Chinese Journal of Stroke

Update on the Diagnosis and Endovascular Treatment of Idiopathic Intracranial Hypertension with Sinus Venous Stenosis

MO Da-Peng

2019, 14(10): 965-967. DOI: 10.3969/j.issn.1673-5765.2019.10.001

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Stenting Versus Balloon Angioplasty in Idiopathic Intracranial Hypertension Patients with Venous Sinus Stenosis

TONG Xu, WANG Su-Jie, WANG Yi-Long, MIAO Zhong-Rong, MO Da-Peng

2019, 14(10): 968-974. DOI: 10.3969/j.issn.1673-5765.2019.10.002

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Objective To compare the clinical outcome of patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS) treated by stenting and balloon angioplasty. Methods The baseline characteristics, operative procedure, perioperative management and clinical outcome of consecutive IIH and VSS patients who underwent stenting and balloon angioplasty in Beijing Tian Tan Hospital, Capital Medical University were prospectively recorded from January 2012 to December 2015. The treatment strategy was decided by consultation between interventional neurologists and patients’ authorized representatives. According to the different treatment options, the eligible patients were divided into stent group and balloon group. The clinical outcome was defined as symptoms unchanged, symptoms improve or symptoms disappear. The proportion of patients with symptoms disappearing at post-procedure 3, 6 and 12 months between both groups was compared. Results A total of 45 patients were finally enrolled in this study, with 26 cases were in the stent group and 19 cases in the balloon group. The baseline characteristics of both groups had no statistical difference. The intracranial venous sinus trans-stenosis pressure difference in stenting group was lower than that in balloon group (0 vs 7 mm Hg, P <0.001). The patients treated with stenting exhibited a higher proportion of asymptomatic conditions at 3 months (57.7% vs 0, P <0.001), 6 months (88.5% vs 5.9%, P <0.001) and 12 months (88.5% vs 23.5%, P =0.001) than those treated with balloon angioplasty. Conclusions Compared with balloon angioplasty, stenting showed a better efficacy for IIH and VSS patients. Future randomized controlled multicenter trials are required to confirm our findings.

Diagnosis Value Comparation of High-resolution MR Vessel Wall Imaging 3D CUBE T1 Weighted Sequence and SWI for Cerebral Venous Sinus Thrombosis

ZHAO Bing, HUANG Miao-Miao, ZHU Mei-Jia, ZHANG Chao, ZHAO Zhang-Ning, WANG Xin-Yi, ZHAO Jian-She

2019, 14(10): 975-980. DOI: 10.3969/j.issn.1673-5765.2019.10.003

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Objective To evaluate the diagnosis value of HR MR vessel wall imaging 3D CUBE T1 sequence and SWI for cerebral venous sinus thrombosis (CVST). Methods This was a prospective study. 34 consecutive suspected CVST patients from Department of Neurology, the First Affiliated Hospital of Shandong First Medical University from March 2016 to September 2017 were included in this study. All the patients underwent MRI plain scan, MRV, SWI and 3D CUBE T1 sequence imaging examination. The diagnostic accuracy for CVST of 3D CUBE T1 and SWI on per patient and per venous sinus segment level were evaluated by calculating their sensitivity, specificity, and the area under the ROC curve (AUC), with referential diagnostic criteria of CVST diagnosis based on the combination of MRI plain scan and MRV. Results Finally, a total of 9 CVST patients were diagnosed according to the referential criteria,including 24 venous sinus stenosis segments. For 3D CUBE T1 sequence, the sensitivity and specificity of were 100% and 95.2% per patient, and were 95.8% and 97.7% per venous sinus segment, and AUC was 0.98 per patient and 0.97 per venous sinus segment, respectively. For SWI, the sensitivity and specificity were 66.7% and 76.2% per patient, and were 70.8% and 95.4% per venous sinus segment, and AUC was 0.71 per patient and 0.83 per venous sinus segment, respectively. Conclusions Compared with SWI, HR MRI 3D CUBE T1 sequence has a higher sensitivity and specificity in diagnosing CVST, which can provide reliable information for diagnosis and treatment of CVST.

Effectiveness of Venous Sinus Stenting on Idiopathic Intracranial Hypertension with Venous Sinus Stenosis: A Single Center Study

HOU Lei, DU Zhi-Hua, CAO Xiang-Yu, SU Hui, LIU Xin-Feng, ZHANG Rong-Ju, LI Bao-Min, WANG Jun

2019, 14(10): 981-986. DOI: 10.3969/j.issn.1673-5765.2019.10.004

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Objective To evaluate the effectiveness of venous sinus stenting on idiopathic intracranial hypertension (IIH) with cerebral venous sinus stenosis (CVSS). Methods Data of consecutive IIH patients with CVSS who underwent stenting in Department of the First Medical Center of Chinese PLA General Hospital from July 2009 to January 2019 were retrospectively collected. The trans-stenosis pressure difference was measured before operation and immediately after operation. Lumbar puncture was performed to measure intracranial pressure 1 week after operation. Clinical symptoms were followed up within 1 year and DSA imaging followup was performed at 6-12 months after operation. Results Finally, a total of 97 patients were included in this study, 75 women and 22 men, with a median age of 35.5 (15-57) years. 74 (76.2%) patients had impaired vision and 54 patients (55.7%) had headache. All patients underwent venous sinus stenting, including 93 cases with unilateral stenting and 4 cases with bilateral stenting. There were no perioperative complications. The transstenosis pressure difference significantly decreased after operation compared with that before operation (18.1±7.1 vs 1.1±1.0 mm Hg, P <0.001). The cerebrospinal fluid pressure measured by lumbar puncture also decreased significantly after operation (297.0±44.8 vs 215.0±41.2 mm H2O,P =0.004). 76 patients completed the follow-up of clinical symptoms. Of 64 cases with impaired vision, vision improved significantly or recovered completely in 56 cases (87.5%). Of 43 cases with headache, headache alleviated or disappeared in 40 cases (93.0%). 62 cases underwent DSA reexamination, in-stent restenosis occurred in 3 cases (4.8%) and dural arteriovenous fistula occurred in 2 cases (3.2%). Conclusions Venous sinus stenting is an effective and safe treatment method for idiopathic intracranial hypertension with venous sinus stenosis.

Ocular Manifestations of Patients with Cerebral Venous Sinus Stenosis and Fundus Changes after Venous Sinus Stenting

WANG Shu-Ran, QU Yuan-Zhen, YANG Liu, FANG Min, TONG Xu, WANG Su-Jie, MO Da-Peng

2019, 14(10): 987-992. DOI: 10.3969/j.issn.1673-5765.2019.10.005

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Objective To understand ocular manifestations of patients with cerebral venous sinus stenosis (CVSS), analyze fundus changes after venous sinus stenting and explore possible related factors of papilledema degree. Methods Data of patients with CVSS in Neurointervention Center, Beijng Tian Tan Hospital from January 2014 to August 2018 were retrospectively analyzed. The ocular characteristics of CVSS patients and ophthalmological changes after CVSS stenting were analyzed and summarized. Results Of 125 patients, 101 (80.8%) had visual impairment, including blurred vision or decreased vision, metamorphosis, transient amaurosis, visual field defect, diplopia. 65 (52.0%) patients had ocular discomfort as the first symptom and 35 (28.0%) patients had only ocular symptom. Of 115 patients (223 eyes) with initial papilledema, the median pepilledema grade was 3 (2-4) (Frisén grades). Some patients showed hemorrhage, exudation, cotton-wool spot, retinal tissue fold surrounding the disc, dilated and tortuous retinal veins, papilla pale. There was a positive relevance between papilledema grade and intracranial pressure (Kendall’s tau-b=0.271, P =0.029), and a negative relevance between papilledema grade and duration of the disease (Kendall’s tau-b=-0.261, P =0.002). 79 patients underwent venous sinus stenting, papilledema of all patients with stenting alleviated soon after operation. At 1 month after stenting, the grade of papilledema was reduced to grade 2 (1-3). At 6 months after stenting, 94.4% eyes (135/143) with initial papilledema had no edema in the disc. Conclusions Patients with binocular papilledema should consider CVSS. The fundus examination is necessary for diagnosis and follow up of CVSS and assessing intracranial pressure. Papilledema degree had a positive relevance with intracranial pressure, and a negative relevance with duration of the disease. Patients with CVSS and papilledema who are refractory for medical treatment should consider venous sinus stenting as possible as earlier to reduce papilledema and irreversible damage of optic nerve.

Relationship of Serum Inflammatory Factor and Recent Visual Impairment in Idiopathic Intracranial Hypertension

CHEN Jie, TIAN Yu, GONG Xi-Ping, DONG Ke-Hui, MO Da-Peng, WANG Yi-Long

2019, 14(10): 993-997. DOI: 10.3969/j.issn.1673-5765.2019.10.006

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Objective To investigate the correlation between serum inflammatory factor level and recent visual impairment in patients with idiopathic intracranial hypertension (IIH). Methods Clinical data of 58 patients with IIH who were hospitalized in Department of Neurology, Beijing Tian Tan Hospital from September 2011 to September 2018 were retrospectively analyzed. According to whether patients had visual impairment or not within recent 1 month on admission, they were divided into the recent visual impairment group (n =13) and non-recent visual impairment group (n =45). Kruskal-Wallis test was used to compare the difference of serum hypersensitive C reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), white blood cell counts, neutrophile granulocyte cell counts, lymphocyte cell counts and neutrophile granulocyte / lymphocyte cell ratio and other inflammatory indicators between the two groups. Results Serum hs-CRP and ESR level in the recent visual impairment group were significantly higher than that in non-recent visual impairment group [5.50 (3.35-8.45) vs 2.60 (2.10-2.90) mg/L, P <0.001; 18.0 (13.0-24.0) vs 11.0 (5.0-14.5) mm/h, P <0.032, respectively], while the other inflammatory indicators between the two groups had no statistical difference.

Conclusions The serum hs-CRP and ESR level in IIH patients with recent visual impairment increased significantly, which suggested that inflammatory response may be involved in the pathogenesis of acute progressive visual impairment in IIH patients.

Relationship between High On-treatment Platelet Reactivity, Nut Consumption and Recurrent Atherosclerotic Cerebral Infarction

YAO Li, ZHANG Xiao-Dong, FAN Song-Hua, SUN Hong, ZHAN Shu-Qin, ZHANG Gui-Lian

2019, 14(10): 998-1003. DOI: 10.3969/j.issn.1673-5765.2019.10.007

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Objective To investigate the correlation between high on-treatment platelet reactivity, nut consumption and recurrent ischemic stroke in patients with large artery atherosclerosis cerebral infarction. Methods This was a prospective cohort study. The patients with large artery atherosclerotic cerebral infarction who consecutively admitted to Department of Neurology of the Second Affiliated Hospital of Xi'an Jiao Tong University from October 2016 to October 2018 were enrolled in this study. The collected clinical data included baseline information, response to aspirine / clopidogrel and nut consumption results. All patients were followed up for 6 months. The patients were divided into recurrence group and control group according to whether the patient experienced recurrent ischemic stroke or not. Multivariate logistic regression analysis was conducted to analyze the relationship between high on-treatment platelet reactivity, nut consumption and recurrent ischemic stroke. Results Finally, a total of 214 patients were included, with 36 cases (16.8%) in recurrence group and 178 cases (83.2%) in control group. The rate of diabetes, baseline LDL-C level in recurrence group were higher than that in control group (P <0.05). The nut consumption rate in recurrence group was lower than that in control group, but there was no statistical difference (11.1% vs 21.3%). The nut intake (P90) in recurrence group was 6.6 g/d, and the nut intake (P50) of the nut consumers was 9.0 g/d, both were lower than that in control group, but the differences were not statistically significant. The detection rates of aspirin resistance and clopidogrel resistance in recurrence group were higher than those in control group (27.8% vs 17.4%; 55.6% vs 31.5%), but only clopidogrel resistance was statistically significant (P =0.006). Logistic regression analysis showed that clopidogrel resistance (OR 2.813, 95%CI 1.282-6.171, P =0.010), diabetes (OR 3.485, 95%CI 1.571-7.729, P =0.002) and high LDL-C level (OR 1.710, 95%CI 1.078-2.710, P =0.023) were independent risk factors of recurrent ischemic stroke in patients with large artery atherosclerosis cerebral infarction. Conclusions Clopidogrel resistance was associated with recurrent ischemic stroke in patients with large artery atherosclerotic cerebral infarction. Nut consumption in patients with recurrent ischemic stroke was lower than that in patients without stroke recurrence, while which did not confirm that nut consumption was an independent influence factor for recurrent ischemic stroke.

Association between Insulin Resistance and Recurrent Stroke in Patients with Non-disabling Ischemic Cerebrovascular Events

CHEN Wei-Qi, ZHANG Guo-Jun, PAN Yue-Song, LIN Jin-Xi, LIANG Xian-Hong, LI Shang-Zhi, WANG Yi-Long, JING Jing, ZHAO Xing-Quan, LIU Li-Ping, WANG Yong-Jun

2019, 14(10): 1004-1010. DOI: 10.3969/j.issn.1673-5765.2019.10.008

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Objective To explore the effect of different insulin resistance state on the prognosis of patients with non-disabling ischemic cerebrovascular events (NICE). Methods The homeostasis model HOMA-IR index was used to evaluate insulin resistance. According to different insulin resistance status, patients were divided into four groups by quartile method. The primary endpoint was 90-day new-onset stroke (including ischemic and hemorrhagic stroke). Multivariate Cox regression model was used to assess the relationship between different insulin resistance status and recurrent stroke. The interaction between different antiplatelet therapeutic regimen and different insulin resistance status on recurrent stroke was also analyzed. Results A total of 2325 NICE patients were enrolled in this study. According to different insulin resistance status, all patients were divided into 4 groups: Q1 (HOMA-IR index <1.35), Q2 (1.35≤ HOMA-IR index <2.17), Q3 (2.17≤ HOMA-IR index <3.39) and Q4 (HOMA-IR index ≥3.39) group. The number of patients in Q1, Q2, Q3 and Q4 group were 585, 575, 585 and 580,respectively. Within 90 days of follow-up, recurrent stroke occurred in 167 patients, including 68 ones in clopidogrel combined with aspirin group and 99 ones in aspirin group. The risk of recurrent stroke in Q2 group (9.2% vs 6.3%; adjusted HR 1.56, 95%CI 1.01-2.41; P =0.04), Q3 group (5.6% vs 6.3%; adjusted HR 1.04, 95%CI 0.64-1.69; P =0.89) and Q4 group (7.6% vs 6.3%; adjusted HR 1.35, 95%CI 0.85-2.15; P =0.21) all did not increase significantly compared with that in Q1 group. Conclusions Insulin resistance is not associated with an increased risk of recurrent stroke in patients with mild stroke and TIA.

Influence of Body Position on Evaluation of Right-to-left Shunt by Contrast Enhanced Transcranial Doppler in Migraine Patients

LI Zhao-Xia, DONG Pei, BAI Ya-Qiu, ZHAO Xing-Quan

2019, 14(10): 1011-1014. DOI: 10.3969/j.issn.1673-5765.2019.10.009

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Objective To analyze the influence of supine position and sitting position in detecting right-to-left shunt (RLS) using contrast enhanced transcranial Doppler (cTCD), to optimize cTCD procedure. Methods Patients with migraine from July, 2014 to February, 2017 were selected. The baseline data and clinical features data were collected. All participants underwent cTCD examination, which was done in state of rest and Valsalva maneuver in every position. The results of cTCD, the occurring time and number of RLS microbubble in different state in two positions were compared. Results Finally, 254 patients (57.1% were female) were included in this study, with 143 (56.3%) ones with RLS. The diagnosis positive rate of RLS in state of rest (38.6% vs 31.1%) and valsalva maneuver (56.3% vs 45.3%) both increased in sitting position, compared with that in supine position. Compared with supine position, sitting position shortened the occurring time of first microbubble (7.56±2.12 vs 9.89±2.31 s, P =0.003; 5.94±1.28 vs 7.34±2.23 s, P <0.001) and increased the total number of microbubbles [2 (0-6) vs 5(4-9); 9 (4-14) vs 10 (6-33); both P <0.001] in state of rest and valsalva maneuver. Compared with the state of rest, Valsalva breathing shortened the occurring time of first microbubble (both P <0.001) and increased the total number of microbubbles (both P <0.001) in supine and sitting position. Conclusions Sitting position is superior to supine position in detecting and quantitative analysis of RLS using cTCD.

Risk Factors for Pressure Sores in Inpatients with Acute Cerebral Hemorrhage

GUO Jun-Ping, LIU Gai-Fen, JU Yi, ZHAO Xing-Quan

2019, 14(10): 1015-1018. DOI: 10.3969/j.issn.1673-5765.2019.10.010

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Objective To investigate the risk factors for pressure sores in patients with acute cerebral hemorrhage during hospital stay. Methods The data were from China National Stroke Registry (CNSR) study. Patients with acute cerebral hemorrhage within 14 days after symptoms onset were included in this analysis. The baseline data were collected. Patients were divided into two groups according to whether patients occurred pressure sore or not during hospitalization. Multivariate Logistic regression model was used to identify the related risk factors for pressure sore in patients with acute cerebral hemorrhage. Results Finally, 3255 patients were included in this analysis, of whom 31 (0.95%) had pressure sores during hospitalization. Multivariate analysis showed that mRS (3-5 points) (OR 4.41, 95%CI 1.60-12.17) and hemoglobin level on admission (10 units per reduction, OR 1.36, 95%CI 1.17-1.66) were independent risk factors for pressure sores in patients with acute cerebral hemorrhage. Conclusions The mRS (3-5 points) and hemoglobin level on admission (10 units per reduction) were risk factors for pressure sores in inpatients with acute cerebral hemorrhage.

Advance in Endovascular Therapy for Venous Sinus Stenosis in Patients with Idiopathic Intracranial Hypertension

WANG Su-Jie, TONG Xu, MO Da-Peng

2019, 14(10): 1020-1025. DOI: 10.3969/j.issn.1673-5765.2019.10.011

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Standard for Construction of Stroke Clinic in China

National Center for Healthcare Quality Management in Neurological Diseases, Management and Improvement of Chinese Medical Care Quality on Stroke

2019, 14(10): 1026-1033. DOI: 10.3969/j.issn.1673-5765.2019.10.012

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