An elderly case with late carotid stent thrombosis: possible role of antiphospholipid antibodies

The case study speculates that the antiphospholipid antibodies acquired during the follow-up period of carotid artery stenting may cause late stent thrombosis that is resistant to direct oral anticoagulants. A 73-year-old man was hospitalized with complaints of weakness in the right lower extremity. The patient had undergone carotid artery stenting for symptomatic stenosis of the left internal carotid artery 6 years prior and had received antiplatelet therapy with clopidogrel 75 mg/day. As the patient had developed atrial fibrillation without stent stenosis at the age of 70 years, anticoagulation therapy with rivaroxaban15 mg/day was initiated while discontinuing clopidogrel. On admission, diffusion weighted imaging (DWI) revealed acute brain infarcts in the territory of the left middle cerebral artery. Contrast-enhanced computed tomography and cerebral angiography exposed severe stenosis in the left carotid artery accompanied by a filling defect caused by a floating thrombus. Laboratory examination revealed the presence of three types of antiphospholipid antibodies, with marked prolongation of activated partial thromboplastin time (APTT). Replacement of rivaroxaban with warfarin eliminated the thrombus without recurrent stroke. In conclusion, late stent thrombosis may be associated with antiphospholipid antibodies acquired during the follow-up period of carotid artery stenting.     

脑动脉狭窄的介入治疗

症状性脑动脉狭窄一直是临床治疗的难点。目前其治疗大致分为3类:(1)药物治疗;(2)外科治疗;(3)介入治疗。内科抗凝、抗血小板治疗往往起不到控制卒中发作的作用;外科颅内-颅外血管吻合术及动脉内膜剥脱术受多种因素的限制,风险较大。近年来,由于安全有效的支架输送、投放工具和支架的发展,介入治疗在脑动脉硬化性狭窄性疾病中的应用逐渐增多;本文就这方面的认识进展做一综述。     

Small Carotid Thrombus and Minimal Stenosis Causing Repeated Embolic Strokes

Despite current developments in neuroradiology, the sources of infarctions go undiagnosed in 28% of cases. An embolic source in the setting of minimal stenosis at the carotid bifurcation has rarely been reported. The authors report a previously healthy 48‐year‐old woman, without any risk factors for cerebrovascular events, sustained multiple cerebral infarctions in the right anterior and middle cerebral artery territory. Repeated imaging of the heart and cerebral vessels missed a very small abnormality arising from the posterior wall of the internal carotid artery, until it was diagnosed by computed tomographic angiography. This is problematic because by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, minimal stenosis essentially excludes the carotid artery as an embolic source. Despite maximum antiplatelet and anticoagulation therapy, she continued to have neurological deteriortation by progression of her strokes. She underwent standard carotid endarterectomy and sustained no new embolic phenomena. Histopathological examination showed an endothelial hyperplasia with organizing thrombus, which on the posterior wall of the internal carotid artery, is likely a hemodynamically induced on top of preexisting atherosclerotic plaque.     

颞浅动脉-大脑中动脉搭桥术治疗动脉粥样硬化性脑缺血13例报告

目的 探讨颞浅动脉-大脑中动脉搭桥术（superficial temporal artery-middle cerebral artery bypass,STA-MCA bypass）治疗动脉粥样硬化性脑缺血的疗效。方法 对北京天坛医院进行STA-MCA bypass治疗的13例经计算机断层扫描灌注成像（computertomography perfusion,CTP）评价存在低灌注的颈内动脉和（或）大脑中动脉粥样硬化性重度狭窄和（或）闭塞患者进行回顾性研究。通过手术中脑血管吲哚菁绿荧光造影和手术后数字减影血管造影（digital subtraction angiography,DSA）、计算机断层扫描血管成像（computer tomography angiography,CTA）等确定吻合血管通畅程度。比较手术前、后美国国立卫生研究院卒中量表（National Institutes ofHealth Stroke Scale,NIHSS）评分、改良的Rankin量表（modified Rankin Scale,mRS）评分及CTP参数值。结果 13例患者中,男11例、女2例,11例行STA-MCA bypass,2例行STA-MCA bypass联合脑-硬脑膜-动脉贴敷术,吻合血管血流通畅。手术后3个月mRS评分较术前下降（0.92±0.76 vs 2.38±1.26,P =0.001）。手术侧比非手术侧MCA供血区域CTP参数绝对值的比较,手术前和术后15 d内相对脑血流量（relative cerebral blood flow,RCBF）、相对平均通过时间（relative mean transit time,RMTT）及相对达峰时间（relative time to peak,RTTP）分别为0.71±0.13 vs 1.00±0.25、2.53±1.32 vs 1.48±0.94和1.20±0.11 vs 1.07±0.12,P =0.002、0.036和0.015）。手术后3～10个月RTTP较术前下降（1.10±0.96vs 1.22±0.82,P =0.043）。13例患者在随访期间无死亡、无新的脑缺血事件发生。结论 对于CTP评价存在低灌注的动脉粥样硬化性脑血管重度狭窄或闭塞患者,STA-MCA bypass可能能够改善低灌注状态、减少缺血症状发作及预防卒中再发生;CTP可能成为简单可靠并有推广价值的评价手段。     

Surgical treatment of cerebrovascular occlusive disease

Surgical therapy for cerebrovascular occlusive disease has a rich and fascinating history. Carotid endarterectomy is the most commonly performed operation for cerebrovascular disease. Other ingenious efforts have been tried and, of these, only the superficial temporal middle cerebral artery bypass procedure has been prospectively studied. All efforts at extracranial and intracranial vascular surgery are under scrutiny presently and many feel that the extracranial-intracranial bypass procedure has little, if any, future. The efficacy of carotid endarterectomy will probably be studied prospectively, but, for the immediate future, endarterectomy is a well-established therapy for certain cases of carotid stenosis or ulceration.     

Magnetic resonance angiographic assessment after extracranial-intracranial bypass surgery.

Extracranial-intracranial (EC-IC) bypass operation may be performed to augment the distal cerebral circulation. The bypass patency is usually assessed postoperatively with conventional cerebral angiography. Six patients are reported in whom the bypass patency was assessed using magnetic resonance angiography (MRA): Two had intracavernous carotid aneurysms, three had base of skull tumours encompassing the internal carotid artery, and one had occlusion of the right internal carotid artery with poor collateral reserve as confirmed by an acetazolamide stimulation test. Postoperative conventional cerebral angiography was also obtained in three patients for comparison. The MRA correlated reasonably well with conventional cerebral angiography in showing bypass patency, although conventional cerebral angiography was superior in demonstrating small vessels; MRA has the added advantage of showing the relative flow contribution and flow direction under physiological conditions by using targeted presaturation pulses.     

FLOW800技术在STA-MCA分流术治疗烟雾病效果评估中的作用

目的 探讨FLOW800技术在判断烟雾病颞浅动脉（STA）-大脑中动脉（MCA）分流术中血管吻合口通畅度及在手术治疗效果评估中的作用。方法 回顾性分析2017年4月至2018年11月接STA-MCA分流术治疗的33例烟雾病的临床资料,手术前后应用FLOW800技术评估血管吻合口通畅情况及手术区域灌注改善情况。使用FLOW800软件对感兴趣区（ROI）进行分析,得到时间-荧光强度曲线,其中造影剂由动脉经循环后流至静脉的时间称为局部循环时间（MVTT）,手术前后MVTT差值定义为ΔMVTT。结果 33例均手术顺利,术中FLOW800分析均显示吻合口通畅。1因吻合口出现未行血管检查,其余32例吻合血管均通畅。术后11例发生并发症,其中低改善组6例（ΔMVTT<3 s）,过改善组5例（ΔMVTT>3 s）。过改善组术前MVTT、ΔMVTT明显高于无并发症组和低改善组（P<0.05）,而后两组均统计学差异（P>0.05）。受试者工作特征曲线分析结果显示ΔMVTT判断无并发症与低改善的最佳临界时间为1.635 s,敏感度和特异度分别为0.667和0.682;ΔMVTT判断无并发症与过改善的最佳临界时间为3.525 s,敏感度和特异度为别为1.000和0.727。结论 FLOW800技术可准确评价烟雾病STA-MCA分流术中吻合口通畅程度,并在术后并发症的预测中起到一定的作用。     

Can Moyamoya Disease Susceptibility Gene Affect Extracranial Systemic Artery Stenosis?

Diseases associated with the RNF213 gene include moyamoya disease, with the p.R4810K (c.14429G>A, rs112735431) homozygous variant thought to be the most pathogenic and significantly associated with severe manifestation such as early onset or cerebral infarction at onset. We report a case of a unique Japanese pedigree associated with RNF213. A 53-year-old woman with no arteriosclerotic risk factors experienced coronary artery disease, followed by coronary artery bypass surgery. In 8 years, she suffered sudden abdominal pain. Her abdominal contrast computed tomography revealed stenosis of abdominal artery and superior mesenteric artery. Though her 2 children and uncle had a typical moyamoya disease with RNF213 p.R4810K heterozygous variant, she has had no clinical and radiological evidence of moyamoya disease. Due to a family history of moyamoya disease, a genetic investigation was performed and revealed RNF213 p.R4810K homozygous variant. A possible role of RNF213 influencing systemic artery stenosis can be further be understood from this rare case harboring the homozygous variant carrier.     

Fatal cerebral embolism following aorto-coronary bypass graft surgery.

In a case of fatal cerebral embolic infarction following aorto-coronary bypass graft (ACBG) surgery, postmortem examination revealed thrombosis of the vein grafts to the left circumflex and left anterior descending coronary arteries. Continguous with the thrombus in the graft to the circumflex artery was thrombotic material adherent to the aortic sutures and extending several millimeters into the lumen of the aorta. A nonadherent thrombus of similar histologic character was found in the right middle cerebral artery, associated with localized brain infarction. In addition to the risks of cerebral complication associated with other types of open-heart surgery, the location of the vein grafts in patients undergoing ACBG operations seems to offer a unique mechansim for the occurrence of systemic and cerebral embolism, which may be operational in other cases.     

The examination of the blood flow velocity in arterial vessel during and after encephalo-dura-arterio-synangiosis. Preliminary results]

The Japanese authors first described encephalo-duro-arterio-synangiosis, a new treatment for moya-moya disease, 17 years ago. The other authors used this method (EDAS, indirect anastomosis) in surgical treatment of patients suffered cerebral transient ischaemic attack and cerebral ischaemia. In our department this method was applied in 5 patients with cerebral ischaemia. All patients had internal carotid artery occlusion. After angiography, to localize carotid artery occlusion, acetazolamid (Diamox) test was performed. The patients with negative Diamox test were treated surgically (EDAS). The authors used the intraoperative microdoppler device to monitor blood flow velocity of the prepared vessel (temporal superficial artery) at every stage of surgery. The device was also useful in controlling the patency of encephalo-duro-arterio-synangiosis percutaneously after the surgery. The proximal and the distal part of the non-bypass anastomosis was examined in the follow up during 5-8 months before angiography.     

替罗非班治疗颈动脉漂浮血栓相关脑梗死

颈动脉漂浮血栓为一种细长的血管内漂浮物,多见于颈内动脉,常为动脉粥样硬化斑块破裂所致,可造成血管重度狭窄或者漂浮物脱落导致下游流域内多发脑栓塞,临床表现为神经功能缺损症状,严重者可出现恶性大脑中动脉脑梗死、脑疝等,并危及生命。其发病率及识别率低、病因多样,治疗方法包括颈内动脉支架置入术、颈内动脉内膜剥脱术以及抗凝、抗血小板聚集等治疗,但目前尚无指南可循。现报道应用替罗非班成功治疗颈动脉漂浮血栓相关脑梗死患者1例,以提高对颈动脉漂浮血栓相关脑梗死的认识,并为其治疗提供新的思路。     

Ultrasonic Doppler assessment of hemodynamics in extra-intracranial arterial anastomosis in children with Moyamoya disease

Recently the extra-intracranial (EC/IC) arterial bypass operation has been introduced in the treatment of Moyamoya disease and excellent postoperative outcomes have been reported. To assess the cerebral hemodynamic changes after the bypass surgery, ultrasonic Doppler flowmetry was performed in 10 children with Moyamoya disease. Their surgical treatments included superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis or encephalo-duro-arterio-synangiosis. The flow velocity and pattern of the major cerebral arteries and STAs, the donor artery of the bypass, were studied both before and after the operation. The results of Doppler flowmetry were compared with clinical symptoms and angiographical findings. Though the Doppler sonography of the major cerebral arteries showed little change, the flow velocity of the STAs revealed a pronounced and rapid increase after the bypass surgery. The flow pattern of the STAs, which was of the external carotid type preoperatively, changed to the internal carotid type postoperatively. These ultrasonic Doppler findings were thought to be due to a decrease in the peripheral vascular resistance, and suggested a good patency of the bypass arteries. These results of the Doppler flowmetry were in good agreement with clinical and EEG improvement and the findings of the postoperative cerebral angiography. It is suggested that ultrasonic Doppler flowmetry is a noninvasive and reliable method of assessing the function of the EC/IC bypass in children with Moyamoya disease.     

Intraoperative infrared brain surface blood flow monitoring during superficial temporal artery–middle cerebral artery anastomosis in patients with childhood moyamoya disease

Objective  To monitor patency of the bypass and to accomplish comprehensive visualized evaluation of brain surface hemodynamics in childhood moyamoya patients, we performed intraoperative monitoring using novel infrared imaging system. Materials and methods  Intraoperative monitoring of brain surface blood flow by IRIS V infrared imaging system has been conducted during superficial temporal artery–middle cerebral artery anastomosis on seven sides of five pediatric patients with moyamoya disease (man/woman = 2:3, 7–8 years old). The range of recipient artery was 0.7–0.8 mm (average 0.75 mm). Magnetic resonance imaging and magnetic resonance angiography were performed routinely before and after surgery. Conclusions  In all cases, patency of bypass, as well as detailed local hemodynamics and changes of brain surface temperature distribution could be evaluated. Intraoperative infrared system will be a feasible monitoring not only for noninvasive intraoperative evaluation of bypass patency but also for local hemodynamics even in patients with childhood moyamoya disease.     

High flow extracranial-to-intracranial brain bypass surgery

High flow extracranial to intracranial (HF EC–IC) cerebral revascularisation may be necessary in the management of complex skull base tumours and intracranial aneurysms. Vascular reconstruction techniques, in addition to direct clip reconstruction, have been described since the first successful bypass more than 50 years ago. Bypass grafting can be considered high flow when a radial artery or the saphenous vein is interposed between the extracranial carotids arteries and intracranial vessels. The decision as to whether to use a low flow or high flow bypass is determined by the anticipated cerebral blood flow needed and the availability of a supply source. In this review, we consider the indications, diagnostic evaluation strategies and long-term graft patency of HF EC–IC bypass surgery.     

脑血运重建术治疗成人脑底异常血管网病的疗效分析

目的 探讨颞浅动脉（STA）-大脑中动脉（MCA）分流术联合颞肌贴敷术治疗脑底异常血管网病（MMD）时单支血管分流术与双支血管分流术的疗效差异。方法 2020年1月至2022年6月前瞻性收治符合标准的MMD共59例,37例应用STAMCA单支血管分流术联合颞肌贴敷术治疗（单支分流组）,22例应用STA-MCA双支血管分流术联合颞肌贴敷术治疗（双支分流组）。结果 术后3个月DSA或CTA显示分流血管通畅,其中分流血管显影良好38例;49例（83.1%）神经功能改善（手术前后mRS评分差值>0）,47例（79.7%）脑组织血供改善（手术前后脑灌注评分差值<0）;未发生手术相关并发症。两组术后3个月m RS评分及脑灌注评分均明显改善（P<0.05）,而且,双支血管分流组明显优于单支血管分流组（P<0.05）。双支血管分流组术后mRS评分改善率、脑灌注评分改善率均明显高于单支血管分流组（P<0.05）。结论 STA-MCA分流术联合颞肌贴敷术治疗MMD疗效良好,而且双支血管分流术的短期预后优于单支血管分流术。     

A case of effective antithrombotic therapy for cerebral infarction presenting long-lasting fluctuation of symptoms]

We report a 78-year-old female presenting fluctuation of cerebral ischemic symptoms for a long time. Three weeks after transient ischemic attack of speech disturbance, she suffered right hemiparesis and motor dominant aphasia. The symptoms gradually progressed. Magnetic resonance angiography (MRA) showed a stenosis of branches of the left middle cerebral artery and single photon emission computed tomography (SPECT) did hypoperfusion of the same artery territory. Though antiplatelet and anticoagulant therapy was continued, the symptoms fluctuated. After 5 months, she recovered to mild deficit and MRI finally showed no responsible infarcted area. The pathophysiology of this course was considered to be progressing stroke based on a stenosis of the middle cerebral artery and the atrial fibrillation. Early diagnosis and treatment for cerebral ischemia may lead to the recovery from fluctuating symptoms.     

"双保险"颅内外血管搭桥术在巨大颈内动脉海绵窦段动脉瘤术中的应用

目的 探讨巨大颈内动脉海绵窦段动脉瘤治疗中,"双保险"颅内外血管搭桥术的适应证、手术技巧和疗效.方法 对5例巨大颈内动脉海绵窦段动脉瘤采用"双保险"颅内外血管搭桥(颞浅动脉-大脑中动脉;颈外动脉-桡动脉-大脑中动脉)、颈内动脉阻断术治疗,分析其治疗效果.结果 术后血管造影显示,4例吻合血管通畅,1例颞浅动脉-大脑中动脉吻合口狭窄.5例动脉瘤均不显影.随访3-24个月,临床症状均有好转,无动脉瘤复发或破裂.结论 "双保险"颅内外血管搭桥能有效防治术中、术后脑缺血,提高手术安全性,是治疗巨大颈内动脉海绵窦段动脉瘤有效、安全的方法.     

大脑中动脉狭窄或闭塞显微手术治疗单中心经验并文献复习

目的 探讨颞浅动脉-大脑中动脉(STA-MCA)搭桥术治疗成人大脑中动脉狭窄或闭塞的疗效.方法 回顾性分析31例行STA-MCA搭桥术治疗的大脑中动脉狭窄或闭塞患者的临床资料,术前均行全脑血管造影(DSA)评价颈外动脉-颞浅动脉、颈内动脉、大脑中动脉的狭窄程度,CT灌注成像(CTP)评估脑血流灌注情况.手术采用经额颞入...     

Multimodal Treatment for Complex Intracranial Aneurysms: Clinical Research

Objective

For patients with giant or dissecting aneurysm, multimodal treatment consisting extracranial-intracranial bypass surgery plus clip or coil for parent artery occlusion may be necessary. In this study, the safety and efficacy of multimodal treatment in 15 patients with complex aneurysms were evaluated retrospectively.

Methods

From January 1995 to June 2007, the authors treated 15 complex aneurysms that were unable to be clipped or coiled. Among them, nine patitents had unruptured aneurysms and 6 had ruptured aneurysms. Aneurysms were located in the internal cerebral artery (ICA) in 11 patients (4 in the dorsal wall, 4 in the terminal ICA, 1 in the paraclinoid, and 2 in the cavernous ICA), in the middle cerebral artery (MCA) in 2, and in the posterior circulation in two patients

Results

Fifteen patients with complex aneurysms were treated with bypass surgery previously. Thirteen patients were treated with external carotid middle cerebral artery (ECA-MCA) anastomosis, and one patient with superficial temporal to posterior cerebral artery (STA-PCA) and another patient with occipital artery to posterior inferior cerebellar artery (OA-PICA) anastomosis. Parent artery occlusion was then performed with a clip in 9 patients, with a coil in 4, with balloon plus coil in one patient. All 15 aneurysms were successfully treated with clip or coil combined with bypass surgery. Follow-up angiograms showed good patency of anastomotic site in 10 out of 11 patients, and perfusion study showed sufficient perfusion in 6 out of 9 patients.

Conclusion

These findings indicate that for patients with complex aneurysms, clip or coil for parent vessel occlusion with additive bypass surgery can successfully exclude the aneurysm from the neurovascular circulatory system.     

Clinical study of amaurosis fugax

Nineteen cases of amaurosis fugax (AF) were analyzed in clinical study undertaken to address the problem of its pathogenetic mechanism. This series comprised 10 male and 9 female with an age range of 26-77 years. In 8 cases, AF was the only clinical manifestation, while in the other 11, AF was accompanied by hemispheric TIA. The attack lasted for a few to 15 minutes on most occasions, occurring on the left side in 7 cases and on the right in 12 cases. On the basis of cerebral angiographic findings and findings on transcranial Doppler blood velocity measurements (TCD), these cases were classified into 4 types of different etiology, i.e. (Group A) micro-embolus via internal carotid artery origin--7 cases (5 with stenosis at the level of siphon, 2 with stenosis of the ophthalmic artery); on TCD the direction of blood flow in ophthalmic artery was normal (forward flow) in 5 cases and antiplatelet therapy proved effective in 4 cases, (Group B) micro-embolus derived via the external carotid artery--5 cases (3 with complete occlusion of internal carotid artery at its origin, 2 with severe stenosis there of); TCD showed blood flow in the ophthalmic artery to be in a direction opposite to the normal (away flow) in 3 cases and 3 cases responded favorably to antiplatelet therapy, (Group C) cerebral hemodynamic crisis--3 cases (severe cardiac hypofunction following myocardial infarction, orthostatic hypotension, and elongation of internal carotid artery), and (Group D) unknown etiology--4 cases; cerebral angiography revealed no abnormalities, suggesting involvement of other factors than cerebrovascular agents.(ABSTRACT TRUNCATED AT 250 WORDS)