Enhanced vessel wall magnetic resonance imaging in the follow-up of intracranial aneurysms treated with flow diversion.

OBJECTIVE: This study aimed to compare the efficacy of enhanced 3D T1-weighted black-blood fast-spin-echo vessel wall magnetic resonance imaging (eVW-MRI) and time-of-flight magnetic resonance angiography (TOF MRA) for follow-up evaluation of aneurysms treated with flow diversion (FD). METHODS: Our study enrolled 77 patients harboring 84 aneurysms treated with FD. Follow-up was by MRI (eVW-MRI and TOF MRA) and digital subtraction angiography (DSA). Two radiologists, blinded to DSA examination results, independently evaluated the images of aneurysm occlusion and parent artery patency using the Kamran-Byrne Scale. Interobserver diagnostic agreement and intermodality diagnostic agreement were acquired. Pretreatment and follow-up aneurysm wall enhancement (AWE) patterns were collected. RESULTS: Based on the Kamran-Byrne Scale, the intermodality agreement between eVW-MRI and DSA was better than TOF MRA versus DSA for aneurysm remnant detection (weighted ĸ = 0.891 v. 0.553) and parent artery patency (ĸ = 0.950 v. 0.221). Even with the coil artifact, the consistency of eVW-MRI with DSA for aneurysm remnant detection was better than that of TOF MRA (weighted ĸ = 0.891 v. 0.511). The artifact of adjunctive coils might be more likely to affect the accuracy in evaluating parent artery patency with TOF MRA than with eVW-MRI (ĸ = 0.077 v. 0.788). The follow-up AWE patterns were not significantly associated with pretreatment AWE patterns and aneurysm occlusion. CONCLUSIONS: The eVW-MRI outperforms TOF MRA as a reliable noninvasive and nonionizing radioactive imaging method for evaluating aneurysm remnants and parent artery patency after FD. The significance of enhancement patterns on eVW-MRI sequences needs more exploration. CLINICAL RELEVANCE STATEMENT: The application of enhanced vessel wall magnetic resonance imaging has proven to be a promising tool to depict aneurysm remnant and parent artery stenosis in order to tailor the antiplatelet therapy strategy in patients after flow diversion. KEY POINTS: • Enhanced vessel wall magnetic resonance imaging has an emerging role in depicting aneurysm remnant and parent artery patency after flow diversion. • With or without the artifact from adjunctive coils, enhanced vessel wall magnetic resonance imaging was better than TOF MRA in detecting aneurysm residual and parent artery stenosis by using DSA imaging as the standard. • Enhanced vessel wall magnetic resonance imaging holds potential to be used as an alternative to DSA for routine aneurysm follow-up after flow diversion.

Randomized, prospective, multicenter trial assessing the numen coil embolization system in the endovascular treatment of small intracranial aneurysms: outcomes from the CATCH Trial.

BACKGROUND AND PURPOSE: The CATCH (Coil Application Trial in China) trial was designed to assess the safety and efficacy of the Numen Coil Embolization System in the treatment of intracranial aneurysms in comparison with the Axium coil (ev3/Medtronic). Although the endovascular treatment of small (< 5 mm) intracranial aneurysms has been reported with favorable long-term clinical and angiographic outcomes, randomized trials are still lacking. Data for aneurysms smaller than 5 mm were extracted from the CATCH trial. MATERIALS AND METHODS: A randomized, prospective, multicenter trial was conducted at ten centers throughout China. Enrolled subjects with small intracranial aneurysms were randomly assigned to receive treatment with the Numen Coil or the Axium coil. The primary outcome was successful aneurysm occlusion at the 6-month follow-up. In contrast, the secondary outcomes included complete aneurysm occlusion, recurrence rate, clinical deterioration, and safety data at the 6-month and 12-month follow-ups. RESULTS: A total of 124 patients were enrolled in the study. Overall, 58 patients were assigned to the Numen group, and 66 were assigned to the Axium group. At the 6-month follow-up, the successful aneurysm occlusion rate was 93.1% (54/58) in the MicroPort NeuroTech group and 97.0% (64/66) in the Axium group, with a common odds ratio of 0.208 (95% confidence interval, 0.023-1.914; P = 0.184). Complications were comparable between the groups. CONCLUSIONS: Compared with the Aixum coil, the Numen coil is safe and effective in treating small intracranial aneurysms. TRIAL REGISTRATION: (13/12/2016, NCT02990156).

Hydrocephalus and Growth Retardation: A Fetal RNU4ATAC-opathy Missed by Whole-Exome Sequencing.

Introduction: Whole-exome sequencing (WES) is becoming widely available in prenatal diagnosis. However, as with most scientific methods, WES also has its limitations. The aim of the study was to report a fetal case of RNU4ATAC-opathy which was missed by prenatal WES. Case Presentation: A 28-year-old healthy primigravida was revealed by ultrasound at 20 + 3 weeks of gestation to have a fetus with ventriculomegaly (left 15.1 mm/right 11.9 mm), hypoplastic vermis, and mild growth retardation. Chromosomal microarray analysis and trio WES failed to detect a pathogenic copy number variation and sequence variant. A repeat ultrasound at 23 + 3 weeks showed worsened growth delay and hydrocephalus (left 20.3 mm/right 11.0 mm) with vermis hypoplasia and agenesis of corpus callosum. Further study with whole-genome sequencing (WGS) detected 2 missense mutations of the noncoding RNU4ATAC (NR_023343.1) gene, n.51G>A (rs188343279) and n.16G>A (rs750325275), in the fetus, which were inherited from the father and mother, respectively. Discussion: Our study highlights the limitation of WES. WGS might be a clinical option for patients who have a structurally abnormal fetus tested negative by WES.

Safety and efficacy of endovascular treatment for tiny ruptured intracranial aneurysms with low-profile visualized intraluminal support stents.

BACKGROUND: Endovascular treatment for tiny ruptured intracranial aneurysms is known to be technically challenging. Thus, we aimed to investigate the safety and efficacy of low-profile visualized intraluminal support (LVIS) stents in the treatment of tiny ruptured intracranial aneurysms. METHODS: From April 2014 to June 2019, among 90 patients with tiny ruptured aneurysms who were treated at our institution endovascularly, 28 underwent stent-assisted coiling with LVIS stents. The clinical and angiographic results were reviewed. RESULTS: In the LVIS group, complete occlusion was achieved in 27 patients (96.4%). Intraprocedural thrombus formation occurred in 3 patients (10.7%). Follow-up angiography in 24 patients at 6-12 months showed complete occlusion in 23 patients (95.8%) and no aneurysm recurrence. In the coiling-only group, complete occlusion was achieved in 58 patients (93.5%). Intraprocedural aneurysm rupture occurred in 2 patients (3.2%), and postprocedural ischemia occurred in 4 patients (6.5%), with a complication rate of 9.7%. Follow-up angiography in 52 patients at 6-12 months showed complete occlusion in 43 patients (82.7%) and aneurysm recurrence in 7 patients (9.2%). No significant (p > 0.05) differences existed between the two groups. CONCLUSIONS: The LVIS stent is safe and effective in the treatment of tiny ruptured intracranial aneurysms.

Devastating iatrogenic internal carotid artery rupture in endoscopic endonasal surgery rescued by a covered stent.

Iatrogenic ICA injury is a life-threatening and underreported complication of EES. For selected patients, covered stent implantation is the best and only way to block the rupture spot immediately and maintain ICA blood flow.

Tandem stents thrombectomy as a rescue treatment for refractory large vessel occlusions.

BACKGROUND: Mechanical thrombectomy with a stent retriever (SR) and/or aspiration is the 'gold standard' for the treatment of acute ischemic stroke due to large vessel occlusion (LVO). However, sometimes clots may not be retrievable with a single SR alone or combined with aspiration. OBJECTIVE: To assess the safety and efficacy of a novel tandem stents thrombectomy (TST) technique as a rescue treatment for acute LVO that is refractory to conventional attempts. METHODS: All patients treated with the TST technique as rescue treatment after failure of conventional attempts were retrospectively reviewed. The postprocedural angiographic and clinical outcome, including modified Thrombolysis in Cerebral infarction (mTICI) grade, National Institutes of Health Stroke Scale (NIHSS) score, and modified Rankin Scale (mRS) score, was assessed. RESULTS: Nine patients (mean age, 65.2 years; median NIHSS score 18) with middle cerebral artery M1 segment (n=6) and terminal internal carotid artery (n=3) occlusions were included in the study. The TST technique was performed as a rescue treatment after unsuccessful stent thrombectomy alone (four cases) and stent thrombectomy plus aspiration (five cases). Successful recanalization (mTICI 2b/3) was achieved in all patients. No procedure-related complications occurred except reversible vasospasms were observed in three patients and one patient developed hemorrhage transformation after the procedure, but was asymptomatic. Three patients had good clinical outcome (mRS score 0-2 at 90 days). Two patients (22.2%) died. CONCLUSIONS: The TST technique seems to be a safe and effective rescue treatment for acute LVO that is refractory to conventional attempts.

Anti-tumor and Phenotypic Regulation Effect of Matrine on Dendritic Cells through Regulating TLRs Pathway.

OBJECTIVE: To investigate the effects of matrine on antigen presentation of dendritic cells (DCs), and to explore the pharmacological mechanism of matrine on anti-tumor effect. METHODS: Different concentrations (0, 1, 2, 4, 8 and 16 µ g/mL) of matrine were co-cultured with DCs, the harvested DCs were co-cultured with antigens of Lewis lung cancer (LLC) cells, and then DCs and T cells were co-cultured to produce DCs-activated killer (DAK) cells, which have significant tumor-killing activity. The expression of cytokines, mRNA and protein of toll-like receptors (TLRs) in DCs were detected by enzyme linked immunosobent assay, polymerase chain reaction and Western blot, respectively. And the killing effect of DAK were measured by MTT assay. RESULTS: Matrine significantly increased the mRNA expression of TLR7, TLR8, myeloid differentiation factor 88 (MyD88), tumor necrosis factor receptor-associated factor 6 (TRAF-6) and I κ B kinase (IKK), as well as the protein expression of TLR7 and TLR8, and up-regulated the levels of interleukin-12 (IL-12), IL-6 and tumor necrosis factor-α (TNF-α), meanwhile, it also increased the expressions of MHC-II, CD54, CD80 and CD86 in DCs. DCs-activated effector T cells had significant tumor-killing activity. When the concentration of matrine was more than 4 µg/mL, all indices had significant difference (P<0.01 or P<0.05). CONCLUSION: Matrine plays an anti-tumor role by regulating TLRs signal transduction pathway, promoting the secretion of inflammatory cytokines and enhancing immune function.

Feasibility and Safety of Paclitaxel-Coated Balloon Angioplasty for the Treatment of Intracranial Symptomatic In-Stent Restenosis.

Objective: Symptomatic in-stent restenosis (sISR) is the major cause of medium- or long-term cerebral infarctions in patients who underwent percutaneous transluminal angioplasty and stenting for severe intracranial atherosclerotic stenosis. This study aims to evaluate the feasibility and safety of paclitaxel-coated balloon (PCB) angioplasty for the treatment of intracranial sISR. Methods: We report 11 cases of PCB angioplasty for intracranial sISR. Lesion locations and number were as follows: intracranial internal carotid artery (n = 4), M1 segment of middle cerebral artery (MCA) (n = 1), V4 segment of vertebral artery (n = 6). The technical success rate, periprocedural complications, and short-term outcome were retrospectively analyzed. Results: All procedures were successfully performed without periprocedural complication. Asymptomatic vessel dissection after PCB inflation occurred in one case. Postprocedural diffusion-weighted imaging (DWI) showed new asymptomatic ipsilateral infarction in one case. All 11 cases did not experience ipsilateral stroke or death within 30 days or ischemic stroke in the territory of the target artery between 31 and 90 days after procedure. Conclusion: This preliminary study indicates that PCB angioplasty is feasible and safe for the treatment of intracranial sISR. Further studies are needed to clarify its efficiency and long-term outcome.

Role of contrast-enhanced magnetic resonance high-resolution variable flip angle turbo-spin-echo (T1 SPACE) technique in diagnosis of transverse sinus stenosis.

PURPOSE: Transverse sinus stenosis (TSS) is the most sensitive imaging characteristic of idiopathic intracranial hypertension (IIH). This study aimed to assess the diagnostic performance of contrast-enhanced magnetic resonance high-resolution variable flip angle turbo-spin-echo (T1 SPACE) technique in TSS patients and evaluate the diagnostic accuracy of enhanced T1 SPACE, and phase-contrast magnetic resonance venography (PC MRV) with digital subtraction angiography (DSA) as standard imaging. METHOD: This prospective study enrolled 62 patients with suspected IIH and PC MRV-confirmed transverse sinus stenosis. All patients underwent lumbar puncture, PC MRV, enhanced T1 SPACE sequences and DSA examination. The accuracy, sensitivity, and specificity of enhanced T1 SPACE in detecting venous sinus stenosis were calculated and compared with those of PC MRV. Intermodality agreement (Kendall's rank correlation coefficients and weighted kappa statistic) was assessed. RESULTS: Sixty-two patients were enrolled from November 2016 to October 2018. For the measured stenosis, better correlation was observed in enhanced T1 SPACE and DSA (AUC = 0.953) than PC MRV (AUC = 0.871). Intermodality agreement of enhanced T1 SPACE (rk = 0.895 and weighted ĸ = 0.868) was better than PC MRV (rk = 0.753 and weighted ĸ = 0.653) compared with DSA. Thirty-seven intrasinus filling defects were detected by contrast-enhanced T1 SPACE, while only twenty of them were detected on source imaging of PC MRV. CONCLUSIONS: The contrast-enhanced T1 SPACE sequence was more sensitive and specific compared with PC MRV in assessing stenosis and detecting lesions in TSS patients. Accurate determination of the presence and extent of TSS using this technique might be useful in patient selection and guiding the treatment.

Endovascular treatment of acute intracranial vertebrobasilar artery occlusion: a multicenter retrospective observational study.

PURPOSE: This study aimed to evaluate prognostic parameters associated with favorable clinical prognosis and assess the feasibility and safety of three different treatment strategies in patients with acute intracranial vertebrobasilar artery occlusion (VBAO). METHODS: A total of 159 patients with acute VBAO at 3 stroke centers between September 2015 and October 2018 were retrospectively analyzed. Eighty-nine patients underwent mechanical thrombectomy (MT) alone, 43 underwent MT with additional rescue angioplasty, and 27 underwent primary balloon angioplasty (without or with stenting). In patients treated with primary or rescue balloon angioplasty (without or with stenting), a low-dose intra-arterial tirofiban injection was used. The reperfusion status was assessed after the procedure, and the functional outcome was assessed at 90-day follow-up. The baseline characteristics and 90-day prognosis of three different treatment subgroups were comparatively analyzed. RESULTS: Overall, successful reperfusion and a favorable outcome were achieved in 96.86% (154/159) and 46.54% (74/159) patients, respectively. The onset to puncture time (461.96 min vs 603.59 min, P = 0.000), procedure time (64.12 min vs 70.47 min, P = 0.007), and onset to reperfusion time (526.08 min vs 674.47 min, P = 0.000) were significantly shorter in patients with favorable outcomes than in those with poor outcomes. Among different endovascular treatment subgroups, no significant differences were found in successful reperfusion and 90-day outcome. Low-dose tirofiban did not increase the risk of symptomatic intracranial hemorrhage and the 90-day mortality in patients with acute VBAO. CONCLUSION: Individualized endovascular treatment strategy for selected patients with acute VBAO could achieve satisfactory reperfusion rate and favorable prognosis.

Neuroform EZ Stenting for Symptomatic Intracranial Artery Stenosis: 30 Days Outcomes in a High-Volume Stroke Center.

Objective: To test whether Neuroform EZ stent placement combined with the modified techniques in symptomatic severe intracranial stenosis (ICAS) would result in lower rates of peri-procedural complications of intracranial stenting. Methods: We retrospectively reviewed the clinical data from 71 consecutive patients who underwent Neuroform EZ stent placement combined with the modified techniques for symptomatic severe ICAS at our institute between January 2016 and October 2017. The primary outcomes were ipsi-lateral ischemic stroke, intra-cerebral hemorrhage, or death within 30 days after stenting. The secondary outcome was technical success. Results: The technical success rate was 100%. The mean pre and post-stent stenoses were 84.2% ± 9.1% (median 85%, IQR75% to 90%) and 16.9% ± 10.2 % (median 15%, IQR 10% to 25%). The frequency of ipsi-lateral stroke, intra-cerebral hemorrhage, or death within 30 days was 0%. Conclusions: The combined use of Neuroform EZ stent placement and the modified techniques for symptomatic severe ICAS is technically feasible and safe, with very low peri-procedural complications. Further studies are required to assess the long-term results of this approach.

Embolization of brain arteriovenous malformations with the diluted Onyx technique: initial experience.

PURPOSE: Insufficient nidus occlusion is a matter of great concern to routine Onyx embolization of brain arteriovenous malformations (AVMs). This paper described an efficient method which using the diluted Onyx embolization technique to treat brain AVM. METHODS: The diluted Onyx technique was performed in a series of 15 patients with brain AVMs (10 males, 5 females; age range, 11-44 years). It consists of initial embolization with routine Onyx-18, followed by the diluted Onyx (1.5 mL of Onyx-18 diluted with 0.5 mL of DMSO) through the same microcatheter. The technical skills and angiographic and clinical outcomes were analyzed. RESULTS: A total of 15 embolization sessions were performed with diluted Onyx via 16 arterial feeders in these 15 patients. Each patient underwent one attempt of diluted Onyx through a single feeder except one patient. In this patient, the AVM was simultaneously embolized with diluted Onyx through double microcatheters which were placed in two feeders. When the length of reflux reached to 2 cm (or close to the determined length) and the embolic material could not move distally any more despite some rounds of "injection-reflux-waiting," regular Onyx 18 was changed to diluted Onyx. Antegrade flow of embolic material into the nidus was observed in 12 cases but failed in 3. An average of 90% (range 55-100%) estimated size reduction was achieved, and 6 AVMs were completely obliterated. No functionally relevant complications occurred. CONCLUSION: The diluted Onyx technique could be a useful adjunct to routine Onyx embolization which may offer more embolic material penetrating into the nidus of AVM, but additional work is needed to validate this technique.

Rescue Glue Embolization of Vessel Perforation During Mechanical Thrombectomy for Acute Ischemic Stroke: Technical Note.

BACKGROUND: Vessel perforation is a serious technical complication during mechanical thrombectomy (MT) for the treatment of acute ischemic stroke with large vessel occlusion. Routine rescue strategy includes balloon occlusion for tamponade, procedure suspension, and lowering or normalizing blood pressure. However, this complication is still associated with poor outcome and high mortality. METHODS: In this paper, the authors report their experience by using glue to embolize the ruptured vessel secondary to microcatheter/microwire perforation, preventing further deterioration in clinical outcome. Rescue glue embolization was attempted in 2 patients who developed intraprocedural vessel perforation while trying to gain access through the blocked artery with a microcatheter/microwire. RESULTS: The ruptured vessels were effectively occluded. Stent retriever thrombectomies were then continued, and TICI 2b and 3 recanalizations were achieved. Both patients' neurologic status improved. CONCLUSIONS: The key benefit of this method exists in embolizing the ruptured vessel without affecting the following MT. We propose the rescue glue embolization is simple yet effective in managing vessel perforation complication during MT.

Percutaneous endovascular biopsy in the diagnosis of venous sinus lesions: technical note.

Intracranial hypertension (IH) may be misdiagnosed owing to the lack of typical imaging features and pathological confirmation of the sinus lesions. The authors report the use of percutaneous endovascular biopsy (PEB) for the diagnosis of IH in patients with venous sinus lesions. A total of 9 patients (age 46 ± 9 years) underwent PEB between June 2016 and August 2017. All patients underwent lumbar puncture and contrast-enhanced MRI before the procedure. PEB was technically successful in 6 patients. No intra- or postprocedural complications occurred. The confirmed lesions were meningioma in 2 patients and fibrous thrombus in 4 patients. All patients received individualized treatment. PEB of venous sinus lesions is a safe and efficient method to establish an early diagnosis and appropriate treatment in patients with IH.

Symptomatic periprocedural intracranial hemorrhage unrelated to coil embolization in 1287 patients with intracranial aneurysms.

PURPOSE: Periprocedural symptomatic intracranial hemorrhage (sICH) unrelated to coil embolization of intracranial aneurysm has been rarely reported. The incidence and characteristics of this complication remain unclear. This study was designed to elucidate the incidence and characteristics of periprocedural sICH unrelated to coiling of intracranial aneurysm, and to explore the possible mechanisms underlying this complication. METHODS: Included in this retrospective study were 1287 patients with 1394 aneurysms who were treated with coil embolization (476 patients with stent assistance and 811 patients without stents) between May 2008 and August 2017. All procedure-unrelated sICHs that occurred within 30 days after coiling were selected. The technical details of the procedure, clinical characteristics, and medical therapy were recorded. RESULTS: A total of 6 patients developed periprocedural sICH unrelated to coil embolization. All these six patients underwent stent-assisted coiling (SAC). Therefore, there was a 1.3% (6/476) procedure-unrelated sICH rate of SAC and 0% (0/811) in patients underwent coiling without stent during the periprocedural period (P = 0.005, RR 0.987; 95% CI, 0.977-0.997). These phenomena occurred more often in patients who received SAC for ruptured aneurysms vs patients underwent this technique for unruptured aneurysms (2.0 vs 0.7%, P = 0.390, RR 2.896; 95% CI, 0.525-15.968). All these phenomena occurred within 7 days after coiling, and resulted in one mortality, one unfavorable outcome (mRS Score 3), and other four favorable outcomes (mRS Scores 0-2) at 90 days after procedure. CONCLUSION: Our findings suggest that the procedure-unrelated sICH, though less frequent, may exist following stent-assisted coiling of intracranial aneurysm during the periprocedural period. Extra caution may be warranted in patients who were treated with SAC for ruptured aneurysms.

MiR-375 targets KLF4 and impacts the proliferation of colorectal carcinoma.

MiR-375 has been identified as oncogenes or tumor suppressor genes which has the potential to the development and growth of cancers. However, the limited information concerning the expression and role of miR-375 in colorectal cancer (CRC) is available. In this work, we provide evidence for a function of miR-375 in the inhibition of CRC proliferation. Here, we showed that miR-375, down-modulated in human colorectal cancer tissues compared with normal human colon tissues, including several colorectal cancer cell lines. Subsequently, using the luciferase reporter assays, we found that the KLF4 untranslated region (3'UTR) carries the direct binding site of miR-375. In terms of function in vitro, CCK-8 assay, colony formation assay, and cell cycle assay demonstrated that the overexpression of miR-375 suppressed CRC cell proliferation. Inhibition of KLF4 performed similar effects with miR-375 overexpression on CRC cells, and overexpression of KLF4 could significantly reverse the tumor suppressive effects of miR-375 on CRC cells. Furthermore, we found overexpressed miR-375 effectively repressed tumor growth via KLF4 in xenograft animal experiment. Taken together, these results illustrated that miR-375 depresses proliferation of CRC through regulating 3'UTR of KLF4 mRNA, which might be a promising therapeutic target for treating colorectal cancers.

[Analysis of acute stroke trials conducted in mainland China in the past 17 years].

OBJECTIVE: To evaluate the current status and trend of acute stroke randomized controlled trials (RCTs) in Mainland China. METHODS: Acute stroke RCTs were retrieved from 8 databases published in Chinese or English language from January 1996 to May 2013. Those with transient ischemic attack (TIA) or traumatic hemorrhage were excluded. Methodological items were referred to the Cochrane Collaboration's tool for assessing risk of bias. The definitions of Wade were used to assess the outcome measures. The data were processed by SPSS 16.0. Data were summarized as frequency (and %) or median and interquartile range. Difference in proportions was assessed with χ(2) test. RESULTS: A total of 13 493 RCTs were identified. The number of acute stroke RCTs increased by years, but only 52 multi-center RCTs were published. There were 13 multi-center placebo controlled drug trials. Among them, only 3 had a sample size of over 500 cases. In multi-center non-drug trials, only 3 used allocation concealment. The studied types of stroke included ischemic stroke (63.9%, 8623/13 493), intracerebral hemorrhage (30.8%, 4157/13 493) and subarachnoid hemorrhage (5.3%, 713/13 495). There were 61.5% (32/52) multi-center drug trials, including 65.6% (21/32) in Western drug treatment and 34.4% (11/32) in traditional Chinese medicine. There were 38.5% (20/52) non-drug trials including 8 physical therapy, 7 surgery and 5 acupuncture treatment. There were 2 multi-center placebo controlled drug trials and 2 multi-center non-drug trials used mortality/disability for assessing outcome measures over a follow-up period of 90 days or more. CONCLUSION: In the past 17 years in mainland China, the number of acute stroke RCTs has increased dramatically, but the high-quality trials are scarce. The future acute stroke trials should pay more attention to true randomization, blinding and better patient outcome measures.

Posterior versus anterior circulation infarction: how different are the neurological deficits?

BACKGROUND AND PURPOSE: Distinguishing between symptoms of posterior circulation infarction (PCI) and anterior circulation infarction (ACI) can be challenging. This study evaluated the frequency of symptoms/signs in the 2 vascular territories to determine the diagnostic value of particular symptoms/signs for PCI. METHODS: Neurological deficits were reviewed and compared from 1174 consecutive patients with a diagnosis of PCI or ACI confirmed by magnetic resonance imaging in the Chengdu Stroke Registry. The diagnostic value of specific symptoms/signs for PCI was determined by measuring their sensitivity, specificity, positive predictive value (PPV), and the OR. RESULTS: Homolateral hemiplegia (PCI, 53.6% versus ACI, 74.9%; P<0.001), central facial/lingual palsy (PCI, 40.7% versus ACI, 62.2%; P<0.001), and hemisensory deficits (PCI, 36.4% versus ACI, 34.2%; P=0.479) were the 3 most common symptoms/signs in PCI and ACI. The signs with the highest predictive values favoring a diagnosis of PCI were Horner's syndrome (4.0% versus 0%; P<0.001; PPV=100.0%; OR=4.00), crossed sensory deficits (3.0% versus 0%; P<0.001; PPV=100.0%; OR=3.98), quadrantanopia (1.3% versus 0%; P<0.001; PPV=100.0%; OR=3.93), oculomotor nerve palsy (4.0% versus 0%; P<0.001; PPV=100.0%; OR=4.00), and crossed motor deficits (4.0% versus 0.1%; P<0.001; PPV=92.3%; OR=36.04); however, all had a very low sensitivity, ranging from 1.3% to 4.0%. CONCLUSIONS: This study indicates that the symptoms/signs considered typical of PCI occur far less often than was expected. Inaccurate localization would occur commonly if clinicians relied on the clinical neurological deficits alone to differentiate PCI from ACI. Neuroimaging is vital to ensure accurate localization of cerebral infarction.