Chinese Journal of Stroke

The Obvious Argument

WANG Yong-Jun

2014, 9(08): 625-626.

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Cerebral Collateral Circulation and Ischemic Stroke

LI Ji-Mei, ZHANG Ying

2014, 9(08): 627-631.

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Collateral Circulation of the Circle of Willis Affects the Compensation and Perfusion
of Acute Ischemic Cerebrovascular Disease

ZHANG Jia-Yue*, XU Zhong-Bao, LI Ji-Mei.

2014, 9(08): 632-637.

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Objective To investigate the compensatory and perfusion differences in acute ischemic cerebrovascular disease (ICVD) with collateral establishment of circle of Willis by computed tomography angiography (CTA) and computed tomography perfusion (CTP). Methods This retrospective study enrolled 231 patients with acute ICVD, who were treated in Beijing Friendship Hospital of Capital Medical University from December 2011 to February 2013. They were divided into cerebral infarction (CI) group and transient ischemic attack (TIA) group according to diffusion weighted imaging of magnetic resonance imaging. Based on their symptoms and imaging, the patients were divided into anterior circulation TIA (59 cases), posterior circulation TIA (66 cases), anterior CI (57 cases) and posterior CI (49 cases). Collect the data of CTA and CTP to describe the circle of Willis, and divide them into four types: (1) Type I, showing an intact circle; (2) Type II, anterior part incompletely; (3) Type III, posterior part incompletely; (4) Type IV, both anterior and posterior parts incompletely. And analyze the relation between the circle of Willis and cerebral ischemic disease in those 4 groups. Results In all 231 cases, circle of Willis Type I, II, III and IV was found in 7.8%, 4.3%, 38.5% and 49.4%, respectively. The frequency of Type I and III in TIA group were more than these in CI group. The frequency of the anterior communicating artery (ACoA) segment in TIA group were more than CI group (χ 2=10.832, P =0.001). The patients with abnormal perfusion area had most rate of Willis circle Type IV (60.33%), the rates of Type I, II, III were less than normal perfusion group (χ 2=12.356, P =0.006). Conclusion Our study suggests that the potential of the primary collateral circulation is ultimately determined by the anatomic variability of Willis circle. ACoA may play a compensatory role when ICVD occurred. Perfusion abnormality in patients with ICVD was associated with the incomplete collateral circulation of Willis circle

The Effective Cerebral Blood Flow Perfusion Pressure Noninvasive Monitoring and Its
Relationship with the Clinical Significance of Acute Cerebral Infarction

LIANG Bing*,YUAN Fang, LIANG Yun-Yun, FU Xian, XIE Long-Chang, YIN Jian-Rui, GAO Qing-Chun.

2014, 9(08): 638-644.

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Objective To explore the effectiveness of noninvasive detection method of the effective cerebral perfusion pressure (CPPe) and the relationship between the CPPe and the internal carotid artery (ICA) stenosis in patients with acute cerebral infarction. Methods For the prospective study, this study collected 41 cases patients with acute cerebral infarction within 1 week in the Second Affiliated Hospital of Guangzhou University from January 2010 to January 2012. We used digital subtraction angiography (DSA) and transcranial Doppler ultrasonography (TCD) to prospectively detect the internal carotid artery stenosis degree, noninvasive blood pressure, invasive blood pressure and cerebral artery blood flow velocity of 41 patients. After calculating CPPe according to tested results, we compared the specificity and accuracy of invasive and noninvasive CPPe in all of the patients with acute cerebral infarction. At the same time according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) standard, all of the patients with acute cerebral infarction were divided into mild stenosis group, moderate stenosis group and severe stenosis group. And we also compared vascular risk factors, CPPe and National Institutes of Health Stroke Scale (NIHSS) score among three groups, and analyzed the correlation between CPPe, NIHSS score and intracranial artery stenosis degree. Results Compare all of the patients with acute cerebral infarction of invasive and noninvasive CPPe, the results showed that the invasive CPPe had a median of 56.6 mmHg, the noninvasive CPPe had a median of 57.8 mmHg, and there was no significant difference between the two evaluation methods by TCD and DSA. The invasive CPPe of three groups of patients with acute cerebral infarction had a median of 60.6 mmHg, 42.5 mmHg and 1.6 mmHg; the noninvasive CPPe of three groups of patients with acute cerebral infarction had a median of 62.2 mmHg, 42.7 mmHg and 0.27 mmHg; while the NIHSS score of three groups of patients with acute cerebral infarction had a median of 4, 3 and 8. The differences of CPPe and NIHSS score among three groups were statistically significant, and the H value was 26.906, 26.906 and 11.233 (P <0.01). Correlation analysis showed that the CPPe with ICA stenosis degree of NASCET stenosis rate was closely related in patients with acute cerebral infarction with significant difference (P <0.01), and the correlation coefficient was -0.782 and -0.814, respectively. While the NIHSS scores had no statistical relationship compared with ICA stenosis degree of NASCET stenosis rate, and the correlation coefficient was 0.222. Conclusion The noninvasive method gained CPPe by TCD was similar to the invasive method to detect CPPe. CPPe was closely related to the degree of ICA stenosis of patients with cerebral infarction. The CPPe maybe could provide reliable evidence for noninvasive detection of the cerebral blood flow and guide the individual blood pressure regulation and control of cerebrovascular disease patients

Endovascular Treatment of Cerebral Artery Stenosis with Unruptured Intracranial Aneurysm

LI Xiao-Qing*, MA Ning, MO Da-Peng, GAO Feng, SUN Xuan, XU Xiao-Tong, LIU Lian, SONG Li-Gang, ZHAO Xing-Quan, MIAO Zhong-Rong.

2014, 9(08): 645-653.

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Objective To explore the safe and effective intervention strategies in the treatment of cerebral artery stenosis with unruptured intracranial aneurysm. Methods We performed a retrospective review of all patients with cerebral artery stenosis who underwent stenting in Beijing Tiantan Hospital between September 2012 and August 2013. Twenty six patients were found to have unruptured intracranial aneurysm. The clinical and imaging data, treatment measures and results, complications, and prognosis were analyzed. Results Twenty six patients found 54 narrow/occluded lesions and 30 aneurysms (16 in the other basin, 7 after the narrow, 3 on the narrow, 4 before the narrow). Twenty one patients (25 narrow/ occluded lesions) placed stents with the technical success rate of 100%. Choose individualized aneurysm intervention measures: 16 patients (17 aneurysms) (in the other basin, diameter less than 5 mm, artery dissection on the narrow) with follow-up observation; 2 patients (2 aneurysms) (diameter greater than 5 mm, irregular shape) were successfully treated with endovascular coiling later; 5 patients (6 aneurysms) (after the narrow, on the narrow, multiple, diameter greater than 5 mm, C7) were successfully treated with endovascular coiling or stenting at the corresponding period; 3 patients (5 aneurysms) (after the narrow, on the narrow, multiple, diameter greater than 5 mm) were advised to undergo endovascular coiling but chose follow-up observation. Perioperative complications occured in 1 case, intraventricular hemorrhage after stenting. Twenty six cases are with good prognosis. In the process of 10~21 months' follow-up, 1 case was found stent restenosis without symptoms. Conclusion Individualized treatment should be performed in cerebral artery stenosis with unruptured intracranial aneurysm according to the relationship between the location of aneurysm and narrow, size, shape, location, quantity, and the clinical situation, etc

Risk of Paradoxical Embolism Score in Cryptogenic Stroke Patients or Tansient
Ischemic Attack with Patent Foramen Ovale

ZHENG Hua-Guang*, WANG Yi-Long,Xiao-Chun, LU Jing-Jing, JU Yi, ZHANG Ning,NING Bin, HE Wen, FU Qiang, CHEN Bu-Xing, LIU Li-Ping, YANG Zhong-Hua, WANGChun-Xue, DONG Ke-Hui, ZHAO Xing-Quan, WANG Yong-Ju

2014, 9(08): 654-662.

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Objective To describe the clinical and image features of paradoxical embolism due to patent foramen ovale (PFO), and to evaluate the Risk of Paradoxical Embolism (RoPE) score. Methods We retrospectively investigated consecutive patients who were suspected to be paradoxical embolism and having PFO admitted to one stroke center in this observational study. PFO was determined by means of TCD salt injection test (contrast-enhanced transcranial Doppler, cTCD) and transesophageal echocardiography (TEE). Demographic data, clinical features, the results of cTCD, TEE and comprehensive compress ultrasound of deep venous in bilateral lower limbs were retrieved with case report form by a neurologist. The patients were divided into 3 groups according to the size of PFO or to the amount of right-to-left shunt. The MRI was evaluated by another neurologist with blinding to the results of cTCD or TEE. PFO was determined to be related to stroke or just by chance after discussing with consultants. The RoPE score and the imaging features were compared within the groups. The relationship between the size of PFO and the amount of RLS was also examined. Results From Jan. 2013 to Jun. 2014, we recruited 79 adult patients with suspected paradoxical embolism. PFO was positive in 44 patients by both cTCD and TEE. After routine consultation, PFO was determined to be causal in the paradoxical embolism in 37 patients and unrelated to stroke in 7 patients. The RoPE scores were 5 (4.5, 7.0) and 6 (4.0, 8.0) respectively and there was no significant difference. Severe stenosis or occlusion in internal carotid artery was more frequent in the group of ischemic stroke with other reasons. The RoPE scores were (5.5±1.9) for PFO <2 mm and (6.3±2.0) for PFO 2 mm, there was no significant difference between them. The percentage of post-circulation infarction in PFO <2 mm group was less than that in PFO 2 mm (P <0.05) . In the groups by the amount of RLS (1~9 microbubbles, 10~20 microbubbles or >20 microbubbles), the RoPE scores were 5.4±1.7, 6.5±2.7, 5.8±2.0 respectively and were different with no significance. The relationship between the size of PFO and the amount of RLS was tested to be no statistical difference. Conclusion PFO can be causal or unrelated to ischemic stroke. The imaging features might give some clues concerning the size of PFO and the amount of RLS. The RoPE score might provide further information to guide clinical decision.

Analysis of Ultrasound Screening Results in 1729 Cases of Stroke in High-risk Groups

ZHANG Zhen-Han*, CHEN Shu-Yan, WANG Yan-Ming, LI Ning, LIU Tao.

2014, 9(08): 663-668.

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Objective To investigate carotid atherosclerosis in population over age 40 with high risk of stroke, and to provide scientific evidence for formulating intervention measures. Methods This study was a cross-sectional study, based on the principle of voluntariness and informed consent 1729 cases with high-risk of stroke were sampled from those residents with age more than 40 by using stroke questionnaire survey. All high-risk groups underwent medical examination, laboratory tests and carotid artery ultrasound examination (detection of carotid artery intima-media and plaque morphology). Results In the 1729 high-risk cases, 453 cases were male (26.2%), 1276 cases were female (73.8%), with an average age of (58.8±9.6). Carotid ultrasound showed 833 cases (48.2%) with abnormalities, including carotid intima-media (intima-media thickness, IMT) simple thickening were 98 cases (5.7% of the total high-risk population, 25.1% of ultrasound abnormalities), the carotid artery atherosclerotic plaques were 735 cases (42.5% of the total high-risk population, 88.2% of ultrasound abnormalities). Stratified by age, 40~49, 50~59, 60~69, older than 70, 4 age groups on the left IMT thickening (χ 2=15.5, P =0.001) and right IMT thickening (χ 2=26.7, P <0.001) were significantly different; for different age groups atherosclerotic plaque ratio was also a significant difference (χ 2=48.6, P <0.001). Conclusion In population with high risk of stroke, the rates of abnormal carotid ultrasound are high, and carotid intimal thickening and atherosclerotic plaque formation increase with age growing.

Collateral Circulation

2014, 9(08): 669-669.

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