Abstract:Medullary infarction is a rare type of stroke with lateral medullary syndrome(Wallenberg syndrome)being the most common condition.While medial medullary infarction on one side is relatively rare,bilateral medial medullary infarction(BMMI)is extremely uncommon in clinical practice.Isolated vertigo is predominantly caused by a peripheral vestibular system lesion,with fewer cases involving the central vestibular system.This article reported a case of acute progressive medullary infarction initially presenting with isolated vertigo,which rapidly progressed to show classic manifestations of medullary infarction,including quadriplegia and dysphagia(coughing while drinking water)within 9 hours.The patient received early aggressive antiplatelet and anticoagulation therapy during the acute phase,followed by secondary prevention measures.At follow-up 3.5 years after onset,the patient ultimately achieved full functional independence,with a modified Rankin scale(mRS)score of 1.This case promotes early MRI in patients with isolated dizziness to screen for BMMI and posterior circulation ischemia,and facilitate timely diagnosis.It also underscores the critical importance of secondary prevention in improving outcomes.By detailing these aspects,we aim to enhance clinicians'awareness of this rare condition and provide valuable references for its diagnosis and management.

Abstract:In recent years,study in reperfusion therapy for acute ischemic stroke(AIS)has made significant progress,endovascular embolectomy(EVT)has become the standardized treatment for patients with large vessel occlusion.However,the ineffective recanalization caused by microcirculation disturbance after successful recanalization has become the key limiting factor of the EVT treatment efficacy.Intra-arterial thrombolysis after successful recanalization of EVT has become a novel treatment strategy targeting at the possible microcirculation disturbance caused by residual thrombus.Based on the latest research progress,this paper summarized the drug application strategy,safety,effectiveness,translational challenges and future direction of intra-arterial thrombolysis after endovascular embolectomy for AIS.

Abstract:Objective To develop and validate a nomogram prediction model for malignant brain edema(MBE)in acute ischemic stroke(AIS)patients undergoing mechanical thrombectomy and achieved successful recanalization by combining dual-energy CT(DECT)imaging parameters with clinical features.Methods AIS patients who underwent mechanical thrombectomy and achieved successful recanalization(immediately post-procedural modified thrombolysis in cerebral ischemia[mTICI]grade≥2b)at the Department of Neurology,Hangzhou First People's Hospital between January 2019 and December 2024 were retrospectively and consecutively enrolled.All patients were divided into a training set and a validation set in a 7∶3 ratio based on stratified random sampling.Clinical data were collected for all patients,including baseline characteristics such as sex,age,hypertension,diabetes,atrial fibrillation,history of ischemic stroke,smoking history,oral anticoagulant use,responsible vessel(internal carotid artery,middle cerebral artery),hyperdense sign of middle cerebral artery on pre-operative CT,admission National Institutes of Health stroke scale(NIHSS)score,admission Alberta stroke program early CT score(ASPECTS),pre-operative blood pressure;and treatment details including pre-operative intravenous thrombolysis,intraoperative use of salvage measures(stent,balloon,stent+balloon),intraoperative use of tirofiban,number of thrombectomy attempts,and time from symptom onset to successful recanalization.All patients underwent non-contrast DECT within 1 hour after mechanical thrombectomy to identify post-interventional cerebral hyperdensities(PCHDs).The absolute iodine concentration and the average(mean),minimum(min),and maximum(max)CT values on virtual non-contrast(VNC)images,iodine overlay maps(IOM),and mixed images(MI)were recorded and calculated,represented as VNCmean,VNCmin,VNCmax,IOMmean,IOMmin,IOMmax,MImean,MImin,MImax.All parameters were measured three times and averaged.The relative iodine concentration was calculated as the ratio of the absolute iodine concentration to the iodine concentration in the superior sagittal sinus.A CT scan was performed within 72 hours postoperatively to assess whether the patient developed MBE.Using the occurrence of MBE after mechanical thrombectomy as the dependent variable,the least absolute shrinkage and selection operator(LASSO)regression was used in the training set to screen for the most predictive key variables,which were then incorporated into a multivariate Logistic regression model to identify independent risk factors for MBE after mechanical thrombectomy in AIS patients achieved successful recanalization,and a nomogram prediction model was constructed.The receiver operating characteristic(ROC)curve was used to evaluate the discriminatory performance of the nomogram model in the training and validation sets.Calibration curves and decision curve analysis(DCA)were plotted in both the training and validation sets to validate the consistency between the predicted and actual values and to assess the clinical applicability of the model.Results A total of 398 AIS patients who underwent mechanical thrombectomy and achieved successful recanalization were enrolled,among which 87 developed MBE post-operatively and 311 did not,yielding an MBE incidence of 21.9%.The training set comprised278patients(61with MBE,217without MBE),and the validation set comprised 120 patients(26 with MBE,94 without MBE).(1)No statistically significant differences were found in the clinical and imaging data between the training and validation sets(all P＞0.05).(2)Based on LASSO regression screening and subsequent multivariate Logistic regression analysis in the training set,the results showed that low admission ASPECTS(OR,0.194,95%CI 0.103-0.366,P＜0.01),high IOMmin(OR,1.680,95%CI 1.052-2.684,P=0.030),high relative iodine concentration(OR,1.816,95%CI 1.350-2.443,P＜0.01),and increased number of thrombectomy attempts(OR,2.324,95%CI 1.416-3.813,P＜0.01)were independent risk factors for MBE after mechanical thrombectomy in AIS patients achieved successful recanalization.A nomogram prediction model for MBE after mechanical thrombectomy in AIS patients achieved successful recanalization was constructed based on above four factors.Calibration curve analysis showed excellent calibration of the nomogram model in both the training set(calibration slope=0.95,intercept=0.02,mean absolute error=0.011)and the validation set(calibration slope=0.91,intercept=0.05,mean absolute error=0.022).ROC analysis results showed that the area under the curve of the nomogram model for predicting MBE after mechanical thrombectomy in AIS patients achieved successful recanalization was 0.909(95%CI 0.870-0.948)in the training set and 0.818(95%CI 0.733-0.903)in the validation set.DCA results showed that in the training set,the nomogram model provided significant net clinical benefit for predicting MBE after mechanical thrombectomy in AIS patients achieved successful recanalization when the threshold probability ranged from 0.00 to 0.91;in the validation set,this effective prediction range was from 0.04 to 0.78.Conclusion Low admission ASPECTS,high IOMmin,high relative iodine concentration,and increased number of thrombectomy attempts are independent risk factors for MBE after mechanical thrombectomy in AIS patients achieved successful recanalization,the nomogram model constructed based on these factors can predict the risk of MBE in a certain extent,and provide a reference for clinical decision-making.

Abstract:Cardiorespiratory fitness(CRF)serves as a pivotal indicator of cardiopulmonary functional reserve.Accumulating evidence substantiates a strong association between impaired CRF and the incidence,progression,and clinical outcomes of stroke.Consequently,enhancing CRF represents a critical component of stroke rehabilitation.This review summarized the alterations in CRF observed across different stages of the disease and outlines the various available assessment methods.Furthermore,the article discussed rehabilitative strategies aimed at improving CRF.The overarching aim of this article is to enhance clinical awareness regarding the significance of CRF in both stroke prevention and treatment strategy optimization.

Abstract:Brain arteriovenous malformation(bAVM)is a complex cerebrovascular disease,and its rupture and hemorrhage can lead to severe neurological dysfunction or even death.Imaging technology plays a crucial role in the assessment,diagnosis,and treatment planning of this disease.In recent years,artificial intelligence(AI)technology has developed rapidly,and demonstrating immense potential in the field of medical imaging.This article aimed to review the recent advances in the application of AI in bAVM imaging,as well as the current limitations in bAVM research related to AI and provided an outlook on future research directions.

Abstract:Cavernous segment carotid artery aneurysms typically present with an indolent course,but when located at the posterior knee and penetrating the"vulnerable areas"of the vessel wall or the fibrous ring of the dura mater,they are prone to causing subarachnoid hemorrhage.This study reported a case of a 52-year-old female patient who presented with sudden severe headache and right ptosis.Imaging revealed a multilobular aneurysm located at the posterior knee of the right cavernous segment,measuring 14.71mm×7.80 mm×15.13 mm,with a girdle sign and thinning of the sphenoid sinus bone,suggesting the aneurysm had crossed the dural fibrous ring into the subarachnoid space.The patient underwent emergency external ventricular drainage and stent-assisted coil embolization.Contrast medium extravasation was observed during angiography,and a flow-diverting stent was immediately placed.Postoperative angiography showed complete occlusion of the aneurysm.The patient's death on the sixth day after the operation may have resulted from cerebral ischemia caused by vasospasm.This case highlights that cavernous segment carotid aneurysms with"girdle sign",lateral"vulnerable area"protrusion,and sphenoid sinus bone defect are lesions with markedly high risks,that require early comprehensive intervention.

Abstract:Deep medullary veins(DMVs)are critical components of the cerebral medullary venous system,responsible for venous drainage of the deep cerebral white matter.Recent research indicates that DMVs are closely related to cerebral small vessel disease(CSVD)and associated cognitive disorders.The morphological structure of DMVs can be clearly visualized on susceptibility weighted imaging and quantitative susceptibility mapping,which could potentially serve as markers for assessing the severity of CSVD.This article reviewed the anatomical characteristics and physiological functions of DMVs,as well as the mechanistic correlations between DMVs and various CSVD imaging markers,aiming to provide novel theoretical insights for early diagnosis and clinical management of CSVD.

Abstract:Objective To investigate the therapeutic effects of upper limb rehabilitation robot training combined with intermittent theta burst stimulation(iTBS)on upper limb motor and neurological function in stroke patients with hemiplegia.Methods This study retrospectively consecutive enrolled 46 stroke hemiparetic patients from the Department of Rehabilitation Medicine,Nanjing Pukou People's Hospital.The patients were randomly assigned to a control group and an experimental group(23patients in each)using a random number table.Baseline data,including sex,age,disease duration,side of hemiplegia,and stroke type,were collected from patients enrolled.All patients received conventional treatment.The control group received upper limb rehabilitation robot training combined with iTBS sham stimulation(coil placed perpendicular to the skull),while the experimental group received upper limb rehabilitation robot training combined with iTBS real stimulation(coil placed parallel to the skull).Both groups underwent treatment for 3 weeks.Upper limb motor function was assessed using the Fugl-Meyer upper extremity(FMA-UE)scale and Wolf motor function test(WMFT);while neurological function was evaluated using the motor-evoked potentials(MEP)latency,amplitude,and central motor conduction time(CMCT)of the affected thumb abductor muscle.Activities of daily living were assessed using the modified Barthel index(MBI).Results(1)No significant differences in baseline data were found between the two groups(all P＞0.05).(2)Before treatment,the FMA-UE and WMFT scores in the experimental group were 27.48±7.87 and 28.22±3.87,respectively;and in the control group were 26.35±4.78 and 28.35±3.33,respectively;there were no significant differences in both FMA-UE and WMFT scores between the two groups(all P＞0.05).After 3weeks of treatment,the FMA-UE and WMFT scores in the experimental group were 40.35±8.96 and 37.74±4.11,respectively;and in the control group were 32.78±4.50 and 32.57±4.11,respectively;there were significant interaction effects of time and group(Ftime×group values of 19.613 and 31.522,both P＜0.01),main effects of group(Fgroup values of 5.401 and 5.897,both P＜0.05),and main effects of time(Ftime values of 176.516 and 211.478,both P＜0.01).(3)Before treatment,the MEP latency,amplitude,and CMCT in the experimental group were(24.39±3.56)ms,(137.77±42.67)μV,and(10.62±2.76)ms,respectively;and in the control group were(24.64±2.77)ms,(136.74±48.77)μV,and(10.73±1.84)ms,respectively,there were no significant differences between the two groups(all P＞0.05).After 3weeks of treatment,the MEP latency,amplitude,and CMCT in the experimental group were(20.39±1.83)ms,(239.91±43.70)μV,and(6.58±1.23)ms,respectively,and in the control group were(22.53±3.53)ms,(198.54±50.37)μV,and(9.19±1.60)ms,respectively,there were significant interaction effects of time and group(Ftime×group values of 7.270,15.554,and 20.110,all P＜0.05)and main effects of time(Ftime values of 76.540,256.706,and 100.629,all P＜0.01),the main effect of group for CMCT was significant(Fgroup=7.406,P＜0.01),but there were no significant difference in the main effect of group on MEP latency,amplitude between two groups(Fgroup values of 2.145,2.778,both P＞0.05).(4)Before treatment,the MBI score in the experimental group was 42.83±7.36,and in the control group was 43.91±6.56,with no significant difference between two groups(P＞0.05).After 3 weeks of treatments,the MBI score in the experimental group was 67.83±12.69,and in the control group was 54.13±5.57,there were significant interaction effects of time and group(Ftime×group=39.862,P＜0.01),main effects of group(Fgroup=8.083,P=0.007),and main effects of time(Ftime=226.241,P＜0.01).Conclusions Upper limb rehabilitation robot training combined with iTBS can improve upper limb motor function and neurological function and enhance the daily living activity ability of stroke patients.Real iTBS combined with robot training has a more significant effect than sham iTBS.

Abstract:Endovascular interventional angioplasty is an important treatment for symptomatic intracranial atherosclerotic stenosis(sICAS).However,conventional endovascular interventions,such as bare-metal stenting and plain balloon angioplasty,are associated with a high risk of restenosis.Drug-coated balloon(DCB),due to the drug-carrying properties,may reduce the long-term restenosis risk and represent a novel option for the endovascular intervention of sICAS.Presently,DCB for sICAS has been a subject of increasing clinical studies,and its clinical application has progressed to small-scale use.Nevertheless,it's lack of an unified guidelines or consensus to standardize its procedural indications,technical details,and perioperative management.This expert consensus summarized the relevant clinical studies on DCB for sICAS and incorporated the practical experience of specialists from neurointerventional field,aiming to provide reasonable guidance for the current clinical use of DCB in treating sICAS.

Abstract:Objective To explore the association between cardiorespiratory fitness and total atherosclerotic burden of brain-and heart-arteries in patients with ischemic stroke.Methods This study retrospectively enrolled consecutive patients with ischemic stroke of the large-artery atherosclerosis or small-artery occlusion subtypes accompanied by cervicocephalic atherosclerosis,who were admitted to the Department of Neurology,Xuanwu Hospital,Capital Medical University,between May 2023 and December 2024.General and clinical data,including age(＜60years,≥60years),sex,admission blood pressure,body mass index,history of hypertension,diabetes mellitus,hyperlipidemia,ischemic stroke,symptomatic coronary artery disease,smoking,alcohol consumption,and medication use(including antiplatelet drugs,anticoagulants,lipid-lowering drugs,antidiabetic drugs,antihypertensive drugs,and β-blockers),characteristics of ischemic stroke(including the duration of onset,ischemic side[left,right,bilateral],and ischemic location[anterior circulation,posterior circulation,bilateral circulation])were collected from all patients enrolled.On the morning after admission,fasting venous blood samples were collected to measure the levels of triglycerides,total cholesterol,low-density lipoprotein cholesterol,high-density lipoprotein cholesterol,fasting blood glucose,glycated hemoglobin,homocysteine,fibrinogen,D-dimer,C-reactive protein,high-sensitivity C-reactive protein,N-terminal pro-B-type natriuretic peptide,creatine kinase-MB,cardiac troponin T,and myoglobin.Transthoracic echocardiography was performed within 7 days after admission to evaluate cardiac function.Left ventricular ejection fraction and cardiac output were recorded,and cardiac index were calculated.Upon admission,neurological impairment,disability,motor function,and balance ability were assessed using the National Institutes of Health stroke scale(NIHSS),modified Rankin scale(mRS),Fugl-Meyer assessment(FMA),and Berg balance scale,respectively.The Saltin-Grimby physical activity level scale was used to evaluate the intensity of habitual physical activity prior to stroke onset.Cardiopulmonary exercise testing was performed within 7 days after admission to assess cardiopulmonary fitness.During the test,peak oxygen uptake(VO2peak),percentage of predicted VO2peak(VO2peak%pred),and metabolic equivalent of task(MET)were recorded.Based on the minimum oxygen uptake required for independent living(15 ml/[kg·min]),VO2peak was classified into low VO2peak(＜15 ml/[kg·min])and high VO2peak(≥15 ml/[kg·min]).With VO2peak%pred＜0.60 as the cutoff,VO2peak%pred was divided into low VO2peak%pred(＜0.60)and high VO2peak%pred(≥0.60).MET were categorized into low MET(＜mean MET)and high MET(≥mean MET)according to the mean value of MET in this study population.Imaging data of cardio-cerebral arteries were obtained by simultaneous CT arteriography within 7 days after admission.Total atherosclerotic burden of brain-and heart-supplying arteries(TAB-BHAs)was used to quantitatively evaluate the overall degree of cardio-cerebral atherosclerosis.And patients were stratified into high TAB-BHAs(≥4 points)and low TAB-BHAs(＜4 points)groups.The differences in general and clinical characteristics,as well as cardiopulmonary fitness indices,were assessed among different groups of TAB-BHAs.Spearman' s correlation was used in the preliminary analysis of the relationship between cardiorespiratory fitness indicators and TAB-BHAs.Multivariate Logistic regression was conducted with VO2peak,low VO2peak%pred,and low METs as independent variables,and high TAB-BHAs as the dependent variable to assess the association between cardiopulmonary fitness and TAB-BHAs.Covariates were selected through regressions stratified by age≥60 years,male,the least absolute shrinkage and selection operator(LASSO),and the variables exhibit statistically significant differences between the low and high TAB-BHAs groups,respectively.Results A total of 104 patients with ischemic stroke were enrolled.Among all patients enrolled,60patients(with ages ranging from 30 to 72years and a mean age of[54±11]years)met the inclusion and exclusion criteria,and were ultimately included.Amid the 60 patients,52 were male and 8 were female.There were 20 patients(33.3%)with low VO2peak,28 patients(46.7%)with low VO2peak%pred,and 31 patients(51.7%)with low MET(MET＜5.0).45 patients were classified into the low TAB-BHAs group and 15 into the high TAB-BHAs group.(1)Compared with the low TAB-BHAs group,patients in the high TAB-BHAs group were significantly older and had a higher proportion of patients aged≥60 years,they also showed significantly higher fibrinogen levels and a history of antihypertensive drug use(all P＜0.05).No significant differences were observed in other general or clinical characteristics between the two groups(all P＞0.05).Regarding cardiopulmonary fitness parameters,patients in the high TAB-BHAs group had lower VO2peak and MET levels,and higher proportions of patients with low VO2peak,low VO2peak%pred,and low MET compared with those in the low TAB-BHAs group(all P＜0.05).(2)Based on the Spearman's correlation analysis,VO2peak(r=-0.298,P=0.021),VO2peak%pred(r=-0.305,P=0.018),MET(r=-0.303,P=0.018)all exhibited negative correlations between and TAB-BHAs.(3)LASSO regression was used to identify the most pertinent variables for high TAB-BHAs,including low VO2peak,low VO2peak%pred,and fibrinogen.Multivariate Logistic regression analysis was then performed with low VO2peak,low VO2peak%pred,and low MET as independent variables and high TAB-BHAs as the dependent variable.The results showed that after adjusting for age≥60 years,male,and fibrinogen,both low VO2peak(adjusted OR,4.420,95%CI 1.052-18.573,P=0.042)and low VO2peak%pred(adjusted OR,7.423,95%CI 1.411-39.046,P=0.018)were independently associated with high TAB-BHAs in ischemic stroke patients.After further adjusting for variables that differed among high and low TAB-BHAs groups(including age≥60 years,male,fibrinogen,and history of using antihypertensive drugs),multivariate Logistic regression showed that low VO2peak%pred remained independently associated with high TAB-BHAs in ischemic stroke patients(adjusted OR,6.347,95%CI 1.170-34.418,P=0.032).Conclusion Poor cardiopulmonary fitness might be associated with high degree of overall cardio-cerebral atherosclerosis,suggesting cardiorespiratory fitness as a potential correlated indicator that could provide clues for improving early screening of patients with heavy cardio-cerebral atherosclerotic burden and for exploring the underlying mechanisms.

Abstract:Objective To establish a prediction model for futile recanalization after mechanical thrombectomy(MT)in acute anterior circulation large vessel occlusion(ACLVO)stroke patients based on multimodal imaging features,and to evaluate its predictive performance.Methods Retrospectively enrolled consecutive ACLVO patients who underwent MT with successful recanalization(modified thrombolysis in cerebral infarction[mTICI]grade≥2b)at the Department of Neurology of Fuyang People's Hospital between June 2023 and December 2024.Demographic and clinical data were collected,including age,gender,hypertension,diabetes mellitus,atrial fibrillation,smoking history,alcohol consumption history,National Institutes of Health stroke scale(NIHSS)score upon admission,intravenous thrombolysis,wake-up stroke,onset-to-puncture time(OPT),puncture-to-recanalization time(PRT),occlusion vessel(internal carotid artery,middle cerebral artery),treatment method(suction thrombectomy,stent thrombectomy,suction+stent thrombectomy).All patients underwent pre-procedural CT perfusion(CTP)+CT angiography(CTA)of the head and neck.Imaging parameters included hypoperfusion(defined as time to peak＞6 s)volume(HPV),core infarct(defined as cerebral blood flow＜30%)volume(CIV),mismatch ratio(MMR;HPV/CIV),and Tan collateral score(poor collaterals:0-1 score,good collaterals:2-3 score).Patients were followed up at 90 days post-procedure via outpatient clinic or re-admission.Patients with a modified Rankin scale(mRS)score≤2 were classified into the effective recanalization group,while those with mRS score≥3 were classified into the futile recanalization group.Imaging variables with statistically significant differences between the futile recanalization and effective recanalization groups were included in multivariate Logistic regression analysis to identify independent predictors of futile recanalization and construct a nomogram model.The predictive value of the model was assessed using the receiver operating characteristic(ROC)curve.Model calibration was evaluated using the Hosmer-Lemeshow test(goodness-of-fit defined as P＞0.50).Results(1)A total of 105 ACLVO patients with successful MT recanalization were included(65 males,40 females,mean age[66±11]years,ranged 31～87 years).There were 60 patients in the effective recanalization group and 45 in the futile recanalization group.Compared to the effective recanalization group,the futile recanalization group had significantly higher age([69±11]years vs.[63±11]years,P=0.012),higher proportion of diabetes mellitus(33.33%[15/45]vs.16.67%[10/60],P=0.047),higher pre-treatment NIHSS score([15.51±2.73]vs.[13.25±2.71],P＜0.01),longer OPT([516.40±192.48]min vs.[322.98±171.22]min,P＜0.01)and PRT([94.96±17.37]min vs.[87.58±15.99]min,P=0.026),larger CIV([74.00±12.76]ml vs.[24.28±14.72]ml,P＜0.01)and HPV([121.43±22.21]ml vs.[91.62±11.34]ml,P＜0.01),smaller MMR([1.65±0.15]vs.[9.42±1.91],P＜0.01),higher 90-day mRS score([3.60±0.54]score vs.[1.22±0.83]score,P＜0.01),and a significantly different distribution of Tan collateral scores(P＜0.01).(2)Multivariate Logistic regression analysis was performed with futile recanalization as the dependent variable,identified the following independent predictors of futile recanalization:HPV(OR,2.042,95%CI 1.296-3.218,P=0.002),CIV(OR,2.373,95%CI 1.315-4.280,P=0.004),MMR(OR,1.758,95%CI 1.135-2.721,P=0.011),and Tan collateral score(OR,5.166,95%CI 2.100-12.651,P＜0.01).(3)A nomogram prediction model for futile recanalization after MT in ACLVO stroke was constructed based on the four imaging parameters as aforementioned.ROC curve analysis demonstrated that the area under the curve for this model in predicting futile recanalization after MT was 0.846(95%CI 0.739-0.912),with a sensitivity of 0.844 and a specificity of 0.817.The calibration curve and the Hosmer-Lemeshow test indicated the goodness-of-fit was high(P=0.617),and the overall stability of the model was good.Conclusion The predictive model for futile recanalization after MT for acute ACLVO constructed base on HPV,CIV,MMR and Tan collateral score facilitates the identification patients with high-risk of futile recanalization.

Abstract:Cerebral proliferative angiopathy(CPA)was initially regarded as a variant of arteriovenous malformation.However,its distinct histological,angiographic,and pathophysiological features have led to its reclassification as an independent entity.CPA is an exceptionally rare form of cerebral vascular malformation,its pathogenesis is primarily linked to diffuse vascular proliferation secondary to chronic hypoperfusion.Clinically,CPA presents with a heterogeneous spectrum of manifestations,most commonly severe headaches and epileptic seizures.Neuroimaging(MR)typically reveals a complex interplay of aberrant vessels within the brain parenchyma,which may complicate the clinical management and lead to a higher rate of poor prognosis.This article reviewed current knowledge on the pathogenesis,epidemiology,clinical features,diagnostic approaches,and treatment options for CPA,with the aim of enhancing understanding of its underlying mechanisms and guiding future therapeutic strategy optimizations.

Abstract:Objective To investigate the neurovascular coupling(NVC)status in the acute phase of patients with minor ischemic stroke(MIS)or transient ischemic attack(TIA)due to intracranial large artery moderate-to-severe stenosis or occlusion using multimodal MRI techniques and to explore its correlation with quality of life(QoL).Methods This prospective,consecutive study enrolled patients with MIS or TIA due to intracranial large artery moderate-to-severe stenosis or occlusion form the Department of Neurology,the First Affiliated Hospital of Xi'an Jiaotong University,between June 2022 and October 2023.Recruit healthy subjects with matched age,sex,and handedness form the community during the same period.Patients were divided into left-sided involvement and right-sided involvement groups based on the affected side of the responsible vessel,while the healthy subjects were set as the healthy control group.Post-hoc power analysis was performed using G*Power 3.1 software.General characteristics(age,gender,body mass index,education level)were collected and compared across all three groups.Clinical data and QoL assessment were collected and compared between the two patient groups.Collected clinical data including type of cerebrovascular events(TIA,MIS),the National Institutes of Health stroke scale(NIHSS)score at admission,the responsible vessel(internal carotid artery,middle cerebral artery)and its side location,the degree of responsibility artery stenosis(moderate-severe stenosis[50%-99%stenosis rate],occlusion[100%stenosis rate]),the intracranial collateral circulation status(American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology[ASITN/SIR]collateral circulation grading),cerebrovascular risk factors(hypertension,diabetes,hyperlipidemia,smoking history),and the laboratory test indicators at admission(glycated hemoglobin,triglycerides,total cholesterol,high-density lipoprotein cholesterol,low-density lipoprotein cholesterol,blood uric acid,blood homocysteine).QoL was assessed using the stroke impact scale(SIS),covering eight functional domains and a patient-reported overall recovery item.Multimodal MR data were acquired for all subjects.Whole-brain cerebral blood flow(CBF)images were generated using statistics parameter mapping 12(SPM 12)software,while regional homogeneity(ReHo)images were generated using DPABI software.The voxel-wise ratio of CBF to ReHo(CBF/ReHo)was calculated as the regional NVC parameter.Differences in regional NVC characteristics were compared between patient groups and the healthy control group.Correlations between NVC parameters and SIS scores within patient groups were explored.Results(1)A total of 38 patients with MIS or TIA due to intracranial large artery moderate-to-severe stenosis or occlusion were included(26 males,12 females,aged 36-69 years,with mean age of[52±11]years),with 23 in the left-sided involvement group and 15 in the right-sided involvement group.Nineteen healthy subjects were included(10 males,9 females,aged 37-67 years,with mean age of[53±10]years).Post-hoc power analysis showed statistical power of 0.808 for comparing the left-sided involvement group with the healthy control group and 0.762 for comparing the right-sided involvement group with control group.(2)No statistically significant differences were found on gender,age,education level,or body mass index across the three groups(all P＞0.05).No statistically significant differences were observed on the type of cerebrovascular event,cerebrovascular risk factors,distribution of the responsible vessel,degree of stenosis in the responsible vessel,admission NIHSS score,or laboratory test results between the two patient groups(all P＞0.05).There were no statistically significant differences in the total SIS score and the scores of subscales between the two patient groups(all P＞0.05).(3)Compared with the healthy control group,the left-sided involvement group exhibited reduced CBF/ReHo values in the left superior and middle temporal gyri,supramarginal gyrus,middle and inferior frontal gyri,precentral gyrus,angular gyrus,postcentral gyrus,insula,and posterior cerebellar lobe(FDR-corrected,all P＜0.05).In the right-sided involvement group,reduced CBF/ReHo values were observed in the right supramarginal gyrus,right postcentral gyrus,inferior temporal gyrus,and insula(FDR-corrected,all P＜0.05).(4)Correlation analysis revealed that the SIS total score in the left-sided involvement group negatively correlated with CBF/ReHo values in the right inferior frontal gyrus(T=-5.91)and the right middle temporal gyrus(T=-6.65,FDR-corrected,both P＜0.05).The SIS subscale score for activities of daily living in the left-sided involvement group showed negative correlations with CBF/ReHo values in the right angular gyrus(T=-7.36),right medial superior frontal gyrus(T=-6.97),right orbitofrontal cortex(T=-8.99),and left thalamus(T=-7.51,FDR-corrected,all P＜0.05).No significant correlation was observed between the SIS total score and CBF/ReHo values in patients with right-sided involvement group.The SIS subscale for communication score in the right-sided involvement group correlated with CBF/ReHo in the left lingual gyrus(T=-12.15),left olfactory cortex(T=-7.68),and right anterior cingulate and paracingulate cortex(T=-9.46,FDR-corrected,all P＜0.05).Conclusions Patients with MIS or TIA due to intracranial large artery moderate-to-severe stenosis or occlusion show abnormal NVC in the acute phase,especially those with left hemisphere involvement,who exhibit more extensive impairments.QoL in left-sided involvement patients is strongly linked to NVC in the right orbitofrontal cortex and right middle temporal gyrus.These findings require further validation in larger-scale studies.

Abstract:Objective This study analyzes the optical coherence tomography(OCT)characteristics of patients with symptomatic carotid artery stenosis(CAS)prior to carotid stenting and the influencing factors associated with symptomatic CAS.Methods This study retrospectively included consecutive CAS patients who underwent carotid OCT examination prior to carotid stenting at Department of Nerolgical Intervention and Nerological Intensive Care,Central Hospital of Dalian University of Technology(Dalian Municipal Central Hospital)from November 2022 to November 2024.Patients were categorized into symptomatic and asymptomatic CAS groups.General clinical data and laboratory test results were collected and compared between the two groups,including age,sex,body mass index,systolic and diastolic blood pressure(measured on the morning of procedure without antihypertensive medication intervention with patient at resting state for over 30 minutes),medical history(including hypertension,diabetes,atrial fibrillation,coronary heart disease,stroke,and transient ischemic attack),smoking history,alcohol consumption history,and fasting laboratory results obtained on the morning before procedure laboratory results(including,white blood cell count,red blood cell count,monocyte percentage,neutrophil percentage,lymphocyte percentage,platelet count,blood creatinine,blood glucose,international normalized ratio,D-dimer,total cholesterol,triglycerides,homocysteine,low-density lipoprotein cholesterol,and high-density lipoprotein cholesterol).Additionally,OCT image parameters were collected and compared between the two groups,including the minimum lumen diameter and minimum lumen area of the target lesion segment,the distal lumen diameter and area of the reference vessel(internal carotid artery),the percentage of lumen area stenosis([reference vessel lumen cross-sectional area-minimum lumen cross-sectional area]/reference vessel lumen cross-sectional area×100%),the lesion length,fibrous cap thickness,lipid arc,and the presence of fibrous plaques,calcified plaques,lipid plaques,white thrombus,cholesterol crystals,macrophage infiltration,microchannels,and plaque rupture.Variables with P＜0.05 from univariate analysis were included in the multivariate Logistic regression analysis to assess the influencing factors of symptomatic CAS.Results A total of 68 patients with CAS were enrolled,comprising 57males and 11females,aged 53 to 84 years with a mean age of(68±7)years.Among them,32 patients were categorized into the symptomatic CAS group and 36 into the asymptomatic CAS group.(1)Compared to the asymptomatic CAS group,patients in the symptomatic CAS group exhibited higher systolic blood pressure([150±23]mmHg vs.[138±21])mmHg,P=0.025).There were no statistically significant differences in general,clinical data,and laboratory test results between the two groups(all P＞0.05).The preoperative OCT imaging parameters comparison between the two groups of CAS patients revealed that the reference vessel distal lumen area was significantly smaller in the symptomatic CAS group([18.67±5.44]mm2 vs.[21.95±5.57]mm2,P=0.017),and the proportion of patients with white thrombus(40.62%[13/32]vs.13.89%[5/36],P=0.013)and microchannels(21.88%[7/32]vs.2.78%[1/36],P=0.014)were higher.(2)A multivariate Logistic regression analysis was conducted using systolic blood pressure,white thrombus,microchannels,and the reference vessel(internal carotid artery)distal lumen area as independent variables.The results indicated that high systolic blood pressure(OR,1.030,95%CI 1.002-1.060,P=0.038),and the presence of white thrombus(OR,3.956,95%CI 1.072-14.600,P=0.039)and microchannels(OR,13.850,95%CI 1.277-150.203,P=0.031)were independent risk factors for symptomatic CAS.Conclusions Compared to patients with asymptomatic CAS,those with symptomatic CAS exhibited higher preoperative(pre-carotid stenting)systolic blood pressure and a smaller distal lumen area of the reference vessel(internal carotid artery),as observed through OCT.Furthermore,a higher proportion of symptomatic CAS patients presented with white thrombus and microchannels.Preoperative systolic blood pressure,along with the presence of white thrombus and microchannels on OCT,are identified as independent risk factors for symptomatic CAS.The conclusions drawn from this study necessitate further validation through large-scale,multicenter,prospective research.

Abstract:Objective To explore the safety and feasibility of mechanical thrombectomy as the first-line endovascular strategy in patients with non-acute symptomatic long-segment internal carotid artery occlusion(ICAO)undergoing revascularization.Methods This study retrospectively and consecutively enrolled non-acute symptomatic long-segment ICAO patients treated in the Department of Neurology,First Hospital of Jilin University,between January 2019 and August 2023,with mechanical thrombectomy as the preferred endovascular modality.Baseline and clinical data were collected,including sex,age,stroke-related risk factors(hypertension,diabetes,dyslipidemia,coronary artery disease,prior stroke,smoking and alcohol use history),admission National Institutes of Health stroke scale(NIHSS)score,pre-operative modified Rankin scale(mRS)score,time from last symptom onset to femoral puncture,time from imaging confirmation to femoral puncture,high-resolution MRI,right-sided ICAO,stump morphology(absent,tapered,flat/blunt,irregular),distal backfilling patterns(above ophthalmic segment,cavernous/clinoid segment,below cavernous segment),pathogenesis(atherosclerosis,dissection),types of anesthesia(local,general),procedure time(time frame from femoral puncture to recanalization or final angiography),site of the original occlusion in successfully recanalized cases,surgical techniques(aspiration+balloon angioplasty,aspiration+balloon angioplasty+stent-retriever thrombectomy,aspiration+balloon angioplasty+stent placement,aspiration+balloon angioplasty+stent-retriever thrombectomy+stent placement),stent placement(yes/no),number of stents implanted,and number of cases with retrieved thrombus,observed indicators.Observed indicators including ratio of technical successful recanalization(immediately post-procedure most severely stenosed site stenosis rate＜50%,expanded thrombolysis in cerebral infarction[eTICI]grade≥2c),intraoperative complications(distal embolization,symptomatic intracranial hemorrhage,arterial perforation)rate,perioperative mortality rate,30-day stroke recurrence,and 90-day mRS score.Compare the baseline data,clinical data and observational indicators of the patients with successful and unsuccessful recanalization.Base on the original occlusion site,successfully recanalized patients were subclassified into isolated extracranial,isolated intracranial,and tandem lesions patients,and their baseline characteristics and observation indicators were compared.Results(1)A total of 65 patients were enrolled(57 men,8 women;age 39-80 years;median 59[52,65]years)in this study.Technical success was achieved in 52cases(80%).Perioperative complications occurred in 4 patients(6.2%),with 3 distal embolization cases(4.6%),1(1.5%)developed symptomatic intracranial hemorrhage,and no arterial perforations were observed.There was no perioperative mortality.The 30-day stroke recurrence rate was 7.7%(5/65).90-day mRS scores ranged from 0 to 4,with a median of 1.0(0.0,1.5).(2)Baseline and clinical characteristics as well as outcome indicators did not differ significantly between patients with successful versus unsuccessful recanalization in the cohort undergoing mechanical thrombectomy for non-acute symptomatic long-segment intracranial carotid artery occlusion(all P＞0.05).(3)Among successfully recanalized patients,17(32.7%)had isolated extracranial lesions,18(34.6%)had isolated intracranial lesions,and 17(32.7%)had tandem lesions.All cases in the extracranial lesions group had original lesion site at the origin of internal carotid artery(C1,17/17).The intracranial group most often had orginal lesion sites at the C4 segment(9/18),whereas tandem lesions predominantly involved C1 plus C4-C5(16/17).Among the three groups,patients with isolated intracranial lesions were younger(57[48,61]years vs.60[52,64],63[58,69]years,P=0.050),and had a lower proportion of right-sided ICAO(4/18 vs.11/17 vs.11/17,P=0.032),while patients with tandem lesions required a greater number of stents(2.0[1.0,2.0]vs.1.0[1.0,1.5],1.0[0.8,2.0],P=0.013).Significant differences were observed in the proportion of patients with retrieved thrombus decreased progressively from patients with isolated extracranial,isolated intracranial to tandem lesions(17/17 vs.17/18 vs.12/17,P=0.024).No significant differences were observed among lesion-site groups with respect to medical history,stump morphology,distal retrograde flow,procedural technique,procedure duration,anesthesia method,or outcome indicators(all P＞0.05).Conclusions This study suggested that utilizing mechanical thrombectomy as the first-line endovascular therapy for non-acute symptomatic long-segment ICAO is safe and feasible.The original occlusive sites of non-acute symptomatic long-segment ICAO predominantly involve the cervical origin and the cavernous segment of the internal carotid artery.The conclusions of this study require further validation.

Abstract:Objective This study aimed to investigate the correlation of cerebral perfusion and cognitive function status in patients with minor stroke(MS)or transient ischemic attack(TIA)complicated by severe intracranial arterial stenosis or occlusion(hereafter referred to as ICAS-MSTIA).Methods Retrospectively enrol consecutive ICAS-MSTIA patients admitted to the Department of Neurology,the First Affiliated Hospital of Xi'an Jiaotong University,from June 2023 to May 2024.In the meantime,healthy controls were openly recruited.The ICAS-MSTIA patients were divided into two groups based on the side of intracranial large artery stenosis or occlusion:the left intracranial large artery involvement group and the right intracranial large artery involvement group.All patients with intracranial large artery stenosis or occlusion underwent MR scanning within 2 weeks after the first episode of TIA or MS,while there was no specific time requirement for MR examination in the healthy control group.On the day of MR scanning,the Montreal cognitive assessment(MoCA)scale was used to evaluate the participants'global cognitive function and performance in various cognitive domains,including visuospatial/executive function,naming,attention,language,abstraction,delayed recall,and orientation.General information of all participants was collected,including age,sex,educational level,body mass index,and history of smoking and alcohol consumption.Clinical data were collected from both left and right intracranial large artery involvement groups,including cerebrovascular risk factors(such as,diabetes mellitus,hypertension,and hyperlipidemia),National Institutes of Health stroke scale(NIHSS)score at admission,responsible stenotic or occluded arteries(internal carotid artery,middle cerebral artery),degree of stenosis in the responsible vessel(severe stenosis[stenosis rate 70%-99%],occlusion[stenosis rate100%])and non-responsible vessel(no stenosis[0],mild stenosis[stenosis rate＞0-49%]),collateral circulation compensation(American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology[ASTIN/SIR]collateral circulation classification),and responsible events(TIA,MS).General data and MoCA scale scores were compared across the three groups,while clinical data were compared between the left and right intracranial large artery involvement groups.Statistical parametric mapping 12(SPM 12)was used to perform voxel-wise independent samples t-tests on cerebral blood flow(CBF)differences among the left ICAS-MSTIA group,right ICAS-MSTIA group,and healthy control group,with cluster-level family-wise error(FWE)correction applied for adjustment.Multiple linear regression analysis was conducted to evaluate the relationship between global CBF values and total MoCA scores in ICAS-MSTIA patients with left or right intracranial large artery involvement.Results A total of 33 ICAS-MSTIA patients and 33 healthy controls were enrolled in the study.Among the ICAS-MSTIA patients,21 had left intracranial large artery involvement and 12 had right involvement.(1)Among the three groups,statistically significant differences were observed in the proportions of individuals with reported smoking history(P=0.024)and alcohol consumption history(P=0.011).The left intracranial large artery involvement group had a higher NIHSS score(0[0,2]vs.0[0,0],P=0.044)and a higher proportion of patients with internal carotid artery involvement(13/21 cases vs.2/12 cases,P=0.027)compared with the right side group.No statistically significant differences were observed in other general or clinical data across the three groups or between the two non-control groups(all P＞0.05).(2)Statistically significant differences were found across the three groups in the MoCA scale total score and scores of visuospatial/executive function,attention,language,abstraction,delayed recall,and orientation cognitive domains(all P＜0.05),while no significant difference was noted in the naming score(P=0.063).The left intracranial large artery involvement group had lower total MoCA score and lower scores in visuospatial/executive function,attention,language,abstraction,delayed recall,and orientation in comparison to the healthy control group(all P＜0.016 7).The right intracranial large artery involvement group had significantly lower scores in language,abstraction,and orientation domains than the healthy control group(all P＜0.016 7).Additionally,the left side group had a lower attention domain score than the right side group(P＜0.016 7).No other statistically significant differences were found in pairwise comparisons(all P＞0.016 7).(3)Patients in both the left and right intracranial large artery involvement groups exhibited a significant decrease in CBF in extensive regions on the affected side,including the temporal lobe,dorsolateral prefrontal cortex,and occipital lobe.Furthermore,after correction,in the left involvement group CBF was higher in the contralateral lingual gyrus,cuneus,and calcarine sulcus compared with the healthy control group(P＜0.05).While in the right involvement group,no regions had increased CBF compared to the healthy control group.(4)Multiple linear regression showed positive correlation between CBF in ipsilateral precentral gyrus and superior temporal gyrus,and the total MoCA score in patients with left intracranial large artery involvement(FWE-corrected,P＜0.05).In contrast,there was no correlation between CBF and total MoCA score in patients with right intracranial large artery involvement.Conclusions ICAS-MSTIA patients exhibited various degrees of impairment in cerebral perfusion and cognitive function.A significant positive correlation is observed between these two impairments in patients with left intracranial large artery involvement.

Abstract:Non-acute symptomatic intracranial artery occlusion carries a high risk of stroke recurrence and can lead to severe neurological deficits.Although endovascular treatment is a pivotal treatment modality,optimal surgical patient selection criteria remain controversial and as its postoperative outcome varies substantially among individuals.This article addressed these critical issues by exploring imaging-based strategies to identify patients who may benefit from endovascular revascularization,analyzing factors influencing technical success and procedural risks and emphasizing the necessity of individualized treatment approaches.Furthermore,this article discussed the current limitations in endovascular treatment and proposed future research directions to standardize and optimize the clinical application of this technology for non-acute symptomatic intracranial artery occlusion.

Abstract:Objective To investigate the effects of emergency endovascular treatment on the short-term and long-term prognosis of patients with minor stroke(National Institutes of Health stroke scale[NIHSS]score≤5)caused by posterior circulation large vessel occlusion(LVO).Methods A retrospective analysis was performed on consecutive patients with minor stroke caused by posterior circulation LVO admitted to the Department of Neurology,the First Affiliated Hospital of Xi'an Jiaotong University from July 2019 to March 2024.The patients were divided into the emergency endovascular treatment group and the standard medical treatment group according to the treatment method.Baseline and clinical data were collected from all patients enrolled,including age,sex,smoking history,history of alcohol consumption,medical history(hypertension,diabetes,hyperlipidemia,atrial fibrillation,transient ischemic attack[TIA],blood pressure on admission,stroke history,coronary heart disease),intravenous thrombolysis,tandem lesions,posterior circulation Alberta stroke program early CT score(pc-ASPECTS)on admission,NIHSS score on admission and discharge,time from onset to admission,responsible occluded vessel(basilar artery,left vertebral artery,right vertebral artery),vertebral artery development(left vertebral artery dominant,right vertebral artery dominant,bilateral vertebral artery dominant),non-lesion side vertebral artery development(poor,good,not applicable),basilar artery on CT angiography(BATMAN)score,leptomeningeal branch compensation(open,not open),surgery-related indicators(number of thrombectomy passes[≤2 times,＞2 times],rescue interventions[stent placement,balloon dilation,arterial thrombolysis,intra-arterial tirofiban infusion],immediate postoperative modified thrombolysis in cerebral infarction[mTICI]grade≥2b[successful recanalization],anesthesia method[general,local],endotracheal intubation status[yes,no],duration of mechanical ventilation[not using a ventilator or successfully intubation for≤24 hours and＞24 hours]),in-hospital systematic complications(deep-vein thrombosis,urinary tract infection,lung infection).The primary outcome for short-term prognosis was an excellent outcome(modified Rankin scale[mRS]score of 0-1)within 90 days after onset.Secondary outcomes included a good outcome(mRS score of 0-2)within 90days after onset,recurrent ischemic stroke within 90 days after onset,all-cause mortality within 90 days after onset.Safety outcomes were symptomatic intracerebral hemorrhage(sICH)within 24 hours of treatment(NIHSS score increased by≥4 points or increased level of consciousness score by≥1 point compared with admission,with visible hemorrhagic lesions on follow-up CT scan)and early neurological deterioration(END,NIHSS score increased by≥2 points or motor score increased by≥1 point compared with admission,within 24 hours after treatment).Long-term outcome was defined as recurrent ischemic stroke within 1 year after onset.Short-term and safety outcomes were compared between the emergency endovascular treatment group and the standard medical treatment group.Kaplan-Meier survival curves was used to evaluate the effect of emergency endovascular treatment on the long-term prognosis.Based on the mRS score at 90 days from onset,all patients were divided into an excellent outcome(mRS score 0-1)group and a non-excellent outcome(mRS score 2-6)group.Baseline and clinical data were compared across the two groups.Variables with statistically significant differences were included in the multivariate Logistic regression analysis to investigate the influencing factor of 90-day excellent outcomes in patients with minor stroke caused by posterior circulation LVO.Results A total of 56 patients with minor stroke caused by posterior circulation LVO were enrolled,including 18 patients in the emergency endovascular treatment group and 38 patients in the standard medical treatment group.45 patients achieved excellent outcomes and 11 patients achieved non-excellent outcomes.(1)The emergency endovascular treatment group had lower pc-ASPECTS on admission(8.0[7.0,9.0]points vs.9.0[8.0,10.0]points,P=0.043)and There were no statistically significant differences in the excellent outcome rate,good outcome rate,and ischemic stroke recurrence rate within 90 days after onset between the two groups(all P＞0.05).No all-cause mortality occurred within 90 days after onset in either group.In the emergency endovascular treatment group,one patient developed sICH and one developed END within 24 hours after treatment.(3)No recurrent ischemic stroke in the emergency endovascular treatment group within 1 year after onset,while 3cases(7.89%)of recurrence were observed within 1year after onset in the standard medical treatment group.The Kaplan-Meier survival curve analysis showed that there was no statistically significant difference in the incidence of ischemic stroke within one year after onset between the two groups(P=0.341).(4)There were statistically significant differences between patients with excellent outcome and patients with non excellent outcome in drinking history,diabetes history,NIHSS score after discharge,distribution of responsible occlusive vessels,and distribution of vertebral artery development(all P＜0.05).The results of multivariate Logistic regression analysis showed that the NIHSS score at discharge was an independent influencing factor for excellent outcome at 90 days after onset in patients with minor stroke caused by posterior circulation LVO(OR,0.448,95%CI 0.275-0.728,P=0.001).Conclusions This study shows potential safety and effectiveness of emergency endovascular treatment on patients with minor stroke caused by posterior circulation LVO,but it is not superior to standard medical treatment in terms of short-term and long-term outcomes.Further large-sample randomized controlled trials are warranted to validate the findings of this study.

Abstract:Objective To evaluate the safety and efficacy of the Neuroform EZ self expanding stent for severe symptomatic intracranial atherosclerotic stenosis(sICAS).Methods Retrospectively enrolled consecutive patients with severe sICAS who underwent percutaneous transluminal angioplasty and stenting(PTAS)with a Neuroform EZ stent in the Department of Cerebrovascular Disease,Henan Provincial People's Hospital,from March 2020 to December 2022.Baseline demographic and clinical data were collected,including age,sex,hypertension,diabetes mellitus,coronary artery disease,dyslipidemia,hyperhomocysteinemia,transient ischemic attack(TIA)and ischemic stroke,smoking history,modified Rankin scale(mRS)score at admission,and National Institutes of Health stroke scale(NIHSS)score.Preoperative imaging data included target vessel(basilar artery,intracranial segment of the internal carotid artery,middle cerebral artery,and intracranial vertebral artery),lesion length,degree of stenosis,and vascular morphology according to the Mori classification(type A,lesion length＜5 mm with concentric or moderately eccentric stenosis;type B,lesion length＜10 mm with severely eccentric stenosis;type C,lesion length＞10 mm or arterial angulation＞90°).Technical success was defined as accurate delivery and deployment of the stent with complete coverage of the target lesion and immediate post deployment residual stenosis＜50%.Postoperative head CT was performed to detect intracranial hemorrhage.Periprocedural complications were recorded,including intracranial hemorrhage,arterial dissection,in stent thrombosis,and perforator occlusion occurring intraoperatively within 72 hours after the procedure.At one-month post-operation,patients were seen through outpatient follow-up for TIA,hemorrhagic or ischemic stroke,and all cause death.At 6 months after surgery,DSA or CT angiography(CTA)was performed to assess in stent restenosis(ISR,defined as＞50%stenosis within the stent or within5mm of its edges,or＞20%luminal loss).At 1 and 2 years postoperatively,ipsilateral ischemic stroke or TIA recurrence was assessed by outpatient visit or telephone follow up.Results A total of 76 patients with severe sICAS underwent PTAS with a Neuroform EZ stent(56 males,20 females,age 47-80 years,with a mean age of[61±10]years).(1)Within all patients enrolled,40 had middle cerebral artery,16 with basilar artery,6 with intracranial vertebral artery and 14 with intracranial internal carotid artery.The preprocedural lesion length was 2-15 mm,with a mean length of(6.2±2.5)mm,and stenosis severity was70%-99%,the mean severity was(83.2±6.9)%,with Mori type B being the most common type(57.9%[44/76]).(2)PTAS was successfully completed on all patients(technical success 100%).Pre dilation with a conventional balloon was performed in all cases(using balloon with diameter of 1.5-3.5mm,and stent with diameter of 2.5-4.5 mm and length of 15-30 mm).Immediate post procedural residual stenosis was(17.4±9.0)%,significantly lower than baseline(t=52.9,P＜0.05),with a mean difference of 65.8%(95%CI63.3%-68.3%).(3)Among all 76patients,one patient developed a flow limiting dissection post balloon angioplasty,which recovered after stent deployment.One patient with basilar artery stenosis experienced recurrent ischemic stroke at 5-day postoperatively,presenting with right sided weakness and coughing on liquids.Imaging showed an acute infarct in the left pons,considered perforator occlusion.The overall periprocedural complication rate was 2.6%(2/76).(4)No deaths occurred within 30 days after surgery.Sixty nine patients(90.8%)underwent 6 month imaging follow up with DSA(52 cases)or CTA(17 cases).ISR occurred in 12 patients(17.4%),including 6 asymptomatic and 6symptomatic cases.The ipsilateral ischemic stroke recurrence rate was 6.6%(5/76)at1 year and13.2%(10/76)at2years.Conclusions Neuroform EZstent assisted PTASappears safe and feasible for the treatment of severe sICAS.The long term effectiveness requires confirmation in large,multicenter,prospective studies.

Abstract:Objective To construct a predictive model for futile recanalization after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke and evaluate its predictive efficacy.Methods Patients with acute stroke caused by anterior circulation large vessel occlusion who underwent endovascular treatment with successful vascular recanalization(modified thrombolysis in cerebral infarction[mTICI]grade 2b or 3)admitted to the Department of Neurosurgery of Tianjin Union Medical Center(the First Affiliated Hospital of Nankai University)from January 2022 to January 2025 were retrospectively and consecutively included.Patients were divided into effective recanalization group(modified Rankin scale[mRS]score≤2)and futile recanalization group(mRS score＞2)according to the mRS score at 90 days after endovascular treatment.Baseline and clinical data were collected,including sex,age,medical history(stroke history,hypertension,diabetes mellitus,atrial fibrillation),personal history(smoking history,alcohol consumption history),and National Institutes of Health stroke scale(NIHSS)score,blood pressure,blood glucose,total cholesterol,triglycerides,high-density lipoprotein cholesterol,low-density lipoprotein cholesterol,creatinine,neutrophil-to-lymphocyte ratio,fibrinogen,D-dimer,lymphocyte-to-monocyte ratio,white blood cell count,hemoglobin,albumin,C-reactive protein-to-albumin ratio,platelet-to-lymphocyte ratio at admission.Imaging data including culprit vessel(middle cerebral artery,anterior cerebral artery,internal carotid artery),Alberta stroke program early CT score(ASPECTS),infarct core volume,hypoperfusion area volume,mismatch volume between infarct core and hypoperfusion area,American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology(ASITN/SIR)collateral circulation grading,trial of Org 10172 in acute stroke treatment(TOAST)classification.Surgery-related data including onset-to-puncture time,successful puncture-to-vascular recanalization time,immediate postoperative mTICI grade,complications within 24 hours postoperatively(fever,hemorrhagic transformation,symptomatic intracranial hemorrhage),immediate postoperative mTICI grade.Factors with P＜0.05 and without multicollinearity(variance inflation factor≥5)in univariate analysis were included in multivariate Logistic regression model analysis to analyze independent influencing factors for futile recanalization after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke.A nomogram prediction model was constructed based on statistically significant factors in multivariate Logistic regression analysis,and Hosmer-Lemeshow test was used to assess the goodness of fit of the model.The receiver operating characteristic(ROC)curve of the nomogram prediction model for predicting futile recanalization after endovascular treatment in patients with anterior circulation large vessel occlusion stroke was drawn,and calibration curve was used to evaluate the calibration of the nomogram prediction model.Results A total of 187 patients who met the criteria of this study were included,comprising 101 males and 86 females,aged 42-85 years,with a mean age of(70±6)years.The mRS scores at 90days after treatment were:0points in 21 cases(11.23%),1 point in 37 cases(19.79%),2 points in 28 cases(14.97%),3 points in 46 cases(24.60%),4 points in 31 cases(16.58%),5 points in 24 cases(12.83%),and 6 points in 0case.There were 86cases in the effective recanalization group and 101 cases in the futile recanalization group.(1)Statistically significant differences between the two groups were observed in age,atrial fibrillation,infarct core volume,admission NIHSS score,neutrophil-to-lymphocyte ratio,lymphocyte-to-monocyte ratio,and C-reactive protein-to-albumin ratio(all P＜0.05).(2)Multicollinearity analysis showed that the variance inflation factors of all independent variables with statistically significant differences in univariate analysis were all＜5,indicating no multicollinearity.Multivariate Logistic regression analysis showed that age(OR,1.101,95%CI 1.046-1.158,P=0.037),infarct core volume(OR,1.350,95%CI 1.202-1.517,P＜0.01),admission NIHSS score(OR,1.501,95%CI 1.213-1.858,P＜0.01),lymphocyte-to-monocyte ratio(OR,0.039,95%CI 0.009-0.179,P＜0.01),and C-reactive protein-to-albumin ratio(OR,6.015,95%CI 1.625-22.257,P=0.007)were independent influencing factors for futile recanalization after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke.(3)The receiver operating characteristic curve of the nomogram prediction model for futile recanalization after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke was constructed based on statistically significant factors in multivariate analysis showed a specificity of 0.970,sensitivity of 0.895,precision of 0.916,recall of 0.970,and area under the curve of 0.979(95%CI0.962-0.996,P＜0.01).The absolute mean error of the calibration curve was 0.008,with predicted values close to actual values.Hosmer-Lemeshow test results showed that the model had good consistency without overfitting(χ2=4.830,P=0.776).Conclusions Age,infarct core volume,admission NIHSS score,lymphocyte-to-monocyte ratio,and C-reactive protein-to-albumin ratio are all independent influencing factors for futile recanalization after endovascular treatment in acute anterior circulation large vessel occlusion stroke.The nomogram prediction model constructed accordingly can predict the risk of futile recanalization after endovascular treatment in patients with anterior circulation large vessel occlusion stroke.