial nerve. Usually, anarterial tortuosity of the posterior circulation compressing the facialnerve as it exits from brainstem induces the ephaptic axono-axonalcross-talk that sparks hemifacial spasm. MRA does not alwaysclearly show the “vascular-nerve conflict”. We sought if anoninvasive method such as color-coded duplex flow imaging ofthese arteries might detect hemodynamical changes in hemifacialspasm. Methods: Twelve patients have been examinedprospectively. Color-coded duplex flow imaging (using 7.5 MHZand 2MHz devices) has been performed by a sonographer who wasblinded to the presence of an HFS. Blood flow velocities of thevertebral (VA), basilar artery (BA), posterior inferior cerebellar(PICA) and anterior inferior cerebellar (AICA) arteries as well asthe diameter of the VA in their intervertebral segment (V2) weremeasured and side-to-side comparison was performed for all ofthem. Results: Nine patients (5 men; mean age 53.4 years) werestudied. Whereas there was no significant association betweenmean blood flow velocities elevation of the VA (V0-4) and HFS(Fisher’s exact p=0.523), an elevation of MFV of the PICA andAICA was found on the side of the hemifacial spasm in the 7 patients (Fisher’s exact p= 0.0285; 2-tailed). Conclusion:Hemifacial spasm seems to relate not only to an unfortunate“malposition” of an artery over the root exit zone of the facial nerve,but also to hemodynamic changes detectable by color-coded duplexflow imaging.

Oral Presentations Session XI: Clinical Cases: My Worst/Best Case

O32Recurrent transient global amnesia: venous etiologyS. Sanguigni1, T. Carboni1, R. Gobbato1, C. Paci1, G.D’Andreamatteo1, G. Nicoletti2, P. De Campora3

1Neurologic Department, San Benedetto del TrontoHospital, Italy; 2Geriatric Dept Matera, Italy; 3CardiologicDept Napoli, Italy

The transient global amnesia(TGA) is a clinical syndrome ofuncertain etiology: -epilepsy; -vasculopathy; -headache. Recently ithas been proposed a possible venous etiology. This hypothesis isbased primarily on a finding that: a) TGA is precipitated by aValsalva Manoeuvre in up to 45%. b) TGA often precipitated bysituations increasing blood flow to the superior vena cava (emotion,arm exercise, etc..). c) thrombosis of the Galenic system may causeamnestic syndroms. Hypothesis: VM may increase venous pressurein the Galenic system especially when blood flow to the vena cavais increased and the jugular vein valves are incompetent. We reporta case of a paz.(male 45 years old), who had recurrent episodes oftransient global amnesia. The paz, who worked as a lawyer,


complained annoying amnestic episodes during his forensic jobwith unpleasant consequences. EEG was normal.The ultrasoundstudy showed normal findings at the arterial level in the neck. TheValsalva maneuver showed a clear pattern of bilateral jugularvalvular incompetence with venous reflux lasting more than 0.88sec. TCCD showed normal flussimetric pattern on the basilar vein(of Rosenthal) bilaterally. However, the distal part of the vein, atthe junction with the vein of Galen, had wall’s covibrations withlocal stenosis. The VM showed an increase in the venous stenoticpattern. NMR showed normal parenchimal patterns withoutabnormality in DWI sequences. A venous angio study showed thepresence of stenosis at the distal segment of Rosenthal Vein.

O33Case report: effects of dantrolene on cerebralvasospasm after subarachnoid haemorrhageM. Lundervik, C.A. HellandSection for Neurosurgery, Department of Surgical Sciences,University of Bergen, and Centre for NeurovascularDiseases, Department of Neurosurgery, HaukelandUniversity Hospital, Bergen, Norway

A 41-year-old male experienced sudden loss of consciousnesswhile going out for a cigarette. The patient was non-hypertensiveand had no previous history of cerebrovascular incidents. Onadmission Glasgow Coma Score was 4-5 and he had right-sidedspastic seizures. Early computed tomography (CT) showed amassive subarachnoid haemorrhage (SAH). CT angiographyrevealed an aneurysm of the anterior communicating artery. Aventricular drain was placed, and endovascular coiling of theaneurysm was performed. Continuous contrast leakage during theprocedure indicated ongoing haemorrhage. Blood pressure wasinitially elevated and pupils dilated, but CSF-drainage quickly re-established cerebral circulation and the aneurysm was safelysecured. Upon extubation the patient was awake and had noapparent neurologic deficit. Due to auto seponation the ventriculardrain was substituted after seven days. Immediate postoperativelythe patient was mute with a right-sided hemiparalysis and lefthemiparesis. CT angiography showed profound global vasospasm(VSP) in proximal parts of Willis’ circle. VSP was treated withHHH-therapy, intravenous and intra-arterial nimodipine.Dantrolene is a ryanodine receptor antagonist, which inhibitsintracellular calcium release from the sarco-endoplasmicreticulum. Increased calcium concentration in smooth muscle isthought to play a significant role in VSP. Recent studies suggestdantrolene to be a promising new therapeutic agent. Day 1 aftervasospasm 100mg dantrolene was given intravenously. Theinfusion was well tolerated, systemic physiological parametersremained stable. Next day 200mg dantrolene was given.Transcranial colour-coded Doppler was done before and afterdantrolene infusions. Peak systolic and mean flow velocitiesdecreased after dantrolene. MRI showed VSP-related infarctionsbifrontally. The patient is undergoing extensive rehabilitation. Hislanguage and motor skills have improved substantially. CerebralVSP is a frequent cause of disability and death after SAH. Treatmentpossibilities are limited. This case report supports previous

hypothesis of dantrolene treatment to be promising, and providesuseful data for future studies.

O34Cerebrovascular neurosonology in isolated acutevestibular syndromesJ. Sargento-Freitas, F. Silva, N. Mendonça, C. Machado, G. Cordeiro, L. CunhaStroke Unit, University and Hospital Centre of Coimbra-H.U.C., Coimbra, Portugal

Background: The clinical approach to acute vestibularsyndromes is often complex and disturbing for the treatingphysician with significant etiologic heterogeneity. Thecerebrovascular neurosonologic study is non invasive, easilyaccessible and already occasionally used in the study of thesepatients, nonetheless its validity as a diagnostic method is still notevaluated in this setting. Objectives: To evaluate the diagnosticaccuracy of neurosonology in the complementary study of isolatedacute vestibular syndrome. Methods: We included all patients thatwere submitted to neurosonology during the year 2011 in contextof acute isolated acute vestibular syndrome (patients with any signof central nervous system lesion on presentation were notincluded). Patients underwent neuroimaging study (CT and MRIwhen CT inconclusive) and neurologic surveillance and the finaletiology was defined by the attending physician. Neurosonologicexam included studying all intra and extracranial segments of thevertebrobasilar circulation. The presence of a positive exam wasdefined as the presence of a stenotic or occlusive disease in any ofthese segments, found to be related to symptoms by theaccompanying physician. Results: We included 49 patients, 21(42.9%) males, mean age: 60.0 years (SD: 13.6). The final diagnosiswas positional paroxistic benign vertigo in 34 (69.4%), vestibularneuritis in 8 (16.3%), cerebrovascular in 4 (8.2%) and geneticcanalopathy in one patient (2.0%). Two patients (4.1%) wereclassified as non specified peripheral vertigo. Evaluating the resultsof neurosonology for the detection of ischemic etiology weidentified a sensibility of 50%, specificity: 100%, positive predictivevalue: 100% and negative predictive value: 95.7%. Conclusions:Our preliminary unicentre study indicates that neurosonology isan highly reliable method for the diagnosis of cerebrovascularpathology in these patients. However its low sensibility make it apoor candidate for diagnostic screening.


O35Arterial tortuosity syndrome: a very rare disease with atypical ultrasound appearance M.L. Zedde1, G. Malferrari1, L. Garavelli2, A. Wischmeijer2, N. Marcello3

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Clinical Genetic Unit, Arcispedale Santa MariaNuova IRCCS, Reggio Emilia, Italy; 3Neurology Unit, StrokeUnit, Dpt. of Neuromotor Physiology, Arcispedale SantaMaria Nuova IRCCS, Reggio Emilia, Italy

Arterial tortuosity syndrome (ATS) (ORPHA3342) is a very rareconnective tissue disorder, with an autosomal recessive inheritance;the main feature of this disease is the tortuosity and elongation oflarge and medium-sized arteries, that are prone to aneurysmalevolution, dissection, and stenosis (only pulmonary arteries). Wedescribed the case of a 12 years girl, born at term after uneventfulpregnancy, with a previous history of hypotonia, abundant skin,torticollis with hypertrophy of the sternocleidomastoid muscle at the right side, abnormal position of feet, and valvular heart abnormalities with septum hypertrophy. Psychomotordevelopment is normal, brain MRI did not reveal pathologicfindings. A skin biopsy showed in the dermis diffuse dysplasia ofcollagen fibres and rarefaction/fragmentation of elastic fibres. Shedoesn’t present subluxation of the lens nor dural ectasia. In thediagnostic pathway of a congenital disorder of connective tissue,she underwent an ultrasound examination of extracranial andintracranial arteries. The sonological findings were a markedelongation with diffuse tortuosity and multiple coilings of thecarotid (both common and internal carotid artery) and vertebralaxis, with a prominent tortuosity of the extracranial segments anda minor tortuosity of the intracranial arteries. The subsequentwork-up was based on genetic testing, showing a mutation in theSLC2A10 gene (20q13.12), encoding the facilitative glucosetransporter 10 (GLUT10). This mutation was previously reportedin 34 families, although the role of GLUT10 in the pathogenesis ofATS is still unknown. The differential diagnosis should includeother connective tissue disorders, as Loeys-Dietz syndrome, thevascular type of Ehlers-Danlos syndrome (EDS IV) and Marfansyndrome.

O36Myelopathy or not: a bad caseM. Atzori, F. Viaro, I. Mattisi, C. Semplicini, F. Farina, C. BaracchiniDepartment of Neuroscience, University of Padua School ofMedicine, Padua, Italy

Background: Acute myelopathy is a clinical definition for anacute neurologic condition that reflects impairment of spinal cordfunction. Acute spinal pathology can be associated with intra-axialor extra-axial disease. The diagnosis and the treatment must bereached as soon as possible to avoid a severe persistent disability

or, at worst, death. Case report: A 67 year-old woman, with amedical history of hypertension, developed weakness andnumbness in her lower limbs. She was visited by her generalpractitioner, referred to a local Emergency Department, treated forhypertensive crisis (PA 220/120) and dismissed. During thefollowing 48 hours, she developed progressively hyposthenia infour limbs, persisting vomiting and dysphonia. She was finallyadmitted to our Emergency Department: a neurologicalexamination showed a rigid extension in lower limbs, a forcedflexion in upper limbs with facial palsy, dysphonia and urinaryretention. She underwent a brain CT (normal), an neurovascularultrasound assessment (no Doppler signal in the right vertebralartery) and a cerebral and cervical MRI that showed a bilateralmedullary ischemic stroke.

Poster Session I-1 : AtheroscleroticPlaque and IMT 1

P1Carotid intima media thickness and ischemic stroke G. Struga, J. Kruja, S. Xhaxho , G. CakciriUniversity Service of Neurology , UHC “Mother Theresa”,Tiranë, Albania

Background: Carotid intima media pathologic thickness it isbeen correlated with clinical coronary artery disease and initialprocess of carotid plaque formation. Method: Data was retrievedand analysed from carotid ultrasound studies of 352 patients usingSiemens Acuson machine. The carotid intima media thickness wasmeasured ne carotid comunis artery in superior 1/3 , patients werespared from atherosclerotic plaque. Pathological were considervalues of IMI > 1.0 mm. Patients were defined as having lacunar ornonlacunar ischemic stroke by clinical diagnosis and imaging CTand /or MRI. Significant were considered the values of p < 0,05.Results: An insignificant statistical correlation between intimamedia thickness and ischemic stroke was evident for both leftCCA (P 0,535) and right CCA (P 0,303) . A significant earlyprominent appearance of pathological IMI was evident in malepatients and in right CCA. Conclusion: Carotid intima mediapathologic thickness is not directly statistically linked with ischemicstroke. A significant early prominent appearance of pathologicalIMI was evident in male patients and in right CCA Abbreviations:IMI intima media index, CCA common carotid artery.


P2Carotid artery IMT values are closely related todecreased left ventricular function in patients withcoronary artery diseaseK. Evensen1, S.I. Sarvari2, O.M. Rønning3,4, T. Edvardsen2,4,D. Russell1, 4

¹Department of Neurology, Oslo University HospitalRikshospitalet; ²Department of Cardiology,Oslo UniversityHospital Rikshospitalet; ³Department of Neurology, MedicalDivision, Akershus University Hospital, Lørenskog; 4 Facultyof Medicine, University of Oslo, Oslo, Norway

Background: Atherosclerosis is the underlying cause of themajority of myocardial infarctions and ischemic strokes. B-modeultrasound of the carotid arteries can measure intima-mediathickness (IMT) and detect carotid plaques, both used as surrogatemeasures of atherosclerotic cardiovascular disease. 2 - D speckle-tracking strain of the heart is a novel non- invasive method whichcan be used for detailed studies of left ventricular function. Weassessed the relationship between carotid IMT and plaques versusleft ventricular function assessed by strain measurements inpatients with CAD. Methods: 67 patients with symptoms of CADwere included. All were examined with coronary angiography,echocardiography and B-mode carotid ultrasound. The first 40consecutive patients were also examined with 2 - D speckle-tracking strain of the left ventricle. Left ventricular longitudinalstrain (LVGS) results were compared to coronary angiographyfindings in a receiver operating curve (ROC) to find the cut-offvalue of strain. The calculated optimal strain value was comparedto maximal averaged IMT values from the common carotid artery(CCA), bifurcation, and internal carotid artery and to the numberof carotid plaques. ROC curves assessed the accuracy of the testwith ROC curve area of 1 being a perfect test and 0.5 worthless.Results: The ROC analysis for strain versus coronary angiographywas: area under curve (AUC) = 0.904, 95 % CI: 0.80 – 1.0, cut-offvalue endocardial LVGS: -16.2%, ROC analysis for CCA IMT > 1mm versus endocardial LVGS was: AUC=0.905, 95 % CI: 0.715-1.094 . ROC curve analysis for strain versus number of carotidplaques was not statistically significant. Conclusion: Commoncarotid artery IMT values greater than 1 mm may indicate ischemicinjury of the left ventricular function and suggests that moreextensive examinations of the heart should be carried out.

P3Relationship between apolipoprotein E polymorphismand carotid subclinical atherosclerosis in patients withmild cognitive impairmentR.M. Romero Sevilla1, A. Falcón García1, J.A. Fermín Marrero1,B. Duque San Juan1, S. Romero Chala2,P.E. Jiménez Caballero1, J.C. Portilla Cuenca1, C. Cámara Hijón2,J.M. Ramírez Moreno3, I. Casado Naranjo1

Department of Neurology, 1Stroke Unit and 2Immunology,Hospital San Pedro de Alcántara Cáceres; 3Department ofNeurology, Hospital Infanta Cristina, Badajoz, Spain

Introduction: Several studies have independently evaluated theassociation between Apolipoprotein (apo) E, subclinical carotidatherosclerosis (SCA) and mild cognitive impairment (MCI). Theaim of this study is to determine the relationship between ApoEand SCA in patients with MCI. Patients and methods: In 60consecutive patients with MCI, sociodemographics characteristics,vascular risk factors, subtype of MCI and apo E genotypes wereevaluated. Intima - media thickness (IMT) and the presence ofatherosclerotic plaques in carotid arteries were determined byduplex-ultrasonography. Results: The mean age was 77,08 ± 9,82years. There were 34 women and 26 men. ApoE alleles frequencieswere ԑ 3 =0.775, ԑ 4 = 0, 183 ԑ 2 = 0.041, and were divided into threegroups according to ApoE genotype: E3 (ԑ 3 / ԑ 3) 58.3%, E4 (ԑ 4 /ԑ 3; ԑ 4 / ԑ 4) 35%, E2 (ԑ 3 / ԑ 2) 2.66%. There were no statisticallysignificant differences between ApoE genotypes and subtypes ofcognitive impairment (p = 0.568). The mean level of LDLcholesterol in E2 genotype was (80.75 + / - 19.7) significantly lowerthan in E3 and E4 genotype (p ≤ 0.05). There were no significantdifferences between ApoE genotype and total cholesterol, HDL andtriglycerides. The carotid IMT was not different between E3: (1.00± 0.22) E4 (1.07 ± 0.36) E2 (1.16 ± 0.51) p ≥ 0.05. Conclusions: Inour study we found no relationship between ApoE polymorphismand IMT in patients with mild cognitive impairment. This studywas funded by ISCIII-Fondo de Investigaciones SanitariasPS09/00727.

P4Clinical application of shear wave elastographyultrasound imaging for assessing carotid plaques.Initial findingsS. Nduwayo1, T.C. Hartshorne2, R.B. Panerai1, A.R. Naylor1, T.G. Robinson1, K.V. Ramnarine3

1Department of Cardiovascular Sciences, University ofLeicester, UK; 2Department of Vascular and EndovascularSurgery; 3Department of Medical Physics, University ofLeicester NHS Trust, Leicester, UK

Introduction: Carotid atherosclerosis is a risk factor forischaemic stroke. Echolucent plaques are associated with unstablecarotid plaques and increased stroke risk compared to echogenicplaques. Shear wave elastography (SWE) imaging is a new method ofquantifying tissue stiffness providing additional information to help

47Cerebrovasc Dis 2012;33(suppl 1); 1-88Abstracts Posters

identify the unstable plaque and improving patient selection forsurgical treatment. The aim of this study is to assess the feasibility ofusing SWE in identifying and characterising carotid plaques.Methods: Twenty-one patients (mean age 71.9±13.7, 11 males) with carotid plaques were recruited and underwent greyscaleimaging using a Philips iU22 scanner and SWE scan using aSuperSonicImagine Aixplorer® ultrasound system. Elasticity wasquantified by measuring Young’s Modulus in a 2mm region ofinterest within the plaque in up to 10 frames. Echogenicity wassubjectively classified into two groups, echolucent and echogenic, inrelation to surrounding tissue. Results: Twenty-four plaques wereanalysed, 17 echogenic (14 patients) and 7 echolucent (7 patients).There was a trend of increasing elasticity with age (R2=0.234). Therewas a significant difference (p<0.0001) in measurements of averageelasticity for echogenic and echolucent plaques, 166.0 ± 6.97kPa and91.4 ± 8.77kPa respectively. Conclusion: Shear wave elastographygives quantitative data on carotid plaque elasticity. The technique isable to obtain values for both echogenic and echolucent plaques.Significant difference in elasticity values in echogenic and echolucentplaques was observed showing potential of SWE assessment ofcarotid plaque. Further work continues to assess clinical value ofSWE and to demonstrate a relationship with histological findings.

P5Correlation between carotid plaque parameters andfrequency of microembolic signalS. Mirčić1, P. Slankamenac2, V. Spasić-Jokić1, B. Radovanović2, S. Ružička-Kaloci2

1Faculty of Technical Sciences, Novi Sad, Serbia; 2Clinic ofNeurology, Clinical Center of Vojvodina, Novi Sad, Serbia

In this study we applied image processing and Artificial NeuralNetworks clasification techniques on the B-mode ultrasound imageof carotid plaque in order to isolate plaque parameters that havehigh correlation with the frequency of microembolic signals (MES)measured in cranial arteries. Nineteen parameters were measuredon each of the seventeen plaques used in this study and results werecorrelated with MES. The results have shown that five parametershave a statistically significant correlation with MES: the percentageof fibrous tissue in the whole plaque, percentage of soft tissue inplaque, percentage of fibrous tissue on the surface of plaque,percentage of fat-muscle tissue in the whole plaque and averagevalue of local entropy on the surface of plaque.

P6Comparison of echographic characteristics ofatherosclerotic plaques (AP) in the carotid arteries (CA)with the results of the analysis of their mobility anddeformationV. Lelyuk1, S. Voynov1, D. Golovin1, S. Lelyuk2

1Russian National Research Medical University named afterN.I. Pirogov, Cerebrovascular and Stroke Research Institute,Moscow, Russia; 2Russian Medical Postgraduate Academy,Ultrasound Department, Moscow, Russia

Objective: The aim of the study was to depending on the studyof traditional characteristics determined with the use of ultrasoundscanning to their mobility and deformity as a possible criteria fordetermining the degree of instability. Methods: Study populationconsisted of 9 patients with AP in CA. Subjectives and objectiveplaque characteristics were assessed (echogenicity, structure, length,area, degree of stenosis, complications). Velocity (V), strain (ST),strain rate (STR), time-to-peak for L, ST and STR (TpkL, TpkST,TpkSTR), radial displacement (DR), radial velocity (VR),сircumferential strain and strain rate (STC, STRC), longitudinalvelocity, strain, strain rate and displacement (VL, STL, STRL, DL)were calculated for plaques in short and long axis. Results: All APwere heterogeneous (3 AP – with a predominance of hypoechoiccomponent, 3 - moderate echogenicity, 3 – hyperechoic). Signs of insitu thrombosis occurred on the surface of 3 AP. Degree of stenosisin diameter was 42%, by area – 43%. Correlation analysis revealedpositive correlations (p<0,01) between smooth cap and thrombosisin situ (r=0,59); smooth cap and inlucent inclusion (r=0,69); STRL,TpkL and degree of stenosis (r=0,94); TpkL and height of AP(r=0,98); VL and inlucent inclusion (r=0,82); STL and inlucentcomponents (r=0,83); DL and inlucent inclusion (r=0,83), DL andarea AP (r=0,83). Correlation analysis revealed negative correlations(p<0,01) between STL and length AP (r=-0,83); STL and smooth cap(r=-0,88).

P7Comparison of objective and subjective characteristicsof the “symptomatic” atherosclerotic plaques (AP) in theinternal carotid artery (ICA) in acute hemisphericischemic stroke (AHIS) with indicators that reflect theirbiomechanical propertiesS. Voynov1, S. Nikitin1,V. Lelyuk1, S. Lelyuk2

1Russian National Research Medical University named afterN.I. Pirogov, Cerebrovascular and Stroke Research Institute,Moscow, Russia; 2Russian Medical Postgraduate Academy,Ultrasound Department, Moscow, Russia

Objective: The aim of the study was to analyze the relationshipsbetween deformation and mobility of the components AP and theirechographic characteristics of patients with AHIS. Methods:Sonographic images were studied in 19 ipsilateral AP in ICA.Subjectives (structure, echogenicity, contour, complications) andobjective (length, height, area, diameter, degree of stenosis (ECST)of AP in long and short axis) characteristics of AP were assessed.


Velocity (V), strain (ST) and strain rate (STR) were calculated forplaques (cap, core and base) and for unchanged wall for eachpatient. Results: All AP were heterogeneous, 9 of them – with a predominance of hypoechoic component, 5 - moderateechogenicity, 5 – hyperechoic. Edge of 11 AP has been irregular, 8– regular. Signs of in situ thrombosis occurred on the surface of 9AP, in the matrix 11 AP visualized inlucent inclusion. Degree ofstenosis in diameter was 48%, by area – 47%. For cap: V (median)– 0,13, ST – 7,11, STR – 0,51; for base: V – 0,11, ST – 6,31, STR –0,45; for core: V – 0,13, ST – 8,15, STR – 0,69; for unchanged wall:V – 0,18, ST – 5,42, STR – 0,39. Revealed significant differences (p<0,01) in V, ST, STR for unchanged wall and all components of AP;in ST, STR for cap and core, for core and base. We obtain an inverserelationship (p<0,01) between strain of cap, core, base AP andlength AP; between strain of cap, core, base AP and degree ofstenosis AP; between strain of core, base AP and area AP.Conclusions: “Symptomatic” AP in their biomechanical propertiesare differ significantly from the unchanged wall of artery. The coreof this AP is experiencing greater deformation than the cap andbase, while the less length and degree of stenosis AP, the greater thedeformation is observed, which apparently indicates a greaterprobability of complications.

Poster Session I-2 : Emboli Detection

P8Influence of microembolism and characteristics ofmicroembolic signals (MES) during thombolytictherapy (TLT) on the forecast and outcome of ischemicstroke (IS)E. Shlyk, G. Ramazanov, V. Lelyuk, V. SkvortsovaСerebrovascular and stroke research institute of Pirogov’sRussian National Research Medical University, Moscow,Russia

Introduction: Transcranial doppler monitoring withmicroembolidetection (TCDM with MED) during TLT is usedfor stimation of decrease degree in a blood-groove in the amazedpool, verification of artery recanalization, fragmentation of bloodclot (embolus) and also strengthenings TLT effect. Materialsand methods: Data on 35 patients with IS in carotid pool areincluded in research, average age - 60,46 ± 11,48 years; 30 (85,7%)men and 5 (14,3%) women. All investigated had been executedduplex scanning (DS), transthoracic echocardiography andTCDM with MED during TLT and in a day after carrying out ofTLT and also neurologic examination at all stages of spenttherapy. Results: MES have been registered in 37% of cases.Correlations between presence of MES and dynamics of DSresults after TLT (r=0,438; p<0,05) and also between presence ofMES and expressiveness of deficiency (NIHSS) after terminationof TLT (r=0,418; p<0,05) and clinical outcome on a Renkin scale(r=0,522; р<0,05) are revealed. Occurrence of MES authenticallycorrelated with presence of atherothrombosis signs (r =0,458,p<0,05). At studying of influence of biophysical characteristics of

MES on clinical outcome correlation of MES frequency andclinical outcome on a Renkin scale (r=0,413; p <0,006) is revealed.At repeated monitoring in a day after TLT from 13 persons withsigns of MES at first examination only at 1 patient MES wereregistered. Conclusion: Occurrence of MES during TLT,apparently, is connected with influence of fibrinolytic agent onblood clot (embolus) in a gleam of the amazed artery. MESfrequency being the indirect characteristic of microembolusstructure has appeared interconnected with a clinical outcome ofstroke. The last, apparently, isn’t accident and reflects associativityof biophysical parameters of MES and success of TLT. Thus,complex ultrasonic research of the vascular status during TLTallows to receive prognostic significant information.

P9Characteristics of microembolic signals (MES) definingtheir clinical importanceE. Shlyk, V. LelyukСerebrovascular and Stroke Research Institute of Pirogov’sRussian National Research, Medical University, Moscow,Russia

Introduction: Clinical value of microembolidetection remainsa discussion subject, therefore studying of influence of the fact ofregistration and characteristics of MES on clinical status is actual.Materials and methods: Data on 269 patients are included inresearch; average age - 62,28 ± 12,4 years; 179 (66,5%) men and 58(33,5%) women. Examination included duplex scanning,transthoracic echocardiography and transcranial dopplermonitoring with microembolidetection at patients with ischemicstroke (IS) and at asymptomatic persons. Results: MES have beenregistered at 46 (17,1%) persons. Significant distinctions dependingon presence of ischemic events and presence of MES ((c2=116,47;р<0,001) are revealed. Average values of MES power (18,44 ± 5,93dB) and frequency (740,22 ± 356,79 Hz) were authentically higher(р<0,05) in group with IS in comparison with asymtomatic group(16,27 ± 4,62 dB and 482,17 ± 283,86 Hz accordingly). At divisionof patients into groups on value of energy index (EI) of MES (groupwhere at least 1 EI>=1,0 and patients with EI<1,0) have beenrevealed distinctions depending on presence of neurologicsemiology (c2=31,391; р<0,001). EI=power*duration (Joule*10-3).At division MES on ranges of frequencies of 0-500 Hz, 500-1000Hz, >1000 Hz (are chosen empirically) authentically big share ofMES with frequency of 500-1000 Hz concerned to symptomaticgroup. Distinctions on microembolism intensity (<30 per hour or>=30) in groups depending on presence of ischemic events((c2=14,696; р<0,001) are revealed. Conclusion: Microemboli cancause development of neurologic semiology. Average values ofpower and frequency of MES at IS are above similar values atasymptomatic persons. Value of EI of MES>=1 is characteristic forsymptomatic patients. The range of MES frequency which ischaracteristic for the signals leading to clinical neurologicsemiology, makes 500-1000 Hz. Threshold value of intensity,leading to development of neurologic deficiency, in our sample was30 MES per hour.


P10Long-term outcome after percutaneous patent foramenovale closureA. Tanzi1, R. Silvano1, U. Taliani2, L. Vignali2, A. Squeri2,E. Aurier2, C. Zanferrari1

1Neurological Unit, Department of Neurosciences,University Hospital of Parma, Italy; 2Cardiological Unit,Cardiac Department, University Hospital of Parma, Italy

Background: Patent Foramen Ovale (PFO) is associated withcryptogenetic stroke/TIA and migraine. Percutaneous PFOclosure has been proposed in the secondary prevention ofischemic stroke and it seems to determine significantimprovement of migraine syndrome. Aim of our study is to assessclinical outcome of patients submitted to PFO closure after a 3-years follow-up. Methods: Among 198 patients whounderwent PFO closure between 2004 and 2009, we enrolledthose who completed follow-up with a time interval fromprocedure of at least 3 years. They were submitted to a clinicalevaluation through a face to face structured interview. Specificitems were used to assess migraine features pre- and post-procedure: resolution, improvement (≥ 50% reduction inattacks’ frequency), unchanged pattern or new-onset. Pre-closureand residual Right to Left Shunt (RLS) were monitored throughechocardiography and/or transcranial doppler (TCD). Results:32 males and 39 females underwent PFO closure mostly becauseof a first or recurrent cerebrovascular event. Mean age ofprocedure was 47 ±12,6. Mean follow-up period was 46,9±9,6.Recurrent thromboembolic events were a vertebro-basilar TIAand a peripheral ischemia. Thirty patients (42%) had a history ofmigraine (with aura, without aura or both forms). Fifteenpatients (50%) showed a complete resolution of migraine, 11(37%) an improvement, 3 (10%) an unchanged pattern, 1 (3%) aworsening and 1 a new-onset migraine. TCD detected a residualminimal shunt during valsalva maneuver in 16 patients (23%),and a medium or large shunt in 7 patients (10%). Conclusions:Long-term follow up after PFO closure shows a low rate ofrecurrent thromboembolic events and a positive impact onmigraine syndrome.

P11Cognitive impairment and antiphospholipid syndrome:Is paradoxical embolism the rule?V.F. Zetola, L. Zamproni, M.C. Lange, M. CarneiroHospital de Clinicas, Neurology Departament, FederalUniversity of Parana, Curitiba, Brazil

Objective: Although cognitive decline (CD) is described inantiphospholipid syndrome (APS), its physiopathology isunknown. Paradoxical embolization (PE) is related to CD inAlzheimer disease. The objective of this study was to determinewhether PE plays a role in CD in APS patients through asignificant right-to-left shunt (sRLS). Methods: A total of 27patients diagnosed with APS without a history of stroke were

tested for the presence of an sRLS using a contrast-enhancedtranscranial Doppler (cTCD) ultrasound. CD was assessed usingthe Mini Mental State Examination (MMSE), the MontrealCognitive Assessment (MoCA) and a battery ofneuropsychological tests. Results: Of the 27 patients, 19 (70%)had a non-sRLS condition (≤ 10 high-intensity transient signs[HITS] on cTCD), and 8 (30%) had an sRLS. Patients with morethan 10 years of scholarship performed significantly better onboth the MMSE (p = 0.048) and MoCA (p = 0.03). Individuals ofthe non-sRLS group with more than 10 years of scholarship hadbetter performances on the Five-Point Test (FPT) when comparedwith the sRLS group (p = 0.01). Conclusions: Patients withoutsRLS and with more years of education exhibited a betterperformance in cognitive tests than sRLS patients. cTCD mayhelp investigation of APS patients with cognitive decline.

P12Correlation of embolic mechanism in patients withtransient global amnesia and transient ischemic attack.Ultrasound studyZ. Jovanovic¹, A. Pavlovic¹, B. Vujisic Tesic², M. Kostic Boricic², E. Cvitan¹, T. Svabic¹, N. Veselinovic¹,N. Sternic¹¹Clinic of Neurology Clinical Center of Serbia, MedicalFaculty University of Belgrade, Serbia; ²Institute ofNeurology Clinical Center of Serbia, Medical FacultyUniversity of Belgrade, Serbia

Background: Embolism is an important mechanism in thedevelopment of transient ischemic attack (TIA). How is theimportance of embolism in the development of transient globalamnesia (TGA)? The aim was to compare ultrasonic embolicparameters for TGA and TIA. Method, patients: We investigated70 patients with TGA and 150 patients with TIAs by color dopplerflow imaging of magistral neck arteries, detection of microembolisignals in cerebral arteries (MESs), detection of right to left (R-L)cardio-pulmonal shunt with air contrast (bubble test), transthoracalechocardiography (TTE) and transesophageal echocardiography(TEE) in patients with positive bubble test. Results: We found thatulcerated plaques were significant less frequent in patients withTGA (3/70) than in patients with TIAs (19/150) (p<0.001). MESswere detected significant less frequent in TGA patients (8/70) thanin TIA patients (34/150) (p<0.01). Bubble test was significant lessfrequent in TGA patients (8/70) than in TIA patients (48/150)(p<0.001). By TEE we confirmed only one potent foramen ovale inTGA patients and 9 in TIA patients, as pathway of paradoxalembolism (p<0.001). There was one cardiac source of embolism inTGA patients – atrial septal aneurysm (ASA) and 24/150 in TIApatients- left atrial thrombus 1, mitral valve prolaps 3, prosteticmechanic valve 1, ASA 3, atrial fibrillation 11, atheroma of aorticarch 5 (p�0.001). Conclusion: We found that ultrasonic embolicparameters were significant less frequent in TGA than in TIApatients. Embolism was not important mechanism for occurrenceof TGA, but it was important for TIA.


P13Microemboli signals in patients with transient ischemicattacksZ. Jovanovic¹, A. Pavlovic¹, B. Vujisic Tesic², M. Boricic Kostic², E. Vitan¹,T. Svabic¹, N. Veselinovic¹, N. Sternic Covickovic¹¹Clinic of Neurology Clonical Center of Serbia, Belgrade, Serbia;²Institute of Cardiology Clinical Center of Serbia, Belgrade,Serbia; ¹,²Medical Faculty University of Belgrade, Serbia

Background: Transcranial doppler (TCD) detection ofmicroemboli signals (MESs)in doppler spectar of middle cerebralarteries (ACMs) has positive predictive value for confirming ofembolic mechanism of transient ischemic attacks (TIAs).The aimwas TCD detection of MESs in both of ACM in patients with TIAs.Patients, method: We investigated MESs in 150 patients withTIAs and explored sources of embolism by color triplex flowimmaging of carotid arteries and by transthoracal endtransesophageal-ehocardiography we investigated cardioembolismand paradoxal embolism. Results: The average age of TIA patientswas 51.8±11.9 years and 43.3% were male. Embolic mechanism ofTIAs was found in 55/150 patients, 36.6%. MESs were detected in34/150 TIA patients, 22.7%. In the group of embolic TIAs, MESswere detected in 34/55 patients, 61.8%. Among 19 patients withulcerated plaques of carotid arteries, MESs were detected in 12/19,63.2%. Among 5 patients with atheroma od aortic arch, MESs weredetected in 4/5, 80%. Cardioembolism was established in 19/150TIA patients, MESs were detected in 13/19, 68.4%. The most oftenMESs were detecten in patients with prostetic mechanical valve andleft atrial thrombus (100%), mitral valve prolaps and atrial septalaneurysm (66,6%), atrial fibrillation (63.6%). Among 9/150 patientswit potent foramen ovale, MESs were detected in 3/9, 33.3%, andamong 3/15 patients with pulmonal right to left shunt, MESs weredetected in 2/3, 66.6%. We didn�t detect MESs in17/55 embolicTIA patients, 30,9% because MESs were not appeared in detectiontime or sources were emptied. Absent MESs in ACMs hadn�tnegative predictive value for embolic mechanism of TIA.Conclusion: Detection of MESs is very important ultrasoundmethod for examination of embolic mechanism of TIAs. Wedetected MESs from 33.3% to 100% in various sources ofembolism. Absence of MESs hasn’t negative predictive value forembolic mechanism of TIAs.

P14Arterial gas bubbles following a deep cold watertechnical dive in subjects without right to left shuntM. Simonetto2, G. Vettore1, A. Nava2, M. Gardin2, L. Zanet3, P. Guarise4, G. Didonè2

1Underwater Technical Research Tek Diving, Vicenza, Italy;2Department of Specialty Medicine, Division of Neurology,Neurophysiology Unit, ULSS 15, Cittadella Hospital, Padova,Italy; 3Department of Neurology and RehabilitationMedicine - Division of Neurology, Pordenone Hospital, Italy;4Department of Specialty Medicine - Division of Cardiology,ULSS 21 - Legnago Hospital, Verona, Italy

Introduction: Decompression sickness (DCS) is a pathologicalevent that occurs during the diver’s ascent due to gas coming out ofsolution forming intravascular and extravascular gas bubbles. It isthought that a right to left shunt (RLS) is necessary for the bubblesto affect the arterial system. To investigate the amount of arterialgas bubbles following a deep dive, we conducted a studyperforming arterious Doppler sonography of middle cerebral artery(MCA). Subjects and methods: Six healthy sport diversunderwent a cTCD for the diagnosis of absent or present RLS priorthe dive. It was a deep dive (50 msw) in a cold lake with SCUBAbreathing compressed trimix air (oxygen, helium and nitrogen).cTCD was carried out for at least 5min after emersion with thesubject in seated position focusing on the right MCA. Results: Wehad not evidence of RLS by cTCD prior the dive and there werenot DCS symptoms after the dive in our sample. Duringmonitoring after dive we detected arterial bubbles in three diverswith a Spencer Score grade 1 and a Kisman Masurel grade I-. Wehave found a slight correlation between presence of arterial bubblesand low BMI. Discussion: Arterial bubbles without evidence ofRLS by cTCD were found in divers. The intra-arterial formation ofgas bubbles are thought to be less likely in absence of RLS becausethe high hemodinamic pressures complicate bubble formation afterself-contained underwater breathing apparatus (SCUBA) dives.Our findings show that even in absence of RLS, the occurence ofintra-arterial gas bubble formation is possible. Further studies areneeded to confirm this data and to give the meaning of thisfenomenon.


Poster Session I-3 : Nerve, Brain and Vein 1

P15The cavernous sinus is a marker of the cerebral venoushemodynamic disturbancesM. Abramova, I. Stepanova, S. Shayunova, M. DuminskajaThe Russian National Research, Medical University namedafter N.I. Pirogov (RNRMU), Pediatric Faculty. Neurology,Neurosurgery and Medical Genetics Department, Laboratoryof Child Cerebrovascular Disorders, Moscow, Russia

The cavernous sinus (CS) and ophthalmic veins are locatedfrom the transorbital access but it is rarely used for children. Anoriginal access to CS proposed by us provides perfectdetermination peculiarities of hemodynamic disturbances.Objective: Study of the structural and ultrasound characteristics ofcavernous sinus. Objects: 230 patients with the same type ofheadaches, nasal bleedings and dizziness (72 patients of them agedfrom 20 to 55 and 158 aged from 2 to 16 years) have been surveyed.Methods: Triplex scanning of the brain vessels by “Logiq P-5” with5-Mhz sector transducer. Results: Evident hemodynamicdisturbances in the vein of Galen, straight sinus (92%), internaljugular veins (92%), cavernous sinus (65%) were observed. Severalforms of structural features of CS have been revealed: 16,6% -cavernous form (the form of venous plexus); 22,5% - lacunar formand mixed form - 58, 3%. It was registered a correlation between ofexpression of the venous outflow disturbances and structuralfeatures of the cavernous sinus: in two-sided lacunar form of thesinus disturbances haven’t been revealed (value of blood flowvelocity (BFV) = 23-25 ± 2,3 cm/s); in cavernous form (BFV = 30± 2,1 cm/s) and expressed increase velocity amounted to 100 cm/shave been registered in the mixed form. Evident disturbances ofcerebral hemodynamics have been revealed at the patients with theabsence of the location of the cavernous sinus on one side (2,7%).In accordance with the data of triplex scanning MRI has beenconducted. It showed a hypoplasia of the cerebral venous sinuses at17% of patients. Conclusion: The new access provides a possibilityto revealed arterial and venous cerebral disturbances (functional,structural) and determines the tactics of advising patients (i.e.diagnosis and therapy).

P16Superior sagittal sinous thrombosis and possibleanatomic aspectsS. Sanguigni1, T. Carboni1, R. Gobbato1 C. Paci1, G. D’Andreamatteo1, M. Tafuro2, A.Dardari2, E. La Piscopia2, B. Di Cioccio2, L. Tamburri2, E.Tomei2

1Neurologic Department, 2Radiologic Department, San Benedetto del Tronto Hospital, Italy

The Superior Sagittal Sinous (SSS) is the venous cerebral vesselmore frequently affected by episodes of cerebral venous thrombosis

(CVT). In case of occlusion the preferential routes of venous outflowand dcongestion are represented by the deep middle cerebral veinand by superficial venous sistem (represented by the Trolard-Labbèsystem). In our case study it is clear that in most cases thethrombotic episode of the sss is located at the level of medio- distalportion of the same vessel. We tried to find an explanation to thisfact. A careful anatomic analysis of the various tributary vesselsshows that : a) While the distal vessels originating from the frontaland parietal lobe converge on the sss in the same direction of themain flow ( antero posterior direction) b) The more distal vesselsflow into the SSS with the direction of flow opposite to that of themain vessel. In our opinion this feature do not represent an elementof secondary importance in that the presence of flows against thecurrent may cause: 1) the appearance of vortices and localturbulences; 2) clear slowing of the flow; 3) factor predisposing tolocal coagulation. We report the case of some patients who have notshown a clear thrombosis at the level of the distal part of sss but, atthe RMN, a clear local congestion at the level of the tributary distalvessels can be detected. Ultimately, even if this anatomical aspectdoes not represent the main cause of the thromboses, it can certainlyrepresent a cofactor of predisposition to this pathology.

P17Is there a vascular impairment in multiple sclerosis(MS)?L. Pascazio, C. Chiapparino, F. Federico F.Stroke Unit, Neurology I, Department of Neurosciences andSense Organs, Bari, Italy

Purpose and Background : It has been assumed that MSresults from a brain vascular pathology and that the inflammation-induced endothelial dysfunction, as well as hypoperfusion, mighttrigger the atherosclerotic process causing thrombo-embolisms. Theobjective was to study arterial vessels in addition to venous ones andcheck the occurrence of an atherosclerotic damage. Methods: tenpts with MS, 8 women and 2 men, age range: 23-51, 2 dislipidemicsand 1 with familiarity for vasculopathy were given arterial-venousSAT echo-color-doppler and TCCD with VMR assessment. Results:1 pt exhibited thickening of the common carotid artery intima, 4 ptsexhibited carotid bifurcation thickening, 1 pt dislipidemic for oneyear exhibited a plaque with a 30-40 % lumen reduction. Thefindings of 4 patients were in the norm. 7 pts exhibited refluxesand/or valve incompetences, brain arterial-venous volumes (BBVs)exhibited a mild, albeit not statistically significant (compared tocontrols in the literature), outflow reduction. In-flow : 736±291, out-flow (IJ2-J3V0°+VV90° Bilaterally): 270 ±163/280 ±198. III ventricleno dilation was observed in any patient. TCCD: reduced VMR in 4pts( 9%, 16%, 22 % and 2 %, respectively). Discussion andConclusions: in only one pt a finding borderlining with low-gradestenosis was observed which is a real expression of atheroscleroticcondition. Both extra and intra-cranial findings of the other ptsmight be ascribable to endothelial dysfunction resulting fromunknown environmental factors or to the expression of a linkbetween MS and vasclular pathology since the impairment of thebrain venous hemodynamics, whose prime mover is characterizedby the perivenular infiltrate, with a resulting microcirculation


damage, might, within a self-keeping mechanisms, favourthromboembolic mechanisms and ultimately ischemic events. Thesephysiopathological mechanisms allow to advance just a mere, albeitinteresting, hypothesis. Additional studies on larger samples arerequired.

P18Ultrasound venous findings do not seem to supportCCSVI in multiple sclerosis (MS)L. Pascazio1, C. Chiapparino1, P. Iaffaldano2, F. Federico1, M. Trojano2

Stroke Unit, 1Neurology I, 2Neurophysiopathology Unit,Department of Neurosciences and Sense Organs , Bari, Italy

Objective: to assess in definite Multiple Sclerosis (MS) patientswhether venous hemodynamic alterations result in CCSVI diagnosis.Methods: fifty-three MS patients (15 men and 38 women, agerange:18-60), underwent venous SAT Echo-color-doppler andTCCD to detect any anomalies: stenoses, blocks, refluxes,incompetences and malformations. Arterial and venous volumes(BVFs) at 0°and 90° were also assessed. Statistical analysis wereperformed through Chi-Square and Mann-Whitney Tests. Results:three patients exhibited jugular veins stenosis in J2 (IJ2Vs), 15 valveincompetence, 16 jugular reflux, 2 vertebral reflux and 2 intracranialreflux. 24 lumen reductions in J3 ( J3LR ) were detected with aspecial focus on the likelihood for this condition to result inadditional haemodynamic perturbations contributing to CCSVI. Themean BVFs in MS pts were: In-Flow 0°: 572 ± 271, Out-Flow (J2-J30°+VV90°): 274 ±172/ 307± 236; in patients with J3LR were:In-Flow 569 ±153, Out-Flow 245 ± 34/245 ± 5 and in patients withIJ2Vs were: In-Flow 790 and Out- Flow 310/290 ( the latter have beencalculated with angle correction). A mild reduction of In-Flow andOut-Flow, in pts with MS compared to normal pts reported in theliterature, is inferred, even though this difference is not statisticallysignificant. The same is true for patients with MS and J3LR and/orIJ2Vs compared to pts with MS without lumen reduction and tonormal pts. No correlations were found between hemodynamicalterations - refluxes/ valve incompetences /J3LR and disease courses(CIS-PP-RR-SP), disease duration and disability level as assessed byEDSS score: p>0.05. Conclusions: the study does not revealalterations of venous haemodynamic and BVFs supporting CCSVI.

P19Evaluation of venous circulation in neurodegenerativediseaseI. Zavoreo, V. Bašić Kes, L. Zadro Matovina, L. Ćorić, S. Drnasin, T. Cvjetičanin, V. DemarinNeurology Department, UHC Sestre Milosrdnice, Zagreb,Croatia

The aim of the study was to evaluate presence of changes invenous circulation by means of Color coded Doppler Flow imaging

(CDFI) in patients with previously established diagnosis ofneurodegenerative disease (Parkinson disease, dementia, multiplesclerosis). We included in the study 60 volunteers, sex and ageadjusted, divided into 4 groups- 3 groups according to theunderlying disease (10 patients in each group) and 30 controls inthe 4th group. Head and neck venous circulation was evaluated bymeans of CDFI in supine and sitting position. All patients weretested for hemodynamic and morphological changes of venouscirculation (according to international criteria). We found thatthere is increased number of patients with venous circulationchanges in groups with neurodegenerative disease in correlationwith controls (p<0,05), there was no statistically significantdifferences in presence of changes in venous circulation betweenthe groups with established neurodegenerative disease. Changes ofvenous circulation were present in control group as well. We canconclude that there is some correlation between changes in venouscirculation and neurodegenerative disease, head and neck CDFI isgood, real time method in evaluation of these changes.

P20Physiologically raised venous flow velocities in thestraight sinus assessed by transcranial duplexultrasoundS.J. Schreiber1, F. Paul2, J. Würfel3, J.M. Valdueza4, M. Nedelmann5, F. Doepp1

1Dept. of Neurology, Charité, Universitätsmedizin Berlin,Germany; 2NeuroCure, Clinical Research Center, Charité,Universitätsmedizin Berlin, Germany; 3Max Delbrueck Centerfor Molecular Medicine, Germany; 4Dept. of Neurology,Segeberger Kliniken, Bad Segeberg, Germany; 5Dept. ofNeurology, Justus Liebig University, Giessen, Germany

Background: Since the introduction of transcranialultrasound, dopplersonographic analysis of blood flow patterns hasbeen described in a number of intracranial veins and sinuses.Normal values in the straight sinus (SS), basal vein of Rosenthal,deep middle cerebral vein, cavernous sinus inflow area, inferiorpetrosal sinus, confluens sinuum and transverse sinus are –compared to arterial flow – low, usually not exceeding 25cm/s. Theonly reported exception so far has been the cavernous inflow regionwith physiological velocities > 60cm/s. Here we report a case seriesof 7 individuals with increased venous flow velocities in theproximal segment of the straight sinus. Methods: Sevenindividuals, 2 male, 5 female (39±13 years) were assessed bytranscranial color-coded ultrasound (TCCS). Non angle-correctedsystolic and diastolic flow velocities of the proximal and middlesegment of the SS were recorded. All individuals unterwentintracranial venous MR or CT angiography. Results: Mean systolicand diastolic flow velocities in the proximal SS were 72±15 and50±13 cm/s, while flow velocities in the middle segment of the SSwere 16±6 and 11±4 cm/s, respectively. Valsalva maoeuvre led to aflow velocity rise and transient sonographic musical murmurs inthree of our cases. Venous MR or CT-angiography demonstrated aprominent Pacchioni granulation in the proximal SS but no othervenous abnormalities. Conclusion: We report high venous flowvelocities with characteristics of a hemodynamically relevant


stenosis (flow rise, flow disturbances) in the proximal part of the SSwithout any clinical symptoms or imaging signs of impaired venousdrainage. This, and the demonstrated findings of prominentPacchioni granulations are suggestive for the observation of aphysiological phenomenon.

P21Ipsilateral approach for transverse sinus insonation byTCCS: a comparison with the contralateral approach andthe training value of virtual navigator technology M.L. Zedde1, G. Malferrari1, P. Prati1, R. Pascarella2, M. Maggi2

1Neurology Unit, Stroke Unit, Dpt. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Department of MedicalImaging, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy;

The study of intracranial venous hemodynamics withultrasound techniques (TCCS) is a validated and widely recognizedapplication of this technique. The ultrasound landmarks of mainintracranial vein and sinuses are known and the scanning planesfor venous examination has been defined years ago and they areslightly different from the arterial ones. The B-mode visualizationon intracranial structures allows to create a virtual tridimensionalmap of vessel course in the mind of sonologist, widening theapproaches to the same structure and so increasing the insonationrate. The Transverse Sinus (TS) is characterized by a great side-by-side interindividual variability for size and functional relevance andit has a relatively low insonation rate through the classicalcontralateral approach. In a single center case series of subjectswithout history and clinical signs of neurological disordersinvolving the venous hemodynamics, 70 consecutive people werecollected among those referred to the Neurosonology Lab forultrasound study and the TS of right and left side was insonated byTCCS both with contralateral and with an ipsilateral approach,comparing insonation rate, blood flow direction, velocityparameters and the pattern of flow during the Valsalva maneuver.A smaller subset of subjects underwent also a fusion imagingtechnology study with Virtual Navigator and the insonation rate ofthe ipsilateral transverse sinus after traing with Virtual Navigatorwas compared with the corresponding rate of a previous sample ofthe same center. The insonation rate of the TS was 120/140 (86%)for the contralateral approach and 137/140 (98%) with thecontralateral approach, considering proximal, middle and distalsegment of the TS. Velocity measurements and flow directions werealso different in the contralateral and ipsilateral approach,depending on the angle of insonation, but the ipsilateral approachcould be standardly used for the TS insonation, added to thecontralateral approach.

P22Ultrasound evaluation in CIDP patients: cross sectionalarea correlates with CSF protein levelM. Lucchetta1, C. Dalla Torre1, G. Granata2,3, C. Pazzaglia2,3, L. Padua2,3, C. Briani1

1Dept. of Neurosciences, University of Padova, Padova, Italy;2Dept. of Neurosciences, Catholic University of Roma, Roma,Italy; 3Don Gnocchi Foundation, Milano, Italy

Background: chronic inflammatory demyelinatingpolyradiculoneuropathy (CIDP) is a sensory-motor peripheralneuropathy. High-resolution ultrasound (US) is a helpful techniquefor the evaluation of the peripheral nervous system. Few US studiesare available on CIDP patients, and they report increased nerve andnerve roots cross sectional area (CSA). Objective: to perform USnerve in patients affected with CIDP and to investigate possiblecorrelation with disease history, clinical findings and cerebrospinalfluid (CSF) protein level. Patients and methods: 17 patients (6women and 11 men, mean age at evaluation 60.3 ± 19.5 yrs) withCIDP (mean disease duration 3.4 ± 2.8 yrs, range: 1 – 10)underwent neurological evaluation and US (Esaote Mylab75)examination of nerves at four limbs. Nerve and single fascicle CSAalterations, structure and echogenicity were analyzed. Six patientswere naïves from therapy while 9 were undergoing treatment withintravenous immunoglobulin, and 2 with plasma exchange. USfindings were correlated with disease duration, clinical picture andCSF protein level. Results: diffuse nerve CSA increase was presentin 8 patients; in 9 mild focal enlargements at the commonentrapment sites was found. Disease duration and clinical picturewere heterogeneous both in patients with diffuse and focalenlargements. Only focal alteration of echogenicity were found. A significant correlation (p=0.011) was found between nerve CSA enlargement and CSF protein level. Discussion andconclusions:a diffuse increase of peripheral nerves CSA was foundin half of our patients with CIDP. US alterations correlate with CSFprotein level, which may be an indirect sign of nerve rootsinflammation. US evaluation on a larger population may helpclarify the relationship between US and clinical picture. Moreover,follow-up US evaluation and correlation with response to therapymight help understand a possible role of nerve US also as a tool formonitoring the disease.

P23SN Hyperechogenicity and DAT-SCAN in the diagnosisand follow-up of the parkinsonismS. Sanguigni1, T. Carboni1, R. Gobbato1, C. Paci1,G. D’Andreamatteo1, S. Zagaglia2, E. Perticaroli2, S. Bifolchetti3,D. Monaco3

1Neurologic Department, San Benedetto del TrontoHospital, Italy; 2Neurologic Department, Ancona University;3Neurologic Department, Chieti University, Italy

The study of neurodenerative diseases represents a newchallenge of ultrasound. The goal of this approach is to detect a


preclinical ultrasound marker. In effect the possibility to make apreclinical diagnosis of the illness is a very important think. Wereport two cases. Pat. N°1(61 years old women) and Pat. N° 2 (a 64year old man). In the first the extrapyramidal simptoms presentedby the Pat. where very light and a correct diagnosis had not yetbeen made. The ultrasound tccd showed the presence of substantianigra iperecogenicity (Area 0.287 cm2 on the right and 0.149 cm2 onthe left). A subsequent SPEC DAT SCAN showed an initialreduction of the presinaptic tracer at the level of right Putamen. Inthe pat N°2 the symptoms where more evident and he presented attccd a marked bilateral iperecogenicity of the SN more evident inthe right side:(area 0.947 cm2 on the right and 0.524 cm2 on theleft). The SPECT DAT SCAN showed a bilateral marked reductionin picking up the presynaptic tracer at the level of putamen. So inconclusion we think that the tccd may be useful -at beginning of theillness as preclinical finding to clarify the diagnosis. In advancedstages to follow the clinical worsening.

Poster Session I-4 : Case Reports

P24The retrobulbar “Spot Sign” as discriminator betweenvasculitic and thrombo-embolic affections of the retinalblood supplyM. Ertl1, M. Altmann2, E. Torka1, H. Helbig2, U. Bogdahn1, M.A. Gamulescu2, F. Schlachetzki1

1Department of Neurology, University of Regensburg,Bezirksklinikum Regensburg, Germany; 2Department ofOpthalmology, University of Regensburg, Germany

Background and Purpose: Sudden retinal blindness is acommon complication of temporal arteritis (TA). Anothercommon cause is embolic occlusion of the central retinal artery(CRA). The aim of this prospective study was to examine thediagnostic value of hyperechoic material in the CRA for exclusionof vasculitis as a cause. The authors used orbital color-codedsonography (OCCS) for the detection of hyperechoic material.Methods: 24 patients with sudden visual loss were included in thestudy after exclusion of other causes (eg. vitreous bleeding, retinaldetachment). Parallel to routine diagnostic workup OCCS wasperformed in all patients. Results: 7 patients with the diagnosis ofTA presented with different degrees of hypoperfusion in the CRAwithout hyperechoic material (referred to as “spot sign”) detectedby OCCS. Diagnostic workup in the remaining 17 patients revealedother causes of sudden visual loss, as central retinal arteryocclusions (CRAO) (12), anterior ischemic optic neuropathies(AION) (2), upstream vascular stenosis or occlusion (2) anddelayed reperfusion of the CRA (1). The hyperechoic “spot sign”was visible in 10 of 12 patients (83%) with embolic CRAO.Detection of embolic CRAO using the “spot sign” had a sensitivityof 83% and a specificity of 100%. The missing “spot sign” in patientswith TA was a highly specific finding (p-value 0,01). Conclusions:

The detection of the “spot sign” specifically minimizes theprobability of TA as a reason for sudden blindness.

P25Neurosonological and angiographic aspects offibromuscular dysplasia with occlusion of left ICA, TIAsand MTHFR gene mutation - case reportA. Poalelungi¹, C. Nica¹, B. Dorobat², O. Bajenaru¹¹ Neurology Department, University Hospital, Bucharest,Romania; ² Radiology Department, University Hospital,Bucharest, Romania

We report a case of a 39 years old white female admitted in ourNeurology department for repetitive left carotidian TIAs in the last3 years, 50 % right ICA stenosis, dissection and occlusion of leftICA, multi drug resistant hypertension. Clinical examination wasnormal. MRI and MRA of cervico-cerebral arteries confirmed 50% right ICA stenosis, dissection and occlusion of left ICA. Cervicaland renal arteries Doppler ultrasound raised the suspicion offibromuscular dysplasia of left vertebral artery and right renalartery. The diagnosis was confirmed by renal and cerebral catheterangiography. Laboratory data showed MTHFR gene mutationwhich has a strong association with peripheral arterial disease(dissection of left ICA). Based on the clinical data we cannotassume that the presence of PFO (right – to – left shunt) at theechocardiography could be an identifiable cause for arterial events.

P26Case report: temporary alopecia following coiling ofpericallosal artery aneurysm after subarachnoidhaemorrhageM. Lundervik, C.A. HellandSection for Neurosurgery, Department of Surgical Sciences,University of Bergen, and Centre for NeurovascularDiseases, Department of Neurosurgery, HaukelandUniversity Hospital, Bergen, Norway

A 46-year-old female experienced sudden onset of headacheand dizziness. The patient was non-hypertensive and did notsmoke. Her mother had previously suffered an aneurysmalsubarachnoid haemorrhage. On hospital admission she hadmoderate headache, slight neck stiffness and no neurologic deficit.A computed tomography (CT) showed a subarachnoidhaemorrhage, Fischer grade II. CT angiography revealed a smallaneurysm of the right pericallosal artery. Endovascular coiling ofthe aneurysm was performed. The duration of angiographicexamination and embolization was 107 minutes, and the totalradiation dose was approximately 2.5 Gy. Fifteen days after theendovascular treatment the patient experienced abrupt foreheadhair loss. Clinical examination showed a 6 x 5.5 cm rectangularlyshaped patch of complete alopecia, congruent with the radiationfield. There was no erythema or dermatitis, and good pulsations in


occipital and superficial temporal arteries. The hair regrew afterapproximately 11 weeks. Hair follicles are sensitive to radiation, andepilation is a well-known effect. Alopecia typically appears 2-4weeks after exposure. Prognosis is dose-dependent. Hair loss isusually temporary after a single exposure to 3–6 Gy and permanentafter doses >7 Gy. Temporary alopecia requires no treatment, andregrowth usually appears after 2-4 months. Alopecia is morecommon after prolonged or repeated endovascular procedures(with consequently higher radiation exposure), for example afterstaged embolization of arteriovenous malformations and tumours.There are however few reports of radiation-induced alopecia afterendovascular coiling of cerebral aneurysms. In this case report theaneurysm was small and axial angulated. The radiation dose wasjust below the usual threshold for temporary alopecia, butcombined with limited variation of the direction of radiation thetreatment resulted in alopecia. One should be aware of potentialhazards of radiation associated with endovascular procedures, liketemporary alopecia. Necessary measures to limit radiation shouldbe undertaken.

P27Fabry disease: a rare but neglected cause of intracranialaneurysm and cerebrovascular disease M.L. Zedde1, G. Malferrari1, R. Pascarella2, M. Maggi2, R. Ghadirpour3, F. Servadei3, N. Marcello4

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Dept. of Medical Imaging,Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy;3Neurosurgery & Neurotraumatology Unit, AziendaOspedaliero-Universitaria di Parma, Italy; 4Neurology Unit,Stroke Unit, Dept. of Neuromotor Physiology, ReggioEmilia, Italy

Fabry disease (FD) is a progressive, X-linked inherited disorderof glycosphingolipid metabolism due to deficient or absentlysosomal α-galactosidase A activity. The reported annualincidence of 1 in 100,000 makes FD a rare disorder, but it mayunderestimate the true prevalence of the disease. Affected peopleare classically hemizygous males, with no residual α-galactosidaseA activity. The characteristic symptoms of a multiorganinvolvement (brain, kidney, peripgheral nervous system, heart,skin) are present in several patients, but there are also atypicalforms with single organ involvement, as the neurological one,mainly of neurovascular type. The finding of marked α-galactosidase A deficiency allows the diagnosis in hemizygousmales, but enzyme analysis may only occasionally help to detectheterozygotes females, so that genotyping of females is mandatory.We reported the clinical case of a young woman who was referredto our Stroke Unit because of the incidental finding of a giantcarotid-ophthalmic aneurysm, treated by endovascular coiling. Theaneurysm was monitored by TCCS and, during the neurovascularwork-up a review of potential causes was performed, using TCCSand neuroradiological data for selecting the most appropriatediagnostic testing. Because of the finding of a dolichoectatic basilarartery the genetic testing for FD was performed, showing a rare

mutation in the exone 6 of GLA gene (p.Asp313Tyr) that wasassociate with the neurological variant of FD. FD is a reported causeof intracranial aneurysms, but it is an often neglected disorders,when involvement of other organs is lacking.

P28Ultrasound monitoring in decompressivehemicraniectomyE. Vassileva1, P. Stoianov2, M. Klissurski1, E. Vavrek1, P. Stamenova3

1Department of Neurology, University Hospital “TsaritsaYoanna, ISUL” Sofia, Bulgaria; 2Department of Neurosurgery,University Hospital “Tsaritsa Yoanna, ISUL” Sofia, Bulgaria;3Department of Neurology, USBALN Seint Naum, SofiaBulgaria

Background: Extracranial color coded duplex sonography(ECCDS) and transcranial color coded duplex sonography(TCCDS) have an established clinical value in the diagnostic work-up of stroke patients. Hemodynamic assessments of the patientswho have had decompressive hemicraniectomy are limited. Casereport: We report a 43-year-old patient presented with acuteischemic stroke (NIHSS=23 on admission), 24 hours after the onsetof symptoms. The patient had no history of previous diseases. Thebrain CT showed a large right middle cerebral artery (MCA)infarction with a midline shift and a transtentorial herniation.ECCDS detected a mass-shaped thrombus in the right internalcarotid artery (ICA) - sub-totally occluding. TCCDS demonstratedright MCA occlusion. The patient underwent emergencyendotracheal intubation. Hemicraniectomy was performed 30minutes after the admission. Ultrasound examination performedafter the surgery demonstrated a restoration of the blood flow in theright ICA and a complete recanalization of the right MCA withreactive postischemic hyperemia. Follow-up TCCDS revealed signsof transient vasospasm in the right MCA due to hemorrhagictransformation, consistent with clinical deterioration. Thethrombus in the ICA disappeared completely after 5-week ofintensive antiplateled therapy. Clinical improvement was observedand the patient was discharged without further events. On thefollow-up evaluation two years later, the patient had no strokerecurrence (mRS = 3). Conclusion: ЕCCDS and TCCDС arecapable of providing rapid, reliable and clinically importantinformation about the hemodynamic status of the cerebralcirculation before and after decompressive surgery.


P29An unusually benign presentation of an uncommoncause of intracranial stenosis: VZV arteriopathy. Aclinical case M.L. Zedde1, G. Malferrari1, G. De Berti2, M. Maggi2, R. Pascarella2, S. Biguzzi1, N. Marcello1

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Dept. of Medical Imaging,Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy

Intracranial stenosis are a relatively common location ofatherosclerotic disease in adult patients with vascular risk factors (e.g.diabetes, hypercholesterolemia) and co-localization in other vascularbeds. In young patients symptomatic for focal neurological deficit,the finding of intracranial stenosis should raise the need ofinvestigating causes other than atherosclerosis. Varicella Zoster Virus(VZV) related arteriopathy is a rare condition that has been associatedwith stroke by intracranial stenosis, both in immunocompromisedand immunocompetent subjects; usually the neurologicalpresentation is a catastrophic ischemic event with a bad prognosisand a VZV skin manifestation is recognizable some weeks before theneurovascular complication. We reported the clinica case of a youngwoman who was referred to our Stroke Unit because of theoccurrence of aphasia and mild right arm paresis, lasting ten minutesand spontaneously resolving; her past medical history wasunremarkable. An urgent ultrasound assesstment of extracranial andintracranial circulation was performed with TCCS, finding a left M1MCA and P2 PCA stenosis. MR imaging confirmed these findings,lacking signs of recent ischemic lesions. In the work-up of intracranialstenosis also a rachicentesis was performed, showing a mild liquorallymphocytic pleiocytosis and a questionable PCR positive for VZV;antibody title against VZV was measured in liquor and blood, with aratio suggestive of intrathecal synthesis. Therefore a diagnosis of VZVarteriopathy was made and a antiviral drug treatment was performedwith acyclovir. During the follow-up a recurrence of transient aphasiawas registered and the patient underwent a DSA with a furtherconfirmation of intracranial stenosis. Other two liquoral studiesconfirmed the VZV antibody synthesis. VZV arteriopathy is aneglected cause of intracranial stenosis in immunocompetent people.

P30Internal carotid artery dissection in a young adult withhyperhomocysteinemia and fibrodysplasiaG. Nicoletti1, G. Coniglio2, S. Sanguigni3 P. Santarcangelo1, S. Tardi1

1Geriatric Division, Madonna delle Grazie Hospital, Matera,2Neurology Division, Madonna delle Grazie Hospital, 3

Madonna del Soccorso Hospital, S.Benedetto del Tronto,Italy

Cervical artery dissection (CAD) account for up to 20% of ischemic strokes in young adult patients. Spontaneous artery dissection are reported in fibrodysplasia (FDP) and

hyperhomocysteinemia. Hyperhomocysteinemia is consideredtoxic to vascular endothelium. Several study suggestedhyperhomocysteinemia as a risk factor for vascular disease andstroke. More recently, studies reported that hyperhomocysteinemiais as an independent risk factor for the development of cervicalartery dissection. The role of hyperhomocysteinemia in the development of artery dissection is unknown. Probablymultifactorial mechanism are involved and the primum movensmay be homocysteine-induced endothelial damage.Hyperhomocysteinemia by a combination of inflammatorychanges, oxidative stress, endoplasmic reticulum stress lead toendothelial cell damage and dysfunction. We report an isolateddissection of the internal carotid artery in a 24 year old man withhyperhomocysteinemia and FDP. The patient came to us with a oneweek history of TIA. His medical history was otherwiseunremarkable An ecodoppler of the cerebral vessels showedsubocclusion of the right internal carotid artery. An angio TC ofthe neck vessels confirmed ecodoppler results and showed avascular imaging suggestive for FDP . Heparin treatment wasstarted. Two days later a stroke occurred. An ecodoppler showed arecanalization of the carotid artery and an intimal flap suggestivefor dissection. In our opinion this case is very interesting not onlyfor the association of the FDP and hyperhomocisyeinemia andCAD but also because demonstre that the knowledge aboutdynamic vessel wall changes during the hyperacute phase ofcerebrovascular diseases requires immediate neurovascularimaging and close follow-up.

Poster Session I-5 : Intracranial Vessel Disease

P31Screening for intracranial stenoses with transcranialDoppler: a preliminary validation studyL. Idrovo Freire1, O. Casals1, D. Quiñones2, F. Gilo1, A. Herrera1, C. Terrón1, V. Anciones1

1Hospital Nuestra Señora del Rosario, Stroke Unit,Neurosonology Laboratory; 2Neuroradiology Dept., Madrid,Spain

Objective: Several velocity parameters have been proposed todetect significant intracranial stenoses. Our aim was to determinethe diagnostic accuracy of our TCD against magnetic resonanceangiography (MRA) for detecting intracranial stenoses. Methods:We included consecutive adult TIA/stroke patients from our strokeunit in which TCD showed a mean flow velocity > 80 cms/sec or 30%asymmetry. We retrospectively analyzed TCD parameters(Mean flowvelocities-MFV, Peak systolic velocities-PSV, Turbulent and/ordivergent flow changes, PI) and MRA (3D-TOF,1.5 T GE) resultsfor detecting >50% intracranial stenosis. Statistical analysis (SPSS)was used for calculating diagnostic accuracy (sensitivity, specificity,ROC curves) of TCD. We used criteria proposed by Felberg et al


(MFV>100cms/sec) and Rother et al (PSV>140 cms/sec) asreference cut-off values. Results: Twenty-three patients wereincluded (mean age 59,7 yrs, 52%men) in this study. We found 8patients with >50% intracranial stenosis (6 with probableatheromatous lesion, 1 with Moya-Moya disease, and 1 withPrimary CNS vasculitis). Middle cerebral artery was the mostcommon affected vessel (57%). Four patients had anatomic variants(hypoplasia, etc). Applying Felberg´s criteria, TCD at our lab hada 62.5%(CI 26%-90%) sensitivity and a specificity of 86.6%(CI 58%-98%); and with Rother´s criteria a sensitivity of 87,5%(CI47%-99%) and specificity of 60%(CI 33%-83%). Our ROC curvefor MFV was 0,867 and for PSV 0,848. We found a sensitivity 86%and a specificity 74% with MFV of 96 cms/s, and with PSV of 158cms/s we obtained a sensitivity of 86% and a specificity of 67%.Conclusions: This study demonstrates that MFV´s and PSV´shave good sensitivity for screening intracranial stenosis. Our bestcut-off values for MFV and PSV for detecting intracranial stenosisare comparable to those proposed by Felberg et al and Rother et al.Nevertheless, a further prospective validation is needed to improveour diagnostic accuracy.

P32Intracranial stenosis (ICS) diagnosis and follow-up: roleof TCCDL. Pascazio, C. Chiapparino, F. FedericoStroke Unit, Neurology I, Department of Neurosciences andSense Organs, Bari, Italy

Objective: to identify ICS patients, to select a subgroup ofindividuals at higher risk of stroke or relapse in order to work outdiagnostic protocols and prevention strategies. Methods: patientshospitalised for acute stroke or outpatients with VRF undergoingneurosonological and angiographic screening. Results: fifty-fourICS pts. Number of stenosis: 83 (17 mild, 56 moderate, and 10severe), 54/83 symptomatic stenosis (SICS) and 29/83 asymptomatic(AICS). SICS/AICS ratio = 2:1 appr.ly. In 21 cases AICS are associatedto SICS, responsible for stroke. In 11 cases multiple stenosis areobserved, in 7 pts. they are concomitant with SICS. Site: 54 ACC(Anterior cerebral circle) stenosis (39 MCA) and 29 Posteriorcerebral circle. Aetiology: dissection in 3 cases, cardio-embolism in2 cases, Moya-Moya in 1 case, atherosclerosis in the other cases. MRIand/or CT-Angiography is consistent in 19/54 pts., inconsistent in14/54 (only TCCD), not performed in 21/54. 2 pts. with SICS,diagnosed both with TCCD and AG, had PTA with stent placementearly last year. The other pts. with AICS and SICS are treated withanticoagulants and statins. Follow-up: half the pts. are stable; otherfollow-ups still ongoing. Discussion: 10% of strokes is to be ascribedto SICS, AICS often evolve in SICS, risk is higher in case of ACC ICS,concomitant extra cranial stenosis, multiple VRF, compromisedVMR, previous stroke. Conclusions: TCCD seems more sensitiveand specific to diagnose ICS than AG; frequent follow-up will allowfor an assessment of ICS progression and stroke risk and to work outinnovative therapeutic interventional strategies for secondaryprevention to support aggressive medical therapy. Technologicalimprovement should allow for the identification of unstable plaquesalso in intracranial vessels.

P33Double occlusion of the basilar artery (BA): comparisonof color-coded duplex ultrasonography (CCDU) with CTangiography (CTA)A.Vishnyakova, K. Anisimov, V. Lelyuk, V. SkvortsovaCerebrovascular Pathology and Stroke Research Institute ofPirogov’s Russian National Research Medical University,Moscow, Russia

Diagnostics of the BA occlusion using CCDU is difficult due toheterogeneity of echographic signs and their dependence on theocclusion level. Male, 63 years old, was admitted with complaints ofdouble vision subjects, the asymmetry of the face, marked ataxia inthe left extremities, horizontal nystagmus. NIHSS was 6. Brain CT(15 hours after symptoms onset) did not revealed focal lesions. Hisstate deteriorated on the 2nd day (NIHSS–17). CCDU (2nd day): thediameter of the right vertebral artery (VA) in the V2-segment was4,2 mm, left VA-3,3 mm. Reduced blood flows with increasedperipheral resistance were detected in the right (Vps=45,8 cm/s,TAMX=11,4 cm/s, Ved=0 cm/s with a negative component in theearly diastole) and left VA (Vps=29,0 cm/s, TAMX=13,0 cm/s,Ved=5,5 cm/s). Transcranial CCDU revealed reduced collateralblood flow in both posterior cerebral arteries (they were filledthrough the right posterior communicating artery). Low-velocity andhigh-intensity signals near the baseline were detected in theprojection of the distal segment of the BA. Antegrade flow wasdetected in the BA on the depths 75-80 mm (Vps=38,1 cm/s,TAMX=28,1 cm/s, Ved=18,6 cm/s, RI=0,51). Thus, CCDU was ableto detect occlusions in the BA (distal segment) and in the right VAin V4-segment. CTA (2nd day) revealed BA occlusions of the distaland proximal segments with the collateral filling of the middleportion of BA (apparently via cerebellar arteries), occlusion of bothVAs (right-in the V3-V4-segments, left-in the V4-segment). CT-perfusion detected infarct focus in the right half of the pons andthe hypoperfusion area in the right hemisphere of the cerebellum.Conclusion: It is possible to detect an antegrade blood flow in themiddle portion of BA in case of its double occlusion in the proximaland distal segments due to extensive collateral compensation inposterior circulation.

P34Intracranial steal phenomenon in patients with severesteno-occlusive disease of intracranial carotid or middlecerebral arteryA. Ahmad1, S. Arvind2, P.R. Paliwal1, L.L. Yeo1, H.L. Teoh1, B.K.C. Ong1, B.P.L. Chan1, P.A. Ping1, V.K. Sharma1

1Department of Medicine, National University HealthSystem, Singapore; 2Department of Radiology, NationalUniversity Health System, Singapore

Background: Intracranial stenosis is associated with strokerecurrence. In severe stenosis, perfusion is maintained by collateralpathways and cerebral autoregulation (CA). CA may be impaireddue to inadequate cerebral vasodilatory reserve (CVR) & intracranial


steal phenomenon, so called ‘reversed-Robin Hood syndrome(RRHS)’. Identification of patients with inadequate CVR and RRHSmay help in selecting high-risk patients. Methods: We prospectivelyincluded patients with symptomatic and severe stenosis ofintracranial carotid (ICA) & middle cerebral artery (MCA), definedaccording to validated transcranial Doppler (TCD) criteria. CVR wasevaluated with TCD & breath-holding index (BHI) <0.69 determinedinadequate CVR. RRHS was detected as transient velocity reductionin affected artery when flow increased in the reference artery. Patientswith RRH were further evaluated with acetazolamide-challengedHMPAO-SPECT. Results: 112 patients (79 males, mean age 57yrs;range 23-79yrs) with severe intracranial stenosis fulfilled our TCDcriteria of inadequate CVR. 35 (31%) patients demonstrated RRHSwith a median steal magnitude of 17% (inter-quartile range, IQR 10).HMPAO-SPECT demonstrated perfusion deficit (median 8%; IQR13%) in 33 out of these 35 cases (sensitivity 78%, specificity 96% withpositive predictive value 96%). A strong relationship between RRHon TCD and SPECT was noted on ROC curve analysis (area undercurve 0.93; 95% confidence interval 0.88-0.98;p<0.00001). Linearrelationship was noted between TCD steal magnitude and SPECT(Pearson correlation coefficient, r=0.643;p<0.0001). Patients withRRHS were at a higher risk of developing recurrent cerebral ischemia(p=0.04; RR 1.7, 95%CI 1.2-3.6). Conclusions: Intracranial stealphenomenon in patients with severe intracranial stenosis isassociated with high risk of cerebral ischemic events. Acetazolamide-challenged HMPAO-SPECT is reliable in the diagnosis of reversedRobin Hood syndrome in patients with severe steno-occlusivedisease of intracranial carotid and middle cerebral artery.Identification of RRHS might help in identifying a target group ofpatients for possible revascularization.

P35Ultrasound examination of cerebral arteries of patientswith ischemic stroke in posterior circulation (PCIS) andthe locked-in syndromeA. Vishnyakova, K. Anisimov, N. Shamalov, V. Lelyuk, V. SkvortsovaCerebrovascular pathology and stroke research institute ofPirogov’s Russian national research medical university,Moscow, Russia

The aim was to determine the type of cerebral arterial lesions inpatients with PCIS with Locked-in syndrome, including patients whounderwent IV thrombolysis with rt-PA (TLT), using intracranialcolor-coded duplex ultrasonography (CCDU). Study populationconsisted of 11 patients with PCIS and Locked-in syndrome aged 50-88 y.o. All patients underwent brain CT and CCDU on the 1st, andMRI on the 3rd days. Vascular lesions were verified by CTA andautopsy. 4 patients underwent TLT. Results: NIHSS (1st day) was 4-40. CT did not reveal acute focal lesions; according to MRI 9 patientshad infarct in the ventral part of the pons. Main vascular lesions ofthe BA were embolism (4 cases) and thrombosis (2 cases-thrombosisin situ, 2-unknown etiology); in 5 cases combined lesions of the BAand vertebral arteries (VA) were detected. BA occlusion wasdiagnosed in 6 cases, subocclusion – in 1 case, and in 1 case theluminal diameter was reduced by 70-80%. Prolonged lesions were

observed in 5 cases, local – in 3 (1-in proximal, 2-in distal segmentsof the BA). 2 patients had isolated occlusion of one VA. In 1 case nolesions of large arteries of PC were found. In all cases arterial lesionsdetected by CCDU were confirmed by reference methods.TLT in 1case led to complete revascularization of the BA (NIHSS decreasedfrom 30 to 5, and MRI did not detect infarct foci) and in 1 caserevascularization was partial with the appearance of the stenoticpattern flow (NIHSS decreased from 30 to 10, lesions were detectedin the medial part of pons, cerebellum and occipital lobe).Conclusion: Locked-in syndrome developed in patients with PCISwith embolism/thrombosis of the BA, rarely VA with the formationof infarct focus in ventral pons. CCDU allows to correctly diagnosethe type and severity of arterial lesions.

P36Correlation between decrease of pulsatility index ofsuperficial temporal artery and improvement ofvascular reserve in single photon emission computedtomography at superficial temporal artery – middlecerebral artery bypass surgeryT. Saguchi, S. Adachi, Y. Karasawa, Y. Kondo, A. Kuwano, S. Ichi, I. Suzuki Japanese Red Cross Medical Center, Department ofNeurosurgery, Japan

Background and Purpose: We investigated a correlationbetween a decrease of pulsatility index (PI) of superficial temporalartery (STA) and an improvement of vascular reserve (VR) beforeand after STA-middle cerebral artery (MCA) bypass surgery amongthe patients who affected a transient ischemic attack (TIA) or cerebralinfarction. Method: Seven patients who have a clinical history TIAor cerebral infarction were entered in this study from October 2009to December 2011. In all patient Doppler measurement of the STAin the affected side was performed and measured a PI before andafter STA-MCA bypass surgery. Angiography was performed twiceto confirm occlusion or stenosis in the internal carotid artery (ICA)or MCA before STA-MCA bypass, and to confirm a vascular patencyafter STA-MCA bypass in all patients. Single photon emissioncomputed tomography (SPECT) was performed before and afterSTA-MCA bypass surgery in all patients. Improvement of the VRrepresents the absolute value of the difference at each before and aftersurgery. Improvement of the VR was evaluated quantitatively usinga nuclear tracer of IMP. Results: Angiography revealed STA-MCAbypass patency in all patients. Pre-operative average PI was 2.004 andpost-operative average PI was 0.813 (significant decrease of 67.1%).Average improvement of the VR was 24.3. VR was improved in allpatients. Except one patient, no post-operative complications and norecurrence of TIA or cerebral infarction were occurred. In the onepatient, post-operative symptomatic cerebral infarction occurred andaphasia was observed. Improvement of the VR in the one patient wasvery high (73.6). One of a possible reason for neurologicaldeterioration was hyperperfusion. Conclusions: Significant decreaseof PI after STA-MCA bypass surgery well correlate a vascular patencythat confirmed in angiography. However, it does not always clinicallycorrelate between change of PIs and improvement of VR.


P37Barriers in provision of transcranial Doppler (TCD)services in acute stroke unit in EnglandD.M. Sinha1, T. Loganathan1, P.C. Guyler 1, L.J. Coward1 , A. O’Brien1, T. Latham2

1Department of Stroke Medicine, Southend Hospital NHSTrust, UK; 2Department of Diagnostic and InterventionalRadiology, Southend Hospital NHS Trust, UK

Background: Tran cranial Doppler (TCD) is an inexpensiveand established safe approach for assessment of cerebral blood flow,detection of micro emboli, Carotid surgery monitoring and evalu-ation of right to left shunts. Despite positive changes in Stroke serv-ices in last 5 years the provision of TCD services appears to varyacross England. There are few established TCD providers whichoffer services for stroke patients. The number of TCD operatorsseems small given the patient numbers involved. Method: Weprospectively recorded our experiences and barriers in setting TCDservices in acute stroke from start to machine, the man and methodmodel. Currently we have Instruments and training and in phase ofestablish it further in routine use in Acute Stroke at Southend Uni-versity Hospital. Results: The perceived challenges to successfuladoption of TCD services are a challenge to the achievement of thebroader NHS management agenda. Barriers for change were foundto relate mainly to difficulty in gaining funding decision; lack ofstandardised training models; time and manpower limitations ofthe assessments. We noted key barrier as lack of resources (includ-ing finances); complexities of the financial and planning models atlocal level. There are no agreed scale at the purchasing stage; lackof awareness of the benefits and few incentives to invest wererecorded. Barriers were found to relate to individual training anduniversally agreed training accreditation in use of TCD in Strokewithin UK clinical governance environment. Conclusion: Despitethe potential of TCD to improve acute stroke prevention, moni-toring and treatment, the current UK system is generally perceivedto be slow to adopt TCD in comparison with health care systems inother developed countries. The resources, time and training needto be addressed and smooth commissioning of services is required.

P38Intracranial atherosclerotic stenosis assessed by US inItalian stroke patients: the ISIDE studyA. Palmieri1, C. Gandolfo2, M. Del Sette2, M. Diomedi3, M. Braga4, R. Bella5, A. Mattioni6, S. Ricci6, G.P. Anzola7, C. Baracchini1, G. Meneghetti1

1Dept of Neurology University of Padua, Italy; 2Dept ofNeurology University of Genua, Italy; 3Dept of NeurologyUniversity of Rome Tor Vergata, Italy; 4Dept of NeurologyHospital of Vimercate, Italy; 5Dept of Neurology Hospital ofCatania, Italy, 6Dept of Neurology Hospital of Città diCastello, Italy; 7Dept of Neurology Hospital of Brescia, Italy

Intracranial atherosclerotic disease (ICAD) is a major cause ofischemic stroke in Western countries. The aim of the Italian Study

Intracranial Stenosis Investigated by Doppler Evaluation – ISIDEstudy – is a systematic US evaluation of the intracranial circulationof consecutive patients admitted for acute ischemic stroke in orderto establish the prevalence of atherosclerotic stenosis of intracranialarteries. The clinical and functional assessments are performedwith the NIH stroke scale and the modified Rankin scalerespectively. The territorial distribution of stroke is assessed withMRI/CT and with the Bamford scale. Both extracranial andintracranial vessels are evaluated by US after hospitalization, atdischarge and at three month follow up. Intracranial stenosesdetected with TCD or TCCD have to be confirmed by CTA orMRA. Among 348 acute stroke patients prospectively evaluated indifferent neurological departments, 203 were males and 145 werefemales; mean age was 70.9 ± 13.9 years. According to the TOASTclassification, 26.9% of strokes were due to large-arteryatherosclerosis, 23.9% to cardioembolism, 27.5% to small-vesselocclusion; 20.1% of all patients had AF. Strokes presented mostly asPartial Anterior Circulation Infarcts (53.5%), mainly in the lefthemisphere (49.7%). 37.5% of the patients were admitted to aStroke Unit and 2.9% underwent intravenous thrombolysis. Thetotal number of intracranial stenoses was 36; 55.6% were locatedin the anterior circulation, while 44.4% in the posterior circulation.Ultrasound study in acute stroke patients disclosed a 9.8%prevalence of intracranial stenoses located in the anteriorcirculation (5.7%) and in the posterior circulation (4.6%)respectively.

Poster Session I-6 : Functional TCD, Vasomotor Reactivity

P39Cerebrovascular reactivity (CVR) of posterior circulation(PC) major arteries using metabolic stimulation(CO2-test)A. Vishnyakova1, S. Lelyuk2, V. Lelyuk1

1Cerebrovascular Pathology and Stroke Research Instituteof Pirogov’s Russian National Research medical university,Moscow, Russia; 2Russian medical academy of postgraduateeducation, Department of ultrasound diagnostics ofMedico-biological faculty, Moscow, Russia

The aim was to assess CVR of the major arteries of PC tometabolic stimulation (CO2-test). Study population consisted of65 healthy voluntaries aged 35,7±11,6 y.o. Blood flow responses tohypercapnia and hyperventilation in V4-segments of the vertebralarteries (VA(V4)), the basilar artery on different depths: 70, 80 and90 mm (BA(70,80,90)) and P1 and P2-segments of the posteriorcerebral arteries (PCA(P1,P2)) were measured using ultrasounddoppler. Capnograph was used for evaluating the partial CO2pressure in the exhaled air. Reactivity indexes (RI) in each test andthe CO2 reactivity index (CO2-RI) [%/mmHg] were calculated. Results: RI on hypercapnia, hyperventilation and CO2-RI in the


right VA(V4) were 1,32±0,19, 1,32±0,16, 2,95±0,93; left VA(V4) –1,31±0,17, 1,32±0,15, 2,80±0,67; in the BA(70) – 1,34±0,15,1,42±0,21, 3,42±0,77; BА(80) – 1,34±0,15, 1,41±0,21, 3,49±0,90;BА(90) – 1,33±0,14, 1,41±0,24, 3,41±0,88; in the right PCA(P1) –1,34±0,16, 1,31±0,16, 3,22±0,89; left PCA(P1) – 1,33±0,13,1,33±0,15, 3,05±0,90; right PCA(P2) – 1,37±0,18, 1,35±0,18,3,50±0,99 and in the left PCA(P2) – 1,39±0,20, 1,31±0,18,3,71±1,15 respectively. Differences between RI on hypercapnia indifferent arteries were insignificant. Vasodilative reaction was non-significantly higher in the PCA(P2). In the BA, the flow responseto vasoconstriction was significantly higher than to vasodilatationand higher than in the VA(V4), PCA(P1) and PCA(P2). CO2-RIwere significantly higher in the BА(70,80,90) and PCA(P2) incomparison with the VA(V4). Significant direct correlations wereobserved between CO2-RI in the VA(V4), BА(70,80,90) andPCA(P1) on both sides (R=0,4-0,6, p<0,05) while RI in thePCA(P2) correlated only with same RI in the VA(V4). Conclusion:Metabolic stimulation results in generalized flow response in PC, itsintensity in different arteries depends on the type of stimulation:vasodilative reaction dominates in the PCA(P2), whereasvasoconstriction – in the BА(70,80,90); intensity of flow responsein the VA(V4) is the same in both tests. In the BA reaction tostimulation occurs simultaneously in all segments of the artery.

P40Validation of bag re-breathing method againstvoluntary breath holding for assessment of cerebralvasodilatory reserveA. Ahmad, P.R. Paliwal, L.L. Yeo, H.L. Teoh, B.K.C. Ong, B.P.L.Chan, P.A. Ping, V.K. SharmaDepartment of Medicine, National University HealthSystem, Singapore

Background: Patients with severe stenoses of majorintracranial arteries may develop hypoperfusion due to failedcerebral vasodilatory reserve (CVR). Assessment of CVR withtranscranial Doppler (TCD) using Breath-Holding Index (BHI) isan established method. But, many patients may not hold breathsufficiently for reliable assessment. We tested rebreathing in astandard bag for assessing CVR in middle cerebral arteries(MCA). Methods: Using Spencer’s head frame, simultaneousmonitoring of mean flow velocities (MFV) of both MCAs wererecorded during breath-holding in patients with severeintracranial ICA or MCA stenoses to calculate BHI. They werethen asked to rebreathe in a standard HDPE/W/ADH 8X12 bagfor 1minute. End-tidal carbon dioxide levels were monitored toensure adequate hypercapnea and relative changes in the MFVswere noted. Receiver-operating characteristic curve was used todetermine the best cut-off value of relative change in MFV topredict BHI of ≤0.4. Tests were performed twice in each patient,separated by 5 minutes. Patients with exhausted CVR werefurther evaluated with acetazolamide-challenged HMPAO-SPECT. Results: Of a total of 58 patients, 39 (67%) were male, 43(74% Chinese) and mean age 46years (range 25-62). All toleratedthe tests without any untoward effects. Intracranial stenoses were42 (72%) in one MCA, 11 (19%) in both MCAs and 7 (10%) in theintracranial ICA. Intracranial steal phenomenon was seen in 10

(17%) cases. Median BHI (interquartile range, IQR) in affectedMCA was 0.13 (0.34) vs. 1.1 (0.43) in the control. Median (IQR)relative change in MFVin affected MCA during bag rebreathingwas 19% (17). Relative change of 15% in MFV of affected MCAwas the best predictor of BHI value of ≤0.4 (sensitivity 97.5%,specificity 96.2%, area under the curve 0.971, 95% confidenceintervals 0.919-1.0; p<0.005). Conclusions: Standardized bagrebreathing test is reliable for the assessment of CVR in patientswith severe stenoses of intracranial ICA and MCA.

P41Changes in central hemodynamic parameters andcerebrovascular reactivity (CVR) during the tilt tabletest (TTT) in acute hemispheric ischemic stroke (IS)E. Malyarova, S. Leliuk, G. Ivanova, V. Leliuk, V. SkvortsovaCerebrovascular and Stroke Research Institute of Pirogov’sRussian National Research Medical University, Moscow,Russia

Objective: The study of cerebral hemodynamic and CVR inthe middle cerebral artery (MCA) during TTT in acutehemispheric IS. Materials and methods: A bilateral transcranialdoppler monitoring of the MCA at rest and during myogenic (TTT and nitroglycerin) and metabolic (breath-holding andhyperventilation) tests were performed for twenty patients withacute IS aged from 37 to 81 (60.7±11.4) years old. Results: Duringthe first several days of IS 5 people (25%) could not be raised up to80o, on the 7th days - 3 people (15%), on the 14th days - 2 people(10%) due to decrease of blood pressure more than 20 mm Hg,while mean flow velocity (MFV) in the MCA remained withinnormal values. There were not significant differences in the valueof MFV and in the degree of its decrease during TTT between theintact and damaged sides and in dynamics. The index of reactivity(IR) in metabolic and myogenic tests for damaged and intact sidesdidn’t differ significantly on the first and 14th day (breath-holding:damaged side - 1.16±0.2, intact - 1.15±0.22, hyperventilation:1.35±0.18 and 1.33±0.22; nitroglycerin: 1.04±0.09 and 1.08±0.05).IR with orthostatic load on the 3, 7, 14 day of IS depending on theangle of tilt was in line with the lower limit of normal value andshowed no differences neither between sides nor in dynamics(damaged side: 15o - 1.01±0.08; 30o – 1.12±0.17; 45o-1.09±0.13; 60o

- 1.11±0.18; 80o - 1.19±0.17; intact – 15o – 1.06±0.15; 30o -1.01±0.12; 45o - 1.06±0.11; 60o - 1.11±0.12; 80o - 1.14±0.11).Conclusion: The results of study demonstrated the safety of TTTin the first days after IS and lack of its influence on the studiedparameters. CVR was on the lower limit of the normative values.


P42A comprehensive functional assessment of cerebralblood flow in ischemic brainL.A. Bokeria, I.P. Aslanidi,T.N. Serguladze, N.A. Darwish, E.I. Gusev, L.I. Pyshkina, A.A. Kabanov, M.R. Bekuzarova Scientific Centre of Cardiovascular Surgery named byA.N.Bakulev RAMS; Department of Neurology andNeurosurgery of Russian State Medical University, Moscow,Russia

Purpose of the study included the possibility of using SPECTwith 99mTs-HMPAO in conjunction with ultrasonic diagnosticmethods in choosing the treatment strategy of chronic cerebralvascular insufficiency, and evaluation of the effectiveness of surgicalrepair. A comparative analysis has been carried out of the resultsof 18 patients with occlusive lesions of the brachiocephalic arteries(both before and after carotid endarterectomy). The average age ofpatients was 58 +/- 8.4 years. All patients was exams full range ofinstrumental studies, including determination of the nature oflesions of the brain arteries (ultrasound duplex scanning,transcranial Doppler (TCD) with a functional load and evaluationof cerebrovascular reserve of carotid and vertebrobasilar basin).SPECT of the brain with 99mTs-HMPAO with pharmacologicalstress and ultrasound stress tests were conducted both before andduring the postoperative period. SPECT was performed (withHMPAO - hexamethyl-propilenaminoksin, labeled 99mTs -«Ceretec») on the dual head rotating gamma camera tomographic«Vertex-Plus» company «ADAC» (USA), using high-resolutionCollimator, record scintigraphic images were performed in 64projections. After surgical correction the tomograms showedimprovement of blood flow in the hemisphere and the growth ratesof cerebrovascular reserve. According to USDS, there wasrestoration of blood flow in the operated vessel. Indicators fromthe SPECT-HMPAO 99mTs correlate with those of functionalloading tests assessing carotid CTA and vertebrobasilar basin withTCD before and after surgical correction. Minimally invasive andhighly informative SPECT, along with Doppler ultrasound andcerebral angiography, isotopic methods for the study of vascularpathology of the brain are also an essential component of acomprehensive assessment of cerebral circulation.

P43Transcranial Doppler for prediction of outcome inspontaneous non traumatic spontaneous intracranialhemorrhageD. Khurana1, P. Kesav1, V. Gupta2, C. Ahuja2, S.Prabhakar1

Postgraduate Institute of Medical Education and Research,Department of 1Neurology and 2Radiodiagnosis,Chandigarh, India

Objectives: To validate the transcranial Doppler(TCD)variables which serve as predictors of outcome in supratentorialspontaneous intracerebral hemorrhage(SICH). Methods: Patientswith SICH( Age > 18years) within 24 hours of symptom onset wereprospectively recruited. Following detailed clinical examination,

baseline cranial CT scan was done followed by TCD study using a2Mhz probe.The hematoma volume was measured (A X B X C/2method). Bilateral MCA velocities were recorded by transtemporalinsonation at a depth of 55mm-mean, peak systolic ,end diastolicvelocities(MV,PSV,EDV),Pulsatility index(PI) were recorded.Follow up CT scan and TCD variables were recorded within 24hours of the baseline. All patients were managed as per standardguidelines.Good outcomes were defined as modified rankin scale(0-2) at 3 months. Results: 25 patients were recruited from July2010-September 2011.Mean age was 52.44+11.35years,72% males,time from symptom onset ranged from 180-990 mins (mean-499mins), GCS ranged from 7-15 ,NIHSS ranged from 6-33 (Mean19.76), Mean systolic diastolic and mean arterial pressures atbaseline were 186.40 ,108.72 and 134.32 mm Hg.On CT scan, 68%had ganglionic and 28% had a lobar bleed, mean hematoma volumewas 17.62cc, 24% had swirl sign,4% had spot sign. On baselineTCD, unaffected and affected MCA MV and PSV and PI were41.27 and 73.57cm/sec,1.229 and 43.07,82.05 cm/sec,1.467.Hematoma expansion(increase in hematoma volume by > 33% at24 hours) was seen in 10(40%) patients. An insignificant trend ofhigher affected MCA (55 mm) PSV, EDV,MV, PI and RI was seenwith hematoma expansion. Unaffected MCA Pulsatility IndexRatio (u PI ratio = 24 hour u PI/Baseline u PI) was found to besignificantly associated with hematoma expansion on univariateanalysis (p value: 0.021) as well as on multivariate analysis(p=0.04).Conclusions: TCD may be an effective bedside modality to predicthematoma expansion which is a marker of mortality and outcomesin supratentorial spontaneous ICH.

P44Cerebral hemodynamics in hypertension: a transcranial Duplex studyF. Abd-Allah1, M.A. Zaki1, A.M. Abdelalim1, N. Abou-Kresha1, M. Salah2

1Cairo University, Cairo, Egypt; 2Al-Sahel Teaching Hospital,Ministry of Health; Egypt

Background: Blood pressure reduction has been shown to bebeneficial in both primary and secondary stroke prevention.Objective: To study the effect of hypertension on cerebral bloodflow hemodynamics and cerebral hemodynamics in relation to age,duration of hypertension, severity of hypertension and body massindex (BMI) by using transcranial color coded duplex. Methods:This study included 40 patients with hypertension: Classified to(Group Ia) Twenty without a history of cerebrovascular stroke and(Group Ib) twenty with evidence of past cerebrovascular stroke)and 20 healthy controls. Blood pressure and body mass index weremeasured and extracranial and transcranial duplex was performedfor all subjects. Results: Comparison between hypertensivepatients without CVS and controls showed no significantdifferences. Comparison of hypertensive patients with CVS andcontrols showed statistically significant older age (p=0.009), higherRight IMT (p=0.002), lower PSV (0.018), lower TAP (p=0.003) andhigher PI (0.004) in hypertensive patients. Comparison ofhypertensive patients without CVS to hypertensive patients withCVS showed higher PI (p=0.037). The only significant finding wasthe correlation between age and increased left CCA-IMT in


hypertensive patients with evidence of cerebrovascular stoke(p=0.033). Conclusion: Hypertension may affect cerebralhemodynamics in stroke patients by an indirect mechanism. Ageand obesity may not have a direct effect on cerebral hemodynamicsin hypertensive patients. TCD appears to be a suitable method forassessment of cerebral hemodynamics and vasculature inhypertensive patients. Key Words: Hypertension, Hemodynamics,IMT, PI, PSV, PI, BMI.

P45Cerebral endothelial dysfunction in patients withobstructive sleep apnea A. Resman-Gašperšič1, B. Žvan1, M. Zaletel1, L. Dolenc-Grošelj2, J. Pretnar-Oblak1

1Department for Vascular Neurology and 2Institute forNeurophysiology, Ljubljana Medical Centre, Ljubljana,Slovenia

Background: Obstructive sleep apnea (OSA) is a common sleepdisorder with a number of complications, such as stroke andcognitive impairment. Endothelial dysfunction could play animportant role in the pathogenesis of these complications. The aimof this study was to test the hypothesis that specific, markedendothelial dysfunction of cerebral arteries is present in patientswith obstructive sleep apnea. Methods: Cerebrovascular reactivityto L-arginine, which reveals the function of the cerebralendothelium, was investigated in patients with OSA (14 patients, 13male and 1 female, aged 53.2 ± 8.7 years) and 15 age- and gender-matched asymptomatic patients with similar cardiovascular riskfactors. The mean arterial velocity (vm) in both middle cerebralarteries was measured by transcranial Doppler sonography duringa 15-minute baseline period, a 30-minute intravenous infusion ofL-arginine and a 15-minute interval after L-arginine infusion.Arterial blood pressure, heart rate and CO2 were measuredcontinuously. Results: The measured vm increase during L-arginineinfusion in the patients with OSA (6.3 % ± 6.4 %) was significantly(p < 0.05) lower compared to the controls (9.8 % ± 5.7 %).Conclusions: Our results showed that cerebrovascular reactivity toL-arginine, which demonstrates cerebral endothelial function, issignificantly impaired in patients with OSA compared to thecontrols with similar risk factors.

P46L-arginine induced cerebral vasodilatation and intima-media thickness in type 1 diabetesG.M. Kozera1, J. Neubauer-Geryk2, B. Wolnik3, S. Szczyrba1,W.M. Nyka1, L. Bieniaszewski2

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

L-arginine infusion is a method that enables the selectiveassessment of NO mediated cerebral vasodilatation. Its use inhumans with type 1 diabetes (DM1) has not been reported to date.Little is also know about the association between the endothelialfunction of cerebral microvasculature and the progression ofarteriosclerosis of large arteries in patient with DM1. Thus we aimedto assess the vasomotor reactivity of middle cerebral artery with useof transcranial Doppler and L-arginine infusion (LARGVMR) inmiddle aged subjects with DM1 and controls without diabetes and toassess the relationship between LARGVMR and the intima-mediathickness of common carotid artery (IMT). Study group consistedof 52 patients with type 1 diabetes (median age 39,3 years) and 22controls without diabetes (median age 37,7 years). Medians ofLARGVMR were similar in both groups (17,6% vs.17,3%, p=0,91).Median of IMT was 0,054 cm in humans with diabetes and 0,052 cmin control subjects (p=0,12). The values of LARGVMR were lower inmales with diabetes than in females (14,6% vs. 20,33%; p<0,01), noother differences between subgroups of patients divided by thepresence of the obesity, smoking, long duration and poor diabetescontrol, concomitant diseases and treatments as well as the presenceof systemic microangiopathy were found. There was negativecorrelation between LARGVMR and IMT (r=-0,29; p=0,036), age(r=-0,32; p=0,02), BMI (r-0,38; p=0,006), CRP (r-0,31; p=0,03) anduremic acid serum levels (r-0,43; p=0,002) in patients with DM1 butnot in controls. We show no impairment of endothelium inducedvasodilatation in middle aged patients with type 1 diabetes whencompared to age matched controls without diabetes. However,endothelium induced cerebral vasodilatation is reduced in maleswith type 1 diabetes and is negatively correlated with the progressionof cerebral macroangiopathy as well as with the obesity andinflammatory parameters.

P47Use of CPAP device in OSAS can influence cerebralcirculationA. Iannolillo2, M.A.E. Rao1, M.V. Manzi1, G. Pagnano1, M. Santoro1, A. Vasta1, N. De Luca1. S. Sanguigni3, F. Accorsi.4

1Department of Clinical Medicine and CardiovascularSciences University’ “Federico II” Naples; . 2ASL Avellino;3“Madonna del Soccorso” Hospital S. Benedetto del Tronto;4Echographic School Bologna

Nocturnal apnoeas are thought to be risk factor for ischemicevents. Not a random, cardiovascular events often happen in the


first hours of the day. The only therapy is the application of CPAP(Continuous Positive Airway Pressure) when the patient go tobedside. Some other studies have demonstrated a relation betweenCPAP and cerebral flux expecially about variations of velocity butnobody have valuated it with transcranial echocolordoppler. Weobserved one obese woman , affected by OSAS, that applys , beforesleeping, the CPAP device. We have measured IR (resistance index)before and immediately after use of the device. We found asignificative decrease of IR after CPAP than its value beforesleeping. (from 0.58 to 0.47). These data show that correcting thenocturnal desaturations permits a better cerebral perfusion. It willbe interesting to confirm these findings studing a larger crew ofpatients. when the patient go to bedside.

Poster Session II-1 : Atherosclerotic Plaque and IMT 2

P48Intima-media thickness in rheumatoid arthritis patientsT. Lepić, G. Ristic, D.Veljančić, B. Labović, Ž. Krsmanović, D. Jekic, M. Lepić, R. RaičevićMilitary Medical Academy Belgrade, Dept. of Neurology andDept. of Rheumatology, Belgrade, Serbia

Background: Intima-media thickness (IMT) of the carotidarteries in patients with RA is potential maker of inflamation andsubclinical atherosclerosis. Methods: IMT was measuredultrasonographicaly in 42 non-diabetic, normotensive, female RApatients and 32 matched healthy controls (age 45.3 ±10.0 vs 45.2±9.8 years) at common carotid arteries (CCAs), carotid bifurcation(BF) and internal carotid arteries (ICAs), bilaterally. Mean IMTswere calculated from three measurements at each site. Clinicalwork-up included laboratory analyses, determination of the diseaseactivity and evaluation of treatment. Results: RA patients hadincreased IMT (mm) in comparison with controls: CCA: 0.671±0.119 vs 0.621 ±0.085; bifurcation: 0.889 ±0.168 vs 0.804 ±0.124;; ICA: 0.577 ±0.101 vs 0.535 ±0.076. Parameters associated withIMT in RA patients were: age, BMI, smoking, RF concentration,sedimentation rate. Duration of MTX + chloroquine therapy werein inverse correlation. Multivariate regression analysis revealed thatRA is an independent risk factor for increased IMT. Factorscorrelating with IMT in the controls were: age, BMI, totalcholesterol, low-density lipoprotein cholesterol, total/high-densitylipoprotein cholesterol, triglycerides and glycaemia. Conclusion:Female RA patients had significantly enlarged carotid IMT thancontrols. RA itself was an independent risk factor for increasedIMT. Impact of chronic inflammation on atherosclerosis was confirmed by negative correlation of IMT and duration of anti-inflammatory treatment.

P49Multilayer image in the intima-media complex in apatient with giant cell arteritisO. Ayo-Martin1,4, J. Garcia-Garcia1,4, J.J. Blanch-Sancho3, R. Collado-Jimenez4, T. Segura1,4

1Neurology Department; 2Internal Medicine Department;3Radiology Department; Complejo HospitalarioUniversitario de Albacete; 4School of Medicine, Universidadde Castilla-La Mancha, Spain

Background: Giant cell arteritis (GCA) is a challengingdiagnosis in many patients due to great variability of the clinicalpresentation and limitations of the diagnostic tests available.Although the biopsy of the temporal artery is the gold standard test,it has some disadvantages: is an invasive and sometimes a delayedprocedure with several false negatives which could promote adelay in treatment onset. Duplex of the temporal and other cervicaland cranial arteries is an useful, fast and reliable tool for GCAdiagnosis. The hypoechoic image around the lumen of temporal(and others) arteries is very characteristic of the disease (halo sign).We present a new echographic finding in the common carotidartery (CCA) related to GCA. Material and methods: In allpatients in whom GCA was suspected a cervical and cranial duplexstudy was performed within 48 hours. We studied carotid,vertebral, occipital, temporal and orbital arteries, searching forvasculitis data (smooth concentric narrowing due to anhypo/anechoic area in the artery). Results: Between 2008-2011 westudied 73 patients with symptoms suggesting GCA. 22(30%)showed echographic signs of GCA. One of them showed athickening and split in the three layers of the intima media complexon both CCAs presenting it a multilayer image (5 layers, alternatinghyper and hypoechogenic ones). In this patient, temporal biopsyconfirmed the diagnosis of GCA. A cervical CT and PET showedthickening and inflammatory activity in both CCAs. After corticoidtreatment, the echographic image disappeared in 4 weeks.Discussion: We found a new echographic sign for vasculitis inGCA, a multilayer image of the intima media complex on CCA.This image might correspond to a break of the internal elasticlamina of CCA, as has been described in severe GCA. Recognizethis sign can help in ecographic study of patients with GCAsuspiction.

P50Examination of the utility of intima-media thicknessand plaque score in the common carotid artery as theaortic stiffness index to aorta and lower limbsK. Fujishiro1, M. Harada2

1Educational Development Office, Faculty of Medicine, Toho University. 2Clinical Functional Physiology Lab. Oomori-Hospital, Toho University, Tokyo, Japan

Purpose: We investigated associations of indicators of aorticstiffness - carotid-femoral pulse wave velocity (cfPWV) and cardio-ankle vascular index (CAVI) . with an indicator of vascular-wallthickening, ie, intima-media thickness (IMT), in common carotid


arteries. When cfPWV and CAVI of 9 or more are assumed inarteriosclerosis, we examined which carotid index was the mostuseful. Methods: A total of 185 patients (81 women, mean age 62.9years; 104 men, mean age 61.2 years) were assessed between June2008 and May 2010. Ultrasonic tomography was used to evaluatethe left and right common carotid arteries and the root of theinternal carotid artery. Mean IMT (calculated from measurementsobtained at the 3 locations), maximum IMT and plaque score weremeasured. The measurement of cfPWV and CAVI usedVasera1000. cfPWV was corrected in diastolic blood pressure80mmHg. Results: cfPWV values ranged from 5.7 to 12.0 m/s;CAVI ranged from 6.3 to 11.2. The area under the curve in ROC ofmean IMT, maximum IMT and plaque score when we assumedcfPWV>=9 arteriosclerosis was 0.682, 0.692, and 0.686 each. Thearea under the curve in ROC of mean IMT, maximum IMT andplaque score when we assumed CAVI>=9 arteriosclerosis was0.650, 0.649, and 0.656 each. Conclusions: From a result of cfPWV,it was thought that maximum IMT was useful for an index of aorticstiffness, and plaque score was useful for the arterial stiffnessindexes from the aorta to lower limbs. However, the differences ofeach value are very few, and it is necessary to examine in large cases.

P51Ultrasonographic evaluation of acute ischemic strokepatients with radiation-induced carotid arteryatherosclerosisH. Mitsumura1, S. Omoto1, S. Takagi1, R. Sengoku1, Y. Kono1,M. Morita1, H. Furuhata2, S. Mochio1

1Department of Neurology, The Jikei University School ofMedicine, Tokyo, Japan; 2ME Laboratory, The Jikei UniversitySchool of Medicine, Tokyo, Japan

Background and Purpose: Radiation therapy (RT) for thepatients with head and neck malignancies is often associated withatherosclerotic change in cervical portion of the carotid artery,which is risk of stroke. To investigate the characteristics ofatherosclerotic change induced by RT, we evaluatedultrasonographic findings of carotid artery in the patients withacute ischemic stroke caused by radiation-induced carotid arteryatherosclerosis. Methods: The subjects were the patients withacute ischemic stroke who had past history of RT for head andneck malignancies. We evaluated ultrasonographic characteristicsof carotid artery as mention bellow; the distribution andproperties of plaque, the grade of stenosis and occlusion ofvessels. Results: Six patients were included in this study (6 male,mean age; 73.3±7.8y.o.). They performed RT with 8±4.5 yearsbefore AIS. Three paitents had laryngeal carcinoma, two patientshad pharyngeal carcinoma and one patient had pharyngeal andtongue carcinoma. All patients had no stenosis of intracranialarteries on MRA. Severe stenosis (over 70%) of infarction side’sinternal carotid artery (ICA) was two patients and occlusion ofinfarction side’s ICA was four patients. In all patients, intimamedia thickness of common carotid artery (CCA) was thickeningin all circumferences and there were multiple low and isointensity plaque or ulcerative plaque. On the other hand,atherosclerotic change of carotid bulb was not so severe comparedto CCA and ICA. Conclusion: Radiation-induced carotid artery

atherosclerosis is more severe in CCA and ICA than in carotidbulb evaluated by ultrasound. This result shows that pathology ofradiation-induced carotid artery atherosclerosis is presumablydifferent from that found in common atherosclerotic disease.

P52Role of carotid plaque morphology in ischemic stroke G.Struga, J.Kruja, S.Xhaxho , G.CakciriUniversity Service of Neurology , UHC “Mother Theresa”,Tiranë, Albania

Background: Carotid Plaque morphology it is been considerimportant for the risk of ischemic stroke. Method : Data wasretrieved and analysed from carotid ultrasound studies of 352patients using Siemens Acuson machine. The atheroscleroticcarotid plaque was classified as heterogeneous, hyperdense andhypoechogenic using gray appearance view ,color flow andDoppler wave form characteristics. Patients were defined as havingan ischemic stroke by clinical diagnosis and imaging CT and /orMRI. Results: Hipoechogen plaque has 66% more risk to causeischemic stroke (OD=1.66, CI95%: (1.01-2.66) while male patientshave 49 % more risk than females to have ischemic stroke fromhipoechogenic plaque (OD=0.49, CI95%: (0.26-0.97). Conclusion:Hipoechogen plaque has significant risk to cause stroke. Malepatients with hipoechogen plaque are at the highest risk of havingischemic stroke. This fact justifies more aggressive treatment forsuch patients.

P53Reproducibility of shear wave elastographymeasurements of carotid plaque stiffness: in-vivo andin-vitro studies K.V. Ramnarine1, S. Nduwayo2, K. Dexter1, T.C. Hartshorne3, R.B. Panerai2, A.R. Naylor2, T.G. Robinson2

1Department of Medical Physics and 3Department ofVascular and Endovascular Surgery, University of LeicesterNHS Trust, Leicester, UK; 2Department of CardiovascularSciences, University of Leicester, UK

Background: Measures of stroke risk may be improved byassessing the physical elastic properties of plaque. A new ultrasoundimaging modality, shear wave elastography (SWE) quantifies tissuestiffness and studies suggest clinical value in assessing relatively statictissues such as breast, liver and thyroid. Aim: To assess the feasibilityand reproducibility of SWE measurements of tissue stiffness (Young’sModulus) in vascular applications assessing carotid artery plaquetissue. Methods: A Supersonic Imagine Aixplorer ultrasoundscanner with L15-4 probe was used to acquire 7 seconds of SWEcine-loop data from longitudinal sections of 24 carotid plaques in 21patients presenting with atherosclerotic disease (stenosis diameterreduction ranged 10%-90%, mean 40%). SWE data were alsoacquired from a 70% symmetrical stenosis vessel flow phantom madeof PVA cryogel of similar stiffness to carotid arterial tissue. A blood


mimicking fluid flowing under both steady and physiologicallyrealistic pulsatile flow conditions simulated static and dynamic tissuemotion respectively. In-vitro data were acquired by 2 observers, eachrecording 3 repeat cine-loop measurements. Mean Young’s Moduluswas quantified by placing 2mm regions of interest within the plaque,in up to 6 cine-loop frames. Results: SWE measurements weresuccessfully obtained in all 24 plaques. Carotid plaques had a meanYoung’s Modulus of 116kPa (range 17-255kPa) and mean inter-framecoefficient of variation 21% (range 2-60%). Young’s Modulusmeasured by 2 observers in the pulsatile phantom differed by 1-47%,mean 31% , compared with a mean difference of 12% (range 3-28%)under steady flow. Mean inter-frame coefficient of variation was 13%(range 8-21%) for observer 1 and 22% (range 19-24%) for observer2 under pulsatile flow and 17% (range 9-26%) and 14% (range 8-19%) respectively under steady flow. Conclusion: SWE can quantifycarotid plaque stiffness with satisfactory reproducibility even in thepresence of pulsatile arterial tissue motion.

P54Vascular ultrasound determinants of brain infarction inrenal patientsT.J. Tegos1, G. Dimas2, C. Pitsalidis1, A. Valavanis1, A. Chatziapostolou1, A. Papadimitriou1, I. Chrysogonidis3,D. Grekas2, A. Orologas1

1A Department of Neurology, 2First Medical PropaedeuticDepartment, 3Radiology Department, AHEPA Hospital,Aristotelian University, Thessaloniki, Greece

Introduction and aims: It has been demonstrated that theultrasound findings of carotid arteries are associated with ischemiaon cerebral imaging. In an effort to better determine the impact ofthe atherosclerotic load on brain parenchyma, a study wasperformed aiming to establish the association of carotid andfemoral ultrasound findings with ischemia on brain computerisedtomography (CT). Methods: Analysis involved imaging by duplexof carotid and femoral arteries of 74 renal patients (46 male and 28female, mean age: 64.29 years) in longitudinal fashion, to detect thepresence of plaque and to assess the intima-media thickness (IMT).Each artery was assigned a score (presence of plaque=1, absence ofplaque=0, IMT≥0.8 mm=1, IMT<0.8 mm=0) and the total score ofthe four vessels (two carotids and two femorals) was calculated perpatient (atherosclerotic ultrasonic score-ATHUS). Subsequently,brain CT scans were performed in all patients and the presence orabsence of ischemia was noted. Results: Group A (ATHUS=0-2,26 patients) was associated with a 19.2 %( 5/26) prevalence of brainCT ischemia. The corresponding values for group B (ATHUS=3-5,24 patients) and group C (ATHUS=6-8, 24 patients) were: 45.8 %(11/24) and 58.3 %( 14/24) respectively (p<0.05). Conclusions:Our results suggested that the degree of atherosclerosis was directlyrelated to brain CT ischemic findings. This position might beclarified in larger studies of patients, aiming to establish the role ofatherosclerosis detected on ultrasound in the development of brainCT ischemic findings.

P55Cerebral and renal arterial functional interactions byusing the ultrasonographic evaluations in criticalmetabolic diordersA. Iannolillo2, M.A.E. Rao1, M.V. Manzi1, G. Pagnano1,M. Santoro1, A. Vasta1, N. De Luca, S. Sanguigni3, F. Accorsi4

1Department of Clinical Medicine and CardiovascularSciences, University’ “Federico II” Naples, Italy; 2ASL Avellino,Italy; 3“Madonna del Soccorso” Hospital S. Benedetto delTronto, Italy; 4Echographic School Bologna, Italy

Introduction: Metabolic alterations are thought to influencecerebral flow in high risk population and represent a major riskfactor in cerebral vascular accidents. Indeed, hyperglicemia isconsidered to negatively influence renal blood flow. However, theevaluations of cerebral and renal vascular functional response atthese chronic critical conditions are difficult to analyze. NowadaysDoppler flow determination represent a non invasive anddiagnostic method which very high accuracy and may be usefulin order to obtain new insight at this regard. Methods: Weundertook a doppler-analysis to assess the interaction between thecerebral and renal blood flow (TC-doppler and R-doppler) indiabetic not controlled by therapy (i.e. Hb1ac >7). We consideredalso their global vascular atherosclerotic functional involvement asrepresented by aortic reflection and determined by arterialstiffness by measuring carotid Pulse Wave Velocity (PWV) inorder to have a global functional index of vascular involvement.Results: We studied 20 diabetic patients (Type II) (Age 71±11years). TCD ranged from 0.61 to 0.81 wile RD ranged from 0.47to 0.81. No significative differences were found in male and femalestatistical comparisons ad in a comparable well controlledhypertensive group (n=20) (IR-TCD range from 0.53to 0.74, n.s.). Conclusion: In high risk population we observe a globalvascular involvement as represented both at renal and cerebrallevel and functional blood flow abnormalities are an early indicesof the different target organ preclinical damage. Indeed althoughit has been suggested that the improvement of metabolicabnormalities are related with indices of vascular blood flow atrenal and cerebral level our results suggest that these impairmentis much more determined by the ageing process.


Poster Session II-2 : Nerve, Brain and Vein 2

P56The basilar vein of Rosenthal (RV): a key-vein for theintracerebral venous studyS. Sanguigni1, T. Carboni1, R. Gobbato1, C. Paci1, G. D’Andreamatteo1, M.L. Zedde2, G. Malferrari2

1Neurologic Department San Benedetto del TrontoHospital, Italy; 2Neurologic Department Reggio Emilia, Italy

The Basilar Vein of Rosenthal (VR) represents the cerebral veinwith an higher rate of ultrasound insonation (Stolz et al). For thisreason this vein may be a good indicator of the intracerebral venouscondition of our patients.And we can use it as a “stethoscope” to getan idea about the venous cerebral hemodinamic. a) VR can bereversed in case of obstructions downstream (venous thrombosis ofthe vein of Galen, of the transverse sinus and / or torcular Herofili).Recanalization, after heparin / dicumarolic therapy, determines thenormalization of the flow direction. So we can detecte the timingand the follow-up of the recanalization. b) We study the flow of thetributary vessels (eg the “lateral mesencephalic vein”) withindication of the progressive flow increase in the proximal-distaldirection caused by the contribution of tributary vessels: thedisappearance of this pattern of increase may be an early sign ofinitial obstruction downstream. c) The presence of stenosis of thevein can be easily demonstrated and is often the cause of transitoryglobal amnesia(TGA). d) Valsalva Manoeuvre can determine theflussimetric impacts on the vein which are easily detectable. e) Toavoid mistakes we must remember the different direction of flowbetween pre-and post-peduncular tract of the vein. f) a carefullystudy of the vein allows us to document the presence of a conflictbetween BV and the posterior cerebral artery (PCA): these “a-vconflicts” are the basis of “isolated headaches” in some patients andmay be the cause of cerebral venous thrombosis. g) By using TCCDmultigate (hitachi) we can study, at same time, two or more vesselsplaced on a sectorial plane and have some information“on-line”about the venous dynamics (inflow, outflow, capacity of the vessels)at baseline, during tilt-up tests(0°-90°), etc.

P57Ultrasound venous findings in pts affected by multiplesclerosis (MS) after liberation treatment (LT)L. Pascazio, C. Chiapparino, F. FedericoStroke Unit, Neurology I, Department of Neurosciences andSense Organs, Bari, Italy

Objective: to evaluate the effect of LT in pts with MS and,consequently, CCSVI. Methods: ten pts., 5 men and 5 women,spontaneously underwent LT, 6 with long disease duration, butonly 4 severely compromised. Subjective symptoms and EDSS scorewere evaluated. 2 pts. performed, in our lab, only pre-LT, 3 post-LT

and 1 pre and post-LT, venous SAT Echo-Color-Doppler andTCCD. Results: The EDSS score remained unchanged in pre-andpost-procedure in all pts. 5 pts. reported a transient improvementof subjective symptoms (fatigue, decreased instability), 2 pts aworsening, 2 no change, 1, without disability, was given a preventiveintervention. Despite the stability of the EDSS score, 2 subjectsreported remission of sphincter disorders and 1 pt also an improvedmotor deficit. Pt. evaluated pre-and post-LT: CSA 0° Right (R) J2: 0.55 - J3: 0.52, Left (L) J2: 0.59 - J3: 0.20. No refluxes. 0° In-Flow: 990, Out-Flow IJ2/J3 + VV: 200/250; 90° Out-Flow: 510/590, 0°J2/J3 + 90° VV bilaterally: 590/ 640-Angle Corrected-(AC). IIIventricle: 8.3 mm. Pre-LT ultrasound-surgery evaluation: L J1ostial stenosis; IJV 0° and 90° bilaterally, R VV, Deep CerebralVein: reflux. Open vertebral plexus at 90°. (Jugular - azygos -lumbar and iliac Venography and R-L IJV and azygos PTA ). Post-LT: CSA 0° R: J2 1.08-J3 0.58, L: J2 0.69-J3: 0.21. 0° In-Flow: 710,Out-Flow J2/J3 + VVBil.: 330/490; Out-Flow 90°: 330/190; 0°J2/J3+90° VV: 300 / 460 (AC). IJV reflux at 0°- 90 °. III ventricle:7.1 mm. Conclusions: in the pt evaluated pre and post-LT at 0° thein-flow is reduced, the out-flow is increased, at 90° and at 0° + 90°reduced. After LT in all pts out-flow is increased at 0°, no specifictrend for the out-flow calculated at 90° and at 0°+ 90°.

P58Jugular vein reversal flow-case reportS. Jolic, M. Jolic, N. Vukasinovic, M. Zivkovic Clinic for Neurology, Clinical Centre Nis, Serbia

The value of extra cranial color Doppler sonography is bestknown in exploration of cervical arterial diseases, a little lesserin venous diseases. There are direct signs, but also indirect signs,that ken show disturbances far from observed vein. Jugular veinreversal flow is very rare finding, in some patients caused by somecompressive effect on brachiocephalic vein. We report a case ofreversal internal jugular vein flow, due to brachiocephalic veinobstruction, caused by lymphoma. 22 years old female started tosuffer from pain in her left arm, with slight left hand swelling. Shewas examined by general practitioner-cause of the pain wasn’tfound. Next step was left arm veins ultrasound and vascularsurgeon examination (no venography was performed). As findingsdid not reveal cause of her problems, she was examined byrheumatologist-no bad results were found. Further, her generalpractitioner sent her to neurologist. She came into our ambulancewith medium left hand swelling, pain in it and nothing else.Neurological examination result was good. As radiologist examinedonly veins of her arm, we decided to examine cervical circulation,with special attention on cervical veins, and left jugular veinreversal flow was found. All other vessels (arteries and veins) weremorphologically and hemodinamicly normal. Just behind leftclavicle was seen some mass that we could not explain. She was sentto chest computerized tomography, where tumor formation inupper mediastinum was find. She was admitted at Chest surgeryClinic, and biopsy of tumor formation was performed, withlymphoma finding on pathohystlogy.


P59Cerebral venous outflow impairment in patients oftransient monocular blindness without carotid stenosisH.H. Hu1, C.Y. Cheng2, A.C. Chao3

1, 2Department of Neurology, Taipei Veterans GeneralHospital, Taipei, Taiwan; 3Department of Neurology,Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung City,Taiwan

Background: The etiology of patients with transientmonocular blindness (TMB) without carotid stenosis has beenlinked to venous hypertension because of higher frequency ofinternal jugular venous values incompetence (IJVVI). Tosubstantiate the venous theory, this study was examine whetherTMB patients have other venous outflow abnormality which mostseen in the patients of chronic cerebrospinal venous insufficiency(CCSVI). Methods: Contrast MRI and time-resolved imaging ofcontrast kinetics (TRICKS) were performed in 23 patients of TMBwithout carotid stenosis and 23 age-and sex-matched controls. Thecalibers of internal jugular veins (IJVs) were assessed at C1 level.The venous caliber was scored as follows: 0, normal round or ovoidappearance; 1, mild flattening; 2, moderate flattening; and 3, severeflattening or not visualized. Results: Of the 23 patients, the meanage was 49.2+/- 17.8 years old, with 10 females, and that of controlswas 50.1+/- 15.3 with 10 females. Severe flattening or not visualizedof IJVs at C1 level were found in 6 patients and none in controls.The venous caliber of IJVs at C1 level scored ³1 were significantlyhigher in patients than in controls (87.0% vs 34.8%, p=0.0003); If taking the venous caliber scored ³2 as significant cerebral venousoutflow impairment, then it was found in 13 patients and only in 2controls (56.5% vs 8.7%, p= 0.0005). Conclusions: patients withTMB without carotid stenosis had impairments of cerebral venousoutflow. The role of venous hypertension as an etiology needsfurther study.

P60The venous hypothesis of transient global amnesia: a complex multifocal cerebral venous drainageimpairment? M.L. Zedde1, G. Malferrari1, R. Pascarella2, M. Maggi2

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Dept. of Medical Imaging,Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy

Transient Global Amnesia (TGA) is a rare condition whosepathogenesis is multifactorial, but it has been associated to animpairment of venous hemodynamics, mainly in extracranialsegments (internal jugular vein –IJV- valve incompetence) butalso in intracranial segments. The role of IJV valve incontinence,although often reported in TGA patients, is under discussion,because of the high rate of this condition in healthy people andthe lack of it in several TGA patients. Also, not all TGA episodesare associable to a Valsalva-like activity. For investigating the

potential role of an impairment of cerebral vein hemodynamics inTGA patients, the data of a subgroup of patients with at least oneepisode of TGA in their life were retrospectively examined,selecting patients among those referred to the Neurosonology Labof a single center for the ultrasound examination of venoushemodynamics. The ultrasound examination of extracranial andintracranial veins is routinely performed in this lab, studying IJVin its proximal, middle and distal segment, at rest and withValsalva maneuver, IJV branches, vertebral veins, mainintracranial veins and sinuses, in both supine and uprightposition. 45 patients were included in the analysis, and 31/45(69%) had a Valsalva-like activity as identifiable trigger of TGAepisode; 14/45 (31.1%) had more than one TGA episode. 24/45(53.3%) had an IJV valve incompetence > 0.88 sec with Valsalvamaneuver, but 41/45 (91.1%) had at least one venous abnormalityoutside of valve incontinence in extracranial or intracranial veins.Patients with multiple episodes have more abnormalities thanpatients with a single episode. The ultrasound evaluation of TGA patients can help to identify several signs of venoushemodynamics impairment.

P61Ultrasound assessment of oxaliplatin-inducedneuropathyM. Lucchetta1, C. Dalla Torre1, M. Campagnolo1, M. Cacciavillani2, G. Granata3,4, L. Padua3,4, C. Briani1

1Dept. of Neurosciences, University of Padova, Italy; 2CemesData Medica, Italy; 3Dept. of Neurosciences, CatholicUniversity of Roma, Italy; 4Don Gnocchi Foundation, Milano,Italy

Background: Chemotherapy-induced peripheral neuropathyis a major adverse effect of Oxaliplatin (OXL) treatment. Whereasneurophysiologic study are commonly used to assess theoccurrence and severity of polyneuropathies, ultrasound (US)analysis of the peripheral nerves, an emerging technique in thestudy of peripheral nerve diseases, has never been used in CIPN.Patients/Methods: Sixteen patients (5 women, 11 men, mean age60.6±10.4 yrs, median 62.5, range 37-75) with colorectal cancertreated with OXL-based treatment have been clinically andneurophysiologically evaluated before and after OXL-therapy. Atinclusion, at course 12 or after completion of treatment, the patientsunderwent oncological and neurological evaluation. The presenceand severity of CIPN were scored with the National CancerInstitute Common Toxicity Criteria version 3 (NCI-CTC 3.0) andthe Total Neuropathy Score, clinical version (TNSc). At the end ofchemotherapy, all patients underwent also US study of peripheralnerves at four limbs, and the findings correlated with clinical andneurophysiologic measures. Results: Fourteen of 16 (87.5%)patients developed sensory axonal neuropathy, 11 of whom severe(2 or more sensory nerve action potential amplitude absent and theother amplitudes decreased of ≥50%). Nerve US did not revealdecreased cross sectional area (CSA), a reported finding in axonalneuropathies. Instead increased CSA at entrapment sites (mediannerve at wrist and ulnar nerve at elbow) was found in 10/16(62.5%) of the patients. Discussion: Sensory axonal neuropathy is


a very common complication of OXL therapy, affecting almost 90%of our population. US findings of enlargement of median and ulnarnerves, mostly at entrapment sites, in patients with no history orsymptoms of compressive neuropathies at recruitment, may beexpression of increased, OXL-induced, nerve susceptibility tomechanical damage. A prospective ongoing study will help clarifyour findings.

P62Optical nerve atrophy in demyelinating diseases: a pilotstudy with transorbital echographyJ. Fernández-Domínguez, R. García-Rodríguez, V. Mateos Department of Neurology, Centro Médico de Asturias,Oviedo, Spain

Demyelinating diseases are a group of heterogenic diseases inwhom mieline is attacked. The optic nerve (ON) is one of the mostcommonly affected. Material and methods: An observationalprospective case-control study with ON orbital echography wasdeveloped. Case group was formed by demyelinating diseases(multiple sclerosis and clinical isolated disease) patients and thecontrol group was formed by healthy people. Results: 31 cases and24 controls. All of them signed the informated consent before beingincluded in the study. Mean age of cases: 48,3 ± 11,8 years old,controls 48,7 ± 9,9 years old. 46% of controls and 42% of caseswere males. We found statistical significance differences regardingthe diameter of right and left ON between cases and controls(OND: controls: 3,64± 0,58 mm vs Patients: 2,84± 0,56 mm inpatients, p <0,001; ONI: Controls: 3,95± 0,84 mm vs Patients: 2,74± 0,54mm, p< 0,001). We found no differences between maximumsystolic and median velocities regarding ophthalmic arteries in bothgroups, neither for previous acute optical neuritis history or visualevocated potentials. Conclusions: ON evaluation with transorbitalechography is an easy, feasible, non invasive, useful and costlesstechnic for the evaluation of the ON atrophy. As visual evocatedpotentials are abnormal in a huge number of patients withoutprevious optical neuritis evidence, the diameter of ON measured bytransorbital Doppler could be a consistent paraclinic marker ofthese diseases. Posterior series should confirm these findings.

P63Reproducibility of automatic measurement ofsubstantia nigra from transcranial sonographic imagesM. Jelínková1,2, J. Blahuta3, P. Čermák3, T. Soukup3, P. Bártová2, R. Herzig4, D. Školoudík2,4

1Department of Neurology, City Hospital, Karvina, CzechRepublic; 2Department of Neurology, Ostrava Universityand University Hospital, Ostrava, Czech Republic; 3Instituteof Computer Science, Faculty of Philosophy and Science,Silesian University in Opava, Opava, Czech Republic;4Department of Neurology, Faculty of Medicine of thePalacký University and University Hospital, Olomouc, CzechRepublic

Background: Recent studies reported increased echogenicityof substantia nigra (SN) in 91 – 100 % PD patients usingtranscranial sonography (TCS). However, the main limitation ofTCS evaluation of SN features is the dependency on thesonographer’s experience and the quality of tissue imaging limitedby quality of bone window. The experimental software formeasurement of area in SN was developed for quantitativeevaluation in patients with Parkinson’s syndromes. The aim ofstudy was to test the reproducibility of measured data usingdeveloped software. Methods: The SN was imaged from righttemporal bone window in mesencephalic plane using TCS.DICOM images of SN were saved and encoded. All images weresubsequently converted into JPEG format, which were processed.The mean values, variance and standard deviation between all 6measurements of each patient were counted. Subsequently, acoefficient of variability was calculated from results of allmeasurements. The 95th percentile of healthy volunteers was usedas a border-line value for a differentiation between normal andpathological results to obtain a ROC curve. The average value ofall 3 measurements of each observer was used for a computing ofCohen’s kappa coefficient to determine an inter-observercorrelation. Cohen’s kappa coefficient as an intra-observercoefficient was counted from the first 2 measurements of bothobservers. Finally two intra-observer correlations were obtainedfor observer 1 and observer 2. Results: Totally 100 images wereevaluated using this software. Mean of standard deviation ofmeasurement was 3.87; Cohen’s kappa for intra-observeragreement of two observers were 0.947, and 0.943, resp.; Cohen’skappa for inter-observers agreement was 0.880. Conclusions: Theresults of the presented study show a very good repeatability and reproducibility of measurement of SN features using designed application with “almost perfect” inter-observer and alsointra-observer agreements.


P64Optic nerve ultrasonography: useful thechnique indifferentiating papilledema from pseudopapiledemaM. Mehrpour, E. Mogharralu, F. Oliaee, M.R. Motamed Tehran University of Medical Sciences (TUMS), FiroozgarHospital, Department of Neurology, Teheran, Iran

Background: The sonographic technique allows measurementof the diameter non-invasively and this diameter is dynamic anddepends on changes in CSF pressure. Transorbital optic nerve sheathultrasound is a reproducible, non-invasive technique and is welltolerated in patients. We want to evaluate reliability of optic nervesonography in diagnosing pseudo-papilledema from papilledema.Method and material: We studied 17 patients for evaluatingbilateral disc swelling with apparent normal brain imaging. Discswelling was confirmed by neuro-ophtalmologist. Because ofapparent papilledma, detecting CSF pressure for ruling outpseudotumor is a must. We discussed the method for patients clearlyand obtained consent from all of the patients. We did optic nervesonography before performing LP to detect CSF pressure. Thetransverse diameter of the optic nerve sheath (ONSD) at 3 mmbehind the optic nerve head was taken using the digital cursor of theultrasound machine. In this study, we employed optic nervesonography to investigate whether papilledema could bedifferentiated from pseudopapilledema. Result: Six men and 12women was evaluated. Our cut-off point was optic sheet diameterless than 5.9 mm. Fourteen patients had above cut-off point diameter(Mean 6.5, Sd:0.3) include four men and 10 women. Their CSFpressure was above 200 mm, in the other hand two men and twowomen had below cut off point optic nerve diameter (mean 4.1 Sd:0.2). Their CSF pressure was below 200. Conclusion: ONSDmeasurements may provide useful information regarding the presence of cerebral oedema and intracranial hypertension, brain injury. It seems that there is a good correlation between CSFpressure and Optic nerve diameter and can reliably differentiatepseudopapilledma from papilledma.

Poster Session II-3: Functional US, Cervical Vessels Disease

P65Hemodynamic effect of compression of ipsilateralexternal carotid artery branches on middle cerebralartery flow parameters in patients with internal carotidartery occlusionA. Frendl1, J. Borok1, L. Csiba1, L. Olah1

1University of Debrecen, Department of Neurology,Debrecen, Hungary

Reversed flow in the ipsilateral periorbital vessels is a commonfinding in patients with internal carotid artery occlusion (ICAO).

Source of the collateral flow can be detected by the use of the socalled compression test, when compression of branch(es) ofipsilateral external carotid artery (ECA) leads to normalization offlow direction in the periorbital vessels. Our aim was to investigatethe effect of compression of these external carotid artery (ECA)branches on the flow parameters of the ipsilateral middle cerebralartery (MCA) in patients with ICAO. Patients with ICAO wereincluded in the study if the flow direction was reversed in theipsilateral periorbital vessels but compression of at least one of theECA branches (maxillary artery, superficial temporal artery, orfacial artery) caused normalization of flow direction. The meanflow velocity and the pulsatility index (PI) were monitored by 2MHz probes in both MCAs at 50 mm depth (n=8). After recordingthe flow parameters at rest, the proper ECA branch which servedcollateral flow was compressed for 1 minute. Breath holding index(BHI) was also determined in both MCAs. The BHI was0.54±0.37%/s on the ipsilateral and 1.09±0.32%/s on thecontralateral side. During the compression of the proper ECAbranch the ipsilateral MCA flow velocity did not changesignificantly (-0.87%±3.33%, compared to the resting phase),however, the PI decreased by 10.87%±14.38%. Our results indicatethat the compression of the ipsilateral ECA branch(es) in patientswith ICAO does not lead to decrease of the flow velocity in theipsilateral MCA, but results in decrease of the PI showingvasodilation of the resistant vessels. One can speculate that in caseof exhausted cerebrovascular reserve capacity, when no furthervasodilation of resistant vessels is possible, severe ECA stenosis mayincrease the risk of cerebral ischemia in patients with ICAO.

P66Evaluation of cerebrovascular reactivity in ICA teno-occlusion: quantitative MRA compared totranscranial Doppler ultrasonographyL. Caputi1, F. Ghielmetti2, F. Longaretti2, G. Faragò2, M. Lamperti3, G.P. Anzola4, M.R. Carriero1, M.G. Bruzzone2, E. Ciceri2, E. Parati1

1Department of Cerebrovascular Diseases, NeurologicalInstitute C. Besta, Milan, Italy; 2Department ofNeuroradiology, Neurological Institute C. Besta, Milan, Italy;3Department of Intensive Care Unit, Neurological InstituteC. Besta, Milan, Italy; 4Service of Neurology, S. OrsolaHospital - Poliambulanza, Brescia, Italy

Background and Objectives: Assessment of cerebrovascularreactivity (CVR) provides information regarding the stroke risk ininternal carotid artery (ICA) steno-occlusion. Exhausted CVRenhances the risk of stroke in such conditions. TranscranialDoppler (TCD), with a vasodilatative stimulus, is currently usedfor CVR evaluation. Higher spatial resolution might be availablewith quantitative magnetic resonance angiography (QMRA),although a few data were provided. We considered TCD the goldstandard for CVR in patients with ICA steno-occlusion. Aims ofthe study were 1) feasibility of QMRA in CVR assessment; 2) safetyof QMRA under vasodilatative stimulus; 3) preliminary evaluationof the diagnostic accuracy of QMRA compared to TCD. Methods:CVR was obtained both with TCD and QMRA by breathing air


plus CO2 5%. Patients had high grade symptomatic and/orasymptomatic ICA stenosis or occlusion. CVR data were comparedto age-matched healthy subjects. QMRA provided absolute flowdata of the arterial vessels evaluated. Results: 13 patients (m.a.65.8±8.5, male; 10 ICA occlusion, 3 stenosis), were enrolled. Allbut one were asymptomatic. Control subjects were 15 (m.a.60.4±8.7, 11 male). Hypertension and dyslipidemia were morefrequent in patients. No differences in hemodynamic patterns wereobserved in both populations. Feasibility and safety of QMRAunder CO2 were ensured in all subjects. CVR from bilateral MCAwas slightly reduced in patients compared to controls during bothTCD (averaged CVR index: ctrls 4.06, pts 3.56) and QMRA(averaged CVR index: ctrls 3.81, pts 3.51). Moreover, CVRipsilateral to the steno-occluded side was more impaired underTCD (CVR index 3.05) than QMRA (CVR index 3.4). Flow datain ICA and basilar artery were substantially higher in patients (ICA250-300 ml/min, BA 180 ml/min) than in controls (ICA < 250ml/min; BA < 150 ml/min). Patients with ICA occlusion had lowerflow data from both MCA, at rest and during CO2 inhalation, thancontrols and those with ICA stenosis. Discussion: Our preliminarystudy showed feasibility and safety of QMRA under CO2 inhalationfor CVR evaluation. CVR appears to be slightly impaired in patientswith ICA steno-occlusion under both techniques. QMRA might bea promising tool for CVR and intracranial flow assessment.Ongoing and more complete evaluations are under way.

P67Cerebral vasomotor reactivity in patients with internalcarotid artery stenosisP. Puz, Z. Kazibutowska, E. Motta, A. BalMedical University of Silesia, Upper Silesia Medical Center,Stroke Unit, Katowice, Poland

Background: Evaluating of the cerebral vasomotor reactivitymay be one of the method in predicting the stroke risk in patientswith internal carotid artery stenosis. The aim of this study was toassess vasomotor reactivity tests: breath holding index (BHI) andvasomotor reserve (VMR) in patients with symptomatic andasymptomatic internal carotid artery stenosis. Methods: 60patients (16 females and 44 males) aged 55-80 years (mean 66,23,SD 7,85) with internal carotid artery (ICA) stenosis ³ 50% whereenrolled to the study. The extent of the ICA stenosis, assessed withthe Color Coded Duplex, was classified into two groups: 50-69%and ³ 70%. In 38 patients ICA stenosis was symptomatic. Stenosisgrade ³ 70% was found in 34 patients. Transcranial dopplerexamination was performed in all patients. Changes of mean bloodflow velocity in middle cerebral artery ipsilateraly to the stenosisof ICA during hypo- and hyperventilation were recorded and BHIand VMR were calculated. Results: ICA stenosis ≥ 70% was foundsignificantly less often in patients with asymptomatic ICA stenosis(7 patients - 31,82%) than in patients with symptomatic ICAstenosis in (27 patients - 71,05 %) (p=0,003). Mean VMR and BHIvalues were singificantly lower in patients with stenosis ³ 70% thanin patients with stenosis 50 – 69% (51,54±18,93 vs 65,56±20,12; p=0,001 for VMR and 0,81±0,49 vs 1,03±0,59; p=0,04 for BHI). Therewere no significant differences in VMR and BHI values between

symptomatic and asymptomatic group (54,81±20,14 vs62,48±20,71; p= 0,07 for VMR and 0,87±0,52 vs 0,96±0,6; p=0,59for BHI). Conclusion: Cerebral vasomotor reactivity is impaired inpatients with high grade internal carotid artery stenosis but itsimplication for neurological symptoms is not clear.

P68Bilateral carotid artery occlusion: descriptive study onhemodynamic features and outcomeJ.R. Pérez Sánchez, A. García Pastor, F. Díaz Otero, P. Sobrino García, P.M. Rodríguez Cruz, G. Vicente Peracho, P. Vázquez Alén, J.A. Villanueva Osorio, A. Gil NúñezStroke Unit and Neurosonology Laboratory, NeurologyDepartment, Hospital General Universitario GregorioMarañón, Madrid, Spain

Introduction: Bilateral carotid artery occlusion (BCAO) is arare and poorly studied entity. Collateral circulation plays a crucialrole in the outcome. Information describing the hemodynamiccharacteristics studied with neurosonological means is scarce.Objectives: To describe hemodynamic characteristics and naturalhistory of patients with BCAO diagnosed in our institution.Methods: Patients with BCAO were recruited from ourNeurosonology laboratory (Stroke Unit) database for a 3 yearsperiod. BCAO was detected with duplex ultrasonography andconfirmed with Computed Tomography Angiography (CTA)and/or conventional digital subtraction angiography. Clinicalfeatures and outcome were recorded, and when possible, a completeneurosonological workup including supra-aortic trunks,ophthalmic and transcranial duplex to study collateral pathwaysand acetazolamide reactivity test in both hemispheres wasperformed. Results: 12 patients with BCAO were identified from1756 neurosonological studies. Four patients presented a carotidnear-occlusion on CTA and were excluded. BCAO was confirmedin 8 patients. All patients were men, age range 48-81 years, nonewith previous history of stroke. 6/8 suffered a hemispheric strokeor TIA at diagnosis and 2/8 were asymptomatic. Modified Rankinscore (mRS) was ≤1 in 5 patients at a mean follow-up period of 17.3months (range 6.5-37.5). 2 patients died, one due to earlycomplications of stroke and other lately from a non-vasculardisease. No cerebrovascular recurrences were observed. 4 patients(mRS≤1) underwent a complete neurosonological study, showingin all cases an extensive collateral flow pattern and an exhausted orreduced cerebrovascular reserve capacity in at least onehemisphere. Conclusion: BCAO is a very unusual disease. Wepoint out in our study the absence of cerebrovascular recurrencesin a medium-term follow-up. Good collateral pathways wereobserved in patients with favourable outcome but we could notassess hemodynamic features in patients with poor outcome. Morestudies are needed to confirm these findings.


P69Cognitive decline and cerebral vasoreactivity inpatients with asymptomatic severe carotid stenosisI. Zavoreo, V. Bašić Kes, V. DemarinUHC Sestre Milosrdnice, Neurology Dept., Zagreb, Croatia

The aim of this study was to evaluate correlation of impairedcerebral vasoreactivity and cognitive decline in patients with severeasyptomatic carotid stenosis as well as the impact of the stenosisside and capacity of the Willis circle collateral circulation. Thirthyone patients with asymptomatic severe unilateral internal carotidstenosis were included, all of them were right handed. Cognitivedecline was assessed by means of Montreal Cognitive Assessment(MoCA) score and Mini Mental State Exam (MMSE) score.Cerebrovascular reactivity (CVR) was evaluated with breathholding index (BHI). Collateral circulation was evaluated withtranscranial color Doppler ultrasonography (TCCD). Results werecompared with sex and age matched contols. All patients with carotid stenosis were in normal range of MMSE score(28,2±1,4), while MoCA score was 22,3±2,4. Subjects with leftcarotid stenosis had lower results in language and episodic memoryperformance,while subjects with right carotid stenosis hadperformances in visuo-spatial skills. Patients with carotid stenosishad BHI (0,58-0,95) lower than normal values and better results ofcognitive testing in case of activating one collateral artery(especially anterior cerebral artery) in correlation with patients withactivated 2 or more collateral arteries. Altered cerebrovascularreactivity and consecutive cerebral hypoperfusion may beresponsible for reduction in some cognitive abilities involving thefunction of the hemisphere ipsilateral to carotid stenosis, thereforeBHI is usefull tool in recognizing asymptomatic patients withcognitive decline who should be considered for carotidendarterectomy or stenting. Key words: carotid stenosis, cerebralvasoreactivity, cognitive decline.

P70Intima-media thickness of internal carotid arteryfollowed different endarterectomy techniques(one year follow–up)P. Ivanova1,2, I. Kikule3,4, V. Zvirgzdins1, D. Krievins2,5

1Riga East Clinical University Hospital, Department ofVascular Surgery, Riga, Latvia; 2University of Latvia, Facultyof Medicine, Riga, Latvia; 3Riga East Clinical UniversityHospital, Department of Neurology, Riga, Latvia; 4RigaStradins University, Riga, Latvia; 5Vascular Surgery Centre, P. Stradina Clinical University Hospital, Riga, Latvia

Backgroud: Intima-media thickness is a response of surgicaltrauma after carotid endarterectomy. Different surgical techniquesgive a different reaction of intima-media layer development. Severe intimal hyperplasia can be a cause for restenosis of internalcarotid artery. The aim of this study: To evaluate and compareintima-media layer of internal carotid artery after differentendarterectomy techniques in one year follow up. Material and

methods: Intima-media complex of the internal carotid artery wasmeasured by ultrasound for 104 patients. Patients were operated indiferent surgical techiques: with primary suture, with patch andeversion. Carotid ultrasound was performed in the first,third, sixt,twelfth months in postoperative period. To evaluate severe restenosispeak systolic velocity was measured in all investigations. All patientsreceived aspirin and statin therapy in postoperative period. Results:In all follow up periods intima-media thickness was growing, nosignificant regression was observed. In some periods intima-mediathickens progresion was very slow (without important diferencebetween them). The maximum thickness was evaluated for patientsfollowed carotid endarterectomy with patch (1,037±0,037 mm,1,097±0,033 mm, 1,090±0,02 mm, 1,130±0,02mm). No severerestenosis was observed in one year follow up. Conclusion: Intimalhyperplasia is progressing during first postoperative year after allcarotid endarterectomy techniques. Intima-media layer is moreincreased after carotid endartereectomy with patch.

P71Deformations of brachycephalic vessels at children M. Abramova, I. Stepanova, N. Shurupova, S. Shayunova, S. NovoselovaThe Russian National Research Medical University namedafter N.I.Pirogov, Pediatric Faculty, Neurology, Neurosurgeryand Medical Genetics Department, Laboratory of ChildCerebrovascular Disorders; Moscow, Russia

Purpose: It is necessary for children with brachycephalic vessels (BCV) deformations to carry out complex investigation forworking out of algorithm of diagnostics, treatment and furtherrecommendations. Methods: Duplex examination of BCV of 6000patients aged from 3 to 18. 68 % has been done. Some abnormalitieshave been found: deformations of internal carotid arteries (ICA) -47,6%; vertebral arteries (VA) - 81,53%. The deformations were thefollowing: 1.C-shaped tortuosity of ICA - 35,87%, VA – 22,7%; 2. S-shaped tortuosity of ICA – 19,24%, VA – 3,8%; coiling of ICA –6,89%, VA – 2,53%. A connection between hemodynamic disturbanceof deformations and localizations (25% of ICA and 5,7% of VA) andtypes (S-tortuosity and coiling) have been found. These childrencomplained about headaches with nausea and vomiting, dizziness,nasal bleedings, lassitude intolerance of weather jumps. Clinicalappearance of deformations depended also on presence and intensityof venous disfunction. We have been surveying children withdeformations of ICA for 12 years and noted the next modification:C- tortuosity turned into rectilinear one at 3% of children; S-shapeddeformation with acute angles turned into S-shaped one with obtuseangles at 7% of children; into C-shaped one or rectilinear one – 1,5%of children; coiling - never changed its configuration. Conclusion:The frequency of examination of brachycephalic vessels abnormalitiesdepends on the type of deformation, its hemodynamic infringementsand clinical appearances: S-shaped tortuosity and coiling – one timein 3-6 months, C-shaped tortuosity – one time in 6-9 months. It isnecessary to conduct a proper research (shouldn’t be hard, tiring forthe children or causing negative emotional reactions), analysis ofreceiving data, considering the experience of managing the cases ofelder patients.


P72Posterior circulation and mild cognitive impairment: anassessment of ultrasonographic correlatesS. Rutkauskas1, S. Lukosevicius1, A. Basevicius1, K. Lauckaite2, Z. Stepanavicius3

1Lithuanian University of Health Sciences, Department ofRadiology, Kaunas, Lithuania; 2Lithuanian University ofHealth Sciences, Department of Neurology, Kaunas,Lithuania; 3Lithuanian University of Health Sciences,Department of Psychiatry, Kaunas, Lithuania

Introduction: Mild cognitive impairment (MCI) is nowrecognized as a risk factor for Alzheimer’s disease (AD). The studiessuggest the presence of vascular modifications, mainly of anteriorcirculation, in AD and in MCI patients who will convert to AD.Our aim was to estimate the correlation of posterior circulation andMCI. Material and methods: A prospective study was carried outat the Hospital of Lithuanian University of Health Sciences in 2011.Altogether, 71 patients with cognitive impairment were examined.The Mini Mental State Examination (MMSE) was a measure ofglobal cognitive function. According to MMSE, the patients wereassorted into the groups: ≥25 (group A, n=44), ≤24 points (groupB, n=27). Voluson 730 duplex ultrasound system (GE Healthcare,Austria) was used for the registration of systolic peak (SPFV),diastolic (DFV), mean (MFV) flow velocities, pulsatility (PI) andresistivity (RI) indexes. Statistical calculations were performed withMedCalc v.11.4.2.0. Values were expressed as the mean±standarddeviation. Results: 71 patients were included in the study. Themean age was 69±9 years, 17 (24%) were males. The mean ofMMSE was 24.8±2.8 points (range 18-30). An internal diameter(mm) of the left vertebral artery (VA) was 3.3±0.6, of the right –3.2±0.5. Ultrasonographic parameters (n=139) were as follows:SPFV 45±9cm/s, DFV 14±3cm/s, MFV 25±5cm/s, PI 0.67±0.05, PI1.2±0.2. Group A and B differed according to VA diameter 3.2±0.5(n=89) vs. 3.4±0.6 (n=53) (p=0.013). The statistically significantcorrelations were detected between age and MMSE scores (r=-0.34,n=142, p<0.001), VA diameter and DFV (r=0.26, n=139, p=0.002),also MFV (r=0.17, n=139, p=0.05), RI (r=-0.26, n=139, p=0.002)and PI (r=-0.26, n=139, p=0.001). Conclusion: The lower MMSEscores were associated with older age, larger inner diameter of VAand higher blood flow velocities. It could be due to altered carotidcirculation and compensatory flow via vertebral system.

P73Assessment of flow-mediated dilatation (FMD) of thebrachial artery (BA) at patients with hemispheric theischemic stroke (IS) and expressed hemiparesisS. Svoevolin1, V. Lelyuk1, S. Lelyuk2

1Russian National Research Medical University named afterN.I. Pirogov/Cerebrovascular and Stroke Research Institute,Moscow, Russia; 2Russian Medical PostgraduateAcademy/Ultrasound Department, Moscow, Russia;

The aim: comparison of estimation methods of the FMD inproximal and distal position of cuff at patients with hemispheric IS

with severe hemiparesis. Materials and Methods. The studyincluded 49 patients who underwent IS in age from 40 to 93 yearswith paresis of one of the hands not less than 3 points ranked intwo groups (depending on the method of applying the cuff: the firstgroup - 33 patients with proximal compression, the second - 16 -with distal). The FMD sample was conducted in all patients firston the right, then on the left hand. Normalization was carried out(nFMD) with the magnitude of shear rate (SR). Results: In the firstgroup the differences of FMD and nFMD in comparable vesselshaven’t been received (11.25%, 9.65% and 0.013sec-1 0.016sec-1,p>0.05 for FMD and nFMD on the intact and paretic hands,respectively), if the study was began with the intact arm. If the trialwas began with the affected part were identified differences FMDand nFMD (13.0%, 7.6%; 0,009sec-1, 0,020sec-1, p<0,05 for FMDand nFMD on the intact and paretic limbs, respectively); in thesecond group – 6.4%; 4.6%; 0.024sec-1 0.020sec-1, p>0.05, and 7.0%,7.6%; 0.019sec-1, 0,020sec-1 p>0,05, respectively. When comparingthe peak SR in the first and second groups there were receiveddifferences (0.399; 0.315, p<0.05). The differences were obtainedfor FMD patients in the first and second groups (10.5%; 5.3%,p<0.05). Conclusion: During the FMD sample of PA from pareticlimb in the proximal compression there were obtained sidedifferences, during initial compression on the intact side differencesweren’t registered. The study of patients with severe hemiparesis toobtain reliable results is preferable to carry out the sample with theproximal compression. Part of the study in this case doesn’t matter.

Poster Session II-4: Functional TCD, Non Atherosclerotic Disease

P74Intracranial velocities in traumatic brain injury.Relationships with intracranial pressure andinflammatory response Sierra R., Diaz R.Universitary Hospital Puerta del Mar, Intensive Care Unit,Cádiz, Spain

Objective: To analyze cerebral hemodynamics estimated byintracranial arterial and venous velocities in patients suffering braininjury secondary to head trauma (TBI) searching for relationshipswith intracranial pressure (ICP). This study also analyze theinflammatory response associated to TBI. Methods: Middle cerebralartery (MCA) and basal cerebral venous (BV) velocities (vel) veremeasured by transcranial Doppler ultrasound (TCD). ICP wascontinuously recorded using Camino transducers. Intracranialhypertension (ECH) was defined by an ICP >=20 mm Hg. Serum C-reactive protein (CRP) was measured. Data were collected at 3 timesafter ICU admission: t0, during the first 48 hours(h); t1, from the48h until 120h; t3, from the 120h until 192h. Data are expressed asmean values. Results: 94 patients with TBI were included. Meanvalues of ICP in 3 times were 16.2, 15,7 and 18,3. Thirty percent of


patients had ECH at t0. The values of mean arterial pressure in t0,t1, t2 were 86.3, 96.8 and 98.7 . Mean values of MCA vel (cm/s) andBV vel (cm/s) were 66.9/14.8 in t0, 79.1/14.2 in t1, and 78.4/15.2 int2. Values of CRP(mg/dl) were 13.1 in t0, 21.4 in t1 and 15.7 in t2.CRP concentrations in patients who had ECH were not higher thanthose without ECH. IPC and BV vel values were positively correlatedin the 3 times (rho= 0.50, 0.41 and 0.35, p<0.05 respectively). Logisticregression analysis showed BV vel to be an independent predictor ofECH at t0 in TBI patients (OR, 1.19(1.11-1.31)) with 76% sensitivityand 72% specificity for a threshold value of 13.5 cm/s (area underROC curve, 0.774). Conclusion: TCD BV vel values are associatedto IPC in patients with TBI. TCD BV vel demonstrated to be an earlypredictor of ECH presence. Although inflammatory responseassociated to TBI is early and considerable, does not appear to berelated with the magnitude of ICP.

P75Statistical validity of non-invasive absolute intracranialpressure value meter for evidence based medicineA. Ragauskas1, L. Bartusis1, R. Zakelis1, G. Daubaris1, V. Matijosaitis2, K. Petrikonis2, D. Rastenyte2

1Kaunas University of Technology, Telematics ScienceLaboratory, Kaunas, Lithuania; 2Lithuanian University ofHealth Sciences, Kaunas Clinics, Department of Neurology,Kaunas, Lithuania

Background: Non-invasive absolute ICP value measurementmethod with no need of patient specific calibration has beenproposed in our previous works. Objectives: To investigateaccuracy and precision of the non-invasive absolute intracranialpressure (aICP) value meter by comparing non-invasivemeasurements with “gold standard” invasive (gsICP) measurements.To assess quality of the aICP measurements’ data in terms of evidencebased medicine. Methods: Prospective clinical study ofsimultaneous “gold standard” invasive and non-invasive absoluteintracranial pressure measurements has been conducted. Data werecollected from 82 neurological patients (92 paired measurements)and 2 TBI patients (9 paired measurements). The average age ofpatients was 46.42 years (from 18 to 78 years). Bland-Altman analysishas been performed in order to estimate agreement between the non-invasive and invasive measurements. ROC analysis has beenperformed, too, in order to investigate classification quality of thenon-invasive aICP meter comparing with invasive ICP meters.Results: 101 simultaneous “gold standard” invasive ICP and non-invasive aICP measurements were performed in the wide range ofICP values (4.0 – 28.0 mmHg). Bland-Altman analysis showed anaccuracy expressed by the mean differences between measured aICPand gsICP is 0.03 mmHg. Precision of non-invasive aICP methodexpressed by SD of random error is 2.3 mmHg. ROC analysis showedcomparable results with invasive parenchymal ICP measurements:achievable area under ROC curve (AUC) of non-invasive aICPmeasurements is 0.957. Conclusions: Statistical analysis ofprospective comparative clinical study validates non-invasive aICPvalue meter as an accurate and precise enough for clinical practice aswell as a reliable diagnostic classifier in neurological patients’treatment decision making.

P76Dyanimic cerebral autoregulation in patients withparasagittal meningiomasV.B. Semenyutin1, D.A. Pechiborsch1, V.A. Aliev1, A. Patzak2, G.K.Panuntsev1, A.V. Kozlov1

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

Background. Parasagittal meningiomas (PSM) are cerebraltumors which along with mass-effect impair cerebral vascularsystem since they arise from the lateral wall of the superior sagittalsinus and often invade its lumen (partially or completely). Thiscould cause hemodynamic (mostly venous) changes and probablydisturbance of dynamic cerebral autoregulation (dCA). The latteralmost hasn’t been studied in this pathology yet. Materials andMethods. 20 patients (aged 26–63, mean 47 years) with PSM havebeen studied. dCA was evaluated based on phase shift (PS) withtransfer function analysis of spontaneous oscillations of arterialblood pressure (BP) and blood flow velocity (BFV) in the middlecerebral arteries within the range of Mayer waves and onautoregualtion index (ARI) with thigh cuff test. Finapres 2300(Ohmeda) and Multi Dop X (DWL) were used for noninvasivemonitoring of BP and BFV respectively. Data were processed inStatistica 6.0 for Windows. Results. PS and ARI didn’t depend onlocation side of PSM. But PS before operation (0.72±0.24 rad) waslower than after operation (0.96±0.33 rad). ARI was almost thesame before and after operation. Absence of ARI changes may beexplained by more sensitivity of PS to changes in dCA than ARI.However, in some cases PS and ARI decreased to 0.06 rad and 3respectively, indicating impairment of dCA. In three patients thisPS decrease (0.57±0.28 rad) might be due to intracranialhypertension, while in other two cases the reason for PS and ARIdecrease remains unclear. Conclusion. Generally dCA is notimpaired in patients with PSM. This could be explained by the factthat PSM are slowly growing brain tumors, and dCA has time toadapt to intracranial volume changes. However, dCA may beaffected in cases of complicated PSM, mostly with intracranialhypertension seen in patients with huge PSM and (or) invasion ofthe superior sagittal sinus.

P77Effect of chemotherapy on the neurovascular couplingin patients with non-Hodgkin lymphoma (NHL)K. Szabo1, L. Rejto2, J. Borok1, B. Rosengarten3, L. Csiba1,L. Olah1

1University of Debrecen, Department of Neurology,Debrecen, Hungary; 2University of Debrecen, Departmentof Internal Medicine, Debrecen, Hungary; 3University ofGiessen, Department of Neurology, Giessen, Germany

Chemotherapeutic agents are known to cause endothelialdysfunction and thus they may lead to the so called reversibleposterior encephalopathy syndrome. We sought the answer


whether chemotherapy influences the visually evoked cerebralblood flow response in the posterior cerebral arteries in patientswith hematological malignant disease (NHL). By using a visualcortex stimulation paradigm, visually evoked peak systolic flowvelocity changes were detected by transcranial Doppler sonographyin both posterior cerebral arteries of 8 young adults suffering fromNHL. The first examination was performed before the firstchemotherapeutic treatment, while the second and thirdmeasurements were repeated 3 weeks and 3 months after the onsetof the chemotherapy (combination of bortezomib, rituximab,cyclophosphamide, doxorubicin, vincristine, prednisone).Repeated measures ANOVA revealed significant group main effect(p=0.0035), indicating significant difference in the flow velocitytime courses between the three phases (pre-treatment phase, 3weeks and 3 months after the treatment). The visually evoked flowresponse was worse in the pre-treatment phase than either in the 3weeks (p=0.0072) or 3 months post-treatment phases (p=0,0047),however, no significant difference could be detected between the 3weeks and 3 months post-treatment phases (p=0.09). Our dataindicate that chemotherapy does not deteriorate the neurovascularcoupling in patients with hematological malignant disorder (NHL).Quite contrary, the results proved worse reactivity before thechemotherapy comparing with the post-treatment phases. It meansthat probably the NHL had harmful effect on the neurovascularcoupling, while its treatment improved the visually evoked flowresponse. Further examinations are necessary to test whether otherthan haematological malignancies deteriorate the neurovascularcoupling.

P78Cerebrovascular reactivity and cerebrospinal fluidbiomarkers association study in AD patientsG. Misaggi, A. Martorana, I. Zivi, Z. Esposito, G. Sancesario, M. DiomediUniversità degli Studi di Roma Tor Vergata, Policlinico TorVergata, Dipartimento di Neuroscienze, Neurologia, Roma,Italy

Introduction: Impaired cerebral hemodynamic is recognizedto play a role in the evolution of Alzheimer’s disease (AD). Impairedcerebral micro-vessels functionality has been demonstrated to beassociated to unfavorable evolution of cognitive decline. Whetherthese alterations are associated to markers of AD progression hasnever been explored. Aim: in this work we studied to what extentchanges of cerebrovascular reactivity could be associated to CSFbiomarkers of AD such as Aβ1-42, total Tau and pTau in a group ofpatients with cognitive decline. Methods: A total of 25 outpatientswith suspect AD were enrolled. Patients were diagnosed by MiniMental State Examination (MMSE) and neuropsychologicalassessment, cerebral MRI, CSF analysis, EEG. Evaluation of basalcerebro-vascular reactivity to hypercapnia was measured withtranscranial Doppler ultrasonography using the breath-holdingindex (BHI). Then, patient were subdivided in groups upon theirBHI (BHI≤0.50; 0.51≤BHI≤0.69; BHI≥3). Clinical evaluationconsidered changes in MMSE from baseline to 6 months follow-up: group1 MMSE ≤ 2 points decrease ; group2 decrease between

2≤ MMSE ≤5; group 3 MMSE≥ 5 points decrease. Results: weconfirm that BHI is directly related to degree of cognitive decline(as compared with MMSE) in AD patients. Moreover, we foundthat BHI decrease was inversely related to CSF total Tau, and notwith Aβ 1-42 and pTau. Contrarily to what expected, after 6 monthsfollow-up, patients with low levels of CSF total Tau resultedassociated to more rapid cognitive decline. Conclusions: BHIindex may represent a marker of “ongoing pathology” in AD. Theassociation with increased tTau CSF levels may be the image ofdisease progression in which Aβ peptides could induce changes ofboth micro-vascular homodynamic and cortical activity(impairment of neural plasticity mechanisms). Aβ peptides arehowever able to induce changes of brain vasculature likelybecoming responsible for cognitive decline progression.

P79Noninvasive assessment of functional eloquence ofintracranial volume ratio alterations in patients withhydrocephalusV.B. Semenyutin1, V.A. Aliev1, V.P. Bersnev1, A.Patzak2, G.K. Panuntsev1, A.V. Kozlov1, S. Ramazanov1

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

Background. The functional eloquence of intracranial volumeratio (IVR) alterations in patients with communicatinghydrocephalus (CH) could be assessed with infusion test. Howeverthe procedure is invasive and is not always safe. Thus search ofnoninvasive methods for evaluation of FE of IVR alterations is anactual task. Apparently, significant alterations of IVR leads todisorders of cerebral hemodynamics, which on an early stage couldmanifest itself by impairment of cerebral autoregulation (CA).Purpose: to define the possibility of CA evaluation for assessmentfunctional eloquence of IVR alterations in patients with CH.Material and Methods. 32 patients (aged 20-52) were studied: 14patients with occlusive hydrocephalus (OH), and 18 patients withCH. Indications for operation were based on the results of clinicalexamination, CT scan and infusion test. CSF pressure andresistance of CSF to outflow (Rout) were measured using lumbarpuncture or ventricular drainage. CA was evaluated with cuff test(autoregulation index – ARI) and cross-spectral analysis ofspontaneous oscillations of systemic blood pressure (Finapres,Ohmeda-2300) and blood flow velocity (Multi Dop X, DWL)within the range of Mayer’s waves (phase shift in radians – PS).Results. All 14 patients with OH underwent surgery. PreoperativeARI and PS were 3.53±0.76 and 0.57±0.19 radians, respectively.CSF pressure varied from 15 to 16 mmHg, Rout – from 15 to 17 mmHg/ml/min. Postoperative regression of intracranialhypertension (ICH) was accompanied with significant increase ofARI (4.82±0.43) and PS (0.91±0.11 radians). 12 patients with CHdue to an absence of ICH and nonsignificant alterations of IVRhave not been operated. Preoperative ARI (6.22±1.72) andPS (1.03±0.28 radians) were reliably higher (p<0.05) CSF pressurevaried from 8 to 10 mmHg, Rout – from 8 to 12 mmHg/ml/min(p<0.05). The remaining 6 patients with CH underwent surgery.


Four of them had enlarged ventricles combined with impairment ofCA: ARI and PS were 3.75±0.71 and 0.63±0.09 rad, respectively.Rout varied from 16 to 19 mmHg/ml/min. Operation led toreduction CSF space and regression of ICH. As for the other twooperated patients with CH preoperative values of CA were withinthe normal range (ARI – 6.10±0.23, PS – 0.95 ±0.21 rad) andpostoperative improvement was not observed. Conclusion. Non-invasive evaluation of CA is not inferior to infusion test, permit toassess functional eloquence of IVR alterations and could be usedfor clarifying indications for surgery in patients with CH.

P80Comparison of cerebrovascular reserve in migraine andtension-type headache patientsH. Akgun1, G. Genc2, T. Kasikci1, S. Demirkaya1, Z. Odabasi1

1Gulhane Medical Academy, Department of Neurology,Ankara, Turkey; 2Maresal Cakmak Hospital, Department ofNeurology, Erzurum, Turkey

Objectives: Cerebral vasomotor reactivity (VMR) is known asthe vasodilatation capacity of cerebral arterioles to perfusionchanges. We aimed to compare the cerebrovascular reserve inmigraine and tension-type headache patients. Methods: Breathholding index (BHI) calculated from bilateral middle cerebralartery (MCA), posterior cerebral artery (PCA) using temporalwindow insonation and ophthalmic artery (OA) using orbitalwindow in 20 migraine patients and 13 age and gender matchedtension-type headache patients. Results: BHI was found 1.49 inmigraine patients and 1.67 in tension-type headache patients forMCA (p=0.002), 1.42 in migraine patients and 1.39 in tension-typeheadache patients for PCA (p>0.05), 1.01 in migraine patients and0.91 in tension-type headache patients for OA (p>0.05).Conclusion: It has been shown that VMR is impaired in migrainepatients according to the healthy individuals. Up to date, there is nostudy comparing VMR in migraine and tension-type headachepatients in literature. Our results revealed that VMR in migrainepatients significantly decreased according to the tension-typeheadache patients and support the existence of both vascular andneurogenic mechanisms for migraine

P81Cerebral hemodynamic differences between migraine,tension type headache and temporomandibulardisorderM. Bosnar-Puretic, A. Lovrencic-Huzjan, I. Martinic-Popovic, M. Roje-Bedekovic, V. Vukovic-Cvetkovic, V. Basic-Kes, V. DemarinSestre Milosrdnice University Hospital Centre, UniversityDepartment of Neurology, Zagreb, Croatia

Introduction. Migraine headache, tension-type headache(TTH) and temporomandibular disorders (TMD) share number of

clinical and patophysiological similarities. Although thepathophysiology of these three types of headache is explained byneuronal mechanisms, the vascular factor in migraine developmentrecently becomes point of interest again. The aim of this study is tocompare the characteristics of cerebral arteries hemodynamics inmigraine, TTH and TMD patients and in control subjects. Patientsand methods. In this study 30 patients with migraine headache,30 with TTH, 30 with TMD and 30 age and sex matched controlswere enrolled. In all subjects color Doppler flow imaging (CDFI) ofinternal carotid artery (ICA) and external carotid artery (ECA) andtranscranial Doppler of middle cerebral artery (MCA) wereperformed. Mean blood flow velocities (MBFV) and pulsatilityindex (PI) were measured in the periods without pain andcompared to control group. Results: The mean age of subjects was46,32 ± 7,34 years. 75 patients (83,3%) were females. In migrainesufferers the MBFV in ICA were significantly higher (50,41±8,24cm/s) than in control group (39,1±7,31 cm/s), p<0,0001. MBFVs inECA an MCA were not significantly different than in control group.We found PI in ICA in migraine sufferers significantly lower(0,89±0,24) than in control group (1,04 ± 0,37), p=0,036. PI in ECAand MCA were not significantly different than in control group. Inpatients with TTH and TMD we found no differences in any ofhemodynamic parameters comparing to control group.Conclusion. Our results have shown that cerebral hemodynamicsdiffer in migraine patients comparing to healthy subject while TTHand TMD showed no hemodynamic differences to controls.

P82Simultaneous bilateral monitoring of blood flowvelocity in the anterior and middle cerebral arteriesduring different cognitive tasksP. Crnac, M. Boban, B. Malojcic, L. Unusic, A. JunakovicUniversity Department of Neurology, Zagreb School ofMedicine and University Hospital Centre, Zagreb, Croatia

Changes in blood flow velocity (BFV) during various cognitivetasks may be recorded in cerebral arteries by using TranscranialDoppler sonography (TCD) with excellent temporal resolution. Wehypothesised that it is possible to add spatial resolution to TCDexamination by simultaneous monitoring of BFV in two internalcarotid artery (ICA) branches. The aim of our study wassimultaneous monitoring of BFVs in both anterior cerebral arteries(ACAs) and middle cerebral arteries (MCAs) during differentcognitive tasks to obtain both temporal and spatial relationsbetween each cognitive task and blood flow in four vascular andcognitive territories. BFVs were recorded with two 2 MHz probesattached to a headframe at the depth of terminal ICAs in bothACAs and MCAs during different cognitive tasks (verbal fluencytest, stroop test, trail making test B) and motor task (movements ofeach leg separately) presented on a computer screen. Healthy right-handed volunteers aged 20 to 33 years were included in the study.Except BFVs, also heart rate and laterality index were measured.Our preliminary results show good temporal relation and specifictemporal pattern between BFV in ACAs and performance of strooptest and trail making test B, and between BFV in both ACAs andMCAs and performance of verbal fluency test. Although, our


results are preliminary and necessitate additional investigations,future results might be of help in wider utilization of TCDtechnique in neuropsychological and neurocognitive studies as wellas in obtaining non-invasive functional anatomy of specificcognitive tasks.

P83Cerebrovascular responses to cortical activation inolder adults. A subcomponent analysisA.M. Salinet1, T.G. Robinson1,2, R.B. Panerai1,2

1Department of Cardiovascular Sciences, University ofLeicester, Leicester, United Kingdom; 2National Institutes forHealth Research (NIHR), Biomedical Research Unit inCardiovascular Science, Clinical Sciences Wing, GlenfieldHospital, Leicester, United Kingdom

Cortical activation induces increases in cerebral blood flow(CBF) that are usually interpreted as increases in metabolicdemand. However, simultaneous changes in peripheralphysiological parameters add to the complexity of the cerebralresponse. We tested the hypothesis that CBF velocity (CBFv)responses to cortical activation involve the interaction of myogenicand metabolic components. In eighteen right-handed healthysubjects (mean age 60 years, 10 male), continuous recordings ofblood pressure (BP, Portapres), bilateral middle cerebral arteryCBFv (TCD), heart rate (3-lead ECG) and end-tidal CO2(Capnograph) were obtained during 60s of active, passive andmental imagined elbow flexion and extension. Each paradigm wasperformed twice in random order with the dominant arm. CBFvchanges were decomposed into standardized subcomponentsdescribing the relative contributions of BP (VBP), resistance areaproduct (VRAP) and critical closing pressure (VCrCP). VRAPmight reflect myogenic activity in response to BP changes, whereasVCrCP is more indicative of metabolic control. All paradigmsshowed similar patterns for the ipsilateral and contralateralhemispheres. BP increases have been shown to be an importantcontributor to CBFv variation, especially in the first 10s of response.VRAP also showed a peak bilaterally coinciding with the rise inVBP, but decreasing sharply to negative levels during the rest ofactivation period (less negative on the contralateral hemisphereVRAP), indicating vasoconstriction. The contribution of VCrCPwas almost entirely positive for both hemispheres for the threeparadigms, with continuous rise during activation, indicating avasodilatory effect. In conclusion, CBFv responses to active, passiveand mental imagined paradigms suggest a combination of initialvasoconstriction with subsequent vasodilatation in thecontralateral (activated) hemisphere, indicating the interaction ofmyogenic and metabolic pathways, but a predominantvasoconstriction only in the ipsilateral hemisphere. Decompositionof the CBFv response might allow a more detailed assessment ofhemodynamic integrity in healthy and pathologic conditions.

Poster Session II-5 : Novel Technologies, New Studies

P84Computer simulation of the carotid arteryA .Santos1, L. Sousa1, J. Tavares1, R. Santos2, P. Castro2, E. Azevedo2

1Dept. Mechanical Engineering of Faculty of Engineeringand 2Dept. Neurology of Faculty of Medicine, University ofPorto, Porto, Portugal

Background: Disturbed flow conditions at the bifurcation ofcommon carotid artery and proximal internal carotid artery playsan important role in the development of local atheroscleroticplaques, which are important causes of stroke. Being able to build3D models based on ultrasound imaging can improve diagnosticassessment and support interventions like endarterectomy orcarotid stenting. Our aim was to describe a carotid segmentationalgorithm to build these 3D models. Methods: We developed anautomatic segmentation algorithm for the lumen of the carotidartery in B-mode images. Hough transform (HT) was used in orderto extract straight lines automatically and consequently performthe initial contour definition, for the application of a level set activemodel detection in the lumen sections of the carotid artery. Ouralgorithm comprises: definition of a region of interest (ROI) in theoriginal image; morphological closing and edge detection, usingthe Sobel operator, resulting in a binary image with 1s at edgelocation after a global thresholding based on the first 15% of thehistogram width; application of the HT for all edge pixels andidentification of the HT parallel to each other and with themaximum width, that will allow defining the artery borders;definition of a rectangular contour for the carotid, which isimproved by using the active level set model. Results: Theautomatic segmentation was applied to carotid common carotidbifurcation ultrasound images, with a satisfactory reconstructionof the arteries. The main advantage of our segmentation methodrelied on the HT initialization, overcoming the limitations oftraditional methods. Conclusion: We were able to successfullyapply a carotid segmentation technique based on cervicalultrasonography, allowing us, in the future, to perform 3Dmodelling. These computational models will be important fortesting hypotheses and address practical clinical vascular problemsrelated to carotid disease.


P85Estimation of dynamics common carotid artery (CCA)wall in healthy individuals by means of the vectorvelocity analysisD. Golovin1, V. Lelyuk1, S. Lelyuk2

1Russian National Research Medical University named afterN.I. Pirogov/Cerebrovascular and stroke research institute,Moscow, Russia; 2Russian Medical PostgraduateAcademy/Ultrasound department, Moscow, Russia

Increase stiffness of wall of CCA can cause the risk of somecerebrovascular diseases. Noninvasive estimation of mechanicalproperties of arterial wall by means of the carotid-femoral pulsewave velocity is limited because of the difference in histologicalstructure of aorta and CCA. Peterson’s and Young’s elastiс modulesand similar indices, reflect local stiffness. In addition they areconnected with the level of arterial pressure (AP). Angle-dependentis the basic limitation for tissue Doppler. Technology of the vectorvelocity analysis can provide us with new information about arterialwall dynamics. Study population consisted of 44 young healthyvolunteers (aged 19-31, mean-24,11±2.8 years; 23M, 21F).Sistolic/diastolic arterial pressure (AP) - 114±9,8/73±5,7 mm. Hg;mean AP – 86.6±6.3 mm. Hg. B-mode ultrasound videoclips of axissection of the distal CCA was analyzed by the vector velocity (VV)application. Radial velocity (RV), time to peak RV (ttpRV), radialdisplacement (RD), time to peak(ttpRD), Systolic and diastolic area(SA, DA) were estimated. Peterson’s and Young’s elastic modules(PEM, YEM) were calculated. Value of RV, ttpRV, RD, ttpRD, SA,DA (mean±sd): 0,158±0,064 cm/s; 202,86±52,15 ms; 0.193±0,078mm; 327,26±86,42 ms; 43,4±8,7 cm2; 36,7±5.6 cm2 respectively.Values of PEM and YEM - 237,89±87,9 mmHg; 694±282 mmHg-1 respectively. Received results did not show the relation betweenthe indicators of local stiffness and VV parameters. However withthe use of Pearson’s tests we revealed a significant correlation(0.33˃r˃0.62, p˂0.05) between AP levels and RD, ttpRD, SA andDA. It suggests that VV analysis can provide additional informationabout arterial wall dynamics. But this discovery does not repeattraditionally used local stiffness technology. Interesting fact is adirect correlation between more values of diastolic diameter CCA,RV and RD (r-0.4;0.46; p˂0.005 respectively). We need furtherinvestigations for more complete understanding of dynamics ofarterial wall caused by some diseases.

P86Non-invasive pulse amplitude of ICP strongly correlateswith outcome after TBIB. Schmidt1, K. Budohosky2, P. Smielewski2, R. Plontke1, M. Czosnyka2, J. Klingelhöfer1

1Chemnitz Medical Centre, Dept. of Neurology, Chemnitz,Germany; 2Academic Neurosurgical Unit, Addenbrooke’sHospital, Cambridge, UK

Background: Non-invasive prediction of ICP usingtranscranial Doppler ultrasonography (TCD) has been exercised

for more than 20 years - starting from simple use of TCD pulsatilityindex and finishing with sophisticated models. The modeldeveloped 1997 by Schmidt et al. [1] has been now encapsulated inplug-in working with brain monitoring software ICM+(www.neurosurg.cam.ac.uk/icmplus). TCD recordings fromAddenbrooke’s Hospital, Cambridge UK performed in TBI patientshave been re-evaluated and accuracy of the method apprised withparticular interest in implication of non-invasive estimates onoutcome after head injury. Method: Middle cerebral artery bloodflow velocity (CBFV) was assessed daily (for 10 minutes to 2 hours).Data were recorded alongside ICP and direct arterial bloodpressure (ABP). Non-linear model connecting ABP and ICP wasidentified using dynamic relationship between blood pressure andCBFV. nICP was calculated as a waveform sampled with the samefrequency as directly monitored data. Mean values and vasogeniccomponents of recorded and generated waveforms were calculated:pulse amplitude (AMP,nAMP), respiratory (Resp, nResp) and slowwaves of ICP (Slow, nSlow). Mean nICP was calculated andcompared with age, outcome and Glasgow Coma Score atadmission. Results: ICP and nICP correlated moderately (R=0.51,ICP range 0-70 mm Hg, 95% limit for prediction +/- 10.3 mm Hg).Vasogenic components of nICP and ICP also correlated moderately(respiratory waves: R=0.59, pulse: R=0.41, slow waves: R=0.23).Correlation with outcome (dichotomized: fatal/survived) ispresented in Table 1. nAMP associated with outcome with the bestaccuracy. There was no correlation of non-invasive parameters withage or GCS on admission. Discussion: Non-invasive ICP has apotential to predict mortality after TBI. Pulse amplitude on nICPcorrelates with outcome stronger that mean value of an estimator.Ref. [1] Schmidt et al.. Noninvasive prediction of intracranialpressure curves using transcranial Doppler ultrasonography andblood pressure curves. Stroke. 1997;28:2465-72

Table 1. Comparison of direct and non-invasive variables in patients who survived and died (units: mmHg)

Survived (175): Died (60): F statistics P valueMean+/-SD Mean+/-SD

ICP 17.4+/-8 22.9+/-14 13 0.003nICP 12.5+/-51 15.3+/-8.1 8.7 0.0034AMP 1.76+/-1.16 2.73+/-2.4 17 0.0001nAMP 1.54+/-0.7 2.29+/-1.5 26 0.00005

P87Non-invasive absolute intracranial pressure valuemeasurements during head up and head down testsA. Ragauskas, L. Bartusis, R. Zakelis, G. DaubarisKaunas University of Technology, Telematics ScienceLaboratory, Kaunas, Lithuania

Background: An innovative non-invasive absolute intracranialpressure (aICP) value measurement device based on two depthTCD technology employs ophthalmic artery (OA) as a pressuresensor. The OA as a natural pair of scales compares aICP with


controlled externally applied pressure Pe. Pe=aICP in the case ofscales’ balance. Two depth TCD is used as a pressure balanceindicator. Objective: To test repeatability and accuracy of the aICPmeasurements and to test linearity of OA as a pressure sensor inthe clinically important range of aICP values below and abovecritical threshold ICP=20 mmHg. Methods: Randomly chosenhealthy volunteers were included into the study (age 20-52 years).ICP was increased artificially by using head down tilt (HDT)method. HDT added hydrostatic pressures to the ICP valuemeasured in supine body position. The length of CSF column wasmeasured on every healthy volunteer, additional hydrostaticpressure was 10 mmHg (HDT1), 20 mmHg (HDT2) and 30 mmHg(HDT3). Body angles were measured for every single HDT case.Results: 10 healthy volunteers were tested in vertical (HUT) bodyposition, 41 - in supine body position, 11 in HDT1, 10 in HDT2and 2 in HDT3 positions. Non-invasively measured aICP and ±SD values (mmHg) were: vertical position 4.2±2.5, supineposition 9.8±2.6, HDT1 18±2.2, HDT2 26.2±1.9, HDT3 41±0.7.Conclusions: Close to ideal linearity of non-invasive aICPmeasurement technology and low enough SDs of random errors ofHUT/HDT were observed in a wide range of aICP values (from 3mmHg up to 40 mmHg). Method shows clinically acceptableaccuracy and repeatability. The experimental results supporthypothesis on no need of calibration to the individual patient orhealthy volunteer of created aICP measurement method and oninvariability of this method to a lot of influential factors.

P88Training value of virtual navigator technique forintracranial venous hemodynamics study: the exampleof superior petrous sinus examination G. Malferrari1, M.L. Zedde1, R. Pascarella2, M. Maggi2

1Neurology Unit, Stroke Unit, Dpt. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2Radiology Unit, Department of MedicalImaging, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy

For the study of brain vasculature the ideal tool is a techniquethat can combine the high spatial resolution of neuroradiology withthe so high temporal resolution of neurosonology (mainly TCCS).Neuronavigation systems allow to use many imaging modalities asa guide for interventional procedures, but a similar system has beenimplemented for diagnostic purposes for the intracranialcirculation and it is known as Virtual Navigator. This tool has beencontinuously improved and applied for the evaluation of veins andsinuses running near the skull base and the skull bone, as SuperiorPetrous Sinus (SPS). The study involved a single center and 40subjects without history and clinical signs of neurological disordersinvolving the venous system, with a suitable temporal bonewindow, referred to the Neurosonology Lab and having performeda brain MRI. 20 subjects underwent a basal TCCS examination,registering the SPS insonation rate and blood flow direction with velocity parameters. The same subjects underwent aneurosonological study with the Virtual Navigator system,acquiring similar data for the comparison with the basal

examination. Finally other 20 subjects underwent basal TCCSexamination after the training of ultrasound anatomy with theVirtual Navigator system. The insonation rate of SPS was 33/40(82%) for the basal examination and 39/40 (97%) for the VirtualNavigator study in the first 20 subjects. The insonation rate of SPSin the second 20 subjects studied by TCCS was 37/40 (92%),showing no significant difference, compared with the insonationrate achieved in the first 20 subjects with the Virtual Navigatorsystem. An imaging fusion technology could help neurosonologistsin the training phase for intracranial venous study.

P89VASP Study: Study protocol of “SyndromeVasoconstriction in the Puerperium”G. Turri1, S. Olivato1, S. Mazzucco1, A. Fiaschi 1, E. Pari2, F. Rinaldi2, A. Padovani2, E. Morandi3, M. Baronio4, R. Brighenti5, M.P. Piras6, G.P. Anzola6

¹Department of Neurological, Neuropsychological,Morphological and Movement, Section of ClinicalNeurology, University of Verona, Italy; ²Department ofNeurology, University of Brescia, Italy; ³Neurology of’ MellinoMellini Chiari Hospital (BS), Italy; 4Service of Anesthesiology,5Obstetrics and Gynecology and 6Neurology Service,Foundation-Poliambulanza of Brescia, Italy

Objective: Reversible Cerebral Vasoconstriction Syndrome(RCVS) is a condition characterized by vasoconstriction of cerebralarteries, which typically begins with daily attacks of recurrentheadache “thunderclap” lasting about 4-6 hours and spontaneouslyresolves within 12 weeks.(1) Sometimes it may be associated withother neurological disorders even in the presence of a normalneuroimaging (2), rarely may be complicated by intraparenchymalor subarachnoid hemorrhage and stroke (3). Reported in theliterature are multiple triggers such as exposure to vasoconstrictivedrugs and the puerperium. The purpose of this study is to identifycases of post-partum headache ones that meet commonly acceptedcriteria for RCVS from two days to a month after childbirth, so thatwe can clarify the real incidence of angiopathy postpartum, itsspectrum of severity and possible predisposing comorbidities suchas pre-eclampsia and eclampsia. Materials and methods: Over aperiod of about 12 months all the mothers of children born at theDepartment of Obstetrics of Poliambulanza Hospital, aresubmitted within 72 hours of birth, to a questionnaire designed inparticular to investigate the presence of headache or in history anda baseline assessment using transcranial Doppler to detect earlysigns of vasospasm (4).The number of women who expected toenroll in the study period, is about 1000. All subjects are taught ina way that readily come to the emergency department in case ofsudden onset of headache in the following month, where they aresubjected to neurological examination, transcranial Doppler, brainCT and AngioTAC. All recruited patients are contacted bytelephone after one month and interviewed about the appearanceof any type headache “thunderclap”. Patients who respondpositively will therefore be invited to make the necessaryinvestigations. Discussion: The information provided by this studywill have an impact in the management of headache in the


puerperium. References: 1. A. Ducros. The Clinical andRadiological Spectrum of Reversibile Cerebral VasoconstrictionSindrome. A prospective series of 67 patients Brain (2007), 130,3091-3101; 2.S.P. Chen. Magnetic Resonance Angiography in Reversibile Cerebral Vasoconstriction Syndromes Ann Neurol2010;67:648–656; 3.A Ducros. Hemorrhagic Manifestations ofReversibile Cerebral Vasoconstriction Sindrome. Frequency,Features, and Risk Factors Stroke (2010);41:00-00; 4.S. P. Chen.Transcranial Color Doppler Study for Reversibile CerebralVasoconstriction Syndromes Ann Neurol 2008;63:751–757.

P90Ancillary study of COSMO. An ultrasound to magneticresonance venography comparison about cerebralvenous hemodynamics with a virtual navigatorsubstudyG. Malferrari1, P. Zaratin2, M.A. Battaglia2, L. Motti1, M.L. Zedde1, S. Montepietra1, S. Sanguigni3, D. Ciampanelli5, C. Mundi5, C. Baracchini6, N. Carraro7, P. Prati1, R. Pascarella4,M. Maggi4

1Neurology Unit, Stroke Unit, Dept. of NeuromotorPhysiology, Arcispedale Santa Maria Nuova IRCCS, ReggioEmilia, Italy; 2AISM – FISM, Sede Nazionale AISM Onlus,Genova, Italy; 3Neurology Unit, Ospedale Madonna delSoccorso, San Benedetto del Tronto, Italy; 4Radiology Unit,Dept. Medical Imaging, Arcispedale Santa Maria NuovaIRCCS, Reggio Emilia, Italy; 5Neurology Unit, AziendaOspedaliera Ospedali Riuniti di Foggia, Foggia, Italy;6Neurology Unit, Stroke Unit, Azienda Ospedaliera diPadova, Italy; 7Neurology Unit, Ospedale Cattinara, Trieste,Italy

The proposal of the impairment of the cerebro-spinal venousdrainage is the origin of the vascular hypothesis for multiplesclerosis, called Chronic-Cerebro-Spinal-Venous-Insufficiency(CCSVI). Many studies were performed about these topics and mostof them concluded with the need to increase the number of enrolledpatients to strengthen the reliability of their results. But thepublished data are contradictory and the huge differences acrossstudies may be due to the inter-individual variability of the anatomicroutes of venous drainage, and moreover to technical reasons anddifferent expertise of sonologists in this field. The aim of thiscomparative ANCILLARY cohort of the COSMO protocol,supported from FISM, is not only to analyze several items of theextracranial and intracranial venous haemodynamics in the selectedpopulation (only RR – MS) with a validated procedure, but also to perform a double sonological examination for deriving aninter-operator reliability. It is a multicenter (three centers) study toexternally validate the ultrasound procedure for CCSVI criteria andcomparative study with intracranial MR venography. We plannedto enroll 20 patients in each center (60 pt) for the ultrasoundprotocol; study of the jugular, vertebral and intracranial veins(BVR, TS) will be performed in supine and sitting position,registering velocity parameters, inflow, outflow and the effects ofthe Valsalva maneuver in J1-J2-J3 IJV and in intracranial veins. Ineach centers two sonologists will perform independently the

ultrasound study. Morover all patients will undergo contrastenhanced MR venography for the assessment of the flow directionof BVR and TS. Further 20 patients will undergo to VirtualNavigator study for intracranial veins. We aimed to establish theinter-operator reliability of ultrasound study parameters, not only for CCSVI, but mostly for validating the examinationmethodology for intracranial venous circulation, to strengthen themethodological basis for the COSMO study.

Poster Session II-6: Various StrokeEtiologies and US Applications

P91Doppler monitoring of free floating carotid thrombusdissolution E. Vassileva1, M. Daskalov1, P. Stamenova2

1Department of Neurology University Hospital “TsaritsaYoanna - ISUL” Sofia, Bulgaria; 2Department of NeurologyUSBALN “Seint Naum” Sofia , Bulgaria

Background: The causes for free-floating trombus (FFT)formation in carotid arteries are heterogeneous. The purpose ofthis study was to evaluate the incidence and natural story of FFT innon-stenotic internal carotid artery (ICA) by means of colour-coded duplex sonography (CCDS). Method: During a 4-yearperiod, 3063 consecutive patients with acute ischemic stroke wereevaluated for carotid artery diseases as well as for the presence ofFFT by CCDS. Diagnostic workup of stroke patients included:brain CT, transthoracic, transesophagic echocardiography, holterECG, hypercoagulability state evaluation. Results: FFT weredetected in 4 patient with non-stenotic ICA. The etiology of FFT formation is: hypercoagulable state in active pulmonarytuberculosis (one case), trombotic complications of non-stenoticatherosclerotic plaques (one case), unknown (two cases). Thetreatment with antiplatelet therapy was started. An improvementwas observed and the patients were discharged without furtherevents. Follow-up CCDS showed complete dissolution of FFT in allcases. There was no stroke recurrency. Conclusion: The presenceof FFT in ICA could be found in young stroke patients withoutidentifiable diseases or pathological arterial process and withoutcardiogenic source of brain embolism. Carotid trombus may beassociated with active pulmonary tuberculosis. Carotid FFT mayresolve with antithrombotic management.


P92Prognostic value of ultrasound patterns in cervicalartery dissection P. Castro, C. Ferreira, R. Santos, E. AzevedoDep. Neurology, Hospital São João and Faculty of Medicineof University of Porto, Portugal

Introduction: Ultrasound examination has proven value indiagnosis and management of carotid and vertebral arteriesdissection, although its prognostic value has not been put on focus.We aimed to review our centre series of carotid and vertebraldissections and investigate the influence of ultrasound findings inprognosis. Patients and Methods: A retrospective study ofclinical and ultrasound data of carotid and vertebral cervicaldissections was performed, using information registered in ourneurosonology unit. Diagnosis was confirmed by MRI, MRA, CTAor DSA. Demographic, clinical and ultrasound findings wererecorded. Outcome was defined as independence at 3 months(modified Rankin scale 0-2). Results: Fifty-six carotid and 12vertebral cervical dissection cases were included [38 men, medianage of 46 (IQR 38-54) and admission NIHSS 4 (3-13)]. Patientswere admitted with ischaemic stroke (74%), TIA (6%) or othercause (20%). There were 4 incomplete transcranial windows.Warfarin was used in 50%, and thrombolysis was performed in16%. Bilateral findings occurred in 3 carotid and 2 vertebral cases.Normal findings were present in only 3 carotid scans. Otherfindings included occlusion or high-grade stenosis (82%), low-grade stenosis (7%), pencil-shaped tapering carotid lesion (16%),double lumen or intima flap (11%). Eighty percent hadabnormalities in TCCS, with high (>=50%) and low-grade (<50%)stenosis in 8 and 4%, respectively, and some evidence ofcollateralization in 66%. After multivariate analysis only NIHSSinfluenced inversely the probability of independence at 3 months[adjusted OR 0.77 (CI 0,68-0,88) p=0,0001]. Conclusion:Ultrasound scan had a high rate of pathological findings in cervicalartery dissections. Although it proved to be a valuable tool indiagnostic assessment, the pathologic pattern had no independentprognostic value in short-term prognosis.

P93Ultrasonography features of position-evokedvertebrobasilar insufficiencyM. Alpaidze¹ , M. Okujava²¹DEKA Medical Centre University Clinic, Tbilisi, Georgia;²Research Institute of Clinical Medicine, Tbilisi, Georgia

Background: Approximately 25% of ischemic strokes involvethe posterior circulation. The prognosis of brainstem stroke is notbenign, has a high early risk of recurrent strokes (33%) andmortality rates. Considerable head position-evoked vertebrobasilarinsufficiency (VBI) is a condition which needs specific therapeuticand surgical approaches. The proper management for improvingposterior circulation and prevent stroke remains a subject ofdebates. Aim: Evaluation of extracranial duplex-sonography (EDS),

transcranial color-coded Dopplerography (TCCD) findings duringrotation-induced dynamic stenoses and estimation of position-evoked VBI symptoms following to lateral head rotation and neckextension (HRNE). Methods: 88 patients with symptoms of VBI(age range 20-68) were examined using EDS, TCCD and HRNEtests with measurement of vertebral arteries (VA) and basilar artery(BAS) diameters, mean flow velocities (MFV) changes duringfunctional maneuvers and pulsatility index (PI). Results: in 38patients revealed unilateral primary hypoplasia of VA or herniatedcervical disc, while in other 11 patients revealed bilateral narrowingand deformation of VA associated with cervical spondylosis.Ultrasound investigation showed a decrease of MFV (23±1.4) inthe V4 segments of VA and an increase of PI (3.2 ±0.3) (p<0.0001)in the extracranial segments (V2, V3). In 42 cases revealeddecrease of MFV in basilar artery and in 28 cases decrease of MFVin both PCA. In 21 cases detected vertebrogenic reflexvasoconstriction in BAS. HRNE tests were positive in 47.8% ofpatients with high correlation (r=0.5) of clinical manifestation. BASMFV decrease ranged between 35.6-45.7% from baseline.Conclusion: Monitoring posterior circulation during headmovements is a noninvasive screening method to identify patientswith true position-evoked hemodynamic insufficiency andtherefore prevent the stroke. Functional testing is important formanual practitioners to rule out the risk of possible injury of VA.Obtained data showed that hypoplasia of VA tends to increasevertebrogenic reflex vasoconstriction and position-evoked VBI.

P94New insights into cerebral arterial structural-functionalinteractions by using the transcranic ultrasonographicevaluations in critical haemodynamic conditionsA. Iannolillo2, M.A.E. Rao1, M.V. Manzi1, G. Pagnano1, M. Santoro1, A. Vasta1, N. De Luca1, S. Sanguigni3, F. Accorsi4

1Department of Clinical Medicine and CardiovascularSciences University’ “Federico II” Naples, Italy; 2ASL Avellino,Italy;, 3 “Madonna del Soccorso” Hospital S. Benedetto delTronto, Italy; . 4Echographic School Bologna, Italy

Introduction: Blood Pressure increasing values are thought toinfluence cerebral flow in hypertensives and represent a major riskfactor in cerebral vascular accidents. Indeed, Metabolic Disorderssuch as hyperglicemia are considered to negatively influencecerebral blood flow. However, the evaluations of cerebral vascularfunctional responsive at these different critical conditions aredifficult to analyze. Nowadays Transcranial Doppler flowdetermination represent a novel, non invasive diagnostic methodwhich may be useful in order to obtain new insight on this regard.Methods: We undertook a doppler-analysis to assess theinteraction between the cerebral blood flow (TC-doppler) in mildto moderate hypertensives with and without glycemic disordersand before (Basal condition) and after (Critical condition) anhypertensive crisis (i.e. BP > 180/110 mmHg). We considered alsotheir global vascular atherosclerotic functional involvement asrepresented by aortic reflection and determined by arterial stiffnessby measuring carotid Pulse Wave Velocity (PWV) in order to have


a global functional index of vascular involvement. Results: Westudied 10 patients with hypertensive crisis in basal and in criticalconditions (Age 67±13 years). IR-TCD ranged from 0.55 to 0.75 inbasal and from 0.58 to 0.72 in critical condition. No significativedifferences were found in a comparable well controlledhypertensive group (n=20) (IR-TCD range from 0.53 to 0.74 n.s.)( PWV ranged from 8.86 to 13 m/sec, reflection time from 94 to176 ms and distance 0.40 to 0.82 metres. Reflection distanceincreased with PWV (r=0.80, p <0.001) and age (r=0.42, p <0.01).Conclusion: Our results seems to suggest the absence ofsignificative differences in resistance index (IR) in relation of anhypertensive crisis probably in relation of a rapid adaptation ofvascular cerebral tone in cerebral circulation and considering themethodologic approach used. In the same population study theglobal vascular involvement is well represented by functional indexsuch as PWV and it is related by the ageing process on the contrarythe cerebral circulation is independently regulated and is parallelinfluenced by metabolic and haemodynamic disorders.

P95Reproducibility of non-invasive cerebral blood flowvelocity measurements through extra- and intracranialarteries in healthy adultsN.P. Saeed1, R.B. Panerai2,3, T.G. Robinson2,3

1Ageing and Stroke Medicine and 2Medical Physics,Department of Cardiovascular Sciences, and 3NIHRBiomedical Research Unit for Cardiovascular Sciences,University of Leicester, Leicester, UK

Background/Objective: Measurement of blood flow velocity(BFv) by non-invasive Doppler ultrasound (US) examination of themajor extra- and intracranial arteries can be used in the evaluationof cerebral haemodynamics. The present study assessed variabilityof baseline BFv measurements at the middle cerebral (MCA),common carotid (CCA) and internal carotid arteries (ICA) bothintra- and intersession. Methods: B-mode US was used at the CCA(1.5cm below carotid bulb) and ICA (1.5cm away frombifurcation), and Transcranial Doppler US was used at MCA. AHandheld 4MHz probe was used to assess BFv at either CCA orICA, simultaneously with frame held 2MHz probe at MCA, withsynchronous measurement of blood pressure (BP) using Portapres,Heart rate (HR) with 3-lead ECG and End-Tidal (ET) CO2 with aCapnograph; these were recorded onto a data acquisition system.Measurements were repeated a mean of 6 days apart. CCA, MCA,ICA BFv’s, BP, HR, ETCO2 signals were processed to extract beat-to-beat values. The intra and intersession reproducibility wascalculated for mean values. Results: 11 healthy volunteers (7female) of mean age 33±9 years were studied. Mean BFv was MCA60±9, CCA 32±3, ICA 35±3 cm/sec; BFv was significantly differentbetween MCA and CCA/ICA (p<0.05), but not between CCA andICA. Good reproducibility was evidenced by Coefficient ofvariations of standard error of measurement for MCA, CCA andICA (2.6%, 1.7, 2.6%) respectively. Conclusion: MCA, CCA ANDICA BFv values were similar to those previously reported in ahealthy population. Importantly, good intra- and intersessionreproducibility was observed for both intra- and extracranial

vessels. Therefore, CCA and/or ICA insonation may provide asuitable alternative to the MCA, when MCA BFv measures cannotbe taken due to the absence of A temporal window or unsuitabilityof TCD such as head-trauma patients.

P96Quantitative assessment of radicality of arteriovenousshunting exclusion from circulationV.B. Semenyutin, G.K. Panuntsev, V.A. Aliev, A.V. KozlovRussian Polenov Neurosurgical Institute, Laboratory ofBrain Circulation Pathology, St. Petersburg, Russia

Background: Evaluation of effectiveness of endovascularembolization of cerebral arteriovenous malformations (AVM) andcarotid-cavernous fistulas (CCF) is based on degree of radicality ofarteriovenous shunting exclusion from circulation. Duplex scaning(DS) precisely determine blood flow index (BFI) in extracranialcerebral vessels. Purpose: To determine possibilitiy of DS forquantitative evaluation of intracranial shunting and radicality of itsexclusion. Materials and methods: 13 patients (20–59 years old)with cerebral arteriovenous shunting (12 patients had AVM, 1 –CCF) were studied. 15 operations were performed: embolisationwith Onyx, Histoacryl and detachable coils. DS of precerbralarteries with Vivid E (GE, USA) was used perioperatively. Results:Total BFI before operation was 1221±349 ml/min, 2 hours afteroperation – 930±306 ml/min (р<0.00005). Most of AVM were fedby all four major arteries, but contribution of each artery wasdifferent. The embolisation of AVM led to decrease of BFI inipsilateral internal carotid artery (ICA) from 531±187 to 368±121ml/min (р<0.0005), in contralateral ICA – from 361±105 to279±89 ml/min (р<0.0005). BFI through both vertebral arteries(VA) also decreased from 329±136 to 283±159 ml/min (р<0.005).According to cerebral angiography radicality of embolisation variedfrom 30 to 90%. It made possible to divide patients into two groups.First group included 8 cases with degree of embolization up to 50%,second group – 7 cases with degree of embolization more than 50%.The decrease of total and ipsilateral BFI for the first group was 13±7и 18±12 %, respectively (р<0.005), for the second group – 32±12and 37±16 % (р<0.005) respectively. Radicality of AVMembolization assessed on the base of BFI was lower but moreaccurate than the one assessed on the base of angiographic data.This may probably related to higher defect of angiograpicassessment of AVM size in compare with DS of BFI before and afteroperation. Conclusion: Thus, DS of precerebral arteries canquantitavely and noninvasively evaluate degree of flow throughintracranial pathologic arteriovenous shunting as well as radicalityof its exclusion from circulation at different treatment stages.


P97How does vagus nerve stimulation change cerebralblood flow velocity?G. Koc1, G. Genc2, T. Kasikci1, Z. Gokcil1, Z. Odabasi1

1Gulhane Medical Academy, Department of Neurology,Ankara, Turkey; 2Maresal Cakmak Hospital, Department ofNeurology, Erzurum, Turkey

Introduction: Vagus nerve stimulation (VNS) has been usedin clinical practice especially in treatment-resistant epilepsypatients since 1997. The effect of the device is not directly to thebrain, it shows its effect in an indirect way by sending electricalimpulses to the vagus nerve. It is still unclear how VNS preventsseizures. In this study we aimed to evaluate the effect of VNS oncerebral blood flow by transcranial Doppler (TCD). Material andMethods: Total 13 records were obtained from 8 patients withVNS. Vagus nerve was stimulated with the magnet. 30 secondsbefore the stimulation, 30 seconds during the stimulation and 30seconds after the stimulation, mean blood flow velocity of left MCAwas assessed by TCD. Results: Mean blood flow velocity of leftMCA was 55,29 cm/s before the stimulation, 52,09 cm/s during thestimulation and 56,03 cm/s after the stimulation. Blood flowvelocity decreased during the stimulation (p<0.001), whereas therewas no significant difference between pre-stimulation and post-stimulation period (p>0.05). Conclusion: It is thought that VNSinhibits the hyper-synchronization of neuronal activity in partialand generalized seizures. Our findings suggest that this inhibitionand the antiepileptic effect of VNS may result from the decrease incerebral blood flow velocity.


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Author Index

Aaslid, R. S2Abbas, A. O18Abd Allah, F. O5, P44Abdelalim, A.M. P44Abou-Kresha, N. P44Abramova, M. P15, P71Abreu, P. O15Accorsi, F. P47, P55, P94Adachi, S. P36Adams, R.J. L6Ahmad, A. P34, P40Ahuja, C. P43Akgun, H. P80Aliev, V.A. P76, P79, P96Alonso, A. O21Alpaidze, M. P93Altamura, C. L22, O23Altavilla, R. L22, O23Altmann, M. P24Anciones, V. P31Andrade, P. O10Anisimov, K. P33, P35Anzola, G. T9, L18, P38, P66,

P89Artemis, D. O21Arvind, S. P34Aslanidi, I.P. P42Assenza, G. L22Assion, H.J. O27Atzori, M. O12, O36Aukrust, P. O18Aurier, E. P10Ayo-Martin, O. P49Azevedo, E. O10, O15, P84, P92Azuma, T. O1

Bajenaru, O. P25Bal, A. P67Baltgaile, G. O11Baracchini, C. O7, O8, O12,

L10, L18, L29, O36, P38, P90Baronio, M. P89Bártová, P. P63Bartusis, L. P75, P87Basevicius, A. P72Bašić Kes, V. P19, P69, P81Basso, G. O7, O8Battaglia, M.A. P90Bekuzarova, M.R. P42Bella, R. P38Berczi, V. L10Bersnev, V.P. P79

Bieniaszewski, L. P46Bifolchetti, S. P23Bignamini, A. L27Biguzzi, S. P29Blahuta, J. P63Blanch-Sancho, J.J. P49Boban, M. P82Bogdahn, U. P24Bokeria, L.A. P42Bolognese, M. O21Bommarito, G. O7, O8Boricic Kostic, M. P13 Bornstein, N. L9Borok, J. P65, P77Bosnar-Puretic, M. P81Braga, M. P38Briani, C. O25, P22, P61Brighenti, R. P89Bruzzone, M.G. P66Budohoski, K. O30, P86

Cacciavillani, M. P61Cakciri, G. P1, P52Cámara Hijón, C. P3Campagnolo, M. O25, P61Caputi, L. P66Carboni, T. O32, P16, P23, P56Cardaioli, G. L10Carneiro, M. P11Carraro, N. L27, L29, T4, P90Carriero, M.R. P66Casado Naranjo, I. P3Casals, O. P31Castellani, S. L32Castro, P. O10, P84, P92Cavalleri, F. O7, O8Čermák, P. P63Chamova, S. O24Chan, B.P.L. P34, P40Chao, A.C. P59Chatziapostolou, A. P54Chaudhry, S.A. O5Cheng, C.Y. P59Chiapparino, C. P17, P18, P32,

P57Chrysogonidis, I. P54Ciampanelli, D. P90Ciceri, E. P66Citton, V. O7, O8Collado-Jimenez, R. P49Colombatti, R. O6, O7, O8 Coniglio, G. P30Cordeiro, G. O34

Ćorić, L. P19Costa-Pereira, A. O10Costa-Santos, C. O10Cotichini, R. L10Coward, L.J. P37Crnac, P. P82Csiba, L. P65, P77Cunha, L. O34Cvitan, E. P12Cvjetičanin, T. P19Czerný, D. O16Czosnyka, M. O30, P86

D’Andreamatteo, G O32, P16,P23, P56

Dalla Torre, C. O25, P22, P61Dardari, A. P16Darwish, N.A. P42Daskalov, M. P91Daubaris, G. P75, P87De Berti, G. P29De Campora, P. O32De Franceschi, L. L5De Luca, N. P47, P55, P94Del Sette, M. L18, L29, P38Demarin, V. P19, P69, P81Demirkaya, S. P80Dexter, K. P53Di Cioccio, B. P16Di Piero, V. L12Díaz Otero, F. P68Diaz, R. P74Didonè, G. P14Diehl, R. R. O30 Díez-Tejedor, E. O13Dimas, G. P54Diomedi, M. P38, P78Doepp, F. O22, P20Dolenc-Grošelj, L. P45Dorobat, B. P25Drnasin, S. P19Duminskaja, M. P15Duque San Juan, B. P3

Edvardsen, T. P2Ertl, M. P24Erts, R O11Esposito, Z. P78Evensen, K. P2Eyding, J. O27

Fagnani, C. L10Falcón García, A. P3

Fanelli, F. L10Faragò, G. P66Farina, F. O12, O36Federico F, P17, P18, P32, P57Fermín Marrero, J.A. P3Fernández-Domínguez, J. O13,

P62Ferreira, C. O10, P92Ferreira, I. O10Fiaschi, A. P89Flumignan Zetola, V. O9Frendl, A. P65Fromm, A. O20Fujishiro, K. P50Fukuda, T. O1Furuhata, H. O1, O3, O4, P51

Gamulescu, M.A. P24Gandolfo, C. L18, P38Garami, Z. L2, L10Garavelli, L. O35García Pastor, A. P68Garcia-Garcia, J. P49García-Rodríguez, R. P62Gardin, M. P14Genc, G. P80, P97Ghadirpour, R. P27Ghielmetti, F. P66Giannoni, M.F. L10, L12Gil Núñez, A. P68Gilo, F. P31Giordani, I. O23Gobbato, R. O32, P16, P23, P56Gokcil, Z. P97Gold, R. O14, O27Golovin, D. P6, P85Granata, G. O25, T6, P22, P61Greis, C. T10Grekas, D. P54Grumolato, M. O7, O8Guarise, P. P14Guerzoni, M. E. O6Guimarães, T. O10 Gupta, V. P43Gusev, E.I. P42Guyler, P.C. P37

Häfner, S. L14Halvorsen, B. O18Harada, M. P50Hartshorne, T.C. P4, P53Haubrich, C. O30Helbig, H. P24

86 Cerebrovasc Dis 2012;33(suppl 1); 1-88 Author Index

Helland, C.A. O33, P26Hennerici, M.G. O21Herrera, A. P31Herzig, R. O16, P63Hoffmann, K. O27Hol, PK. O17Hrbáč, T. O16 Hu, H.H. P59Hurtíková, E. O16

Iaffaldano, P. P18Iannolillo, A. P47, P55, P94Ichi, S. P36Idrovo Freire, L. P31Ivanova, G. P41, P70

Jekic, D. P48Jelínková, M. P63Jiménez Caballero, P.E. P3Jolic, M. P58Jolic, S. P58Jonszta, T. O16Jovanovic, Z. P12, P13Juckel, G. O27Junakovic, A. P82

Kabanov, A.A. P42 Karakaneva, S. O24Karasawa, Y. P36Karlinger, K. L10Kasikci, T. P80, P97Kasprowicz, M. O30Kazibutowska, Z. P67Kerasnoudis, A. O14Kern, R. O21Kesav, P. P43Khurana, D. P43Kikule, I. P70Kim, D.J. O30 Klingelhoefer, J. T2, P86Klissurski, M. P28Koc, G. P97Köhnlein, M. O22Kondo, Y. P36Kono, Y. P51Kostic Boricic, M. P12Kostic, V. O26, O28Koyama, M. O3Kozera, G.M. P46Kozlov, A.V. P76, P79, P96Krajča, J. O16Kresojevic, N. O28Krievins, D. P70Krogias, C. O14, O27Krsmanović, Ž. P48Kruja, J. P1, P52Kubota, J. O1Kuliha, M. O16

Kuwano, A. P36La Piscopia, E. P16Labović, B. P48Lamperti, M. P66Lange, M. O9, P11Langová, K. O16 Lannert, A. L10Latham, T. P37Lauckaite, K. P72Leliuk, S. P41Leliuk, V. P41Lelyuk, S. P7, P6, P39, P73,

P85Lelyuk, V. P6, P7, P8, P9, P33,

P35, P39, P73, P85Lenzi, G.L. L12Lepić, M. P48Lepić, T. P48List, J. O22Littvay, L. L10Logallo, N. O20Loganathan, T. P37Longaretti, F. P66Lovrencic-Huzjan, A. P81Lucchetta, M. O25, P22, P61Lukosevicius, S. P72Lundervik, M. O33, P26

Machado, C. O34Maestrini, I. L12Maggi, M. O19, O29, P21, P27,

P29, P60, P88, P90Maggio, P. L22, O23Magistris, M. O31Majidi, S. O5Malandrucco, I. O23Malferrari, G. L29, O19, O29,

O35, P21, P27, P29, P56,P60, P88, P90

Malojcic, B. P82Malyarova, E. P41Manara, R. O6, O7, O8Mancini, M. L29Manoli, S. O6Manzi, M.V. P47, P55, P94Marcello, N. O19, O35, P27, P29Martínez-Sánchez, P. O13Martinic-Popovic, I. P81Martinoli, C. T6Martorana, A. P78Mateos, V. P62Matijosaitis, V. P75Mattioni, A. P38Mattisi, I. O36Mazzucco, S. P89Meairs, S. O21Medda, E. L10Mehrpour, M. P64Meireles, J. O15

Mendonça, N. O34Meneghetti, G. L10, L18, L32,

O6, O7, O8, O12, P38Mess, W.H. L31Meves, S.H. O14Migliozzi, C. O6Mijajlovic, M. O26, O28Mikazane, H. O11Mirčić, S. P5Misaggi, G. P78Mitsumura, H. P51Mochio, S. P51Mogharralu, E. P64Molnar, A. A. L10Monaco, D. P23Montanaro, M. O6Montepietra, S. P90Morandi, E. P89Morita, M. P51Motamed, M.R. P64Motta, E. P67Motti, L. P90Mumme, A. O14Munaretto, V. O7, O8Mundi, C. P90

Nakagawa, M. O3Nava, A. P14Naylor, A.R. P4, P53Nduwayo, S. P4, P53Nedelmann, M. P20Neubauer-Geryk, J. P46Newell, D.W. S2Nica, C. P25Nicoletti, G. O32, P30Nikitin, S. P7Nisticò, L. L10Norra, C. O27Novoselova, S. P71Nyka, W.M. P46

O’Brien, A. P37Odabasi, Z. P80, P97Ogihara, M. O1Okujava, M. P93Olah, L. P65, P77Oliaee, F. P64Olivato, S. P89Omoto, S. P51Ong, B.K.C. P34, P40Orologas, A. P54Osztovits, J. L10Otáhal, D. O16

Paci, C. O32, P16, P23, P56Padovani, A. P89Padua, L. T6, L23, O25, P22,

P61,

Pagnano, G. P47, P55, P94Palazzi, G. O6, O7, O8 Palazzo, P. L22, O23Paliwal, P.R. P34, P40Palmieri, A. P38Panerai, R.B. P4, P53, P83,P95Panuntsev, G.K. P76, P79, P96Papadimitriou, A. P54Parati, E. P66Pari, E. P89Pascarella, R. O19, O29,

P21,P27, P29, P60, P88, P90Pascazio, L. L26, P17, P18, P32,

P57Passarelli, F. O23Patzak, A. P76, P79Paul, F. P20Pavlovic, A. O26, O28, P12, P13Pazzaglia, C. P22Pechiborsch, D.A. P76Pekmezovic, T. O28Pérez Sánchez, J.R. P68Perren, F. O31Perticaroli, E. P23Pestana, M. O10Petrikonis, K. P75Petrovic, I. O26Picconi, F. O23Ping, P.A. P34, P40Piras, M.P. P89Pitsalidis, C. P54Pizzolato, G. L27Plontke, R. P86Poalelungi, A. P25Portilla Cuenca, J.C. P3Powers, J. O21Prabhakar, S. P43Prati, P. P21, P90Pretnar-Oblak, J. P45Procházka, V. O16Pugliese, M. O6Puz, P. P67Pyshkina, L.I. P42

Quiñones, D. P31Qureshi, A.I. O5

Radovanović, B. P5Ragauskas, A. P75, P87Raičević, R. P48Ramazanov, G. P8, P79Ramírez Moreno, J.M. P3Ramnarine , K.V. P4, P53 Rampazzo, P. O6, O7, O8Rao, M.A.E. P47, P55, P94Rastenyte, D. P75Rejto, L. P77Resman-Gašperšič, A. P45

87Cerebrovasc Dis 2012;33(suppl 1); 1-88Author Index

Ricci, S. L18, P38Rinaldi, F. P89Ristic, G. P48Robinson, T.G. P4, P53, P83,

P95Rodríguez Cruz, P.M. P68Röhl, J.E. O22Roje-Bedekovic, M. P81Romero Chala, S. P3Romero Sevilla, R.M. P3Rønning, O.M. L13, P2Rosengarten, B. P77Roubec, M. O16Russell, D. T1, L1, L13, O17,

O18, P2Rutkauskas, S. P72Ružička-Kaloci, S. P5

Saeed, N.P. P95Saguchi, T. P36Sainati, L. O6, O7, O8Saito, O. O4Salah, M. P44Salgueiro, F. O10Salinet, A.M. P83Sancesario, G. P78Sanguigni, S. L29, O29, O32,

P16, P23, P30, P47, P55, P56,P90, P94

Santarcangelo, P. P30Santoro, M. P47, P55, P94Santos, A. P84Santos, R. O15, P84, P92Sargento-Freitas, J. O34Sarmento, A. O10Sarvari, S.I. P2Sasaki, A. O1Sasaki, K. O1Schaafsma, A. O2Scheibe, F. O22Schillaci, G. L10Schlachetzki, F. P24Schmidt, B. P86Schreiber, S.J. T5, O22, P20Scott, H. O17

Segura, T. P49Semenyutin, V.B. P76, P79, P96Semplicini, C. O36Sengoku, R. P51Serguladze, T.N. P42Servadei, F. P27Servillo, G. L27Shamalov, N. P35Sharma, V.K. P34, P40Shayunova, S. P15, P71Shimizu, J. O1, O4Shiogai, T. O3Shlyk, E. P8, P9Shurupova, N. P71Sierra, R. P74Silva, F. O34Silvano, R. P10Simonetto, M. P14Sinha, D.M. P37Sirimarco, G. L12Skagen, K. O17 Skjelland, M. O17, O18 Školoudík, D. O16, P63Skvortsova, V. P8, P33, P35, P41Slankamenac, P. P5Smielewski, P. O30, P86Sobrino García, P. P68Sorrentino, E. O30Soukup, T. P63Sousa, L. P84Spasić-Jokić, V. P5Squeri, A. P10Stamenova, P. P28, P91Stazi, M.A. L10Stefanova, E. O26Stepanavicius, Z. P72Stepanova, I. P15, P71Sternic Covickovic, N. P13Sternic, N. P12Stoianov, P. P28Stolz, E. L25, L29Struga, G. P1, P52Stumbra, E. O11Suzuki, I. P36Svabic, T. P12, P13

Svetel, M. O26, O28Svoevolin, S. P73Szabo, K. P77Szczyrba, S. P46

Tafuro, M. P16Takagi, S. P51Taliani, U. P10Tamburri, L. P16Tanzi, A. P10Tardi, S. P30Tarnoki, A. D. L10 Tarnoki, D.L. L10Tavares, J. P84Tegos, T.J. P54Teoh, H.L. P34, P40Terrón, C. P31omassen, L. O20Titianova, E. O24Tomei, E. P16Tomic, A. O28Torka, E. P24Toscano, M. L12Tournev, I. O24Trojano, M. P18Turri, G. P89

Umemura, S. O1Unusic, L. P82

Valavanis, A. P54Valdueza, J.M. T7, O22, P20 Vassileva, E. P28, P91Vasta, A. P55, P47, P94Vavrek, E. P28Vázquez Alén, P. P68Veljančić, D. P48Vernieri, F. L22, O23Veselinovic, N. P12, P13Vettore, G. P14Viaro, F. O12, O36Vicente Peracho, G. P68 Vicenzini, E. L12Vignali, L. P10 Villanueva Osorio, J.A. P68

Vishnyakova, A. P33, P35, P39Vitan, E. P13Voynov, S. P6, P7Vujisic Tesic, B. P12, P13Vukasinovic, N. P58Vukovic-Cvetkovic, V. P81

Waje-Andreassen, U. O20Walter, U. T11, L24Watanabe, M. O5Wischmeijer, A. O35Wolnik, B. P46Würfel, J. P20

Xhaxho, S. P1, P52

Yamamoto, M. O3Yeo, L.L. P34, P40Yoshikawa, K. O3

Zadro Matovina, L. P19Zagaglia, S. P23Zakelis, R. P75, P87Zaki, M.A. P44Zaletel, M. P45Zamproni, L. P11Zanatti, M.G. O7, O8Zanet, L. P14Zanferrari, C. P10Zani, F. O6Zanproni, L. O9Zaratin, P. P90Zavoreo, I. P19, P69Zedde, M.L. L29, O19, O29,

O35, P21, P27, P29, P56,P60, P88, P90

Zetola, V.F. P11Zivi, I. P78Zivkovic, M. P58Zorzon, M. L27Žvan, B. P45Zvirgzdins, V. P70

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