Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy / 대한뇌졸중학회지

Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians’ preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.

Endovascular versus Medical Management of Acute Basilar Artery Occlusion: A Systematic Review and Meta-Analysis of the Randomized Controlled Trials / 대한뇌졸중학회지

Background@#and Purpose The optimal management of patients with acute basilar artery occlusion (BAO) is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared to medical management (MM) for acute BAO through a meta-analysis of randomized controlled trials (RCTs). @*Methods@#We performed a systematic review and meta-analysis of RCTs of patients with acute BAO. We analyzed the pooled effect of EVT compared to MM on the primary outcome (modified Rankin Scale [mRS] of 0–3 at 3 months), secondary outcome (mRS 0–2 at 3 months), symptomatic intracranial hemorrhage (sICH), and 3-month mortality rates. For each study, effect sizes were computed as odds ratios (ORs) with random effects and Mantel-Haenszel weighting. @*Results@#Four RCTs met inclusion criteria including 988 patients. There were higher odds of mRS of 0-3 at 90 days in the EVT versus MM group (45.1% vs. 29.1%, OR 1.99, 95% confidence interval [CI] 1.04–3.80; P=0.04). Patients receiving EVT had a higher sICH compared to MM (5.4% vs. 0.8%, OR 7.89, 95% CI 4.10–15.19; P<0.01). Mortality was lower in the EVT group (35.5% vs. 45.1%, OR 0.64, 95% CI 0.42–0.99; P=0.05). In an analysis of two trials with BAO patients and National Institutes of Health Stroke Scale (NIHSS) <10, there was no difference in 90-day outcomes between EVT versus MM. @*Conclusion@#In this systematic review and meta-analysis, EVT was associated with favorable outcome and decreased mortality in patients with BAO up to 24 hours from stroke symptoms compared to MM. The treatment effect in BAO patients with NIHSS <10 was less certain. Further studies are of interest to evaluate the efficacy of EVT in basilar occlusion patients with milder symptoms.

Collateral Flow in Magnetic Resonance Angiography:Prognostic Value for Vertebrobasilar Stenosis With Stroke Recurrence

Background@#and Purpose Intracranial vertebrobasilar atherosclerotic stenosis (IVBAS) is a major cause of posterior circulation stroke. Some patients suffer from stroke recurrence despite receiving medical treatment. This study aimed to determine the prognostic value of a new score for the posterior communicating artery and the P1 segment of the posterior cerebral artery (PCoA-P1) for predicting stroke recurrence in IVBAS. @*Methods@#We retrospectively enrolled patients with severe IVBAS (70%–99%). According to the number of stroke recurrences, patients were divided into no-recurrence, single-recurrence, and multiple-recurrences groups. We developed a new 5-point grading scale, with the PCoA-P1 score ranging from 0 to 4 based on magnetic resonance angiography, in which primary collaterals were dichotomized into good (2–4 points) and poor (0 or 1 point). Stroke recurrences after the index stroke were recorded. Patients who did not experience stroke recurrence were compared with those who experienced single or multiple stroke recurrences. @*Results@#From January 2012 to December 2019, 176 patients were enrolled, of which 116 (65.9%) had no stroke recurrence, 35 (19.9%) had a single stroke recurrence, and 25 (14.2%) had multiple stroke recurrences. Patients with single stroke recurrence (odds ratio [OR]= 4.134, 95% confidence interval [CI]=1.822–9.380, p=0.001) and multiple stroke recurrences (OR=6.894, 95% CI=2.489–19.092, p<0.001) were more likely to have poor primary collaterals than those with no stroke recurrence. @*Conclusions@#The new PCoA-P1 score appears to provide improve predictions of stroke recurrence in patients with IVBAS.

DIRECT-SAFE: A Randomized Controlled Trial of DIRECT Endovascular Clot Retrieval versus Standard Bridging Therapy / 대한뇌졸중학회지

Background@#and Purpose The benefit regarding co-treatment with intravenous (IV) thrombolysis before mechanical thrombectomy in acute ischemic stroke with large vessel occlusion remains unclear. To test the hypothesis that clinical outcome of ischemic stroke patients with intracranial internal carotid artery, middle cerebral artery or basilar artery occlusion treated with direct endovascular thrombectomy within 4.5 hours will be non-inferior compared with that of standard bridging IV thrombolysis followed by endovascular thrombectomy. @*Methods@#To randomize 780 patients 1:1 to direct thrombectomy or bridging IV thrombolysis with thrombectomy. An international-multicenter prospective randomized open label blinded endpoint trial (PROBE) (ClincalTrials.gov identifier: NCT03494920). @*Results@#Primary endpoint is functional independence defined as modified Rankin Scale (mRS) 0–2 or return to baseline at 90 days. Secondary end points include ordinal mRS analysis, good angiographic reperfusion (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b–3), safety endpoints include symptomatic intracerebral hemorrhage and death. @*Conclusions@#DIRECT-SAFE will provide unique information regarding the impact of direct thrombectomy in patients with large vessel occlusion, including patients with basilar artery occlusion, with comparison across different ethnic groups.

International Survey of Mechanical Thrombectomy Stroke Systems of Care During COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. AIMS: We conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. METHODS: The survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th and May 15th, 2020. RESULTS: There were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15th, 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). CONCLUSION: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. DATA ACCESS STATEMENT: The corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data.

A novel diffusion-weighted imaging-based posterior circulation score for prediction of futile recanalization in acute basilar artery occlusion / 中华神经科杂志

Objective:To develop a novel posterior circulation score (PCS) based on pretreatment diffusion-weighted imaging (DWI) for predicting futile recanalization (FR) of acute basilar artery occlusion (BAO) after endovascular therapy (EVT).Methods:A prospectively registered consecutive cohort of BAO patients treated with EVT in Beijing Tiantan Hospital, Capital Medical University during a six-year period was reviewed. This novel DWI-based PCS (DWI-PCS) was calculated according to the characteristics of acute infarction at four sites (pons, midbrain, thalamus and cerebellum), with a normal score of 0 point and a full score of 16 points. FR was defined as the occurrence of poor outcome (modified Rankin Scale score>3) at 90 days despite successful recanalization (modified Thrombolysis In Cerebral Infarction ≥ 2b) at final angiogram after EVT. The independent association of DWI-PCS with FR was evaluated by multivariable Logistic regression, and the predictive discrimination of DWI-PCS was measured by the area under the receiver operating characteristic (ROC) curve. Additionally, the effects of DWI-PCS on FR in different subgroups stratified by age, time window, stroke severity and etiology were explored.Results:Of 109 patients in this study, 48 (44.0%) suffered from FR. The multivariable Logistic analysis showed that DWI-PCS was significantly associated with FR (adjusted OR=1.31, 95% CI 1.07-1.62, P=0.01). The ROC curve analysis demonstrated that the area under the curve of DWI-PCS for predicting FR was 0.74 (95% CI 0.65-0.83), and the optimal cut-off value was ≥ 3 points (sensitivity 0.75, specificity 0.66, accuracy 0.70). Finally, the effects of DWI-PCS on FR were not found to be different across all subgroups ( P>0.10 for all interactions). Conclusions:The novel DWI-PCS may be a valid and reliable predictor of FR in BAO patients treated with EVT. Nevertheless, external validation with blinded outcome is still needed to confirm its performance before clinical application.

Endovascular recanalization for non-acute internal carotid artery occlusion using a new angiographic classification / 中华放射学杂志

Objective:To evaluate the safety and feasibility of endovascular recanalization for non-acute internal carotid artery occlusion (NA-ICAO), and to propose a new angiographic classification.Methods:From April 2015 to October 2019, 95 consecutive patients with symptomatic NA-ICAO who received endovascular recanalization were retrospectively analyzed in Beijing Tiantan Hospital, Capital Medical University. All the patients were divided into four groups according to DSA: type Ⅰ, petrous segments were distally reconstituted by collateral vessels; type Ⅱ, cavernous segments were distally reconstituted by collateral vessels; type Ⅲ, ophthalmic segments were distally reconstituted by collateral vessels; type Ⅳ, communicating segments were distally reconstituted by collateral vessels. Study data including clinical characteristics, surgical details, lesion classification, recanalization rate and perioperative complications. For the counting data, the χ 2 test was used to compare between groups. For the quantitative data, the ANOVA was used for the normal distribution data, otherwise the Kruskal-Wallis H test was used. The primary safety outcome was any stroke or death within 30 days. Results:Among the 95 patients, 67 (70.53%) had successful recanalization. The recanalization rates of type Ⅰ－Ⅳ were 92.31% (36/39), 81.82% (18/22), 47.83% (11/23) and 18.18% (2/11) respectively (χ2=29.557, P<0.001). And the complication rates of the four types were 5.13% (2/39), 13.64% (3/22), 21.74% (5/23) and 9.10% (1/11) respectively. The incidence of perioperative ischemic stroke was 2.11% (2/95). No other serious stroke and death occurred. Conclusions:Endovascular recanalization may be feasible and safe for carefully selected patients with NA-ICAO and therefore represents an alternative treatment. The patients with type Ⅰ and Ⅱ lesions had higher recanalization rates, while the patients with type Ⅳ lesions had significantly lower recalculation rate. The new angiographic classification is conducive to the selection of suitable patients and difficulty in grading.

A comparative analysis of bridging therapy versus direct endovascular treatment in acute ischemic stroke patients aged 80 years and over / 中华老年医学杂志

Objective:To compare the safety and therapeutic effect of bridging therapy versus direct endovascular treatment in patients with acute ischemic stroke(AIS)aged 80 years and over, who received the therapy within 4.5 h of onset.Methods:A total of 89 AIS patients aged 80 years and over receiving the endovascular therapy at our hospital from January 2016 to June 2019 were studied with versus without intravenous thrombolysis before endovascular therapy(the former as bridging therapy group, n=49; the latter as the direct endovascular treatment group, n=40). Baseline information including gender, the modified Rankin scale(mRS)score, medical history, smoking history, preoperative national institute of health stroke scale(NIHSS)score were collected.Clinical data related to the operation including the times from onset to hospital, door-to-puncture and door-to-recanalization, complications(symptomatic cerebral hemorrhage, mortality)and mRS at 90 d after treatment were compared between the two groups.Multiple logistic regression analysis was used to determine whether or not bridging therapy with intravenous thrombolysis was a prognostic factor.Results:There was no significant difference in baseline information between the two groups( P>0.05). The times from onset to hospital, door-to-puncture, door-to-recanalization had no significant difference between the two groups( P>0.05). There was no significant difference in the incidence of symptomatic cerebral hemorrhage and mortality within 90 d between the two groups(26.5% or 13 cases vs. 17.5% or 7 cases, 14.3% or 7 cases vs.7.5% or 3 cases, χ2=1.031 and 1.017, P=0.310 and 0.313). With different clinical outcomes as dependent variables, after adjusting factors such as gender, admission NIHSS and medical history, Logistic regression analysis showed that the bridging therapy with intravenous thrombolysis was not a prognostic factor( OR=0.795, 95% CI: 0.280~2.258, P=0.666). Conclusions:The bridging therapy is as safe and effective as the direct intravascular therapy for AIS patients aged 80 and over within 4.5 hours of onset.The intravenous thrombolysis should be given as soon as possible within time window.

Correlation of memory impairment and cerebral perfusion in patients with vertebral-basilar artery stenosis / 中华行为医学与脑科学杂志

Objective To evaluate the correlation between cerebral blood flow perfusion and memory impairment in patients with severe stenosis of vertebral basilar artery (VBA).Methods 62 cases of patients with VBA stenosis diagnosed by digital subtraction angiography(DSA) in Beijing Tiantan Hospital from September 2016 to March 2017 were enrolled.Mental State Examination (MMSE),Clinical Memory Scale (CMS) test and CT perfusion(CTP) was performed.All patients were divided into memory normal group(n=24,including 1 excellent case,6 above normal cases,and 14 normal cases) and memory impairment group(n =38,including 18 below normal cases,12 periphery cases,8 impaired cases) according to CMS.The ratios of side-to-side period were compared between bilateral mesial temporal lobe and anterior circulation area.The relative time to peak (rTTP),relative mean transit time(rMTY),relative cerebral blood flow(rCBF) and relative cerebral blood volume (rCBV) were calculate.Results The incidence of CTP decompensation in the medial temporal lobe was higher than that in the patients with memory impairment(P＜0.05).The difference of rTTP and rMTT value between the two groups in the bilateral medial temporal lobes was statistically significant (rTFP:(1.131 ±0.037),(1.437±0.139),t=10.520,P＜ 0.05);rMTT:(1.081 ±0.059),(1.281 ±0.174),t=5.423,P＜0.05).Conclusion The patients with VBA severe stenosis are more likely to get memory impairment due to cerebral hypoperfusion.

The therapeutic effects of stent retriever-based thrombectomy on acute ischemia stroke in patients aged 80 years and over / 中华老年医学杂志

Objective To evaluate the safety and therapeutic effects of stent retriever-based thrombectomy (SRT) on acute ischemic stroke (AIS) in patients aged 80 years and older.Methods A cohort of 157 AIS patients hospitalized in Capital Medical University Affiliated Beijing Tiantan Hospital were selected for SRT from January 2016 to May 2017.Based on the age,all patients were divided into two groups:groups aged ＜ 80 years and ≥ 80 years.Baseline information including gender,the Modified Rankin Scale (mRS) score,past medical history,smoking history,preoperative National Institutes of Health Stroke Scale (NIHSS),the Alberta Stroke Program Early CT Scores (ASPECTS),intravenous thrombolysis and clinical outcomes were compared between two groups.The informations related to the operation,including time from onset to hospital,door-to-needle puncture time,door-to-recanalization time,SRT complications (symptomatic cerebral hemorrhage,mortality) and good outcome,were compared between two groups.Logistic regression analysis was used to determine whether the age of 80 years and over was a risk factor for adverse prognosis after SRT.Results There were 130 patients in the group ＜ 80 years of age,and 27 patients in the group ≥80 years.No significant differences were found in baseline information between the two groups (all P＞ 0.05).In addition,there were no significant differences in the proportions of the operative information,complications of SRT and the good outcome (all P＞0.05).Furthermore,advanced age (≥80 years) was not a risk factor for adverse outcome after SRT (OR =0.738,95％ CI:0.300-1.813).Conclusions Stent retriever-based thrombectomy is safe and beneficial for patients with acute ischemic stroke,even in patients aged 80 years and over.

Efficacy analysis of stenting in patients with internal carotid artery cavernous segment symptomatic stenosis / 中国脑血管病杂志

Objective To evaluate the safety,effectiveness,and middle or long-term efficacy of endovascular stenting of internal carotid artery stenosis at the cavernous segment. Methods Thirty-two patients underwent endovascular stenting at the cavernous segment of internal carotid artery from January 2012 to February 2015 were enrolled retrospectively. Angioplasty and stenting were conducted using Apollo or Winspan stent system. The improvement of internal carotid artery cavernous segment stenosis and perioperative safety and the results of the medium and long-term follow-up of the 2 kinds of stents were observed. Results All the 32 patients achieved technical success. The symptoms of cerebral ischemia of the patients were relieved significantly. The length of the stenosis at cavernous segment of the internal carotid artery was 4 to 13 mm (mean,7. 2 ±2. 9 mm). The stenosis rate from 82 ± 7% before treatment decreased to the 24 ± 7% . One patient had perioperative complication (4. 7%),26 of them were followed up with DSA,and 6 were lost to follow-up. The follow-up period ranged from 7 to 29 months (mean,16 ± 7 months). During the follow-up period,1 patient had intracerebral hemorrhage,1 had cerebral infarction,and none of them died. Four patients had in-stent restenosis,three of them used Winspan stents, and 1 used Apollo stents. Conclusion The patients should be screened strictly,particularly paying attention to the length of lesions. Endovascular stent angioplasty for the treatment of internal carotid artery cavernous segment stenosis is a safe and effective method.

Follow-up of vertebral artery stent in origin segment by color Doppler flow imaging / 中华超声影像学杂志

Objective To evaluate and follow-up the effection of vertebral artery origin stenting (VAOS) by color Doppler flow imaging(CDFI) and assess the rate of restenosis after stenting. Methods One hundred and thirty-five patients with stenosis of vertebral artery origin segment underwent stent input,135 pieces of stent was input in vertebral artery origin segment with moderate or severe stenosis,in which 70 bare metal stent(BMS) and 65 drug-eluting stent(DES). The diameter of VAOS, peak systolic velocity (PSV),end diastolic velocity (EDV) and resistence index(RI) of segment at origin and cervical vertebral were evaluated before and every 1,3,6, 12 month after VAOS by CDFI. The incidence of restenosis were calculated,and the factors of restenosis were analysed by COX regression. Results The diameter of VAOS was improved from (1.20±0.38) mm to (2.61±0.49) mm after stent procedure ( P = 0. 000), PSV and EDV also decreased from (296.02 ± 113.86)cm/s to ( 113.47 ± 36.35 )cm/s and (90.08 ± 47. 59)cm/s to (32. 21 ± 12. 69)cm/s respectively(P=0.000). The PSV and RI in cervical segment were increased from (46. 88 ± 17.46)cm/s to (67.79 ± 24.31 ) cm/s and 0. 54 ± 0. 10 to 0.62 ± 0.09 respectively( P = 0. 000).Over a median 7 months follow up(range 1 to 12 months) ,the cumulative restenosis rate at 3,6,12 month were 7.9% ,16. 9% and 25.0% respectively. DES was the only one negtive predictor of restenosis(OR=0. 388,95% CI:0.162-0.931, P = 0.034),and the factor of residual stenosis contributed to the occurance of restenosis after stenting(OR = 3.758,95% CI:1.498-9.427, P=0.005). Conclusions CDFI is a sensitive and noninvasive examination to follow-up VAOS and detect in-stent restenosis immediately. VAOS has a high rate of restenosis. DES is effective to prevent in-stent restenosis.

Carotid angioplasty and stenting for carotid stenosis in high-risk symptomatic NASCET-ineligible patients / 国际脑血管病杂志

Objective To investigate the efficacy and safety of carotid angioplasty and stenting for carotid stenosis in high-risk symptomatic NASCET-ineligible patients. Methods Twenty patients with symptomatic carotid stenosis at high risk ineligible for NASCET were treated with carotid angioplasty and stenting,12 of them were men,and 8 wre women,the patients ranged in age from 62 to76 years (mean age,69 years). Eleven patients had transient ischemic attack and 9 had cerebral infarction. Digital subtraction angiography showed that the degree of carotid stenosis in all patients was ＞ 70% (NASCET criteria). Among them,9 patients had unilateral carotid artery severe stenosis (2 had restenosis after endarterectomy),6 had bilateral carotid artery severe stenosis,5 had unilateral carotid artery occlusion with contralateral severe sentoses (1 had undergone cervical radiotherapy for nasopharyngeal carcinoma). The embolic protection devices,predilation,and self-expandable stents were used in all patients. Results The success rate of the procedure was 100%. The residual stenosis rate was ＜ 30%. The different levels of a transient decline in heart rates and blood pressure occurred in all the patients during the procedure. One patient was complicated with microembolic embolism. No ischemic stroke occurred in the remaining patients in the periprocedure. The postoperative examination with carotid ultrasound showed that the stenoses were improved significantly. No ipsilateral ischemic stroke and coronary ischemic events were observed at 1 and 3 months follow-up after the procedures. Conclusions Carotid artery stenting is less invasive,and the perioperative complications are fewer,The treatment of symptomatic carotid stenosis with high surgical risks is safe and effective.

Endovascular mechanical recanalization of subclavian artery total occlusion / 介入放射学杂志

Objective To discuss the skills and effects of several endovascular mechanical techniques for the recanalization of subclavian artery total occlusion. Methods Endovascular mechanical recanalization of subclavian artery total occlusion was performed in 32 patients with symptomatic subclavian artery total occlusion. The re-open rate and the therapeutic results were observed and analyzed. Results Several endovascular mechanical techniques, including percutaneous transluminal angioplasty, were employed in treating 32 patients with subclavian artery total occlusion. After the procedure, the ischemic 8ymptoms of posterior circulation and/or upper extremity were markedly relieved. Conclusion It is safe and feasible using appropriate endovascular mechanical technique for re-canalizing the occluded subclavian artery.

Clinical evaluation of interventional treatment of severe complicated stenosis of vertebrobasilar system / 介入放射学杂志

Objective To evaluate the feasibility,safety and efficacy of percutaneous transluminal stenting angioplasty for severe complicated stenosis of vertebrobasilar system. Methods From November 2003 to February 2006,5 candidates underwent percutaneous transluminal stenting for severe complicated stenosis of vertebrobasilar system. Results Four out of 5 candidates,had occlusion of unilateral vertebral artery (VA),1 had severe bilateral proximal segmental stenosis of VA. There were 4 with severe proximal segmental stenosis of the VA associated with multiple segmental stenosis of intracranial VA and basilar artery (BA),and 1 with multiple segmental severe stenosis of intracranial VA and BA. Stenosis rate ranges from 80% ～95% with involved length from 10-20 mm. Technical success was achieved in all of the patient (100%),and residual stenosis rate was less than 20%. All the symptoms due to vertebrobasilar blood supply insufficiency disappeared. Follow-up with DSA 6-12 months later demonstrated no restenosis; showing satisfactory short term efficacy. Conclusions Percutaneous transluminal stenting for vertebrobasilar blood supply insufficiency is a safe and efficacious option with favorable short term outcome,especially with furthermore prevention of stroke.

Treatment and Short-Term Follow-up of Symptomatic Atherosclerotic Intracranial Artery Stenosis by Stent-Assisted Angioplasty.

SUMMARY: Atherosclerotic intracranial artery stenosis can cause hypoperfusion of brain tissues and embolus formation, causing stroke. Conservative medical treatment seemed to have little effect on the natural history and prevent the stroke attack caused by artery stenosis. The purpose of stent-assisted angioplasty is to reconstruct the damaged vessels: the indications, feasibility, effectiveness, complications and follow-up for this new treatment method are discussed. A series of 32 cases with symptomatic intracranial artery stenosis were accepted from 1998 to 2002. The mean age was 42 yrs (31 ~ 76 yr), male/female ratio=23/9. All patients were refractory to optimal medical therapy. Lesions included 12 middle cerebral arteries (37.5%), six basilar arteries (18.75%), three distal ICAs (9.38%) and 12 intracranial Vas (37.5%). All patients were treated by methods of transluminal stent-assisted angioplasty under general anesthesia. Patients were premedicated with Aspirin (300mg/per day) and Ticlopidine (250mg/per day), this was continued for six weeks after the procedure. Medical history, anamnesis, and treatment protocol were reviewed and evaluated retrospectively, shortterm follow-up (2mths ~ 1 yr) was also obtained. Primary clinical presentations were TIAs (21/32, 65.63%), minor stroke ( 8/32, 25%) and severe stroke (3/32, 9.38%). 31 cases (96.86%) were successfully implanted with coronary stents within the stenosed vessels; technical success rate was 96.86%. Instant angiographic results showed the stenosed extent had decreased from 72.36% +/- 5.69 to 10.16% +/- 6.94. One vessel ruptured during the procedure, the patient recovered after surgical repair of the ruptured vessel. Clinical follow-up demonstrated symptoms resolved in most patients (30/32, 93.75%) within the follow- up period, two cases with MCA stenosis had TIAs within two months after the procedure. 12 cases accepted angiographic follow-up.Velocities of stented vessels of five cases (5/21, 23.81%) increased compared to instant results, suggesting restenosis, three of them were confirmed by angiography which included two cases with MCA stenosis (figure 3) and one with distal VA, one of the five cases had recurred TIAs. With the newer generation of coronary stent, this technique seemed safe, feasible and effective to prevent stroke attack, but the indication is very important for the technical success. Restenosis remains a common problem as with coronary stenting. Long-term follow-up will be needed.

Complications of stent-assisted angioplasty of carotid artery stenosis:an analysis of 23 cases / 中国普通外科杂志

Objective To evaluate the mechanism,prevention and prognosis of complications after stent angioplasty in the treatment of carotic artery stenosis. Methods[WT5”BZ] From 1997 to 2003,312 cases of carotid artery stenosis were treated by transluminal stent-assistant angioplasty. Results Procedure-related complication developed in 23 cases including 19 cases of transient mild complications such as transient arrhythmia and hypotension in 10 cases (3.2%) during deploying stent or balloon dilation,transient cerebral ischemia symptoms in 6 cases after balloon dilation,hypotension in 3 cases after the procedure. Severe complications occurred in 4 cases after the procedure,including embolus detachment,stent migration,carotic artery occlusion and fatal cerebral hemorrhage. Conclusion Although stent-assistant angioplasty are effective for treatment of carotid artery stenosis,severe complications could develop.

Percutaneous vertebroplasty for symptomatic vertebral hemangiomas / 中国普通外科杂志

Objective To assess the outcome of percutaneous vertebroplasty for symptomatic vertebral hemangiomas. Methods Five cases with 7 symptomatic vertebral hemangiomas were treated with percutaneous vertebroplasty. Aggressive lesions were treated with absolute alcohol injection in addition. Patients were followed-up and clinical manifestations were observed and CT, MRI and X-ray plain film were compared between before and after vertebroplasty. Results Procedures were successful without complications. Most of the symptoms resolved within 24 hours after vertebraplasty. All patients were followed-up for 12～50 months and free of neurological deficits and symptoms. Imaging follow-up showed no vertebral collapse, nor recurrance of hemangiomas. Conclusion With effective long-term follow-up and quick elimination of symptoms, precutaneous vertebroplasty, added with absolute alcohol injection in aggressive cases, proves to be a safe and effective treatment for symptomatic vertebral hemangiomas.

Multiple modality endovascular treatment for intracranial venous thrombosis / 中华放射学杂志

Objective To review the experience of multiple modality endovascular treatment for intracranial venous thrombosis, and to evaluate the efficacy and risk of endovascular thrombolysis for intracranial venous thrombosis.Methods From October, 2000 to October, 2001, 12 patients with intracranial venous thrombosis confirmed by CT, MRI, MRV, and/or DSA were treated with multiple modality endovascular thrombolysis including intravenous thrombolysis, mechanical thrombus maceration, intraarterial thrombolysis, and stenting.After thrombolysis, treatment aimed at the primary diseases was continued and warfarin was used for 6 months.The patients were followed-up for 17-29 months, averaged 23 months.Results Of the twelve patients, all underwent transvenous thrombolysis, ten underwent combined transvenous thrombolysis and clot maceration, seven underwent transvenous infusion of urokinase combined with transarterial infusion of urokinase.Two underwent transvenous infusion of urokinase combined with transarterial infusion of urokinase.The thrombolysis duration was from one to three days.The infusion dose of urokinase was 800 000 to 2 900 000 IU, the averaging dosage of urokinase was less than 1 000 000 IU per day.All patients achieved from recanalization of sinuses as confirmed on postprocedural angiography, MRI, and MRV studies prior to hospital discharge.At discharge, all the patients improved neurologically, and GCS improved from averaged 12 of pre-operation to 14 of post-operation.During the averaging 23 months follow-up, no patient recurred. Conclusion Combined multiple modality endovascular treatment is an effective and safe procedure for potentially catastrophic intracranial venous thrombosis.

Balloon occlusion test and therapeutic occlusion on traumatic carotid cavernous fistulas / 中华创伤杂志(英文版)

OBJECTIVE: To evaluate the safety of the balloon occlusion test(BOT) and therapeutic occlusion of the internal carotid artery(ICA). METHODS: The data of 43 patients hospitalized consecutively with traumatic intractable carotid cavernous fistulas (TICCF) were analyzed. Therapeutic occlusion of ICA was performed on 39 cases and BOT was only performed on the remaining 4 cases. Our assessment consisted of: (1) angiographic evaluation of collateral circulation with or without BOT of ICA, and (2) evaluation of clinical tolerance to therapeutic occlusion of ICA with hypotensive challenge for 30 minutes. Complications of BOT and therapeutic occlusion of ICA were also analyzed retrospectively. RESULTS: Complications related to BOT occurred in 1 case (2.3%) without causing permanent deficits. Complications related to therapeutic occlusion of ICA occurred in 4 cases (10%), including 1 technical (2.5%), 2 temporary (5%) and 1 permanent (2.5%) deficit. There was no fistula recurrence or mortality. CONCLUSIONS: BOT of ICA is safe and economical. The reliability of the results is almost the same compared with that of other more complicated methods of assessing therapeutic occlusion of ICA. And it is easy to treat TICCF with therapeutic occlusion of ICA.