Intracranial Atherosclerotic Disease (ICAD) is a significant cause of ischemic stroke which is used to be neglected. Due to developments in imaging technologies as well as increased use of endovascular interventional procedures and conventional catheter angiography on practice of stroke, ICAD found being much more associated with the etiology of ischemic stroke and transient ischemic attack today. That it is more common among Asians, Hispanics and Afro-Americans compared to caucasians indicates the heterogeneous tendency of this subgroup of stroke in terms of race and ethnicity. Stroke due to ICAD occurs in various mechanisms such as thrombotic occlusion, artery to artery embolism, hemodynamic ischemia and penetrating vascular occlusion, and moreover, clinically significant findings can be seen in the presence of moderate stenosis (<%50). It is required to be clarified whether such various mechanisms have a role in frequent occurrence of recurrent strokes in ICAD, and which strategies are required to be applied in diagnosis and treatment. In this review, the management of ICAD will be discussed in accompaniment of current publications.

INTRODUCTION: This study was carried out as a cross-sectional study for the purpose of evaluating 112 teams working in the Aydýn dependent to the Ministry of Health, for the correct diagnosis of stroke cases and their interventions before the hospital.
METHODS: In the study, the incident reports, which were transferred to the hospital, were received from A2-type emergency health-stations located in the center of Aydýn province. In the first phase of the study, 1453 incident reports were examined to determine the situation. In the light of the obtained data, the emergency medical team was trained for using “Cincinnati Prehospital Stroke Scale” in terms of stroke and diagnosis. In the second phase of the study 2029 incident reports (in total=3484 incidents) were examined to evaluate the efficiency of the training.) The data were analyzed through “Structured Questionnaire”, “CPSS” and hospital emergency service records. Data analyses process was assessed by calculating sensitivity, specificity, and accuracy rates.
RESULTS: In the first phase, 91 cases and in the second phase 55 cases were pre-diagnosed with stroke and transferred to hospital emergency services. In the hospital emergency services, 63 cases were diagnosed with stroke in the first phase, and 63 cases were diagnosed with stroke in the second phase. The examination of diagnosis similarity between the two groups showed that in the first phase, 69.9% of the cases which were diagnosed with stroke in emergency services were consistent with the diagnosis of the 112 emergency medical team. The findings showed that in the second phase, %38,1 of the cases which were diagnosed with stroke in emergency services was consistent with the diagnosis of the 112 emergency medical team..Furthermore, in the second phase, it was determined that among the 55 incidents that were pre-diagnosed with stroke by 112 emergency medical teams, only 30 (%54,5) of them were pre-diagnosed with CPSS. The results demonstrated that the CPSS sensitivity to true stroke pre-diagnosis was %47. On the other hand, the results revealed that the trainings have had a positive impact on respiration support, circulation support and medical support interventions provided to stroke pre-diagnosed cases.
DISCUSSION AND CONCLUSION: The research study revealed that 122 emergency medical teams have deficiencies in terms of true diagnosis of stroke cases in the pre-hospital phase, and therefore training support should be maintained.

INTRODUCTION: Hyperglycemia in acute ischemic stroke decreases the effectiveness of intravenous tissue plasminogen activator (IV tPA) and increases its hemorrhagic complications. Therefore, optimization of blood glucose (BG) is suggested. But, no consensus is achieved on which of the BG parameters to be used such as admission BG, post-treatment BG, first day maximum and average BG (maxBG and aveBG), or BG variability indices such as the standard deviation of mean BG (SDBG), coefficient of variation of BG (CVBG) and J-index.
METHODS: Admission and 24h BG were measured in 145 acute stroke patients (55% female, age: 70±13 yr; NIHSS: 14 ± 6, symptom-to-needle time: 160 ± 58 minutes) treated with IV tPA. BG variability indices were evaluated in 107 patients with serial BG measurement available.
RESULTS: AveBG was significantly higher in patients with 3rd month mRS>2 (46.2%), but admission BG, SDBG, CVBG and J-index were not significantly different. An exploratory regression analysis indicated that the connection of aveBG to worse prognosis (β=-0.155, p=0.045) persisted after adjustment for admission NIHSS, age and DM history. No BG parameter predicted symptomatic tPA-associated type-II intracerebral hemorrhage (6.7%), albeit these patients had marginally higher average BG levels (p=0.045). Presence of diabetes, HbA1c, admission BG, average first day BG and variability indices had not modified the beneficial (52%) and dramatic response (28%) to IV tPA.
DISCUSSION AND CONCLUSION: Sustained hyperglycemia, not glucose variability, during the first 24 hour predicts poor prognosis in acute stroke patients treated with IV thrombolysis

INTRODUCTION: Cryptogenic ischemic stroke (CS) includes 30-40% of all ischemic strokes. Several studies using different methods of prolonged cardiac monitoring determined atrial fibrillation (AF) in 12-25% of CS patients, however these findings are not enough to explain the etiology of most of the CSs. Our aim is to research thromboembolic sources and vascular risk factors in CS patients.
METHODS: The study enrolled 125 patients older than 45 years, 65 of them with CS according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Control group included patients admitted cardiology outpatient clinic with symptoms of nonspecific chest pain or dyspnea without cerebrovascular diseases. Patients with any history of AF or paroxysmal AF, intra-cardiac thrombus or valvular heart disease and left ventricular dysfunction, heart failure were excluded. Cardiovascular risk factors, left atrium diameter, left ventricle ejection fraction (EF) (%) and 24-hour Holter ECG monitoring were examined. Blood total cholesterol, LDL, HDL, urea, creatine levels were also analyzed and compared.
RESULTS: Hypertension, diabetes mellitus, coronary artery diseases were more prevalent in the study group (p<0.05). LDL, total cholesterol and blood urea levels were significantly higher and HDL was lower in the study group (p<0.05). There was no significant difference between two groups in terms of Holter ECG results. In the study group, six patients had non-sustained AF episodes (<30 sec.) and two had paroxysmal AF episodes. In control group only two patients had frequent AF episodes continuing >30 sec.
DISCUSSION AND CONCLUSION: Cardiovascular risk factors leading thromboembolism were prominently higher in CS patients, long-term ECG monitoring may explain only the cardioembolic sources due to arrhythmia. Investigation of thromboembolic sources is vital for determining the etiology of CS.

INTRODUCTION: Cerebral edema is the leading cause of mortality and morbidity in ischemic stroke patients. Decompressive hemicraniectomy may be beneficial to patients that fail to respond to medical treatment. In this study, clinical features and prognostic factors of patients that underwent decompressive hemicraniectomy due to acute ischemic stroke were evaluated.
METHODS: We examined 21 ischemic stroke patients who underwent decompressive hemicraniectomy. Demographic features and neuroimaging findings were recorded. Functional status of patients were evaluated with modified Rankin Scale. Clinical features and neuroimaging findings of the patients who died were compared with the survivors during hospitalization.
RESULTS: Twenty-one patiens were included in this study. Twelve of the patients were male, 9 were female. The mean age of these patiens was 58.7±8.2 (46 - 78). The main initial NIHSS score was 12.5±4.5. Territory of infarctions were supplied by middle cerebral arter in 17 patients, internal carotis arter in 4 patients. The mean time of decompressive hemicraniectomy was 2.9±2.5 days, hospitalization duration was 42.6±39.2 days. Five (% 23.8) patiens died in-hospital. There were no relation between clinical features, neuroimaging findings and mortality.
DISCUSSION AND CONCLUSION: Decompressive hemicraniectomy is a significant treatment option for ischemic stroke patients who deteriorate despite receiving medical treatment.

INTRODUCTION: Early neurological deterioration (END) is a common problem of stroke practice. Although lacunar pontine infarcts are known with the high risk of END, such worsening can also be seen in patients with pontine infarcts attributed to basilar artery stenosis. Since the quality of collateral supply are considered one of the proposed mechanisms of END, we hypothesized that the pattern of posterior communicating arteries (PcoA) would be associated with END in pontine infarcts with basilar artery stenosis.
METHODS: Patients with acute pontine infarcts and having ≥50 basilar artery stenosis were included in the study. END was diagnosed as an increase of at least 2 points on the National Institutes of Health Stroke Scale from baseline during the 5 days. A diagnosis of PcoA hypoplasia was based on the presence of either a PcoA of less than 1 mm in diameter or the absence of a PcoA, based on computed tomography angiography (CTA). Univariate and multivariate analysis were performed to compare demographics, risk factors and the hypoplasi of PcoA between patients with END and those without END.
RESULTS: Of 60 patients included, 17 patients (28.3%) exhibited END. Demographics and vascular risk factors did not differ between groups. END was significantly higher in patients having at least one hypoplastic PcoA and those with bilateral PcoA hypoplasia as compared to patients without hypoplasia (p=0.040, p=0.006, respectively). In multivariate analysis, there was a trend for the development of END in patients with bilateral hypoplastic PcoA (β =1.9, 95% CI 0.8-59; p=0.073).
DISCUSSION AND CONCLUSION: Bilateral hypoplasia of PcoA might be associated with the development of END in pontine infarcts attributed to basilar arteries.

We report two cases of reversible hypertensive brainstem encephalopathy (RHBE) syndrome with other concurrent manifestations of malignant hypertension. RHBE was accompanied by hypertensive putaminal hemorrhage in one case, and by intra-ventricular hemorrhage resulting acute obstructive hydrocephalus along with multiple small acute infarctions in the other. Diffusion-weighted imaging and corresponding apparent diffusion coefficient mapping disclosed increased diffusion suggestive of vasogenic edema centered in the pons. No lesion indicative for posterior reversible encephalopathy syndrome (PRES) was noted in the supratentorial regions. These cases indicate that mechanisms involved in development of RHBE and hypertensive PRES may have some differences, albeit both share main lines. These cases also underline that awareness and knowledge about relatively specific clinic-radiological syndrome caused by RHBE seem to be critical. Acute treatment and early prognostification are just only accurate with such a familiarity.

The most feared and frequent complication of carotid artery stenting is distal embolization during the intervention.. To prevent to embolization in clinical practise, roughly two categories of embolic protection devices (EPDs) are routinely used: distal EPDs with flow preservation using filters, and the proximal occlusive protective systems. We report a case with transient neurological deficit such as monoparesia and anosognosia following of the internal carotid artery stenting using a proximal EPD (the Mo.Ma system). The proximal occlusive protective system may cause transient signs and symptoms due to cerebral hypoperfusion without distal embolization.