Robin Hood Syndrome Research Articles

Acute Revascularization Induced Reversed Robin Hood Syndrome

Paradoxical intracranial hemodynamic steal (IHS) is a contradictory reduction of cerebral blood flow volume in the territory of the impaired perfusion area occurring spontaneously or in response to vasodilatory stimuli, which can be recorded and evaluated on transcranial doppler (TCD). IHS followed by early neurological worsening (change in National Institute of Health Stroke Scale [NIHSS]> 2) in acute ischemic stroke patients has been described as reversed Robin Hood syndrome (RRHS). We describe two cases of RRHS following carotid artery stenting (CAS) in patients with contralateral carotid occlusion and its further management. Two patients with a history of anterior circulation strokes presented with recent complaints of dizziness and a sensation of being pulled back (patient 1), and episodic numbness of upper limbs (patient 2). On CT angiogram, both of the patients had severe extracranial internal carotid artery (ICA) stenosis on the symptomatic side associated with complete occlusion of the ICA on the contralateral side. In addition, both patients had impaired vasomotor reactivity (VMR) on TCD in the bilateral middle cerebral artery (MCA). Therefore, CAS on the symptomatic side was performed in both patients by femoral artery access without any periprocedural and postprocedural complications. However, on day 1 post CAS, complaints of transient upper limb tingling (patient 1) and limb shaking (patient 2) were reported corresponding to the completely occluded ICA, and TCD examinations confirmed RRHS in both patients. Patients were managed by decreasing the dose of antihypertensive medication to augment the blood pressure for 2 weeks. Normalization of the VMR on TCD was seen on follow-up, and both patients remain asymptomatic.

Thinking Reverse Robin Hood Syndrome in the Emergency Room: Case of a Male with Vertigo

Thinking Reverse Robin Hood Syndrome in the Emergency Room: Case of a Male with Vertigo

Reversal of the reversed ‘Robin Hood syndrome’ after superficial temporal-Middle cerebral artery bypass for severe intracranial stenosis

Background: Intracranial arterial stenosis is a common cause of ischemic stroke. Recent attempts with intracranial stenting and superficial temporal-middle cerebral artery (STA-MCA) bypass failed to show benefit. Perhaps, better strategies are needed for selecting suitable patients. Acetazolamide-challenged single photon emission computed tomography (SPECT) can demonstrate reversed Robin Hood syndrome (RRHS) due to intracranial steal phenomenon and identify high-risk patients.Methods: We describe the clinical and SPECT findings of RRHS.Results: In our patient with severe and symptomatic severe stenosis of the right MCA, STA-MCA bypass resulted in complete resolution of RRHS.Conclusion: STA-MCA bypass surgery should be considered a possible option in patients with severe stenosis of intracranial internal carotid artery or MCA in carefully selected patients.

Reversed Robin Hood Syndrome in the Light of Nonlinear Model of Cerebral Circulation

The brain is supplied by the internal carotid and vertebro-basilar systems of vessels interconnected by arterial anastomoses and forming at the base of the brain a structure called the Circle of Willis (CoW). An active intrinsic ability of cerebral vascular bed maintains constant Cerebral Blood Flow (CBF) in a certain range of systemic pressure changes. This ability is called autoregulation and together with the redundant structure of the CoW guarantee maintaining CBF even in partial occlusion of supplying arteries. However, there are some situations when the combination of those two mechanisms causes an opposite effect called the Reversed Robin Hood Syndrome (RRHS). In this work we proposed a model of the CoW with autoregulation mechanism and investigated a RRHS which may occur in the case of Internal Carotid Artery (ICA) stenosis combined with hypercapnia. We showed and analyzed the mechanism of stealing the blood by the contralateral side of the brain. Our results were qualitatively compared with the clinical reports available in the literature.

Abstract TP379: Excessive Daytime Sleepiness in Stroke Survivors: Evidence From an Integrative Literature Review

Background and Purpose: Excessive daytime sleepiness (EDS) is a prevalent symptom among stroke survivors. An understanding and accurate diagnosis of EDS is important, not only because EDS has been identified as an independent risk factor for stroke, but also because EDS may reduce stroke survivors’ quality of life, cognitive functioning and daytime functional performance. The lack of a universally accepted definition of EDS makes it difficult to measure and synthesize research. The purpose of this integrative review is to describe post-stroke EDS; to ascertain conceptual and operational definitions of EDS; to identify factors that contribute to EDS in stroke survivors; and to explore consequences of EDS in stroke survivors. Methods: Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an integrative review of the literature was conducted. We searched the following databases: PubMed, MEDLINE (OvidSP 1946 - April, Week 2, 2015), Embase (OvidSP 1974 - March, Week 1, 2015) and PsycINFO (OvidSP 1967 - April, Week 2, 2015), which yielded 340 articles and 27 articles met inclusion criteria. Results: The evidence suggests EDS is a multidimensional construct that is operationalized with subjective and objective measures. Choosing measures that can quantify both the objective and subjective components is useful to gain a comprehensive understanding of EDS. The antecedents of EDS are sub-types of stroke, sleep disordered breathing, Reversed Robin Hood Syndrome and depression. Consequences of EDS in stroke are serious and negative. A potential framework of post-stroke EDS is proposed and may be of use in clinical practice and in research to identify valid quantifying methods for EDS as well as to prevent harmful outcomes in stroke survivors. Conclusion: EDS is frequently experienced after stroke and may not always be caused by SDB. Healthcare providers and sleep specialists can seek to influence stroke survivors’ functional, neurological, and health-related outcomes through interventions that avoid EDS, depressive symptoms or SDB. Whenever SDB is suspected in stroke survivors, choosing both a subjective and objective evaluation of sleep may be indicated.

Excessive Daytime Sleepiness in Stroke Survivors: An Integrative Review.

Excessive daytime sleepiness (EDS) is a prevalent symptom among stroke survivors. This symptom is an independent risk factor for stroke and may reduce stroke survivors' quality of life, cognitive functioning, and daytime functional performance. The lack of a universally accepted definition of EDS makes it difficult to measure EDS and synthesize research. The purpose of this integrative review is to describe poststroke EDS, ascertain conceptual and operational definitions of EDS, identify factors that contribute to EDS in stroke survivors, and explore outcomes associated with EDS in stroke survivors. We searched the following databases: PubMed and MEDLINE (OvidSP 1946-April; Week 2, 2015), Embase (OvidSP 1974-March; Week 1, 2015), and PsycINFO (OvidSP 1967-April; Week 2, 2015). Our search yielded 340 articles, 27 of which met inclusion criteria. The literature reveals EDS to be a multidimensional construct that is operationalized with both subjective and objective measures. Choosing measures that can quantify both the objective and subjective components is useful for gaining a comprehensive understanding of EDS. The antecedents of EDS are stroke, sleep-disordered breathing, reversed Robin Hood syndrome, and depression. The outcomes associated with EDS in stroke patients are serious and negative. Via synthesis of this research, we propose a possible framework for poststroke EDS, which may be of use in clinical practice and in research to identify valid quantifying methods for EDS as well as to prevent harmful outcomes in stroke survivors.

Intracranial Pressure and Collateral Blood Flow.

Leptomeningeal collateral vessels, linking the 3 major arterial territories over the surface of the brain, have been recognized for >140 years.1 More widespread use of advanced clinical imaging in the past decade has led to increasing recognition of the key importance of collaterals in ischemic stroke outcome.2 However, recent studies from several groups indicate that failure of initially good collateral supply is a key feature of patients with delayed infarct expansion.3,4 This clinically challenging problem typically occurs in the first 1 to 2 days after hospital admission in patients with initially mild stroke symptoms. Rethrombosis of reperfused vessels was previously thought to be the likely cause of delayed infarct expansion in most patients. However, this theory is not supported by more recent evidence from imaging studies. Despite the important recent observations, there is limited understanding of the dynamic control of the collateral circulation, in particular, the cause of collateral blood flow failure. In this article, we will discuss recent observations from our experimental stroke model, indicating a dramatic increase in intracranial pressure (ICP) occurring around 24 hours after onset of even small stroke.5,6 We have also shown a significant linear reduction of collateral blood flow in response to progressive ICP elevation.7 We believe that a similar transient ICP elevation occurring during the first 1 to 2 days post stroke is a likely mechanism to explain delayed infarct expansion in patients with minor stroke. Perhaps surprisingly, we can find no published data on ICP at 24 hours in patients with minor stroke. The preclinical findings suggest that gathering such data should be a priority. ### Human Stroke There is a strong association between the extent of leptomeningeal collaterals and clinical stroke outcome. Initial studies using digital subtraction angiography permitted direct visualization of collateral vessels and …

Robin Hood Caught in Wonderland

We present the case of a 53-year-old woman presenting several episodes of body image distortions, ground deformation illusions, and problems assessing distance in the orthostatic position corresponding to the Alice in Wonderland syndrome. No symptoms were reported when sitting or lying down. She had uncontrolled hypertension, hyperglycemia, hypercholesterolemia, and a history of head trauma. Her condition had been diagnosed with left internal carotid artery dissection 2 years earlier. Brain SPECT with 99mTc-ECD performed after i.v. injection of the radiotracer in supine and in standing positions showed hypoperfusion in the healthy contralateral frontoparietal operculum (Robin Hood syndrome), deteriorating when standing up.

Abstract TP150: Intracranial steal phenomenon in Patients with Severe Steno-occlusive Disease of Intracranial Carotid or Middle Cerebral Artery

Background: Intracranial stenosis is a strong risk factor for stroke recurrence. In severe stenosis, perfusion is maintained by collaterals and cerebral autoregulation (CA). CA may be impaired due to inadequate cerebral vasodilatory reserve (CVR) & intracranial steal phenomenon, so called ‘reversed-Robin Hood syndrome (RRHS)’. Identification of patients with inadequate CVR and RRHS may help in selecting high-risk patients. Methods: We prospectively included patients with symptomatic and severe stenosis of intracranial carotid (ICA) & middle cerebral artery (MCA). CVR was evaluated with TCD & breath-holding index (BHI) <0.69 represented inadequate CVR. RRHS was detected as transient velocity reduction in affected artery when flow increased in the reference artery. Patients with RRH were further evaluated with acetazolamide-challenged HMPAO-SPECT. Results: TCD detected inadequate CVR in 112 patients (79 males, mean age 57yrs; range 23-79yrs) with severe intracranial stenosis of ICA or MCA. RRHS with a median steal magnitude of 17% (inter-quartile range, IQR 10) was seen in 35 (31%) patients. HMPAO-SPECT demonstrated perfusion deficit (median 8%; IQR 13%) in 33 out of these 35 cases (sensitivity 78%, specificity 96% with positive predictive value 96%). A strong relationship between RRH on TCD and SPECT was noted on ROC curve analysis (area under curve 0.93; 95% confidence interval 0.88-0.98;p<0.00001). Linear relationship was seen between TCD steal magnitude and SPECT (Pearson correlation coefficient, r=0.643;p<0.0001). Patients with RRHS were at a higher risk of developing recurrent cerebral ischemia (RR 1.7, 95%CI 1.2-3.6; p=0.04). Conclusions: Intracranial steal phenomenon in patients with severe intracranial stenosis is associated with high risk of cerebral ischemic events. Acetazolamide-challenged HMPAO-SPECT is reliable in the diagnosis of reversed Robin Hood syndrome in patients with severe steno-occlusive disease of intracranial carotid and middle cerebral artery. Identification of RRHS might help in identifying a target group of patients for possible revascularization

A Case of Reversed Robin Hood Syndrome: A Prognostic Indicator for an Urgent Therapy

IntroductionIn acute stroke, the diagnosis of reversed Robin Hood syndrome (RRHS) by transcranial Doppler (TCD) helps to identify patients at high risk for neurological deterioration. ReportA patient with left intracranial internal carotid artery (ICA) dissection and concomitant inadequate collateral circulation suffered from recurrent ipsilateral ischaemic symptoms, not prevented by the best medical treatment. TCD showed an RRHS. Stenting of ICA could restore an adequate flow with disappearance of the RRHS and prevention of further episodes. DiscussionAn invasive emergency treatment should be considered in those stroke patients in which TCD detects an inadequate haemodynamic status.

A Case of Reversed Robin Hood Syndrome: A Prognostic Indicator for an Urgent Therapy

Introduction: In acute stroke, the diagnosis of reversed Robin Hood syndrome (RRHS) by transcranial Doppler (TCD) helps to identify patients at high risk for neurological deterioration. Report: A patient with left intracranial internal carotid artery (ICA) dissection and concomitant inadequate collateral circulation suffered from recurrent ipsilateral ischaemic symptoms, not prevented by the best medical treatment. TCD showed an RRHS. Stenting of ICA could restore an adequate flow with disappearance of the RRHS and prevention of further episodes. Discussion: An invasive emergency treatment should be considered in those stroke patients in which TCD detects an inadequate haemodynamic status. A Case of Reversed Robin Hood Syndrome: A Prognostic Indicator for an Urgent TherapyEJVES ExtraVol. 24Issue 6PreviewIn acute stroke, the diagnosis of reversed Robin Hood syndrome (RRHS) by transcranial Doppler (TCD) helps to identify patients at high risk for neurological deterioration. Full-Text PDF Open Access

Cerebrovascular consequences of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is defined by interrupted breathing during sleep due to airway obstruction with an ongoing respiratory effort. In adults, OSA most commonly is caused by decreased muscle tone (required for patency) in the soft tissues of the upper airway.[1][1] Symptoms of OSA include

Reversed Robin Hood Syndrome in a Patient With Luxury Perfusion After Acute Ischemic Stroke

A 49-year-old man presented with a 1-day history of multiple transient episodes of right-sided weakness. The episodes were stereotypical, precipitated by exertion, and lasted 5 to 10 minutes. He denied any chest pain, palpitation, headache, or injury. He was a chronic smoker (40 cigarettes per day for 20 years) and denied any past or family history of hypertension, diabetes mellitus, dyslipidemia, stroke, or ischemic heart disease. On arrival, he was fully conscious and oriented and had regular pulse (65 bpm), and blood pressure (145/90 mm Hg). Some word-finding difficulties and mild right-sided weakness (power, Medical Research Council grade 4) were noted (National Institute of Health Stroke Scale score, 4 points). Magnetic resonance imaging of the brain (Figure 1A) revealed multiple areas of restricted diffusion in the left middle cerebral artery (MCA) territory. Although the classic ultrasonographic findings were not seen on carotid duplex, the absence of significant atherosclerotic plaques …

Sleep-Disordered Breathing and Arterial Blood Flow Steal Represent Linked Therapeutic Targets in Cerebral Ischaemia

The pathogenic link between sleep-disordered breathing and early neurological deterioration in acute ischaemic stroke patients is now a subject of clinical investigations. Vasomotor reactivity and intracranial blood flow steal in response to changing vasodilatory stimuli like carbon dioxide play a pivotal role in clinical deterioration with reversed Robin Hood syndrome. A mechanical ventilatory correction in selected acute stroke patients might have a beneficial effect on sleep-disordered breathing and brain perfusion. This is a novel therapeutic target and the missing link in the pathogenesis of early neurological deterioration and stroke recurrence.

Association of reversed Robin Hood syndrome with risk of stroke recurrence

Reversed Robin Hood syndrome (RRHS) has recently been identified as one of the mechanisms of early neurologic deterioration in acute ischemic stroke (AIS) patients related to arterial blood flow steal from ischemic to nonaffected brain. We sought to investigate the association of RRHS with risk of stroke recurrence in a single-center cohort study. Consecutive patients with AIS or TIA affecting the anterior circulation were prospectively evaluated with serial NIH Stroke Scale assessments and bilateral transcranial Doppler monitoring with breath-holding test. RRHS was defined according to previously validated criteria. A total of 360 patients (51% women, mean age 62 ± 15 years) had an ischemic stroke (81%) or TIA (19%) in the anterior circulation, and 30 (8%) of them had RRHS. During a mean follow-up period of 6 months (range 1-24), a total of 16 (4%) recurrent strokes (15 ischemic and 1 hemorrhagic) were documented. The cumulative recurrence rate was higher in patients with RRHS (19%; 95% confidence interval [CI] 1-37) compared to the rest (15%; 95% CI 0-30; p = 0.022 by log-rank test). All recurrent strokes in patients with RRHS were cerebral infarcts that occurred in the ipsilateral to the index event anterior circulation vascular territory. After adjusting for demographic characteristics, vascular risk factors, and secondary prevention therapies, RRHS was independently associated with a higher stroke recurrence risk (hazard ratio 7.31; 95% CI 2.12-25.22; p = 0.002). Patients with AIS and RRHS appear to have a higher risk of recurrent strokes that are of ischemic origin and occur in the same arterial territory distribution to the index event. Further independent validation of this association is required in a multicenter setting.

Intellectual Property Crime: The Urgent Need for Global Attention

In the last couple of months I have spent considerable time with police officials in India. I am worried, very worried about the conversations I have had with them which were largely centred around the state of the informal economy, in which Intellectual Property (IP) crime plays a huge part. The most unsettling linkage is the one between the proceeds of IP crimes and terrorist activities. A senior police officer with whom I have had extensive discussions on the subject acknowledged some recent reports that many terrorist organisations now source their funding through IP crimes. According to him the terrorist outfits or organised criminal networks do not operate in a vacuum but very much in the real world. They need an interface with real commerce in order to fund their nefarious activities. These organisations are becoming increasingly sophisticated and are beginning to control the majority of IP crimes that are taking place, particularly in developing countries. The officer claims that in his state alone (India has 28 states) rampant music piracy results in a massive loss to the economy. He estimates that the size of the informal music sector is at least 12 times the size of legitimate industry. He does not stop there and quotes many more examples from fake designer goods to more serious instances, such as counterfeit drugs, food products and adulterated petrol, which have major health and safety implications. This analysis of the situation in India also applies to other high-growth countries as well as some Organisation for Economic Cooperation and Development (OECD) countries. Most global surveys however frequently cite the BRIC (Brazil, Russia, India and China) nations as the worst IP offenders. The BRIC economies are playing a major role in global economic growth and weak IP regimes in these countries are a cause of major concern for companies that sell products into these markets.

P35-23 Reversed Robinhood syndrome by normobaric hyperoxia therapy in patients with acute ischemic stroke

P35-23 Reversed Robinhood syndrome by normobaric hyperoxia therapy in patients with acute ischemic stroke

Prevalence and Risk Factors Associated With Reversed Robin Hood Syndrome in Acute Ischemic Stroke

Early deterioration can occur after acute stroke for a variety of reasons. We describe a hemodynamic steal and associated neurological deterioration, the reversed Robin Hood syndrome (RRHS). We aimed to investigate the frequency and factors associated with RRHS. Consecutive patients with acute cerebral ischemia underwent serial National Institutes of Health Stroke Scale and bilateral transcranial Doppler monitoring with breathholding. Steal magnitude (%) was calculated from transient mean flow velocity reduction in the affected arteries at the time of velocity increase in normal vessels. Excessive sleepiness and likelihood of sleep apnea were evaluated by the Epworth Sleepiness Scale and Berlin Questionnaire. Among 153 patients (age, 61+/-14 years; 48% women; 21% transient ischemic attack) admitted within 48 hours from symptom onset, 21 (14%) had steal phenomenon (median steal magnitude, 20%; interquartile range, 11%; range, 6% to 45%), and 11 (7%) had RRHS. RRHS was most frequent in patients with proximal arterial occlusions (17% versus 1%; P<0.001). The following factors were independently (P<0.05) associated with RRHS (multivariate logistic regression model): male gender, younger age, persisting arterial occlusions, and excessive sleepiness (P<0.001). A 1-point increase in the Epworth Sleepiness Scale was independently related to an increased likelihood of RRHS of 36% (95% CI, 7% to 73%). RRHS and hemodynamic steal can be found in 7% and 14%, respectively, of consecutive patients with stroke without other known causes for deterioration. Patients with persisting arterial occlusions and excessive sleepiness can be particularly vulnerable to the steal.

Prognostic impact of microembolic signals in arterial sources of embolism

Sir I read with interest the review by Ritter et al. [3] regarding the prevalence and prognostic impact of microembolic signals (MES) in arterial sources of cerebral embolism. I wish to comment on some important issues related to this review. Emboli originating from an atherosclerotic stenotic plaque are considered to play an important etiological role in subsequent cerebral ischemic events [2], and the detection of MES may help in clinical decision-making, especially in patients previously considered to have asymptomatic arterial stenoses. However, this approach is still not widely accepted and appears to be looking at ‘only one side of the picture.’ Cerebral ischemic events secondary to hemodynamic disturbances (hypoperfusion) in patients with significant stenotic lesions constitute an important clinical group, and these patients can be easily evaluated with transcranial Doppler and assessment of cerebral autoregulation (CA). CA is the inherent ability of the cerebral blood vessels to maintain the blood flow over a wide range of systemic blood pressure and various provocative stimuli [6] and can be assessed by testing the vasomotor reactivity (VMR). Flow velocities obtained in real-time by TCD can reflect cerebral blood flow volume (CBFV), and the velocity changes can be proportionate to the changes in CBFV if certain parameters are known and remain constant (e.g., angle of insonation, perfusion territory, and arterial diameter) and the effect of only one stimulus is observed [5]. Evaluation of VMR to various ‘challenges’ and maneuvers may help in the prognostic assessment of patients with significant stenosis in the cervico-cranial cerebral arteries. Silverstrini et al. [4] demonstrated a significantly higher risk of subsequent cerebral ischemic events in patients with asymptomatic carotid stenosis and having impaired VMR, assessed by breath-holding index. VMR can be easily assessed by monitoring the blood flow velocities (by TCD) during voluntary breath-holding in any intracranial artery distal to the stenosis. Elevation of carbon-dioxide levels in blood during breath-holding is a strong vasodilatory stimulus and results in significant augmentation of flow velocities in the intracranial arteries. However, the arteries distal to the segment with significant stenosis tend to maintain maximal vasodilation and may not dilate further in response to hypercapnia, reflected by a blunted response in the blood flow velocities. The response may be further affected, in some cases, due to ‘intracranial steal phenomenon’ known as ‘reversed Robin Hood syndrome’ [1]. I propose that, in addition to the MES monitoring, patients with hemodynamically significant stenosis in the cervical or intracranial cerebral arteries should be evaluated for VMR by TCD. Assessment of VMR in the arterial segments distal to the atherosclerotic segment would reveal, at least to some extent, the ‘other side of the picture’ and help in better understanding of cerebral hemodynamics and the pathogenic mechanisms of cerebral ischemia in these patients. Well-designed prospective studies would, however, be needed to test the feasibility and efficacy of this approach in clinical decision-making.

Reversed Robin Hood Syndrome in Acute Ischemic Stroke Patients

Recurrent hemodynamic and neurological changes with persisting arterial occlusions may be attributable to cerebral blood flow steal from ischemic to nonaffected brain. Transcranial Doppler monitoring with voluntary breath-holding and serial NIH Stroke Scale (NIHSS) scores were obtained in patients with acute middle cerebral artery or internal carotid artery occlusions. The steal phenomenon was detected as transient, spontaneous, or vasodilatory stimuli-induced velocity reductions in affected arteries at the time of velocity increase in normal vessels. The steal magnitude (%) was calculated as [(MFVm-MFVb)/MFVb]x100, where m=minimum and b=baseline mean flow velocities (MFV) during the 15- to 30-second period of a total 30 second of breath-holding. Six patients had steal phenomenon on transcranial Doppler (53 to 73 years, NIHSS 4 to 15 points). Steal magnitude ranged from -15.0% to -43.2%. All patients also had recurrent neurological worsening (>2 points increase in NIHSS scores) at stable blood pressure. In 3 of 5 patients receiving noninvasive ventilatory correction for snoring/sleep apnea, no further velocity or NIHSS score changes were noted. Our descriptive study suggests possibility to detect and quantify the cerebral steal phenomenon in real-time. If the steal is confirmed as the cause of neurological worsening, reversed Robin Hood syndrome may identify a target group for testing blood pressure augmentation and noninvasive ventilatory correction in stroke patients.