Improvement Of Cerebral Hemodynamics Research Articles

Neurocognitive outcome post cranioplasty: The role of cerebral hemodynamics and cerebrospinal fluid dynamics.

Cranioplasty has been useful in treating the symptoms associated with the "Sunken skin flap syndrome" post decompressive craniectomy, for which various mechanisms have been proposed. In this study, we aim to assess the changes in the cerebral blood flow and intracranial cerebrospinal fluid (CSF) dynamics post cranioplasty and correlate with the improvement in the neurocognitive status. Computed tomography perfusion and cine magnetic resonance imaging studies were done to study the changes in cerebral perfusion and CSF flow dynamics postcranioplasty. The cognitive status was assessed using Montreal cognitive assessment, mini-mental state examination, and frontal assessment battery scores in the preoperative period and at 1 and 6 months follow-up. There was a significant change in cognitive status postcranioplasty, both at 1 and 6 months follow-up, which was associated with a significant improvement in cerebral blood flow, decreased mean transit time, and improvement in the mean and peak CSF flow velocities at the foramen of Magendie and aqueduct of Sylvius. Cranioplasty leads to a marked improvement in cerebral hemodynamics, which is more significant on the ipsilateral side. It also leads to increased CSF turnover and improved CSF circulation. Improved cerebral perfusion and, more importantly, CSF dynamics may be responsible for the demonstrable improvement in the neurocognition in the postcranioplasty period.

Head Down Tilt 15° in Acute Ischemic Stroke with Poor Collaterals: A Randomized Preclinical Trial

Cerebral collaterals are recruited after arterial occlusion with a protective effect on tissue outcome in acute ischemic stroke. Head down tilt 15° (HDT15) is a simple, low cost and accessible procedure that could be applied as an emergency treatment, before recanalization therapies, with the aim to increase cerebral collateral flow. Spontaneously hypertensive rats have been shown to display anatomical differences in morphology and function of cerebral collaterals, compared to other rat strains, resulting in an overall poor collateral circulation. We investigate the efficacy and safety of HDT15 in spontaneously hypertensive (SHR) rats, which were considered as an animal stroke model with poor collaterals. Cerebral ischemia was induced by 90 minute endovascular occlusion of the middle cerebral artery (MCA). SHR rats were randomized to HDT15 or flat position (n = 19). HDT15 was applied 30 minutes after occlusion and lasted 60 minutes, until reperfusion. HDT15 application increased cerebral perfusion (+16.6% versus +6.1%; p = 0.0040) and resulted in a small reduction of infarct size (83.6 versus 107.1 mm3; − 21.89%; p = 0.0272), but it was not associated with early neurological improvement, compared to flat position. Our study suggests that the response to HDT15 during MCA occlusion is dependent on baseline collaterals. Nonetheless, HDT15 promoted a mild improvement of cerebral hemodynamics even in subjects with poor collaterals, without safety concerns.

Surgical Approaches to Pediatric Moyamoya Disease

Moyamoya disease(MMD)is a chronic, occlusive cerebrovascular disease with unknown etiology, characterized by progressive stenosis of the internal carotid artery terminus and abnormal vascular network formation at the base of the brain. MMD has bimodal age distribution, with peaks in children and young adults, and surgical revascularization is a reasonable management choice for pediatric and adult patients with ischemic MMD. The superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis(combined revascularization)is a preferred surgical procedure for adult and pediatric MMD patients, providing early cerebral hemodynamic improvement and long-term favorable outcomes. Pediatric patients with MMD can present intrinsic postoperative hemodynamic complications, such as watershed shift ischemia and transient global hypoperfusion, even after successful revascularization. Therefore, perioperative management based on the early hemodynamic study is critical to avoid surgical complications, including perioperative cerebral infarction.

A Preliminary Report of One-Session Treatment with Cranioplasty and Superficial Temporal Artery-Middle Cerebral Artery Bypass for Hemorrhagic Moyamoya Disease Patients with Skull Defect

The objective of this study was to conduct a retrospective analysis of the safety and efficacy of one-session treatment with cranioplasty and superficial temporal artery-middle cerebral artery (STA-MCA) bypass after decompressive craniectomy in hemorrhagic moyamoya disease (MMD). From March 2019 to August 2021, 5 patients with hemorrhagic MMD after DC were admitted in Nanfang Hospital. All patients underwent digital subtraction angiography to exclude any spontaneous revascularization between the cortex and temporal muscle and the preservation of STA. Then one-stage treatment with STA-MCA bypass and cranioplasty were performed. If no suitable recipient artery was available, an encephalo-myo-synangiosis procedure was used as a salvage plan. Four patients underwent direct STA-MCA bypass, while one underwent encephalo-myo-synangiosis due to absence of a suitable recipient artery. All patients had no hemorrhage on postoperative computed tomography, and no new infarcts were detected on magnetic resonance imaging. There were no new recurrent symptoms at clinical follow-up 8 to 24 months after surgery. Three patients had improved Glasgow Outcome Scale scores, and 2 patients had stable Glasgow Outcome Scale scores. Perfusion computed tomography showed improvement in cerebral hemodynamics. Four follow-up digital subtraction angiographies were performed, suggesting graft patency. One-session treatment with extracranial to intracranial bypass and cranioplasty are safe and effective in patients with MMD who have undergone previous decompressive craniectomy due to hemorrhagic attack.

Вплив препарату Білобіл інтенс на функціональний стан центральної нервової системи у хворих похилого віку, які перенесли ішемічний інсульт

У статті надано клініко-інструментальний аналіз впливу препарату Білобіл інтенс на функціональний стан центральної нервової системи у хворих похилого віку, які перенесли ішемічний інсульт (у ранній відновний період). Відзначається позитивний вплив препарату на загальний стан хворих, когнітивні функції, неврологічний статус, якість життя, соціально-побутову адаптацію, також відбувається гармонізація структури біоелектричної активності головного мозку і поліпшення церебральної гемодинаміки, що дає авторам підставу рекомендувати включення препарату Білобіл інтенс до системи комплексної медикаментозної реабілітації хворих, які перенесли ішемічний інсульт.

Assessing efficacy of endoscopic ventriculocisternostomy using a semi-rigid needle endoscope in сhildren with hydrocephalus and concomitant drug-resistant epilepsy: results of CT brain perfusion and time-frequency EEG analysis

Background. The probability of seizures after endoscopic surgical treatment of hydrocephalus may comprise up to 9.5%, therefore accounting for a need to find solutions for alleviating the surgical trauma to the brain. One option to this problem might be based on using “seamless” neurosurgery, particularly endoscopes with a minimal outer sheath diameter (needle endoscopes, shunt endoscopes).Objective: to evaluate major outcomes of surgically treated epilepsy, cerebral haemodynamics and electroencephalogram (EEG) in children with hydrocephalus and concomitant drug-resistant epilepsy before and after endoscopic ventriculocysternostomy of the third ventricular floor by using a semi-rigid needle endoscope.Material and methods. In the early and remote postoperative periods, no epileptic seizures were observed in 57.1% of subjects (Engel Class I). Mean seizure frequency decreased from 12.9±6.1 to 0.82±0.31 per month (p<0.01). A significant decline in slow-wave amplitude and the paroxysmal index from 19.1±2.5% to 6.9±1.7% (p<0.01) were observed, as well as improvement of cerebral hemodynamics in the form of increased mean cerebral blood flow by 29.1±4.3% (p<0.01), mean circulating blood volume by 22.4±5.27% (p<0.05) and decreased mean transit time by 12.8±2.5% (p<0.05).Results. In the early and remote postoperative periods, no epileptic seizures were observed in 57.1% of subjects (Engel Class I). Mean seizure frequency decreased from 12.9±6.1 to 0.82±0.31 per month (p<0.01). A significant decline in slow-wave amplitude and the paroxysmal index from 19.1±2.5% to 6.9±1.7% (p><0.01) were observed, as well as improvement of cerebral hemodynamics in the form of increased mean cerebral blood flow by 29.1±4.3% (p><0.01), mean circulating blood volume by ><0.01). A significant decline in slow-wave amplitude and the paroxysmal index from 19.1±2.5% to 6.9±1.7% (p<0.01), mean circulating blood volume by 22.4±5.27% (p<0.05) and decreased mean transit time by 12.8±2.5% (p><0.05).

Effect of nape cluster acupuncture on swallowing function and respiratory function in patients with post-stroke dysphagia

To observe the effect of nape cluster acupuncture on swallowing function and respiratory function in patients with post-stroke dysphagia, and to explore its relationship to cerebral arterial flow and neurotrophic factors. A total of 120 patients with post-stroke dysphagia were randomized into an observation group and a control group, 60 patients in each one. The conventional swallowing rehabilitation therapy and respiratory function training were adopted in the control group. On the basis of treatment in the control group, nape cluster acupuncture was applied at Fengchi (GB 20), Tianzhu (BL 10), Wangu (GB 12), Lianquan (CV 23), Panglianquan (Extra), once a day; pricking blood was applied at Jinjin (EX-HN 12) and Yuye (EX-HN 13), once every 2 days. Both groups were treated for 2 weeks. The therapeutic efficacy was compared between the two groups, and the swallowing function (scores of Kubota water swallowing test, standardized swallowing assessment [SSA] and video fluoroscopic swallowing study [VFSS]), the respiratory function indexes (forced vital capacity [FVC], maximal voluntary ventilation [MVV] and maximal expiratory time), the bilateral cerebral arterial hemodynamics parameters (systolic peak velocity [Vs], mean flow velocity [Vm] and vascular resistance index [RI]) and the serology indexes (brain-derived neurotrophic factor [BDNF], nerve growth factor [NGF] and insulin-like growth factors-1 [IGF-1]) before and after treatment were observed in the both groups. The total effective rate was 80.0% (48/60) in the observation group, which was superior to 60.0% (36/60) in the control group (P<0.05). After treatment, the scores of Kubota water swallowing test and SSA in the observation group were lower than the control group (P<0.05), the VFSS score, FVC, MVV and maximal expiratory time were higher than the control group (P<0.05). After treatment, the Vs and Vm of bilateral cerebral artery and serum levels of BDNF, NGF and IGF-1 in the observation group were higher than the control group (P<0.05), the RI of bilateral cerebral artery was lower than the control group (P<0.05). On the basis of the conventional rehabilitation training, nape cluster acupuncture can effectively improve the swallowing function and respiratory function in patients with post-stroke dysphagia, its mechanism may be related to the improvement of cerebral hemodynamics and the regulation of neurotrophic factors.

Late (5-20 years) outcomes after STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis in patients with moyamoya disease.

Surgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5-20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]). Cumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods. During the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients. The study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.

Cerebral Hemodynamics During Neonatal Cerebrospinal Fluid Removal

BackgroundStandard treatment of neonatal posthemorrhagic hydrocephalus is cerebrospinal fluid removal. The aim of this study was to assess how much cerebrospinal fluid volume removal, by ventricular reservoir taps, is needed to improve cerebral hemodynamics and oxygenation in neonatal posthemorrhagic hydrocephalus. MethodsCerebral hemodynamics and oxygenation were continuously monitored by near-infrared spectroscopy in four newborns (one term and three preterm) during 28 ventricular reservoir taps. At each tap, 10 mL/kg of cerebrospinal fluid was removed. Near-infrared spectroscopy detected changes in the concentration of oxy-hemoglobin and total hemoglobin, considered as estimates of cerebral blood flow and volume, respectively. Cerebral tissue oxygenation index was also measured. During cerebrospinal fluid removal, variation in cerebral blood flow, volume, and oxygenation were analyzed by repeated measures analysis of variance. The associations between changes in cerebral hemodynamics and oxygenation, during cerebrospinal fluid removal and after its conclusion, were analyzed by Pearson's r correlation coefficient. ResultsA significant increase in cerebral blood flow and volume was already evident at 50% of targeted cerebrospinal fluid volume removal (P < 0.001). Although cerebral tissue oxygenation index absolute value remained unchanged, variations in cerebral blood flow and oxygenation were positively correlated, both during cerebrospinal fluid removal and after its conclusion (r = 0.57; P = 0.002). ConclusionsOn the basis of the results from this small cohort, the volume of cerebrospinal fluid removal associated with an improvement in cerebral hemodynamics and perfusion seems to be less than the traditional 10 mL/kg. Further research is needed to define the potential role of near-infrared spectroscopy monitoring to individualize cerebrospinal fluid removal.

Changes in Cerebral Hemodynamics in Patients With Cirrhosis After Liver Transplantation.

Improvement in cognitive function after orthotopic liver transplantation (LT) has been demonstrated in the acute setting immediately after LT and in acute liver failure. However, the longterm changes in cerebral hemodynamics after LT remain unexplored. Therefore, we aimed to evaluate the longterm changes in cerebral hemodynamics of patients with cirrhosis after LT. In this prospective cohort study, we performed transcranial Doppler ultrasonography (TCD) measuring the pulsatility index (PI), resistance index (RI), and breath-holding index (BHI) to evaluate cerebrovascular structural integrity and reactivity, respectively, in both middle cerebral arteries before and after LT. Neuropsychometric tests and West-Haven criteria were used for hepatic encephalopathy (HE) characterization. Interleukin 6 and tumor necrosis factor α plasma levels were measured. Descriptive statistics and Wilcoxon's test were used. There were 27 patients who were included. Median follow-up after LT was 6 months, mean age before LT was 46.3 ± 10.3 years, the main etiology was hepatitis C virus (59%), and most of the patients were Child-Pugh B (15/27). Model for End-Stage Liver Disease (MELD) score was 16 ± 7.5, MELD-Na was 19.3 ± 7.1, Psychometric Hepatic Encephalopathy Score was -3.48 ± 3.66, and critical flicker fusion (CFF) was 40.28 ± 5.70 Hz. Before LT, 17/27 patients had HE and 11/27 ascites. A decrease of 20.8% and 13.5% in PI and RI was observed after LT (P < 0.001, both), together with an increase in BHI (32.4%, P = 0.122). These changes in cerebral hemodynamics paralleled those in systemic inflammation. Clinical improvement in cognition was observed in all patients with overt HE after LT. In conclusion, these results show a significant improvement in cerebral hemodynamics after LT, obtained through TCD, indicating less arterial cerebral vasoconstriction together with a decrease in systemic inflammation. Changes in cerebral vasoconstriction can be the basis for the improvement in cognitive function after LT in the long term.

Persistent Primitive Olfactory Artery as Novel Collateral Channel to the Anterior Cerebral Artery in Moyamoya Disease

Background: There are a variety of collateral routes to compensate persistent cerebral ischemia in moyamoya disease. However, there is no report presenting the persistent primitive olfactory artery (POA) as a spontaneous collateral route to the anterior cerebral artery (ACA) in moyamoya disease. Methods: We precisely examined cerebral angiography in 84 patients with moyamoya disease to identify the collateral channel through the persistent POA. Its anatomy was evaluated on pre- and postoperative angiography. Results: Of 84 patients, four (4.8%) had spontaneous collateral channel through the persistent POA. All of these four hemispheres were categorized into Stage 5. In all four patients, the collateral blood flow arose from the ophthalmic artery and run to the persistent POA through the ethmoidal moyamoya. The persistent POA provided collateral blood flow from the ophthalmic artery to the ACA in all four patients. Superficial temporal artery to middle cerebral artery anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis was performed in three of four patients. After surgery, the collateral channel through the persistent POA completely disappeared or markedly regressed, suggesting a significant improvement of cerebral hemodynamics in the territory of not only the MCA but also the ACA. Conclusion: The persistent POA can potentially provide collateral blood flow to the ACA in about 5% of patients with moyamoya disease, and should be recognized as a novel collateral channel in moyamoya disease. The persistent POA may be useful to evaluate therapeutic effects of surgical revascularization on the ACA territory.

Abstract WP131: Repeat Bypass Surgery for Moyamoya Disease Refractory to Previous Surgery

Background and Purpose: Surgical revascularization is known to reduce subsequent incidence of ischemic and hemorrhagic stroke with low morbidity in moyamoya disease. However, repeat bypass surgery is required for a certain subgroup of patients, although the information on indication, surgical technique, and outcome is limited. Therefore, this study was aimed to precisely analyze clinical features, surgical technique, and long-term outcome of repeat bypass surgery for refractory moyamoya disease. Methods: This study included totally 20 surgeries for18 patients who underwent repeat bypass surgery because previous surgery was inadequate in 10 surgeries (Group A) or because the posterior cerebral artery was further involved after surgery in 10 (Group B). There were 7 males and 11 females. Their age ranged from one to 69 years. Precise radiological examinations were performed before surgery, using MRI, cerebral angiography, and SPECT. In Group A, all patients who previously underwent inadequate surgery repeated headache attack, TIA, or hemorrhagic stroke, and underwent repeat bypass surgery targeted to the non-revascularized area, using STA-MCA anastomosis and/or indirect synangiosis as appropriate. On the other hands, occipital artery to posterior cerebral artery (OA-PCA) anastomosis and/or indirect bypass was required in Group B who developed disease progression in the PCA. Results: All 18 patients successfully underwent repeat bypass surgery. Postoperative course was uneventful. Postoperative examinations revealed good revascularization in the operated hemispheres and the improvement of cerebral hemodynamics. Headache attack and TIA disappeared within 6 months at the latest after surgery. During follow-up periods, one (5.6% per person) of 18 patients died of recurrent hemorrhagic stroke two years after repeat bypass surgery. Conclusion: Repeat bypass surgery is feasible and effective to reduce further incidence of headache attack, TIA, and ischemic and hemorrhagic stroke. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

Dynamic of cerebrovascular disorders in patients with carotid stenosis

To study the state of cerebral hemodynamics and platelet hemostasis in patients with carotid stenosis (CS). The prospective study included 123 patients with atherosclerotic CS. The 1st group included 53 patients (mean age 52±12.5 yrs) who underwent carotid endarterectomy (CEA); the 2nd group - 70 patients who were treated conservatively (mean age 58.5±15.9 yrs). The state of blood flow through the main arteries of the head (Doppler flowmetry), platelet aggregation induced by adrenaline, the frequency of acute cardiovascular events that occurred during 12 months were evaluated. The severity of neurological deficits and cognitive impairment increased with increasing of the degree of CS. CEA leads to an improvement of cerebral hemodynamics and stabilization of cognitive functions. The adverse course of the disease occurred in 23.6% of patients (stroke/heart attack during the year in 5.7%, progression of cerebral ischemia in 20%, restenosis within 5 years after CEA in 15%). Hyperaggregation of platelets induced by ADP and epinephrine and decreased aggregation of platelets induced by collagen in patients receiving ASA were identified in 53% of the operated and in 60% of non-operated patients. The use of combined antiplatelet therapy normalize the platelet hemostasis and reduce the frequency of acute cardiovascular events.

Efficacy of superficial temporal artery-middle cerebral artery bypass in cerebrovascular steno-occlusive diseases: Hemodynamics assessed by perfusion computed tomography.

Objectives:Our purpose of this study was to assess the cerebral hemodynamic improvement with perfusion computed tomography (CT), before and after superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery in patients with cerebrovascular steno-occlusive diseases including both moyamoya disease and nonmoyamoya steno-occlusions.Materials and Methods:Twenty-four STA-MCA bypasses were performed to 22 patients with symptomatic cerebrovascular steno-occlusive diseases, including both moyamoya disease and nonmoyamoya steno-occlusive diseases. Brain perfusion CT images were obtained before and after the bypass surgery. The relative parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) derived from the perfusion CT were collected and analyzed to assess the efficacy of STA-MCA bypass.Results:The CBF increased, and MTT decreased after the bypass surgery in both moyamoya group and nonmoyamoya group. The increase of CBF in nonmoyamoya group and the decrease of MTT delay in moyamoya group, overall group were statistically significant (P < 0.05). No significant postoperative change in CBV was noted. During the postoperative follow-up period, none of the 22 patients experienced any repeated ischemic/hemorrhagic attacks nor any newly developed neurologic deficits.Conclusion:The STA-MCA bypass is an effective surgical management for patients with cerebrovascular steno-occlusive diseases, such as moyamoya disease and internal carotid artery/MCA steno-occlusion. And perfusion CT can be used as an effective quantitative modality to assess the cerebral perfusion before and after the STA-MCA bypass surgery.

Clinical and radiological assessment of cerebral hemodynamics after cranioplasty for decompressive craniectomy – A Clinical study

ObjectivesTo find the correlation between radiologically proven improvement in cerebral hemodynamics with clinical improvement in patients undergoing cranioplasty. Material and methodsThe study is a prospective observational study of 10 cases, in M S Ramaiah Institute of Neurosciences, involving patients treated by a decompressive craniectomy for intractable intra cranial hypertension either due to trauma or stroke and afterwards underwent cranioplasty. ResultsOf the 10 patients, 70% patients showing significant improvement in motor functions on Barthel index scale, 60% patients showed improvement in speech, mean duration from date of decompressive craniectomy to cranioplasty being 122.4days. Cerebral perfusion was remarkably better after cranioplasty, as demonstrated decrease in the Pulsatility index on the ipsilateral side of decompression on Trans cranial Doppler (<0.73 mean). This data also favored improved cerebral blood flow and permeability on the CT perfusion with increase in cerebral blood flow (CBF), Cerebral Blood Volume (CBV) and decrease in Time to Peak (TTP) and a positive outcome when correlated with Barthel index with P-values of 0.093, 0.017 and 0.001 respectively. ConclusionCranioplasty influences the cerebral hemodynamics after cranioplasty and has a positive correlation on the functional outcome and cerebral blood flow in the MCA territory.

Transcutaneous Electrical Stimulation on Mastoid Regions Increased Mean Flow Velocity in Patients with Ischemic Stroke

Background: Transcutaneous electrical stimulation had been proven to modulate nervous system activity, leading to improvements in blood flow and trophism of tissues. Very few studies had focused on the cerebral hemodynamic effects of transcutaneous electrical stimulation on mastoid regions. Objective: To investigate the cerebral hemodynamic effects of transcutaneous electrical stimulation on mastoid regions in patients with ischemic stroke. Methods: A total of 40 patients with ischemic stroke were enrolled in this study. Patients were divided into two groups, 20 patients received drugs and transcutaneous electrical stimulation on mastoid regions as an experimental group, while other 20 patients only received drugs as a control group. All patients received 3 weeks of therapeutic intervention. Transcranial Doppler sonography (TCD) was used to detect the mean flow velocity (mFV) values of the anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) at the baseline and end of therapy. A paired t-test and and one-way analysis of variance (ANOVA) with independent samples t test were used to determine the effects of the intervention. Results: Patients of the experimental group had a higher mFV values than those in the control group at the end of therapy (p<0.05). The mFV values of the experimental group at the end of therapy had more favorable elevation in the ACA, MCA and PCA than those at the baseline (p<0.001). In the control group, the mFV values at the end of therapy were also higher compared to the baseline (p<0.001). Conclusion: Our findings seemed to demonstrate that transcutaneous electrical stimulation on mastoid regions had significant effects in the improvement of cerebral hemodynamics for patients with ischemic stroke. Transcutaneous electrical stimulation on mastoid regions might be a valuable neuromodulation technique for ischemic stroke. The mechanisms behind this effect needed to be clarified by further investigations.

Jogging Therapy for Hikikomori Social Withdrawal and Increased Cerebral Hemodynamics: A Case Report.

Severe social withdrawal, called hikikomori, has drawn increased public attention. However, an optimal clinical approach and strategy of treatment has not been well established. Here, we report a case of hikikomori for which an exercise intervention using jogging therapy was effective, showing cerebral hemodynamic improvement. The patient was a 20 year old Japanese male who was hospitalized in order to evaluate and treat severe social withdrawal. Although depressive and anxiety symptoms partially subsided with sertraline alone, social withdrawal persisted due to a lack of self confidence. With his consent, we implemented exercise therapy with 30 minutes of jogging three times a week for three months. We did not change the pharmacotherapy, and his social withdrawal remarkably improved with continuous jogging exercise. Using near infrared spectroscopy to evaluate hemodynamic alteration, bilateral temporal hemodynamics considerably increased after the three-month jogging therapy. Regarding exercise therapy for mental illness, numerous studies have reported the effectiveness of exercise therapy for major depression. This case implied, however, that the applicability of exercise therapy is not limited to major depressive disorder. Jogging therapy may contribute to reinforcing self confidence associated with “resilience” in conjunction with neurophysiological modulation of neural networks.

Abstract 101: Repeat Bypass Surgery for Moyamoya Disease Refractory to Previous Surgery

Purpose: Surgical revascularization is known to reduce subsequent incidence of ischemic and hemorrhagic stroke with low morbidity in moyamoya disease. However, repeat bypass surgery is required for a certain subgroup of patients, although the information on indication, surgical technique, and outcome is limited. Therefore, this study was aimed to precisely analyze clinical features, surgical technique, and long-term outcome of repeat bypass surgery for refractory moyamoya disease. Methods: This study included 16 patients who underwent repeat bypass surgery because previous surgery was inadequate in 10 patients or because the posterior cerebral artery was further involved after surgery in 6. There were 7 males and 9 females. Their age ranged from one to 69 years. Precise radiological examinations were performed before surgery, using MRI, cerebral angiography, and SPECT. All 10 patients who previously underwent inadequate surgery repeated headache attack, TIA, or hemorrhagic stroke, and underwent repeat bypass surgery targeted to the non-revascularized area, using STA-MCA anastomosis and/or indirect synangiosis as appropriate. OA-PCA anastomosis and/or indirect bypass was required in 6 patients who developed disease progression in the PCA. Results: All 16 patients successfully underwent repeat bypass surgery. Postoperative course was uneventful. Postoperative examinations revealed good revascularization in the operated hemispheres and the improvement of cerebral hemodynamics. Headache attack and TIA disappeared within 6 months at the latest after surgery. During follow-up periods, one of 16 patients died of recurrent hemorrhagic stroke two years after repeat bypass surgery. Conclusion: Repeat bypass surgery is feasible and effective to reduce further incidence of headache attack, TIA, and ischemic and hemorrhagic stroke. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

Cerebral hemodynamic benefits after carotid artery stenting in patients with near occlusion

The natural history and management of patients with near occlusion (NO) of the internal carotid artery are controversial. In particular, it is unclear whether cerebral hemodynamics are compromised in these patients and whether improvement by carotid revascularization leads to the prevention of ischemic stroke. In this study, we measured cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) using single-photon emission computed tomography before and after carotid artery stenting (CAS) for NO to examine the effectiveness of CAS from the perspective of cerebral hemodynamics. CAS was performed in 15 patients with NO and in 78 with severe stenosis (≥70%) but without NO at our institution. Resting CBF and CVR to acetazolamide were measured using N-isopropyl-p-[I-123] iodoamphetamine single-photon emission computed tomography before and at 3 to 6months after CAS. We also measured CBF using the same method for healthy individuals and compared the results among the three groups. CAS was successfully performed in all patients. Before CAS, the mean resting CBF was 26.68± 4.23mL/100g/min, and the mean CVR was-0.8%± 15.1% in the patients with NO, both of which were significantly lower than in patients with severe stenosis without NO and in healthy individuals. After CAS, the mean resting CBF and mean CVR in patients with NO increased significantly to 30.07± 5.67mL/100g/min and 37.0%± 21.4%, respectively, and there were no significant differences among the three groups. Before CAS, patients with NO were more hemodynamically compromised than those with severe stenosis without NO. After CAS, significant cerebral hemodynamic improvement and normalization occurred long-term. Thus, from a hemodynamic perspective, CAS was effective in patients with NO.

Cerebral Hemodynamic Benefits after Contralateral Carotid Artery Stenting in Patients with Internal Carotid Artery Occlusion

CEA contralateral to an ICA occlusion is considered a surgical risk, and CAS may be an alternative for these patients. Our goal was to examine whether CAS improves cerebral hemodynamics on the treated side and on the side of the ICA occlusion, on the basis of measurement of CBF and CVR by using SPECT. The subjects were 8 patients who underwent contralateral CAS. Resting CBF and CVR to acetazolamide were measured by using (123)I-IMP SPECT before and chronically (3-6 months) after CAS. Resting CBF was also measured immediately (<2 hours) after CAS by using (123)I-IMP SPECT. There were no significant differences in resting CBF in both hemispheres immediately after CAS. However, resting CBF and CVR both significantly increased in the chronic period in both hemispheres. Contralateral CAS in patients with ICA occlusion resulted in cerebral hemodynamic improvement on the treated side and on the side of ICA occlusion.