Abstract:Unruptured intracranial aneurysms(UIA)are relatively common.Their rupture can result in high rates of mortality and disability.Small UIA,defined as those with the largest dimension less than 5 mm,account for approximately 90%of all UIA.Although multiple studies indicate a low annual rupture risk for small UIA,they nonetheless account for a considerable proportion of ruptured aneurysms.Assessing the rupture risk of small UIA and selecting safe and appropriate management strategies remain critical challenges in clinical practice.This article aimed to review recent advances in the rupture risk assessment and management of small UIA,and to provide insights for clinical decision-making.

Abstract:Objective To construct an optimal machine learning model for predicting cryptogenic stroke in patients with right-to-left shunt(RLS)and perform interpretability analysis.Methods Retrospectively enroll continuous patients with RLS diagnosed with contrast-enhanced transcranial Doppler ultrasound(c-TCD)foaming experiment for migraine,dizziness(of unknown etiology),stroke,etc.,treated in the Department of Neurology at Laoshan Campus,the Affiliated Hospital of Qingdao University from January 2018 to December 2024.Patient demographics and cardiac parameters from transthoracic echocardiography(TTE)were collected including sex,age,smoking history,alcohol consumption history,hypertension,diabetes,hyperlipidemia and left atrial diameter(LAd),left atrial short diameter(LASd),left atrial longitudinal diameter(LALd),left ventricular end-diastolic inner diameter(LVDd),left ventricular end-systolic inner diameter(LVDs),left ventricular posterior wall thickness(LVPW),interventricular septal thickness(IVS),left ventricular ejection fraction(LVEF),and pulmonary artery systolic pressure(PASP).All patients were categorized into cryptogenic stroke and non-stroke group based on the occurrence of cryptogenic stroke.General characteristics and TTE cardiac parameters were compared between groups.Six machine learning models,including Logistic regression,decision tree,random forest,extreme gradient boosting(XGBoost),gradient boosting,and extreme tree were constructed using general characteristics and cardiac parameters collected from TTE to predict the occurrence of cryptogenic stroke in RLS patients.The performance of the six machine learning models was evaluated using 5-fold cross-validation repeated 10 times.Receiver operating characteristic(ROC)curves were plotted for each model,and the area under the curve(AUC),precision,recall,accuracy,and F1 score were calculated.Calibration curves were plotted for each model to assess whether predicted probabilities approximated true probabilities.Decision curve analysis(DCA)was used to evaluate the net benefit provided by each of the 6 models in predicting cryptogenic stroke in RLS patients within specific threshold probability ranges to determine its clinical value.Threshold ranged 0-＜0.3 was defined as low-risk zone,0.3-0.6 as moderate-risk zone,and>0.6-1.0 representing high-risk zone.The optimal machine learning model was selected based on the best performance across 10rounds of 5-fold cross-validation(primarily using AUC as the metric;when AUC was equal,the model with the highest sensitivity was prioritized).The Delong test was employed to compare the AUC differences between the best-performing model and other models.All patients were randomly divided into training and testing sets at an 8∶2 ratio.The optimal machine learning model was retrained on the training set and then applied to the testing set data for Shapley additive explanations(SHAP)analysis.Core predictors for cryptogenic stroke in RLS patients were identified by descending average SHAP values in feature importance histograms.SHAP scatter plots was plotted to reveal the correlations between feature-value and model outputs.SHAP Force plots was used to test individual patient prediction mechanisms,and to represent each feature's directional and intensity contribution to case-specific decisions through area-based visualization.Partial dependency plots(PDPs)were generated for the top two SHAP-ranked features to evaluate their marginal effects and nonlinear trends in predicting cryptogenic stroke in RLS patients,and explore how the SHAP tree model quantified the relationship between key predictors and risk.Results A total of 310 patients with RLS were included,comprising 181 males and 129 females aged 18 to 70 years with median of 52(43,52)years.Among them,164 patients was categorized into the cryptogenic stroke group and 146 to the non-stroke group.(1)Compared with the non-stroke group,patients with RLS in the cryptogenic stroke group had significantly higher age,more male patients,and higher proportion of patients with hypertension,diabetes hyperlipidemia,smoking history,and alcohol consumption history.Additionally,they demonstrated significantly larger LAd,LASd,LALd,LVDd,LVDs,LVPW,IVS,and PASP(all P＜0.05).No statistically significant differences were observed in LVEF between groups(P=0.306).(2)ROC curve analysis of six machine learning models predicting cryptogenic stroke using RLS,evaluated via 5-fold cross-validation with 10 repetitions.From the analysis,the extreme tree model had the highest average AUC(0.804)in the prediction of cryptogenic stroke in RLS patients,with random forest(0.792)ranked second,and in descending order,gradient boosting(0.777),XGBoost(0.776),Logistic regression(0.764),and decision tree(0.717).(3)Calibration curve results indicated that the extreme tree model's calibration curve(Brier score0.197)most closely approximated the reference line,followed by random forest(Brier score 0.210),Logistic regression(Brier score 0.222),gradient boosting(Brier score 0.244),decision tree(Brier score 0.263),and with the XGBoost(Brier score 0.280)performing worst.DCA revealed that within certain medium probability threshold ranges(0.3-0.6),the extreme tree model's DCA curve demonstrated higher net gain rates,showing significantly better performance than other models at specific points.At high probability thresholds(>0.6-1.0),the net gain rate decreased.At low probability thresholds(0-＜0.3),the net gain rate was low and approached the non-intervention curve,with the difference narrowing.Among the six machine learning models,the extreme tree model performed best,achieving an AUC of 0.804,accuracy of 0.719,and F1 score of 0.736.Delong's test revealed a statistically significant difference in AUC between the extreme tree and decision tree models(P＜0.05),while no significant differences were observed with other machine learning models(all P>0.05).(4)Among 310 RLS patients,248 were in the training set and 62 in the test set.Compared with the test set,RLS patients in the training set had significantly higher PASP(P=0.037).No statistically significant differences were observed between the training and test sets in general characteristics or TTE cardiac parameters(all P>0.05).(5)The extreme tree model was retrained based on the training set data and tested with data in the testing set.An SHAP analysis was then performed on this result.The SHAP analysis showed that LAd was the most important feature,followed by LALd,age,LVPW,LVDs,hypertension,LVDd,smoking history,and PASP.The SHAP scatter plot indicated that the top two factors potentially increasing the risk of cryptogenic stroke in RLS patients were LAd and LALd.(6)The Force plot of the decision tree model showed that when the patient's SHAP value was 1.0,the age was 68years old,and the corresponding LAd,LALd,LVDd,IVS,and LVDs were 34,56,48,10,and 30 mm,respectively.Among these,the LALd region had the largest proportion,while the LVEF region had the smallest proportion.(7)The partial dependency plot generated based on the top two feature importance values of LAd and LALd from the extreme tree model showed that,when LAd＜32 mm,the prediction probability was around 0.40;when LAd was between32-42mm,it increased from0.35 to0.60,if LAd>42mm,the growth rate of slows,with an average prediction probability value of 0.65.While,if LALd＜40 mm,the prediction probability remains stable below 0.40;if LALd was between 40-55 mm,it steadily increased to nearly 0.60;and the growth rate slowed when LALd>55 mm.Conclusions The extreme tree model constructed using general and cardiac parameters of RLS patients can make relatively accurate prediction of the risk of cryptogenic stroke in patients with RLS,with LAd and LALd ranked as the top two factors influencing the model's output.The model's validity in external cohorts and its potential for translating predictive value for cryptogenic stroke risk remain to be determined.

Abstract:Subarachnoid hemorrhage(SAH)is associated with high rates of mortality and disability,the vast majority of survivors suffered from severe cognitive impairments affecting multiple key domains such as language,memory,executive function,and processing speed.Research suggested that post-SAH cognitive impairment was closely related to factors such as early brain injury and delayed cerebral ischemia,yet its specific pathophysiological mechanisms remain incompletely understood.This article reviewed the pathophysiology,risk factors,assessment,and treatment of cognitive impairment following SAH,aiming to provide insights for clinical research and practice.

Abstract:Objective To investigate the associations of body mass index(BMI)and triglyceride-glucose(TyG)index with early neurological deterioration(END)in patients with large artery atherosclerosis(LAA)-type minor ischemic stroke,and to analyze the mediating effect of TyG index on the relationship between BMI and the risk of END in LAA-type minor ischemic stroke.Methods A retrospective consecutive cohort study was conducted on patients with LAA-type minor ischemic stroke(National Institutes of Health stroke scale[NIHSS]score≤5 on admission)diagnosed and treated in the Department of Neurology of Suqian First Hospital,from January 2023 to July 2025.Clinical data of the patients,including gender,age,BMI,admission blood pressure(systolic and diastolic blood pressure),risk factors for cerebrovascular diseases(hypertension,diabetes mellitus,coronary heart disease,history of stroke,smoking history[smoking was defined as smoking at least 1 cigarette per day for≥1 year],heavy alcohol consumption[alcohol intake≥24 g/d]),and NIHSS score on admission were collected.Fasting blood samples were collected within 24 hours after admission for complete laboratory examinations,including platelet count,neutrophil count,lymphocyte count,fasting blood glucose,creatinine,total cholesterol,triglycerides,high-density lipoprotein cholesterol,and low-density lipoprotein cholesterol.The treatment regimens within 72 hours after admission included monotherapy antiplatelet therapy,dual antiplatelet therapy,statins,antihypertensive drugs,and hypoglycemic drugs.The TyG index was calculated as ln(fasting triglycerides[mg/dl]×fasting blood glucose[mg/dl]/2),where triglycerides(mg/dl)=triglycerides(mmol/L)×88.57 and fasting blood glucose(mg/dl)=fasting blood glucose(mmol/L)×18.02.END was defined as an increase of≥2 points in the NIHSS score or an increase of≥1 point in the motor subscore within 72 hours after the onset of acute ischemic stroke compared with the scores at admission.All patients were divided into the END group and non-END group according to the occurrence of END.Clinical data were compared between the two groups,and variables with statistically significant differences in univariate analysis were included in multivariate Logistic regression analysis to explore the independent risk factors for END in LAA-type minor ischemic stroke.Spearman correlation analysis was used to investigate the correlations of BMI and TyG index with the occurrence of END in patients with LAA-type minor ischemic stroke,as well as the correlation between BMI and TyG index,with the correlation intensity classified as:extremely strong correlation(0.8≤|r|＜1.0),strong correlation(0.6≤|r|＜0.8),moderate correlation(0.4≤|r|＜0.6),weak correlation(0.2≤|r|＜0.4),and extremely weak correlation(0＜|r|＜0.2).The Bootstrap method was adopted to analyze whether the TyG index mediated the association between BMI and END in LAA-type minor ischemic stroke;the mediating effect was considered to be established if the total effect(c),the effect of the independent variable(BMI)on the mediating variable(TyG index)(a),the effect of the mediating variable(TyG index)on the dependent variable(END in LAA-type minor ischemic stroke)(b),and the indirect effect(95%CI excluding 0)were all statistically significant.If the 95%CI of the indirect effect included 0,there was no mediating effect.Based on the established mediating effect,the partial mediating effect was confirmed if the direct effect coefficient c' of BMI on END in LAA-type minor ischemic stroke was statistically significant(P＜0.05)after controlling for the mediating variable(TyG index).Results A total of 381 patients with LAA-type minor ischemic stroke were enrolled,including 227 males and 154 females,aged 34 to 94 years,with a mean age of(66±11)years.Among them,120 patients were in the END group and 261 in the non-END group.(1)Statistically significant differences were observed between the END group and non-END group in the proportion of patients with diabetes mellitus(33.3%[40/120]vs.21.8%[57/261]),admission systolic blood pressure([167±21]mmHg vs.[158±21]mmHg),admission diastolic blood pressure([93±15]mmHg vs.[86±16]mmHg),fasting blood glucose(6.36[5.34,8.85]mmol/L vs.5.51[4.95,6.57]mmol/L),total cholesterol([4.74±1.18]mmol/L vs.[4.31±1.05]mmol/L),triglycerides(1.25[0.84,1.91]mmol/L vs.1.09[0.73,1.43]mmol/L),low-density lipoprotein cholesterol([3.08±0.88]mmol/L vs.[2.75±0.90]mmol/L),BMI([26.20±3.85]kg/m2 vs.[24.35±2.84]kg/m2),and TyG index(8.84±0.83 vs.8.42±0.78,all P＜0.05).(2)Multivariate Logistic regression analysis(excluding fasting blood glucose and triglycerides)showed that BMI(OR,1.136,95%CI 1.051-1.228)and TyG index(OR,1.631,95%CI 1.160-2.295)were independent risk factors for END in patients with LAA-type minor ischemic stroke(both P＜0.05).(3)Spearman correlation analysis revealed that TyG index(r=0.222)and BMI(r=0.216)were positively correlated with the occurrence of END in LAA-type minor ischemic stroke(both P＜0.01),and TyG index was also positively correlated with BMI(r=0.214,P＜0.01).(4)Mediation effect analysis using the Bootstrap method with TyG index as the mediating variable showed that BMI had a direct effect on END in patients with LAA-type minor ischemic stroke(c'=0.155,95%CI 0.081-0.230,P＜0.01),and TyG index exerted a partial mediating effect on the association between BMI and END(β=0.032,95%CI 0.012-0.060,P＜0.01).The total effect value c was 0.187,and the mediating effect accounted for 17.11%of the total effect.Conclusions Both BMI and TyG index are associated with the occurrence of END in patients with LAA-type minor ischemic stroke,and TyG index exerts a mediating effect on the relationship between BMI and the risk of END in these patients.Therefore,in clinical practice,the TyG index may serve as a simple and valuable auxiliary metabolic marker for assessing the risk of END in patients with LAA-type minor ischemic stroke.

Abstract:Acute basilar artery occlusion is a cerebrovascular disease with high mortality and disability rates.Early recanalization of the occluded vessel is the cornerstone of treatment.In patients with tandem lesions involving the dominant vertebral artery,revascularization of the occluded vertebral artery is the priority to establish access for subsequent basilar artery thrombectomy.When antegrade recanalization of the vertebral artery is challenging,a retrograde approach via collateral circulation may serve as an alternative strategy.This article presented a case of acute basilar artery occlusion with failed initial antegrade recanalization of the occluded left dominant vertebral artery.Successful retrograde revascularization was subsequently achieved via the anastomosis between the ascending cervical artery and the left vertebral artery,followed by antegrade guide catheter placement through the left radial artery approach to perform thrombectomy.The occluded vessel achieved favorable recanalization,and the patient's 90-day follow-up modified Rankin scale score was 1.

Abstract:Complex intracranial aneurysms are refractory cerebrovascular lesions.In the context of microsurgical clipping or endovascular treatment,complex intracranial aneurysms are defined as intracranial aneurysms that cannot be safely and effectively managed using conventional methods due to factors such as morphology,size,aneurysm neck structure,and the intricate relationship between the parent artery and its branch vessels.In recent years,with advancements in microsurgical techniques and intraoperative monitoring,the application of cerebral revascularization for the treatment of complex intracranial aneurysms has become increasingly mature,demonstrating overall safety and efficacy.This article reviewed the classification of bypass methods,indications,selection of donor and recipient vessels,preoperative assessment,intraoperative monitoring,and clinical effectiveness aiming to provide a comprehensive reference for clinicians to formulate individualized treatment strategies for intracranial complex aneurysms.

Abstract:Objective To analyze factors influencing falls in elderly patients with multimorbidity in the chronic phase of cerebral infarction and construct a nomogram model for predicting the risk of falls.Methods Consecutive elderly patients(aged≥60 years)with multimorbidity(co-occurrence of≥2 mental conditions)in chronic phase of cerebral infarction(latest onset to admission time≥1 month)who were admitted to the Geriatrics Department of the Second People's Hospital of Hefei from August 2022 to October 2024 were retrospectively included in this study.General and clinical data were collected from patients enrolled,including gender,age,body mass index,number(≥3 or 2)and types of comorbidities(hypertension,diabetes,coronary heart disease,chronic heart failure,sarcopenia,osteoporosis,and other chronic diseases such as hypothyroidism and hyperplasia of prostate,et al),nutritional status(nutritional risk screening 2002[NRS-2002]scale score),and fall risk score(Tinetti performance-oriented mobility assessment[Tinetti POMA]scale),limb function(modified Rankin scale[mRS]),cognitive status(Montreal cognitive assessment[MoCA]scale score),lower limb hemiplegia(Brunnstrom stage),and incidence of falls during follow-up period(6months after admission).On the morning following admission,fasting venous blood samples were collected to measure the levels of glycated hemoglobin,fasting blood glucose,albumin,prealbumin,triglyceride,total cholesterol,low-density lipoprotein,high-density lipoprotein,creatinine,and uric acid.According to whether falls occurred during 6 months follow-up period,the patients were divided into the fall group and the non-fall group.General data,clinical data and laboratory indexes of the two groups were compared.Factors with statistically differences found by univariate analysis were included in multivariate Logistic regression to identify the influencing factors of falls in elderly patients with multimorbidity in the chronic phase of cerebral infarction,and a nomogram prediction model was constructed.The receiver operating characteristic(ROC)curve,calibration curve,and clinical decision curve were used to assess the predictive efficacy of the nomogram model.Results A total of 147 elderly patients with coexistence of multiple diseases in chronic phase of cerebral infarction were included,including 59 males and 88 females,age ranged from 61 to 93 years old,with an average age of(77±7)years old.The time from last onset to admission was 17-122months,with an average of(63±17)months.The number of comorbidities was 2-6types,with a median value of 3(2,4)kinds.The top three comorbidity types were hypertension(94.56%[139/147]),diabetes(57.14%[84/147]),sarcopenia(42.86%[63/147]),and osteoporosis(42.86%[63/147]).During the follow-up period,54(36.73%)patients experienced falls and were assigned to the fall group.The remaining 93 patients were assigned to the non-fall group.(1)Compared with the non-fall group,the fall group had significantly older age(82[76,85]years vs.75[69,82]years),higher NRS-2002 scale score(4[3,4]points vs.3[2,3]points),higher incidence rate of≥3 types of comorbidities(94.44%[51/54]vs.44.09%[41/93]),higher prevalence of osteoporosis(70.37%[38/54]vs.26.88%[25/93])and sarcopenic(81.48%[44/54]vs.20.43%[19/93]);and,significantly lower Tinetti POMA scale score([16.59±1.09]points vs.[17.41±1.02]points)and albumin level(37.65[35.60,39.73]g/L vs.39.90[37.55,41.95]g/L;all P＜0.01).(2)Multivariate Logistic regression analysis showed that osteoporosis(OR,3.059,95%CI 1.063-8.797),sarcopenia(OR,23.698,95%CI 5.157-108.912),having≥3 types of comorbidities(OR,16.839,95%CI 2.227-127.348),and high NRS-2002 scale score(OR,5.346,95%CI 2.035-14.047)were risk factors for falls in elderly patients with multimorbidity in the chronic phase of cerebral infarction(all P＜0.05),while high Tinetti POMA scale score was a protective factor(OR,0.434,95%CI 0.217-0.868,P=0.018).(3)A nomogram for falls in elderly patients with multimorbidity in the chronic phase of cerebral infarction was plotted based on multivariate Logistic regression analysis results.ROC curve showed that the area under the curve of the nomogram model for predicting falls in elderly patients with coexistence of multiple diseases in chronic phase of cerebral infarction was 0.894(95%CI 0.840-0.948).The sensitivity and specificity were 77.80%and 90.30%,respectively.Hosmer-Lemeshow goodness of fit test showed that the nomogram model fitted well(χ2=9.612,P=0.293).The decision curve showed that better clinical benefits could be achieved at the threshold between 0.01 and 0.99.Conclusions Hypertension and diabetes are common comorbidities in elderly patients with multimorbidity in the chronic phase of cerebral infarction.Such patients have a relatively higher incidence of falls.Moreover,the incidence of falls is related to factors such as osteoporosis,sarcopenia,high number of comorbidities,high nutritional risk,and low Tinetti POMA score.The nomogram model constructed based on above factors demonstrates good predictive efficacy and can serve as a quantitative tool for prediction of falls and generation of prevention strategies in clinical practice.

Abstract:Ischemic stroke is characterized by high incidence,high disability rate,and high mortality rates.Its pathophysiological mechanisms involve multiple forms of cell death,including apoptosis,necroptosis,pyroptosis,ferroptosis,and cuproptosis.These forms interacted with each other and collectively drive disease progression.This review systematically reviewed the characteristics and regulatory mechanisms of different cell death forms,as well as their roles in ischemic stroke.It also discussed the crosstalk among these forms and summarized research progress on pharmacological interventions targeting various forms of cell death modalities,aiming to provide a basis for identifying novel therapeutic targets and strategies for the treatment of ischemic stroke.

Abstract:Objective To develop a standardized arterial transit artifact(ATA)scoring system and evaluate its prognostic value for 90-day clinical outcomes in patients with anterior circulation large vessel occlusion(LVO)stroke undergoing mechanical thrombectomy,and to investigate the association between preoperative infarct volume and the ATA score.Methods Prospectively and consecutively included patients with acute anterior circulation LVO stroke who were admitted to the Department of Neurology of Songyuan Jilin Oilfield Hospital from January 2023 to December 2024,had an onset within 24 hours,underwent mechanical thrombectomy,and completed three dimensional-arterial spin labeling(3D-ASL)MR examination before the operation.All general and clinical data were collected,including sex,age,cerebrovascular risk factors(hypertension,diabetes mellitus,atrial fibrillation,smoking history,alcohol consumption,prior stroke history,hyperlipidemia,hyperhomocysteinemia),admission National Institutes of Health stroke scale(NIHSS)score,preoperative infarct volume,time from symptom onset to preoperative MR,site of the responsible occluded vessel(internal carotid artery or M1 segment of the middle cerebral artery),time from symptom onset to successful vessel recanalization,intravenous thrombolysis,and procedural variables(preferred endovascular approach[stent retriever alone,stent retriever combined with aspiration]),number of thrombectomy passes≤2,and rescue interventions(balloon angioplasty,stent placement,balloon angioplasty plus stent placement,or intra-arterial tirofiban infusion),time from femoral artery puncture to successful vessel recanalization.For patients within 4.5hours of onset and without contraindications to intravenous thrombolysis,intravenous thrombolysis with alteplase or tenecteplase was administered.Prior to bridging therapy following intravenous thrombolysis,a comprehensive brain MR was performed,including T1-weighted imaging,T2-weighted imaging,fluid-attenuated inversion recovery,diffusion-weighted imaging,MR angiography,and 3D-ASL.The middle cerebral artery perfusion territory was delineated according to the Alberta stroke program early CT score(ASPECTS)framework and divided into 7 anatomically defined regions(insular lobe,M1-M6 blood supplying area),for each region,the presence or absence of ATA signal within the cerebral sulci was assessed:a score of 1 was assigned if a distinct ATA signal was observed,and a score of 0 if no signal was detected.The total ATA score ranged from 0 to 7,with higher scores indicating more extensive distribution of ATA signals.The ATA scoring was conducted independently by two associate chief physicians from the MR department,each with over nine years of specialized experience in neuroimaging.Inter-rater agreement between the two raters was assessed using Cohen's Kappa coefficient,with the Kappa value interpreted as a measure of effect size.Agreement levels were defined as follows:Kappa value≥0.81,almost perfect;Kappa value 0.61-0.80,good;Kappa value 0.41-0.60,moderate;Kappa value 0.21-0.40,fair;and Kappa value≤0.20,slight.In cases of discordance,a third,senior chief physician from the same department provided the final decision.All patients were classified into two groups based on their 90-day modified Rankin scale(mRS)scores:a favorable outcome group(mRS score≤2)and an unfavorable outcome group(mRS score＞2).Variables exhibiting statistically significant differences between favorable outcome group and unfavorable outcome group were entered into a multivariate Logistic regression model,adjusted for potential confounders,to assess the association between preoperative ATA scores and 90-day favorable outcomes among anterior circulation LVO stroke patients undergoing mechanical thrombectomy and achieved successful recanalization.Receiver operating characteristic(ROC)curve analysis was performed to evaluate the predictive performance of preoperative ATA scores,as quantified by the area under the curve(AUC).Patients were subsequently stratified into low-ATA and high-ATA sub groups according to the optimal cutoff value determined by ROC analysis,and general and clinical characteristics were compared between two subgroups.The correlation between preoperative infarct volume and ATA scores was analyzed using Pearson or Spearman rank correlation,as with|r|≥0.8 indicating an extremely high correlation,and 0.6-＜0.8 indicating a high correlation,0.4-＜0.6 indicating a moderate correlation,0.2-＜0.4 indicating a weak correlation,and＜0.4 indicating an extremely weak correlation or no relation.Results A total of 81 patients with acute anterior circulation LVO who underwent mechanical thrombectomy and achieved successful recanalization were included,56male and25female patients,aged 38 to 81 years with a median age of 66(57,72)years.Of these,43 patients were assigned to the favorable outcome group and 38 patients to the unfavorable outcome group.(1)The ATA scores generated by two MR radiologists demonstrated a high degree of inter-rater agreement,with a Cohen's Kappa value of 0.811(95%CI 0.716-0.905,P＜0.01).(2)Significant differences were identified between the favorable outcome group and the unfavorable outcome group on hyperlipidemia,alcohol consumption,admission NIHSS score,ATA score,and infarot volume(all P＜0.05).(3)After adjustment for potential confounders,multivariate Logistic regression analysis showed that higher preoperative ATA score was an independent predictor of favorable 90-day outcomes in patients with acute anterior circulation LVO who underwent successful mechanical thrombectomy(OR,1.510,95%CI 1.111-2.051,P=0.008).(4)The optimal cutoff value of the preoperative ATA score for predicting 90-day outcomes in patients with anterior circulation LVO stroke who underwent successful mechanical thrombectomy was established at 3.5,with an AUC of 0.742(95%CI 0.635-0.890),sensitivity of 0.628,and specificity of 0.789.Based on this threshold,patients were categorized into the ATA low-score group(＜4 points;46 patients)and the ATA high-score group(≥4 points;35 patients).Comparative analysis demonstrated that the ATA high-score group had significantly lower admission NIHSS scores(12.00[10.50,14.00]scores vs.15.00[12.00,18.75]scores),smaller preoperative infarct volume(16.90[9.80,39.85]ml vs.36.15[17.38,96.85]ml)and a higher proportion of favorable outcomes(77.14%[27/35]vs.34.78%[16/46])than the ATA low-score group(all P＜0.01).(5)Spearman correlation analysis demonstrated a weak negative correlation between preoperative infarct volume and ATA score in acute anterior circulation LVO stroke patients who underwent successful mechanical thrombectomy(r=-0.359,P=0.001).Conclusions The preoperative ATA score was significantly associated with 90-day favorable outcomes in patients undergoing successful mechanical thrombectomy for acute anterior circulation LVO stroke,where higher ATA scores were indicative of a more favorable clinical prognosis.Furthermore,a weak negative correlation was observed between preoperative infarct volume and ATA score.

Abstract:Subarachnoid hemorrhage(SAH)is a severe cerebrovascular disease with high mortality and disability rates which significantly affect patient prognosis.Ferroptosis,a type of cell death characterized by iron accumulation and lipid peroxidation,has garnered increasing attention in primary brain injury and secondary brain injury following SAH.To provide new insights for both basic research and clinical treatment of SAH,this article summarized the characteristics,the relative signaling pathways of ferroptosis after SAH,ferroptosis-mediated alterations in neuron-glia interactions,and therapeutic strategies targeting ferroptosis.

Abstract:Objective To investigate the association between intraprocedural DSA signs-specifically early venous drainage(EVD)and capillary blush(CB)-observed following successful endovascular treatment(EVT)recanalization,with hemorrhagic transformation(HT)and its severe subtypes,parenchymal hematoma type 2(PH2)and symptomatic intracranial hemorrhage(sICH),in patients with anterior circulation large vessel occlusion acute ischemic stroke(LVO-AIS).Methods This study retrospectively and consecutively enrolled patients with anterior circulation LVO-AIS who underwent EVT within 24 hours of symptom onset and achieved successful recanalization(defined as a post-procedural modified thrombolysis in cerebral infarction[mTICI]grade≥2b)at the Department of Cerebrovascular Diseases,Henan Provincial People's Hospital between October 2022 and July 2024.Patient demographics and clinical data were collected,including gender,age,history of hypertension,diabetes,hyperlipidemia,coronary heart disease,atrial fibrillation,smoking,alcohol consumption,and prior stroke.Clinical assessments included the admission National Institutes of Health stroke scale(NIHSS)score,Glasgow coma scale(GCS)score,and Alberta stroke program early CT score(ASPECTS).Etiology was classified using the trial of Org 10172 in acute stroke treatment(TOAST)criteria(atherosclerotic,cardioembolic,other determined etiology,undetermined etiology).Treatment details encompassed the time window from onset to puncture(OPT;≤6h,＞6-＜12h,12-24h),occlusion site(internal carotid artery,M1 or M2 segment of the middle cerebral artery,A1 segment of the anterior cerebral artery,tandem occlusion),pre-procedural intravenous thrombolysis,revascularization technique(mechanical thrombectomy,direct angioplasty,or mechanical thrombectomy plus rescue angioplasty)and procedural time metrics(OPT,puncture-to-recanalization time,and onset-to-recanalization time)were recorded.Admission laboratory values included neutrophil count,lymphocyte count,platelet count,fibrinogen,glucose,neutrophil-to-lymphocyte ratio(NLR),and systemic immune-inflammation index(SII).On post-recanalization DSA,the presence of EVD was denoted as EVD+,and its absence as EVD-.The presence of CB was denoted as CB+,and its absence as CB-.EVD+CB-standed for the presence of EVD with the absence of CB,while EVD-CB+standed for the absence of EVD with the presence of CB.A composite sign of EVD+CB+was defined as the presence of both,while EVD+/CB+as either(EVD and/or CB).Patients were evaluated for the occurrence of HT,PH2,and sICH within 72 hours post-procedure.Patients with any type of intracranial hemorrhage were assigned to the HT group,while those had no intracranial hemorrhage assigned to the non-HT group.PH2 group was consisted of patients with a hematoma exceeding 30%of the infarct area with significant mass effect,or hemorrhage remote from the infarct zone.While patients with any intracranial hemorrhage associated with neurological deterioration(an increase in the NIHSS total score by≥4 points or an increase in any single NIHSS item score by≥2 points from baseline)were signed to the sICH group.Variables showing statistically significant differences(between the HT group and the three other groups)in univariate comparisons were selected via stepwise forward regression for inclusion in multivariate Logistic regression analyses to identify independent factors associated with the occurrence of HT,PH2,and sICH within 72 hours after EVT.Receiver operating characteristic(ROC)curves were plotted,and the area under the curve(AUC)was calculated to assess the predictive performance of the EVD+CB+and EVD+/CB+signs for HT,PH2,and sICH.Results A total of 190 patients with anterior circulation LVO-AIS who achieved successful recanalization after EVT were included.There were 112 males and 78 females,aged 25-84 years with a mean age of 63±14 years.There were 39 patients(20.5%)in HT group,18 patients(9.5%)in PH2 group,and 18 patients(9.5%)in the sICH group;among these,13patients(6.8%)had both PH2 and sICH.Immediate post-procedural DSA revealed EVD+in 20 patients(10.5%),CB+in 45 patients(23.7%),EVD+CB-in 5 patients(2.6%),EVD-CB+in 30 patients(15.8%),and EVD+CB+in 15 patients(7.9%).(1)Compared to patients without HT,those in the HT group had significantly higher admission NIHSS scores,blood glucose,NLR,and SII,and significantly lower admission GCS scores,ASPECTS,lymphocyte counts,and platelet counts(all P＜0.05).The proportions of patients with EVD-CB+,EVD+CB+,and EVD+/CB+were also significantly higher in the HT group(all P＜0.05).No significant differences were found in other baseline and clinical characteristics(all P＞0.05).Compared to patients without HT,those in the PH2 group had significantly lower admission ASPECTS and a higher proportion of diabetes,as well as higher blood glucose,NLR and SII(all P＜0.05).The proportions of patients with EVD+CB+and EVD+/CB+were also significantly higher(both P＜0.05).No significant differences were found in other characteristics(all P＞0.05).Compared to patients without HT,those in the sICH group had significantly lower admission ASPECTS,lymphocyte counts,and platelet counts,and significantly higher NLR and SII(all P＜0.01).The proportions of patients with EVD+CB+and EVD+/CB+were also significantly higher(both P＜0.01).No significant differences were found in other characteristics(all P＞0.05).(2)Multivariate Logistic regression analysis revealed that higher platelet count(OR,0.992,95%CI 0.985-0.999,P=0.022)and higher admission ASPECTS(OR,0.607,95%CI 0.424-0.871,P=0.007)were independent protective factors for HT after successful EVT recanalization.Both EVD+CB+(OR,8.664,95%CI 1.533-48.953,P=0.015)and EVD+/CB+(OR,5.866,95%CI 2.261-15.217,P＜0.01)were independent risk factors for HT.Higher admission ASPECTS(OR,0.595,95%CI 0.362-0.975,P=0.039)was an independent protective factor for PH2 after successful EVT recanalization,while EVD+CB+(OR,25.450,95%CI 3.719-174.158,P＜0.01)and EVD+/CB+(OR,7.747,95%CI 1.664-36.066,P=0.009)were independent risk factors for PH2.Higher admission ASPECTS(OR,0.563,95%CI 0.357-0.888,P=0.014)was an independent protective factor for sICH after successful EVT recanalization,while EVD+CB+(OR,52.576,95%CI 7.866-351.432,P＜0.01)was an independent risk factor for sICH.(3)ROCcurve analysis showed that the AUC of EVD+CB+for predicting HT,PH2,and sICH after successful EVT recanalization was 0.660,0.771,and 0.716,respectively.The AUC of EVD+/CB+for predicting HT,PH2,and sICH after successful EVT recanalization was 0.754,0.837,and 0.726,respectively.Conclusions The combined evaluation of EVD and CB signs during EVT demonstrates predictive utility for HT,PH2,and sICH following successful recanalization in patients with anterior circulation LVO-AIS.It may serve as a real-time intraoperative imaging marker for identifying patients at high risk of hemorrhage.

Abstract:In recent years,the incidence of acute ischemic stroke(AIS)among children and young adults has increased significantly.This condition is characterized by complex etiologies,high disability and mortality rates,and a high burden of disease.Endovascular treatment(EVT)has demonstrated remarkable clinical value in treating AIS with large vessel occlusion(AIS-LVO).Multiple studies indicated that EVT can significantly enhance outcomes of AIS-LVO and achieve high recanalization rates in children and young adults,and could potentially lead to a better prognosis compared to elderly patients.This article reviews the research progress on the etiology,pathological characteristics,current EVT status,and key influencing factors of prognosis in AIS-LVO in children and young adults.

Abstract:Objective To investigate the current status,research hotspots and trends in Moyamoya disease from 2015 to 2025.Methods Relevant articles on Moyamoya disease included in the Web of Science database from January 1,2015 to October 2,2025 were retrieved.Special publication types such as contents page and editorials were excluded,while only original research articles,reviews,brief commentaries,and case reports were included.The search query was:TS(topic)="moyamoya disease OR moyamoya",with the language restricted to English.The bibliographic records of all retrieved documents were downloaded in plain text format for further data processing.EndNote 21.3 was used for data cleaning,including deduplication and correction of erroneous information.VOSviewer 1.6.20 was employed to perform co-occurrence analysis of countries,authors,and keywords.Literature was included in the co-occurrence analysis if the country had≥2 publications,the author had≥15 publications,or the keyword appeared≥15 times.VOSviewer 1.6.20 was used to calculate the association strength between keywords through counting the number of journals with two co-occurring keywords.The association strength of each keyword was the sum of the strength values of all its links.Keywords appearing≥5 times were statistically analyzed and ranked in descending order of association strength.The cleaned data were imported into CiteSpace 6.3.R1,which was used to perform a time-zone overlay analysis of author co-occurrence.The development and changes in Moyamoya disease research from 2015 to 2025 were explored through keyword co-occurrence burst detection combined with publication time.In this study,the publication counts for countries,institutions,and authors were all based on frequency of appearance.Author appearances included the first author,corresponding author,and co-authors.Institutional appearances included all affiliated institutions listed for the authors.For authors with potentially identical names,suspicious cases were identified based on analysis results.The author name and"moyamoya disease"were used as co-keywords for retrieval,followed by manual review of the retrieved literature to differentiate authors with identical names based on their affiliated institutions.Publication counts and total citation counts were then calculated separately for each distinct author.The total citation count was the sum of citations for all publications in which the author appeared.Results(1)A total of 2 700 publications on Moyamoya disease meeting the inclusion criteria were retrieved from the Web of Science database for 2015-2025.China ranked first in terms of publication count(784),followed by Japan(620)and the United States(614).The country co-occurrence cluster map indicated that China,the United States,and Japan formed the three core hubs.The countries with the highest association strengths with others were the United States(263),China(106),and Japan(83),ranked in descending order.Publishing countries showed distinct regional clustering characteristics,with close associations among European countries such as Germany,Italy,France,and Switzerland.(2)Among institutions publishing in the Web of Science database from 2015 to 2025,Capital Medical University had the highest number of publications(220),followed by the China National Clinical Research Center for Neurological Diseases(108)and the Stroke Research Institute,Beijing Institute for Brain Disorders(105).(3)Core author groups in the Web of Science database from 2015 to 2025 included Zhang Dong(127 publications),Wang Rong(110),and Zhang Yan(93),among others.The author collaboration network revealed that it primarily consisted of 13 groups,with the collaboration networks led by Zhang Dong,Wang Rong,and Susumu Miyamoto being particularly prominent.(4)Among Moyamoya disease-related publications in the Web of Science database from 2015 to 2025,there were 301 keywords appearing≥5 times.Excluding keywords containing"moyamoya"and"moyamoya disease",the top three keywords by frequency were"stroke"(315 times),"vascular disorders"(181 times),and"revascularization"(169 times).VOSviewer keyword clustering analysis identified seven main clusters:a blue cluster centered on"stroke",a red cluster on"genetics",a purple cluster on"magnetic resonance imaging",a green cluster on"cerebral revascularization",a cyan cluster on"biomarker",a yellow-green cluster on"perfusion",and a brown cluster on"risk factor".(5)CiteSpace keyword burst detection showed the keyword with the highest burst strength was"brain",followed by"pial synangiosis".The most recent keyword with a burst was"machine learning",starting in 2024.The VOSviewer time-overlay keyword clustering analysis indicated that literature published from 2015 to 2020 primarily focused on themes such as"genetics""intracerebral hemorrhage"and"ec-ic bypass".In contrast,the research focus of literature published from 2021-2025 shifted towards"stroke""biomarker""magnetic resonance imaging""cerebral revascularization""cerebral blood flow"and"perfusion".Conclusions From 2015 to 2025,the number of published articles on Moyamoya disease worldwide has shown a steady upward trend year by year.The research focuses on the etiology and pathological mechanism,diagnosis,treatment,and prognostic evaluation and management of Moyamoya disease.The main research institutions are medical and scientific research located in China,Japan,Korea and America.Biomarkers,cerebral perfusion and perfusion imaging,risk factors,MRI,and revascularization techniques of Moyamoya disease may become the research hotspots and trends in the future.

Abstract:Objective To investigate the safety and efficacy of endovascular treatment for acute anterior circulation medium vessel occlusion(MeVO).Methods A retrospective,consecutive series of 31 patients with primary anterior circulation MeVO who underwent mechanical thrombectomy in the Department of Interventional Therapy(Section 1)of the First Affiliated Hospital of Dalian Medical University from February 2017 to January 2025 were included.Baseline and procedural data were collected.Baseline data included sex,age,admission National Institutes of Health stroke scale(NIHSS)score,admission Alberta stroke program early CT score(ASPECTS),hypertension,diabetes,smoking,atrial fibrillation,occlusion site(M2 or M3 segment of middle cerebral artery,A2 or A3 segment of anterior cerebral artery),and trial of Org 10172 in acute stroke treatment(TOAST)classification.Procedural data included onset-to-femoral artery puncture time(≤6 h,＞6-＜12h,12-24h),femoral artery puncture-to-reperfusion time(≤60min,＞60-＜120min,≥120min;for unsuccessful reperfusion femoral artery puncture-to-reperfusion time was defined as puncture-to-procedure end time),intravenous thrombolysis,first-line MT technique(including primary stent retriever thrombectomy,primary contact aspiration thrombectomy,thrombus fragmentation with microguidewire),number of thrombectomy attempts,rescue measures(balloon angioplasty,stenting,or combined balloon angioplasty and stenting),and immediate postoperative reperfusion status(with thrombolysis in cerebral infarction[TICI]grade 0-2a defined as reperfusion failure,2b-3 defined as successful reperfusion).Neurological function at 3 months was assessed using the modified Rankin scale(mRS)and patients were divided into a favorable outcome group(mRS score 0-2)and a poor outcome group(mRS score 3-6).Safety outcomes included intracranial hemorrhage hemorrhage within 24 h(symptomatic intracranial hemorrhage[confirmed by CT within 24 h postoperatively with a NIHSS score increase of≥4 points from baseline],asymptomatic subarachnoid hemorrhage[confirmed by CT within 24 h postoperatively without typical symptoms like headache,nausea,or impaired consciousness]),procedure-related complications(arterial dissection[non-flow-limiting],vessel perforation,vasospasm,distal embolization),and all-cause mortality at 3 months.Efficacy outcomes included immediate postoperative successful reperfusion rate and proportion of patients with good functional outcome(mRS score 0-2)at 90 days.Results(1)Among the 31 anterior circulation MeVO patients meeting the criteria,19 were male,and 12 were female,aged 57-86 years,mean age(69±10)years.The median admission NIHSS score was15.0(12.5,17.0),ranged 6-30score.Atrial fibrillation was the most common cerebrovascular risk factor(74.2%,23/31),followed by hypertension(54.8%,17/31).Cardioembolism was the predominant TOAST subtype(74.2%,23/31),with 16.1%(5/31)having large-artery atherosclerosis.Among all patients enrolled,there were 30 cases with occlusion site at M2 segment of middle cerebral artery and1case at A2 segment of anterior cerebral artery.(2)Twenty-five patients(80.6%)received endovascular treatment within 6 h of onset,and 6(19.3%)in＞6-＜12 h(median time 8.00[6.75,10.25]h).Femoral artery puncture-to-reperfusion time was within 120 min for 26patients(83.9%).Eight patients(25.8%)received bridging treatment with intravenous thrombolysis before endovascular therapy.Twenty-seven patients received primary Solitaire stent retriever thrombectomy,with a mean of(1.1±0.2)retrieval attempts.In one patient,near-occlusive severe stenosis persisted after primary Solitaire thrombectomy,which was successfully treated with rescue stenting angioplasty,achieving TICI grade 3 flow.Three patients underwent primary thrombus fragmentation with microguidewire,with 2 cases achieved TICI grade of 2b in two and 1 case obtained a TICI grade of 2a immediately after the surgery.At 3-month follow-up,two had an mRS score of 3 and one of 0.One patient underwent primary contact aspiration thrombectomy,achieving immediate TICI grade 3 and a mRS score of 1 at 3 months.(3)For safety assessment,procedure-related complications occurred intraoperatively in 6 cases,including distal embolization to M4 segment in 2 patients which were treated with local administration of 2 ml tirofiban leading to partial dissolution.Intraoperative non-flow-limiting dissection occurred in 2 patients and culprit vessel vasospasm occurred in 2.Asymptomatic subarachnoid hemorrhage occurred in 2 M2 occlusion patients,managed conservatively without new symptoms.Two patients died during hospitalization(one from gastrointestinal bleeding,one from myocardial infarction).No new deaths occurred within 3 months post-discharge.(4)To assess the efficacy,among 31 patients,27(87.1%)achieved immediate successful reperfusion,with 18 achieving TICI grade 3.At the 3-month follow-up,16 patients were in the favorable outcome group and 15 in the poor outcome group.Compared with the poor outcome group,the favorable outcome group had a higher proportion of male patients(13/16 vs.6/15,P=0.029),a higher admission ASPECTS(9.00[8.75,9.25]score vs.8.00[7.00,8.50]score,P=0.042),and a lower proportion of hypertension(3/16 vs.14/15,P=0.001).No statistically significant differences were found in other comparisons between the groups(all P＞0.05).Conclusion Endovascular therapy for acute anterior circulation MeVO achieved a high rate of successful reperfusion and can lead to favorable clinical outcomes,although procedure-related complications still require attention.

Abstract:Objective To explore the characteristics of quantitative electroencephalogram(QEEG)and their correlation with early cognitive impairment in patients with acute cerebral infarction.Methods Patients with acute cerebral infarction in the Department of Neurology,Affiliated Hospital of Nanjing University of Chinese Medicine from January 2022 to December 2024 were prospectively and consecutively enrolled.General and clinical data were collected,including age,sex,history of hypertension,diabetes,coronary heart disease,admission National Institutes of Health stroke scale(NIHSS)score,and educational years.Patients were divided into a cognitive impairment(Montreal cognitive assessment[MoCA]scale score＜26)group and a non-cognitive impairment(MoCA scale score≥26)group based on their MoCA scale scores on the 2nd day after admission,with adjustments for educational years.QEEG parameters were collected and quantitatively analyzed on the 2nd day after admission,including the absolute power of α,θ,β,and δ waves,frontal-δ/α absolute power ratio(F-DAR),frontal-(δ+θ)/(α+β)absolute power ratio(F-DTABR),posterior-δ/α absolute power ratio(P-DAR)and posterior-(δ+θ)/(α+β)absolute power ratio(P-DTABR).Pearson correlation analysis was used to evaluate the correlation between QEEG parameters and MoCA scale scores,with|r|≥0.7 and＜0.9 indicating a high correlation,and|r|≥0.9 and＜1.0 indicating an extremely high correlation.Receiver operating characteristic(ROC)curves were used to assess the diagnostic value of composite QEEG parameters with high and extremely high correlation to MoCA scale scores for early cognitive impairment in patients with acute cerebral infarction.Results A total of 60 patients with acute cerebral infarction were included,including 49 males and 11 females,aged 30-79 years,with mean age of(62±11)years.Among them,30 patients were in the cognitive impairment group and 30 patients in the non-cognitive impairment group.(1)Compared with the non-cognitive impairment group,the cognitive impairment group had shorter educational years([10.47±3.06]years vs.[15.07±4.36]years)and higher admission NIHSS scores([13.30±2.59]points vs.[8.80±1.99]points;both P＜0.01),while no significant differences were observed in other general and clinical data between the two groups(all P＞0.05).(2)Compared with the non-cognitive impairment group,the cognitive impairment group had lower α absolute power([6.35±0.41]μV2 vs.[7.70±0.39]μV2,P＜0.01),and higher θ absolute power([14.72±0.85]μV2 vs.[13.13±0.34]μV2),δ absolute power([25.38±2.03]μV2 vs.[23.28±3.87]μV2),F-DAR(3.94±0.47 vs.2.95±0.51),P-DAR(4.10±0.60 vs.3.28±0.49),F-DTABR(3.83±0.30 vs.3.01±0.47),and P-DTABR(3.94±0.35 vs.3.22±0.33;all P＜0.05).(3)Pearson correlation analysis showed that α absolute power was positively correlated with MoCA scale scores(r=0.790),while θ absolute power(r=-0.787),δ absolute power(r=-0.351),F-DAR(r=-0.726),P-DAR(r=-0.509),F-DTABR(r=-0.758),and P-DTABR(r=-0.654)were negatively correlated with MoCA scale scores(all P＜0.01,all adjusted P＜0.008).Among these,α absolute power,θ absolute power,F-DAR,and F-DTABR showed a high correlation with MoCA scale scores.(4)ROC curve analysis showed that the area under the curve(AUC)of F-DAR for diagnosing early cognitive impairment after acute cerebral infarction was 0.912(95%CI 0.844-0.981),with a sensitivity of 1.00,specificity of 0.67,and optimal cutoff value of 3.03.For F-DTABR,the AUC was 0.933(95%CI 0.876-0.990),with a sensitivity of 0.87,specificity of 0.80,and optimal cutoff value of 3.47.The combined diagnosis of F-DAR and F-DTABR yielded an AUC of 0.949(95%CI 0.895-1.000),with a sensitivity of 0.97 and specificity of 0.80.Conclusion The characteristic indicators in QEEG can provide important objective evidence for the evaluation of early cognitive impairment after acute cerebral infarction.

Abstract:In recent years,with the rapid iteration of robotic technology,microsurgical robots have emerged prominently in the field of vascular anastomosis due to their advantages of high precision,high stability,and high flexibility at the microscopic scale.This article reviewed the research progress of microsurgical robots in intracranial vascular anastomosis,and presented the existing difficulties,challenges,and future prospects,aiming to provide references for researchers and clinicians in related fields.

Abstract:Objective To explore the value of a multimodal integration strategy combining clinical factors,CT angiography(CTA)features,and radiomics features for identifying carotid atherosclerotic(CAS)plaques related to acute ischemic stroke(AIS).Methods CAS patients who underwent head and cervical CTA and brain MRI within 1 month between January 2019 and December 2024 at three centers:Lishui Central Hospital(Center Ⅰ),the Second Affiliated Hospital of Soochow University(CenterⅡ),and the Affiliated Changshu Hospital of Soochow University(CenterⅢ)were retrospectively and consecutively enrolled.The center with the largest sample was split into a training set and an internal validation set at 7∶3 ratio;the remaining centers' patients formed the external validation set.All the patients were grouped into AIS group and non-AIS group based on the presence of AIS.Clinical characteristics including age,sex,hypertension,diabetes,smoking history,and the latest laboratory measurements(homocysteine,total cholesterol,triglycerides,low-density lipoprotein cholesterol,high-density lipoprotein cholesterol)within 30 days prior to imaging,were collected.In the AIS group,plaques corresponding to acute infarction lesions on diffusion-weighted imaging(DWI)were evaluated as AIS-related CAS plaques.In the non-AIS group,plaques from the more severely stenosed side of the extracranial carotid artery were evaluated.CTA features,including stenosis rate of the plaque-bearing arterial segment,maximum plaque thickness,plaque ulceration(defined as contrast extending≥1 mm into the plaque),and plaque length(measured on CT curved planar reformations along the vessel centerline from the plaque's proximal to distal margins),were also collected.Differences on clinical characteristics and CTA features between AIS group and non-AIS group in the training set,internal validation set,and external validation set were compared.Factors with statistically significant differences in univariable analysis between AIS group and non-AIS group in the training set were included in multivariable Logistic regression analysis to identify independent risk factors for AIS in CAS patients and to construct a clinical-CTA model.Radiomic features were extracted from the plaque regions using the Radcloud platform and standardized via Z-score.Feature reduction was performed using least absolute shrinkage and selection operator(LASSO)regression and five machine learning classifiers(support vector machine[SVM],extreme gradient boosting[XGBoost],random forest[RF],Logistic regression[LR],and naive Bayes[NB])were constructed separately in the training set,internal validation set,and external validation set to identify AIS-related CAS plaques.The receiver operating characteristic(ROC)curves were plotted for each machine learning classifier,and area under the curve(AUC)values were compared using the Delong test.Sensitivity,specificity,and accuracy were also reported to help select the optimal machine learning classifier to derive the radiomics score(Rad-score).A combined model integrating features from clinical-CTA model and Rad-score was then developed using multivariable Logistic regression,and a nomogram was generated.Performance of the clinical-CTA model,radiomics model and the combined model in the training set,internal validation set,and external validation set was evaluated using ROC analysis,decision curve analysis(DCA),and calibration(Bootstrap,B=1 000).Results A total of 231 CAS patients were included,119 patients in the training set(58 AIS,61 non-AIS),52 patients in the internal validation set(25 AIS,27 non-AIS)and 60 patients in the external validation set(26 AIS,34 non-AIS).(1)In the training set,high-density lipoprotein cholesterol level was lower in the AIS group compared to the non-AIS group(P=0.010),but no significant difference was found in the internal or external validation sets(both P＞0.05).In all three datasets,maximum plaque thickness and plaque ulceration ratio were significantly higher/more frequent in the AIS group than those in the non-AIS group(all P＜0.05).Other clinical and CTA feature differences between two groups were not statistically significant(all P＞0.05).(2)Multivariable Logistic regression analysis based on the training set revealed that plaque ulceration(OR,4.231,95%CI 1.375-13.018,P=0.012)and maximum plaque thickness(OR,1.428,95%CI 1.004-2.030,P=0.048)were independent risk factors for AIS in CAS patients and were included in the clinical-CTA model.(3)For identifying AIS-related CAS plaques,XGBoost achieved AUCs of 0.851,0.820,and 0.786 in the training,internal validation,and external validation sets,respectively.XGBoost outperformed NB in all datasets(all P＜0.05),outperformed RF in the internal validation set(P=0.025),and outperformed LR in the external validation set(P=0.043),while showing no significant difference compared to SVM in all three datasets(all P＞0.05).In the external validation set,XGBoost achieved an accuracy of 76.65%,sensitivity of 76.92%,and specificity of 76.47%,indicating a more balanced performance than SVM(accuracy 71.83%,sensitivity 61.54%,specificity 82.35%).XGBoost was selected as the optimal machine learning classifier for building the radiomics model.(4)A combined model integrating plaque thickness,plaque ulceration from the clinical-CTA model,and the Rad-score from the XGBoost radiomics model achieved AUCs of 0.896(95%CI 0.836-0.955),0.845(95%CI 0.723-0.967),and 0.807(95%CI 0.684-0.897)in the training,internal validation,and external validation sets,respectively.Delong test results showed that the combined model outperformed the clinical-CTA model in the training and internal validation sets(both P＜0.05),while no significant difference was found compared to the radiomics model(both P＞0.05).In the external validation set,AUCs were not significantly different among the three models(both P＞0.05).DCA showed that the combined model provided high net benefit within threshold probabilities of 0.37-0.92(training set),0.07-0.78(internal validation set),and 0.06-0.85(external validation set).After optimism correction using Bootstrap(B=1 000),calibration curves closely followed the ideal line,and apparent Brier scores were 0.142,0.086,and 0.095,optimism Brier scores was 0.150,0.112 and 0.114 in the training set,internal validation set and external validation set,respectively,indicating low prediction error and good calibration.Conclusion A multimodal strategy integrating head and cervical CTA with radiomics features improves the identification of AIS-related CAS plaques,demonstrating good diagnostic performance and promising clinical applicability.

Abstract:Objective To summarize the preliminary experience of applying transcarotid artery revascularization(TCAR)for the treatment of patients with carotid artery stenosis.Methods This study retrospectively and consecutively enrolled patients with carotid artery stenosis who underwent TCAR treatment between March 2025 and May 2025 at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University,and the Stroke Center,Xuanwu Hospital,Capital Medical University,Jinan Branch.Demographic characteristics and preoperative evaluation data were collected,including sex,age,side of stenosis,stenosis rate,symptomatic status,aortic arch type(Myla classification type Ⅰ,Ⅱ and Ⅲ),level of carotid bifurcation,and presence of communicating arteries.All operators were chief physicians with over 10 years of experience in independently performing carotid endarterectomy(CEA)and transfemoral carotid artery stenting(TF-CAS).The first TCAR case for each operator was completed under the guidance of a technically proficient surgeon.Indicators on surgical performance included anesthesia time,intraoperative common carotid artery(CCA)clamping duration,residual stenosis rate,new infarct on diffusion-weighted imaging(DWI)within 48 hours postoperatively and their locations(cortex,subcortical white matter,centrum semiovale,periventricular white matter,basal ganglia).For patients with intraoperative transcranial Doppler(TCD)monitoring,the number of microemboli at different time points(before CCA clamping,after CCA clamping,after stent implantation,after CCA clamping removed,at the end of surgery)and the mean flow velocity of the ipsilateral middle cerebral artery(MCA;baseline,after clamping,ratio of baseline to post-clamping)were recorded.Technical success was defined as immediate post-procedural angiography showing complete coverage of the stenotic lesion by the stent with residual stenosis＜50%.Postoperative complications included new ischemic stroke within 30 days,any intracranial hemorrhage,and other conditions leading to a postoperative hospital stay exceeding 10 days.Results A total of 8 patients with carotid artery stenosis who underwent TCAR were enrolled,comprising 7 males and 1 female,aged 62-71 years with a mean age of(68±3)years.There were 2 cases of right carotid artery stenosis and 6 cases of left carotid artery stenosis,all being severe stenoses with a mean stenosis rate of(83.3±7.4)%.Symptomatic and asymptomatic stenoses each accounted for 4 cases.Aortic arch types Ⅰ,Ⅱ,and Ⅲ were observed in 6 cases,1 case,and 1 case,respectively.The carotid bifurcation was level with the C3 and C4 vertebral bodies in 3 cases each,and between C4 and C3 in 2 cases.Two patients lacked both anterior and posterior communicating arteries.TCAR was technically successful in all 8patients without clinical complications.The mean anesthesia time was(182.50±47.90)min,the mean CCA clamping time was(21.63±10.58)min,and the mean residual stenosis rate was(13.4±12.2)%.Three patients had new infarct foci on DWI within 48 hours postoperatively,with 2 located in the cortex and 1 in the periventricular white matter.TCAR was performed by 5 operators.For the first TCAR case of each operator,the mean anesthesia time was(185.40±58.53)min and the mean CCA clamping time was(24.80±11.97)min.Operator who performed the highest number of cases(3cases),had a mean patient anesthesia time of(156.33±34.37)min and a mean CCA clamping time of(14.00±2.94)min.Seven patients underwent intraoperative TCD monitoring.After CCA clamping,the mean MCA flow velocity on the operated side decreased in all 7 patients,averaging(65.53±12.23)%of the baseline value.Microembolic signals were detected intraoperatively in all 7patients,with a mean cumulative count of(30.00±24.87)microemboli by the end of the procedure.There were still microemboli detected during CCA clamping in 4 patients.Conclusion For surgical teams proficient in TF-CAS and CEA techniques,under the guidance of experienced surgeons and with the intraoperative TCD monitoring,performing TCAR for Chinese patients with carotid artery stenosis meeting specific vascular anatomical conditions appears to be safe and effective.The findings of this study require further validation through large-scale multicenter clinical trials.

Abstract:Objective To investigate the characteristics and influencing factors of periodic limb movement in sleep(PLMS)in patients with acute cerebral infarction.Methods A retrospective consecutive study was conducted on patients with acute cerebral infarction who were hospitalized in the Neurology Department of Beijing Friendship Hospital,Capital Medical University,from October 2020 to June 2024.General and clinical data of the patients,including age,sex,infarction location(frontal lobe,parietal lobe,temporal lobe,occipital lobe,insular lobe,cortical radiata,internal capsule,thalamus,basal ganglia,brainstem[midbrain,pons,medulla],cerebellum[cerebellar hemisphere,cerebellar vermis],patients with multiple cerebral infarctions record each infarction location),baseline National Institutes of Health stroke scale(NIHSS)score and modified Rankin scale(mRS)score,blood indicators on the day of admission or the next day(hemoglobin,platelets,glycosylated hemoglobin,creatinine,total cholesterol,low-density lipoprotein cholesterol),past medical history(hypertension,diabetes,atrial fibrillation,coronary heart disease,hyperlipidemia,chronic kidney disease,previous cerebral infarction),smoking history,drinking history and treatment method(standard drug treatment,standard drug treatment+endovascular treatment)were collected.The mini-mental state examination(MMSE)scale and Montreal cognitive assessment(MoCA)scale of patients who completed cognitive function assessment within 14 days after onset were collected.Collecte all the indicators of polysomnography(PSG),including periodic limb movement index(PLMI),sleep apnea,sleep efficiency,N1,N2,N3,R-phase sleep ratio,R-phase latency time,limb movement-related awakening times,limb movement-related awakening index,sleep apnea-hypopnea index,average blood oxygen saturation,and minimum blood oxygen saturation.Patients were divided into the PLMS group(PLMI≥5times/h)and the non-PLMS group(PLMI＜5times/h)based on PLMI.General and clinical data,and PSG-related indicators were compared between the PLMS group and non-PLMS group,variables with P＜0.1 were included in the multivariate Logistic regression analysis model using the forward stepwise regression based on maximum likelihood estimation to investigate the influencing factors of PLMS in patients with acute cerebral infarction.The goodness of fit of the model was tested using the Hosmer-Lemeshow test,and P＞0.05 was considered a high goodness of fit.Results A total of 220 patients with acute cerebral infarction were collected,including 163 males and 57 females,aged 30 to 86 years,with an average age of(62±10)years.Among them,130 patients(59.1%)were in the PLMS group and 90patients(40.9%)were in the non-PLMS group.(1)Compared with the non-PLMS group,patients in the PLMS group were older([64±10]years vs.[61±10]years,P=0.04),and had lower hemoglobin levels([138.83±15.19]g/L vs.[143.66±15.03]g/L,P=0.02),and there were no statistically significant differences in the other general and clinical data between the two groups(all P＞0.05).(2)Among 92 patients who completed cognitive function assessment,37 patients in the non-PLMS group and 55 patients in the PLMS group,the scores of MoCA scale of the PLMS group was lower than that of the non-PLMS group(24[19,26]points vs.26[22,28]points,P=0.02),and there was no statistically significant difference in MMSE scale score between the two groups(P=0.37).(3)The median PLMI of patients in the PLMS group was 19.90(11.90,44.03)times/h,and that of the non-PLMS group was 0.85(0.00,2.00)times/h and there was a statistically significant difference between the two groups(P＜0.01).Compared with the non-PLMS group,patients in the PLMS group had more limb movement-related awakening times(0.00[0.00,1.00]times vs.0.00[0.00,0.00]times,P＜0.01)and higher limb movement-related awakening index(0.00[0.00,0.85]times/h vs.0.00[0.00,0.00]times/h,P＜0.01).There were no statistically significant differences in the other PSG-related indicators between the two groups(all P＞0.05).(4)Age,hyperlipidemia,low-density lipoprotein cholesterol,hemoglobin,and the number of limb movement-related awakenings were included in the multivariate Logistic regression model.The results showed that hyperlipidemia might be an influencing factor for PLMS in patients with acute cerebral infarction(OR,0.49,95%CI 0.26-0.94,P＜0.05),but the goodness of fit of this model was low(Hosmer-Lemeshow test P=0.04).Conclusions The proportion of acute cerebral infarction patients who have PLMS is relatively high,and compared with patients without PLMS,they are older,and have lower hemoglobin levels,more limb movement-related awakenings during sleep,and lower MoCA scale scores.Hyperlipidemia might be an influencing factor for PLMS in patients with acute cerebral infarction,while this finding should be interpreted with caution.

Abstract:Cerebral venous sinus thrombosis(CVST)is a rare cerebrovascular disease.Due to its rarity in clinical practice and the absence of typical symptoms and signs,it is prone to misdiagnosis or missed diagnosis,thereby delaying the treatment.The author retrospectively analyzed the case data of a child with refractory mycoplasma pneumoniae pneumonia and CVST,admitted to the hospital for mycoplasma pneumoniae pneumonia.The anti-infection effect of macrolide antibiotics was poor,and headache occurred during the course of the disease.Cranial MRI and MR venography showed the formation of CVST.After anti-infection and anticoagulation treatments,the condition improved,and the patient was discharged.At follow-up two months after discharge,re-examination of MR venography revealed the disappearance of venous sinus thrombosis.Meanwhile,relevant literature was reviewed to analyze the clinical characteristics,diagnosis,and treatment strategies of CVST,with the aim of enhancing clinicians'understanding of this disease.