Etiological analysis of single small subcortical infarction with different imaging features / 中华神经科杂志

Objective:To investigate the etiological mechanism in single small subcortical infarction (SSSI) with different imaging features.Methods:The patients registered in a database of ischemic stroke in the Department of Neurology of the First Affiliated Hospital of Zhengzhou University from January 2016 to December 2019 were analyzed. According to the lowest slice (LS) and the total number of involved slices (TNS) on diffusion-weighted imaging, the SSSI was divided into 3 types: proximal SSSI (pSSSI; LS≤2), distal and large SSSI (dl-SSSI; LS>2, TNS>2) and distal and small SSSI (ds-SSSI; LS>2, TNS≤2). The clinical and imaging features among 3 different lesion patterns were compared by using χ 2 test, Kruskal-Wallis H test and multiple Logistic regression analysis, etc. Results:In the 3 groups of ds-SSSI ( n=205), dl-SSSI ( n=157) and pSSSI ( n=166), the prevalences of parent artery disease (PAD)[10.7% (22/205) , 19.1% (30/157) , 42.8% (71/166), respectively, χ 2=54.89, P<0.001], coronary artery disease [8.3% (17/205), 14.0% (22/157), 16.9%(28/166), respectively, χ 2=6.44, P=0.040] and severe white matter hyperintensities (sWMHs)[58.0% (119/205), 43.3% (68/157), 41.0% (68/166), respectively, χ 2=12.94, P<0.001], the level of serum homocysteine (Hcy)[18.01 (13.54, 25.56), 16.03 (12.50, 21.09), 14.72 (11.12, 19.14) μmol/L, respectively, H=19.36, P<0.001], and the National Institutes of Health Stroke Scale (NIHSS) score[2(1, 3), 3(1, 4), 3(2, 6), respectively, H=39.53, P<0.001] showed statistically significant differences. Multiple Logistic regression analysis showed that compared with dl-SSSI patients, the lesion pattern of patients with higher proportion of PAD ( OR=3.12, 95% CI 1.86-5.24, P<0.001) was closer to pSSSI; the lesion pattern of patients with higher serum Hcy level ( OR=1.02, 95% CI 1.00-1.04, P=0.046) or higher proportion of sWMHs ( OR=1.79, 95% CI 1.12-2.86, P=0.015) was closer to ds-SSSI, and the lesion pattern of patients with higher proportion of PAD ( OR=0.50, 95% CI 0.27-0.93, P=0.029) or higher NIHSS score ( OR=0.84, 95% CI 0.77-0.92, P<0.001) was closer to dl-SSSI. Conclusions:The pathogenesis of ds-SSSI tends to be cerebral small vessel disease. The pathogenesis of pSSSI is related to atherosclerosis. The patients with dl-SSSI have the intermediate characteristics of pSSSI and ds-SSSI and may be unstable.

Factors for rupture of intracranial aneurysms with parent artery stenosis: A preliminary analysis / 中国脑血管病杂志

Objective To preliminarily analyze the risk factors for rupture of intracranial aneurysms combined with proximal parent artery stenosis. Methods From June 2016 to December 2018, 52 admitted patients with intracranial aneurysms combined with proximal parent artery atherosclerotic stenosis and admitted in Neurosurgery Department of First Hospital Affiliated to Naval Military Medical University were enrolled. All patients were diagnosed by DSA. The 52 patients were divided into the ruptured group and the unruptured group, with each group containing 26 patients. The baseline data, 3D DSA data, morphology and hemodynamic parameters of intracranial aneurysms with parent artery stenosis were collected and compared between the two groups. The baseline data included age, gender, prior history of hypertension, smoking, diabetes, cerebral infarction, oculomotor palsy and multiple aneurysms. 3 D DSA data included degree of stenosis (mild to severe). Morphological and hemodynamic parameters included normalized wall shear stress (NWSS), percentage of low wall shear stress area (LSA), aspect ratio (AR), distance of stenosis, size ratio (SR) and degree of stenosis (quantitative index). Results (1) The proportion of female in the ruptured group was higher than that in the unruptured group (80.8% [21/26] vs. 53. 8% [14/26] , χ2 =4. 282, P = 0. 039). There was no difference in ypertension, diabetes, smoking history, multiple aneurysms, cerebral infarction and oculomotor paralysis between the two groups (all P >0. 05). (2) There was no difference in the degree of stenosis (mild to severe) between the two groups (P > 0.05). (3) The ruptured group had lower NWSS than that of the unruptured group, but higher LSA and AR(0.691 [0. 560, 0. 867] vs. 0.852 [0.701, 1.097], Z = -2. 397; 7. 91% [1.28%, 11. 94%] vs. 1.36%[0.28%, 3.48%], Z = 2.581;[1. 1 ±0. 3] vs. [0. 9 ±0.4], t =2.751; all P 0. 05). Conclusion Female, high LSA, high AR and low NWSS may have an impact on the rupture of intracranial aneurysms with parent artery stenosis.

Assessment of Arterial Wall Enhancement for Differentiation of Parent Artery Disease from Small Artery Disease: Comparison between Histogram Analysis and Visual Analysis on 3-Dimensional Contrast-Enhanced T1-Weighted Turbo Spin Echo MR Images at 3T

OBJECTIVE: The purpose of this study was to compare the histogram analysis and visual scores in 3T MRI assessment of middle cerebral arterial wall enhancement in patients with acute stroke, for the differentiation of parent artery disease (PAD) from small artery disease (SAD). MATERIALS AND METHODS: Among the 82 consecutive patients in a tertiary hospital for one year, 25 patients with acute infarcts in middle cerebral artery (MCA) territory were included in this study including 15 patients with PAD and 10 patients with SAD. Three-dimensional contrast-enhanced T1-weighted turbo spin echo MR images with black-blood preparation at 3T were analyzed both qualitatively and quantitatively. The degree of MCA stenosis, and visual and histogram assessments on MCA wall enhancement were evaluated. A statistical analysis was performed to compare diagnostic accuracy between qualitative and quantitative metrics. RESULTS: The degree of stenosis, visual enhancement score, geometric mean (GM), and the 90th percentile (90P) value from the histogram analysis were significantly higher in PAD than in SAD (p = 0.006 for stenosis, < 0.001 for others). The receiver operating characteristic curve area of GM and 90P were 1 (95% confidence interval [CI], 0.86–1.00). CONCLUSION: A histogram analysis of a relevant arterial wall enhancement allows differentiation between PAD and SAD in patients with acute stroke within the MCA territory.

Preliminary Experience with Vascular Plugs for Parent Artery Occlusion of the Carotid or Vertebral Arteries

OBJECTIVE: The purpose of this study was to report the authors' preliminary experience using the Amplatzer Vascular Plug (AVP) (St. Jude Medical, Plymouth, MN, USA) for parent artery occlusion of the internal carotid artery (ICA) or vertebral artery (VA). MATERIALS AND METHODS: Between September 2008 and December 2015, we performed 52 therapeutic parent artery occlusions (PAOs) by an endovascular technique. Among them, 10 patients underwent PAO of the carotid or vertebral arteries using AVPs. Clinical and radiographic data of these patients were retrospectively reviewed. RESULTS: The devices were used for VA dissection that presented with subarachnoid hemorrhage (SAH) in five patients, traumatic arteriovenous fistula (AVF) in two patients, spontaneous AVF in one patient, recurrence of carotid-cavernous fistula (CCF) in one patient, and symptomatic unruptured giant ICA aneurysm in one patient. The devices were used in conjunction with detachable and/or pushable coils and in the extracranial segments of the ICA or VA. Complete occlusion of the parent artery was achieved in all patients. There was one intra-procedural rupture of the VA dissection during coiling prior to using the device. CONCLUSION: Results from the current series suggest that the AVP might be used for therapeutic PAO in the extracranial segments of the ICA or VA.

Efficacy analysis of endovascular treatment of vertebral basilar artery dissecting aneurysms / 中国脑血管病杂志

Objective To investigate the effect of endovascular treatment of vertebral basilar artery dissecting aneurysms. Methods The clinical data of 40 patients with vertebral basilar artery dissecting aneurysm admitted to Beijing Xuanwu Hospital and Haidian hospital,Capital Medical University from August 2013 to September 2014 were analyzed retrospectively. Their clinical symptoms and imaging were followed up. According to the treatment methods,they were divided into either a stent-assisted coil emboliza-tion group (group A;n = 34)or a parent artery occlusion (group B;n = 6),and according to the clinical symptoms and imaging followed-up,the efficacy was assessed at 1 year after procedure. Results The patients were followed up for 1 year after procedure,29 patients (85. 3%)were improved in group A, 1 (2.9%)was stable,and 4 (11. 8%)deteriorated. All the 4 deteriorated patients died of cerebral infarction complications (at 1 week to 6 months after procedure). The 6 patients in group B were improved compared with before procedure. No intracranial hemorrhage and ischemic events occurred. Conclusion Using the stent-assisted coil embolization technique and the parent artery occlusion technique for the treatment of the vertebral basilar artery dissecting aneurysms are relatively safe and effective.

Influence of Parent Artery Segmentation and Boundary Conditions on Hemodynamic Characteristics of Intracranial Aneurysms

PURPOSE: The purpose of this study is to explore the influence of segmentation of the upstream and downstream parent artery and hemodynamic boundary conditions (BCs) on the evaluated hemodynamic factors for the computational fluid dynamics (CFD) analysis of intracranial aneurysms. MATERIALS AND METHODS: Three dimensional patient-specific aneurysm models were analyzed by applying various combinations of inlet and outlet BCs. Hemodynamic factors such as velocity pattern, streamline, wall shear stress, and oscillatory shear index at the systolic time were visualized and compared among the different cases. RESULTS: Hemodynamic factors were significantly affected by the inlet BCs while there was little influence of the outlet BCs. When the inlet length was relatively short, different inlet BCs showed different hemodynamic factors and the calculated hemodynamic factors were also dependent on the inlet length. However, when the inlet length (L) was long enough (L>20D, where D is the diameter of inlet section), the hemodynamic factors became similar regardless of the inlet BCs and lengths. The error due to different inlet BCs was negligible. The effect of the outlet length on the hemodynamic factors was similar to that of the inlet length. CONCLUSION: Simulated hemodynamic factors are highly sensitive to inlet BCs and upstream parent artery segmentation. The results of this work can provide an insight into how to build models and to apply BCs for more accurate estimation of hemodynamic factors from CFD simulations of intracranial aneurysms.

Enlarged Parent Artery Lumen at Aneurysmal-Neck Segment in Wide-Necked Distal Internal Carotid Artery Aneurysms / 신경중재치료의학

PURPOSE: Hypothesizing that the parent artery (PA) diameter of the aneurysm-neck segment is larger than those of normal segments, especially in wide-necked aneurysm cases, we conducted 3D angiographic analyses in wide-necked aneurysm cases focusing on the luminal morphologic change of the PA. MATERIALS AND METHODS: Under the approval of local IRB, we enrolled 26 patients with distal internal carotid artery (ICA) aneurysms, which were treated with stent assisted coiling. The PA diameters along the centerline were measured at 6 points with built-in software by two observers. Those 6 points were P1 and P2 proximally, P3 and P4 at the aneurysm ostium margins, and P5 and P6 distally. We performed an ANOVA test and a Bonferroni method for post hoc analyses. Linear regression analysis was performed to find any morphologic influencing factors. RESULTS: There were 20 distal ICA aneurysms out of 26 consecutive cases after exclusion. The differences in diameter at each point were statistically significant (p<0.0001). On post hoc analyses, the difference between P4 and P5 was significant both in maximum and mean PA diameters (p<0.0001 and p<0.001, respectively). Multivariate analyses failed to reveal any morphological influencing factor. CONCLUSION: PAs harboring a wide-necked aneurysm requiring stent assistance for coiling showed significant enlargement of the lumen, especially at the distal transition segment of the aneurysm ostium and the PA.

Comparison of three different endovascular approaches for the treatment of intracranial giant or large type aneurysms / 介入放射学杂志

Objective To evaluate the clinical efficacy of detachable balloons,detachable coils and intracranial covered stents in management of intracranial giant aneurysms.Methods From April 1998 to March 2006,20 patients with a giant or very large aneurysm were treated by parent artery occlusion(PAO), coils embolization and covered stent,in which 9 aneurysms were treated by PAO,8 by coils embolization and 3 by covered stent at initial management.Two recurrent aneurysms treated by coils embolization were performed by covered stent.Follow-up 9-83 months,mean 41.1?25.3 months.Immediate postprocedural angiographic outcomes were categorized as complete occlusion(100%),subtotal occlusion(95%-99%),and incomplete occlusion(＜95%)of the aneurysms;and follow-up angiographic outcomes were categorized as stable, thrombosis,and recanalization.Clinical outcomes were graded according to a modified Glasgow Outcome Scale (GOS).Results Endovascular treatment was technically feasible in all aneurysms without procedural-related complications.Immediate postprocedural angiograms showed complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7 and incomplete occlusion in 2.One patient with incomplete occlusion died on the seventh day with a rebleeding.The final angiographic findings in nineteen survival patients confirmed a complete occlusion in 15 aneurysms,subtotal occlusion in 3 and incomplete occlusion in 1,in which 10 parent arteries were successfully preserved.No rebleeding occurred during the follow-up period.The clinical evaluation performed at final follow-up in 19 patients revealed that the symptoms disappeared in 11 patients and improved in 8 in the modified GOS.Conclusions Treatment of giant intracranial aneurysms with coiling was associated with a low complete occlusion rate and a high recanalization rate.Treatment with endovascular parent artery occlusion remains practical,but this technique may result in damage to the parent artery and cause cerebral ischemic events.The use of an intracranial covered stent proved to be a relatively simple and safe procedure and maintained the pateney of the parent artery.

Analysis on correlation factors of cerebral intragenic ischemia after temporary parent arterial occlusion during intracranial aneurysm surgery / 第三军医大学学报

Objective To identify the correlation factors associated with cerebral intragenic ischemia after temporary parent arterial occlusion in intracranial aneurysm surgery. Methods One hundred and eighteen patients who underwent temporary arterial occlusion in the 120 aneurysms (from a group of 324 consecutive aneurysm patients treated from 1996 to 2002) were reviewed retrospectively. These variables included sex, age, presence of preoperative subarachnoid hemorrhage (SAH), neurological clinical grade, operational timing, duration of arterial occlusion, numbers of temporary occlusion, mode of arterial occlusion, intraoperative aneurysm rupture, hypertension, the location of temporary occlusion, aneurysm size, hyperglycemia, atheromatous mass. Univariate and multivariate were used to investigate the relationship between the variates and postoperative ischemic changes. Results The total times of temporary occlusion were 156, with an average of 1.30. The duration of arterial occlusion ranged from 1 to 45 min (9.75?7.75). Seventeen patients (14.4%) demonstrated evidence of new infarction in the vascular territory subjected to temporary arterial occlusion. Conclusion In the univariate analysis, age, presence of preoperative SAH, duration of arterial occlusion, atheromatous mass are all significantly correlated with postoperative ischemic injuries. Multivariate logistic regression revealed that the age, older more than 60 (P= 0.010 3 , relative risk=4.335), and the duration of arterial occlusion, lasting more than 20 min (P= 0.032 9 , relative risk=4.177), have significant correlation with the injuries. Based on these findings, temporary occlusion is safe and useful in aneurysm surgery and the postoperative cerebral ischemia is less likely to occur when the duration of clipping is shorter than 20 min.