Backgound: Flow diversion (FD) can occur with an acute middle cerebral artery (MCA) occlusion. FD is thought to represent the collateral blood flow to the occluded MCA territory, but it is unclear whether or not FD lessens the stroke severity or leads to improved outcome. Methods: Patients with a proximal MCA occlusion were selected from the CLOTBUST trial data bank. FD to the anterior or posterior cerebral artery was determined using transcranial Doppler ultrasound. Stroke severity and clinical improvement were measured using the National Institutes of Health Stroke Scale (NIHSS) scores. Results: We evaluated 47 patients with an isolated M1 MCA occlusion who received intravenous tissue-type plasminogen activator (t-PA) within 3 h of symptom onset. FD was present in 83% of the patients. Median baseline NIHSS scores were 15.5 in the FD– group and 18 in the FD+ group (n.s.). Complete recanalization rates were 25 and 25.6% (n.s.). In 35 patients with a persistent occlusion, the average NIHSS score reduction was 22% (FD+) and 0.52% (FD–) during 90 min after t-PA bolus (p = 0.017), and 29 versus –25% during the first 24 h after the t-PA bolus, respectively (p = 0.01). Conclusions: In patients with persistent MCA occlusions after thrombolytic treatment, arterial blood flow diversion is associated with earlier and better neurological improvement. FD has protective effects on the ischemic brain tissue with persistent MCA occlusion.

Keywords:
Cerebral infarction, Flow diversion, Collateral circulation, Transcranial Doppler ultrasound
1.
Albers GW, Bates VE, Clark WM, Bell R, Verro P, Hamilton S: Intravenous tissue type plasminogen activator for treatment of acute stroke: the standard treatment with alteplase to reverse stroke (STARS) study. JAMA 2000;283:1145–1150.
2.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–1587.
3.
Demchuk AM, Tanne D, Hill MD, Kasner SE, Hanson S, Grond M, Levine SR, the Multicentre t-PA Stroke Study Group: Predictors of good outcome after intravenous tPA for acute ischemic stroke. Neurology 2001;57:474–480.
4.
Davalos A, Toni D, Iweins F, Lesaffre EP, Bastianello S, Castillo J: Neurological deterioration in acute ischemic stroke: potential predictors and associated factors in the European Cooperative Acute Stroke Study (ECASS) I. Stroke 1999;30:2631–2636.
5.
Barber PA, Demchuk AM, Zhang J, Buchan AM: Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet 2000;355:1670–1674.
6.
Molina CA, Alexandrov AV, Demchuk AM, Saqqur M, Uchino K, Alvarez-Sabin J: Improving the predictive accuracy of recanalization on stroke outcome in patients treated with tissue plasminogen activator. Stroke 2004;35:151–156.
7.
Kucinski T, Koch C, Eckert B, Becker V, Kromer H, Heesen C, Grzyska U, Freitag HJ, Rother J, Zeumer H: Collateral circulation is an independent radiological predictor of outcome after thrombolysis in acute ischaemic stroke. Neuroradiology 2003;45:11–18.
8.
Demchuk AM, Christou I, Wein TH, Felberg RA, Malkoff M, Grotta JC, Alexandrov AV: Specific transcranial Doppler flow findings related to the presence and site of arterial occlusion. Stroke 2000;31:140–146.
9.
Mattle H, Grolimund P, Huber P, Sturzenegger M, Zurbrugg HR: Transcranial Doppler sonographic findings in middle cerebral artery disease. Arch Neurol 1988;45:289–295.
10.
Zanette EM, Fieschi C, Bozzao L, Roberti C, Toni D, Argentino C, Lenzi GL: Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke. Stroke 1989;20:899–903.
11.
Brass LM, Duterte DL, Mohr JP: Anterior cerebral artery velocity changes in disease of the middle cerebral artery stem. Stroke 1989;20:1737–1740.
12.
Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, Montaner J, Saqqur M, Demchuk AM, Moye LA, Hill MD, Wojner AW: Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004;351:2170–2178.
13.
Demchuk AM, Burgin WS, Christou I, Felberg RA, Barber PA, Hill MD, Alexandrov AV: Thrombolysis in brain ischemia (TIBI) transcranial Doppler flow grades predict clinical severity, early recovery, and mortality in patients treated with intravenous tissue plasminogen activator. Stroke 2001;32:89–93.
14.
Demchuk AM, Christou I, Wein TH, Felberg RA, Malkoff M, Grotta JC, Alexandrov AV: Accuracy and criteria for localizing arterial occlusion with transcranial Doppler. J Neuroimaging 2000;10:1–12.
15.
Burgin WS, Malkoff M, Felberg RA, Demchuk AM, Christou I, Grotta JC, Alexandrov AV: Transcranial Doppler ultrasound criteria for recanalization after thrombolysis for middle cerebral artery stroke. Stroke 2000;31:1128–1132.
16.
Haley EC Jr, Lewandowski C, Tilley BC: Myths regarding the NINDS rt-PA stroke trial: setting the record straight. Ann Emerg Med 1997;30:676–682.
17.
Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F: Intra-arterial prourokinase for acute ischemic stroke. The Proact II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 1999;282:2003–2011.
18.
Meyer JS, Denny-Brown D: The cerebral collateral circulation. I. Factors influencing collateral blood flow. Neurology 1957;7:447–458.
19.
Yamaguchi T: Regional cerebral blood flow in experimental cerebral infarction, with special reference to hyperemia in the ischemic cerebral hemisphere. Int J Neurol 1977;11:162–178.
20.
Symon L, Ishikawa S, Meyer JS: Cerebral arterial pressure changes and development of leptomeningeal collateral circulation. Neurology 1963;13:237–250.
21.
Toni D, Fiorelli M, Bastianello S, Falcou A, Sette G, Ceschin V, Sacchetti ML, Argentino C: Acute ischemic strokes improving during the first 48 hours of onset: predictability, outcome, and possible mechanisms. A comparison with early deteriorating strokes. Stroke 1997;28:10–14.
22.
Meyer JS: Circulatory changes following occlusion of the middle cerebral artery and their relation to function. J Neurosurg 1958;15:653–673.
23.
Pranevicius M, Pranevicius O: Cerebral venous steal: blood flow diversion with increased tissue pressure. Neurosurgery 2002;51:1267–1273.
24.
Hatashita S, Hoff JT: Cortical tissue pressure gradients in early ischemic brain edema. J Cereb Blood Flow Metab 1986;6:1–7.
25.
Guadagno JV, Warburton EA, Jones PS, Fryer TD, Day DJ, Gillard JH, Carpenter TA, Aigbirhio FI, Price CJ, Baron JC: The diffusion-weighted lesion in acute stroke: heterogeneous patterns of flow/metabolism uncoupling as assessed by quantitative positron emission tomography. Cerebrovasc Dis 2005;19:239–246.
26.
Baron JC: Stroke research in the modern era: imaging versus dogmas. Cerebrovasc Dis 2005:20:154–163.
© 2006 S. Karger AG, Basel
2006
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.