Objective To explore the influencing factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial internal carotid artery(ICA)stenosis and to construct a nomogram prediction model.Methods This study retrospectively and consecutively enrolled patients diagnosed with unilateral moderate-to-severe extracranial ICA stenosis and exhibited indications for carotid endarterectomy(CEA)hospitalized in the Department of Neurosurgery at the First Affiliated Hospital of Soochow University,between August 2019 and September 2024.The patients were divided into a stroke group and a non-stroke group,based on their clinical presentation and head MRI results.Baseline characteristics and clinical data including age,sex,body mass index,blood pressure(systolic and diastolic pressure[＜140 mmHg,140-＜160 mmHg,≥160 mmHg]),hypertension,diabetes,smoking and alcohol consumption history,use of statin and antiplatelet medication,fasting blood glucose,high-density lipoprotein cholesterol(HDL-C),low-density lipoprotein cholesterol(LDL-C),triglycerides(TG),total cholesterol(TC)were collected and ratios between LDL-C/HDL-C,TG/HDL-C,non-HDL-C(calculated according to equation:non-HDL-C=TC-HDL-C),and non-HDL-C/HDL-C(nHHR)were calculated based on aforementioned data.The clinical and baseline data were then compared between two groups.Imaging data included side of carotid artery stenosis(identified through neck vascular ultrasound,CT angiography and/or DSA),degree of carotid stenosis(with 50％-69％categorized as moderate stenosis,and,70％-99％as severe stenosis),plaque echogenicity(predominantly low,medium or high),plaque calcification(surface and basal calcification),plaque ulceration(exists or not),bilateral middle cerebral artery(MCA)hemodynamic parameters measured by transcranial Doppler ultrasound(including,mean flow velocity[Vm],peak systolic velocity[Vs],end-diastolic velocity[Vd]),and the pulsatility index(PI,calculated via formula:PI=[Vs-Vd]/Vm).The hemodynamic parameter differences(△Vm,△Vs,△Vd,△PI)between the healthy and affected MCA were calculated.The baseline,clinical and imaging data with P＜0.05 in univariate analysis were included in multivariate Logistic regression analysis using forward stepwise selection to identify influencing factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis,and a nomogram prediction model was then constructed base on the analyzed results.Receiver operating characteristic curves were plotted,and the area under the curve(AUC)was calculated to evaluate the predictive performance of the nomogram.Delong's test was used to compare AUC differences between single indicators and the combined model.Results A total of 166 patients with unilateral moderate-to-severe extracranial ICA stenosis and CEA indication were included.In which,99 patients were in the stroke group and 67 patients were in the non-stroke group.The stroke group had a significantly higher proportion of hypertension patients(78.8％[78/99]vs.59.7％[40/67],P=0.008),higher systolic blood pressure([152±15]mmHg vs.[137±18]mmHg,P＜0.01),higher diastolic blood pressure([84±10]mmHg vs.[80±10]mmHg,P=0.042),higher TG(1.33[0.95,1.77]mmol/L vs.1.10[0.87,1.48]mmol/L,P=0.019),higher TG/HDL-C(1.35[0.97,2.08]vs.1.07[0.81,1.52],P=0.003),and higher nHHR(2.89[2.25,3.61]vs.2.48[1.93,3.27],P=0.027)than the non-stroke group.The HDL-C was significantly lower in the stroke group(0.96[0.80,1.15]mmol/L vs.1.03[0.91,1.16]mmol/L,P=0.014).Statistically significant differences were also observed in the distribution of systolic blood pressure between the groups(P＜0.01).No significant differences were found in other clinical data(all P＞0.05).The proportion of patients with carotid plaque ulceration was higher in the stroke group(35.4％[35/99]vs.16.4％[11/67],P=0.007),while stenosis side,stenosis degree,plaque echogenicity,and plaque calcification type showed no significant differences between the groups(all P＞0.05).△Vm(19[4,32]cm/s vs.10[-3,21]cm/s,P=0.001),△Vs(32[9,55]cm/s vs.24[3,40]cm/s,P=0.005),and △Vd(10[-1,19]cm/s vs.6[-3,12]cm/s,P=0.006)were significantly higher in the stroke group.No significant difference was found in △PI(P=0.076).Multivariate Logistic regression analysis identified high systolic blood pressure(OR,1.063,95％CI 1.036-1.090,P＜0.01),high TG/HDL-C(OR,2.802,95％CI 1.551-5.061,P=0.001),high △Vm(OR,1.032,95％CI 1.010-1.055,P=0.004),and plaque ulceration(OR,2.777,95％CI 1.123-6.871,P=0.027)as independent risk factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis.Systolic blood pressure,TG/HDL-C,△Vm and plaque ulceration were involved in the construction of a combined predictive model for ischemic stroke in the targeted patient group(with unilateral moderate-to-severe extracranial ICA stenosis).The AUC of the combined prediction model was 0.828(95％CI 0.765-0.892,P＜0.01),which was significantly higher than the predictive efficacy of any single factor(all P＜0.01).Conclusions High systolic blood pressure,high TG/HDL-C ratio,high △Vm,and plaque ulceration are independent risk factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis.The nomogram prediction model based on these factors demonstrates good predictive value for assessing ischemic stroke risk in this patient population.

Objective To investigate the severity of white matter lesions （WML） in patients with right-to-left shunt （RLS）-positive migraine. Methods A total of 415 patients with RLS-positive migraine who were consecutively admitted to Department of Neurology， The First Affiliated Hospital of Soochow University， from January 2022 to January 2025 were enrolled， and all these patients met the diagnostic criteria in The International Classification of Headache Disorders， 3 rd edition. RLS was diagnosed based on contrast-enhanced transcranial Doppler and contrast-enhanced transesophageal echocardiography， and the type and grade of RLS were assessed. After a series of statistical analyses was conducted， the factors with P<0.05 in the univariate logistic regression analysis were included in the multivariate binary logistic regression analysis to investigate the risk factors for the onset and severity of WML， with P<0.05 indicating statistical significance. Results The analysis of the baseline data of patients with different grades of WML showed that the grade of WML increased with age in the patients with RLS-positive migraine （P<0.05）. Comparison of multimodal ultrasound findings between the patients with different grades of WML showed that there were significant differences between the patients with different grades of WML in the factors such as large RLS， potential RLS， prolonged PFO tunnel， higher PFO at the right atrial side in resting state and after Valsalva maneuver， higher PFO at the left atrial side after Valsalva maneuver， early appearance of shunt， and longer duration of shunt （P<0.05）. For the establishment of a predictive model， large RLS shunt （P=0.037）， higher PFO at the right atrial side after Valsalva maneuver （P=0.018）， and longer duration of shunt （P<0.001） were independent risk factors for the onset of WML in patients with RLS-positive migraine， and further research showed that prolonged PFO tunnel （P<0.001） was a risk factor for the onset of moderate-to-severe WML in patients with RLS-positive migraine. Conclusion The predictive model established based on the ultrasound factors including large RLS shunt and prolonged PFO tunnel can be used as an imaging method to screen for WML， especially moderate-to-severe WML， which provides a theoretical basis for subsequent treatment.

Objective To explore the influencing factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial internal carotid artery(ICA)stenosis and to construct a nomogram prediction model.Methods This study retrospectively and consecutively enrolled patients diagnosed with unilateral moderate-to-severe extracranial ICA stenosis and exhibited indications for carotid endarterectomy(CEA)hospitalized in the Department of Neurosurgery at the First Affiliated Hospital of Soochow University,between August 2019 and September 2024.The patients were divided into a stroke group and a non-stroke group,based on their clinical presentation and head MRI results.Baseline characteristics and clinical data including age,sex,body mass index,blood pressure(systolic and diastolic pressure[＜140 mmHg,140-＜160 mmHg,≥160 mmHg]),hypertension,diabetes,smoking and alcohol consumption history,use of statin and antiplatelet medication,fasting blood glucose,high-density lipoprotein cholesterol(HDL-C),low-density lipoprotein cholesterol(LDL-C),triglycerides(TG),total cholesterol(TC)were collected and ratios between LDL-C/HDL-C,TG/HDL-C,non-HDL-C(calculated according to equation:non-HDL-C=TC-HDL-C),and non-HDL-C/HDL-C(nHHR)were calculated based on aforementioned data.The clinical and baseline data were then compared between two groups.Imaging data included side of carotid artery stenosis(identified through neck vascular ultrasound,CT angiography and/or DSA),degree of carotid stenosis(with 50％-69％categorized as moderate stenosis,and,70％-99％as severe stenosis),plaque echogenicity(predominantly low,medium or high),plaque calcification(surface and basal calcification),plaque ulceration(exists or not),bilateral middle cerebral artery(MCA)hemodynamic parameters measured by transcranial Doppler ultrasound(including,mean flow velocity[Vm],peak systolic velocity[Vs],end-diastolic velocity[Vd]),and the pulsatility index(PI,calculated via formula:PI=[Vs-Vd]/Vm).The hemodynamic parameter differences(△Vm,△Vs,△Vd,△PI)between the healthy and affected MCA were calculated.The baseline,clinical and imaging data with P＜0.05 in univariate analysis were included in multivariate Logistic regression analysis using forward stepwise selection to identify influencing factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis,and a nomogram prediction model was then constructed base on the analyzed results.Receiver operating characteristic curves were plotted,and the area under the curve(AUC)was calculated to evaluate the predictive performance of the nomogram.Delong's test was used to compare AUC differences between single indicators and the combined model.Results A total of 166 patients with unilateral moderate-to-severe extracranial ICA stenosis and CEA indication were included.In which,99 patients were in the stroke group and 67 patients were in the non-stroke group.The stroke group had a significantly higher proportion of hypertension patients(78.8％[78/99]vs.59.7％[40/67],P=0.008),higher systolic blood pressure([152±15]mmHg vs.[137±18]mmHg,P＜0.01),higher diastolic blood pressure([84±10]mmHg vs.[80±10]mmHg,P=0.042),higher TG(1.33[0.95,1.77]mmol/L vs.1.10[0.87,1.48]mmol/L,P=0.019),higher TG/HDL-C(1.35[0.97,2.08]vs.1.07[0.81,1.52],P=0.003),and higher nHHR(2.89[2.25,3.61]vs.2.48[1.93,3.27],P=0.027)than the non-stroke group.The HDL-C was significantly lower in the stroke group(0.96[0.80,1.15]mmol/L vs.1.03[0.91,1.16]mmol/L,P=0.014).Statistically significant differences were also observed in the distribution of systolic blood pressure between the groups(P＜0.01).No significant differences were found in other clinical data(all P＞0.05).The proportion of patients with carotid plaque ulceration was higher in the stroke group(35.4％[35/99]vs.16.4％[11/67],P=0.007),while stenosis side,stenosis degree,plaque echogenicity,and plaque calcification type showed no significant differences between the groups(all P＞0.05).△Vm(19[4,32]cm/s vs.10[-3,21]cm/s,P=0.001),△Vs(32[9,55]cm/s vs.24[3,40]cm/s,P=0.005),and △Vd(10[-1,19]cm/s vs.6[-3,12]cm/s,P=0.006)were significantly higher in the stroke group.No significant difference was found in △PI(P=0.076).Multivariate Logistic regression analysis identified high systolic blood pressure(OR,1.063,95％CI 1.036-1.090,P＜0.01),high TG/HDL-C(OR,2.802,95％CI 1.551-5.061,P=0.001),high △Vm(OR,1.032,95％CI 1.010-1.055,P=0.004),and plaque ulceration(OR,2.777,95％CI 1.123-6.871,P=0.027)as independent risk factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis.Systolic blood pressure,TG/HDL-C,△Vm and plaque ulceration were involved in the construction of a combined predictive model for ischemic stroke in the targeted patient group(with unilateral moderate-to-severe extracranial ICA stenosis).The AUC of the combined prediction model was 0.828(95％CI 0.765-0.892,P＜0.01),which was significantly higher than the predictive efficacy of any single factor(all P＜0.01).Conclusions High systolic blood pressure,high TG/HDL-C ratio,high △Vm,and plaque ulceration are independent risk factors for ischemic stroke in patients with unilateral moderate-to-severe extracranial ICA stenosis.The nomogram prediction model based on these factors demonstrates good predictive value for assessing ischemic stroke risk in this patient population.

Objective To construct a predictive model for patients with ischemic stroke(IS)based on the clinical features of carotid plaques.Methods A total of 189 patients with suspected acute IS who were admitted to the Depart-ment of Neurology at the First Affiliated Hospital of Soochow University for the first time were included in the study.Ac-cording to the results of diffusion-weighted imaging(DWI)of cranial magnetic resonance imaging,these patients were di-vided into IS group and non-ischemic stroke(NIS)group.According to the features of carotid atherosclerotic plaque as-sessed by ultrasound,the lesions were divided into vulnerable plaques and stable plaques.Logistic regression was used to analyze the nature of carotid plaques and clinical features in patients with IS,and the area under the ROC curve was calcu-lated.Results There were significant differences in the number of patients with vulnerable plaques,degree of carotid ste-nosis,hypertension,diabetes,and neutrophil-lymphocyte ratio(NLR)between the IS group and the NIS group(P<0.05).Multivariate logistic regression analysis revealed that the presence of vulnerable carotid plaques,poor control of hypertension and diabetes,and elevated NLR were the main influencing factors for IS events(P<0.05).The area under the ROC curve of vulnerable carotid plaques combined with clinical features(poor control of hypertension and diabetes and elevated NLR)to predict the occurrence of IS events in patients was 0.776(95%confidence interval:0.709?0.842),with a sensitivity of 0.748 and a specificity of 0.758.Conclusion The predictive model based on vulnerable carotid plaques combined with clinical features shows promise.

Objective To develop a model for predicting cryptogenic stroke(CS)in patients with right to left shunt(RLS)through the patent foramen ovale(PFO).Methods We consecutively included 66 patients with CS confirmed by cranial magnetic resonance imaging and PFO-related RLS verified by contrast-enhanced transcranial Doppler ultrasonogra-phy and transesophageal echocardiography who were admitted to the Department of Neurology of The First Affiliated Hospi-tal of Soochow University from January 2020 to October 2022.83 patients diagnosed with PFO-RLS without stroke during the same period were included in the non-stroke(NCI)group.We analyzed the clinical data,anatomical parameters of PFO,and PFO-RLS status of patients;explored factors affecting the risk of CS in patients with PFO-RLS through a multi-variable logistic regression analysis;and built a combined prediction model,and evaluated its performance using the area under the receiver operating characteristic curve(AUC)in comparison with those of individual indicators with the use of the Delong test.Results At baseline,the CS group had significantly higher systolic and diastolic blood pressure levels and D-dimer levels as well as significantly greater PFO diameter and length than the control group(all P<0.05).The mul-tivariable logistic regression analysis revealed that hypertension,higher D-dimer levels,larger PFO diameter,and longer PFO length were factors affecting the risk of CS in patients with PFO-RLS,with the odds ratios[95%confidence intervals(CI)]being 4.16(1.31-13.15),1.01(1.00-1.01),2.29(1.14-4.61),and 1.19(1.03-1.36),respectively(all P<0.05).The AUCs(95%CI)of the combined prediction model,hypertension,D-dimer,PFO diameter,and PFO length were 0.79(0.71-0.86),0.64(0.55-0.73),0.62(0.53-0.71),0.67(0.58-0.75),and 0.65(0.56-0.74),respectively.According to the Delong test,the AUC of the combined prediction model differed sig-nificantly from those of individual indices(all P<0.05).At the optimal cut-off value,the sensitivity and specificity of the combined prediction model were 0.73 and 0.76,respectively.Conclusion Hyperten-sion,increased D-dimer levels,larger PFO diameter,and longer PFO length were factors associated with CS in patients with PFO-RLS.The combined prediction model is effec-tive in predicting the risk of CS for patients with PFO-RLS.

Objective To explore the dynamic changes in cerebral hemodynamics in patients with unilateral middle cerebral artery(MCA)occlusion after superficial temporal artery(STA)-MCA bypass surgery.Methods One hundred and nine patients diagnosed with unilateral MCA occlusion by DSA who underwent STA-MCA bypass surgery were retrospectively included in the Department of Neurosurgery of the First Affiliated Hospital of Soochow University.Clinical data of patients were collected within 24 hours after admission,including age,sex,body mass index,stroke risk factors including hypertension,hyperlipidemia,diabetes,smoking,drinking history and atrial fibrillation,clinical manifestations(within the last 6 months;nonspecific symptoms[dizziness,memory loss,unresponsiveness,etc.],transient ischemic attack,and stroke),blood biochemical markers(low density lipoprotein cholesterol,high density lipoprotein cholesterol,triglyceride,total cholesterol,fasting blood glucose,and hypersensitive C-reactive protein),and National Institutes of Health stroke scale(NIHSS)score at admission.Color Doppler ultrasound(CDU)and transcranial color coded Doppler(TCCD)ultrasound were used to evaluate the hemodynamic parameters of STA before and at different periods after surgery(4-7 days and 1,3,6,12 months after surgery)to analyze the patency of bypass arteries and intracranial hemodynamic changes,and to check the consistency of the results of the bridge artery patency at 12 months postoperatively by CDU and DSA,consistency test was performed.According to the results of the DSA examination 12months after surgery,the patients were divided into the bypass artery patency group and the non-patency group(stenosis or occlusion).The hemodynamic parameters at the trunk of STA,namely the extracranial segment,transcranial,and intracranial part of the bypass arteries,were compared between the two groups.It included inner diameter(D),peak systolic velocity(PSV),end-diastolic velocity(EDV),resistance index(RI),pulsation index(PI),time-averaged mean velocity(TAMV),time-averaged peak velocity(TAPV),and calculated flow of the STA trunk including TAMV flow and TAPV flow.Head CT,CT angiography(CTA)above the aortic arch,and CT perfusion(CTP)of the whole brain were performed 1 to 3 days before surgery and 12 and 18 months after surgery to observe the changes in cerebral perfusion.Head CT was performed 1 to 2 days after the operation to observe whether there were new hemorrhagic and ischemic lesions in the operative area.the CTP parameters of the two groups were compared including 12 and 18 months after the operation with 1 to 3 days before the surgery,and the differences in CTP parameters between the two groups were compared.The modified Rankin scale(mRS)was used to evaluate the neurological function prognosis of the patients at 12 and 18 months after surgery.The mRS score 2 was divided into a good prognosis and mRS score≥3 was a poor prognosis.NIHSS score of the patients was recorded 7 days,12,and 18 months after surgery.Results(1)Consistency analysis of CDU and DSA:the consistency of the assessment of bypass artery patency was excellent at 12 months after surgery,and the Kappa value was 0.94(95％CI 0.81-1.00,P＜0.01).According to DSA,101 cases(92.7％)were in bypass artery patency group,while 8 cases(7.3％)in the non-patency group(no case of occluded bridge vessel was found),and the sites of stenosis in the bypass arteries were all located in the transcranial segment.(2)Hemodynamic parameters:compared with the preoperative results,the D of the extracranial segment increased on 4-7 days and 1,3,6,and 12 months after the operation(Wald x2=30.438).Hemodynamic parameters included increased blood velocity such as PSV,EDV,TAMV,and TAPV(Waldx2 was 12.117,29.310,31.075 and 17.525,respectively)and blood flow including TAMV flow and TAPV flow(Wald x2 was 54.503 and 34.986,respectively)increased,while RI and PI values were decreased(Waldx2 was 112.568 and 103.629,respectively),and the differences were statistically significant(all P＜0.05).However,there was no significant difference in hemodynamic parameters in the non-patency group at 12 months after operation(all P＞0.05).Compared with 4-7 days after surgery,PSV(252.0[206.8,315.3]cm/s vs.102.5[84.0,119.0]cm/s)and EDV(119.5[106.3,159.8]cm/s vs.43.5[36.8,52.0]cm/s)in the non-patency group were significantly higher at the cranial entrance 12 months after surgery(both P＜0.05),but there was no significant difference in RI and PI values(both P＞0.05).Compared with 4-7 days after surgery,the blood flow parameters of STA intracranial segment,including PSV(29.4[24.8,41.4]cm/s vs.111.5[63.3,120.0]cm/s),EDV(19.7[15.2,22.2]cm/s vs.58.5[28.3,70.0]cm/s)and PI(0.55[0.42,0.63]vs.0.83[0.61,0.90])values in the non-patency group at 12 months after surgery were significantly decreased(all P＜0.05).(3)CTP parameters:the relative cerebral blood flow(rCBF)of the patency group increased at 12 and 18 months after surgery compared to preoperative levels,while relative cerebral blood volume(rCBV),relative peak time(rTTP)and relative mean transit time(rMTT)decreased,with statistical significance(all P＜0.05).At 12 and 18 months after operation,rCBF increased,while rMTT decreased in the non-patency group(both P＜0.05),but there was no significant difference as for rCBV and rTTP.The rTTP of the patency group at 12 and 1 8 months was lower than that of the non-patency group(12 months after surgery:1.14[1.06,1.15]vs.1.20[1.14,1.28],P=0.024;1 8 months after surgery:1.14[1.06,1.15]vs.1.20[1.14,1.28],P=0.023),but there was no statistical significance for other parameters between the two groups(all P＞0.05).(4)NIHSS score and prognosis:clinical follow-up results 18 months after the operation showed that no new stroke occurred during the follow-up period.The NIHSS scores in the patency group and the non-patency group were remarkably lower at 7 days,12,and 18 months after surgery than at admission(patency group:2[0,4],1[0,2],0[0,2]vs.3[0,6],respectively;the non-patency group:3[1,5],3[1,6],2[1,6]vs.4[1,7],respectively),with significant differences(all P＜0.05);However,the NIHSS scores in the patency group were significantly lower than that in the non-patency group at 12 and 18 months after surgery,and the proportion of patients with good prognosis in the patency group was substantially higher than that in the non-patency group(12months:87.1％[88/101]vs.4/8,P=0.039;18 months:90.1％[91/101]vs.4/8,P=0.025).Conclusion CDU can quantitatively evaluate the hemodynamic changes of bypass arteries after the STA-MCA bypass procedure,which can be applied to the long-term dynamic follow-up after the surgery.

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 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 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.