ASPECTS-Region-Dependent Functional Outcomes after Endovascular Therapy in Patients with Cardioembolic Stroke

ObjectivesCardioembolic stroke has a poor prognosis. We evaluated the region-dependent efficacy of endovascular therapy (EVT) based on diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS).MethodsThis post-hoc analysis of the RELAXED study, which investigated the optimal timing of rivaroxaban to prevent nonvalvular atrial fibrillation (NVAF) recurrence in patients with acute ischemic stroke (AIS), included NVAF patients admitted with AIS or transient ischemic attack in the middle cerebral artery (MCA), with internal carotid artery (ICA), M1, or M2-MCA occlusion. Relationships between DWI-ASPECTS region and functional outcome (modified Rankin Scale [mRS]), mortality, recurrence, and hemorrhagic stroke were compared between patients with and without EVT, and adjusted odds ratios for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS), ICA occlusion, infarct size, recombinant tissue plasminogen activator (rt-PA) use, and onset-to-hospitalization time were estimated.ResultsEVT patients had significantly lower hemoglobin levels, higher median NIHSS scores, more lentiform nucleus infarcts, ICA or M1-MCA occlusions, treatment with rt-PA, and fewer M3, M5, or M6 infarcts and M2-MCA occlusions than no-EVT patients. EVT patients had shorter onset-to-hospitalization times and more frequent favorable functional outcomes (p=0.007). Mortality, recurrent ischemic stroke, and hemorrhagic infarction were similar in both groups. EVT was associated with significantly better functional outcomes among patients with insular ribbon (p=0.043) and M3 (p=0.0008) infarcts. M3 patients had significantly fewer rt-PA and EVT, and longer onset-to-hospitalization times.ConclusionsAn occlusion in the insular ribbon or M3 region was associated with favorable functional outcomes in patients treated with EVT after cardioembolic stroke.     

Symbiotic relationship of IV-tPA and mechanical thrombectomy in a case of acute tandem ICA–MCA occlusion

Intro: In light of the recent successful mechanical thrombectomy trials, the need for IV-tPA prior is under investigation. Few cases demonstrate angiographically the role of both mechanical and chemical strategies at achieving reperfusion. Case report: A 63 year-old male presented with an NIHSS 20. CTA demonstrated an acute occlusion of the left cervical and intracranial ICA and MCA. IV-tPA was administered, followed by immediate reperfusion of the cervical ICA with carotid stenting and mechanical thrombectomy. Within the next 10 min, the entire intracranial clot burden dissolved under angiographic control. TICI 3 reperfusion was achieved without any further intervention. Post-procedure, the patient recovered fully to an NIHSS of 0. Conclusion: This case underscores the importance of IV-tPA administration in conjunction to mechanical thrombectomy. The interventionalist should take advantage of the symbiotic effect of the IV-tPA administration, which remains the standard of care so far.     

脑白质区域非腔隙性梗死灶与颅内外血管狭窄关系的探讨

目的 探讨脑白质区域非腔隙性梗死灶与颅内外血管狭窄的关系.方法 对30例脑白质区域非腔隙性梗死患者的头颅MRI以及主动脉弓、全脑数字减影血管造影(DSA)检查资料进行分析.结果 本组MRI示12例单侧基底节区片状异常信号中,DSA表现为一侧颈内动脉(ICA)起始部闭塞或高度狭窄9例,一侧大脑中动脉(MCA)M1段高度狭窄2例,无明确血管病变1例.6例基底节以及侧脑室旁白质区域病灶中,一侧ICA起始部闭塞或高度狭窄3例,一侧ICA C5段闭塞1例,一侧MCA M1段闭塞2例.4例侧脑室旁或半卵圆中心白质区域病灶中,一侧ICA C6段闭塞1例,一侧MCA M1段高度狭窄2例,无明确血管病变1例.8例皮质下上型或皮质下侧型分水岭脑梗死患者中,一侧ICA起始部闭塞或高度狭窄6例,双侧ICA起始部闭塞1例,一侧MCA M1段高度狭窄1例.结论 脑白质区非腔隙性梗死灶的发生与ICA系统大血管的狭窄或闭塞有密切的关系.     

Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site

Background: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. Methods: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. Results: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). Conclusions: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.     

经颅多普勒超声脑缺血溶栓分级与阿替普酶静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死预后相关性研究

目的探讨分析经颅多普勒超声脑缺血溶栓分级与静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死患者血管再通评价与预后的相关性研究。方法选择急性前循环大动脉闭塞性脑梗死患者,对符合静脉溶栓者给予阿替普酶静脉溶栓治疗,分别于溶栓前及溶栓后24 h行床旁经颅多普勒超声(transcranial Doppler,TCD)检查并记录脑缺血溶栓分级(thrombolysis in brain ischemia,TIBI)。采用美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分记录患者临床神经功能缺损,3个月随访时采用改良Rankin量表(modified Rankin Scale,m RS)评分评估患者预后,分析前循环不同大血管闭塞性脑梗死患者静脉溶栓前后血管再通情况及患者3个月预后。结果共入选46例患者,其中颈内动脉(internal carotid artery,ICA)闭塞患者19例,大脑中动脉(middle cerebral artery,MCA)闭塞患者27例。溶栓前与溶栓后24 h TCD监测TIBI分级提示血管再通者,ICA闭塞组5.26%,MCA闭塞组55.56%。ICA闭塞组与MCA闭塞组比较,MCA闭塞组90 d随访生活自理及良好预后的比例均高于ICA闭塞组,死亡率低于ICA闭塞组,而两组间溶栓后的症状性颅内出血发生率差异无显著性。结论急性前循环大动脉闭塞性脑梗死经静脉溶栓治疗后可获得血管再通,尤其是MCA闭塞患者;溶栓前后TIBI血流分级变化可反映大动脉血管再通情况,且有助于判断患者临床预后。     

Computed Tomography Angiogram Derived From Computed Tomography Perfusion Done with Low Iodine Volume Protocol Preserves Diagnostic Yield for Middle Cerebral Artery-M2 Occlusions

Background: Computed tomography angiogram (CTA) derived from computed tomography perfusion (CTP) has been proposed to avoid addition of separate CT perfusion protocol for selection of large vessel occlusion in acute stroke patients. Previous studies have validated this technique for proximal large vessel occlusions. In this study, we test reliability for identifying M2 occlusions on CTA derived from CTP. Methods: Through a retrospective search of the institutional thrombectomy database, we identified 28 cases with M2-MCA occlusion, of which 24 met the inclusion criteria for analysis. An additional 20 cases without M2-MCA occlusion (either normal or M1-MCA occlusion) were randomly mixed in the database to reduce observer bias. The baseline images of the CTP study in these 48 cases were then independently analyzed by 3 readers with varying level of expertise. The digital subtraction angiography (DSA) images were also independently reviewed where available. The percentage of agreement among reviewers as well as the probability of agreement of the reviewers, when compared to the DSA findings was also calculated. Results: The observed agreement for the image quality amongst the 3 readers (n = 48) varied between 0.78 and 0.95 and tended to be higher for the M1 segment MCA and lower for distal M2-MCA. The observed agreements comparing 3 image reviewers versus DSA in M2 patients (n = 24) was 98% for identifying occlusion (95% CI 95%-100%), 94% for identifying proximal M2 occlusion (95% CI 88%-98%), and 91% (95% CI 84%-97%) and 90% (95% CI 83%-95%), respectively for correctly identifying inferior and superior branch of M2 occlusion. Conclusion: CTA data derived from CT Perfusion study preserves diagnostic yield for correctly identifying M2 occlusion.     

The Prognostic Value of CT-Angiographic Parameters After Reperfusion Therapy in Acute Ischemic Stroke Patients With Internal Carotid Artery Terminus Occlusion: Leptomeningeal Collateral Status and Clot Burden Score

Background

The objective of this study was to investigate the prognostic value of computed tomographic angiography (CTA) based on leptomeningeal collateral (LMC) status and other parameters in acute ischemic stroke (AIS) patients with internal carotid artery (ICA) terminus occlusion treated with endovascular treatment (EVT).

Clinical implications of collateral middle cerebral artery flow in acute ischaemic stroke with internal carotid artery occlusion

Background and purpose: The presence of collateral middle cerebral artery (MCA) flow via the primary collateral pathway is thought to protect against the progression of cerebral ischaemia. However, there have been few reports on early clinical outcomes according to the presence of collateral MCA flow in acute ischaemic stroke (AIS) with internal carotid artery (ICA) occlusion. Therefore, we sought to investigate the early clinical outcomes and lesion patterns according to the presence of collateral MCA flows in AIS with ICA occlusion. Methods: This is a retrospective study of patients with AIS with ICA occlusion consecutively admitted to our stroke center between October 2008 and March 2010. Patients were included if they were admitted within 12 h of symptom onset with AIS and symptomatic ICA occlusion. Collateral MCA flow was defined as the presence of MCA signals from proximal M1 to distal MCA branches ipsilateral to the ICA occlusion by magnetic resonance angiography. Early neurological deterioration (END) was defined as a 4‐point increase in the National Institutes of Health Stroke Scale (NIHSS) score and persistent neurological deterioration for at least 24 h or newly developed neurological symptoms within 7 days. Results: Sixty‐five patients (42 men, 23 women) were finally included. Initial NIHSS scores were significantly lower, and favorable outcomes at 3 months were better in patients with collateral MCA flow than in those without (P < 0.001). Initial lesion patterns were different according to the collateral MCA flow. However, patients with mild AIS might more frequently deteriorate than those with moderate to severe AIS. Conclusions: In our study, collateral MCA flow reduced initial stroke severity and was associated with favorable outcomes at 3 months but did not seem to protect against END in mild AIS patients with ICA occlusion. Therefore, the results of this study suggest that mild AIS patients with ICA occlusion should be carefully managed because their conditions may deteriorate.     

The Yield of Multimodal Computed Tomography among Emergency Department Patients with Suspected Large Vessel Occlusion Stroke

Objectives: Endovascular therapy (EVT) improves outcomes for appropriately selected acute ischemic stroke patients. Guidelines suggest rapid acquisition of noninvasive vascular imaging to screen suspected ischemic stroke patients for large vessel occlusion (LVO) and candidacy for EVT. We sought to quantify the yield of an LVO stroke screening process in an undifferentiated emergency department (ED) suspected stroke population as well as identify predictors of successful EVT. Methods: We identified a cohort of consecutive ED patients who received CT angiography and brain perfusion (CTA/P) imaging to determine candidacy for EVT during 2016. In keeping with the guidelines at that time, hospital protocol directed physicians to obtain CTA/P studies if time from the onset of symptoms was less than or equal to 6 hours, and the National Institute of Health Stroke Scale (NIHSS) more than or equal to 6 or if recommended by the consulting stroke neurologist. Final discharge diagnoses, EVT attempts, and successful reperfusion (TICI 2b or better) were recorded. Yield of CTA/P was compared among patients based on NIHSS and duration of symptoms. Results: Over a 12-month period, 406 suspected stroke patients were screened with CTA/P; 273 (67%) received a final diagnosis of ischemic stroke. Among cases screened, 53 (13%) underwent attempted EVT; 35 (9%) achieved successful reperfusion. Only 1 of 113 (1%) patients with an NIHSS less than 6 was successfully treated with EVT compared to 34 of 285 (12%) with higher NIHSS (p = 0.001). The probability of successful EVT declined with increasing symptom duration (p = 0.009 for trend). In multivariable analysis, NIHSS more than or equal to 6 was associated with successful EVT (odds ratio [OR] 4.0 [1.6 to 9.9]) but presentation within 6 hours of onset was not (OR 2.3 [0.8 to 6.7]). Conclusions: EVT candidates were common among suspected stroke patients screened with CTA/P in the ED, however, patients with NIHSS less than 6 rarely received successful EVT.     

Modification by an aspiration catheter for vessel stretching in thrombectomy using a stent retriever in vitro

ObjectivesPost-thrombectomy subarachnoid hemorrhage, which is caused by vessel stretching when retrieving a stent retriever (SR), is a complication of endovascular mechanical thrombectomy (EVT) using an SR. This in vitro study examined the association between EVT for middle cerebral artery (MCA) occlusion and M2 vessel stretching depending on the positioning of the SR or combined use of SR and aspiration catheter (AC) technique (CBT).Materials and methodsA silicone vascular model was used. The maximum migration distance (MMD) in the anteroposterior view of an X-ray impermeable metal marker located at an M2 trunk 20 mm distal to the M1-2 bifurcation in angiographic images during an SR retrieval was calculated. According to the positioning of SR deployment (distal or proximal) and use of an AC [SR alone without an AC (SR alone) group, stent retrieval into an AC (SA) group, and stent-AC retrieval as a unit into a guiding catheter (SA unit) group], 60 attempts were conducted with each group of 10 attempts.ResultsIn distal SR deployment, the MMD in the CBT group, consisting of SA and SA unit groups, was significantly smaller than the SR alone group (1.36 ± 0.32 mm VS 2.39 ± 1.10 mm; p = 0.001). In proximal SR deployment, the CBT group showed a tendency to decrease MMD (1.38 ± 0.33 mm VS 1.63 ± 0.28 mm; p = 0.077).ConclusionsThis in vitro study showed that CBT might help modify the stretching of M2 when an SR is distally deployed in MCA occlusion.     

Mechanisms involved in large subcortical infarcts]

Large subcortical infarcts(maximum diameter of infarct > or = 20 mm) result from various stroke patterns, including striatocapsular infarcts (SCI), corona radiata infarcts, centrum semiovale infarcts, and internal borderzone infarcts. A systematic investigation of stroke pathogenesis involved in large subcortical infarcts, however, has not been performed. This study attempted to clarify the stroke mechanisms involved in large subcortical infarcts, by examining 50 patients with large subcortical infarcts out of 430 ischemic stroke patients consecutively registered in our department. The subjects were divided into two groups according to the vascular territories involved on the MRI: 1) the lenticulostriate arteries group for 39 patients whose infarcts were restricted to within the vicinity of the lenticulostriate arteries; 2) the internal borderzone group for 11 patients whose infarcts mainly involved the internal borderzone (the upper part of the corona radiata and the centrum semiovale) between the territories of the deep perforating branches from the basal cerebral arteries and the medullary branches from the superficial pial arteries. Stroke pathogenesis were classified into the following 6 categories: A) cardiogenic embolism, 9 patients; B) artery-to-artery embolism, 6 patients; C) cryptogenic embolism, 2 patients; D) thrombotic MCA (M1) occlusion, 9 patients; E) thrombotic ICA occlusion, 10 patients; F) undetermined cause, 14 patients. The lenticulostriate arteries group consisted of 9 patients with cardiogenic embolism, 6 with artery-to-artery embolism, 2 with cryptogenic embolism, 8 with thrombotic M1 occlusion, and 14 with undetermined cause. The internal borderzone group consisted of 10 patients with thrombotic ICA occlusion and 1 patient with thrombotic M1 occlusion. The stroke pathogenesis of the undetermined cause is considered to be thrombotic occlusion at the orifice of the lateral lenticulostriate artery, a so-called "branch atheromatous disease (BAD)". The patients in this group experienced a gradual onset, and did not have a cardiac source of the embolism or proximal large artery disease. Among the patients reported as having SCI, BAD may play a role in some cases, especially in those whose the cause was classified as "undetermined". In conclusion, the lenticulostriate arteries group exhibited a higher frequency of cerebral embolisms (cardiogenic embolism, artery-to-artery embolism, and cryptogenic embolism) and thrombotic M1 occlusion, whereas the internal borderzone group had a higher frequency of thrombotic ICA occlusion.     

颈内和大脑中动脉狭窄与闭塞的梗死类型及卒中机制的研究

目的 研究单侧动脉粥样硬化性MCA/ICA狭窄与闭塞的急性缺血性脑卒中患者在DWI上的梗死类型及发病机制.方法 起病48h内DWI诊断的急性脑梗死伴有动脉粥样硬化性MCA/ICA狭窄与闭塞的131例患者,有潜在心源性栓子患者除外.急性期DWI上梗死病灶分为：（1）单发病灶（小的穿动脉梗死灶;大的穿动脉梗死灶,皮层支梗死,大面积梗死,分水岭梗死）;（2）多发梗死病灶.结果 131例患者,ICA51例,MCA80例.ICA出现最多的梗死类型：穿支动脉伴分水岭梗死,但与MCA比较,皮层支伴分水岭梗死具有统计学意义（8/51,P=0.001）.MCA以穿支动脉伴皮层支梗死最多,且与ICA比较,具有统计学意义（12/80,P=0.003）.MCA中任何皮层支梗死与狭窄程度无关,ICA中任何分水岭梗死与狭窄程度相关.结论 颈内和大脑中动脉狭窄与闭塞在DWI上的梗死类型有明显的不同,提示有着不同的卒中发病机制.     

Cause of cerebral infarction in the carotid territory. Its relation to the size and the location of the infarct and to the underlying vascular lesion

Seventy-three patients with acute nonhemorrhagic stroke in the carotid territory were investigated for the cause of the stroke: middle cerebral artery (MCA) occlusion/stenosis or internal carotid artery (ICA) occlusion/stenosis; embolus from the heart and extra-cranial arteries or thrombosis. The study is prospective and consecutive comprising stroke patients below the age of 75 years, admitted in the acute state i.e. within 3 days after stroke onset. Excluded were patients with intracerebral hematoma, subarachnoid hemorrhage, vertebrobasilar stroke and patients in whom another severe disease was present. Cerebral angiography and CT-scan were performed in all patients within one and two days after admission. CT-scan was repeated 2 weeks and 6 months later. Forty percent had MCA occlusion, none had MCA stenosis, 12% had ICA occlusion, 14% had severe ICA stenosis (half of these were associated with MCA occlusion) and 41% were without significant MCA/ICA lesions. Twenty-seven percent had large infarcts with a diameter greater than 3 cm; 34% had medium-sized infarcts with a diameter between 3 and 1.5 cm; 21% had small infarcts with a diameter less than 1.5 cm; 18% had no identifiable infarct on CT-scan. MCA occlusion was responsible for 62% of the large or medium-sized infarcts. ICA occlusion or severe ICA stenosis were responsible for only 27% of the large or medium-sized infarcts. Only 11% of the patients with small or no infarct on CT-scan had significant MCA/ICA lesion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in blood gas values and electrolytes in the occluded artery predict outcomes after endovascular treatment in ischemic stroke

Background and purposeEndovascular treatment (EVT) is the best treatment for acute ischemic stroke with large vessel occlusion (LVO) and makes it possible to analyze the blood contents from the occluded vascular compartments. In this study, we attempted to evaluate regional changes in blood gas values and electrolytes in the occluded vessels, aiming to determine whether these changes can predict outcomes in LVO patients receiving EVT.Materials and methodsWe prospectively observed 45 consecutive ischemic stroke patients with LVO of the anterior circulation who underwent EVT. We collected the arterial blood proximal to the occlusion site before and after EVT, and the blood within the core of the occluded vascular compartment (distal to the thrombus) and evaluated the labs for blood gas values and electrolytes. Femoral samples were obtained under physiological flow conditions to represent systemic arterial blood.ResultsCompared with the femoral arterial blood samples, significant decreases in K+, Ca2+, HCO3−, BE, HCT, tHbc, and TCO2 levels were observed in the proximal luminal blood before EVT. Decreases in K+ and Ca2+ levels were also observed in the proximal luminal blood after EVT. Proximal/femoral ratio of pH and Na+ was associated with short-term clinical outcomes at 72 hours after EVT. A higher proximal/femoral Na+ ratio was associated with successful recanalization. Further analysis after propensity score matching showed significant changes in blood gas and electrolyte among different arterial locations in ICA and MCA LVO participants. Linear regression analyses indicated that the proximal/femoral ratio of pH, Na+, pCO2, HCO3, and TCO2 before EVT were associated with decrease in NIHSS score at 72 hours in ICA-LVO group.ConclusionsObvious changes in several parameters of arterial blood gas and electrolyte from the ischemic vasculature occur during hyperacute stroke. Proximal/femoral pH and Na+ ratio before EVT may be associated with short-term clinical outcome, which deserve to be further investigated.     

大脑中动脉供血区梗死灶形态与可能发病机制的回顾性研究

目的 探索大脑中动脉(MCA)供血区的梗死灶形态与脑卒中可能发病机制之间的关系.方法 回顾性分析了148例连续的急性缺血性脑卒中患者,所有患者均为颈内动脉(ICA)系统脑梗死,DWI显示相应MCA供血区责任病灶,根据血管及心脏检查将患者分为ICA病变组、MCA病变组、ICA+MCA病变组、心源性栓塞组(CE组)及检查结果阴性组(NR组).将梗死灶形态分为单发和多发,前者按部位分为:穿动脉梗死灶(PAI)、皮质支梗死灶(PI)、分水岭梗死灶(BZ)、大面积梗死灶.结果 MCA供血区的梗死灶形态可分为12种;不同病变所致脑卒中的梗死灶形态存在差异(χ2=55.88,P=0.004).但在MCA组、ICA组、MCA+ICA组及CE组中,未发现各自特异的梗死灶形态,仅PAI更多见于MCA组;与NR组相比,ICA组患者中更多出现PAI伴PI(7/27,χ2=6.61,P<0.05),而MCA组和CE组均未见特征性的梗死灶形态.动脉狭窄的程度与梗死灶形态亦存在一定关联,重度ICA病变更多地表现为PAl伴PI(5/16,χ2=7.32,P<0.05);而重度MCA病变则好发PAI伴BZ(4/30,χ2=5.59,P<0.05)及PAI伴PI和BZ(6/30,χ2=6.41,P<0.05).结论 MCA供血区内的梗死灶形态与其颅内动脉病变之间存在一定的关系,揭示脑卒中发生的不同机制,可能与动脉-动脉栓塞、灌注不良有关;我们以检查结果阴性患者为对照比较,尚不能完全揭示MCA供血区内的梗死灶形态和与脑卒中的不同机制之间的相关性.     

不同大血管闭塞性急性缺血性卒中患者静脉溶栓疗效比较

目的 对不同大血管闭塞所致的急性缺血性卒中患者静脉溶栓疗效进行比较分析,探讨适宜静脉 溶栓治疗的大血管闭塞患者。 方法 本研究的入选患者来自中国急性缺血性卒中溶栓监测登记研究,从中选取所有完成了溶栓 前多模式计算机断层扫描（computed tomography,CT）或磁共振成像（magnetic resonance imaging,MRI）, 且血管成像提示有责任大血管闭塞的患者,对不同大血管闭塞的急性缺血性卒中患者静脉溶栓的有 效性及安全性结局进行比较分析。 结果 共入选122例患者,大脑中动脉闭塞组溶栓后血管再通率为55.2%,而颈内动脉闭塞组为0%, 基底动脉闭塞组为40%。大脑中动脉闭塞组90 d随访生活自理［53.9% vs 21.1%,P =0.007,比值比 （odds ratio,OR）=5.68］及良好预后（42.7% vs 21.1%,P =0.041,OR =3.76）的比例均优于颈内动脉 闭塞组,死亡率低于颈内动脉闭塞组（4.5% vs 47.4%,P <0.001,OR =0.03）,而两组溶栓后的症状 性颅内出血发生率差异无显著性（1.1% vs 0%,P =0.962）。 结论 不同大血管闭塞性急性缺血性卒中患者静脉溶栓效果有明显差异,大脑中动脉闭塞患者静 脉溶栓开通率最高,疗效明显优于颈内动脉闭塞患者。     

Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy

Introduction: There is continued interest in identifying factors that predict a favorable outcome after endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (ACLVO). We compared the predictive values of 2 different scoring systems for evaluating venous collateral circulation. Methods: A retrospective review of patients who underwent EVT for ACLVO at a single institution was performed. Those who underwent preprocedural computed tomography angiography (CTA) were selected. The Cortical Vein Opacification Score (COVES) and Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) score were calculated from each patient's CTA. Our primary outcome of interest was the Modified Rankin Scale (mRS) score at 90 days. Results: A total of 103 patients were included in the study (average age = 68.3 years, median National Institutes of Health Stroke Scale = 15). The mean time to reperfusion was 6.4 hours and Thrombolysis in Cerebral Infarction 2B or 3 reperfusion was achieved in 77.7% of cases. An unfavorable COVES score was significantly associated with an unfavorable (mRS 3-6) outcome (adjusted odds ratio [aOR]: 3.06; 95% confidence interval [CI] 1.15-8.13, P = .025), while an unfavorable PRECISE score was not (aOR: 1.02; 95% CI .37-2.80, P = .966). Based on the Receiver Operating Characteristic analysis, the COVES score had a sensitivity of 68.1%, specificity of 71.4%, and area under the curve (AUC) of .77. The PRECISE score had a sensitivity of 68.9%, specificity of 70.7%, and the AUC of .73. Conclusions: The COVES score, but not the PRECISE score, is associated with functional outcomes at 90 days after EVT for ACLVO.     

Carotid pseudo-occlusion on CTA in patients with acute ischemic stroke: A concerning observation

Objective

Differentiation between an occluded and a patent extracranial internal carotid artery (ICA) is crucial in the diagnostic workup of patients with acute ischemic stroke; particularly in patients eligible for endovascular treatment. We report neurological and radiological findings of cases in which CTA in the acute phase incorrectly revealed an occlusion of the ICA.

Methods

In our image data base of 54 patients with acute ischemic stroke eligible for endovascular treatment, we searched for patients with an occluded extracranial ICA on CTA whereas DSA proved that this artery was patent. Of these patients, all available images were re-examined to investigate possible causes of these so-called pseudo-occlusions.

Results

We detected 6 patients (11%) with a pseudo-occlusion. The pseudo-occlusions on CTA were associated with reduced flow due to carotid T-occlusions (4 cases) or a combination of a high degree stenosis of the extracranial ICA and MCA occlusion (2 cases).

Conclusion

CTA in the acute phase of ischemic stroke needs to be interpreted with severe caution, and in endovascular treatment decisions we should be aware that an extracranial ICA occlusion may be a false positive finding.     

Safety and efficacy of mechanical thrombectomy with the Solitaire device in large artery occlusion

Background and Purpose: Intravenous tissue plasminogen activator (TPA) has limited efficacy in proximal large vessel occlusions. This study was to assess the safety and efficacy of mechanical thrombectomy with a retrievable Solitaire stent in acute large artery occlusions . Materials and Methods: This is a single center study enrolling patients treated with Solitaire-assisted thrombectomy between November 2010 and March 2011. Inclusion criteria were severe stroke of National Institutes of Health Stroke Scale (NIHSS) score ≥10, treatment initiation within 6 hours from onset, and an angiographically verified occlusion of proximal middle cerebral artery (MCA) or internal carotid artery (ICA). The primary outcome was recanalization defined as Thrombolysis in Cerebral Infarct (TICI) reperfusion grade 2b/3. Secondary outcomes were good functional outcome at 3 months (modified Rankin Scale [mRS] ≤2), early substantial neurological improvement (NIHSS score improvement ≥8 at 24 hours), and symptomatic hemorrhagic transformation (SHT). Results: Ten patients were consecutively enrolled: Age: 72.4 ? 5.7 years; female: 70%; baseline median NIHSS score: 19.5; and ICA occlusion in 50% and M1 portion of MCA occlusion in 50%. Six patients received intravenous TPA before intra-arterial treatment, and five patients were treated with adjuvant intra-arterial urokinase. Successful recanalization was achieved in 7 (70%) patients. Four (40%) patients had a good functional outcome at 3 months, and three (30%) patients had an early substantial neurological improvement. SHT occurred in two patients (20%), and 3-month mortality rate was 30%. There was no procedure-related complication. Conclusions: Mechanical thrombectomy with the Solitaire device can effectively recanalize proximal large vessel occlusions, and potentially improves clinical outcome.     

症状性颅内动脉闭塞患者脑灌注缺损与侧支循环的相关性研究

目的 研究症状性颅内动脉闭塞患者脑灌注缺损与侧支循环的关系。 方法 回顾性纳入2017年1月-2018年10月于解放军总医院第一医学中心连续收治的症状性单侧颈 内动脉（internal carotid artery,ICA）颅内段或大脑中动脉（middle cerebral artery,MCA）M1/M2段闭塞 患者,根据闭塞部位分为ICA闭塞组和MCA闭塞组。收集患者临床资料并记录影像学特征,采用定量 分析软件获取患侧脑血流残余功能达峰时间（time to maximum of the residual function,Tmax）>4 s和 Tmax>6 s的低灌注区容积,并采用多时相CTA 6级评分法对侧支循环进行评分。比较两组患者低灌注 区容积与侧支循环的差异,并分析低灌注区容积与侧支循环评分的相关性。 结果 最终纳入42例患者,平均年龄54.9±13.9岁,男性29例（69.0%）,其中I CA闭塞组19例,MCA 闭塞组23例。ICA闭塞组Tmax>4 s容积（163.1±98.6 mL vs 64.6±54.2 mL,P <0.001）、Tmax>6 s容积 （92.4±87.1 mL vs 13.0±27.6 mL,P <0.001）均大于MCA闭塞组;ICA闭塞组侧支循环评分低于MCA闭 塞组[3（2～4）分 vs 4（3～4）分,P =0.021]。ICA闭塞组Tmax>4 s 、Tmax>6 s容积与侧支循环评分呈负相关 （r =-0.667,P =0.002;r =-0.717,P <0.001）;MCA闭塞组Tmax>4 s 、Tmax>6 s容积与侧支循环评分呈负 相关（r =-0.498,P =0.016;r =-0.494,P =0.017）。 结论 症状性颅内动脉闭塞患者低灌注区容积与闭塞部位及侧支循环相关,ICA闭塞患者较MCA闭 塞患者有更大的低灌注缺损和更差的侧支循环。