Thrombolytic therapy is the first choice for the treatment of acute ischemic stroke,while the recanalization rate of intravenous thrombolysis for large vessel occlusion stroke is low.As a representative.of endovascular treatment,endovascular mechanical thrombectomy can effectively recanalize the occluded cerebral vessel and inprove the outcome in patients with acute ischemic stroke.This article reviews the recent research progress and the future direction of intravenous thrombolysis bridging.

Objective Cerebral venous sinus thrombosis (CVST) is easily misdiagnosed for lack of specificity in its pathogenesis and clinical symptoms and characteristics.This study was to investigate the association of the clinical features of CVST with the time of diagnosis and the impact of diagnostic delay on the prognosis of the disease.Methods We retrospectively studied the clinical data about 94 cases of CVST treated in our hospital from March 2004 to August 2016.According to the interquartile-range time of diagnosis, we divided the patients into four groups, <5 d, 5-9 d, 10-16 d, and >16 d, and analyzed the correlation between the time of diagnostic delay with the clinical characteristics of the patients.The primary and secondary endpoints were the modified Rankin Scale score (mRS) ≤1 and ≤2 respectively at 3 months after discharge.Results Papilledema, isolated intracranial hypertension syndrome, and Glasgow Coma Score of 14-15 were associated with a longer diagnostic delay than seizure and hemorrhagic or infarction lesions (P<0.05).A significantly higher rate of earlier diagnosis was found in patients with lower levels of albumin and total protein, longer thrombin time, and a higher level of C-reaction protein (P<0.05).However, no significant correlation was observed between the time of diagnostic delay and the prognosis CVST.Conclusion The symptoms and laboratory indexes of the CVST patients at admission can be used as markers for the diagnosis of CVST, which may provide some new idea for its early diagnosis.

Objective To evaluate the value of echocardiography in transcatheter closure of ruptured sinus of Valsalva aneurysm(TC-RSVA).Methods TC-RSVA was attempted in 11 patients.The location,shape,size of defects and its relationship with the neighbor structures were revealed before the procedure.Then the deployment of occluder was monitored during the procedure,and the effectiveness was observed in the follow-up.Results Eleven patients were diagnosed as the isolated RSVA by echocardiography.The size of defects was 2 - 13 mm estimated by echo.The procedures were successful in all patients.Usually the Amplatzer duct occluders were chosen to be 1 to 5 mm larger than the size of defects.Three patients had mild residual shunt during the procedure,which all dispeared in the first month of follow-up,but one of them demonstrated recurrent mild residual shunt in the 32nd month of follow-up.There was no aggravating aortic regurgitation in the follow-up.Conclusions TC-RSVA is relatively safe and effective.Observation of long-term effectiveness is still necessary.Echocardiagraphy plays an important role in TC-RSVA.

Objective To evaluate the effect of the percutaneous transluminal septal myocardial ablation(PTSMA)on the left ventricular function in patients with hypertrophic obstructive cardiomyopathy(HOCM).Methods All HOCM patients underwent echocardiogram measurements before and after the PTSMA procedure.The peak velocity of mitral annulus was measured at Doppler tissue pulsed wave mode.Doppler tissue imaging(DTI)was obtained at the 4- and 2-chamber apical view,and the peak systolic(Sa),early diastolic(Ea),and late diastolic(Aa)myocardial velocities of mitral annulus was measured at the long apical view.Results Compared with the velocity parameters before the PTSMA procedure,the peak Sa and Ea after the PTSMA were significantly lower while Aa was un-significantly lower.Conclusions In patients with HOCM,the diastolic and systolic function of the left ventricle decreased after the PTSMA procedure.

Objective: To evaluate the effect of echocardiography for occluding the multiple seconded atria1 septal defects ( MASD) in relevant patients.
Methods: A total of 42 MASD patients were selected by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). The transcatheter closure was monitored by TTE and X-ray, the effect of treatment was evaluated by TTE, ECG and chest X-ray at 24 hours and 1, 3, 6 months after the procedure. There were 38 patients with 2 defects, 3 with many central small defects and 1 with 3 defects. The patients included 17 male and 25 female with the mean age of (32.6 ± 13.4) years.
Results: The size and distance of the defects were measured with 4 cardiac chambers cross sectional study. The mean diameter of bigger defect from up to down was (9-27) mm, with the mean of (20.7 ± 6.1) mm, from front to back was (8-23) mm, with the mean of (16.9 ± 5.7) mm;the mean diameter of small defect from up to down was (3-12) mm, with the mean of (6.8 ± 3.6) mm. The length of the defect interva1 was (4-18) mm, with the mean of (7.9 ± 2.6) mm. There were 4 patients with 2 defect interval at 8.7 mm who received 2 occluders without post-operative lfow shunt. The rest 38 patients received 1 Amplatzer occluder which was (14-36) mm with the mean of (25.1 ± 6.4) mm which was (6.9 ± 1.7) mm larger than echocardiographic prediction. The success rate of implantation was 100%. There were 17 (40.5%) patients with post-operative lfow shunt. The patients were followed-up for (6-36) months, with the mean of 18.7 months, there were 11 (26.2%) patients with small amount of lfow shunt at 3 months after the operation.
Conclusion: Echocardiography is important for choosing the type and size of occluder devices, in-operative monitoring and post-operative effect evaluation for treating the ASD patients.

Objective: To investigate the predictors of death after endovascular mechanical thrombectomy (EMT) in patients with acute vertebrobasilar occlusive stroke (VBOS). Methods: Patients with acute VBOS treated with EMT in Wuhan No. 1 Hospital were enrolled retrospectively. The demographic and clinical data were collected. According to whether the patients died at 90 d after procedure, they were divided into survival group and death group. The demographic and clinical data were compared between the two groups. Multivariate logistic regression analysis was used to determine the independent risk factors for death at 90 d after EMT. Results: A total of 47 patients were enrolled. The median age was 62 years, 34 were males (72.3%), the median baseline National Institutes of Health Stroke Scale (NIHSS) score was 16, 42 patients (89.4%) had recanalization (modified Thrombolysis in Cerebral Infarction[mTICI] 2b/3 grade), and 12 (25.5%) died within 90 d after procedure. Univariate analysis showed that the baseline NIHSS score (26 [21-28]vs. 12 [5-23]; Z=-3.165, P=0.002), percentage of neutrophil (81.61% ±11.82% vs. 72.20% ±12.09%; t=-2.137, P=0.033), neutrophil/lymphocyte ratio (10.54±7.17 vs. 4.98±3.57; t=-2.393, P=0.017), and incidence of sICH (25.0% vs. 2.9%; χ²=5.627, P=0.018) in the death group were significantly higher than those in the survival group, while the percentage of lymphocyte (12.00%±9.04% vs. 20.67%±10.39%; t=-2.429, P=0.015) was significantly lower than that of the survival group. Multivariate logistic regression analysis showed that high baseline NIHSS score (odds ratio [OR] 1.243, 95% confidence interval [CI] 1.046-1.318; P=0.038), high neutrophil/lymphocyte ratio (OR 1.278, 95% CI 1.002-1.630; P=0.049) and symptomatic intracranial hemorrhage (OR 5.088, 95% CI 1.065-38.718; P=0.046) were the independent predictors for death. Conclusion High baseline NIHSS score, high neutrophil/lymphocyte ratio and symptomatic intracranial hemorrhage are the independent predictors for death within 90 d after EMT in patients with acute VBOS.

Objective To investigate the relationship between the times of thrombectomy and the prognosis of acute ischemic stroke. Methods From June 2014 to June 2016,the clinical data of 61 consecutive patients with ischemic stroke treated with emergency endovascular thrombectomy in Jinling Hospital,Medical School of Nanjing University were collected retrospectively. According to the times of thrombectomy,they were divided into either a routine thrombectomy group ( <3, n =48 ) or a multiple thrombectomy group (≥3,n=13). The modified Rankin scale (mRS) was used to evaluate the neurological function prognosis at 90 d in both groups of patients. The mRS score 0-2 was defined as good prognosis,3-6 were defined as poor prognosis,and 6 was death. Univariate analysis was used to compare the differences between the groups (excluding the patients whose DSA data missing or of poor quality). Spearman correlation analysis was used to evaluate the relationship between the times of thrombectomy and prognosis and fatality rate. Results Univariate analysis showed that the recanalization rate of the patients in the routine thrombectomy group (73. 9%[34/46] vs. 25. 0%[3/12],P =0. 005) and the rate of good collateral compensatory (55. 6%[25/45] vs. 8. 3%[1/12],P =0. 004) were higher than those in the multiple thrombectomy group. The incidence of symptomatic intracranial hemorrhage in the routine thrombectomy group was lower than that in the multiple thrombectomy group (14. 6%[7/48] vs. 53. 8%[7/13],P =0. 003). The mortality rate at 90 days was 18. 0%(n=11). Further Spearman correlation analysis showed that the times of thrombectomy were moderately positive correlated with the mortality rate ( r=0. 517,P=0. 000). There was no significant correlation between the times of thrombectomy and the good function prognosis (r=0. 076,P=0. 560). However,the effects of the differences between recanalization rate,collateral compensation and symptomatic intracranial hemorrhage could not be ruled out. Conclusion Emergency intravascular interventional therapy of multiple thrombectomy is positively related to the mortality rate at 90 d in patients with acute ischemic stroke,however,a study with larger sample is needed to confirm it.

Objective To investigate the risk difference of early neurological deterioration (END) in minor stroke patients with large artery atherosclerosis (LAA) and small vessel occlusion (SVO). Methods From January 2012 to August 2016, consecutive patients with first-ever acute ischemic stroke registered in the Nanjing Stroke Registration System were enrolled. The patients with minor stroke whose National Institutes of Health Stroke Scale (NIHSS) ≤3 on admission were screened. Propensity score matching analysis and McNemar's test were used to analyze the risk difference of END in minor stroke patients with LAA and SVO. Results A total of 778 patients with minor stroke were included, including 249 with LAA, 183 with SAO, and 145 matched pairs with propensity score matching method. The proportion of patients with END in the LAA group was significantly higher than that in the SVO group (6.2% vs. 1.4%; P<0.001). Conclusion Minor stroke due to LAA is more prone to have END than that due to SVO.

Objective To evaluate the value of stroke prognostication using age and National Institute of Health Stroke Scale index (SPAN) for outcome after early endovascular treatment for anterior circulation large vessel occlusion.Methods The patients who underwent early endovascular treatment were prospectively,sequentially collected in Yijishan Hospital of Wannan Medical College from December 2014 to September 2017 and Jinling Hospital from March 2014 to March 2017.Individuals whose age in years plus NIHSS score was greater than or equal to 100 were designated as SPAN-100-positive patients,while those with a score less than 100 were designated as SPAN-100-negative patients.We compared the baseline data and perioperative data between the two groups.The 90 days modified Rankin Scale score≤2 was regarded as favorable outcome.Single factor and multivariable Logistic regression analyses were used to determine the association between SPAN-100 and outcomes.Results One hundred and ninety patients were enrolled,20 (10.5％) of which were SPAN-100 positive,and 170(89.5％) were SPAN-100 negative.There were no significant differences between the two groups on postoperative intracerebral hemorrhage and 90 days mortality.Ninety days independence rates were higher in SPAN-100-negative patients (77/170,45.3％) than in SPAN-100 positive patients (4/20,20.0％;x2 =4.681,P =0.030).Multi-factor Logistic regression analysis showed that the higher preoperation systolic pressure (OR =1.030,95％ CI 1.008-1.052,P =0.007),the lower Alberta Stroke Program Early CT Score (OR =1.609,95％ CI 1.056-2.453,P =0.027) and poor collateral circulation(OR =5.714,95％ CI 1.668-19.570,P =0.006) were the independent risk factors of outcomes.Conclusion SPAN-100 is not an independent predictor of favorable outcome after adjusting for factors of outcomes in patients with anterior circulation large vessel occlusion.

Objective To investigate the differential effect of neutrophil to lymphocyte ratio (NLR) at admission on large artery atherosclerosis (LAA) and small vessel occlusion (SVO) in patients with minor stroke.Methods Patients with first-ever acute ischemic stroke registered in Nanjing Stroke Registration System were enrolled retrospectively.Minor stroke was defined as the National Institutes of Health Stroke Scale (NIHSS) score ≤3.Binary logistic regression was used to evaluate the independent relationship between NLR and LAA.Results A total of 417 patients with minor stroke were included,of which 242 were in a LAA group and 175 were in a SVO group.Univariate analysis showed that there were significant differences in leukocyte count,neutrophil count,lymphocyte count,NLR,glycosylated hemoglobin,highdensity lipoprotein cholesterol,onset to treatment time,and onset to NLR detection time between the patients of the LAA group and the SVO group (all P ＞0.05).Binary logistic regression analysis suggested that after adjusting for sex and high-density lipoprotein cholesterol,NLR (with the highest quartile as a reference,the first quartile:odds ratio [OR] 0.207,95％ confidence interval [CI]0.089-0.482;P ＞ 0.001;the second quartile:OR 0.277,95％ CI 0.122-0.625,P=0.002;the third quartile:OR 0.456,95％ CI 0.197-1.057;P =0.067),onset to NLR detection time (OR 1.216,95％ CI 1.038-1.424;P =0.015),and glycosylated hemoglobin (OR 1.414,95％ CI 1.142-0.751;P=0.002) were independently associated with LAA.The area under the ROC curve of NLR predicting the LAA was 0.611 in patients admitted within 7 d after onset,and was 0.673 in patients admitted within 24 h after onset.Conclusions The increased NLR was independently associated with the LAA in patients with minor stroke.Early NLR value may have higher predictive value for LAA.