Chinese Journal of Stroke

Never Give up

WANG Yong-Jun

2015, 10(08): 625-627.

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Application and New Development of Neurosonology

CHEN Ying, XING Ying-Qi

2015, 10(08): 633-646.

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Study on the Factors of the Recurrent Stroke in Patients with Minor Ischemic Stroke at 1 Year——from the Chinese Intracranial Atherosclerosis Study (CICAS)

LI Jing-Jing, JU Yi, WANG Chun-Xue, et al.

2015, 10(08): 647-653.

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Objective To evaluate various brain magnetic resonance imaging diffusion weighted imaging (MRI-DWI) lesion patterns and the severity of large vessel stenosis assessed in the acute phase of minor ischemic stroke to figure out the predictors for recurrent stroke at 1 year. Methods We studied patients presenting with minor ischemic stroke in the Chinese Intracranial Atherosclerosis Study (CICAS)-group. The inclusion criteria of our study have included that within 7 days of stroke onset, the modified Rankin Scale (mRS) score was 2 before enrollment, minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS]<4), the complete baseline and follow-up data and acute MRI-DWI lesions. Baseline characteristics, treatment, different MRI-DWIlesion patterns and the severity of large vessel stenosis were collected. Predictors of recurrent stroke, combined cardiac and cerebrovascular events, poor outcome at 1 year were analyzed by univariate and multivariate analysis. Results A total of 843 patients, mean age of (61.67±11.04) years, were included in the study. The incidence of cumulative stroke recurrence rate at 1 year were 4.39%. Multivariate analysis showed that age>75 years ([hazard ratio] HR 3.18, 95% [confidence interval] CI 1.140~7.211, P =0.006), symptomatic artery occlusion ( HR 2.35, 95% CI 1.094~5.030, P =0.029), multiple asymptomatic artery stenosis ( HR 2.74, 95% CI 1.311~5.730, P =0.007), multiple cortical, subcortical and deep white matter DWI lesions ( HR 2.06, 95% CI 1.006~4.229, P =0.048) were significant predictors for recurrent stroke at 1 year. Conclusion Imaging is a useful judgment implement for the outcome of patients with minor ischemic stroke. Multiple cortical, subcortical or deep white matter lesions, multiple intracranial and extracraninal arterial stenosis are significant predictors for recurrent stroke at 1 year.

Inhibition of 15-LOX/15-HETE on the Expression of Kv Channels Participates in the Cerebral Vasoconstriction Induced by Hypoxia

ZHU Yu-Lan, WANG Di, LIU Wen-Juan

2015, 10(08): 654-659.

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Objective To investigate the effect of the inhibition of 15-lipoxygenase (15-LOX)/15- hydroxyeicosatetraenoic acid (15-HETE) on the expression of Kv channels in the cerebral vasoconstriction induced by hypoxia. Methods Smooth muscle cells originated from the cerebral artery of Wistar rats were separated and cultured by enzyme digestion method. The cells were then assigned randomly into four groups: group A:control group, carotid artery smooth muscle cells (CASMCs) were cultured under normoxic condition for 48 h; group B:hypoxia group, CASMCs were cultured under hypoxic condition for 48 h; group C:15-LOX gene overexpression under normoxic condition group, 15- LOX gene of CASMC was overexpressed and then the CASMCs were cultured under normoxic condition for 48 h; and group D:15-LOX gene knockout under hypoxic condition group, 15- LOX gene of CASMC was knocked out and then the CASMCs were cultured under hypoxic condition for 48 h. The production of 15-HETE in each group was detected by using enzyme-linked immunosorbent assay (ELISA), the expression of Kv2.1 channel messenger ribonucleic acid (mRNA) and protein were detected by using reverse transcription-polymerase chain reaction (RT- PCR) and Western blot analysis respectively. Results After interference of 15-LOX gene on the CASMC, the production of 15-HETE and the expression of Kv2.1 were significantly different from the normal cells group. The production of 15-HETE was higher and the expression of Kv2.1 channel mRNA and protein were lower in both hypoxia group and 15-LOX gene overexpression under normoxic condition group than control group; the production of 15-HETE was lower and the expression of Kv2.1 channel mRNA and protein were higher in 15-LOX gene knockout under hypoxic condition group than hypoxia group. Conclusion The expression of 15-LOX increased in hypoxia, which increased the production of 15-HETE, and then leading to cerebral vasoconstriction via enhancing Kv2.1 channel inhibition. So the inhibition of 15-LOX/15-HETE on the Kv channels expression plays an important role that leads to cerebral vasoconstriction by hypoxia.

Clinical Characteristics and Causes of Suspected Acute Ischemic Stroke with Negative Diffusion Weighted Imaging

DU Wan-Liang, ZHANG Xin-Miao, LI Shu-Ya, et al.

2015, 10(08): 660-665.

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Objective Diffusion weighted imaging (DWI)-negative acute ischemic stroke is not uncommon, but likely to cause difficulty to diagnose. The purpose of this study was to describe the clinical and imaging features of DWI-negative patients with acute ischemic stroke and discuss the potential causes. Methods We retrospectively selected DWI-negative patients with suspected acute ischemic stroke presented to the Code Stroke System of Beijing Tiantan Hospital, from January 2012 to July 2014. Data of demographic characteristics, clinical presentations and imaging were collected, and causeswere classified. Results 134 patients (90 men and 44 women) were included. Median age was 57 years (interquartile range 50~70). Median interval from the onset to DWI were 266.5 minutes (interquartile range 205.3~362.5). Median National Institutes of Health Stroke Scale (NIHSS) score 2 (interquartile range 1~3). 33 patients were hospitalized for further treatment. There are 27 cases (81.8%) diagnosed as ischemic stroke, 6 cases (18.2%) diagnosed as other diseases. Among the 27 patients with ischemic stroke, infarction leisions were found in 9 cases (33.3%) after the films were re- read, in 5 cases (18.5%) when DWI repeated after symptoms getting worse, in 1 case (3.7%) when DWI repeated without aggravating. Large vessel occlusion/stenosis on magnetic resonance angiography (MRA) or hypoperfusion on perfusion weighted imaging (PWI) responsible for symptoms were found in 1 case (3.7%) with aggravating, in 6 cases (22.2%) without aggravating. No infarction leision or large vascular abnormalities on MRA was found in 5 cases (18.5%). In 27 patients with ischemic stroke, based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification criteria, 15 cases (55.6%) were attributed to large artery atherosclerosis, 11 cases (40.7%) were attributed to small artery occlusion, 1 case (3.7%) was attributed to unknown etiology. In 33 hospitalized patients, besides 1 case with disability, all the other 32 cases (97.0%) were discharged with good outcome. 101 patients were discharged after emergency treatment. Among them, infarction leisions were found in 5 cases (5.0%) after the films were re-read. Large vessel occlusion/stenosis on MRA or hypoperfusion on PWI responsible for symptoms were found in 14 cases (13.9%) and the diagnosis was modified as ischemic stroke. Another 2 patients (2.0%) were diagnosed as diseases other than cerebral infarction. No abnormality on imaging was found in the other 80 cases (79.2%). Conclusion DWI-negative acute ischemic strokes are mostly minor stroke. Large artery atherosclerotic occlusion/stenosis and small artery occlusion are the main cause. In the the Code Stroke System, DWI-negative patients with suspected acute ischemic stroke primarily interpreted by stroke doctors have a possibility of lesions omitted and imaging delayed, also the risk of aggravation.

Thrombolytic Therapy for Alcohol-triggered Cerebral Infarction

DU Wan-Liang, LI Zi-Xiao, ZHENG Hua-Guang, et al.

2015, 10(08): 666-670.

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Objective Alcohol drinking is a trigger factor of cerebral infarction. We summarize and discuss the characteristics, thrombolysis decisions and outcomes of alcohol-triggered cerebral infarction. Methods We retrospectively selected patients with alcohol-triggered cerebral infarction presented to the Code Stroke System of Beijing Tiantan Hospital from September 2012 to June 2013. Data of clinical presentations, imaging, thrombolysis and outcomes were collected. Results Eleven cases of patients with alcohol-triggered cerebral infarction within 0.5~8 hours after onset were presented to the Code Stroke System of Beijing Tiantan Hospital from September 2012 to June 2013. All the patients were male, with a median age of 59 years (interquartile range 53.5~60). Median interval from the onset to arrival at hospital were 120 minutes (interquartile range 45~250).The main symptoms at presentation:9 cases with partial body weakness, 1 case with involuntary movements, 1 case with single-limb numbness. Minor stroke accounted for 73% (8%). The clinical course and prognosis:2 cases received intravenous thrombolysis and significantly improved, 1 case received arterial thrombolysis and significantly improved, 2 cases refused thrombolysis but got spontaneous remission, 3 cases with mild symptoms got spontaneous remission without thrombolysis, 2 cases exceeding 3-hour window didn't receive thrombolysis due to normal perfusion-weighted imaging (PWI), 1 case exceeding 3-hour window didn't receive thrombolysis due tonormal diffusion-weighted imaging (DWI) and PWI. In all, there were 5 cases with definite infarction focus on the imaging. In the 3 patients thrombolysed with recombinanttissue-type plasminogen activator (rt-PA), based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification criteria, 2 cases (66.7%) were attributed to large artery atherosclerosis, 1 cases (33.3%) were attributed to small artery occlusion. All the 8 patients who were excluded from or refused thrombolysis, were attributed to small artery occlusion. Conclusion The prognosis of most of the alcohol-triggered cerebral infarction is good. Alcohol- triggered cerebral infarction may benefit from thrombolysis. Cause of most patients was small artery occlusion. A small part attributes to large artery atherosclerotic occlusion.

Analysis of 70 Patients with Brain Artery Dissection

CHEN Qi-Dong, ZHANG Rong, ZHANGJing, et al.

2015, 10(08): 671-675.

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Objective To analyze the clinical characteristics of brain artery dissection and promote the early diagnosis and treatment. Methods The clinical, neuroimaging characteristic and treatment was retrospectively analyzed. Results Totally 70 patients were analyzed. The mean age was (50.0±12.8) years old. There were 52 (74%) males and 18 (26%) females. There were 21 (30%) patients had extracranial carotid dissection, 30 (43%) had vertebral artery dissection, 15 (21%) had basilar artery dissection. There was 1 (1%) patient had dissection at horizontal segment, lateral fissure segment, post brain artery and subclavian artery respectively. Total 19 (27%) patients had headache, 3 (4%) had dizzness, 11 (16%) had neck pain. There were 16 (23%) patients had ischemic stroke, 5 (7%) patients had subarachnoid hemorrhage (SAH), 4 (6%) patients had transient ischemic attack (TIA) (3 patients had ischemic stroke diagnosed latterly). One of the patients had headache and neck pain at the same time. 3 patients had ischemic stroke and headache, 1 (1%) patient had TIA, neck pain, ischemic stroke at the same time. Imaging showed dilatation like aneurysm, intial flap, crescent high signal in the artery wall. About 9 (13%) patients had antithrombus therapy, 2 (3%) had anticoagulant therapy, 17 (24%) had coil therapy with stent assistant, 11 (16%) had stent therapy, 1 (1%) had anticoagulantand stent therapy. Total 23 (33%) patients had no therapy and 2 (3%) were dead. Conclusion Patients with brain artery dissection may have no symptom, or headache and neck pain, or TIA, ischemic stroke or SAH. Early diagnosis and suitable treatment are very important.

Study on Etiology Classification and Related Risk Factors for Youth Ischemic Stroke

YINTie-Lun, DU Zhi-Hua

2015, 10(08): 676-681.

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Objective To investigate the etiology classification features and related risk factors of ischemic stroke in young adults. Methods We retrospectively analyzed the clinical data of 120 successive patients with first-ever ischemic stroke in young adults from January 2010 to June 2014 in the Department of Neurology, Beijing Haidian Hospital as young patient group. And 136 middle-aged and old patients with ischemic stroke were selected randomly as control group. The clinical data of all the subjects were collected. The study was to identify the etiology classification and related risk factors in whole cohort, and further to compare the difference between the two groups in above characteristics based on China Ischemic Stroke Subclassification (CISS). Results There were 82 (68.3%) male and 38 (31.7%) female in young ischemic stroke group. There were 76 (55.9%) male and 60 (44.1%) female in the control group. Male stroke incidence in the young group was significantly higher than in the elderly group ( χ 2 =4.183, P =0.041). The CISS classification in young patient group was as follows: large artery atherosclerotic (LAA)25.8%, stroke of other undetermined etiology (SUE) 22.5%, perforating branch artery occlusion (PAO) 20.8%, cardioembolism (CE) 19.2%, stroke of other etiology (SOE) 11.7%. Middle-aged and old patient group showed LAA 40.5%, PAO 33.8%, CE 21.3%, SOE 2.9%, SUE 1.5%. LAA, PAO, SOE, SUE between the two groups were significantly different except CE ( P <0.05). The youth group SOE, SUE etiology classification was obviously higher than in the control group, and the difference was significant ( P <0.05). Young ischemic stroke risk factors of the top 5 are smoking 48.3%, hypertension 44.2%, hyperlipidemia 40.8%, alcohol drinking 36.7%, family history of stroke 23.3%. In contrast, the middle-aged stroke group is hypertension 57.4%, diabetes 47.1%, hyperlipidemia 43.4%, carotid atherosclerosis 37.5%, smoking 35.3%. Comparison of risk factors between the two groups, young group, smoking, drinking and family history of stroke was significantly higher than that in the middle-aged and old group.There was significant difference between two groups ( P <0.05). Conclusion Young ischemic stroke etiology classification characteristics and related risk factors differ from the middle-aged and old patients. Early etiological classification and detection of risk factors are beneficial to the prevention and treatment for ischemic stroke in young adults.

Comparative Study of Escitalopram and Sertraline in the Treatment of Senile Depression after Stroke

YAO Xian-Wei, YU Zhi-Jun, LI Yan-Lan

2015, 10(08): 682-687.

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Objective To evaluate the efficacy and safety of escitalopram and sertraline in the treatment of senile post-stroke depression. Methods Eighty patients with senile post-stroke depression were divided into treatment group and control group with 40 cases in each. The treatment group was given escitalopram combined with routine cerebrovascular disease drug treatment, the control group received sertraline combined with routine cerebrovascular disease drug treatment. In the treatment of 1, 2, 4, 6 weeks, Hamilton Depression Scale (HAMD), National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI) were used and their scores were compared. Results In the treatment group and the control group, HAMD, NIHSS scores were significantly improved, but no significant difference between groups, BI index difference had statistical significance in the treatment of the fourth and sixth week ( P =0.016, P =0.025). Conclusion Escitalopram have significant effects on treatment of senile post-stroke depression, and the ability of daily life is better than the sertraline group.

Advance in Cerebral Autoregulation of Hemorrhagic Stroke

MA Hong-Yin, XING Ying-Qi,YANG Yi

2015, 10(08): 689-694.

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Cerebral autoregulation (CA) refers to the inherent ability to maintain the cerebral blood flow stable despite fluctuation in arterial blood pressure or cerebral perfusion pressure. An intact CA helps to avoid brain tissue from neither hyper- nor hypoperfusion. CA is impaired in hemorrhagic stroke in various extents and relates with clinical factors and outcome. CA assessment could not only evaluate clinical prognosis but also render more information in the management of blood pressure and cerebral perfusion pressure. In this review, we aim to target on CA status and its clinical application in hemorrhagic stroke, mainly involving intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).

Study Progress on Etiology of Cryptogenic Stroke

HAN Yi-Hua, XING Ying-Qi, CHEN Jia-Feng.

2015, 10(08): 695-700.

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Cryptogenic stroke refers to the ischemic stroke with not yet clear etiology. With the development of medical technology, more and more rare causes of cryptogenic stroke have been found, such as paradoxical embolism, aortic atherosclerosis, cerebral artery dissection, hyperhomocysteinemia, obstructive sleep apnea-hypopnea syndrome, migraine, and single gene genetic disease etc. Based on relevant literature in recent years, this article reviews the progress of study on etiology of cryptogenic stroke, in order to increase awareness in clinical work and reduce the incidence of stroke.

One Case of Bilateral Medullary Infarction: a Unique "Y " Appearance Sign by Magnetic Resonance Imaging

ZHANG Fu-Liang, LIU Yang, XING Ying-Qi, et al.

2015, 10(08): 701-704.

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One Case of Successfully Detecting Immediate Thrombus during the Intraoperation of Carotid Endarterectomy by Transcranial Doppler

WANG Shuang, YANG Yi, LUO Qi, et al.

2015, 10(08): 705-709.

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