Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke-The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial.
BACKGROUND
External counterpulsation (ECP) increases perfusion to a variety of organs and may be helpful for acute stroke.


METHODS
We conducted a single-blinded, prospective, randomized controlled feasibility and safety trial of ECP for acute middle cerebral artery (MCA) ischemic stroke. Twenty-three patients presenting within 48 hours of symptom onset were randomized into one of two groups. One group was treated with ECP for 1 hour at a pressure of up to 300 mmHg ("full pressure"). During the procedure, we also determined the highest possible pressure that would augment MCA mean flow velocity (MFV) by 15%. The other group was treated with ECP at 75 mmHg ("sham pressure"). Transcranial Doppler MCA flow velocities and National Institutes of Health Stroke Scale (NIHSS) scores of both groups were checked before, during, and after ECP. Outcomes were assessed at 30 days after randomization.


RESULTS
Although the procedures were feasible to implement, there was a frequent inability to augment MFV by 15% despite maximal pressures in full-pressure patients. In sham-pressure patients, however, MFV frequently increased as shown by increases in peak systolic velocity and end diastolic velocity. In both groups, starting ECP was often associated with contemporaneous improvements in NIHSS stroke scores. There were no between-group differences in NIHSS, modified Rankin Scale Scores, and Barthel Indices, and no device or treatment-related serious adverse events, deaths, intracerebral hemorrhages, or episodes of acute neuro-worsening.


CONCLUSIONS
ECP was safe and feasible to use in patients with acute ischemic stroke. It was associated with unexpected effects on flow velocity, and contemporaneous improvements in NIHSS score regardless of pressure used, with a possibility that even very low ECP pressures had an effect. Further study is warranted.
Department of Emergency Medicine, University of California, San Diego, California, USA. Electronic address: kguluma@ucsd.edu.
Kama Z
KZ
Guluma
UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, California, USA.
David S
DS
Liebeskind
Family Medicine and Public Health and Neurosciences, University of California, San Diego, La Jolla, California, USA.
Rema
R
Raman
UCSD Stroke and Coordinating Center, University of California, San Diego, La Jolla, California, USA.
Karen S
KS
Rapp
Family Medicine & Public Health, University of California, San Diego, La Jolla, California, USA.
Karin B
KB
Ernstrom
Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
Andrei V
AV
Alexandrov
Neurosonology, Comprehensive Stroke Center, University of Alabama, Birmingham, Alabama, USA.
Reza B
RB
Shahripour
Department of Neurology, Dresden University Stroke Center, Carl Gustav Carus University Hospital Dresden, Dresden, Germany.
Kristian
K
Barlinn
UCLA Stroke Center and Departments of Emergency Medicine and Neurology, University of California, Los Angeles, California, USA.
Sidney
S
Starkman
UCLA Stroke Network, University of California, Los Angeles, California, USA.
Ileana D
ID
Grunberg
Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA.
Thomas M
TM
Hemmen
Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA.
Brett C
BC
Meyer
College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
Anne W
AW
Alexandrov
D000368:Aged; D002545:Brain Ischemia / Q000150:complications; D002560:Cerebrovascular Circulation / Q000502:physiology*; D015908:Counterpulsation / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D011446:Prospective Studies; D012720:Severity of Illness Index; D016037:Single-Blind Method; D020521:Stroke / Q000209:etiology / Q000628:therapy*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
Cerebral blood flow velocity; External counterpulsation; Ischemic stroke; Transcranial Doppler