Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging enables non-invasive spatial mapping of changes in cerebral blood flow (CBF). By applying a vasodilatory stimulus (such as inhaled CO2) during BOLD MR imaging, one can measure cerebral vasodilatory capacity. "Cerebrovascular reactivity" (CVR) is defined as the change in CBF per unit of vasodilatory stimulus. Vasodilatory capacity is clinically important as vasodilatation is a mechanism by which the brain maintains constant CBF despite reductions in cerebral perfusion pressure.ii Patients with arterial narrowing commonly demonstrate a paradoxical response: vasodilatory stimulus-induced reduction of BOLD MR signal. BOLD MR depends on CBF but on other factors too. Does a reduction of BOLD MR signal indicate a decrease in flow? Does BOLD MR CVR correlate with CVR measured using arterial spin labeling (ASL) MR? I studied thirty-eight patients with stenosis of brain-supplying arteries and found that the BOLD CVR and ASL CVR results correlate strongly (R=0.83, P<0.0001 for cerebral hemispheric gray matter). The second study aimed to determine whether preoperative CVR predicts the hemodynamic effect of extracranial-intracranial bypass surgery. Whereas prior studies relied on right-left interhemispheric CVR asymmetry indices, this study used “absolute” CVR from each hemisphere. I studied twenty-five patients with intracranial arterial stenosis. I found that the group with normal pre-operative CVR showed no change in CVR following bypass surgery (0.22% ± 0.05% to 0.22% ± 0.01% (mean ± SD)(P=0.881)), the group with reduced pre-operative CVR demonstrated an improvement (0.08% ± 0.05% to 0.21 ± 0.08% (mean ± SD)(P<0.001)), and the group with paradoxical pre-operative CVR demonstrated the greatest improvement (-0.04% ± 0.03% to 0.27% ± 0.03% (P=0.028)). ii Patients with arterial narrowing commonly demonstrate a paradoxical response: vasodilatory stimulus-induced reduction of BOLD MR signal. BOLD MR depends on CBF but on other factors too. Does a reduction of BOLD MR signal indicate a decrease in flow? Does BOLD MR CVR correlate with CVR measured using arterial spin labeling (ASL) MR? I studied thirty-eight patients with stenosis of brain-supplying arteries and found that the BOLD CVR and ASL CVR results correlate strongly (R=0.83, P<0.0001 for cerebral hemispheric gray matter). The second study aimed to determine whether preoperative CVR predicts the hemodynamic effect of extracranial-intracranial bypass surgery. Whereas prior studies relied on right-left interhemispheric CVR asymmetry indices, this study used “absolute” CVR from each hemisphere. I studied twenty-five patients with intracranial arterial stenosis. I found that the group with normal pre-operative CVR showed no change in CVR following bypass surgery (0.22% ± 0.05% to 0.22% ± 0.01% (mean ± SD)(P=0.881)), the group with reduced pre-operative CVR demonstrated an improvement (0.08% ± 0.05% to 0.21 ± 0.08% (mean ± SD)(P<0.001)), and the group with paradoxical pre-operative CVR demonstrated the greatest improvement (-0.04% ± 0.03% to 0.27% ± 0.03% (P=0.028)). The third study arose from an unexpected observation: paradoxical reactivity in the white matter of young healthy subjects. I evaluated healthy subjects using BOLD CVR and ASL CVR, transformed all CVR maps into a common brain space, and generated composite maps of CVR. Composite maps confirmed regions of significant paradoxical iii reactivity in the white matter. These regions may represent the physiological correlate of previously anatomically defined border-zones (watershed zones). The regions match the locations where elderly patients develop white matter rarefaction, so-called leukoaraiosis.

Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging enables non-invasive spatial mapping of changes in cerebral blood flow (CBF). By applying a vasodilatory stimulus (such as inhaled CO2) during BOLD MR imaging, one can measure cerebral vasodilatory capacity. "Cerebrovascular reactivity" (CVR) is defined as the change in CBF per unit of vasodilatory stimulus. Vasodilatory capacity is clinically important as vasodilatation is a mechanism by which the brain maintains constant CBF despite reductions in cerebral perfusion pressure.ii Patients with arterial narrowing commonly demonstrate a paradoxical response: vasodilatory stimulus-induced reduction of BOLD MR signal. BOLD MR depends on CBF but on other factors too. Does a reduction of BOLD MR signal indicate a decrease in flow? Does BOLD MR CVR correlate with CVR measured using arterial spin labeling (ASL) MR? I studied thirty-eight patients with stenosis of brain-supplying arteries and found that the BOLD CVR and ASL CVR results correlate strongly (R=0.83, P<0.0001 for cerebral hemispheric gray matter). The second study aimed to determine whether preoperative CVR predicts the hemodynamic effect of extracranial-intracranial bypass surgery. Whereas prior studies relied on right-left interhemispheric CVR asymmetry indices, this study used “absolute” CVR from each hemisphere. I studied twenty-five patients with intracranial arterial stenosis. I found that the group with normal pre-operative CVR showed no change in CVR following bypass surgery (0.22% ± 0.05% to 0.22% ± 0.01% (mean ± SD)(P=0.881)), the group with reduced pre-operative CVR demonstrated an improvement (0.08% ± 0.05% to 0.21 ± 0.08% (mean ± SD)(P<0.001)), and the group with paradoxical pre-operative CVR demonstrated the greatest improvement (-0.04% ± 0.03% to 0.27% ± 0.03% (P=0.028)). ii Patients with arterial narrowing commonly demonstrate a paradoxical response: vasodilatory stimulus-induced reduction of BOLD MR signal. BOLD MR depends on CBF but on other factors too. Does a reduction of BOLD MR signal indicate a decrease in flow? Does BOLD MR CVR correlate with CVR measured using arterial spin labeling (ASL) MR? I studied thirty-eight patients with stenosis of brain-supplying arteries and found that the BOLD CVR and ASL CVR results correlate strongly (R=0.83, P<0.0001 for cerebral hemispheric gray matter). The second study aimed to determine whether preoperative CVR predicts the hemodynamic effect of extracranial-intracranial bypass surgery. Whereas prior studies relied on right-left interhemispheric CVR asymmetry indices, this study used “absolute” CVR from each hemisphere. I studied twenty-five patients with intracranial arterial stenosis. I found that the group with normal pre-operative CVR showed no change in CVR following bypass surgery (0.22% ± 0.05% to 0.22% ± 0.01% (mean ± SD)(P=0.881)), the group with reduced pre-operative CVR demonstrated an improvement (0.08% ± 0.05% to 0.21 ± 0.08% (mean ± SD)(P<0.001)), and the group with paradoxical pre-operative CVR demonstrated the greatest improvement (-0.04% ± 0.03% to 0.27% ± 0.03% (P=0.028)). The third study arose from an unexpected observation: paradoxical reactivity in the white matter of young healthy subjects. I evaluated healthy subjects using BOLD CVR and ASL CVR, transformed all CVR maps into a common brain space, and generated composite maps of CVR. Composite maps confirmed regions of significant paradoxical iii reactivity in the white matter. These regions may represent the physiological correlate of previously anatomically defined border-zones (watershed zones). The regions match the locations where elderly patients develop white matter rarefaction, so-called leukoaraiosis.

Atherosclerotic diseases including stroke are the leading causes of morbidity, mortality as well as disability in industrialized countries. Carotid endarterectomy was long considered the stan- dard approach for the treatment of atherosclerotic carotid disease, one of major causes of stroke. Over time, carotid artery stenting (CAS) has evolved as an alternative approach and is considered equivalent to surgical treatment in selected patients. Particularly in the last years, CAS has gained attention with the increasing knowledge regarding atherosclerotic plaque and cerebrovascular flow. In our study, we focused on patients undergoing CAS and evaluated structural and hemodynamic characteristics of atherosclerotic plaques together with relation to endovascular manipulation. The major part of the study includes transcranial doppler ultrasound evaluation which is able to detect flow in major cerebral arteries as well as to detect microembolizations of atherosclerotic particles during CAS. In eligible patients, we investigated the usefulness of cerebrovascular reserve (CVR) testing to predict severe hemodynamic changes in ipsilateral middle cerebral artery induced by temporary carotid occlusion during proximally protected CAS. CVR was tested by means of a breath-holding test and ophthalmic artery flow...

Introduction: Internal Carotid Stump Syndrome may be one of the possible causes of ischemic stroke (iCMP), as well as retinal infarction (RI). Syndrome of the occluded internal carotid (ACI) (stump syndrome) is a nosological unit, which is characterized by an onset of ipsilateral iCMP or RI of thromboembolic ethiology in patients with occlusion of ACI via the externa carotid or arteria ophthalmica. In my thesis, I have concentrated upon the specification of the stump syndrome, its diagnostics and treatment; furthermore I have assessed the appropriateness of surgical approach in comparison with conservative approach. Material and methods: A total of 621 patients with occlusion were treated in two centres in the course of five years. In a group of 40 patients, the ACI occlusion was detected sonographically, the length of the occluded ACI being >5 mm, with normal vasoreactivity based upon SPECT CO2 and excluded cardiogenic cause of iCMP. The patients were divided in two groups - surgical and conservative. Patients were monitored in 6-month intervals for the total period of four years. Results: No RI or iCMP were detected in the surgical group; one patient died six months after surgery. We observed one case of amaurosis fugax in the conservative group. Conclusion: Ultrasound examination is a fully sufficient...

Introduction: Internal Carotid Stump Syndrome may be one of the possible causes of ischemic stroke (iCMP), as well as retinal infarction (RI). Syndrome of the occluded internal carotid (ACI) (stump syndrome) is a nosological unit, which is characterized by an onset of ipsilateral iCMP or RI of thromboembolic ethiology in patients with occlusion of ACI via the externa carotid or arteria ophthalmica. In my thesis, I have concentrated upon the specification of the stump syndrome, its diagnostics and treatment; furthermore I have assessed the appropriateness of surgical approach in comparison with conservative approach. Material and methods: A total of 621 patients with occlusion were treated in two centres in the course of five years. In a group of 40 patients, the ACI occlusion was detected sonographically, the length of the occluded ACI being >5 mm, with normal vasoreactivity based upon SPECT CO2 and excluded cardiogenic cause of iCMP. The patients were divided in two groups - surgical and conservative. Patients were monitored in 6-month intervals for the total period of four years. Results: No RI or iCMP were detected in the surgical group; one patient died six months after surgery. We observed one case of amaurosis fugax in the conservative group. Conclusion: Ultrasound examination is a fully sufficient...