Objective To evaluate the efficacy and reliability of intraoperative microvascular Doppler uhrasonography (IMDU)in urgent clipping surgery of ruptured aneurysms,and assess the impact of this method on the surgical procedure itself.Methods For 62 patients who underwent urgent clipping surgery for the treatment of ruptured aneurysms,both blood flow velocities in the aneurismal sac and in the adjacent vessels and alterations of the Doppler spectrum were determined by IMDU before and after aneurysm clipping.The findings of IMDU were analysed and compared with those of visual inspection of the surgical site and postoperative angiography. Results A relevant stenosis of an adjacent vessel induced by efip position that had escaped detection by visual inspection was identified by IMDU in 12 out of 62 patients.In addition, IMDU demonstrated a primarily incomplete clipping aneurysm in 4 out of 62 patients.The clipping aneurysm was repositioned on the basis of the IMDU findings in 16 out of 62 patients.The findings from IMDU equated with those from angiography in 38 eases.Conclusion IMDU is a safe,instantaneous,effective and reliable technique for the urgent dipping surgery of raptured aneurysms.

Objective To investigate the consistency of carotid Doppler ultrasonography （CDU）, computed tomography angiography （CTA）, and digital subtraction angiography （DSA） in the diagnosis of subclavian artery stenosis, as well as the hemodynamic parameters for different degrees of subclavian artery stenosis with DSA as the gold standard. Methods A retrospective analysis was performed for 179 patients who were admitted to Stroke Center of The First Affiliated Hospital of Soochow University from January 2018 to December 2021. CDU, CTA, and DSA were performed within one week, and at least one examination suggested subclavian artery stenosis. The 179 patients were analyzed in terms of the degree of subclavian artery stenosis at both sides. DSA was used as the gold standard to evaluate the degree of subclavian artery stenosis diagnosed by CDU and CTA, and the Kappa consistency analysis was performed for CDU and CTA in evaluating the degree of stenosis. DSA was used as the gold standard for the classification of stenosis degree, and the ROC curve analysis was used to determine the optimal cut-off values of blood flow velocity [peak systolic velocity （PSV） and end-diastolic velocity （EDV）] and blood flow velocity ratio （PSVOR/PSVDIS） in mild stenosis （< 50%）, moderate stenosis （50% ~ 69%）, and severe stenosis （70%~99%）. Results The Kappa consistency analysis showed that CTA had a high consistency with DSA （κ=0.777）, and CDU had a good consistency with DSA （κ=0.813）. With DSA as the standard, the cut-off values of PSV, EDV, and PSVOR/PSVDIS based on CDU were PSV<252 cm/s, EDV<21 cm/s, and PSVOR/PSVDIS<1.9 in the diagnosis of mild stenosis, 252 cm/s≤PSV<339 cm/s, 21 cm/s≤EDV<39 cm/s, and 1.9≤PSVOR/PSVDIS<4.0 in the diagnosis of moderate stenosis, and PSV≥ 339 cm/s, EDV≥39 cm/s, and PSVOR/PSVDIS≥4.0 in the diagnosis of severe stenosis. Conclusion CDU can evaluate the degree of subclavian artery stenosis and hemodynamic changes in a noninvasive, real-time, and dynamic manner and provide a basis for the hierarchical management of clinical precision treatment.

Objective To investigate the clinical efficacy of carotid endarterectomy ( CEA) for the treatment of patients with dolichoarteriopathies of internal carotid artery combined with carotid artery severe stenosis. Methods From January 2013 to February 2018,the clinical data of 18 consecutive patients with dolichoarteriopathy of internal carotid artery combined with carotid artery severe stenosis admitted to the Department of Neurosurgery,the First Affiliated Hospital of Soochow University were analyzed retrospectively. All patients underwent color Doppler ultrasound,CT angiography (CTA),and DSA to assess the diseased vessels before operation,and blood perfusion of the cerebral hemisphere was evaluated by CT perfusion (CTP) imaging. Six patients of Metz grade Ⅱ and 4 of grade Ⅲ underwent valgus CEA +excision of the redundant internal carotid arteries;8 patients of Metz grade I were treated with standard CEA. Postoperative cervical vascular ultrasound,CTA,and CTP examinations were performed in order to understand the vascular patency of the surgery and correction of dolichoarteriopathies of internal carotid artery. The follow-up time was 6 to 72 months. The color Doppler flow imaging and CTA were used to assess the presence or absence of restenosis and MRI was used to evaluate the presence of new cerebral infarction. Results All 18 patients were successfully operated, and they had good vascular patency after operation. The Postoperative CTA showed that the distorted blood vessels had been straightened to varying degrees for ten patients who underwent valgus CEA treatment and the plaques were removed satisfactorily without stenosis for 8 patients treated with standard CEA. After operation,one patient developed sublingual nerve injury symptoms,which was improved after 3 months. One patient developed mild hyperperfusion syndrome,which was improved after 2 weeks. No patients died. Follow-up reexamination showed that all patients had no carotid artery restenosis and new stroke events. Conclusions CEA is a safe and effective treatment for patients with internal carotid artery dolichoarteriopathy combined with severe carotid stenosis. According to the characteristics of the lesions evaluated before surgery, surgical methods should be selected reasonably.

Objective To investigate the hemodynamic,cerebral perfusion and neurological function changes between unilateral symptomatic internal carotid artery occlusion(SICAO)and symptomatic middle cerebral artery occlusion(SMCAO)after superfical temporal artery-middle cerebral artery(STA-MCA)bypass surgery as well as the correlation between relative peak volume of blood flow(rPVOL)in STA measured by carotid Doppler ultrasonography(CDU)and relative cerebral blood flow(rCBF)by CT perfusion(CTP).Methods Retrospective analysis of 112 patients who diagnosed with unilateral SICAO or SMCAO through DSA and/or CT angiography(CTA)and underwent superficial temporal artery-middle cerebral artery(STA-MCA)bypass in the Department of Neurosurgery at First Affiliated Hospital of Soochow University from March 2019 to June 2022.The patients were divided into SICAO group(50 cases)and SMCAO group(62 cases)and followed up for 360 days.General clinical and imaging data of patients in two groups were collected.General clinical information included age,gender,clinical manifestations(stroke,transient ischemic attack[TIA]),hypertension,diabetes,smoking history,blood biochemical indicators(total cholesterol,triacylglycerol,low-density lipoprotein cholesterol,high-density lipoprotein cholesterol,high-sensitivity C-reactive protein),National Institute of Health stroke scale(NIHSS)scores at admission and 7 days after surgery,and modified Rankin Scale(mRS)scores at admission and 7,180 and 360 days after surgery(mRS scores 2 as good prognosis,＞2 as poor prognosis).Imaging data included hemodynamic parameters(STA diameter[D],resistance index[RI],time-averaged-mean velocity[TAMV],and time-average-peak flow velocity[TAPV])evaluated by CDU within 7 days before and 7,30,180 and 360 days after STA-MCA bypass,as well as CTP parameters(rCBF,relative cerebral blood volume[rCBV],relative mean transit time[rMTT]and relative time to peak[rTTP])of the head region of interest(ROI)before and 7,180 and 360 days after surgery.Patients were observed 1 year after surgery through outpatient or telephone follow-up to determine if they have experienced recurrent stroke(TIA,cerebral infarction,etc.)and other postoperative complications(subdural hematoma,cerebral hemorrhage,etc.).DSA imaging was also performed to determine the patency of vascular anastomosis of patients in SICAO and SMCAO groups.STA hemodynamic parameters,head CTP parameters,NIHSS scores,and mRS scores at different time points before and after STA-MCA bypass surgery were compared between SICAO and SMCAO groups correspondingly;STA hemodynamic parameters,head CTP parameters,and mRS scores were pairwise compared between different time points within each group.A correlation analysis was conducted between rCBF and rPVOL in STA which was measured by CTP and CDU accordingly in the SICAO and SMCAO groups to further determine the consistency of the blood flow through STA and intracranial cerebral blood flow.Results(1)There was no statistically significant difference in general clinical data between the two groups(all P＞0.05).(2)Comparison of STA hemodynamic parameters:D,TAMV,and TAPV of both groups significantly increased at 7,30,180,and 360 days after surgery(all P＜0.05)compared with preoperative,and reaching their peak at 7 days after surgery,and there was no statistically significant difference in D,TAMV,and TAPV among 30,180,and 360days after surgery(all P＞0.05).There was no statistically significant difference in D,TAMV,or TAPV between the two groups at each time point(D:F=2.286,TAMV:F=0.180,TAPV:Wald x=1.709;all P＞0.05).RI of the two groups was significantly reduced at 7,30,180,and 360 days after surgery(all P＜0.05)compared with preoperative,and there was no statistically difference in RI among 7,30,180,and 360 days after surgery(all P＞0.05).There was also no statistically difference in RI between the two groups at each time point(Wald x2=0.788,P＞0.05).(3)Comparison of CTP parameters between two groups:compared to preoperative,rCBF and rCBV in the SICAO group and SMCAO group increased at 7,180,and 360 days after surgery(all P＜0.05),there was no statistically difference in CTP parameters within the two groups at different time points(Wald x2 was 0.177,2.954,respectively,all P＞0.05),and the rMTT and rTTP of both groups decreased at 7,180,and 360 days after surgery(all P＜0.05),there was no significant difference in rMTT and rTTP between the two groups at different time points(Waldx2 was 2.157,1.706,respectively,all P＞0.05),and there was no statistically difference in the parameters of each postoperative time point within each group(all P＞0.05).(4)Comparison of vascular patency between two groups:1 year DSA showed that 91.1％(102/112)of patients were patent,with 92.0％(46/50)in the SICAO group and 90.3％(56/62)in the SMCAO group.There was no statistically difference between the two groups(x2=0.001,P＞0.05).The STA hemodynamics and intracranial CTP parameters of the two groups of patients with patent anastomosis were significantly improved compared to preoperative.A total of 10 patients were non-patent by 1 year DSA,including 4 cases in the SICAO group and 6 cases in the SMCAO group.In 1 non-patent SICAO patient and 3 non-patent SMCAO patients,the STA hemodynamic parameters evaluated by CDU 180 days and 360 days after surgery also showed corresponding improvement compared to preoperative,with an increase in TAMV and TAPV,and a decrease in RI.(5)Comparison of neurological improvement between the two groups:compared with preoperative,the mRS scores of the SICAO group and the SMCAO group significantly decreased at 7,180,and 360days postoperatively(all P＜0.05);there was no statistically difference in the mRS scores within each group at 7,180,and 360 days after surgery(P＞0.05).There was no statistically difference in mRS scores between the two groups at different time points including admission and 7,180 and 360 days after surgery(Wald x2=0.006,P＞0.05).The NIHSS scores of the SICAO group and the SMCAO group decreased at 7 days after surgery compared to admission(Z was 21.040,-5.183,respectively,all P＜0.01),and there was no statistically difference in NIHSS scores between the two groups at admission and 7 days after surgery(both P＞0.05).(6)Spearman rank correlation analysis showed that rPVOL and rCBF were highly positively correlated in the SICAO group(r=0.865,P＜0.01)and in the SMCAO group(r=0.864,P＜0.01).Conclusions Unilateral STA-MCA bypass can improve cerebral perfusion and neurological function in patients with SICAO and SMCAO,and there is no statistical difference between the two groups of patients.The rPVOL measured by CDU was highly correlated with the rCBF in patients after STA-MCA bypass surgery.

Objective To investigate the agreement between cervical vascular Doppler ultrasound （CDU） and high-resolution magnetic resonance imaging （HRMRI） for the assessment of unilateral extracranial vertebral artery dissection （VAD）. Methods We retrospectively included 132 consecutive patients who presented to the Stroke Center of The First Affiliated Hospital of Soochow University from January 2017 to March 2023 due to clinically suspected cervical artery dissection with sudden pain in the neck and posterior occipital region， neurological dysfunction， and a history of neck massage. They underwent CDU and three dimensional （3D） HRMRI at the same time. The sensitivity， specificity， and accuracy of CDU for assessing unilateral extracranial VAD were analyzed using the Kappa agreement test with 3D HRMRI findings as the reference standard. Furthermore， we examined CDU and HRMRI images for the location and specific signs （including intimal tear， intramural hematoma， double-lumen sign， intraluminal thrombus， dissecting aneurysm， and irregular lumen） of extracranial VAD. The degree of vascular stenosis was calculated by the North American Symptomatic Carotid Endarterectomy Test （NASCET）. The agreement of the two examinations was analyzed using the Kappa test. Results The positive rates of unilateral extracranial VAD assessed by CDU and by HRMRI were 93.2% （123/132） and 93.9% （124/132）， respectively， indicating excellent agreement between the two examinations （Kappa value， 0.87）. For CDU detecting extracranial VAD， the sensitivity was 99.2%， the specificity was 87.5%， and the accuracy was 86.7%. CDU and HRMRI showed excellent agreement in assessing the double-lumen sign， dissecting aneurysm， irregular lumen， lesion location， and the degree of vascular stenosis， with the Kappa values being 1.00， 0.85， 0.88， 0.94， and 0.89， respectively； the two methods showed good agreement for intramural hematoma and intraluminal thrombus， with the Kappa values being 0.79 and 0.80， respectively， and the positive rate of enhanced intramural hematoma detected by HRMRI was 17.7%； the agreement for the intimal tear sign was moderate， with the Kappa value being 0.58. Conclusion CDU can effectively evaluate the imaging signs and the degree of stenosis of extracranial VAD， providing reliable imaging evidence for the early diagnosis and treatment and regular follow-up of VAD.

Objective To investigate the relationship between atherosclerotic plaque characteristics and clinical symptoms in patients with unilateral moderate-to-severe stenosis of the extracranial segment of the internal carotid artery. Methods We included a total of 151 patients who underwent carotid endarterectomy for unilateral moderate-to-severe carotid stenosis [confirmed by carotid Doppler ultrasonography(CDU) and computed tomography angiography] at the Department of Neurosurgery of the First Affiliated Hospital of Soochow University. They were divided into symptomatic group and asymptomatic group according to clinical manifestations. The two groups were examined by CDU for the characteristics of carotid artery plaques(fibrous cap integrity,ulcerative plaques,plaque calcification,etc.) and the degree of vascular stenosis. Transcranial Doppler ultrasonography was performed to record the hemodynamic parameters(Vm,Vs,Vd,and PI) of bilateral middle cerebral arteries(MCA). Computed tomography perfusion imaging(CTP) was performed to record the parameters(CBF,CBV,MTT,and TTP) of bilateral basal ganglia and temporal lobes. The two groups were compared for carotid plaque characteristics and the degree of stenosis using the chi-square test,and for the differences in the hemodynamic parameters of MCA between the unaffected and affected sides and the CTP parameters of the basal ganglia and temporal lobe on the affected side using the independent samples t test and the Mann-Whitney U test. Results The symptomatic group was significantly older at the age of onset than the asymptomatic group(P<0.05). The incidence rates of ulcerative plaques and plaque surface calcification were significantly higher in the symptomatic patients with moderate/severe carotid stenosis than in the asymptomatic groups(P<0.05). The differences in Vm,Vs,and Vd of MCA between the unaffected and affected sides were significantly larger in the symptomatic moderate/severe stenosis groups than in the asymptomatic moderate/severe stenosis groups(P<0.05). There were significant differences in CBF,MTT,and TTP of the basal ganglia and temporal lobe on the affected side between severe stenosis groups(P<0.05),but those CTP parameters showed no significant differences between moderate stenosis groups(P>0.05). Conclusion Severe carotid artery stenosis can cause intracranial hypoperfusion,and moderate stenosis with unstable plaques can also produce clinical symptoms. It is of great clinical significance to evaluate carotid plaque characteristics and the degree of stenosis for individualized diagnosis and treatment.

Objective To analysis the correlation between the vulnerability of carotid plaque and ischemic stroke and to explore the clinical significance of assessing vulnerable plaques accurately.Methods A total of 64 patients,who underwent carotid endarterectomy (CEA) in First Affiliated Hospital of Soochow University from October 2014 to February 2016,were classified into ischemic and non-ischemic stroke group according to whether ischemic stroke symptoms occurred during the last 6 months before surgery.To judge the stable and vulnerable plaques,the patients underwent carotid doppler ultrasonography (CDU) before surgery,and the carotid plaques were evaluated with HE staining after CEA.We also analyzed the risk factors of plaque formation and the relevance between the plaque characteristic and ischemic stroke with chi-square test.Kappa test were used to analyze the consistency of CDU and pathology.Results Of the 44 cases in ischemic stroke group,CDU identified 81.8％ (36/44) vulnerable plaques and 18.2％ (8/44) stable plaques,while pathology confirmed 86.4％ (38/44) vulnerable plaques and 13.6％ (6/44) stable plaques.Of the 20 cases in non-ischemic stroke group,CDU identified 35％ (7/20) vulnerable plaques and 65％ (13/20) stable plaques,while pathology confirmed 40％ (8/20) vulnerable plaques and 60％ (12/20) stable plaques.In both CDU and pathology,vulnerable plaques in ischemic stroke group were obviously higher than that in non-ischemia group (x2=13.67,P ＜ 0.001;x2=14.62,P ＜ 0.001).The results of CDU agreed well to that of pathology results (Kappa=0.669,P ＜ 0.01).Conclusions The vulnerability of plaques were closely related to the ischemic stroke.CDU is a reliable examination method to identify vulnerable plaques.The accurate assessment of vulnerability of plaques has a great significance in preventing ischemic stroke.

Objective To investigate the feasibility and reliability of three-dimensional ultrasound in evaluating carotid artery vulnerable plaques with the method of prospective plaque scoring.Methods From February 2016 to March 2017,41 patients who performed carotid endarterectomy (CEA) in the department of neurosurgery at the First Affiliated Hospital of Soochow University were scheduled for conventional cervical vascular ultrasonography,three-dimensional ultrasonography (3D-US),CT angiography (CTA),CT perfusion imaging (CTP) and / or digital subtraction angiography (DSA) examinations before surgery.On pathology,the atherosclerotic plaque morphology and HE staining findings were evaluated after surgery.The results of preoperative 3D-US were compared with the corresponding postoperative pathologic findings.Each plaque was scored based on the plaque morphology,homogeneity,echo characteristics and degree of vascular stenosis in 3D-US.According to the pathological results,the plaques were divided into vulnerable plaque group (n=35) and stable plaque group (n=10).The plaque score difference between groups was compared using independent sample t test.Patients were classified into ischemic stroke group (n=27) and non-ischemic stroke group (n=14) according to whether ischemic stroke symptoms occurred during the last 6 months.Pearson x2 test was used to analyze the correlation between ischemic events and the vulnerable plaques.Results Plaque scores were significantly different between vulnerable plaque group and stable plaque group (5.3 ±0.2 vs 3.4±0.3,t=5.339,P ＜ 0.05).The accuracy of identifying vulnerable plaque by plaque score is high,while the area under the ROC curve is 0.907 with a cutoff 4.5 (the maximum Youden index is 0.671,the sensitivity is 77％,the specificity is 90％).There is a significant positive correlation between the occurrence of ischemic events and plaque vulnerability (r=0.858,P ＜ 0.05).Conclusion 3D-US can accurately and quantitatively assess vulnerability of carotid plaques,carotid artery vulnerable plaque was significantly associated with ischemic stroke,which can provide the basis for clinical individualized treatment.

Objective To evaluate the correlation between intracranial vertebral artery (VA) stenotic lesions at different locations and posterior circulation ischemia (PCI) symptoms.Methods The present study included 362 cases of patients with unilateral VA severe stenosis or occlusion confirmed by carotid Doppler ultrasonography,CT angiography and (or) digital subtraction angiography.According to the relationship between the location of stenotic lesion and posterior inferior cerebellar artery (PICA),all cases were divided into pre-PICA group (n=73) and post-PICA group (n=289).According to presentation of PCI symptoms,all cases were divided into symptomatic group (n=133) and asymptomatic group (n=229).On CDFI,hemodynamic parameters were analyzed and recorded,which included the peak systolic velocity (PSV),end diastolic velocity (EDV),resistance index (RI) and VA diameter (VAD) and spectrum shape.And the correlation between location of intracranial VA stenosis / occlusion and PCI symptoms was evaluated.The hemodynamic parameters of bilateral intervertebral segments were compared in patient with unilateral intracranial VA stenosis by paired t test.The ipsilateral intervertebral segment hemodynamic changes were compared among patents with different locations of unilateral intracranial VA stenosis by using independent sample t test.Using 2 × 2 crosstables and Pearson 22 test,the correlation between the location of VA stenosis and PCI symptoms was analyszed.Results Hemodynamic parameters of VA were associated with its stenotic location to PICA.The comparison of the ipsilateral and contralateral VA showed that PSV,EDV and RI,VAD had significant difference (43.97± 1.22 vs 55.82± 1.08,6.35±0.23 vs 19.41 ±0.48,0.850±0.004 vs 0.640± 0.005,2.75 ± 0.04 vs 4.00± 0.03),difference was statistically significan (t=-7.086,-23.754,-32.603,23.842,all P ＜ 0.001).The intervertebral segment PSV,EDV and RI of ipsilateral VA were significantly related to the stenotic location to PICA (t=-6.665,-17.459,22.143,P＜0.001),but not for VAD (P＞0.05).In pre-PICA group,the intervertebral segment spectrum of ipsilateral VA was unimodal-style,while in post-PICA group the spetrum was high-resistance-style.VA intracranial severe stenosis at different locations was not associated with the symptoms of PCI (r=0.023,P=0.782),while VA intracranial occlusion at different locations was associated with the symptoms of PCI significantly (r=0.792,P ＜ 0.05).Conclusions CDU is a non-invasive,real-time and dynamic assessment tool for VA intracranial lesions in different locations,which can provide reliable information for clinical treatment and prognosis prediction.

Objective To investigate the influence of lengthening or tortuous basilar artery (BA) on the BA hemodynamic parameters measured by transcranial doppler (TCD).Methods 153 cases with CTA and TCD simultaneously evaluating the BA were included.According to CTA criterion,144 cases were with lengthening and/or tortuous BA and 9 cases were without lengthening and/or tortuous BA.The TCD cerebral hemodynamic parameters included peak systolic velocity (PSV),mean blood flow velocity (MFV),end diastolic velocity (EDV),pulsatility index (PI) and resistant index (RI).The relationship between the grading of lengthening/tortuous of BA and TCD parameters were analyzed.Results ①The TCD parameters (PSV,MFV,EDV,PI,RI) showed no significant statistical differences among the grades of lengthening BA.The correlation between the TCD paremeters (PSV,MFV,EDV,PI,RI) and the grades of lengthening BA showed no significant statistical differences.②The TCD parameters (PSV,MFV,PI,RI) showed significant statistical differences among the grades of tortuous BA.The TCD parameters (PSV,MFV,PI,RI) showed significant statistical differences between grade 0 and grade 3 of tortuous BA.The significant negative correlation between the TCD parameters (PSV,MFV,EDV,PI,RI) and the grades of tortuous BA was found.Conclusion The tortuosity of BA can lead to hemodynamic alterations,whereas the lengthening of BA does not affect cerebral hemodynamics significantly.