Carotid atherosclerosis is one of the important causes of cerebral stroke. Carotid endarterectomy ( CEA) is a classic operation for the treatment of carotid atherosclerotic stenosis. Evaluation by means of ultrasonography pre - and post - operative is of great clinical significance for the success of CEA.

Objective To investigate the predictive value of carotid remodeling index (CRI), plaque characteristics, and hemodynamic changes in patients with severe carotid atherosclerotic stenosis. Methods A total of 185 continuous patients with unilateral severe carotid artery atherosclerotic stenosis who underwent surgical treatment were enrolled retrospectively in the Department of Neurosurgery and Vascular Surgery of Xuanwu Hospital, Capital Medical University from January 2016 to January 2019. According to the clinical symptoms, patients were divided into the symptom group ( 104cases) and the asymptomatic group (81 cases). The general clinical data, CRI, echo characteristics of plaque, and hemodynamic parameters were compared between the two groups. Multivariate logistic regression analysis was performed after excluding the collinearity of parameters. The value of CRI for predicting clinical ischemic events was analyzed through the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results (1) There were no significant differences in age and risk factors of cerebrovascular disease between the two groups (all P >0. 05). However, the rate of male patients was significantly higher in the symptom group compared with the asymptomatic group (92. 3% [96/104] vs. 80. 2% [65/81) , P < 0.05). (2)There were lower in the peak systolic velocity( PSV) of the distal internal carotid artery (50.0[28.3, 62.8] cm/s vs. 60. 0[44.5, 74.5] cm/s, P<0.01), the end-diastolic velocity (EDV) of the distal internal carotid artery(23.0[14.0, 30.0] cm/s vs. 29. 0[21. 5 , 33. 5 ] cm/s, P<0.01), the PSV of the ipsilateral middle cerebral artery ( [74 ±21 ] cm/s vs. [ 85±21]cm/s, P<0.01) , and the EDV of the ipsilateral middle cerebral artery([39 ±11] cm/s vs. [42 ± 10] cm/s, P <0.05) in the symptom group compared with the asymptomatic group. There were higher in the ratio of PSV at the stenosis lesion of the internal carotid artery to the distal internal carotid artery( PSVprox/PSVdist, 10. 3[6.1, 16.6]ta.7.2[5.0, 11.8]), CRI ( 1. 82 [ 1. 65, 2. 08] is. 1. 64 [ 1. 51, 1.80]), hypoechoic plaques (83.7% [ 87/104 ] vs. 37. 0% [ 30/81 ]) , and ulcerative plaques (27. 9% [ 29/104 ] vs. 7. 4% [6/81]) in the symptom group compared with the asymptomatic group (all P <0. 05). (3) Multivariate logistic regression analysis showed that CRI ( OR = 12. 43, 95% CI 2. 85 -54. 25 , P < 0. 01) , ulcerative plaque (Oft =4. 04, 95% CI 1.40-11.62, P<0.05), and hypoechoic plaque( OR =5. 54, 95% C/2.65-11.58, P<0.01) were independent risk factors for ischemic clinical events. (4)The best cutoff value of CRI was 1.74 for predicting ischemic clinical events in severe carotid artery atherosclerotic stenosis ( AUC = 0.714,95% C/0.64-0.79, P<0.05), with the specificity of 69. 1% , and sensitivity of 65. 4% . Conclusions CRI, ulcerative plaques, and hypoechoic plaques can increase the risk of clinical ischemic events in patients with severe carotid atherosclerotic stenosis. CRI can be used to predict clinical ischemic events in patients with severe carotid stenosis.

Objective To investigate the feasibility of Doppler ultrasonography in evaluating the vulnerability of carotid atherosclerotic plaque prospectively. Method A total of 44patients (46plaques) who performed carotid endarterectomy were continuously enrolled in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University from March 2019 to October 2019. Several examinations such as carotid Doppler ultrasonography (CDU) , CT angiography, CT perfusion imaging, and/or digital subtraction angiography were scheduled conventionally before surgery. Pathologic examination, including the plaque morphology, histopathologic hematoxylin eosin(HE) staining, and immunohistochemical CD31 staining, were evaluated after surgery. The plaque vulnerable score was calculated based on the parameters of CDU consisting of plaque morphology, characteristic of echo, fiber cap integrity, presence of ulcer, degree of vascular stenosis, assigned with 0 to 3 points, respectively. The plaque was defined as the vulnerable plaque if vulnerable score was more than 4, otherwise, the plaque was the stable plaque. Then the plaques were divided into vulnerable group ( n =36) and stable group ( n = 10) according to the pathological results. The patients were divided into the stroke group ( n = 33) and the non-stroke group (n = 11) based on the incidence of ischemic stroke within the last 6 months. The evaluation of neovascularization in the plaque was referring to the immunohistochemical CD31 staining. The independent-sample t test, Wilcoxon rank-sum test, and χ2test were used to compare the differences between the two groups in general data, laboratory tests, clinical symptoms, vulnerable scores, and the rates of vulnerable plaques. Kappa value was used to evaluate the consistency between CDU and histopathological HE staining in the evaluation of plaque vulnerability. Results ( 1) The differences in the National Institute of Health stroke scale score and neurological symptoms between the vulnerable group and stable group were statistically significant (all P < 0. 05). (2) The vulnerable score was significantly different between the vulnerable group and stable group (6.00 [5.00,7.00] scores vs. 4.00 [4.00,4.25] scores, P<0.01), and between the stroke group and non-stroke group (6.00 [5.00,7.00] scores vs. 4.00 [4.00,5.00] scores, P = 0.002). (3) Diagnostic efficacy: compared with histopathologic results, the sensitivity and specificity of CDU were respectively 88.9% and 8/10, positive predictive value was 94. 1% .negative predictive value was 8/12, and the Youden index was 68. 9%. The consistency between CDU and histopathological HE staining was strong ( Kappa = 0. 642, P < 0. 01). (4) Neovascularization; immunohistochemical CD31 staining showed neovascularization in vulnerable plaque; the microvessel density in vulnerable group was higher than that in stable group([2. 84 ± 1. 56] mm3vs. [ 1. 38 ±0. 61 ] mm3). (5) The relationship between plaque vulnerability score and ischemic stroke: the rates of vulnerable plaques in the stroke group was higher than that in the non-stroke group (88. 6% [31/35 ] vs. 3/11 ;χ2= 13. 286, P < 0. 01 ). Conclusion The plaque vulnerable score evaluating by vascular ultrasound can accurately and quantitatively assess the vulnerability of carotid plaques, and angiogenesis can be observed in the vulnerable plaque, which provides a theoretical basis for clinical diagnosis and accurate treatment.

Objective To investigate the necessity of several issues of vascular ultrasound referring to the formulation of Chinese expert consensuses for Chinese ultrasound doctors. Methods Ultrasound doctors or related professional doctors in hospitals at all levels over the country were taken as the research object, using the questionnaires survey by WeChat on the mobile phone to investigate and analyze whether expert consensus should be established on several problems of carotid vascular ultrasonography. The questions involved in the diagnosis and differential diagnosis of carotid artery plaques ( Q1 -Q3 ) , the evaluation of ultrasonography for the vulnerable plaques ( Q4 and Q5 ) , the diagnostic criteria of carotid stenosis (Q6-Q8) , and the abnormal development and course of the carotid artery ( Q9 -Q11). The R x C contingency table chi-square test was used to analyze the correlation of Kendall's tau-b classification variables. Results All 3 658 valid questionnaires were collected from various physicians at all levels of hospitals in 34 provinces, municipalities, and autonomous regions. The response rate of the questionnaire has some differences in the regional division, hospital level, and professional title. Among them, the highest responding rates were in east China, at the top three hospitals, and from the attending physicians, with the rates of 43. 44% (1 589/3 658) , 45. 90% ( 1 679/3 658) and 41. 53% (1 519/ 3 658), respectively. The cumulative response rates for the necessary consensus from Ql to Qll were 81.00% (2 963/3 658), 91.94% (3 363/3 658), 85. 24% (3 118/3 658), 96.61% (3 534/3 658), 87.64% (3 206/3 658), 92.62% (3 388/3 658), 86.80% (3 175/3 658), 90.08% (3 295/3 658), 84.53% (3 092/3 658) , 95.02% (3 476/3 658), and 89.99% (3 292/3 658), respectively. Q1, Q2, Q3, Q5, and Q8 were negatively correlated with geographic divisions (r= -0.032, -0.032, -0.030, -0.031, and -0.030, all P <0.05), while Q3, Q7, and Q9, were negatively correlated with occupations (r= -0.030, -0.033, and -0.040, all P< 0.05), Q3, Q8, and Q9, Q10 were negatively correlated with hospital grades (r= -0.039, -0.042, and -0.053, -0.035, all P<0.05). Ql, Q4, Q6, Q7, Q8, and Q10 were negatively correlated with doctors' titles (r = -0.079, -0.032, -0.035, -0.030, -0.030, and -0.052, all P < 0. 05). Conclusions Several problems of carotid artery ultrasound need expert consensus. The urgency of expert consensus is related to the region, hospital level, and doctor title level. Expert consensus is conducive to eliminating the cognitive differences between different levels of ultrasound physicians, unifying standards, standardizing reports, and achieving quality control.

Objective To investigate the geographic variation in the distribution and risk factors of cerebral artery diseases in Chinese patients with ischemic stroke. Methods All 9 346 continuously hospitalized patients with ischemic stroke in 20 hospitals from June 2015 to May 2016 were enrolled in j this multicenter study, using carotid ultrasonography and transcranial color-coded sonography/transcranial 1 doppler to evaluate the degree of extra- and intra- cranial arteries stenosis and verifying by CT angiography or magnetic resonance angiography. All patients were divided into the southern group and the northern group by the definition of the Huai River-Qinling Mountains line to compare the differences of the distribution and risk factors of cerebrovascular diseases. Meanwhile, all patients were divided into the lesion group (defined as the degree of stenosis more than 50% ) and the non-lesion group according to the degree of stenosis to compare the differences of baseline data and geographic distribution of cerebrovascular diseases. i Results The 2 561 northern patients and 6 785 northern patients were enrolled in the study. The proportion of patients with more than 50% degree of extra- and intra-cranial arteries stenosis was significantly higher in northern China than that in southern China (33. 1% [2 243/6 785 ] vs. 25. 0% [639/2 561 ], χ2= 57. 295, P <0.01). The proportions of northern patients with more than 50% degree of stenosis located in the extracranial segment of internal carotid artery, vertebral artery, subclavian artery, middle cerebral artery, the terminal segment of internal carotid artery, intracranial segment of the vertebral artery, and basilar artery were higher than those of southern patients (all P <0. 05). The proportion of patients with intracranial artery stenosis was higher than that with extracranial arteries stenosis in both southern and northern patients (χ2=2.790,P =0. 248). The distribution of arterial lesions in the anterior and posterior circulations was significantly different in southern and northern patients (χ2= 13. 433, P = 0. 001). The proportion of anterior circulation arteries stenosis was higher in southern patients than that in northern patients (58.5% [374/639] vs. 50.3% [1 129/2 243]). While the posterior circulation artery stenosis (27.2% [609/2 243]rs. 23.0% [147/639]) and combined anterior with posterior circulation artery stenosis (22.5%[505/2 243 ]vs. 18.5% [118/639]) were more common in northern patients compared to southern patients. Multivariate logistic regression analysis showed that age, male gender, hypertension, diabetes mellitus, family history of stroke, smoking, and obesity were independent risk factors of cerebral artery stenosis ( OR values were 1.006, 1.670, 1.202, 1.176, 1.546, 1.414 and 1. 230, allP<0.05). While living in northern China was an independent risk factor for cerebral arterial stenosis after modifying the aforementioned parameters ( OR = 1. 385, 95% CI: 1. 237 -1. 550, P < 0. 01). Conclusion The distribution and risk factors of cerebrovascular stenosis in patients with ischemic stroke were significantly different in the north and south of China.

Objective To explore the association between potential intracranial pressure (ICP) and optic nerve sheath diameter ( ONSD) evaluated by transcranial Doppler( TCD) and ultrasonographic measurement in encephalitis patients. Methods A total of 17 patients with encephalitis received lumbar puncture were enrolled continuously in the Department of Neurology and Neuroscience of the First Hospital of Jilin University from October 2019 to January 2020. The ONSD and TCD examinations were performed before the operation of lumbar puncture, and the relevant data were recorded. All patients were divided into the elevated ICP group (more than 200 mmH2O) (n = 10 ) , the normal ICP group (80 -200mmH2O) (n=7) according to the results of the initial ICP. The difference of baseline data, ONSD, and the parameters of TCD such as peak systolic velocity (PSV) , end-diastolic velocity ( EDV) , mean blood flow velocity (MV) , and pulse index (PI) , were compared between the two groups. Moreover, the correlation between ICP and ONSD was analyzed. Results (1 ) The difference of gender, age, body mass index, systolic blood pressure, and diastolic blood pressure was not statistically different between the normal and the elevated ICP groups (all P >0. 05). The ONSD was significantly lower in the normal ICP group compared with that in the elevated ICP group ([4.2±0.4] mm vs. [ 4.9 ± 0.4 ] mm, t = - 3. 873, P = 0.002). (2) TCD related parameters (PSV, EDV, MV and PI) were not significantly different between the elevated ICP group and the normal ICP group (all P >0. 05). (3) Univariate analyses revealed that ICP was significantly associated with ONSD (r =0. 87 ,P < 0. 01). Conclusion Results of the study indicate that ONSD is a predictive index for elevated ICP in encephalitis patients.

Objective To observe the protective effects of fluoxetine on working memory impairment induced by chronic cerebral ischemia and further explore its mechanism in rats. Methods The rat model of chronic cerebral ischemia was made by surgical ligation of the bilateral carotid artery. 44 male Sprague Dawley rats were divided into sham group (n = 10) , ischemic model group (ra = 12), ischemic + fluoxetine group (n = 12) , and sham + fluoxetine group (n = 10). Fluoxetine was administered by gavage after 1 week of ischemic surgery and continued for 4 weeks. The sham group and the ischemic model group were given the same volume of 0. 9% saline. The performance of working memory was tested by a modified Morris water maze experiment that lasted for 4 days. The expression of neuronal nuclei (NeuN) , S-100(3, G protein gated inwardly rectifying K channels 1,2, and 3 ( GirKl , 2 , and 3 ) , and sorting nexin 27 ( SNX27 ) in the prefrontal cortex ( PFC) of rats were tested by Western blot, and compare between groups. Results (1) There was no significant difference in swimming speed among the four groups ( P > 0.05 ). In the training experiment, there was no significant difference among the four groups in the escape latency and the swimming distance ( both P > 0.05 ). In the memory retention test, the escape latency of rats in the ischemic model group was significantly increased on 2nd, 3rd and 4th day compared with the sham group (day2: [48.2 ±6. 3] s vs. [27.4±4.0]s, day 3 :[53.9 ±6.4] s vs. [29.4±6.3]s, day4: [41.4± 4. 9] s vs. [23.8 ±3.7] s; all P <0.05). The escape latency of rats in the ischemia + fluoxetine group on 3rd and 4th day was decreased compared with the ischemia model group ([31. 0 ± 6. 6]s, [26. 2 ± 3.7] s, respectively; both P<0.05). In the memory retention test, the swimming distance of rats in the ischemic group was significantly increased on 2nd, 3rd and 4th compared with the sham operation group (day 2: [553 ±76] cm vs. [313 ±51] cm, day 3: [619 ±81] cmis. [329 ±65] cm, day4: [433 ± 48] cm vs. [282 ±47] cm; all P<0.05). The swimming distance in the ischemic + fluoxetine group on 2nd, 3rd and 4th day was decreased compared with the ischemic group([373 ±54] cm, [321 ±70] cm, and [279 ±44] cm, respectively; all P<0.05). (2) There was no statistically significant difference in the expression of NeuN and S-100J3 among four groups of rats (both P >0.05). (3) There was no significant difference in the membrane expression of GirKl protein among the four groups (P > 0. 05). Taking the sham group as a reference and the relative grey value of GirK2 and GirK3 is defined as 1, the relative grey values of GirK2 in the ischemia model group and the ischemia + fluoxetine group were 1. 27 ± 0. 07 and 1. 06 ±0.06, the relative grey values of GirK3 in the ischemia model group and the ischemia + fluoxetine group were 1.23 ±0.08 and 1.00 ±0.06. The membrane expression of GirK2 and GirK3 in the ischemic model group was higher than that in the sham group. The membrane expression of GirK2 and GirK3 in the ischemic + fluoxetine group was down-regulated compared with the ischemic model group ( both P < 0. 05). (4) Taking the sham group as a reference and the relative grey value of SNX27 in the sham group is defined as 1, the relative grey values of SNX27 in the ischemia model group, the ischemia + fluoxetine group, and the sham + fluoxetine group were 0. 78 ± 0.09, 0.97 ± 0.04, and 0. 94 ±0.05, respectively. The expression of SNX27 in the ischemic model group was lower than that in the sham group, and the down-regulation of SNX27 expression in the ischemic model group was reversed after fluoxetine treatment (P<0. 05). Conclusion Fluoxetine can ameliorate working memory impairment of rats induced by chronic cerebral ischemia, which may partly reverse the increase of surface expression of GirK2 and GirK3 in the prefrontal cortex through acting on SNX27.

The etiology of posterior circulation ischemic stroke caused by bilateral vertebral artery dissection ( VAD) is often difficult to detect. In this study, the authors report a case of posterior circulation ischemic stroke with a history of excessive back elevation of the neck. The dissection of bilateral vertebral arteries was detected by carotid Doppler ultrasonography and further confirmed by magnetic resonance imaging and high-resolution magnetic resonance imaging. After 6 months of standard administration of dual antiplatelet therapy, recanalization of the bilateral vertebral artery was achieved. It proves that the early diagnosis and standardized medical treatment of VAD can significantly improve patients' prognosis.

Ultrasonography revealed that a ease of acute internal carotid artery (ICA) occlusion caused by acute thrombosis due to severe stenosis and intraplaque hemorrhage. The patient is male and 81 years old with blurred vision in the right eye. Carotid artery ultrasound ( CDU) showed that severe stenosis of right proximal ICA, the discontinuous fibrous cap at the top of atherosclerotic plaques, and intraplaque hemorrhage. Besides, the blood flow of the right distal ICA disappeared suddenly during the examination. Therefore, ICA occlusion caused by acute thrombosis was detected by CDU. The patient was followed-up day by day using ultrasonography and treated with dual antiplatelet therapy. Three days later, CDU showed that the right ICA was re-open but still accompanied by severe stenosis. The patient was treated by carotid endarterectomy for revascularization after six days of admission. According to this process of diagnosis and treatment, carotid ultrasound provides an important clinical role for the diagnosis, treatment, and follow-up of acute thrombosis with carotid artery stenosis.

Dural arteriovenous fistula is a rare subtype of intracranial arteriovenous malformation, accounting for 10%-15% of all intracranial vascular malformations, with the characteristic of pathological anastomosis between the dural branch of the dural artery or intracranial artery and dural vein, or meningeal vein, or cortical vein. In this paper, a patient with headache suspected of temporal arteritis was analyzed retrospectively. Ultrasonography showed that arteriovenous fistula supplied by bilateral branches of the superficial temporal artery of the external carotid artery is likely. Finally, a dural arteriovenous fistula was diagnosed using digital subtraction angiography. The case shows that patients with headaches should also pay attention to other rare diseases causing headaches excepted for the temporal arteritis in practice.