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Preliminary experience of overlapping multi-stent angioplasty for the treatment of vertebral artery dolichoectasia

Zhiwen LU ; Xi WU ; Jianmin LIU ; Qinghai HUANG

Chinese Journal of Cerebrovascular Diseases.2017;14(8):434-437. doi:10.3969/j.issn.1672-5921.2017.08.009

Objective To preliminarily investigate the safety and long-term efficacy of endovascular overlapping multi-stent angioplasty for the treatment of vertebral artery dolichoectasia.Methods From May 2009 to January 2011,the clinical and imaging data of 3 patients with vertebral artery dolichoectasia treated with overlapping multi-stent implantation at the Department of Neurosurgery,Changhai Hospital,the Second Military Medical University were analyzed retrospectively.All 3 patients had prolongation and dilation on the left intracranial vertebral artery.One suffered compression of left medulla oblongata accompanied by old infarction of right thalamus,one complicated with ruptured aneurysm of left posterior cerebral artery received coil occlusion of the parent artery,and the other had a lacuna infarction on the left medulla oblongata with left intracranial vertebral artery dissection.Results 2-5 LEO stents were implanted into the left vertebral artery of each patient and the lesions were covered completely.The revascularization was successful in all patients and no perioperative complications occurred.The 3 patients were followed up for 5-8 years and no new clinical symptoms occurred.The modified Rankin scale score was 0.The DSA follow-up revealed that the vascular morphology of 2 cases was significantly improved compared with that before procedure.Conclusion The preliminary experience has shown that overlapping multi-stent angioplasty for the treatment of vertebral artery dolichoectasia is safe and the long-term effect of revascularization is satisfactory.

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Role of digital subtraction angiography in surgical treatment of intracranial arteriovenous malformations in children

Deqiu CUI ; Gao ZENG ; Jianxin DU ; Xinglong ZHI ; Jingwei LI

Chinese Journal of Cerebrovascular Diseases.2017;14(8):429-433. doi:10.3969/j.issn.1672-5921.2017.08.008

Objective To investigate the safety and effectiveness of digital subtraction angiography (DSA) in the surgical treatment of intracranial arteriovenous malformations (AVMs) in children.Methods Between December 2015 and February 2017,the clinical and imaging data of 9 children with AVM (2-14 years) underwent hybrid surgery at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively.According to the Spetzler-Martin grade,there were 2 patients with grade Ⅰ,3 with grade Ⅱ,2 with grade Ⅲ,and 2 with grade Ⅳ.All the children were treated with microsurgery,and their AVMs were removed by real-time assistance using DSA technique during the operation.The imaging cure rate of surgical treatment and the complications of intraoperative angiography of the children were analyzed.The children were followed up clinically after procedure.According to the modified Rankin scale (mRS) score,their prognoses were evaluated.Results Intraoperative angiography revealed that the AVMs in 8 of 9 children were resected completely,and 1 had a residual lesion,then it was resected completely.Immediately after the resection of the nidi,the angiography confirmed that the nidi of 9 children were resected completely.No related complications caused by intraoperative angiography were observed.Nominal aphasia occurred in 1 child after procedure,and he recovered gradually after 6 months.Pulmonary infection occurred in 2 children,and they were cured after anti-infection treatments.Postoperative follow-up mRS scores were 0-1 in 8 children,2 in 1 child,and no rebleeding was observed.Conclusions In children undergoing AVM surgery,initial observation of DSA is safe and effective.Intraoperative angiography can guide the complete resection of the lesions in real time,improve the surgical cure rate of AVMs,and improve the prognosis of children.

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Types of vertebral artery occlusion and their compensatory hemodynamic changes influence to posterior circulation ischemia

Yinghua ZHOU ; Yang HUA ; Lingyun JIA ; Lili WANG ; Chun DUAN ; Weihong HOU

Chinese Journal of Cerebrovascular Diseases.2017;14(8):424-428,433. doi:10.3969/j.issn.1672-5921.2017.08.007

Objective To evaluate the correlation between the types of vertebral artery occlusion and their compensatory hemodynamic changes and posterior circulation ischemia using color Doppler flow imaging combined with transcranial color-coded sonography.Methods From June 2015 to June 2016,A total of 108 patients with vertebral artery occlusion confirmed by vascular sonography,digital subtraction angiography (DSA) or CT angiography (CTA) were enrolled retrospectively.According to the magnetic resonance imaging (MRI)-diffusion weighted imaging (DWI) findings,they were divided into posterior circulation infarction (n=78 in infarction group) and non-posterior circulation infarction (n=30 in TIA group).Color Doppler flow imaging and transcranial color Doppler ultrasonography were used to examine the contralateral vertebral artery extracranial diameter, peak systolic velocity(PSV) and end diastolic velocity(EDV) of bilateral extracranial and intracranial vertebral arteries.The differences of the vertebral artery occlusion types,establishment of collateral circulation and hemodynamic changes of the contralateral vertebral artery were compared between the two groups.Results The patients with single vertebral artery occlusion in the infarction group and TIA group were 69 (88.5%) and 26 (86.7%) respectively;those with bilateral vertebral artery occlusion were 9 (11.5%) and 4 (13.3%) respectively.There was no significant difference in the number of vertebral artery occlusion between the two groups (χ2=0.000,P=1.000).The proportion of patients with vertebral artery occlusion in intracranial segment in the infarction group was higher than that in the TIA group (70.5% [55/78] vs.36.7% (11/30);χ2=10.444,P=0.001).The proportion of patients with the establishment of collateral circulation in the infarction group was lower than that in the TIA group (14.1% [11/78] vs.43.3% (13/30);χ2=10.711,P=0.001).The peak systolic velocity (PSV) and the end diastolic velocity (EDV) of contralateral extracranial vertebral artery in patients with single vertebral artery occlusion in the TIA group were higher than those in the infarction group (65±21 cm/s vs.57±15 cm/s,25±8 cm/s vs.20±7 cm/s,t=2.043 and 2.606 respectively,all P<0.05).Conclusion The establishment of collateral circulation and hemodynamic compensation of the contralateral vertebral artery after vertebral artery occlusion were closely associated with the occurrence of posterior circulation ischemia.

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Value of high-resolution magnetic resonance black-blood imaging for evaluation of the stage of disease in intracranial venous and sinus thrombosis

Qi YANG ; Xiaoxu YANG ; Xianggong DUAN ; Fang WU ; Ye WU ; Xiangying DU ; Jiangang DUAN ; Xunming JI

Chinese Journal of Cerebrovascular Diseases.2017;14(8):420-423. doi:10.3969/j.issn.1672-5921.2017.08.006

Objective To evaluate the value of magnetic resonance black-blood thrombus imaging (BTI) of the stage of disease in intracranial venous and sinus thrombosis(CVT).Methods From June 2015 to October 2016,37 patients with CVT diagnosed with routine imaging examinations in Beijing Xuanwu Hospital,Capital Medical University were enrolled prospectively,and they also underwent BTI examination.The patients were randomly divided into either a acute group (≤14 d,n=23) or a chronic group (>15 d,n=14) according to the time from the onset of symptoms to BTI.Signal to noise ratio(SNR) and contrast to noise ratio(CNR) difference between acute and chronic CVT groups were compared.The magnetic resonance venography (MRV) examination was used as a reference to calculate the accuracy of BTI on per-segment level.Results (1) The SNR and CNR of thrombosis in the acute group and chronic group were 206±97 and 94±41,201±96 and 86±40,respectively.There was significant difference between two groups (t=4.9 and 5.0 respectively;all P<0.01).(2) In 37 patients with CVT,the thrombi in 159 cerebral veins and venous sinus segments were detected with MRV.BTI identified the thrombi accurately in 152 vascular segments,and the thrombi in 352 vascular segments were eliminated.The diagnostic sensitivity and specificity were 95.6% (152/159) and 98.0% (352/359) respectively.Conclusion Achieving direct angiography of cerebral venous thrombosis,BTI technique can accurately differentiate acute or chronic thrombus.It has higher accuracy.

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Relationship between self-rated health of the elderly in Beijing and the occurrence of stroke based on a competitive risk model:a cohort study

Chengbei HOU ; Haibin LI ; Zhe TANG ; Lixin TAO ; Deqiang ZHENG ; Xianghua FANG ; Xunming JI ; Xiuhua GUO

Chinese Journal of Cerebrovascular Diseases.2017;14(8):415-419. doi:10.3969/j.issn.1672-5921.2017.08.005

Objective To investigate the risks of self-rated health in the ≥55-year elderly in Beijing and the occurrence of stroke.Methods The subjects (n=2 101;aged ≥55) from Beijing longitudinal study of aging (BLSA) were collected by Xuanwu Hospital,Capital Medical University from January 1992 to December 2016.One hundred and twenty-one subjects with stroke at baseline and 92 with incomplete information were excluded,and finally,1 888 elderly patients without cerebrovascular disease at baseline were included in the analysis.Based on the actual situation,the self-rated health was to identify an item that matched their current state from good,general to poor.The deadline for the survey was December 31,2012.The competitive risk model was used to assess the health self-rated status and the risk of stroke.Non-stroke deaths,including cancer and car accidents were treated as competitive events.Results Of the 1 888 subjects enrolled,946 (50.1%) self-rated health were good,616 (32.6%) were general,and 326 (17.3%) were poor;438 (23.2%) had stroke,751 (37.8%) had non-stroke death,and 699 (37.0%) were right censored data.Using the competing risk model and adjusting the age,sex,living area,marital status,education level,smoking,alcohol consumption,physical exercise,hypertension,diabetes mellitus,coronary heart disease,and body mass index,the occurrence of stroke in patients with poor self-rated health was 1.44 times (95%CI 1.11-1.87,P<0.01) as good as those who were good.Conclusion In the self-rated health of the elderly ≥55 years old in Beijing,the people with poor self-rated health increased the occurrence of stroke after considering the competitive risks.

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Efficacy analysis of intravenous thrombolysis in elderly patients with acute ischemic stroke

Bo SONG ; Li GAO ; Shuai JIANG ; Lei WANG ; Haitao ZHANG ; Meng WANG ; Zhong ZHANG

Chinese Journal of Cerebrovascular Diseases.2017;14(8):410-414,419. doi:10.3969/j.issn.1672-5921.2017.08.004

Objective To investigate the safety and efficacy of intravenous thrombolysis (IVT) in elderly patients (aged≥80 years) with acute ischemic stroke.Methods From July 2014 to February 2016,157 consecutive patients with acute cerebral infarction treated with alteplase for intravenous thrombolysis within 4.5 h after onset at the Department of Neurology,the Third People's Hospital of Chengdu were collected retrospectively.They were confirmed by head CT or MRI.They were divided into a ≥80-year old group (n=47) and a <80-year old group (n=110) according to the age of onset.The baseline data were documented,including the risk factors for cardiocerebrovascular diseases,National Institute of Health stroke scale (NIHSS) score,onset to thrombolytic time (3.0-4.5 h),and application of anticoagulant drugs,etc.The adverse reactions of the patients were observed and the safety and efficacy of thrombolysis were evaluated,that is 7 d and 3 months mortality,symptomatic intracranial hemorrhage rate,and good recovery rates of intravenous thrombolysis at 24 h,1 week,and 3 months.Results (1) Compared with the <80-year old group,the ratio of atrial fibrillation and median age in the ≥80-year old group were higher.There were significant differences between the two groups (59.6% [n=28] vs.32.7% [n=36],83 [81,85] vs.67 [59,75] years old,all P<0.01).There were no significant differences in the remaining baseline data between the two groups (all P>0.05).(2) In the subtypes of cerebral infarction etiology,the proportion of cardiogenic embolism in the ≥80-year old group was higher than that in the <80-year old group.There was significant difference between the two groups (59.6% [n=28] vs.32.7% [n=36],P<0.01).There was no significant difference in the other etiological types between the two groups (all P>0.05).(3) There were no significant differences at one week (6.4% [n=3] vs.6.4% [n=7] respectively) and 3 months (12.8% [n=6] vs.9.1% [n=10]) in the mortality rates between the ≥80-year old group and the <80-year old group (all P>0.05).There were no significant differences in the proportions of intracranial hemorrhage (10.6% [n=5] vs.8.2% [n=9]) and symptomatic intracranial hemorrhage (4.3% [n=2] vs.6.4% [n=7]) between the two groups (all P>0.05).There was no significant difference between the good recovery rate at 24 h (38.3% [n=18] vs.45.5% [n=50]) and that at one week (53.2% [n=25] vs.62.7% [n=69];all P>0.05).The long-term (3 months) favorable prognosis rate in the ≥80-year old group was lower than that in the <80-year old group.There was significant difference between the two groups (51.1% [n=24] vs.71.8% [n=79], P<0.05).Conclusion For the onset within 4.5 h (aged≥80 years) in elderly patients with acute ischemic stroke,selecting the appropriate cases for intravenous thrombolysis is help to increase safety and early benefit.

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Analysis of feasibility and safety of endovascular recanalization of chronic occlusion of large intracranial artery

Peng GAO ; Yan MA ; Yabing WANG ; Yanfei CHEN ; Fengshui ZHU ; Liqun JIAO

Chinese Journal of Cerebrovascular Diseases.2017;14(8):405-409. doi:10.3969/j.issn.1672-5921.2017.08.003

Objective To investigate the feasibility and safety of endovascular recanalization of chronic occlusion of large intracranial artery.Methods From January 2009 to January 2017,the clinical and imaging data of 15 patients with chronic occlusion of large intracranial artery admitted to the Department of Interventional Neuroradiology,Xuanwu Hospital,Capital Medical University for endovascular recanalization were analyzed retrospectively.Twelve patients were V4 segment occlusion of vertebral artery and 3 were internal carotid artery occlusion.Preoperative whole brain digital subtraction angiography (DSA) was used to assess the occlusion length and location.High-resolution magnetic resonance imaging (MRI) was used to evaluate the nature of occlusion and the feasibility of recanalization.The intraoperative bilateral femoral artery sheath placement was conducted in 13 cases,one side was used for recanalization and stenting,and the other side was compensated by filling the distal occlusion of the artery through collateral circulation as the reference path map,and increased the feasibility of recanalization.According to the thrombolysis in cerebral infarction (TICI) grades after procedure,the forward flow after recanalization was systematically evaluated,and grade ≥2b was defined as the success of recanalization.Results The median time between the first onset of symptoms and recanalization was 50 (range,18-365) days.The occluded recanalization sites included intracranial segment of vertebral artery in 12 cases and intracranial segment of internal carotid artery in 3 cases.Recanalization was successful in 13 cases and recanalization failure of the intracranial segment of vertebral artery was in 2 cases.Recanalization was successful in 13 cases,and intracranial vertebral artery recanalization failed in 2 cases.Of the 13 patients of successful recanalization,the forward flow of angiography returned to grade TICI 3 in 12 cases after recanalization,and returned to TICI 2b in 1 case;the symptoms of 7 cases were improved,the symptoms of 4 cases did not have any change,and the symptoms of 2 patients aggravated after procedure and developed transient ischemic attack or stroke.After 11 patients were followed up for a median of 39 (3-89) months,the median mRS score was 1 (0-2).Conclusion For recanalization of chronic large intracranial artery occlusion,using preoperative high-resolution magnetic resonance imaging evaluation and intraoperative bilateral sheath placement technique may increase the patency rate and reduce the perioperative complications.

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Preliminary application of multiple angiographic patterns in the hybrid surgery of cerebral and spinal arteriovenous malformations

Tao HONG ; Hongqi ZHANG ; Guilin LI ; Chuan HE ; Ming YE ; Peng HU ; Yongjie MA

Chinese Journal of Cerebrovascular Diseases.2017;14(8):399-404. doi:10.3969/j.issn.1672-5921.2017.08.002

Objectives To investigate the application modes of indocyanine green (ICG) angiography,digital subtraction angiography (DSA) and methylene blue angiography in the hybrid surgery of cerebral and spinal arteriovenous malformations (AVMs) and to compare the application value of different intraoperative angiographic methods.Methods From July 2013 to December 2015,55 patients treated with hybrid surgery of cerebral and spinal AVMs in Xuanwu Hospital,Capital Medical University were analyzed retrospectively,including 8 patients with cerebral AVM(Spetzler-Martin grade ≥Ⅲ) and 47 with spinal AVM.Their mean age was 33.8±15.6 years.Intraoperative DSA was performed in a hybrid operation room and methylene blue angiography was performed via the feeding artery.ICG angiography was performed in 4 cases in the initial stage as a comparison.Anatomic cure was confirmed by DSA at 3 months after surgery and the results were assessed.Results All 55 patients performed intraoperative DSA,32 underwent methylene blue angiography and 4 performed intraoperative ICG angiography.The frequency of intraoperative DSA was 3.6±1.3 times for each case.After the resection of the first lesion,the residual lesions revealed by DSA accounted for 27.3% (15/55).85.5% (47/55) patients achieved anatomic cure,in which the patients with midbrain AVM (8/8) and spinal AVM 83.0% (39/47) achieved anatomic cure.Three patients were lost to follow up at 1 year after procedure.The median modified Rankin scale (mRS) score of the cerebral AVMs was 2.0 (0.0-3.8).Compared with 3.5 (2.0-4.0) before procedure,there was significant difference (Z=-2.264,P<0.05).The Aminoff score in patients with spinal AVM after procedure was 3.5 (1.0-6.0).Compared with 4.0 (1.0-6.0) before procedure,there was no significant difference (Z=-0.262,P>0.05).The patients with function preservation (function score equal or better than pre-operation) accounted for 88.5% (46/52).Conclusions Intraoperative DSA could precisely localize the nidi and verify the complete resection.Intraoperative methylene blue angiography could selectively reveal the feeding artery supplied nidi in the operative field and identify the angioarchitecture.ICG angiography could reveal the structures of nidi on the surface of the operation area.The intraoperative methylene blue angiography could replace ICG angiography and achieve the treatment target of anatomical cure of the hybrid surgery of the cerebral and spinal cord vascular malformations.

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Early adverse outcomes in young patients with ischemic stroke:an analysis of the related factors

Meng LIANG ; Meng ZUO ; Nana ZHAO ; Dezhi LIU ; Peng WANG ; Yan MA ; Xinfeng LIU

Chinese Journal of Cerebrovascular Diseases.2017;14(8):393-398. doi:10.3969/j.issn.1672-5921.2017.08.001

Objective To investigate the related factors of early adverse outcomes in young patients with ischemic stroke.Methods From January 2006 to June 2016,685 young patients (18-45 years old) with acute ischemic stroke admitted to the Department of Neurology,Nanjing General Hospital of Nanjing Military Command were enrolled retrospectively.They were diagnosed as the first onset with head CT or MRI.According to the modified Rankin scale (mRS) at 90 d,the patients were divided into a favorable outcome (mRS 0-2) group (n=554) and a poor outcome (mRS 3-6) group (n=131).The collection of clinical data were completed on the day of admission,including the risk factors for cerebrovascular disease (oral contraceptives,etc),the National Institutes of Health stroke scale (NIHSS) score on admission,the mean systolic blood pressure (>140 mmHg was analyzed) and laboratory examination.The stroke subtypes were classified with the trial of org 10172 in acute stroke treatment (TOAST) classification criteria.Univariate analysis was used to analyze the difference of clinical data between groups,and multivariate logistic regression analysis was used to analyze the risk factors for early poor outcomes.Results Compared with the favorable outcome group,the patients with the ratio of mean systolic pressure >140 mmHg in the first 3 d after hospitalization (37.4% [49/131] vs.21.7% [120/554],χ2=14.131),NIHSS score on admission (10.0 [7.0,14.0] vs.1.5 [0,3.0],Z=-15.300),white blood cell count (7.5 [6.0,9.0] ×109/L vs.6.8 [5.7,8.2] ×109/L,Z=-3.157),fasting glucose (4.9 [4.6,6.0] mmol/L vs.4.8 [4.4,5.3] mmol/L,Z=-2.726),higher fibrinogen level (2.8 [2.3,3.4] g/L vs.2.6 [2.3,3.2] g/L,Z=-2.018,blood uric acid level (291[220,346] mmol/L vs.315 [261,374] mmol/L,Z=-3.443),and plasma albumin level (43.1[40.0,45.9] g/L vs.44.8 [42.4,47.4] g/L,Z=-4.708) were decreased in the poor outcome group.There were significant differences between the two groups (all P<0.05).TOAST classification comparison:the proportion of the patients with cardioembolism in the poor outcome group was higher than that in the favorable outcome group.There was significant difference between the two groups (6.9% [9/131] vs.2.5% [14/554];χ2=4.893,P<0.05).There were no significant differences in the remaining clinical data between the two groups (all P>0.05).Multivariate logistic regression analysis showed that the higher NIHSS score on admission (OR,1.474,95%CI 1.378-1.576,P<0.01),the mean systolic pressure >140 mmHg at the first 3 d after admission (OR,2.134,95%CI 1.210-3.764,P=0.009) and the cardioembolism(OR,4.902,95%CI 1.073-22.222,P=0.040) were the risk factors for early poor outcome,and the elevated plasma albumin level (OR,0.902,95%CI 0.850-0.956,P=0.001) was a protective factor of early favorable outcome.Conclusion The higher NIHSS score at admission,the cardioembolism and the increased mean systolic blood pressure in the first 3 d after admission may result in early poor outcome in young patients with ischemic stroke,while the elevated plasma albumin level is beneficial to the early outcome.

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Treatment of vertebrobasilar aneurysms using suboccipital muscle stratification via far lateral approach

Liyong SUN ; Guilin LI ; Mingchu LI ; Yan MA ; Peng HU ; Chuan HE ; Hongqi ZHANG

Chinese Journal of Cerebrovascular Diseases.2017;14(5):267-272. doi:10.3969/j.issn.1672-5921.2017.05.009

Objective To discuss the technical essentials of microsurgery using suboccipital muscle stratification for the treatment of complex vertebrobasilar aneurysms via far lateral approach.Methods The clinical data of 8 patients with vertebrobasilar aneurysm underwent suboccipital muscle stratification via far lateral approach at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively,including 5 patients with subarachnoid hemorrhage (Hunt-Hess grade Ⅱ 3 cases;grade Ⅲ 1 case;grade Ⅳ 1 case),and 3 with symptomatic dissecting aneurysm.Six patients underwent occipital artery-posterior inferior cerebellar artery and anterior inferior cerebellar artery bypass grafting,and aneurysm trapping,and the aneurysms of the other 2 cases were clipped directly in the operation.The modified Rankin scale (mRS) was used to evaluate the clinical efficacy.Results Postoperative digital subtraction angiography (DSA) revealed that all the bridge vessels were patent.The obtained length of occipital artery in the actual measurement of the operation was 12.5±1.1 cm.The distance between the anastomosis site and the skin incision in 6 cases was 50±6 mm.They were followed up for 4-21 months after procedure.The mRs score in 7 cases was 0-1.Two patients had new-onset hoarseness and recovered completely within 3 months after procedure.Another patient had postoperative cerebellar hemisphere dominant regional cerebral infarction and the mRs score was 4.None of them had poor wound healing,infection and cerebrospinal fluid leakage after procedure.Conclusion Suboccipital muscle stratification via far lateral approach can effectively obtain a longer occipital artery,reduce the occupation effect of muscle and depth of field.It is beneficial to expose lesions and operation of deep anastomosis.It is a more safe and practical technique in neurosurgery for the treatment of vertebrobasilar artery aneurysms.

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