Background and Purpose-TIMI angiographic classification measures coronary residual flow and recanalization. We developed a Thrombolysis in Brain Ischemia (TIBI) classification by using transcranial Doppler (TCD) to noninvasively monitor intracranial vessel residual flow signals. We examined whether the emergent TCD TIBI classification correlated with stroke severity and outcome in patients treated with intravenously administered tPA (IV-tPA). Methods-TCD examination occurred acutely and on day 2. TIBI flows were determined at distal MCA and basilar artery depths, depending on occlusion site. TIBI waveforms were graded as follows: 0, absent; 1, minimal; 2, blunted; 3, dampened; 4, stenotic; and 5, normal. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 24 hours after administration of tPA. Results-One hundred nine IV tPA patients were studied. MeanϮSD age was 68Ϯ16 years; median NIHSS score before administration of tPA (pre-tPA) was 17.5. The tPA bolus was administered 143Ϯ58 minutes and the TCD examination 141Ϯ57 minutes after symptom onset. Pre-tPA NIHSS scores were higher in patients with TIBI grade 0 than TIBI grade 4 or 5 flow. TIBI flow improvement to grade 4 or 5 occurred in 35% of patients (19/54) with an initial grade of 0 or 1 and in 52% (12/23) with initial grade 2 or 3. The 24-hour NIHSS scores were higher in follow-up in patients with TIBI grade 0 or 1 than those with TIBI grade 4 or 5 flow. TIBI flow recovery correlated with NIHSS score improvement. Lack of flow recovery predicted worsening or no improvement. In-hospital mortality was 71% (5/7) for patients with posterior circulation occlusions; it was 22% (11/51) for patients with pre-tPA TIBI 0 or 1 compared with 5% (1/19) for those with pre-tPA TIBI 2 or 3 anterior circulation occlusions. Key Words: stroke, acute Ⅲ thrombolysis Ⅲ ultrasound Ⅲ ultrasonography, Doppler, transcranial C linical benefit of tissue plasminogen activator (tPA) in ischemic stroke is linked to accelerated clot lysis and early recanalization. 1,2 However, previous angiographic studies 3 with systemic tPA in stroke have revealed only a 30% to 40% recanalization rate. Cardiology studies 4 suggest that circulation to and about the thrombus appears to be the most important factor associated with thrombolytic failure. Persisting perfusion or residual flow around coronary arteries is best measured angiographically and can be graded with the thrombolysis in myocardial ischemia (TIMI) flow grades. 5 Such a grading system has not been established for intracranial vessels. Transcranial Doppler (TCD) is the ideal noninvasive, real-time bedside tool for evaluation of cerebral vessels, particularly in the setting of thrombolysis. We sought to develop a grading system for residual flow with use of TCD. This study describes and evaluates a novel TCD grading system for residual flow called Thrombolysis in Brain Ischemia (TIBI; Health Outcomes Institute, Inc) in a series of systemically treated acute stroke patients. Conclusions-Emergent Subjects and ...

Background and Purpose-Early identification of stroke patients at risk for fatal brain edema may be useful in selecting patients for aggressive interventions. Prior studies suggested that early nausea/vomiting and major hypodensity on baseline computed tomography (CT) were predictive of herniation. Methods-This study was a retrospective multicenter case-control study of patients with large middle cerebral artery (MCA) strokes admitted within 48 hours of symptom onset. Medical records, laboratory data, and CT scans were analyzed. Cases, defined as patients who died of massive brain swelling, were compared with all remaining patients as controls. Results-Two hundred one patients with large MCA strokes were identified: 94 (47%) died of brain swelling, 12 (6%) died of non-neurological causes, and 95 (47%) survived at day 30. Multivariable analysis, adjusted for age and clustered by center, identified the following predictors of fatal brain edema: history of hypertension (OR 3.0, 95% CI 1.2 to 7.6, Pϭ0.02), history of heart failure (OR 2.1, 95% CI 1.5 to 3.0, PϽ0.001), elevated white blood cell count (OR 1.08 per 1000 white blood cells/L, 95% CI 1.01 to 1.14, Pϭ0.02), Ͼ50% MCA hypodensity (OR 6.3, 95% CI 3.5 to 11.6, PϽ0.001), and involvement of additional vascular territories (anterior cerebral artery, posterior cerebral artery, or anterior choroidal artery; OR 3.3, 95% CI 1.2 to 9.4, Pϭ0.02). Initial level of consciousness, National Institutes of Health Stroke Scale score, early nausea/vomiting, and serum glucose were associated with neurological death in bivariable but not multivariable analyses. Conclusions-Among patients with large MCA infarctions, an increased risk of fatal brain edema is associated with history of hypertension or heart failure, increased baseline white blood cell count, major early CT hypodensity involving Ͼ50% of the MCA territory, and involvement of additional vascular territories. These data confirm and expand on prior research with a broad-based patient population. The presence of these risk factors identifies those stroke patients who may require aggressive therapeutic approaches. (Stroke. 2001;32:2117-2123.)

The authors determined transcranial Doppler (TCD) accuracy for the proximal internal carotid artery (ICA), distal ICA, proximal middle cerebral artery (MCA), distal MCA, anterior cerebral artery (ACA), posterior cerebral artery (PCA), terminal vertebral artery (tVA), and basilar artery (BA) occlusion in cerebral ischemia patients. Detailed diagnostic criteria were prospectively applied for TCD interpretation independent of angiographic findings. Of 320 consecutive patients referred to the neurosonology service with symptoms of cerebral ischemia, 190 (59%) patients also underwent angiography (MRA or DSA). 48 of those 190 patients had angiographic occlusion and 12 of those 48 patients had involvement of multiple vessels. Median time from TCD until angiography was performed was 1 hour (41 patients had angiography before TCD). TCD showed 40 true positive, 8 false negative, 8 false positive, and 134 true negative studies with sensitivity 83.0%, specificity 94.4%, positive predictive value 83.0%, negative predictive value 94.4%, and accuracy 91.6% to determine all sites of occlusion. Sensitivity for each individual occlusion site was: proximal ICA 94%, distal ICA 81%, MCA 93% tVA 56%, BA 60%. Specificity ranged from 96% to 98%. TCD is sensitive and specific in determining the site of the arterial occlusion using detailed diagnostic criteria, including proximal ICA and distal MCA lesions. TCD has the highest accuracy for ICA and MCA occlusions. If the results of TCD are normal, there is at least a 94% chance that angiographic studies will be negative.

Background and Purpose-Transcranial Doppler (TCD) can localize arterial occlusion in stroke patients. Our aim was to evaluate the frequency of specific TCD flow findings with different sites of arterial occlusion. Methods-Using a standard insonation protocol, we prospectively evaluated the frequency of specific TCD findings in patients with or without proximal extracranial or intracranial occlusion determined by digital subtraction or MR angiography. Conclusions-Specific TCD findings are common with major arterial occlusion and can be used to broaden diagnostic batteries and improve the predictive value of noninvasive screening in stroke patients. TCD findings useful to localize anterior circulation occlusion include collaterals, abnormal waveforms or velocities, and flow diversion to perforators. Results-Of

Background and Purpose-Transcranial Doppler (TCD) can demonstrate arterial occlusion and subsequent recanalization in acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA). Limited data exist to assess the accuracy of recanalization by TCD criteria. Methods-In patients with acute middle cerebral artery (MCA) occlusion treated with intravenous tPA, we compared posttreatment TCD with angiography (digital subtraction or magnetic resonance). On TCD, complete occlusion was defined by absent or minimal signals, partial occlusion by blunted or dampened signals, and recanalization by normal or stenotic signals. Angiography was evaluated with the Thrombolysis In Myocardial Ischemia (TIMI) grading scale. Results-Twenty-five patients were studied (age 61Ϯ18 years, 16 men and 9 women). TCD was performed at 12Ϯ16hours and angiography at 41Ϯ57 hours after stroke onset, with 52% of studies performed within 3 hours of each other. Recanalization on TCD had the following accuracy parameters compared with angiography: sensitivity 91%, specificity 93%, positive predictive value (PPV) 91%, and negative predictive value (NPV) 93%. To predict partial occlusion (TIMI grade II), TCD had sensitivity of 100%, specificity of 76%, PPV of 44%, and NPV of 100%. TCD predicted the presence of complete occlusion on angiography (TIMI grade 0 or I) with sensitivity of 50%, specificity of 100% Key Words: angiography Ⅲ recanalization Ⅲ thrombolysis Ⅲ ultrasonography T he advantages of transcranial Doppler (TCD) evaluation of cerebral vessels include the fact that it is a low-cost, noninvasive bedside assessment. However, in the context of acute stroke, digital subtraction angiography (DSA), magnetic resonance angiography (MRA), and computed tomography angiography (CTA) are more commonly used. These methods are more expensive and more time consuming and do not provide continuous blood flow monitoring.As experience with cerebral thrombolysis increases, there is mounting evidence that improved outcomes are associated with recanalization and improved brain perfusion. [1][2][3][4] With intra-arterial thrombolysis, 2 recanalization can be monitored by the use of concurrent angiography, but recanalization is not routinely evaluated after intravenous thrombolysis. 3,5 Information about recanalization may help to determine patient prognosis and direct further management. 6 TCD offers an inexpensive and continuous means of monitoring vessel patency.TCD criteria for identifying intracranial occlusion and recanalization have been described previously. 6 -9 Accuracy parameters for TCD assessment of middle cerebral artery (MCA) occlusion were established previously. 7,8,10 However, the accuracy of TCD in identifying recanalization after thrombolysis remains unknown. The goal of the present study was to compare TCD findings after intravenous thrombolysis with subsequent angiography to determine accuracy parameters for identifying MCA recanalization. Subjects and MethodsWe evaluated patients who received intravenous tissue plasm...