Chinese Journal of Stroke

Motherland

WANG Yong-Jun

2018, 13(01): 1-2. DOI: 10.3969/j.issn.1673-5765.2018.01.001

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Current Study Situation of Pathogenesis and Risk Factors of Nonarteritic Anterior Ischemic Optic Neuropath

JIANG Han-Qiu, ZHANG Xiao-Jun

2018, 13(01): 3-6. DOI: 10.3969/j.issn.1673-5765.2018.01.002

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General Risk Factors Analysis of Non-arteritic Anterior Ischemic Optic Neuropathy

JIANG Han-Qiu, PENG Jing-Ting, ZHANG Xiao-Jun, WANG Jia-Wei

2018, 13(01): 7-11. DOI: 10.3969/j.issn.1673-5765.2018.01.003

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Objective To explore the general risk factors of non-arteritic anterior ischemic optic neuropathy (NA-AION). Methods The clinical data of 357 NA-AION patients admitted in Beijing Tongren hospital of Capital Medical University from January 2007 to December 2015 were collected retrospectively. The general risk factors included hypertension, diabetes and impaired glucose tolerance, hyperlipidemia, obstructive sleep apnea syndrome (OSAS), nocturnal hypotension, and so on. The clinical factors and the results of auxiliary examination of different sex were compared and analyzed. Results There were 357 NA-AION cases in our study, including 240 male patients and 117 female patients. The mean age of onset was (50.9±9.5) years old. About 252 cases (70.6%) were monocular involvement, including 162 male patients and 90 female patients. The male cases were significantly more in binocular involvement (32.5% vs 23.1%, P =0.004), hypertension (66.3% vs 53.8%, P =0.003), carotid atherosclerotic plaque (51.3% vs 38.5%, P =0.018) and other atherosclerotic plaques (10.0% vs 2.6%, P =0.021). The female incidence (10.3%) was more than male (4.6%) of heart disease (P =0.039), while coronary atherosclerotic heart disease cases were more in male than in female (45.5% vs 8.3%, P =0.046). OSAS was diagnosed in 108 cases (48.0%), and nocturnal hypoxemia was found in 127 patients (56.4%), and the incidence of the two risk factors were much more in male than female (OSAS: 57.1% vs 32.9%, P <0.001; hypoxemia: 70.0% vs 34.1%, P <0.001). Conclusion Male patients are susceptible to both eyes in NA-AION. Hypertension, diabetes and hyperlipidemia are more important general risk factors of NA-AION. OSAS, hypoxemia and hypotension at night are common risk factors. The general risk factors are more prominent in male NA-AION patients than in female.

An Etiology and Prognosis Analysis on Patients with Ophthalmoplegia Associated with Vascular Diseases

LI Ran, LI Wen-Wen, HU Xiao-Ming, WANG Jia-Wei, JING Yun

2018, 13(01): 12-16. DOI: 10.3969/j.issn.1673-5765.2018.01.004

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Objective To analyze the etiology, clinical characteristics and prognosis of ophthalmoplegia associated with vascular diseases. Methods It was a retrospective case series study. The clinical data of patients with ophthalmoplegia associated with vascular diseases who received consultation in Beijing Tongren hospital, Capital Medical University from December 2012 to July 2016 were collected, including the clinical manifestations, physical examination, past history of disease, laboratory tests and imaging examinations. The patients were followed up and the remission time of ophthalmoplegia were recorded. The etiology, clinical characteristics and prognosis of ophthalmoplegia were analyzed. Results A total of 126 patients were enrolled into this study. The results were shown as below: (1) Microvascular ischemic (MVI) disease was the most common cause of ophthalmoplegia associated with vascular diseases, accounting for 81.7 percent, followed by brainstem infarction (13.5%), and aneurysm, ophthalmoplegia migraine (OM), cavernous sinus venous fistula were rare causes. The major risk factors of MVI and brainstem infarction were hypertension, hyperlipidemia, smoking, diabetes and alcoholism. (2)The oculomotor nerve was the most common involved nerve(57.3%) by MVI disease of ocular motor nerves,followed by abducens nerve (26.2%), trochlear nerve(16.5%). The ophthalmoplegia caused by brainstem infarction involved the oculomotor nucleus most (70.6%), followed by medial longitudinal fasciculus (17.6%). (3)About 49.5% MVI patients might be associated with headache or periorbital pain. (4)The symptoms of 88.5% MVI could relieve, of which about 50% within 3 months and 75% within 6 months. Conclusion MVI disease is the most common cause of ophthalmoplegia associated with vascular diseases. Hypertension, hyperlipidemia, smoking, diabetes, alcoholism are major risk factors of MVI. Most patients of MVI disease could relieve in 6 months after treatment.

Clinical Manifestations Analysis of Venous Sinus Thrombosis with Main Manifestations of Visual Disturbance

SUN Lin, WANG Jia-Wei

2018, 13(01): 17-22. DOI: 10.3969/j.issn.1673-5765.2018.01.005

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Objective To investigate the clinical characteristics of patients with cerebral venous sinus thrombosis and visual disorders as main manifestations, so as to provide a new thought for diagnosis and treatment. Methods The clinical data of 34 patients with venous sinus thrombosis and visual impairment as the manifestation who were admitted into the department of Neurology in Tongren hospital during Jan. 2004 to July 2016 were collected. The demographic data, clinical manifestations, laboratory tests and imaging characteristics were analyzed and summarized. Results Among 34 patients, 18 (52.9%) were male and 16 (47.1%) were female, with mean age of (36.1±12.9) year-old.There were 11 cases (32.4%) with sub-acute onset and 23 cases (67.6%) with chronic onset.There were 5 cases (14.7%) caused by infection, and other 29 cases (85.3%) caused by no-infection. Visual disturbance (n =29, 85.3%) and headache (n =9, 26.5%) were the first common clinical sign. Impaired vision included binocular vision loss (n =23), monocular vision loss (n =6),paroxysmal amaurosis (n =8, 23.5%), and 1 (2.9%) diplopia. Other accompanied symptoms were 9 cases of headache, 1 case of eye pain, 1 case of neck pain, 1 case of tinnitus, 1 case of dizziness and 2 cases of symptomatic epilepsy. The main sign of 29 cases was optic disc edema, including both eyes in 27 cases and one eye in 2 cases. Severe visual field defect means diffuse visual field defect or whole visual field defect. There were 18 (52.9%) cases which had severe visual field defect, including both eyes in 11 cases (32.4%) and one eye in 7 cases (20.6%). Lumbar puncture were performed in 33 cases. There were 1 case (3.0%) of intracranial pressure less than 180 mm H2O, 14 cases (42.4%) of 180-300 mm H2O, and 18 cases (54.5%) more than 330 mm H2O. All 34 patients underwent neuroimaging. The data showed that there were 7 cases (20.6%) with 1 cerebral venous thrombosis and 26 cases (76.5%) with more than 1 cerebral venous thrombosis.There were 12 cases (35.3%) who had brain lesion or dural lesion, and 22 cases (64.7%) who had no brain lesion. Conclusion Venous sinus thrombosis with visual impairment as the main manifestation mainly occurs young adults and most cases don’t have explicit causes.Intracranial hypertension is the most common clinical manifestation.In addition, about half of cases had severe static vision field loss. Neuroimaging showed that the most common affected sites were sigmoid sinus and bilateral transverse sinus. Most cases had more than one site of thrombosis and no brain lesion.

Risk Factors Analysis of Noncardiogenic Ischemic Stroke Recurrence

ZHANG Chang-Qing, WANG Yi-Long, WANG Chun-Xue, LIU Li-Ping, ZHAO Xing-Quan, WANG Yong-Jun

2018, 13(01): 23-28. DOI: 10.3969/j.issn.1673-5765.2018.01.006

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Objective To investigate the risk factors of noncardiogenic ischemic stroke (IS) recurrence at 1 year after onset of IS. Methods A total of 1978 noncardiogenic IS patients with onset of symptoms <7 days were enrolled consecutively. Demographic information, vascular risk factors, main symptoms and signs of onset were collected. The cerebral magnetic resonance imaging (MRI) results of these patients were evaluated, including locations, numbers of infarction focus, distribution characteristics culprit cerebral artery of acute infarcts and having severe stenosis or not, and etiological subtypes of IS. Cox regression analysis was used to identify risk factors associated with IS or TIA recurrence within 1 year. Results A total of 95 patients (4.8%) experienced recurrent IS or TIA within 1 year after IS or TIA. History of coronary heart disease, history of IS, repeated TIAs within 3 months before stroke, culprit artery stenosis ≥70%, and posterior circulation IS were risk factors for recurrent IS or TIA within 1 year. Conclusion Patients with noncardiogenic IS who have posterior circulation infarction, severe culprit artery stenosis and history of ischemic cardiocerebrovascular diseases are at higher risk of stroke recurrence.

Predicting Stroke-associated Pneumonia Following Ischemic Stroke Using the PLAN Score in China

TIAN Rui, WANG Yu, ZHANG Run-Hua, FANG Ji-Ming, ZHENG Huan-Guang, WANG Peng-Lian, WANG Yi-Long, WANG Yong-Jun, LIU Gai-Fen

2018, 13(01): 29-34. DOI: 10.3969/j.issn.1673-5765.2018.01.007

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Objective To explore the value of the preadmission comorbidities, level of consciousness, age, and focal neurologic deficit (PLAN) score in predicting the risk of stroke-associated pneumonia after ischemic stroke in China. Methods Patients who were eligible for inclusion criteria from China National Stroke Registry (CNSR) were screened. Their clinical data were collected and assessed by PLAN score. The predictive ability of the PLAN score on ischemic stroke-related pneumonia was analyzed. The receiver operating characteristic curve (ROC) and the area under curve (AUC) were applied to evaluate the identification capacity of PLAN. The calibration of the score was analyzed by using Hosmer-Lemeshow goodness-of-fit test. Results A total of 8909 patients (mean age, 65.4±12.3 years; female: 3410, 38.3%) from CNSR were included into the study. The proportion of patients with post-stroke pneumonia was 12% (1069/8909). The risk of post-stroke pneumonia increased with the increasing of PLAN score. The area under the ROC curve was 0.78 [95% confidence interval (CI) 0.79-0.83], and the P value of Hosmer-Lemeshow χ 2 test was 0.001. The area under the ROC curve was 0.79 (95%CI 0.77-0.81) in male, 0.77 (95%CI 0.75-0.80) in female, 0.77 (95%CI 0.75-0.80)in patients under 70 years old, and 0.73 (95%CI 0.71-0.75) in patients older than 70 years, respectively. Conclusion The PLAN score is a reliable tool to predict the risk of post-stroke pneumonia in Chinese ischemic stroke patients.

Two Cases Analysis of Sneddon Syndrome

LIU Yan-Jun, MA Yan-Ling, LIU Xin-Xin, YE Na, CHEN Hong-Yan, ZHANG Yu-Mei

2018, 13(01): 35-40. DOI: 10.3969/j.issn.1673-5765.2018.01.008

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Objective To investigate the clinical features, diagnosis and treatment in patients with Sneddon syndrome (SS), aiming to improve the clinical doctors’ understanding of this syndrome and enhance the ability of diagnosis and treatment of SS. Methods A total of 2 cases who were admitted to neurological disease center of Beijing Tiantan hospital, Capital Medical University during Aug.1st, 2014 to Aug.1st, 2017 and diagnosed with SS were reviewed. Their clinical descriptions, laboratory examinations, neuroimaging, cognitive function evaluation, pathological characteristic and treatment were analyzed. Results Clinical manifestations: 2 cases both suffered from generalized livedo racemosa of the skin and multiple recurrent ischemic stroke events. No specific blood biochemical and cerebral spinal fluid (CSF) abnormalities were found in both patients. Intracranial multiple abnormal signals was seen in magnetic resonance imaging (MRI). Intracranial and extracranial large vascular imaging evaluations were not significantly abnormal. Both patients had cognitive dysfunction. Skin biopsy was performed in 2 patients and the pathologic results were consistent with SS feature. Both cases were given antiplatelet and improving cognitive function therapy. Conclusion The diagnosis of SS should be made considering the patient's clinical manifestations, laboratory tests, imaging findings and the skin biopsy. Characteristic manifestations of the skin and multiple recurrent ischemic stroke events are helpful to the diagnosis of the disease. When necessary, skin biopsy can be performed in order for make clear diagnosis.

Research of Influential Factors of Cognitive Function Decline in Aged Patients with White Matter Lesion

HAN Kun-Qiang, WANG Lin-Yu, GUAN Sheng, CHEN Zhen

2018, 13(01): 41-45. DOI: 10.3969/j.issn.1673-5765.2018.01.009

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Objective To explore the influential factors and predictive factors of cognitive function decline in patients with white matter lesion (WML). Methods WML patients without cognitive dysfunction from out-patients and in-patients in departments of geriatrics and neurology in the first affiliated hospital of Zhengzhou University from September 2014 to September 2016 were registered consecutively. Their general demographic data, vascular risk factors, biochemical test results and magnetic resonance imaging were collected. Montreal cognitive assessment scale (MoCA) and age - related white matter changes rating scale (ARWMCRs) evaluation were used. According to 1 year follow-up MoCA evaluation scores, the patients were divided into group with mild cognitive impairment (MCI) and group without MCI. Single factor analysis and multi-factors Logistic regression analysis were used to find out the influential factors and predictive factors of cognitive decline in aged patients with WML. Results There were 118 cases of WML including 67 males and 51 females, with mean age of 68.07±3.70 years old. At 1 year follow-up, 100 patients’ (84.75%) cognitive state remained unchanged and the rest 18 patients (15.25%) were diagnosed with MCI. Logistic regression analysis demonstrated that hypertension [odds ratio (OR)=1.47, 95%confidence interval(CI) 1.08-1.93, P =0.013] and diabetes (OR 1.38, 95%CI 1.01-1.88, P =0.042) were independent risk factors of MCI,and ARWMCRs ≥8 scores (OR 1.84, 95%CI 1.38-2.47, P =0.004) was predictive factor of MCI. Conclusion Hypertension and diabetes are independent risk factors of MCI, and ARWMCRs ≥8 scores is the predictive factor of MCI.

Study on Correlation between Carotid Plaque Magnetic Resonance Imaging Characteristics and Acute Cerebral Infarction Focus Features in Patients with Diabetes Mellitus

SUN Bei-Bei, LI Xiao, LIU Xiao-Sheng, ZHAO Xi-Hai, XU Jian-Rong, ZHAO Hui-Lin

2018, 13(01): 46-53. DOI: 10.3969/j.issn.1673-5765.2018.01.010

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Objective This study aimed to investigate the correlation between the carotid plaque magnetic resonance imaging (MRI) characteristics and acute cerebral infarction focus features in patients with type 2 diabetes mellitus (DM). Methods It was a cross section study. Patients with acute cerebrovascular syndrome in internal carotid artery territory were recruited and the cardiogenic factors were excluded. All patients underwent both carotid and brain MRI scans including magnetic resonance angiography (MRA) and diffusion-weighted imaging (DWI) within 1 week of symptom onset. Ipsilateral carotid plaque morphological and compositional characteristics intracranial and extracranial carotid arteries stenosis were also determined. Acute cerebral infarction patterns and size were evaluated on DWI. Results Of the 140 patients been recruited, 68 (48.6%) patients had DM. The multivariate analysis showed that DM was found to be an independent risk factor for the presence of lipi-rich necrotic core (LRNC) plaque [odds ratio (OR) 3.35, 95% confidence interval (CI) 1.33-8.43], and type 2 DM patients exhibited higher prevalence of carotid type IV-VI lesions, larger plaque burden as well as larger lipid-rich necrotic core plaques compared with non-DM patients. Among the patients with carotid LRNC plaque on symptomatic side, larger acute cerebral infarction size and more concomitant large perforating artery infarct patterns in the internal carotid artery territory were found in DM group than those of non-DM group [(15.45±8.97) ml vs (9.09±8.64) ml, P =0.011; 34.0% vs 13.2%, P =0.024]. Conclusion This study shows that more concomitant large perforating artery infarct patterns in the internal carotid artery territory are found in the type 2 DM patients with ipsilateral carotid plaque features, particularly the LRNC, than those of non-DM patients. Quantification of the carotid plaque characteristics by MRI combined DM has the potential usefulness for stroke risk stratification and individualized diagnosis and treatment.

Effect of Butylphthalide Injection on Volume of Acute Massive Cerebral Infarction and the Matrix Metalloproteinase-9

WANG Xi-Feng, LI Gang, FU Qun-Fang, YU Xiao-Mei, ZHANG Jing, WANG Min, XIAO Yao, SHEN Wei

2018, 13(01): 54-57. DOI: 10.3969/j.issn.1673-5765.2018.01.011

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Objective To investigate the effect of butylphthalide injection on matrix metalloproteinase-9 and the volume of acute massive cerebral infarction. Methods A total of 58 cases with acute massive cerebral infarction were randomly divided into control group (n =29) and treatment group (n =29). The control group was given conventional treatment of cerebral infarction, and the treatment group was given butylphthalide injection based on the conventional treatment. Two groups of patients underwent magnetic resonance imaging (MRI) scan on admission (first day), third day and tenth day, respectively. The cerebral infarction volume were measured. The serum matrix metalloproteinase-9 levels were detected at 12 hours, 48 hours, 72 hours after onset of disease. Results Comparing with the control group, the infarct volume of the treatment group at third day [(144.09±29.41) cm3 vs (170.21±33.09) cm3] and tenth day [(116.57±25.73) cm3 vs (140.21±29.48) cm3] were significantly reduced, which had statistical significance. Comparing with the control group, the serum matrix metalloproteinase-9 level decreased significantly in the treatment group at 48th hour and 72th hour after the onset of disease [48 h: (212.69±10.51) ng/ml vs (247.79±8.25) ng/ml); 72 h: (86.14±4.84)ng/ml vs (106.10±7.03) ng/ml], which had statistical significance. Conclusion Butylphthalide injection can decrease the expression of matrix metalloproteinases-9 and reduce the volume of acute massive cerebral infarction.

The Mechanism and Neuroprotection Study of Perarin on Cerebral Ischemia Reperfusion Injury in Mice

JIANG Chen, YANG Hao-Peng

2018, 13(01): 58-63. DOI: 10.3969/j.issn.1673-5765.2018.01.012

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Objective To observe the neuroprotection of Puerarin on cerebral ischemia reperfusion injury and investigate its effect on the expression of estrogen receptor α (ER-α) , hypoxia inducible factor-1 (HIF-1α) and related inflammatory cytokines. Methods Mice were randomly divided into a sham group, a solvent-control group and three Puerarin-treated groups with different doses (100, 250, 500 mg·kg-1). Middle cerebral artery occlusion (MCAO) model was made and then the infarct volume, water content and neurological scores were evaluated after 2 h ischemia and 24 h reperfusion. Western blot was used to determine the expression of ER-α and HIF-1α after 2 h, 6 h, 12 h, 24 h reperfusion respectively. Both Western blot and ELISA were used to determine the effect of Puerarin on the expression of ER-α, HIF-1α and related inflammatory cytokines such as tumor necrosis factor-α (TNF- α), interleukin-1β (IL-1β) and interleukin-6 (IL-6) in 2 h ischemia and 12 h reperfusion mice. Results Compared with solvent-control group, Puerarin reduced the infarct volume [low dose group (29.6±3.6)%, medium dose group (15.2±3.9)%, high dose group (8.2±2.1)% vs control group (39.3±5.0)%] and water content [low dose group (84.9±8.8)%, medium dose group (83.7±8.2)%, high dose group (80.9±8.7)% vs control group (85.3±10.2)%], which had significant difference. It also activated ER-α and suppressed HIF-1α. In addition, medium and high dose of Puerarin further inhibited TNF-α [(420.7± 27.2) μg·g-1, (379.6±23.9) μg·g-1], IL-1β [(211.8±19.2) μg·g-1, (182.4±13.5) μg·g-1] and IL-6 [(111.2±9.1) μg·g-1, (104.1±12.4) μg·g-1] respectively compared to solvent control group [TNF-α (505.8±36.7) μg·g-1; IL-1β (291.6±21.8) μg·g-1; IL-6 (138.4±11.7) μg·g-1] in 2 h ischemia and 12 h reperfusion mice. Conclusion Puerarin within certain range of doses could reduce the water content and infarct volume of cerebral ischemia reperfusion injury. Its mechanism might be linked to activation of ER-α, inhibition the expression of HIF-1α, and the inhibition of release of related inflammatory cytokines such as TNF-α, IL-1β and IL-6.

Study Progress of Etiology of Ophthalmoplegia Associated with Vascular Disease

LI Ran, JING Yun

2018, 13(01): 65-70. DOI: 10.3969/j.issn.1673-5765.2018.01.013

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Ophthalmoplegia are common symptoms of neurologic, ophthalmologic, and neuro-ophthalmologic diseases. According to the lesion site, ophthalmoplegia associated with vascular disease could be classified as supranuclear, nuclear, internuclear and peripheral-nerve types. Different types are triggered by different causes. Supranuclear, nuclear and internuclear ophthalmoplegia are frequently reported in patients with stroke, and oculomotor-nucleus involvement is the most common in nuclear ophthalmoplegia. Peripheral-nerve type arises from numerous causes, such as diabetic ophthalmoplegia, aneurysm, internal carotid cavernous sinus fistulas, etc. Diabetic ophthalmoplegia often involves oculomotor nerve, while pupil involvement is lighter, the patients with the disease generally start to recover after a few weeks. It is required to perform digital subtraction angiography (DSA) for diagnosing aneurysm and internal carotid cavernous sinus fistulas. The patients with pituitary apoplexy show serious symptoms, and need emergency treatment. Most of cavernous sinus thrombosis are caused by infection, so anti-infection therapy is the primary principle. Ophthalmoplegia migraine are often seen in young women and mostly present a benign course. Clinical doctors should ask the history of disease carefully, and give appropriate auxiliary examination, so as to make correct diagnosis and corresponding treatment, when meeting patients with ophthalmoplegia.

Neurosurgery: What is the Ipsilateral Pupillary Dilation Following Carotid Endarterectomy?

YANG Zhong-Hua

2018, 13(01): 71-71. DOI: 10.3969/j.issn.1673-5765.2018.01.014

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Neurology: A Case Report of Orbital Infarction Syndrome

YANG Zhong-Hua

2018, 13(01): 72-72. DOI: 10.3969/j.issn.1673-5765.2018.01.015

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Short Story about Stroke: Who Was the First to Find the Basilar Artery Ring (1st Section)

John H.Zhang

2018, 13(01): 73-75. DOI: 10.3969/j.issn.1673-5765.2018.01.016

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