As a classic cerebral revascularization procedure, carotid endarterectomy (CEA) has been widely used in the treatment of high-grade extracranial carotid artery stenosis. In recent years, carotid artery stenting (CAS) has a trend to replace CEA gradually. A large number of clinical studies have found that in addtion to perioperative complications, carotid restenosis after CEA and CAS also has important influence on the prognosis of patients. This article reviews the current status of diagnosis and treatment of restenosis after CEA and CAS.

Objective To study the clinical therapeutic effects of early rehabilitation training combined with acupuncture on dysphagia after acute cerebral infarction.Methods One hundred patients with dysphagia caused by acute cerebral infarction were randomly divided into 4 groups:a comprehensive treatment group(25 cases,received rehabilitation training,acupuncture and routine medication),a routine drug group(25 cases,routine medication),a rehabilitation group(25 cases,received comprehensive rehabilitation training and routine mediciation)and an acu-puncture group(25 cases,received acupuncture therapy and routine medication).Dysphagia was evaluated with videofluoroscopic swallowing study(VFSS),and the incidence of pneumonia was observed before treatment and at the 14th day after daily treatment. Results After treatment,the VFSS scores of the 4 groups were significantly higher than before treatment,and VFSS scores in the comprehensive treatment group were significantly higher than those in the other groups.The effectiveness rate in the comprehensive treatment group was significantly higher than that in the other three groups.and the incidence of pneumonia was significantly lower.Conclusions Early rehabilitation com-bined with acupuncture can improve swallowing and reduce the incidence of aspiration pneumonia in acute stroke pa-tients.

Objective To investigate the correlation of the lesion pattern of internal border zone infarction (IBZI) with atherosclerosis and outcome.Methods Eighty-one patients with IBZI were retrospectively divided into a simple IBZI group and a mixed IBZI group (combined with other infarct patterns) according to diffusion-weighted imaging (DWI).The clinical characteristics were compared between the 2 groups.And then,the mixed IBZI group was further divided into 3 subgroups:IBZI + pial infarct (PI),IBZI + perforating artery infarct (PAI),and IBZI + PI + PAI.They were compared with the simple IBZI group respectively.Results There were no significant differences in the dinical characteristics,such as age,hypertension,and the numbers of patients with stent implantation between the simple IBZI group and the mixed IBZI group.The proportions of severe stenosis and occlusion of internal carotid artery (ICA) and/or middle cerebral artery (MCA) (P =0.009) and MCA lesions (P =0.032) in the mixed IBZI group were significantly higher.Among the patients with MCA lesions,the severe stenosis in the simple IBZI group was significantly more than that in the mixed IBZI group (P =0.042),while the occlusive lesions in the mixed IBZI group were significantly more than those in the simple IBZI group (P =0.022).The short-term (within 7 days) exacerbation (P =0.039) and poor outcome at 90 days (modified Rankin Scale＞ 3) in the mixed IBZI group (P=0.030) were significantly higher than those in the simple IBZI group.The subgroup analysis showed that the proportions of the short-term exacerbation (P =0.001 ) and poor outcome in patients at 90 days (P =0.010) in the IBZI + PI +PAI subgroup were significantly higher than those in the simple IBZI group.Conclusions The IBZI patients combined with other infarct patterns often exist severe cerebrovascular stenosis and occlusion,and their clinical outcome was poorer.For patients with MCA lesions,the mixed IBZI occurred more in patients with MCA occlusion,and the simple IBZI occurred more in patients with severe MCA stenosis.

Objective To study the lesion patterns of hemorrhagic type of moyamoya disease (MMD) in adults. Methods Seventy-two consecutive cases of hemorrhagic type of MMD, confirmed by digital cerebral angiography in Jinling hospital between January 2004 and February 2010, were retrieved from the Nanjing Stroke Registry Program. MMD patients were classified according to the hemorrhagic sites into 4 types: non-thalamic parenchymal, thalamic, primary ventricular and subarachnoid. The ipsilateral anterior choroidal artery and posterior communicating artery (AChA-PComA) were evaluated by the modified Morioka's 3-points grading system: normal or mild to moderate dilation, severe dilation with abnormal extension and non-visualization. The relationship between lesion patterns and the angiographic findings was analyzed. Results In the stage of normal or mild to moderate dilation of AChA-PComA, non-thalamic parenchymal hemorrhage was the more frequent type (51.6%, 16/31 ;Z = -3.266,P =0.001 ), and there was a high incidence of intrastriatal hemorrhage occurred (22.6%, 7/31 ). In the stage of severe dilation with abnormal extension, intraventricular hemorrhage was most common ( 58.8%, 20/34 ;Z = -2.696 ,P =0.008). In addition, posterior circulation subarachnoid hemorrhage (SAH) was associated with a higher grade of AChA-PComA than anterior circulation SAH (Z = -4.655 ,P ＜ 0.01 ). Furthermore, posterior circulation SAH was the only type of SAH in the stage of non-visualization(9.7% ,7/72; x2 =42.999,P ＜0.01 ). Conclusion In adult patients with MMD, different subtypes of hemorrhagic stroke were associated with angiographic changes of AChA-PComA, and the angiographic characteristics may predict the location of hemorrhage.

Objective To investigate the relationship between isehemic lesion patterns and Suzuki's vessel grades in adult moyamoya disease(MMD).Methods Forty-four consecutive MMD patients,12 with transient ischemic attack(TIA),30 with cerebral infarct(CI)and 2 with combined TIA and CI,who were diagnosed in Jinling hospital between January of 2004 and July of 2009,were retrieved from Nanjing Stroke Registry Program.Ischemic lesions patterns of CI type of MMD were further divided into two paired subgroups including subcortical subgroup versus cortical subgroup, and subgroup of anterior cerebral circulation versus subgroup of posterior cerebral circulation.In addition,the ipsilateral vessel grades of all symptomatic hemispheres were evaluated by Suzuki's 6-grade system according to the results of cerebral angiography of internal carotid arteries.The percentage of number of hemispheres with ischemic events among the paired groups,including TIA group versus CI group,subcortical subgroup versus cortical subgroup,and subgroup of anterior cerebral circulation versus subgroup of posterior cerebral circulation,were analyzed respectively with changes of the Suzuki's grading.Results For above-mentioned each paired groups.the percentage of number of hemispheres with ischemic events was gradually decreased in the former (namely,11/26,2/13,1/8,0 and 0;15/15,9/11,1/7,0 and 0;15/15,10/11,4/7,0 and 0)and increased in the latter(namely,15/26,11/13,7/8,2/2 and 1/1;0,2/11,6/7,2/2 and 1/1;0,1/11,3/7,2/2 and 1/1 ) from grade 2 to grade 6, and the differences were statistically significant (Z = -2. 33 and P =0. 019,Z = - 4.49 and 0. 00, Z = - 3.66 and 0. 01, respectively ). Moreover, the mean value of Suzuki' s grade was lower in the former than the latter for above-mentioned three groups (2. 29 vs 2. 97, 2. 44 vs 4. 18 and 2. 62 vs 4. 13, respectively). Conclusion The ischemic lesion patterns of adult MMD is changing with the change of Suzuki' s vessel grading. The higher the Suzuki' s grade, the greater the likelihood of ischemic lesions involving the cortical areas of posterior cerebral circulation.

Objective To investigate the differences of risk factors,imaging features,etiologies,and long-term outcomes in young adults with anterior and posterior circulation ischemic stroke.Methods Consecutive young patients (15-45 years) with ischemic stroke were divided into an anterior circulation group and a posterior circulation group.They were followed up regularly for a long term,and the endpoint events included stroke,cardiovascular events,and death.Results A total of 289 patients were enrolled in the study,including 220 males.Their mean age was 38.0 ±6.5 years.There were 213 patients (73.7％) in the anterior circulation group and 76 (26.3％) in the posterior circulation group.In terms of risk factors,valvular heart disease was more common in the anterior circulation group (6.6％ vs.0.0％;Fisher's exact test,P =0.025),while hypertension (51.3％ vs.36.6％;x2 =5.021,P=0.025) and prodromic infection (6.6％ vs.1.4％;Fisher's exact test,P =0.018) were more common in the posterior circulation group.In the etiologies of stroke,large-artery atherosclerosis was more common in the anterior circulation group (32.4％ vs.13.2％;x2 =10.435,P =0.001),while small vessel occlusion (26.3％ vs.15.5％;x2 =4.381,P =0.036) and arterial dissection (19.7％ vs.9.9％;x2 =5.012,P =0.025) were more common in the posterior circulation group.There was no significant difference in the incidence of 5-year cumulative end-point events between the anterior circulation group and the posterior circulation group (20.2％ vs.18.5％;log-rank test P =0.614).Multivariate Cox proportional hazards regression analysis showed that after adjusting for age and gender,the independent predictors of end-point events in the posterior circulatory group included hypercholesterolemia (hazard ratio [HR] 3.622,95％ confidence interval [CI] 1.216-17.766;P =0.030),old infarction (HR 6.045,95％ CI 1.602-29.580;P =0.016),and CE (HR 8.256,95％ CI 1.398-27.302;P=0.029).Conclusion There were significant differences in the risk factors,etiologies,and influencing factors of long-term outcome between the anterior circulation and posterior circulation in Chinese young patients with ischemic stroke,suggesting that the different diagnosis and treatment strategies should be adopted for the two types of patients.

Objective To preliminarily investigate the safety and feasibility of intra-arterial cold saline infusion combined with intravascular reperfusion for acute ischemic stroke with large artery occlusion. Methods From March 2016 to March 2018, consecutive acute ischemic stroke patients with large artery occlusion within 8 h after onset admitted to the Department of Neurology, the People's Hospital of Longhua District, Shenzhen and recanalized successfully after endovascular treatment were enrolled. After recanalization, cold saline was infused through the guiding catheter via the ipsilateral guilty vessel (10 ℃, 33 ml/min for 30 min). Results A total of 20 patients were enrolled, including 15 males. Their median age was 67 years (interquartile range, 53-80 years). Fifteen patients were treated with thrombolysis. A median onset-to-needle time was 300 min (interquartile range, 260-360 min). During the infusion of cold saline, the lowest rectal temperature was only decreased 0. 1 ℃, but within 5 min after completion of perfusion, it returned to the temperature before perfusion. Complications associated with intra-arterial hypothermia were not observed. The median National Institutes of Health Stroke Scale score was significantly decreased from 21 (interquartile range 15-55) before needle to 15 (interquartile range 10-16; Z = -4. 549, P < 0. 001) at discharge. Conclusion Selective intra-arterial cold saline infusion combined with intravascular reperfusion for acute ischemic stroke with large artery occlusion is safe and feasible.

Objective To investigate clinical, imaging features, and long-term outcomes in patients with isolated anterior cerebral artery (ACA) territory infarction due to ACA atherosclerosis, and compare with isolated ACA territory infarction due to other etiologies. Methods The consecutive patients with acute isolated ACA territory infarction confirmed by diffusion-weighted imaging were enrolled prospectively. According to their stroke etiology, they were divided into ACA atherosclerotic stroke and non-ACA atherosclerotic stroke. The infarction patterns were classified as single infarction including perforating artery infarction (PAI), small branch infarction (SBI) and cortical branch infarction(CBI), and multiple infarctions (a combination of PAI,SBI or CBI).The clinical,imaging features and long-term outcomes were compared between the ACA atherosclerotic stroke group and the non-ACA atherosclerotic stroke group. Results A total of 86 patients (47 males) were enrolled, ages ranging from 39 to 88 years (mean 67.5 ± 12.5 years). There were 56 patients in the ACA atherosclerotic stroke group, and 30 patients in the non-ACA atherosclerotic stroke group (12 carotid atherosclerosis, 6 cardioembolism, 2 internal carotid artery dissection, 10 undetermined etiology). The proportions of females (53.6% vs. 30.0%; P= 0.043), progressive onset of stroke(58.9% vs. 20.0%;P=0.001),SBI alone(21.4% vs. 3.3%;P=0.029)and infarction involving small branches(80.4% vs. 46.7%;P=0.001)in the ACA atherosclerotic stroke group were higher than those in the non-ACA atherosclerotic stroke group, and CBI alone (17.9% vs. 55.3%, P=0.001) was lower. The follow-up times in the ACA atherosclerotic stroke group and the non-ACA atherosclerotic stroke group were 29.8 ± 16.5 months and 30.4 ± 18.5 months, respectively (P=0.534). Five-year cumulative incidence of adverse events (stroke, cardiovascular events and death) in the ACA atherosclerotic stroke group and the non-ACA atherosclerotic stroke group were 36.3% and 69.9% respectively(log rank test,P=0.021).Conclusions ACA atherosclerosis is the common etiology for isolated ACA territory infarction. The isolated ACA territory infarction due to ACA atherosclerosis had distinctive infarction patterns and a lower long-term incidence of adverse events compared with those due to non-ACA atherosclerosis.

Objective To investigate the risk and predictors of stroke recurrence in patients with symptomatic intracranial internal carotid artery(IICA)stenosis.Methods Consecutive patients with first-ever ischemic stroke or transient ischemic attack (TIA) caused by IICA atherosclerotic stenosis were enrolled prospectively. The patients were regularly followed up to assess stroke recurrence. Results A total of 70 patients were enrolled, 49 patients were males, and the mean age was 68.2 ± 12.3 years. The mean follow-up time was 34 ± 17 months (median, 33 months). Twenty-seven patients (38.6%) experienced recurrent events during the follow-up period (5 TIAs and 22 ischemic strokes);92.6% of recurrent events occurred in the original symptomatic stenotic IICA territory. Internal watershed infarction in patients with recurrent stroke was more common than those without stroke recurrence(74.1% vs. 44.2%,P=0.025). Kaplan-Meier survival analysis showed that the risks of stroke recurrence at 1,3 and 5 years were 26.8%, 42.5%, and 46.9%, respectively in patients with symptomatic IICA stenosis. Multivariate Cox proportional risk regression analysis showed that the predictors for stroke recurrence in patients with symptomatic IICA stenosis included diabetes (hazard risk [HR] 3.68,95% confidence interval[CI] 1.43-9.46; P=0.007), combined asymptomatic intracranial artery occlusive disease(HR 2.95,95% CI 1.16-7.50;P=0.023),and internal watershed infarction (HR 4.50, 95% CI 1.43-14.17; P=0.010) after adjusting for sex, age and traditional vascular risk factors. Conclusions The risk of long-term stroke recurrence in patients with symptomatic IICA stenosis is still high under the current drug treatment. Diabetes, combined asymptomatic intracranial arterial occlusive disease, and internal watershed infarction are closely associated with stroke recurrence.

Objective To evaluate whether MRI fluid attenuated inversion recovery (FLAIR)vascular hyperintensity (FVH) is an effective indicator for severe vascular stenosis or occlusion and disease severities in patients with acute anterior circulation infarction.Methods Three hundred and forty consecutive patients with acute anterior circulation infarction,admitted to our hospital from May 2013 to May 2014,were enrolled as subjects.All subjects were completed brain MR diffusion-weighted imaging (DWI),FLAIR and neck vascular or brain magnetic resonance angiography (MRA).According to the extent of FVH,all subjects were classified into negative FVH and positive FVH groups.Clinical data were obtained and compared among patients with different grades of FVH,and receiver operating characteristic (ROC) curve was used to calculate the sensitivity and specificity of FVH diagnosis of vascular severe stenosis or occlusion.The value of FVH in evaluating the disease severities of patients with large artery atherosclerosis combined with acute cerebral infarction according to new TOAST classification was evaluated.Results FVH was observed in 109 (32.06％) of the 340 patients.Significant differences were noted in the new TOAST classification ratio and vascular stenosis grading between the two groups; in the positive FVH group,the largest ratio was patients with large-artery atherosclerosis (82.6％),while that was patients with small vessel diseases (56.3％); the ratio of patients with severe vascular stenosis and occlusion in positive FVH patients was significantly higher than that in negative FVH patients (34.9％ vs.5.6％,39.5％ vs.0.9％).Spearman rank correlation analysis indicated that the degrees of vascular stenosis of carotid artery-middle cerebral artery were positively correlated to FVH (r=0.599,P=0.000).As compared with the negative FVH group,FVH patients had larger infarct volume and higher initial NIHSS scores (P＜0.05).ROC curve indicated that FVH had a sensitivity of 84.38％ and a specificity of 88.52％ in detecting artery stenosis (area under the curve [AUC]=0.892,95％ CI=0.85-0.94,P＜0.05),and a sensitivity of 88.89％ and a specificity of 85.76％ in detecting the vessel occlusion (AUC=0.929,95％CI:0.89-0.97,P＜0.05).In patients with acute cerebral infarction combined with artery atherosclerosis,patients with high FVH scores showed smaller infarct volumes and slighter neurological symptoms as compared with those with low FVH (P＜0.05).Conclusions FVH predicts vascular severe stenosis or occlusion with high sensitivity and specificity.In severe vascular stenosis or occlusion group,higher FVH scores are associated with lighter strokes.