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1/610. Monitoring of venous hemodynamics in patients with cerebral venous thrombosis by transcranial Doppler ultrasound.

    OBJECTIVES: To test the assumption that transcranial Doppler ultrasound (TCD) is able to detect and to monitor intracranial venous blood flow velocities in patients with confirmed cerebral venous thrombosis (CVT). DESIGN: Prospective case study in 18 patients. SETTING: Inpatient neurologic service in a university hospital. SUBJECTS AND methods: Serial TCD examinations were performed in 18 consecutive patients with CVT (14 females, 4 males) aged 16 to 64 years (mean /-SD, 36.8 /-13.1 years) during a mean follow-up ranging from 34 to 783 days (mean /-SD, 201 /-185 days) between 1993 and 1997. Venous TCD was performed with a 2-MHz range-gated transducer. RESULTS: Venous blood flow velocities were successfully measured in all patients. The highest measured velocities in the monitored intracranial venous vessels ranged from 20 to 150 cm/s (mean /-SD, 58.9 /-38.8 cm/s), and the lowest were from 9 to 84 cm/s (mean /-SD, 27.9 /-17.0 cm/s). Fifteen patients (83%) showed a decrease of velocities-2 of them after a transient increase during cessation of heparin therapy. The percentage of velocity decrease ranged from 34% to 73% (mean /-SD, 56.4% /-10.9%). A plateau phase, defined as no further decrease in velocities, was reached in these patients within 4 to 314 days (mean /-SD, 59.9 /-73.7 days). Three patients (17%) showed no changes in velocities as defined by a limit of velocity variation of 30% during the course of CVT. High venous velocities were significantly associated with altered consciousness (P = .001). A nonsignificant relationship was observed with affliction of the superior sagittal sinus. No correlations were noted for onset of disease, initial motor deficits, and presence of bleeding. No predictive value was gained from analyzing the outcome in relation to absolute velocities or their decrease. CONCLUSIONS: Serial TCD studies allow monitoring of venous hemodynamics and collateral pathways in patients with CVT. Normal venous velocities in serial measurements, however, do not exclude a diagnosis of CVT.
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2/610. Angiographical extravasation of contrast medium in hemorrhagic infarction. Case report.

    Leakage of the contrast medium was noted on angiograms of a patient whose autopsied brain disclosed typical pathological findings of hemorrhagic infarction. The case was a 63-year old woman with mitral valve failure, who suddenly had loss of consciousness and right-sided hemiplegia. The left carotid angiography performed six hours after onset demonstrated middle cerebral arterial axis occlusion, and the second angiography performed three days after onset displayed recanalization of the initially occluded artery as well as extravasation of the contrast medium. Fourteen days after onset the patient died and an autopsy was performed. The brain demonstrated perivascular punctate hemorrhages in the area supplied by the middle cerebral artery, and neither hematoma nor microaneurysm was disclosed pathologically. A short discussion is given on the possible relationship between recanalization and hemorrhagic infarction. The clinical assessment of hemorrhagic infarction has not been established successfully.
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3/610. Near-infrared spectroscopy monitored cerebral venous thrombolysis.

    BACKGROUND: Cerebral venous thrombosis is a clinical entity which is readily diagnosed with the advent of modern imaging techniques. Anticoagulation is now a standard therapy, but more recent treatment strategies have included endovascular thrombolysis. While the endpoint of this intervention both clinically and radiographically has not been defined, noninvasive monitoring techniques may add further objective measures of treatment response. CLINICAL PRESENTATION: We present a patient with a four day history of worsening headache and papilledema on exam. Superior sagittal, straight, and bilateral transverse sinus thromboses were identified on computed tomography and angiography. INTERVENTION: Emergent endovascular thrombolysis by a transvenous approach re-established venous patency and resulted in immediate resolution of the patient's symptoms. Cerebral oximetry by near-infrared spectroscopy was utilized during the procedure, and changes in chromophore concentrations correlated directly with angiographic and clinical resolution of the thrombosis. CONCLUSION: Near-infrared spectroscopy can provide continuous feedback during thrombolytic therapy in cerebral venous thrombosis and may help define endpoints of such intervention.
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4/610. Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke.

    PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.
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keywords = cerebral
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5/610. Fatal haemorrhagic infarct in an infant with homocystinuria.

    Thrombotic and thromboembolic complications are the main causes of morbidity and mortality in patients with homocystinuria. However, it is unusual for thrombosis and infarction to be the presenting feature leading to investigation for homocystinuria and cerebrovascular lesions in the first year of life. We describe a previously healthy 6-month-old infant who presented with a large middle-cerebral-artery territory infarction and died of massive brain swelling. homocystinuria due to cystathionine beta-synthase (CBS) deficiency was diagnosed by metabolite analysis and confirmed by enzymatic activity measurement in a postmortem liver biopsy. homocystinuria should be considered in the differential diagnosis of venous or arterial thrombosis, regardless of age, even in the absence of other common features of the disease. We recommend systematic metabolic screening for hyperhomocysteinemia in any child presenting with vascular lesions or premature thromboembolism.
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keywords = cerebral
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6/610. Twinkling artifact on intracerebral color Doppler sonography.

    Transcranial Doppler sonography shows potential as a noninvasive technique for long-term follow-up of treated intracranial saccular aneurysms. This technical note describes a color Doppler artifact related to microcoil architecture that might represent a potential pitfall in transcranial Doppler sonographic evaluation of aneurysmal cavity thrombosis, since it may be wrongly interpreted as residual flow or aneurysmal cavity recanalization.
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keywords = cerebral
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7/610. Acute embolic carotid occlusion after cardiac catheterization: effect of local intra-arterial urokinase thrombolysis.

    A 64-year-old woman developed a severe embolic cerebral attack with total left hemiplegia approximately 30 hours after cardiac catheterization for mitral stenosis. She underwent intra-arterial thrombolysis of the right internal carotid artery four and one-half hours after the onset of neurologic deficit with subsequent recanalization of the occluded vessel and near complete neurologic recovery.
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ranking = 0.2
keywords = cerebral
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8/610. subarachnoid hemorrhage due to septic embolic infarction in infective endocarditis.

    During antibiotic therapy, a 56-year-old man with a streptococcus bovis endocarditis developed an infarction of the right middle cerebral artery (MCA). Thirty hours after stroke onset, cranial computed tomography controls demonstrated a secondary subarachnoid hemorrhage, marked in the cistern of the right MCA. The latent period, cerebrospinal fluid analysis, angiographic and pathologic findings favor the assumption of a pyogenic arterial wall necrosis of the MCA due to a septic embolus. This pathomechanism of intracranial hemorrhage in infective endocarditis should be distinguished from a rupture of a mycotic aneurysm.
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9/610. Cerebral and renal embolization after lymphography in a patient with non-Hodgkin lymphoma: case report.

    An unusual case of lipid embolization to brain and kidney after lymphography in a patient with non-Hodgkin lymphoma of the upper anterior mediastinum is reported. Contrast material-enhanced echocardiography demonstrated a right-to-left shunt to the left atrium without evidence of a patent foramen ovale. Echo contrast particles were transiently present within the tumor surrounding the great vessels.
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keywords = foramen
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10/610. diffusion- and perfusion-weighted magnetic resonance imaging in deep cerebral venous thrombosis.

    BACKGROUND: diffusion-weighted (DWI) and perfusion-weighted (PI) MRI are highly sensitive techniques for early diagnosis of arterial infarction, but little data on venous cerebral ischemia are available. We describe a case in which DWI, PI, and fast T2-weighted sequences were performed in the acute phase of deep cerebral venous thrombosis (CVT). CASE DESCRIPTION: An 11-year-old girl with Crohn's disease developed deep CVT in which extensive edema was shown in the deep gray matter on T2-weighted sequence images. Isotropic echo-planar DWI demonstrated a local augmentation of the apparent diffusion coefficient (1.1 to 1.6x10(-3) mm2/s), consistent with vasogenic edema. In dynamic contrast-enhanced PI, the regional cerebral blood volume was increased and the passage time of the contrast bolus was markedly prolonged. Clinically, the patient recovered totally after intravenous full-dose heparinization. T2 abnormalities, apparent diffusion coefficient values (0.8 to 0.92x10(-3) mm2/s), and brain perfusion alterations resolved without damage to brain tissue. CONCLUSIONS: Unlike arterial infarction, DWI demonstrated vasogenic edema in a patient with deep CVT, which proved to be reversible in follow-up magnetic resonance imaging. PI showed areas with extensive venous congestion, but perfusion deficits were missing. Therefore, we believe that DWI and PI may play a role in detecting venous congestion in CVT and in prospective differentiation of vasogenic edema and venous infarction.
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ranking = 1.4
keywords = cerebral
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