**7. Conclusion**

Neurosonology is a safe, reliable and useful technique for evaluate acute stroke patients It may provide relevant information about the prognosis and guide the selection of the most adequate treatment for each patient. The recent development of intrinsic therapeutic

Neurosonological Evaluation of the Acute Stroke Patients 291

Baumgartner RW, Arnold M, Gönner F, Staikow I, Herrmann C, Rivoir A, Müri RM,

Baumgartner RW, Mattle HP, Schroth G. Assessment of 50% and 50% intracranial stenoses by transcranial color-coded duplex sonography. Stroke. 1999;30:87–92. Baumgartner RW. Transcranial color duplex sonography in cerebrovascular disease: a

Benninger DH, Georgiadis D, Gandjour J, Baumgartner RW. Accuracy of Color Duplex

Burgin WS, Malkoff M, Felberg RA, Demchuk AM, Christou I, Grotta JC, Alexandrov AV.

Burgin WS, Wojner AW, Demchuk AM, et al. Validity and reliability of the Thrombolysis In

Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link

Chappell FM, Wardlaw JM, Young GR, Gillard GH, Roditi GH, Yip B, Pell JP, Rothwell PM,

Christou I, Felberg RA, Demchuk AM, et al. Accuracy parameters of a broad diagnostic

Cintas P, Le Traon AP, Larrue V. High rate of recanalization of middle cerebral artery

Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant

Clark WM, Albers GW, Madden KP, Hamilton S. Thrombolytic therapy in acute ischemic

Daffertshofer M, Gass A, Ringleb R, et al., Transcranial Low- Frequency Ultrasound-

Del Zoppo G, Poek K, Pessin MS, et al. Recombinant Tissue Plasminogen Activator in Acute

Thrombotic and Embolic Stroke. Ann Neurol 1992; 32: 78-86

carotid artery stenosis or occlusion. J Neuroimaging 2001; 11: 236 –242 Christou I, Felberg RA, Demchuk AM, et al. Intravenous tissue plasminogen activator and

Cerebrovascular Disease. Stroke. 1997;28:2473-2478

systematic review. Cerebrovasc Dis. 2003;16:4–13

middle cerebral artery stroke. Stroke. 2000;31:1128 –1132

Brain Infarction [TIBI] flow grades. Stroke 2001; 32: 324

occlusion. J Neuroimaging 2002; 12: 119 –123.

thrombolytic drug. Stroke 2002; 33: 626–628

Clinical Trial. Stroke 2005; 36; 1441-1446

2006;37:377-381

1475–1482

251:493–502

1999; 282: 2019–2026

2000;31: 811– 816

Contrast-Enhanced Transcranial Color-Coded Duplex Sonography in Ischemic

Ultrasound Diagnosis of Spontaneous Carotid Dissection Causing Ischemia. Stroke.

Transcranial Doppler ultrasound criteria for recanalization after thrombolysis for

between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998; 55:

Brown MM, Gough MJ, Randall MS, Carotid Artery Stenosis: Accuracy of Noninvasive Tests—Individual Patient Data Meta-Analysis, Radiology 2009;

battery for bedside transcranial Doppler to detect flow changes with internal

flow improvement in acute ischemic stroke patients with internal carotid artery

occlusion during 2 MHz transcranial colour-coded continuous monitoring without

tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA

stroke study investigators. The rtPA (alteplase) 0- to 6-hour acute stroke trial, part A (A0276g): results of a double-blind, placebo-controlled, multicenter study. Stroke

Mediated Thrombolysis in Brain Ischemia: Increased Risk of Hemorrhage With Combined Ultrasound and TissuePlasminogen Activator: Results of a Phase II

perspectives, as ultrasound-enhanced thrombolysis, make even more recommendable its use in this setting.

#### **8. References**


perspectives, as ultrasound-enhanced thrombolysis, make even more recommendable its

Alecu C, Fortrat J, Ducrocq X, et al. Duplex scanning diagnosis of internal carotid artery

Alexandrov AV, Demchuk AM, Wein TH, Grotta JC. Yield of Transcranial Doppler in Acute

Alexandrov A, Demchuk AM, Felberg RA, et al. High rate of complete recanalization and

classification and short-term improvement. Circulation 2001; 103: 2897–2902 Alexandrov AV, Wojner AW, Grotta JC. CLOTBUST: Design of a randomized trial of

Alexandrov AV, Molina CA, Grotta JC, et al. for the CLOTBUST Investigators. Ultrasound-

Alexandrov AV. Ultrasound enhancement of fibrinolysis. Stroke. 2009; 40 (3Suppl): S107–

Alexandrov AV, Sloan MA, Tegeler CH, Newell DN, Lumsden A, Garami Z, Levy CR,

Allendoerfer J, Goertler M, von Reutern GM, for the Neurosonology in Acute Ischemic

Arnold M, Nedeltchev K, Mattle HP, et al. Intra-arterial thrombolysis in 24 consecutive

Arnold M, Baumgartner RW, Stapf C, Nedeltchev K, Buffon F, Benninger D, Georgiadis D,

Carotid Dissection With Isolated Horner Syndrome, Stroke. 2008;39:82-86 Bang OY, Heo JH, Kim JY, Park JH, Huh K, Middle Cerebral Artery Stenosis Is a Major

Bartlett ES, Walters TD, Symons SP, and Fox AJ, Diagnosing Carotid Stenosis Near-

Baumgartner RW, Mathis J, Sturzenegger M, Mattle HP. A validation study on the

velocity measurements. Ultrasound Med Biol. 1994;20:233–237.

with 2-MHz transcranial Doppler monitoring. Stroke 2000; 31: 610-614 Alexandrov AV, Burgin SW, Demchuk AM, El-Mitwalli A, Grotta JC. Speed of intracranial

dramatic clinical recovery during rt-PA infusion when continuously monitored

clot lysis with intravenous tissue plasminogen activator therapy: sonographic

ultrasound-enhanced thrombolysis for acute ischemic stroke. J Neuroimaging.

Enhanced Systemic Thrombolysis for Acute Ischemic Stroke. N Engl J Med 2004;

Wong LKS, Douville C, Kaps M, Tsivgoulis G, for the American Society of Neuroimaging Practice Guidelines Committee, Practice Standards for Transcranial Doppler (TCD) Ultrasound. Part II. Clinical Indications and Expected Outcomes, J

Stroke (NAIS) Study Group. Prognostic relevance of ultra-early doppler sonography in acute ischaemic stroke: a prospective multicenter study. Lancet

patients with internal carotid artery T occlusion. J Neurol Neurosurg Psychiatry

Sturzenegger M, Mattle HP, Bousser MG, Ultrasound Diagnosis of Spontaneous

Clinical Determinant in Striatocapsular Small, Deep Infarction, Arch Neurol.

Occlusion by Using CT Angiography AJNR Am. J. Neuroradiol. 2006; 27(3): 632 -

intraobserver reproducibility of transcranial color-coded duplex sonography

dissections. A case control study. Cerebrovasc Dis 2007; 23:441–447

Cerebral Ischemia. Stroke. 1999;30:1604-1609

use in this setting.

**8. References** 

2004;14:108 –112

351: 2170-8 (b)

Neuroimaging 2010;20:1-10.

Neurol 2006; 5:835–40

2003; 74: 739-742

2002;59:259-263

637

S110


Neurosonological Evaluation of the Acute Stroke Patients 293

Gerriets T, Seidel G, Fiss I, Modrau B, Kaps M. Contrast-enhanced transcranial color-coded duplex sonography: efficiency and validity. Neurology. 1999;52:1133–1137 Gerriets T, Postert T, Goertler M, et al.; for the DIAS (Duplex Sonography in Acute Stroke)

Goertler M, Kross R, Baeumer M, Jost S, Grote R, Weber S, Wallesch CW. Diagnostic impact

Gorelick PB, Wong KS, Bae HJ, Pandey DK, Large Artery Intracranial Occlusive Disease. A

Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw

Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue

Hacke W, Kaste M, Fieschi C, et al. Second European-Australasian Acute Stroke Study

Hacke W, Furlan AJ, Al Rawi Y, et al. Intravenous desmoteplase in patients with acute

Kenton AR, Martin PJ, Abbott RJ, Moody AR. Comparison of transcranial color-coded

Khan HG, Gailloud P, Bude RO, Martin JB, Szopinski KT, Khaw C, Rufenacht DA, Murphy

Kidwell C, Saver J, Mattiello J, et al. Thrombolytic reversal of acute human cerebral ischemic

Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV, for the CLOTBUST

Middle Cerebral Artery Occlusion. Stroke 2005; 36: 869-871

Giller CA. Is angle correction correct? J Neuroimaging. 1994;4:51–52.

duplex sonography in acute stroke. Stroke. 1998;29:955–962.

Acute Stroke Study (ECASS). JAMA 1995; 274: 1017–1025

controlled study. Lancet Neurol. 2009;2:141-150

Strategies. Cerebrovasc Dis 2007; 23:229–241

2345

2399

Radiology 2003; 229:340–346

1998; 352:1245–1251.

1997;28:1601–1606.

2000; 47: 462– 469

Study Group. DIAS I: Duplex-Sonographic Assessment of the Cerebrovascular Status in Acute Stroke. A Useful Tool for Future Stroke Trials. Stroke 2000;31:2342-

and prognostic relevance of early contrastenhanced transcranial color-coded

Large Worldwide Burden but a Relatively Neglected Frontier, Stroke. 2008;39:2396-

M, Gocke J, Hertzberg BS, Katanick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler E, Carotid Artery Stenosis: Gray-Scale and Doppler US Diagnosis—Society of Radiologists in Ultrasound Consensus Conference;

plasminogen activator for acute hemispheric stroke: The European Cooperative

Investigators. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet

ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-

sonography and magnetic resonance angiography in acute stroke. Stroke.

KJ. The effect of contrast material on transcranial Doppler evaluation of normal middle cerebral artery peak systolic velocity. Am J Neuroradiol. 2000;21:386–390 Kjellström T, Norrving B, Shatchkute A. Helsingborg Declaration 2006 on European Stroke

injury shown by diffusion/perfusion magnetic resonance imaging. Ann Neurol

Collaborators. Early Recanalization Rates and Clinical Outcomes in Patients With Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion and Isolated


Del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M, for the PROACT

Delgado-Mederos R, Rovira A, Alvarez-Sabn J, et al. Speed of tPA-Induced Clot Lysis Predicts DWI Lesion Evolution in Acute Stroke. Stroke 2007; 38: 955-960 Demchuk AM, Christou I, Wein TH, et al. Accuracy and criteria for localizing arterial

Demchuk AM, Christou I, Wein TH, et al. Specific transcranial Doppler flow findings related to the presence and site of arterial occlusion. Stroke 2000;31:140–146 (b) Demchuk AM, Burgin WS, Christou I, et al. Thrombolysis In Brain Infarction [TIBI]

Eggers J, König IR, Koch B, Händler G, Seidel G. Sonothrombolysis with transcranial color-

Eggers J, Pade O, Rogge A, Schreiber SJ and Valdueza JM, Transcranial Color-Coded

Eicke BM, Tegeler CH, Dalley G, Myers LG. Angle correction in transcranial Doppler

El-Mitwalli A, Saad M, Christou I, Malkoff M, Alexandrov AV. Clinical and sonographic

Fiehler J, Knudsen K, Kucinski T, et al. Predictors of apparent diffusion coefficient

Flaherty ML, Woo D, Kissela B, et al. Combined IV and intraarterial thrombolysis for acute

Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic

Fusco MR, Harrigan MR, Cerebrovascular Dissections—A Review Part I: Spontaneous

Garami Z, Calleja S, Labiche L, et al. Yield of urgent carotid scanning in acute cerebral

Georgiadis D, Oehler J, Schwarz S, Rousson V, Hartmann M, Schwab S. Does acute

normalization in stroke patients. Stroke 2004;35: 514 –519

Cerebral Thromboembolism. JAMA 1999; 282:2003-2011

tissue plasminogen activator-treated patients. Stroke 2002; 33: 99 –102 Felberg RA, Okon NJ, El-Mitwalli A, Burgin WS, Grotta JC, Alexandrov AV. Early Dramatic

occlusion with transcranial Doppler. J Neuroimaging 2000; 10: 1–12

Cerebral Thromboembolism. Stroke 1998; 29: 4–11

American Journal of Neuroradiology 2009;30:1589

sonography. J Neuroimaging. 1994;4:29 –33

ischemic stroke. Neurology 2005; 64:386–388

Dissections, Neurosurgery 2011; 68:242–257

ischemia. Stroke 2003;34:266

2001; 32: 89 –93

1301-1307

26

Stroke. 2008; 39: 1470–1475

investigators. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Prolyse in Acute

transcranial Doppler flow grades predict clinical severity, early recovery, and mortality in patients treated with intravenous tissue plasminogen activator. Stroke

coded sonography and recombinant tissue-type plasminogen activator in acute middle cerebral artery main stem occlusion: results from a randomized study.

Sonography Successfully Visualizes All Intracranial Parts of the Internal Carotid Artery Using the Combined Transtemporal Axial and Coronal Approach,

patterns of tandem internal carotid artery/middle cerebral artery occlusion in

Recovery During Intravenous Tissue Plasminogen Activator Infusion Clinical Pattern and Outcome in Acute Middle Cerebral Artery Stroke. Stroke 2002; 33:

stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute

occlusion of the carotid T invariably have a poor outcome? Neurology 2004; 63: 22–


Neurosonological Evaluation of the Acute Stroke Patients 295

Malferrari (Editor), Neurosonological examination in acute stroke patients. A pocket guide.

Manu S. Goyal and Colin P. Derdeyn, The diagnosis and management of supraaortic arterial

Mead GE, Wardlaw JM, Dennis MS, et al. Relationship between pattern of intracranial artery

Meyer-Wiethe K, Cangür H, Schindler A, Koch C, Seidel G. Ultrasound perfusion imaging:

Molina CA, Alexandrov AV, Demchuk AM, Saqqur M, Uchino K, Alvarez-Sabn J.

Molina CA. et al. ,Differential pattern of tissue plasminogen activator induced middle cerebral artery recanalization among stroke subtypes. Stroke 2004; 35: 486-490 (b) Molina CA, Ribo M, Rubiera M, Montaner J, Santamarina E, Delgado-Mederos R, Arenillas

Molina CA, Barreto AD, Tsivgoulis G, Sierzenski P, Malkoff MD, Rubiera M, Gonzales N,

Nabavi DG, Droste DW, Kemeny V, Schulte-Altedorneburg G, Weber S, Ringelstein EB.

NASCET Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients

Nedelmann M, Stolz E, Gerriets T, Baumgartner RW, Malferrari G, Seidel G, Kaps M, for the

Nedeltchev K, Bickel S, Arnold M, Sarikaya H, Georgiadis D, Sturzenegger M, Mattle HP,

NINDS (National Institute of Neurological Disorders and Stroke) rt-PA Stroke Study Group.

Ogata T, Kimura K, Nakajima M, Naritomi H, Minematsu K. Diagnosis of middle cerebral

sonography in acute stroke. Neuroradiology. 2005;47:256 –262

sonothrombolysis (TUCSON) trial. Ann Neurol. 2009;66:28 –38

with high-grade carotid stenosis. N Engl J Med. 1991;325:445-453

patients: a pilot study. Stroke. 1998;29:949–954

Trials on Acute Stroke, Stroke. 2009;40:3238-3244

Stroke. 2009;40:499-504

1581–1587

treated with tissue plasminogen activator. Stroke 2004; 35: 151–156

abnormalities on transcranial Doppler and Oxfordshire community stroke project

determination of thresholds for the identification of critically disturbed perfusion in acute ischemic stroke: a pilot study. Ultrasound in Med. & Biol 2007; 33: 851–856 Molina CA, Alvarez-Sabín J, Montaner J, et al. Thrombolysis-Related Hemorrhagic

Infarction A Marker of Early Reperfusion, Reduced Infarct Size, and Improved Outcome in Patients With Proximal Middle Cerebral Artery Occlusion. Stroke 2002;

Improving the predictive accuracy of recanalization on stroke outcome in patients

JF, Huertas R, Purroy F, Delgado P, Alvarez-Sabin J. Microbubble administration accelerates clot lysis during continuous 2-MHz ultrasound monitoring in stroke patients treated with intravenous tissue plasminogen activator. Stroke. 2006;37:425–

Mikulik R, Pate G, Ostrem J, Singleton W, Manvelian G, Unger EC, Grotta JC, Schellinger PD, Alexandrov AV, Transcranial ultrasound in clinical

Potential and limitations of echocontrast-enhanced ultrasonography in acute stroke

TCCS Consensus Group, Consensus Recommendations for Transcranial Color-Coded Duplex Sonography for the Assessment of Intracranial Arteries in Clinical

Baumgartner RW, Recanalization of Spontaneous Carotid Artery Dissection,

Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:

artery occlusive lesions with contrast-enhanced transcranial color-coded real-time

dissections, Current Opinion in Neurology 2009, 22:80–89

clinical classification of ischemic stroke. Stroke 2000; 31: 714-719

Grandi ed. 2010

33:1551-1556

429


Krejza J, Mariak Z, Babikian VL. Importance of angle correction in the measurement of

Krejza J, Baumgartner RW. Clinical applications of transcranial color-coded duplex

Krejza J, Swiat M, Pawlak MA, Oszkinis G, Weigele J, Hurst RW, Kasner S. Suitability of

Kunz A, Hahn G, Mucha D, Muller A, Barrett KM, von Kummer R, Gahn G. Echo-enhanced

Jansen O, Von Kummer R, Forsting M, Hacke W, Sartor K. Thrombolytic therapy in acute

Iannuzzi A, Wilcosky T, Mercuri M, Rubba P, Bryan FA, Bond MG. Ultrasonographic

IMS Study Investigators. Combined intravenous and intra-arterial recanalization for acute

Labiche LA, Malkoff M, Alexandrov AV. Residual flow signals predict complete

Lee DH, Gao FQ, Rankin RN, Pelz DM, Fox AJ. Duplex and color Doppler flow sonography

Lee KY, Kim DI, Kim SH et bal. Sequential combination of intravenous recombinant tissue

Lewandowski C, Frankel M, Tomsick T, et al. for the EMS Bridging Trial investigators.

Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery

Maeda H, Etani H, Handa N, Tagaya M, Oku N, Kim BH, Naka M, Kinoshita N, Nukada T,

Malferrari G, Bertolino C, Casoni F, Zini A, Sarra VM, Sanguigni S, Pratesi M, Lochner P,

Malferrari G, Zedde M, Marcello N, Role of Ultrasound Vascular Imaging in the Acute

events: a validation study. Am J Neuroradiol. 2006;27:2122–2127.

sonography. J Neuroimaging. 2004;14:215–225

Neuroradiol 1995;16:1977–1986

Neuroradiol 2004;25:1470–1475

duplex sonography. J Neuroimaging. 2007;17:311–314

2001;22:1743–1747

1995; 26: 614–619

904 –911

1267–1274

1999; 30:2598–2605

2007;24:469–476.

252-269

Stroke 2002; 33:2066–2071

velocimetry. Ultrasound Med Biol. 1990;16:9 –14.

blood flow velocity with transcranial Doppler sonography. Am J Neuroradiol.

temporal bone acoustic window: conventional TCD versus transcranial color-coded

transcranial color-coded duplex sonography in the diagnosis of cerebrovascular

occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J

correlates of carotid atherosclerosis in transient ischemic attack and stroke. Stroke

ischemic stroke: the Interventional Management of Stroke Study. Stroke 2004; 35:

recanalization in stroke patients treated with TPA. J Neuroimaging 2003; 13: 28 –33

of occlusion and near occlusion of the carotid artery. Am J Neuroradiol 1996; 17:

plasminogen activator and intra-arterial urokinase in acute ischemic stroke. Am J

Combined intravenous and intra-arterial rtPA vs intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke [EMS] Bridging Trial. Stroke

vs middle cerebral artery occlusions after intravenous tissue plasminogen activator.

Fukunaga R. A validation study on the reproducibility of transcranial Doppler

Coppo L, Brusa G, Guidetti D, Cavuto S, Marcello N. The ELIGIBLE study: ultrasound assessment in acute ischemic stroke within 3 hours. Cerebrovasc Dis.

Phase of Stroke, Vascular Disease Prevention, Vol. 5, No. 4. (November 2008), pp.


Neurosonological Evaluation of the Acute Stroke Patients 297

Stolz E, Babacan SS, Bodeker RH, Gerriets T, Kaps M. Interobserver and intraobserver

Thanvi B and Robinson T, Complete occlusion of extracranial internal carotid artery: clinical

Thomassen L, Waje-Andreassen U, Naess H, Aarseth J, RussellD. Doppler ultrasound and

Tomsick T, TIMI, TIBI, TICI: I Came, I Saw, I Got Confused, American Journal of

Trouillas P, Nighoghossian N, Derex L, et al. Thrombolysis with intravenous rtPA in a series

U-King-Im JM, Graves MJ, Cross JJ, Higgins NJ, Wat J, Trivedi RA, Tang T, Howarth SPS,

Valaikiene J, Schuierer G, Ziemus B, Dietrich J, Bogdahn U, Schlachetzki F. Transcranial

von Kummer R, Holle R, Rosin L, Forsting M, Hacke W. Does arterial recanalization improve outcome in carotid territory stroke? Stroke 1995;26:581–587 Wardlaw JM, Chappell FM, Best JJK, Wartolowska K, Berry E, on behalf of the NHS

Wardlaw JM, Carotid imaging for secondary stroke prevention in routine practice,

Wiesmann M, Meyer-Wiethe K, Albers T, Seidel G. Parametric Perfusion Imaging with Contrast-Enhanced Ultrasound in Acute Stroke. Stroke 2004; 35: 508-513 Wong KS, Li H. Long-term mortality and recurrent stroke risk among Chinese stroke patients with predominant intracranial atherosclerosis. Stroke. 2003;34:2361–2366. Zaidat OO, Suarez JI, Santillan C, et al. Response to intra-arterial and combined intravenous

Zanette EM, Fieschi C, Bozzao L, Roberti C, Toni D, Argentino C, Lenzi GL. Comparison of

International Journal of Stroke Vol 3, February 2008, 20–32

topographic and radiological outcome factors. Stroke 1998; 29: 2529-2540 Tsivgoulis G, Eggers J, Ribo M, Perren F, Saqqur M, Rubiera M, Sergentanis TN, Vadikolias

Randomized and Nonrandomized Studies. Stroke. 2010;41:280-287

thrombolysis. European Journal of Neurology 2005; 12: 462–465

Neuroimaging. 2001;11:385–392

Neuroradiology 28:382-384, February 2007

stenosis. Am J Neuroradiol. 2008;29:347–353.

artery occlusion. Stroke 2002; 33: 1821–1826

1, 2007; 83: 95 - 99

222

1503–12

1989;20:899 –903

reliability of venous transcranial color-coded flow velocity measurements. J

features, pathophysiology, diagnosis and management, Postgrad. Med. J., February

clinical findings in patients with acute ischemic stroke treated with intravenous

of 100 cases of acute ischemic carotid territory stroke: determination of etiological,

K, Larrue V, Molina CA, Alexandrov AV, Safety and Efficacy of Ultrasound-Enhanced Thrombolysis. A Comprehensive Review and Meta-Analysis of

Kirkpatrick PJ, Antoun NM, Gillard JH, Internal Carotid Artery Stenosis: Accuracy of Subjective Visual Impression for Evaluation with Digital Subtraction Angiography and Contrast-enhanced MR Angiography; Radiology 2007; 244:213–

color-coded duplex sonography for detection of distal internal carotid artery

Research and Development Health Technology Assessment Carotid Stenosis Imaging Group, Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis, Lancet 2006; 367:

and intra-arterial thrombolytic therapy in patients with distal internal carotid

cerebral angiography and transcranial Doppler sonography in acute stroke. Stroke.


Ois A, Cuadrado-Godia E, Jimenez-Conde J, et al. Early Arterial Study in the Prediction of

Postert T, Braun B, Meves S, Koster O, Przuntek H, Weber S, Buttner T. Contrast-enhanced

Razumovsky AY, Gilliard JH, Bryan RN, Hanley DF, Oppenheimer SM. TCD, MRA, MRI in

Ribo M, Molina CA, Rovira A, et al. Safety and Efficacy of Intravenous Tissue Plasminogen

Ringelstein EB, Biniek R, Weiller C, Ammeling B, Nolte PN, Thron A. Type and extent of

Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem Internal Carotid Artery/Middle

Saqqur M, Shuaib A, Alexandrov AV, Hill MD, Calleja S, Tomsick T, Broderick J, Demchuk

Saqqur M, Uchino K, Demchuk AM, et al. for CLOTBUST Investigators. Site of Arterial

Saqqur M, Tsivgoulis G, Molina CA, Demchuk AM, Shuaib A, Alexandrov AV. Residual

Seidel G, Karsten Meyer W, Grit B, et al. Ultrasound Perfusion Imaging in Acute Middle Cerebral Artery Infarction Predicts Outcome. Stroke 2004; 35: 1107-1111 Seidel G, Cangür H, Albers T, Burgemeister A, Meyer-Wiethe K., Sonographic evaluation of

Sloan MA, Alexandrov AV, Tegeler CH, Spencer MP, Caplan LR, Feldmann E, Wechsler LR,

Academy of Neurology. Neurology 2004 May 11;62(9):1468-81.

Duplex Sonography–Guided Pilot Study. Stroke 2006; 37: 1805-1809 Seidel G, Kaps M, Gerriets T. Potential and limitations of transcranial color-coded

sonography in stroke patients. Stroke. 1995;26:2061–2066

ischemic stroke, Stroke. 2009 Jan;40:119-23

Transcranial Doppler/MRI Selection Protocol. Stroke 2005; 36: 602-606 Ribo M, Alvarez-Sabn J, Montaner J, et al. Temporal Profile of Recanalization After

transcranial color-coded sonography in acute hemispheric brain infarction. Stroke.

Activator Stroke Treatment in the 3- to 6-Hour Window Using Multimodal

Intravenous Tissue Plasminogen Activator Selecting Patients for Rescue

hemispheric brain infarctions and clinical outcome in early and delayed middle

Cerebral Artery Occlusion An Independent Predictor of Poor Outcome After

AM., Derivation of transcranial Doppler criteria for rescue intra-arterial thrombolysis: multicenter experience from the Interventional Management of

Occlusion Identified by Transcranial Doppler Predicts the Response to Intravenous

flow at the site of intracranial occlusion on transcranial Doppler predicts response to intravenous thrombolysis: a multicenter study. Cerebrovasc Dis. 2008;27:5–12 Sekoranja L, Loulidi J, Yilmaz H, et al. Intravenous vs Combined (Intravenous and Intra-

Arterial) Thrombolysis in Acute Ischemic Stroke A Transcranial Color-Coded

hemorrhagic transformation and arterial recanalization in acute hemispheric

Newell DW, Gomez CR, Babikian VL, Lefkowitz D, Goldman RS, Armon C, Hsu CY, Goodin DS. Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American

Mortality After Acute Ischemic Stroke. Stroke 2007; 38: 2085-2089

acute cerebral ischemia. Acta Neurol Scand 1999; 99: 65–76

cerebral artery recanalization. Neurology 1992; 42: 289-298

Reperfusion Techniques. Stroke 2006;37: 1000-1004

Systemic Thrombolysis. Stroke 2006; 37: 2301-2305.

Thrombolysis for Stroke. Stroke 2007; 38: 948-954

Stroke study. Stroke. 2005;36:865-8.

1999;30:1819 –1826.


**15** 

*Italy* 

**Is There a Place for Clinical** 

**in Synucleinopathies?** 

D. Monaco V. Onofrj and F. Anzellotti *University G.d'Annunzio of Chieti-Pescara* 

**Neurophysiology Assessments** 

M. Onofrj, L. Bonanni, A. Thomas, L. Ricciardi, F. Ciccocioppo,

Parkinson Disease (PD), Dementia with Lewy Bodies (DLB) and Multiple System Atrophy (MSA) are characterized by deposition of Lewy Bodies (LB), consisting of eosinophilic intracellular (intraneural in PD and DLB and intraglial in MSA) inclusions of α-synuclein and allowing the three disorders to be categorized as synucleinopathies. The identification in the last two decades of specific clinical features of synucleinopathies has been a major breakthrough in Neurology, as it prompted a reconsideration of diagnostic and therapeutic approaches to dementia and parkinsonism. The recognition of synuclein and ubiquitin markers in dementia resulted in the reclassification of patients previously considered as affected by Alzheimer Disease (AD) and Vascular Dementia (VaD), and there is now agreement that DLB is the second most common cause of dementia in elderly population: its

DLB is clinically characterized by the presence of prominently dysexecutive dementia (frontal lobe or subcortical dementia according to earlier classification [1]), cognitive fluctuations, consisting of remitting-relapsing episodes of blunted conscience reaching levels of stupor, by the occurrence of visual hallucinations and delusions, by parkinsonian motor signs and hypersensitivity to neuroleptic treatment, ranging from worsening of parkinsonism to the possible lethal neuroleptic-malignant syndromes [2]. Yet, variances of presentation and overlapping symptoms with AD and Fronto-Temporal lobe Degeneration (FTD), could be misleading in the process of addressing a clinical diagnosis with consequent therapeutic risks(e.g. introducing neuroleptic treatments in patient with DLB), or economic costs (e.g. addressing patients with DLB to treatment protocols dedicated to AD patients, based on vaccines or antibodies against β amyloid proteins, a neuropathological feature

It is evident the stringent need for improvement of reliable diagnostic tools (u.e. biomarkers) to differentiate the diseases associated with dementia. In 2010 the National Institute of Health, NIH, held a symposium focused on the development of possible biomarkers for DLB. Among the different suggested biomarkers, neurophysiological assessments were reconsidered, as a large amount of neurophysiological studies had been devoted to AD and

prevalence is reported to be in the 25-43% range in different studies.

PD, whose characteristics are shared by DLB.

**1. Introduction** 

of AD).

