Table of Content

20 October 2023, Volume 18 Issue 10

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Brain Health: Precise Evaluation and Scientific Managment

ZHENG Huaguang, WANG Yongjun

2023, 18(10):  1095-1100.  DOI: 10.3969/j.issn.1673-5765.2023.10.001

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Brain Health is defined as a normal status of the brain in the structure and in the function, as well as in the social adaption, without overt diseases in the brain. Stroke and dementia consist the two major contributors of the neurological disorders burden. A synergism in the prevention for stroke and dementia will beneficial. The risk factors of stroke and dementia are similar. The neurovascular unit is fundamental for brain health. The decrease in the cerebral blood flow or in the cerebral perfusion, vascular endothelial cell functional lesions will lead to the amyloid β-protein accumulation and secondary neurological degeneration. The incidence of dementia had been decreased when the risk factors for vascular diseases were controlled in the randomized controlled trials. Hence, the World Stroke Orgnization proposed “ the Preventing dementia by preventing stroke ”. In addition to the population-wide strategies and strategies for individuals with high risk in stroke prevention, the strategies with precise medicine focused on the uncommon cause for stroke, the special subgroups and key pathophysiological mechanisms will improve the practice. Brain health service emphasised on prevent dementia and promote brain health through cognitive risk prediction, risk communicaion, risk reduction and cognitive enhancement. The brain health initiative, will get more support around the world. The innovations in research and technology will promote the managment of the brain health.

Brain Health

ZHENG Huaguang

2023, 18(10):  1101-1101. 

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Research Progress of Subjective Cognitive Decline

LI Shiping, WANG Yue, ZHENG Huaguang

2023, 18(10):  1102-1114.  DOI: 10.3969/j.issn.1673-5765.2023.10.002

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Subjective cognitive decline (SCD) is a recent research hotspot, which refers to patients with self-perceived cognitive decline but no abnormality in objective assessment. Recently, there have been increasing studies on the incidence, risk factors, and intervention treatment of SCD. This paper summarizes the relevant studies at home and abroad to review the characteristics of SCD, including the definition, epidemiological characteristics, etiology, clinical evaluation, differential diagnosis, and intervention. The objective is to explore the clinical significance of SCD and to provide information for subsequent clinical research.

Advances in Study of Asymptomatic Carotid Artery Stenosis and Asymptomatic Intracranial Artery Stenosis

LI Wenbo, LIU Jie, LIU Yang, ZHANG Longyou, LI Shiping, ZHENG Huaguang

2023, 18(10):  1115-1120.  DOI: 10.3969/j.issn.1673-5765.2023.10.003

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To discuss the optimizing strategy in screening for the asymptomatic carotid artery stenosis (aCAS) or asymptomatic intracranial artery stenosis (aICAS) and the precise strategy in prevention for stroke based on the biomarkers and the imaging manifestations. The prevalence of aCAS was about 1.5% and the risk scores of aCAS were helpfull in the screening. The prevalence of aICAS was 6.9%～12.8%, according to the different study population and the screening tools. In patients with aCAS or aICAS, the severity of the vascular stenosis and the stability of the tube wall will affect the risk for stroke. Intraplaque hemorrhage was proved to increase the risk of incidence in stroke or coronary heart disease in the recent study. The cerebral blood flow and the cerebral perfusion decreased in the patients with aCAS or aICAS, which increased the risk of dementia or cognitive impairment with one to three times. Whether the patients with aCAS will benefit from carotid endarterectomy (CEA) or carotid artery stenting (CAS) need reevaluation as the drug therapy has made great progress. It play an important role to select a suitable patient and to reduce the complication of operation when making decisions. For the patients with aICAS, especially those with severe stenosis or multiple stenosis, progressive intracranial atherosclerosis disease, silent brain infarction within the brain territory distal to the aICAS, antiplatelet therapy and statins could be beneficial, with the consideration of cerebral hemorraghe or other adverse effects.

The Relationship between the Distribution Characteristics of Cerebral Infarction and Involved Vascular Segments in Patients with Spontaneous Vertebral Artery and Basilar Artery Dissection

WU Di, LIAO Xiaoling, PAN Yuesong, CHEN Xuzhu, WANG Yilong, ZHAO Xingquan

2023, 18(10):  1121-1128.  DOI: 10.3969/j.issn.1673-5765.2023.10.004

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Objective  To investigate the relationship between the distribution characteristics of cerebral infarction and vascular segments in patients with spontaneous vertebral artery dissection (sVAD), spontaneous vertebral-basilar artery dissection (sV-BAD) and spontaneous basilar artery dissection dissection (sBAD). 
Methods  This was a single-center retrospective study. Hospitalized patients diagnosed with cerebral infarction caused by sVAD, sV-BAD and sBAD from January 1, 2015 to November 15, 2021 were continuously enrolled. General clinical data, past medical history, characteristics of cerebral infarction lesions, and involved vascular segments of patients were collected. The patients were divided into single cerebral infarction group and multiple cerebral infarction group according to the number of cerebral infarction lesions. The differences of  the above indexes were compared between the two groups.
Results  A total of 41 patients were enrolled in this study, including 17(41.5%) in single cerebral infarction group and 24(58.5%) in multiple cerebral infarction group. Comparison of the main affected vascular segments between single cerebral infarction group and multiple cerebral infarction group: V3 segment[right side 7(41.2%) vs. 8(33.3%), P=0.61; left side 7(41.2%) vs. 7(29.2%), P=0.42]; V4 segment[right side 9(52.9%) vs. 6(25.0%), P=0.07; left side: 6(35.3%) vs. 8(34.8%), P=0.97]. The difference was not statistically significant. Comparison of the location of cerebral infarction between single cerebral infarction group and multiple cerebral infarction group: thalamus [0(0) vs. 9(39.1%), P=0.005], occipital lobe [0(0) vs. 8(33.3%), P=0.01], cerebellum [2(11.8%) vs. 20(83.3%), P<0.001], pons [1(5.9%) vs. 11(45.8%), P=0.006], medulla oblongata [14(82.4%) vs. 3(12.5%), P<0.001]. The medulla oblongata is most commonly seen in single cerebral infarction group, while other parts are more common in multiple cerebral infarction group. There was significant difference between the two groups. The number of involved vascular segments was compared between single cerebral infarction group and multiple cerebral infarction group: single segment 7(41.2%) vs. 9(37.5%), two segments 7(41.2%) vs. 9(37.5%), and multiple segments 3(17.6%) vs. 6(25.0%), with P=0.68, and there was no statistically significant difference.
Conclusions  In the cases of sVAD, sV-BAD and sBAD related cerebral infarction included in this study, single cerebral infarction was more common in medulla oblongata. The main involved vascular segments were V3 and V4. The relationship between the number of cerebral infarction lesions and the number of involved artery segments was still not clear.




Endovascular Treatment for Acute Posterior Circulation Stroke with Large Vessel Occlusion: A Single-center Case Series Report

YIN Mengxin, ZHANG Shuting, REN Weichao, WANG Tiejun, DUAN Chunmiao

2023, 18(10):  1129-1135.  DOI: 10.3969/j.issn.1673-5765.2023.10.005

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Objective  To evaluate the safety and effectiveness of endovascular treatment (EVT) for acute posterior circulation stroke with large vessel occlusion.
Methods  Patients within 72 hours with acute posterior circulation stroke due to large vessel occlusion who underwent emergency EVT in Beijing Daxing District People's Hospital from September 2020 to March 2023 were included. Demographic information, past history, baseline blood pressure, TOAST classification, admission and preoperative NIHSS score, onset to treatment time and in-hospital treatment information were collected. The effectiveness outcome included postoperative mTICI grading (defined as vascular recanalization at 2b/3), NIHSS score at 24 h after surgery and at discharge, mRS score at discharge (0 to 3 scores defined as good prognosis). The safety outcome included the incidence of symptomatic intracranial hemorrhage (sICH) within 36 h and mortality during hospitalization.
Results  A total of 26 patients with acute posterior circulation stroke with large vessel occlusion were included (7 patients in the intravenous thrombolysis bridging EVT group and 19 in direct EVT group). 16 patients (62%) were male, and 10 patients (38%) were female. The mean age was (64.2±11.1) years old. Successful recanalization was observed in 25 patients (96%). The 
24 h-NIHSS score at postoperation was 8.0(3.0-14.0) [the intravenous thrombolysis bridging EVT group 3.0(2.0-12.5) versus direct EVT group 8.0(4.3-16.3)]. 16 patients (62%) had good prognoses at discharge. 3 patients (12%) died, and no sICH occurred.
Conclusions  EVT could effectively achieve successful reperfusion in acute posterior circulation stroke with large vessel occlusion, which showed good security.




Exploration into Endovascular Therapy of Symptomatic Carotid Free-floating Thrombus

ZHANG Lei, WANG Xiaoya, JIAN Yating, GAO Zhen, FAN Hong, FAN Songhua, WANG Huqing, SUN Hong, ZHANG Ru, ZHAN Shuqin, ZHANG Guilian

2023, 18(10):  1136-1142.  DOI: 10.3969/j.issn.1673-5765.2023.10.006

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Objective  This study aimed to explore safety and efficiency of endovascular therapy for symptomatic carotid free-floating thrombus (CFFT).
Methods  Patients admitted to the Department of Neurology, the Second Affiliated Hospital of Xi´an Jiaotong University from August 2008 to November 2022 and diagnosed with symptomatic CFFT and treated with carotid artery stenting were retrospectively enrolled. For each patient clinical presentation, risk factors, location of the thrombus, type of carotid stent and adjunctive devices, surgical approach, clinical efficacy were recorded and analyzed.
Results  A total of 6 patients with acute cerebral infarction caused by CFFT were included, with 4 females (66.7%) , the median age at onset was 63.5 (48.0-68.7) years. The median NIHSS was 3.0 (0-3.5) and mRS was 2.0 (1.0-3.0) at pre-operation. The CFFT was located in the distal segment of right common carotid artery in 1 case, the C1 segment of left internal carotid artery in 1 case and right internal carotid artery in 4 cases. 2 cases with CFFT had severe carotid stenosis. All patients were treated with carotid stenting under protection of distal filter device. Balloon predilation was used in 2 cases with severe carotid stenosis before carotid stenting. The Wallstent closed-cell stent was used in 5 patients with the Precise open-cell stent being used in 1 patient. None of the patients had clot migration or distal intracranial large vessel occlusion. In one case (16.7%) in-stent thrombosis occurred and this induced brain edema and symptom aggravation. The median NIHSS was 1.0 (0-3.0) at 7 days after operation, and mRS was 1.0 (0-2.0) at 90 days follow-up.
Conclusions  Carotid artery stenting may be a feasible approach for symptomatic CFFT with good safety and efficiency profile.




Objective  To assess the efficacy and safety of drug treatment of vascular parkinsonism (VP) using network meta-analysis.

CUI Yating, QU Yan, HUO Yuan, LI Xiaohong

2023, 18(10):  1143-1153.  DOI: 10.3969/j.issn.1673-5765.2023.10.007

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Objective  To assess the efficacy and safety of drug treatment of vascular parkinsonism (VP) using network meta-analysis.
Methods  A computerized search of randomized controlled trials of VP drug treatment in CNKI, Wanfang, VIP, PubMed, Web of Science, MEDLINE, Embase, and Cochrane Library was conducted from the inception each database to January 1, 2023. Two researchers independently performed literature screening, data extraction, and quality evaluation of the included studies. R was applied to perform a network meta-analysis of the data.
Results  Twenty studies were included, including butylphthalide in combination with levodopa, edaravone in combination with levodopa, pramipexole dihydrochloride in combination with levodopa and levodopa alone. The overall literature quality level is medium. The results of the network meta-analysis showed that: (1) in terms of total treatment effectiveness, the surface under the cumulative ranking curve (SUCRA) showed that butylphthalide in combination with 
levodopa > edaravone in combination with levodopa > pramipexole dihydrochloride in combination with levodopa > levodopa alone. (2) In terms of unified Parkinson's disease rating scale (UPDRS) scores, the SUCRA showed that butylphthalide in combination with 
levodopa > edaravone in combination with levodopa > pramipexole dihydrochloride in combination with 
levodopa > levodopa alone. (3) In terms of adverse reactions, the SUCRA showed that butylphthalide in combination with levodopa > levodopa alone > pramipexole dihydrochloride in combination with  levodopa > edaravone in combination with levodopa.
Conclusions  Butylphthalide in combination with levodopa had the highest efficiency, the most significant improvement in UPDRS scores, and the best safety profile for the treatment of VP, and no significant increased risk of adverse effects was observed. However, the methodological quality of the included studies was generally low, so the conclusions remain to be further validated by studies with larger samples and high quality.




Retrospective Study of Ginaton in the Treatment of Vascular Cognitive Impairment

SUN Xiaowei, JING Yunnan

2023, 18(10):  1154-1159.  DOI: 10.3969/j.issn.1673-5765.2023.10.008

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Objective  To evaluate the effect of Ginaton on vascular cognitive impairment.
Methods  A retrospective analysis was conducted on clinical and follow-up data of patients with vascular cognitive impairment from the First Affiliated Hospital, Heilongjiang University of Chinese Medicine from January 2018 to May 2020. Patients were grouped according to whether or not they received continuous Ginaton during the follow-up period, and then matched using a propensity score. After 2 years of follow-up, the MoCA and functional activities questionnaire (FAQ) scores were observed to evaluate the efficacy of Ginaton.
Results  A total of 233 patients were included, 59 in the Ginaton group and 174 in the control group. Noreplacement propensity score matching was performed, 56 cases were matched in the Ginaton group and control group respectively, and there was no significant difference between the two groups at baseline. At the end of follow-up, the MoCA scores of both groups decreased (P<0.001), and the MoCA score of the Ginaton group was better than control group, with statistical difference (P=0.029) . At the same time, the FAQ score of the Ginaton group had no significant change (P=0.059), while the FAQ score of the control group had a significant increase (P<0.001) . There was no significant difference in FAQ scores between the two groups during 2-year follow-up (P=0.136) .
Conclusions  Ginaton can alleviate the cognitive decline of patients with vascular cognitive impairment and maintain the ability of daily living.


Neuroimaging Standards for Research into Cerebral Small Vessel Disease (STRIVE-2) —Advances Since 2013

YE Jinyi, WANG Zan, GONG Yutian, GUO Lei, GUO Tong, HU Kun, LU Yao, SHAN Shuyi, WANG Ling, YUE Fangfang, ZHU Jinghan, ZHENG Xinya, CHEN Weiqi, WANG Yilong

2023, 18(10):  1160-1174.  DOI: 10.3969/j.issn.1673-5765.2023.10.009

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Cerebral small vessel disease (SVD) is a common disease in the aging process that would result in stroke, cognitive impairment, neuropsychological disorders or symptoms, and other functional impairments. Standards for reporting vascular changes on neuroimaging-1 (STRIVE-1) categorised and standardised the diverse features of SVD that are visible on structural MRI, including white matter hyperintensity, perivascular space, cerebral microbleed, recent small subcortical infarcts, lacune (of presumed vascular origin) and brain atrophy. With the understanding of the influence of SVD image features becoming clearer, combined with the rapidly emerging machine learning methods, a new neuroimaging standard for the study of small cerebral vascular disease has been updated which is STRIVE-2. In order to capture the effect of SVD on the brain more comprehensively, STRIVE-2 newly added imaging features such as cortical cerebral microinfarct and incidental DWI+ lesion. In addition, the STRIVE-2 presents the dilemmas of current researches and the hopes for future research development.



Interpretation of the Updates on Standards for Reporting Vascular Changes on Neuroimaging 2

YE Jinyi, CHEN Weiqi, WANG Yilong

2023, 18(10):  1175-1180.  DOI: 10.3969/j.issn.1673-5765.2023.10.010

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Cerebral small vessel disease (CSVD) is a common disease in the aging process that would result in stroke, cognitive disorder, neuropsychological disorders or symptoms, and other functional impairments. CSVD often co-exists with neurodegenerative diseases, further exacerbating cognitive impairment or other symptoms that affect the patient's ability to live independently. Standards for reporting vascular changes on neuroimaging 1 (STRIVE-1) classifies and standardizes the different features of CSVD seen on structural MRI. The STRIVE-2, published in 2023, further updates the neuroimaging guidelines for vascular changes in CSVD. This paper will explain the update points of STRIVE-2.


Intracranial Venous Sinus Thrombosis Caused by Iron Deficiency Anemia: A Case Report

LU Ming, YANG Shuna, HE Youdi, HU Wenli

2023, 18(10):  1181-1185.  DOI: 10.3969/j.issn.1673-5765.2023.10.011

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Iron deficiency anemia is a rare cause of intracranial venous sinus thrombosis. This study described the diagnosis and treatment of a young female with persistent headache for 3 weeks accompanied by transient loss of consciousness. The patient had long term heavy menstrual flow, no other vascular risk factors. Head CT and MRV confirmed thrombosis of the left transverse sinus and sigmoid sinus. Blood routines revealed iron deficiency anemia. Her intracranial venous sinus thrombosis caused by iron deficiency anemia. The patient was given ferrous succinate for anemia and anticoagulant treatment for venous sinus thrombosis. She was improved rapidly discharged later.



Ulnar Artery Approach for Digital Subtraction Angiography and Carotid Artery Stenting: A Case Report and Literature Review

WU Jian, LI Qiuping, QI Biao

2023, 18(10):  1186-1190.  DOI: 10.3969/j.issn.1673-5765.2023.10.012

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In recent years, the transforearm vascular approach such as radial artery approach has been widely used, but some patients cannot continue the radial artery approach due to congenital slender radial artery, radial artery stenosis or even occlusion after previous repeated radial artery punctures. In this case, the patient required interventional therapy for severe stenosis at the origin of the left internal carotid artery. The patient has a bovine aortic arch, which is suitable for the radial artery approach surgery. However, the patient had undergone several previous operations via the radial artery approach, resulting in a slender radial artery, and further radial artery approach for interventional therapy cannot be completed. The color Doppler ultrasonography found that the diameter of ulnar artery was thick enough for puncture and sheath placement. Therefore, this study tried to perform digital subtraction angiography and carotid artery stenting through ulnar artery approach. The operation was successfully completed without complications, providing a reference for the interventional surgery via ulnar artery approach.



Advances in the Study of Early Neurological Deterioration in Patients with Branch Atheromatous Disease

WANG Lu, WANG Jian

2023, 18(10):  1191-1195.  DOI: 10.3969/j.issn.1673-5765.2023.10.013

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Patients with branch atheromatous disease (BAD) are prone to arteriosclerosis early neurological deterioration (END), which leads to poor functional prognosis and poses a great challenge to clinicians. At present, the pathogenesis of END in patients with BAD has not been elucidated, and there is a lack of strong evidence-based medical evidence in terms of treatment, with some observational studies suggesting that strategies of enhanced antithrombotic therapy may be justified. This paper reviews the research on the mechanism, risk prediction and intervention strategy of END in BAD patients in order to improve the awareness and attention of clinicians.

Stroke Rehabilitation Quality Indicators Contribute to the Improvement of the Stroke Rehabilitation

GUO Shuanghui, ZHANG Yumei

2023, 18(10):  1196-1201.  DOI: 10.3969/j.issn.1673-5765.2023.10.014

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Stroke rehabilitation quality indicator is an important part to improve the medical quality of stroke rehabilitation in China. Donabedian triad model is the basic theory for the establishment of stroke rehabilitation quality indicators. This paper summarized the role of structure, process and outcome of Donabedian triad model in the improvement of stroke rehabilitation medical quality. The existing stroke rehabilitation quality indicators at home and abroad were also reviewed in order to provide a new perspective for the development and improvement of the stroke rehabilitation quality indicators in China.

Trend of Intravenous Thrombolysis and a Comparative Analysis of In-hospital Outcomes of Intravenous Thrombolysis with Alteplase or Urokinase in Acute Ischemic Stroke in China from 2016 to 2022

ZONG Lixia, GU Hongqiu, YANG Xin, JIANG Yingyu, LI Zixiao, WANG Chunjuan

2023, 18(10):  1202-1208.  DOI: 10.3969/j.issn.1673-5765.2023.10.015

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Objective  To investigate the temporal trend of intravenous thrombolysis in patients with acute ischemic stroke (AIS) who arrived within 6 hours after onset from 2016 to 2022 in China, and compare the risks of in-hospital outcomes between rt-PA and urokinase thrombolysis.
Methods  A total of 555 991 AIS patients who arrived within 6 hours after onset were enrolled in the Chinese Stroke Center Alliance (CSCA) from January 2016 to December 2022. The rates of rt-PA and urokinase intravenous thrombolysis in AIS patients within 6 hours after onset were calculated respectively of each year. Multivariate logistic regression was used to analyze the risks of hemorrhagic transformation, in-hospital death and good functional outcome at discharge (mRS score 0-1) of urokinase thrombolysis group compared with rt-PA group. 
Results  113 521 and 30 950 patients were treated with rt-PA and urokinase intravenous thrombolytic therapy respectively. The thrombolysis rates of rt-PA and urokinase were 20.42% and 5.57% respectively. From 2016 to 2022, the rt-PA intravenous thrombolysis rate increased from 11.26% to 30.19%, while the urokinase thrombolysis rate fluctuated at a low level. Multivariate logistic regression analysis showed that compared with rt-PA intravenous thrombolytic therapy, patients with urokinase intravenous thrombolytic therapy had a lower risk of hemorrhagic transformation (OR 0.740, 95%CI 0.662-0.827, P<0.01) and in-hospital death (OR 0.820, 95%CI 0.764-0.881, P<0.01). There was no significant difference in the rate of good functional outcome at discharge between the two groups (OR 0.989, 95%CI 0.951-1.028, P=0.57).
Conclusions  The rate of rt-PA intravenous thrombolysis in AIS patients who arrived within 6 hours after onset increased year by year from 2016 to 2022. The risk of hemorrhagic transformation and in-hospital death after urokinase thrombolysis may be lower than that of rt-PA intravenous thrombolysis.




Analysis on Knowledge of Post-stroke Depression among Neurology Nurses

MIAO Yajie, YIN Zhike, DENG Yongmei

2023, 18(10):  1209-1214.  DOI: 10.3969/j.issn.1673-5765.2023.10.016

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Objective  To analyze the knowledge status of post-stroke depression in neurology nurses, and analyze its influencing factors so as to provide reference for clinical training on post-stroke depression and improve clinical nursing practice.
Methods  The convenience sampling method was used to select nurses from 7 provinces and cities as the research objects. The self-designed questionnaire was conducted to investigate the knowledge status of post-stroke depression in neurology nurses and impacting factors. 
Results  A total of 600 nurses were selected. There was no significant difference in the total score of post-stroke depression knowledge status among nurses with gender, stroke nursing years, education, professional title and marital status. Only 25% of the participants received training in post-stroke depression, and the knowledge level of nurses who received training was significantly higher than that of nurses who did not receive training (P<0.001). The nurses had the lowest knowledge status of post-stroke depression diagnosis, insufficient cognition of drug treatment for post-stroke depression (50.33%), and high awareness of health education (90.33%) and psychological intervention (88%).
Conclusions  The lack of knowledge of post-stroke depression in neurology nurses is closely related to the lack of training. In the future, manager should strengthen training of nurses on post-stroke depression, promote the collaboration of medical, nursing, rehabilitation, traditional Chinese medicine, psychiatry and other disciplines, to improve the quality of stroke nursing.