Hence, patients with persisting arterial occlusions

and excessive sleepiness can be particularly vulnerable to the steal. In the first two reports describing RRHS no further END was observed in patients with intracranial arterial steal that were treated with non-invasive ventilatory correction. [27] and [31] Moreover, early noninvasive ventilatory correction in AIS patients has been shown to be safe and feasible in a recent pilot study [33]. In view of the former considerations, it has been hypothesized that: (i) RRHS may provide a missing link between the respiratory status and END in ACI with history of obstructive sleep apnea [34] TCD can reliably detect in real-time asymptomatic microembolic signals (MESs) in cerebral circulation that are characterized as “High Intensity Transient Signals” (HITS) [35], [36], [37], [38] and [39]. Asymptomatic Epacadostat solubility dmso cerebral embolization can be detected by TCD in 7–71% of patients with ACI (Fig. 5) [35], PD-1 antibody inhibitor [36], [37], [38] and [39]. The prevalence of MES is highest in patients with large-artery atherosclerotic stroke with cardioembolic infarction being the second most common stroke subtype with concomitant asymptomatic microembolization. MES are rarely identified in patients with lacunar stroke. The number of MES detected by TCD negatively correlates to the elapsed time from symptom onset

in patients with ACI [35], [36], [37], [38] and [39]. In other words, the sooner TCD-monitoring is performed from symptom onset the higher the yield of ultrasound detection of MES. MES have been shown to

predict recurrent stroke risk in acute stroke, symptomatic carotid stenosis and postoperatively after CEA (Table 1) [35]. MES may also predict first-ever stroke risk in patients with asymptomatic carotid stenosis (Table 1) [36]. More specifically, MES detection by TCD-monitoring increases the risk of recurrent stroke by almost ten-fold (OR: 9.6; 95%CI: 1.5–59.3) in patients with symptomatic carotid artery stenosis (Table 1). Similarly, MES detection by TCD-monitoring increases Aspartate the risk of ipsilateral stroke by almost seven-fold (OR: 6.6; 95%CI: 2.9–15.4) in patients with asymptomatic carotid artery stenosis (Table 1). Consequently, MES have been used for risk stratification and assessment of therapeutic efficacy in the former conditions [35], [36], [37] and [39]. Hao et al. have recently shown that MES have been associated with END and worsening of neurological deficit in patients with ACI due to large artery atherosclerosis [38]. Iguchi et al. have also reported that the presence of MES at 48 h after symptom onset was associated with recurrence of cerebral ischemia on diffusion weighted imaging (DWI) independent of underlying stroke subtype, [40] while MES detection on baseline TCD-monitoring has been related to the presence of multiple infarction on baseline DWI [35] and [38].

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