Recanalization of Extracranial Internal Carotid Artery Occlusion after i.v. Thrombolysis for Acute Ischemic Stroke

Background

Although extracranial internal carotid artery (e-ICA) occlusion is a common pathology in patients undergoing intravenous thrombolysis for treatment of acute ischemic stroke, no data on e-ICA recanalization rate or potential effects on outcome are yet available.

Methods and Results

This study included 52 consecutive patients with e-ICA occlusion and ischemic stroke undergoing standard intravenous thrombolysis. The rate of e-ICA recanalization was 30.8% [95%CI, 18.2–43.3], documented at 3.5 [2.0–11.8] (median [IQR]) days after stroke, as compared to 8.6% [95%CI, 3.5–13.7] in a series of 116 consecutive patients with symptomatic e-ICA occlusion not undergoing thrombolysis (P<0.001 for difference). Functional outcome three months after stroke did not significantly differ for those with or without e-ICA recanalization following intravenous thrombolysis (modified Rankin scale ≤2: 31.3% vs. 22.2%, odds ratio 1.6 [95%CI, 0.4–5.9], P = 0.506). In patients with e-ICA occlusion of atherothrombotic origin, recanalization resulted in most instances in residual high-grade stenosis (13 of 14).

Conclusions

Recanalization of e-ICA occlusion after stroke thrombolysis occurred in about one third of patients. Although e-ICA recanalization had no significant effect on patient outcome, control sonography in the early days after thrombolysis is recommended for the detection of potential residual e-ICA stenosis.     

视网膜静脉阻塞与颈动脉狭窄的相关性研究

目的:探究视网膜静脉阻塞与颈动脉狭窄的相关性研究,并为其临床检测、治疗与预后提供参考。方法:选择我院55例视网膜静脉阻塞患者(55只眼)为研究组,对其裸眼视力、矫正视力、眼压、眼底血管荧光造影(FFA)等检查资料进行分析,并进行多普勒彩超检查,记录其颈动脉狭窄情况,并对两种疾病之间的关系进行分析。同时选取55例健康人作为对照组。结果:研究组55例患者确诊为视网膜静脉阻塞(RVO),多普勒结果显示患者患侧与健侧劲动脉血流动力学各项差异不明显(P0.05);其IMT值较之对照组显著增高(P0.05);其PSV与EDV值有所降低,差异具有统计学意义(P0.05)。结论:视网膜静脉阻塞患者大多存在颈动脉狭窄,因此检测颈动脉血流动力学对于诊断与预防视网膜静脉阻塞有着重要作用。     

Histological Analysis of Extracranial Carotid Artery Aneurysms

Introduction

Extracranial carotid artery aneurysms (ECAA) are rare but may be accompanied with significant morbidity. Previous studies mostly focused on diagnostic imaging and treatment. In contrast, the pathophysiological mechanisms and natural course of ECAA are largely unknown. Understanding the pathophysiological background may add to prediction of risk for adverse outcome and need for surgical exclusion. The aim of this study was to investigate the histopathological characteristics of ECAA in patients who underwent complete surgical ECAA resection.

Material and Methods

From March 2004 till June 2013, 13 patients were treated with open ECAA repair. During surgery the aneurysm sac was resected and processed for standardized histological analysis. Sections were stained with routine hematoxylin and eosin and special stains to detect elastin, collagen, different types of inflammatory cells, vascular smooth muscle cells and endothelial cells.

Results

Histopathological characterization revealed two distinct categories: dissection (abrupt interruption of the media; n = 3) and degeneration (general loss of elastin fibers in the media; n = 10). In the degenerative samples the elastin fibers in the media were fragmented and were partly absent. Inflammatory cells were observed in the vessel wall of the aneurysms.

Conclusion

Histological analysis in this small sample size revealed dissection and degeneration as the two distinct underlying mechanisms in ECAA formation.     

家兔颈内动脉内皮损伤引起血管狭窄模型的研究

目的探讨颈内动脉内皮不同损伤强度在不同时间出现狭窄的相关性。方法由颈外动脉向颈内动脉插入相同规格气囊,分别充入1、2、3Pa的压力,反复重复3次,分别在造型1、2、3周时各处死一批家兔,观察造型家兔血管内皮的病理学改变及相关活性因子的变化。结果实验结果表明,在血管内膜损伤强度为2Pa,球囊直径为3.0mm,球囊长度为20mm,插入深度为30mm的条件下,在造型时间为3周时,造型家兔血管内皮可呈现典型狭窄性病理变化,血浆TXB2、GMP-140、ET-1、CGRP含量、全血粘度明显增高,红细胞聚集指数、聚集面积增加,红细胞变形指数、变形面积、血浆6-keto-PGF1α含量明显减少。结论在球囊压力为2Pa,造型时间为3周时可得到与临床极为相似的狭窄性动物模型,血管内膜、中膜明显增厚,相关活性因子变化显著,能满足药理学研究的需要。     

Partial Carotid Occlusion as Treatment for Intracranial Internal Carotid Aneurysms

A study was undertaken to investigate the possibility of using partial carotid occlusion instead of complete carotid ligation for the treatment of intracranial internal carotid aneurysms with a view to avoiding such complications of the latter procedure as neurological deficit resulting from cerebral ischemia, and ascending thrombus formation. The beneficial effect of carotid ligation has been explained by the interruption of pulsatile flow which can cause rupture of an aneurysm by resonance phenomena. Studies on blood flow in the aorta in dogs, as well as in a human carotid artery in vivo and in vitro, showed that the same object could be achieved by the use of constriction by a Poppen clamp. This changed the pulsatile blood flow to a relatively non-pulsatile state with slight diminution in mean flow. Partial occlusion of the common carotid artery is recommended for those cases of intracranial aneurysm in which complete carotid occlusion would not likely be tolerated.     

Endarterectomy of the Internal Carotid Artery

Results of 219 operations in 171 patients for arteriosclerotic stenosis of the internal carotid artery were consistently good in patients with lateralizing, transient ischemic attacks. Although less consistent, relief of symptoms may be expected in a high proportion of patients with significant stenosis and more nonspecific symptoms. A small number of patients (10 percent) may have significant stenosis without a bruit. Asymptomatic stenosis, which has an unpredictable prognosis, may be operated upon with low mortality and morbidity. The use of local anesthesia and shunting when necessary proved to be the safest technique for the authors.     

颈内动脉支架置入术对颈动脉狭窄患者认知功能影响的研究

目的：研究颈动脉狭窄对认知功能的影响,探讨颈动脉支架置入术（CAS）患者术后不同时期认知功能的变化及其可能的机制。方法：选取2010年1月至2012年12月我院神经内科收住的急性脑梗死（前循环）患者75例,按颈内动脉狭窄程度,分成无狭窄组,轻度狭窄组（狭窄程度〈30％）,中度狭窄组（30-69％）和治疗组（70．99％）,前三组给予药物治疗,治疗组同时给予颈内动脉支架置入术,应用蒙特利尔认知评估量表（MoCA）、简易精神状态检查表（MMSE）、搭火柴测验（stickTest）,对患者进行认知功能评估,比较术前、术后不同时期认知功能的变化,同时利用SPECT／CT对治疗组20例患者术后局部脑血流改善状况进行评价。结果：治疗组和对照组在术前比较MoCA总分、MMSE评分、StickTest评分,发现治疗组评分低于对照组,且随着颈动脉狭窄程度的加重,认知功能受损越明显;治疗组在术后1周与术前比较,评分反而降低,差异有统计学意义;术后3个月、术后6个月与术前比较,评分均有所提高,差异有统计学意义;通过SPECT／CT对治疗组术前感兴趣区血流量与同侧小脑平均脑血流量比较,术后再与同侧小脑比较,结果显示术后脑灌注明显改善。结论：颈动脉狭窄与血管性认知功能障碍有关,而且认知功能障碍的程度与颈动脉狭窄程度呈正相关,颈内动脉支架置入术可最终改善认知功能,尤其表现在视空间／执行能力,延迟回忆能力,注意力等方面。     

Effect of Carotid Artery Stenting on Cognitive Function in Patients with Internal Carotid Artery Stenosis and Cerebral Lacunar Infarction: A 3-Year Follow-Up Study in China

Background and Objectives

Carotid artery stenting (CAS) is an important therapeutic strategy for patients with carotid artery stenosis. However, the potential influence of CAS on cognitive function in patients with carotid artery stenosis and cerebral lacunar infarction has not been determined. This study investigated changes in cognitive function associated with CAS and the factors related to these changes.

Methods

This prospective cohort study comprised 579 Chinese patients with cerebral lacunar infarction and carotid artery stenosis for whom CAS was indicated, and a matched control group of 552 healthy individuals. Cognitive function before CAS and at scheduled intervals from 6 months to 3 years was assessed with instruments that included the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scale. Potential factors that might affect cognitive function were analyzed via logistic regression.

Results

The MMSE and MoCA scores of the patients before CAS were significantly lower than that of the control subjects. These scores were significantly higher 6 months after CAS and sustained or increased throughout the 3-year follow-up. Also significantly improved after CAS from baseline were scores for an alternating trail test, cube copying, clock-drawing, attention, and delayed recall in an auditory-verbal learning test. Logistic regression analyses showed that age greater than 65 y, little education, diabetes, and hypertension were independent risk factors for deteriorated MoCA scores 3 years after CAS.

Conclusion

CAS was associated with significantly improved cognitive function in cerebral lacunar infarction patients with severe stenosis.     

Clinical Investigation of Fasudil for the Prevention of Cerebral Vasospasm in Extracranial Carotid Artery Stenting

To evaluate fasudil hydrochloride for the prevention of cerebral vasospasm (CVS) in extra-cranial carotid angioplasty and stenting (CAS). We retrospectively analyzed 178 patients with unilateral CAS who were given intravenous fasudil hydrochloride during the perioperative period. CVS, hypotension, stroke, and mortality incidence rates were recorded. Of the cohort studied, 80.9 % patients exhibited no local CVS, asymptomatic vasospasm was observed in 17.4 % patients and symptomatic vasospasm in 1.7 % patients via DSA imaging. All CVS was relieved and symptoms disappeared after intra-arterial infusion of papaverine hydrochloride. Intracerebral hemorrhage occurred in two cases during the perioperative period, one of which resulted in death. CVS is a severe complication of CAS. Fasudil hydrochloride can rapidly relieve cerebral vasospasm, has no selective effect on cerebral vasculature, and little influence on blood pressure. It is suitable for the prevention of CVS during interventional treatment of ischemic cerebrovascular disease.     

Surgical Management of Meatal Stenosis with Meatoplasty

Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.Download video file.^{(30M, mov)}     

颈动脉粥样硬化及主动脉瓣钙化与动脉粥样硬化性肾动脉狭窄的关系

目的:探讨颈动脉粥样硬化、主动脉瓣膜钙化(aortic valve calcification,AVC)与动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)的关系。方法:对我院162例行选择性冠脉造影合并肾动脉造影的患者进行颈动脉超声和超声心动图检查,测量颈动脉内中膜厚度(carotid artery intima-media thickness,CIMT)和主动脉瓣钙化的情况,根据患者是否患有ARAS进行分组,比较两组的性别、年龄、吸烟、病史、血脂水平、CIMT、颈动脉粥样硬化发生率和AVC发生率,计算颈动脉粥样硬化和AVC对ARAS的预测价值。结果:ARAS组高血压病史患者的构成比、胆固醇水平、CIMT、颈动脉粥样硬化发生率、AVC发生率均显著高于对照组,有明显的统计学差异(P0.05)。颈动脉粥样硬化预测ARAS的灵敏度较高,特异度偏低;AVC的灵敏度低,而特异度高;二者联合特异度明显增高。结论:颈动脉粥样硬化、AVC对ARAS的诊断有一定的参考价值,可用于排除诊断。