Potential role of PMD-TCD monitoring in the management of hemodynamically unstable intracranial stenosis.

A 54-year-old woman started to loose vision 2 days prior to admission and also experienced left-sided headache, nausea, emesis, and disorientation. Magnetic resonance imaging (MRI) revealed bilateral posterior cerebral artery and cerebellar infarctions. Transcranial power motion Doppler (PMD-TCD) showed blunted flow signal in the proximal basilar artery (BA) suggestive for a high-grade stenosis also seen on magnetic resonance angiography (MRA). Dual antiplatelet therapy with aspirin and clopidogrel was started. Catheter angiography confirmed the proximal high-grade BA stenosis. After angiography, the patient experienced hypertensive crisis with severe headache. Blood pressure was lowered and headache resolved. One hour later she developed fluctuating level of consciousness and motor symptoms. PMD-TCD findings were suggestive for an intraluminal thrombus that moved from the proximal to the distal basilar artery, presumably further contributing to brain stem hypoperfusion and neurological deterioration. To achieve a compromise between lower blood pressure and maintenance of brain perfusion, hypervolemic hemodilution with intravenous dextran-40 was initiated. Patient's symptoms resolved to baseline and MRI showed no new parenchymal lesions.