Stent-assisted coiling of intracranial carotid ophthalmic segment aneurysm segment aneurysms:Long-term follow-up from a single center

Background:To evaluate the efficacy of stent-assisted coiling(SAC)for the treatment of carotid ophthalmic segment aneurysm segment aneurysms(OSAs)of the internal carotid artery(ICA)through detailed long-term follow-up of a large patient cohort.Methods:We retrospectively analyzed 88 consecutive patients with OSAs between January 2009 and January 2020 at our center.Angiographic results were evaluated using the modified Raymond grading system and clinical outcomes were evaluated using the mRS scale.The primary endpoints were major aneurysm recurrence and poor clinical outcomes for at least 18 months of follow-up.The patients were asked to attend clinical follow-up assessments and possibly undergo DSA or MR via telephone.Results:We enrolled 88 patients with 99 OSAs treated with coiling,of whom 76 were treated with SAC.The coiling procedures were successful in all 88 patients.Overall,complications occurred in 8 patients(9.1%).No procedure-related mortality was observed.67(76.1%)experienced immediate aneurysm occlusion at the end of the procedure.Long-term angiographic follow-up(18 months)was available in 45/88 aneurysms(51%)(average 18.7±5.2 months).Four patients continued their follow-up for 5 years after initial aneurysm treatment.After a clinical follow-up time of 28.7 months(range,12-51 months),85 patients(95.5%)achieved favorable clinical outcomes(mRS scores of 0-2).Conclusions:This study indicates that SAC treatment is a safe and effective therapeutic alternative for ruptured and unruptured OSAs.The procedural risks are low with relatively long-term effectiveness.

Treatment of the acute thromboembolic event during endovascular embolization of intracranial aneurysm

Objective:The study aimed to discuss the treatment of acute thromboembolic event(TE)during endovascular embolization of intracranial aneurysms.Methods:Between April 2013 and April 2019,158 patients with 167 intracranial aneurysms were treated with endovascular embolization in our hospital,in which 9 cases of acute TEs occurred during the embolization procedures.The clinical data,radiological findings and treatments of the 9 patients were reviewed and analyzed.Results:The TEs occurred at the aneurysmal neck in 3 patients,at distal part of the parent artery in 3,in the stent in 2,and at the proximal part of the parent artery in 1.Intra-arterial(IA)infusion of tirofiban were performed in 6 patients,mechanical thromboectomy(MT)with a stent in 2 patients,and combined use of the two methods in 1 patients.According to the modified Thrombolysis In Cerebral Infarction(mTICI)score,7 patients had recanalization of 2b/3a,1 patients had recanalization of 1,and 1 patients had recanalization of 0.At discharge,the mRS score was 0 in 3 patients,1 in 3 patients,and 2,3,4 in 1 patient each.6 months after the endovascular treatment,the mRS score was 0 in 5 patients,1 in 2 patients,and 3 in 1 patient.Conclusions:IA tirofiban and MT are effective remedies for the acute TE during endovascular embolization of intracranial aneurysm,reasonable selection of which may improve the prognosis of patients.

Bumetanide promotes neural precursor cell regeneration and dendritic development in the hippocampal dentate gyrus in the chronic stage of cerebral ischemia

Bumetanide has been shown to lessen cerebral edema and reduce the infarct area in the acute stage of cerebral ischemia. Few studies focus on the effects of bumetanide on neuroprotection and neurogenesis in the chronic stage of cerebral ischemia. We established a rat model of cerebral ischemia by injecting endothelin-1 in the left cortical motor area and left corpus striatum. Seven days later, bumetanide 200 μg/kg/day was injected into the lateral ventricle for 21 consecutive days with a mini-osmotic pump. Results demonstrated that the number of neuroblasts cells and the total length of dendrites increased, escape latency reduced, and the number of platform crossings increased in the rat hippocampal dentate gyrus in the chronic stage of cerebral ischemia. These findings suggest that bumetanide promoted neural precursor cell regeneration, dendritic development and the recovery of cognitive function, and protected brain tissue in the chronic stage of ischemia.

Resolution of Symptoms after Parent Artery Occlusion Treatment for Giant Cavernous Carotid Artery Aneurysms

Background and Objective: Giant cavernous carotid artery aneurysms (CCAAs) often produce a variety of neurological deficits, primarily those related to ophthalmoplegia/paresis and headache. This study was designed to evaluate the resolution of symptoms after parent artery occlusion (PAO) treatment for giant CCAAs. Methods: We retrospectively reviewed a series of 17 consecutive giant CCAAs treated with PAO treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by PAO. The following outcomes were analyzed: angiographic assessment, evolution of symptoms and outcome at clinical follow-up using modified Rankin Scale (mRS). Results: A total number of 17 giant CCAAs were treated by PAO. The initial post-procedure and follow-up angiogram revealed complete occlusion in all patients, no new lesion was detected. Periprocedural infarcts occurred in 1 patient (5.9%). Procedure-related mortality and morbidity were 0% and 5.9%, respectively. At mean 31.8 months clinical follow-up, symptoms had disappeared in 7 (41.2%) of the patients, partially improved in 5 (29.4%), remained unchanged in 4 (23.5%) and worsened in 1 (5.9%) of cases. Sixteen (94.1%) patients presented a good clinical outcome (mRS 0 - 1). Conclusion: Most patients in our series improved or remained stable after PAO. The results of this study indicate that PAO can improve the outcome of those symptomatic giant CCAAs if BOT can be tolerated.

Outflow Vessel in the Plane of Main Vortex of Large Cerebral Aneurysms: A Study of Hemodynamic Analyses

Purpose: This study was designed to quantify and characterize the variations of hemodynamic parameters for those large cerebral aneurysms with outflow vessel in the plane of main vortex. Materials and Methods: A total of 19 consecutive patients with large cerebral aneurysms were constructed with the data of digital subtraction angiography. Those large cerebral aneurysms with outflow vessel in the plane of main vortex were included. Blood flow was hypothesized to be laminar and incompressible and blood Newtonian fluid. Computational fluid dynamics ICEM and Fluent software were used to simulate the computational hemodynamics of large cerebral aneurysms. Results: Hemodynamics parameters result of computational fluid dynamics showed that the velocity in the aneurysm neck, impact fields and the origin area of outflow vessels was obvious higher than that in the aneurysm sac and aneurysm dome. Wall shear stress was obvious higher in aneurysm neck, impact fields and the origin area of outflow vessels than that in the aneurysm sac and aneurysm dome. Conclusions: The location of outflow vessel played an impact on the level of blood flow within aneurysm sac for those large cerebral aneurysms with outflow vessel in the plane of main vortex.

Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS): protocol of a prospective, multicentre, randomised, controlled trial

Background The superiority of balloon angioplasty plus aggressive medical management(AMM)to AMM alone for symptomatic intracranial artery stenosis(sICAS)on efficacy and safety profiles still lacks evidence from randomised controlled trials(RCTs).Aim To demonstrate the design of an RCT on balloon angioplasty plus AMM for sICAS.Design Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis(BASIS)trial is a multicentre,prospective,randomised,open-label,blinded end-point trial to investigate whether balloon angioplasty plus AMM could improve clinical outcome compared with AMM alone in patients with sICAS.Patients eligible in BASIS were 35–80 years old,with a recent transient ischaemic attack within the past 90 days or ischaemic stroke between 14 days and 90 days prior to enrolment due to severe atherosclerotic stenosis(70%–99%)of a major intracranial artery.The eligible patients were randomly assigned to receive balloon angioplasty plus AMM or AMM alone at a 1:1 ratio.Both groups will receive identical AMM,including standard dual antiplatelet therapy for 90 days followed by long-term single antiplatelet therapy,intensive risk factor management and life-style modification.All participants will be followed up for 3years.Study outcomes Stroke or death in the next 30 days after enrolment or after balloon angioplasty procedure of the qualifying lesion during follow-up,or any ischaemic stroke or revascularisation from the qualifying artery after 30 days but before 12 months of enrolment,is the primary outcome.Discussion BASIS trail is the first RCT to compare the efficacy and safety of balloon angioplasty plus AMM to AMM alone in sICAS patients,which may provide an alternative perspective for treating sICAS.Trial registration number NCT03703635;https://www.clinicaltrials.gov.

Roles of light transmission aggregometry and CYP2C19 genotype in predicting ischaemic complications during interventional therapy for intracranial aneurysms

Background and purpose Light transmission aggregometry(LTA)and CYP2C19 genotype analysis are commonly used to evaluate the antiplatelet effects of clopidogrel during the interventional treatment of intracranial aneurysms.The aim of this study was to determine which test can predict ischaemic events during these treatments.Methods Patient demographic information,imaging data,laboratory data and ischaemic complications were recorded.LTA and CYP2C19 genotype results were compared,and multiple linear regression was performed to examine factors related to platelet reactivity.Multivariate regression analysis was performed to determine whether LTA and CYP2C19 could predict ischaemic complications and to identify other clinical risk factors.Receiver operating characteristic curve analysis was conducted to calculate the cut-off value for predicting ischaemic complications.A subgroup analysis was also performed for different CYP2C19 genotype metabolisers,as well as for patients with flow diverters and traditional stents.Results A total of 379 patients were included,of which 22 developed ischaemic events.Maximum platelet aggregation induced by ADP(ADP-MPA)could predict ischaemic events(p<0.001;area under the curve,0.752(95%CI 0.663 to 0.842)),and its cut-off value was 41.5%.ADP-MPA(p=0.001)and hypertension duration>10 years(p=0.022)were independent risk factors for ischaemic events,while the CYP2C19 genotype was not associated with ischaemic events.In the subgroup analysis,ADP-MPA could predict ischaemic events in fast metabolisers(p=0.004)and intermediate metabolisers(p=0.003).The cut-off value for ischaemic events was lower in patients with flow diverters(ADP-MPA=36.4%)than in patients with traditional stents(ADP-MPA=42.9%).Conclusions ADP-MPA can predict ischaemic complications during endovascular treatment of intracranial aneurysms.Patients with flow diverters require stronger antiplatelet medication than patients with traditional stents.

Microglia activation,classification and microglia-mediated neuroinflammatory modulators in subarachnoid hemorrhage

Subarachnoid hemorrhage is a devastating disease with significant mortality and morbidity,despite advances in treating cerebral aneurysms.There has been recent progress in the intensive care management and monitoring of patients with subarachnoid hemorrhage,but the results remain unsatisfactory.Microglia,the resident immune cells of the brain,are increasingly recognized as playing a significant role in neurological diseases,including subarachnoid hemorrhage.In early brain injury following subarachnoid hemorrhage,microglial activation and neuroinflammation have been implicated in the development of disease complications and recovery.To understand the disease processes following subarachnoid hemorrhage,it is important to focus on the modulators of microglial activation and the pro-inflammatory/anti-inflammatory cytokines and chemokines.In this review,we summarize research on the modulators of microglia-mediated inflammation in subarachnoid hemorrhage,including transcriptome changes and the neuroinflammatory signaling pathways.We also describe the latest developments in single-cell transcriptomics for microglia and summarize advances that have been made in the transcriptome-based classification of microglia and the implications for microglial activation and neuroinflammation.

Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10- year neurointerventional experience

Background The management of bilateral intracranial vertebral artery dissecting aneurysms(IVADAs)is controversial,and requires the development of endovascular treatment modalities and principles.We aim to investigate the endovascular treatment strategy and outcomes of bilateral IVADAs.Methods We identified all bilateral IVADAs at a high-volume neurointerventional centre over a 10-year period(from January 2009 to December 2018).Radiographic and clinical data were recorded,and a treatment algorithm was derived.Results Twenty-seven patients with bilateral IVADAs(54 IVADAs in total,51 unruptured,3 ruptured)were diagnosed.Four patients(14.8%)received single-stage endovascular treatment,12 patients(44.4%)with staged endovascular treatment and 11 patients(40.8%)with unilateral endovascular treatment of bilateral IVADAs.Thirty-six IVADAs(85.7%)have complete obliteration at the follow-up angiography.Two of three ruptured IVADAs with stent-assisted coiling recanalised,and had further recoiling.Three patients(11.1%)have intraprocedural or postprocedural complications(two in single-stage and one in staged).Twenty-five patients(92.6%)had a favourable clinical outcome,and two patients(7.4%,all in single-stage)showed an unfavourable clinical outcome at follow-up.For the patients with unilateral reconstructive endovascular treatment,the contralateral untreated IVADAs were stable and had no growth or ruptured during follow-up period.None of all IVADAs had rebleeding during the clinical follow-up.Conclusions Endovascular treatment can be performed in bilateral IVADAs with high technical success,high complete obliteration rates and acceptable morbidity/mortality.Contralateral IVADAs had low rates of aneurysm growth and haemorrhage when treated in a staged/delayed fashion.

Effects of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms

Background:This study analyzed the safety and efficacy of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms by examining stent-vessel apposition,operative complications,embolization outcomes,and clinical outcomes.Methods:We retrospectively reviewed the medical records of patients with wide-necked intracranial aneurysms who underwent Enterprise 2 stent-assisted coiling in our hospital from November 2018 to October 2019.Intraoperative VasoCT was performed immediately after stent release in a continuous cohort of patients to observe stent-vessel apposition.Patient demographic,clinical,and imaging data were recorded and analyzed.Results:A total of 106 wide-necked aneurysms in 106 patients were treated.Stent release was successful in all patients.Twenty-one patients were enrolled consecutively for VasoCT scanning,and incomplete stent apposition was observed in 5(23.8%).Perioperative complications occurred in 10 patients(9.4%):cerebral infarction in 6,intraoperative coil prolapse in 1,puncture site pseudoaneurysm in 1,deep vein thrombosis at multiple sites in 1,and transient brainstem mass effect in 1.Among the 95 aneurysms with angiographic follow-up,embolization was satisfactory(Raymond-Roy classifications I and II)in 89(93.7%).Hyperlipidemia was an independent risk factor for incomplete aneurysm occlusion.At the last clinical follow-up,seven patients had a poor clinical outcome(modified Rankin Scale score≥3).Independent risk factors for poor outcomes were preoperative subarachnoid hemorrhage at presentation and cerebral infarction.Conclusion:Enterprise 2 stent-assisted coiling for treatment of wide-necked intracranial aneurysms showed good safety and efficacy;however,incomplete stent apposition can still occur in vessels with a large curvature.Preoperative subarachnoid hemorrhage at presentation and cerebral infarction are the main reasons for poor clinical outcomes after stent-assisted coil embolization.

<i>De novo</i>cavernous aneurysms development after contralateral parent artery occlusion—Two cases report

A 53-year-old woman developed a de novo aneurysm after contralateral internal carotid artery occlusion, and another 42-year-old woman developed a de novo aneurysm after contralateral vertebral artery occlusion. Both patients experienced a rapid development of de novo aneurysm formation, 6 and 9 months, respectively. The development of de novo aneurysm on the contralateral artery after parent artery occlusion showed that female and medium age may be contributory factors. In addition, the hemodynamic changes may be associated with the development of de novo aneurysm after contralateral parent artery occlusion.

A cardioembolic stroke

A 76-year-old woman with unspecified congenital heart disease was admitted on April 25th for TIA. She had a possible history of atrial fibrillation. A slight fever was noted on admission. Her ECG was abnormal, as well as her transthoracic echocardiography (TTE). Troponin I was slightly increased. On May 11th, a stroke occurred, in relation with an occlusion of the basilar artery. The patient was transferred to our institution for an emergency desobstruction. A dramatic improvement allowed her to be discharged to a rehabilitation center on May 18th. However, she was re-hospitalized on June 5th, due to sepsis and neurological worsening. MRI showed new ischemic brain lesions. Several episodes of paroxysmal atrial fibrillation were documented, as well as pulmonary hypertension. Effective heparin therapy was initiated and transesophageal echocardiography (TEE) was requested this time. It revealed a congenital valvular heart disease (a subaortic membrane), complicated by infective endocarditis. Despite a monitoring of aPTT, a fatal hemorrhagic shock occurred. We report this unfortunately remarkable case to address the following important points: 1) In the setting of a neurological event, abnormal ECG and/or abnormal TTE and/or Troponin I elevation may indicate a cardioembolic mechanism and therefore seek a cardiac source of embolism. 2) When TTE fails to identify a cardiac source of embolism, TEE should be performed, especially when a preexisting heart disease is suspected or known. 3) The multiplicity in space (infarcts in both the anterior and posterior circulation, or bilateral) and/or the multiplicity in time (infarcts of different age) may indicate a cardioembolic stroke. 4) Congenital subaortic membrane predisposes to infective endocarditis. 5) When anticoagulant therapy is initiated on strong arguments in a septic patient (much discussed in infective endocarditis), aPTT monitoring alone may not be enough. An anti-Xa monitoring may be more appropriate.

Chinese expert consensus on the management of aneurysmal subarachnoid hemorrhage-related hydrocephalus

Aneurysmal subarachnoid hemorrhage-related hydrocephalus(aSAH-H)refers to a clinical syndrome of excessive secretion,obstructive absorption,or circulatory disturbance of cerebrospinal fluid(CSF)with subarachnoid hemorrhage following rupture of aneurysm that leads to excessive accumulation of intracranial CSF and enlargement of ventricles impairing neurological function.aSAH is an important risk factor for hydrocephalus[1,2].According to fluid dynamics,aSAH-H is divided into communicating and obstructive hydrocephalus;according to the time of occurrence.

Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core(ANGEL-ASPECT):protocol of a multicentre randomised trial

Background The benefit of stroke thrombectomy for large infarct core still lacks robust randomised controlled studies.Aim To demonstrate the design of a clinical trial on endovascular therapy for acute anterior circulation large vessel occlusion(LVO)patients with large infarct core volume.Design ANGEL-ASPECT is a multicentre,prospective,randomised,open-label,blinded End-point trial to evaluate whether best medical management(BMM)combined with endovascular therapy improves neurological functional outcomes as compared with BMM alone in acute LVO patients with Alberta Stroke Program Early CT Score(ASPECTS)of 3-5 on non-contrast CT or infarct core volume range of 70-100 mL(defined as rCBF<30%on CT perfusion or ADC<620 on MRI)up to 24 hours from symptom onset or last seen well.Study outcomes The primary efficacy outcome is 90(±7)days modified Rankin Scale.Symptomatic intracranial haemorrhage within 48 hours from randomisation is the primary safety outcome.Discussion The ANGEL-ASPECT trial will screen patients with large infarct core(ASPECTS 3-5 or 70-100 mL)through image evaluation criteria within 24 hours and explore the efficacy and safety of endovascular therapy compared with BMM.

Movable typing of full-lumen personalized Vein-Chips to model cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis(CVST)is a type of stroke associated with COVID-19 vaccine-induced immune thrombotic thrombocytopenia.The precise etiology of CVST often remains elusive due to the highly heterogeneous nature of its governing mechanisms,specifically,Virchow’s triad that involves altered blood flow,endothelial dysfunction,and hypercoagulability,which varies substantially amongst individuals.Existing diagnostic and monitoring approaches lack the capability to reflect the combination of these patient-specific thrombotic determinants.In response to this challenge,we introduce a Vein-Chip platform that recapitulates the CVST vascular anatomy from magnetic resonance venography and the associated hemodynamic flow profile using the“Chinese Movable Type-like”soft stereolithography technique.The resultant full-lumen personalized Vein-Chips,functionalized with endothelial cells,enable in-vitro thrombosis assays that can elucidate distinct thrombogenic scenarios between normal vascular conditions and those of endothelial dysfunction.The former displayed minimal platelet aggregation and negligible fibrin deposition,while the latter presented significant fibrin extrusion from platelet aggregations.The low-cost movable typing technique further enhances the potential for commercialization and broader utilization of personalized Vein-Chips in surgical labs and at-home monitoring.Future research and development in this direction will pave the way for improved management and prevention of CVST,ultimately benefiting both patients and healthcare systems.

Residual inflammatory risk predicts long-term outcomes following stenting for symptomatic intracranial atherosclerotic stenosis

Background and purpose Residual inflammatory risk(RIR)can predict the unfavourable outcomes in patients with minor ischaemic stroke.However,the impact of preprocedural RIR on long-term outcomes in patients with symptomatic intracranial atherosclerotic stenosis(sICAS)who underwent stenting remains understudied.Methods This retrospective,single-centre cohort study evaluated consecutive patients with severe sICAS who underwent intracranial stenting.Patients were categorised into four groups based on preprocedural high-sensitivity C-reactive protein(hs-CRP)and low-density lipoprotein cholesterol(LDL-C):residual cholesterol inflammatory risk(RCIR,hs-CRP≥3 mg/L and LDL-C≥2.6 mmol/L),RIR(hs-CRP≥3 mg/L and LDL-C<2.6 mmol/L),residual cholesterol risk(RCR,hs-CRP<3 mg/L and LDL-C≥2.6 mmol/L)and no residual risk(NRR,hs-CRP<3 mg/L and LDL-C<2.6 mmol/L).The long-term clinical outcomes included recurrent ischaemic stroke and death.The long-term imaging outcomes consisted of in-stent restenosis(ISR)and symptomatic ISR(sISR)after stenting.Results In this study,952 patients were included,with 751(78.9%)being male.Forty-six cases were categorised into the RCIR group,211 into the RIR group,107 into the RCR group and 588 into the NRR group.Patients with RCIR(adjusted HR 6.163;95%CI 2.603 to 14.589;p<0.001)and RIR(adjusted HR 2.205;95%CI 1.294 to 3.757;p=0.004)had higher risks of recurrent ischaemic stroke than those with NRR during the 54 months of median follow-up time.Patients with RCIR(adjusted HR 3.604;95%CI 1.431 to 9.072;p=0.007)were more likely to occur ISR,and patients in the RIR group showed a significant increase in the risk of sISR(adjusted HR 2.402;95%CI 1.078 to 5.351;p=0.032)compared with those in the NRR group with a median follow-up time of 11.9 months.Conclusions In patients with sICAS,preprocedural RIR may predict long-term recurrent ischaemic stroke,ISR and sISR following intracranial stenting.

Pipeline Embolization Device for intracranial aneurysms presenting with mass effect:a large Chinese cohort

Background Unruptured intracranial aneurysm treatment aims to reduce the risk of aneurysm rupture and bleeding,relieves symptoms and improve the quality of life for patients.This study aimed to assess the safety and efficacy of Pipeline Embolization Device(PED,Covidien/Medtronic,Irvine,CA)treatment for intracranial aneurysms presenting with mass effect in real-world settings.Methods We selected patients from the PED in China Post-Market Multi-Center Registry Study with mass effect presentation.The study endpoints included postoperative mass effect deterioration and mass effect relief at follow-up(3–36 months).We conducted multivariate analysis to identify factors associated with mass effect relief.Subgroup analyses by aneurysm location,size and form were also performed.Results This study included 218 patients with a mean age of 54.3±11.8 years and a female predominance of 74.0%(162/218).The postoperative mass effect deterioration rate was 9.6%(21/218).During a median follow-up period of 8.4 months,the mass effect relief rate was 71.6%(156/218).Notably,immediate aneurysm occlusion following treatment was significantly associated with mass effect relief(OR 0.392,95%CI,0.170 to 0.907,p=0.029).Subgroup analysis demonstrated that adjunctive coiling contributed to mass effect relief in cavernous aneurysms,while dense embolism impeded symptom relief in aneurysms<10mm and saccular aneurysms.Conclusions Our data confirmed the efficacy of PED in relieving mass effect.The findings of this study provide support for endovascular treatment to alleviate mass effect in unruptured intracranial aneurysms.Trial registration number NCT03831672.

Staged carotid artery angioplasty and stenting for patients with high-grade carotid stenosis with high risk of developing hyperperfusion injury:a retrospective analysis of 44 cases

Background:Hyperperfusion syndrome(HPS)is a rare but potentially a life-threatening complication after carotid artery angioplasty and stenting(CAS).Staged CAS has been an alternative to prevent HPS.Materials and methods:44 of 908 patients with high-grade internal carotid artery stenosis or near occlusion were at risk of HPS because of poor collateral flow and impaired cerebral blood flow(CBF).They were treated with first(stage 1),followed by a full CAS(stage 2)1 month later.Their 30-day outcomes were tabulated and analysed.Results:During follow-up,1 of the 44(2.2%)patients developed HPS immediately,3(7%)had postprocedural HPS(ie,transcranial Doppler(TCD)>120%)without clinical symptoms and 3(7%)required stenting at stage 1 for carotid dissections.After stage 1,there were significant improvement between the preprocedural and postprocedural CBF(0.98±0.06 vs 0.85±0.05,p<0.05),mean transit time(MTT;1.05±0.05 vs 1.15±0.05,p<0.05),time to peak(TTP;1.04±0.06 vs 1.20±0.06,p<0.05)on CT perfusion(CTP),and CBF(66.41±7.41 vs 44.44±6.43,p<0.05)on TCD.After stage 2,improvement was seen in CBF(1.01±0.07 vs 0.98±0.06,p<0.05),MTT(1.01±0.05 vs 1.05±0.05,p<0.05),TTP(0.99±0.06 vs 1.04±0.06,p<0.05)on CTP and CBF(66.41±7.41 vs 93.78±18.81,p<0.05)on TCD.2 had postoperative increase of middle cerebral artery mean flow velocity of 120%after stage 2 without clinical symptoms.Conclusion:Staged carotid artery stenting probably decreased the chance of developing HPS in this group of selected patients.Although requiring a 2-step intervention,staged CAS may be a safe and effective alternative.

Associations between haemodynamics and wall enhancement of intracranial aneurysm

Background and purpose Previous studies have reported about inflammation processes(IPs)that play important roles in aneurysm formation and rupture,which could be driven by blood flow.IPs can be identified using aneurysmal wall enhancement(AWE)on high-resolution black-blood MRI(BB-MRI)and blood flow haemodynamics can be demonstrated by four-dimensional-flow MRI(4D-flow MRI).Thus,this study investigated the associations between AWE and haemodynamics in unruptured intracranial aneurysms(IA)by combining 4D-flow MRI and high-resolution BB-MRI.Materials and methods Between April 2014 and October 2017,48 patients with 49 unruptured IA who underwent both 4D-flow MRI and high-resolution BB-MRI were retrospectively included in this study.The haemodynamic parameters demonstrated using 4D-flow MRI were compared between different AWE patterns using the Kruskal-Wallis test and ordinal regression.Results The results of Kruskal-Wallis test showed that the average wall shear stress in the IA(WSSavg-IA),maximum through-plane velocity in the adjacent parent artery,inflow jet patterns and the average vorticity in IA(vorticityavg-IA)were significantly associated with the AWE patterns.Ordinal regression analysis identified WSSavg-IA(p=0.002)and vorticityavg-IA(p=0.033)as independent predictors of AWE patterns.Conclusion A low WSS and low average vorticity were independently associated with a high AWE grade for IAs larger than 4 mm.Therefore,WSS and average vorticity could predict AWE and circumferential AWE.

Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of cerebral venous sinus thrombosis

Aim Cerebral venous sinus thrombosis(CVST)is a less common cerebrovascular disease that predominantly affects young patients.The incidence of CVST is 2-5/10000000/year,accounting for 0.5%-1%of all stroke.To reduce mortality and morbidity associated with CVST,Chinese Stroke Association commissioned the authors to write the current guideline on the management of CVST.Methods PubMed(MEDLINE),CNKI and Wanfang database were searched for studies related to CVST from 1 January 1990 to 31 July 2019.Data were synthesised by evidence tables.Each recommendation was fully discussed by the writing group members and reviewed by Chinese Stroke Association Stroke Fellow Committees.Levels of evidence grading algorithm of Chinese Stroke Association was used to grade each recommendation.results This guideline mainly focuses on the diagnostic evaluation,therapeutic strategies and secondary prevention of CVST.CT/CTV and MRI/MRV are recommended in the initial imaging evaluation of patients with suspected CVST.Anticoagulation therapy with low-molecular weight heparin should be initiated in patients with CVST immediately.After the acute stage,warfarin is recommended for 3-6 months to prevent the recurrence of CVST and other venous thromboembolic events.Conclusions The guideline summarises the current evidence regarding the management of CVST,and provides references for diagnosis,treatment and secondary prevention of CVST in China.