[Short term effect of multiple stents parallel placement and reconstruction technique for the treatment of giant fusiform vertebrobasilar dissecting aneurysms].

OBJECTIVE: To investigate the feasibility,safety and follow-up results of multiple stents parallel placement and reconstruction technique for treating giant vertebrobasilar dissecting aneurysms. METHODS: Five consecutive patients with giant fusiform vertebrobasilar dissecting aneurysms in Department of Neurology,Chinese People's Liberation Army General Hospital were retrospectively reviewed from April 2011 to October 2013. All patients were diagnosed vertebrobasilar dissecting aneurysms by MRI and digital subtraction angiography (DSA), the aneurysm size ranged 8.2-15.0 mm. All patients were treated by multiple stents parallel placement and reconstruction technique under general anesthesia. In the endovascular treatment process, 2-3 Solitaire or Neuroform self-expandable stents were parallel implanted in the maximum extension segment of the aneurysms to reconstruct the cavity of the aneurysm and solved the problem that the diameter of the intracranial stent is less than the diameter of the aneurysms. Multiple stents parallel placement can keep the stents stable in the cavity. The parallel stent can close the dissection as well as strengthen the aneurysm walls to alleviate the vessel pulsative compression of the brain stem. Furthermore, one of the parallel stents was selected for the main blood flow channel. Based on the main channel, telescope technique was used to completely covering the dissection. It can not only prevent the progress of dissection to normal regions, but also be helpful for blood flow channel reconstruction to reduce the hemodynamic disorders. All Patients received routine antiplatelet therapy before and after endovascular treatment. RESULTS: The operative procedures were succeeded in all patients. Five patients were implanted 18 stents (3 stents in 3 patients; 4 stents in 1 patient; 5 stents in 1 patient; parallel 3 stents in 2 patients; parallel 2 stents in 3 patients). The signs and symptoms of brain stem and posterior group of cranial nerves improved significantly. All patients lived and worked normally and had no recurrent symptoms on follow-up of 6-24 months. All patients performed DSA reexamination at 6-12 months postoperation. The aneurysm size lessened in 2 patients and had no change in 3 patients. CONCLUSIONS: Multiple stents parallel placement and reconstruction technique for treating giant fusiform vertebrobasilar dissecting aneurysms is feasible and have good operation safety. It may control the dilatation of the aneurysm and reduce the probability of thrombosis or hemorrhage. It can improve the patients' clinical symptoms and quality of life in short term follow-up. The long term result need for further follow-up.

Lipopolysaccharide promotes lipid accumulation in human adventitial fibroblasts via TLR4-NF-κB pathway.

BACKGROUND: Atherosclerosis is a chronic degenerative disease of the arteries and is thought to be one of the most common causes of death globally. In recent years, the functions of adventitial fibroblasts in the development of atherosclerosis and tissue repair have gained increased interests. LPS can increase the morbidity and mortality of atherosclerosis-associated cardiovascular disease. Although LPS increases neointimal via TLR4 activation has been reported, how LPS augments atherogenesis through acting on adventitial fibroblasts is still unknown. Here we explored lipid deposition within adventitial fibroblasts mediated by lipopolysaccharide (LPS) to imitate inflammatory conditions. RESULTS: In our study, LPS enhanced lipid deposition by the up-regulated expression of adipose differentiation-related protein (ADRP) as the silencing of ADRP abrogated lipid deposition in LPS-activated adventitial fibroblasts. In addition, pre-treatment with anti-Toll-like receptor 4 (TLR4) antibody diminished the LPS-induced lipid deposition and ADRP expression. Moreover, LPS induced translocation of nuclear factor-κB (NF-κB), which could markedly up-regulate lipid deposition as pre-treatment with the NF-κB inhibitor, PDTC, significantly reduced lipid droplets. In addition, the lowering lipid accumulation was accompanied with the decreased ADRP expression. Furthermore, LPS-induced adventitial fibroblasts secreted more monocyte chemoattractant protein (MCP-1), compared with transforming growth factor-ß1 (TGF-ß1). CONCLUSIONS: Taken together, these results suggest that LPS promotes lipid accumulation via the up-regulation of ADRP expression through TLR4 activated downstream of NF-κB in adventitial fibroblasts. Increased levels of MCP-1 released from LPS-activated adventitial fibroblasts and lipid accumulation may accelerate monocytes recruitment and lipid-laden macrophage foam cells formation. Here, our study provides a new explanation as to how bacterial infection contributes to the pathological process of atherosclerosis.

[Stenting treatment of venous sinus stenosis for intractable pulsatile tinnitus].

OBJECTIVE: To evaluate the application, effectiveness and safety of stenting in venous sinus stenosis for intractable pulsatile tinnitus via endovascular treatment. METHODS: From January 2010 to July 2011, 12 cases with intractable pulsatile tinnitus originating from cerebral venous sinus stenosis underwent stenting treatment. All of them were diagnosed by digital subtraction angiography (DSA). There was ipsilateral stenosis in junction segment of sigmoid and transverse sinuses. The diverticulum of sigmoid sinus was found in 6 cases. Eleven patients underwent stenting placement and angioplasty for venous sinus stenosis. RESULTS: All pulsatile tinnitus symptoms disappeared immediately after stenting. No related complication was found during stenting and over a follow-up period of 3 - 22 months. There was no recurrence of pulsatile tinnitus. CONCLUSIONS: Stent placement is a safe and effective procedure for pulsatile tinnitus with cerebral venous sinus stenosis.

[Evaluation of carotid angiography and stenting for patients with contralateral carotid occlusion].

OBJECTIVE: To discuss the efficiency and safety of carotid angioplasty stenting (CAS) in patients with contralateral carotid artery occlusion. METHODS: From January 2001 to January 2010, 56 carotid artery stenosis patients with contralateral carotid artery occlusion were performed CAS and the feature and results of these cases were analyzed retrospectively. All the cases were confirmed to be carotid artery stenosis with contralateral carotid artery occlusion by digital subtraction angiography (DSA). The diameter stenosis rate was 72% ± 15%. CAS were performed with distal protection device in 56 cases. RESULTS: The technique success rate of CAS were 100% in all the 56 patients with contralateral carotid artery occlusion and post-procedure stenosis rate descended to 13% ± 8%, and the symptoms of cerebral ischemia were all improved. Only 1 case occurred remote hemorrhage in the position of previous cerebral infarction in the side of CAS after the procedure, and recovered with light neurological deficit after the craniotomy to remove the hematoma. No ischemic complications or death occurred. During the following up of 6 months to 3 years, no cerebral ischemic symptoms reoccurred. The rechecking results of color Doppler of 47 cases and DSA of 2 cases showed no restenosis in-stent. CONCLUSIONS: CAS is safe and effective for the patients with contralateral carotid artery occlusion. Critical election of the case, operation of skilled doctors and scrupulous post procedure general management can decrease the rate of complication.

[Clinical study on endovascular treatment for symptomatic atherosclerotic stenosis of basilar artery].

OBJECTIVE: To study the feasibility, safety and validity of percutaneous angioplasty and stenting (PTAS) for symptomatic atherosclerotic stenosis of basilar artery. METHODS: The results of treatment and follow-up of 40 cases with symptomatic atherosclerotic stenosis of basilar artery performed PTAS from August 2003 to December 2009 were studied retrospectively, who had either recurrent transient ischemic attacks (TIAs) or obvious ischemic symptoms and resistant to medical therapy. RESULTS: PTAS were successfully performed in all the 40 cases and the post-operative average residual stenosis descended to 14% ± 11% from pre-operative 82% ± 14%. After operation the patients were administrated with antiplatelet drugs. After procedure the clinic symptoms and signs of ischemia were improved obviously in 38 cases and deteriorated in 2 cases whose CT scanning showed that the range of infarction in brain stem enlarged. The symptoms improved after treatment but 2 patients had neurological deficit. No hemorrhagic complications occurred in the group. During the follow-up for 2 months to 7 years, transcranial doppler ultrasonography in 26 cases demonstrated the blood flow was faster than normal in 2 cases, and digital subtraction angiography (DSA) in 6 cases showed restenosis in-stent in 1 case. The second stent was implanted because of the symptomatic restenosis. In another case the follow-up DSA showed occlusion of basilar artery in-stent but there was no ischemia of post circulation because the generation of anastomoses. CONCLUSIONS: PTAS is a feasible, safe and effective therapeutic method for the patients with symptomatic atherosclerotic stenosis of basilar artery. Further study in large number of patients is needed for long-term outcome.

[Cause and treatment for intracranial hemorrhage during the perioperative period of carotid artery stenting].

OBJECTIVES: To discuss the possible cause of intracranial hemorrhage and treatment after carotid artery stenting (CAS) in patients with carotid artery stenosis. METHODS: From January 2003 to August 2009, 403 patients with carotid artery stenosis that were performed CAS, intracranial hemorrhage occurred in 5 cases after the procedure. We analyzed the feature of these cases and perioperative management retrospectively to summarize the possible cause of intracranial hemorrhage and preventive measure. RESULTS: Cerebral hemorrhage were found 30 min after CAS in 2 cases, 5 days in 2 cases and 3 days in 1 case. One patient was treated conservatively whose hemorrhage was about 2 ml, one was performed draining of ventricle and the other three cases were all performed craniotomy to remove the hematoma and to depress. The position of hemorrhage were all in the side of carotid artery stenosis, and in 2 cases of them the hemorrhage were at the region of previous cerebral infarction. One patient was cured conservatively, the one who was performed draining of ventricle died. Among the other three cases performed craniotomy, one recovered with light neurological deficit and two died of multiple organ failure. CONCLUSION: Intracranial hemorrhage is the most serious complication of CAS of carotid artery, and general measure should be taken to prevent it from occurring.

[Endovascular interventional treatment for symptomatic stenosis of middle cerebral artery].

OBJECTIVE: To study the feasibility, security and validity of percutaneous angioplasty (PTA) or percutaneous angioplasty and stenting (PTAS) for symptomatic stenosis of middle cerebral artery. METHODS: The results of treatment and follow-up of 39 cases with symptomatic stenosis of middle cerebral artery who had either recurrent transient ischemic attacks (TIAs) or resistant to medical therapy and were performed PTA or PTAS were studied retrospectively. RESULTS: Among the 39 cases with stenosis of middle cerebral artery (23 in left, 13 in right, 3 in bilateral side and 5 cases combining with stenosis of carotid artery) PTA were successfully performed in 9 cases and PTAS in 30 (whose post-operative residual stenosis were less than 10%). After operation the patients were administrated with antiplatelet drugs. The clinic symptom and sign of ischemia were improved obviously after operation. During the procedure the contrast could be seen outside the vessel in 2 cases, the patients had no obvious symptom of hemorrhage and got well rapidly. But in another case her consciousness changed 1 h after PTAS and the limbs could not move in right side. Emergency CT scan showed cerebral hemorrhage in left basic node area. The patient suffered language barrier and incomplete hemiplegy in right side. No complication was occurred in the others. During 5 to 60 months follow-up, the symptom of weakness in right arm reoccurred but lighter than before in only one case. TCD rechecked in 26 cases and demonstrated the blood beam speed was faster than normal in two case. DSA rechecked in 14 cases showed restenosis in-stent in the 2 cases and they were treated by medicine. CONCLUSIONS: PTA and PTAS is a feasible, safe and effective therapeutic method for the patients with symptomatic stenosis of middle cerebral artery. Further study in large number of patients is needed for long-term outcome.

Application of parallel stent placement in the treatment of unruptured vertebrobasilar fusiform aneurysms.

OBJECTIVE Large vertebrobasilar fusiform aneurysms (VFAs) represent a small subset of intracranial aneurysms and are often among the most difficult to treat. Current surgical and endovascular techniques fail to achieve a complete or acceptable result because of complications, including late-onset basilar artery thrombosis and perforator infarction. The parallel-stent placement technique was established in the authors' department, and this study reports the application of this technique in the treatment of unruptured VFAs. METHODS Eight patients with 8 unruptured VFAs who underwent parallel stent placement between April 2011 and August 2012 were included. The diameters of the VFAs ranged from 7.9 to 14.0 mm, and the lengths from 27.5 to 54.4 mm. Of the 8 patients with unruptured VFAs, 3 received double or triple parallel stents and 5 patients received a series-connected stent with another 1 or 2 stents deployed parallel to them. Outcomes for these patients were tabulated, based on the modified Rankin Scale (mRS) score and angiographic results. RESULTS All of the 25 stents were successfully placed without any treatment-related complications. During follow-up, 5 patients had decreased mRS scores, 2 were unchanged, and 1 was increased for subarachnoid hemorrhage. Immediate and follow-up clinical outcome was completely or partially recovered in most patients. Follow-up angiograms revealed 2 aneurysms were reduced in size and 6 were unchanged after stent placement. No in-stent stenosis, occlusion of the posterior inferior cerebellar artery, or perforators jailed by the stent occurred in any of the aneurysms. CONCLUSIONS These results provide encouraging support for the parallel-stent placement technique, which can be envisaged as an alternative strategy against unruptured VFAs. However, testing in more patients is needed.

Occult Pulsatile Tinnitus in Association with a Prominent Vein of Hypoglossal Canal: Two Case Reports.

The pathway of the vein of hypoglossal canal has not been mentioned in venous origin pulsatile tinnitus. We wished to clarify the possible complications related to this venous variant. We described 2 rare cases of troublesome pulsatile tinnitus associated with prominent vein of hypoglossal canal, which communicates with the jugular bulb and the marginal sinus. Both cases were successfully treated by positioning a stent across the vein of hypoglossal canal and jugular bulb. The 2 present clinical cases represent the first report of such a condition. The therapeutic decision-making is discussed in relation to the persistent pulsatile tinnitus and the etiopathologic hypothesis put forward.

Stent-Assisted Coil Embolization of a Transverse-Sigmoid Sinus Diverticulum Presenting with Pulsatile Tinnitus.

When tinnitus is pulse-synchronous, a vascular etiology is suggested. We present a case of persistent and troublesome pulsatile tinnitus caused by a transverse-sigmoid sinus diverticulum that was endovascularly treated with stent-assisted coiling. A 39-yearold woman presented with a 4-year history of progressive pulsatile tinnitus involving the right ear. Slight pulsatile bruit was heard on the right mastoid bone by auscultation. Cerebral angiography demonstrated a diverticulum of the transverse-sigmoid sinus. The procedure was performed with an 8F guiding catheter (Cordis, USA) catheterized into the right sigmoid sinus. The diverticulum was completely coiled following deployment of a 5.5 mm-50 mm Leo stent. This patient awakened without any neurological deficit and with immediate resolution of her tinnitus. This case report describes a stent-assisted coil embolization of venous sinus diverticulum, which provides immediate resolution of pulsatile tinnitus.

Incidence and risk factors for medical complications and 30-day end points after carotid artery stenting.

With the extensive use of carotid artery stenting (CAS) surgeries, scholars are paying more attention to the safety and efficiency of CAS. Our study aims to analyze the clinical efficiency, safety, and technical feasibility of CAS surgery in the treatment of carotid artery stenosis. A total of 379 cases of CAS were collected and retrospectively analyzed. The outcomes were summarized according to decrease in stenosis extent, incidence of early complications after procedure, 30-day end point events, and the follow-up data. Logistic regression was employed to analyze the correlations between risk factors and complications within 30 days and 30-day end points of stroke, myocardial infarctions (MIs), and mortality. The average extent of stenosis reduced from preoperative (81% ± 17%) to postoperative (26% ± 17%). In all, 53 patients had 72 medical complications, including 6 (1.58%) cerebral hemorrhage, 7 (1.85%) cerebral infarction, 5 (1.32%) transient ischemic attack (TIA), 5 (1.32%) heart failure, 10 (2.63%) symptomatic hypertension, 21 (5.54%) symptomatic hypotension, 10 (2.63%) symptomatic bradycardia, and 8 other complications; 15 patients had at least 2 complications. Advanced age, diabetes, and heart failure were associated with the high incidence of early complications (P < .05). Asymptomatic stenosis (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.131-1.131, P = .0426) and diabetes (OR = 3.38, 95% CI: 1.340-8.574, P = .0099) were correlated with the incidence of 30-day end point events. Diabetes and symptomatic stenosis are independent risk factors for 30-day end point events of CAS. Advanced age, hypertension, and vascular unstable plaque will increase the risk of postoperative complications.

[Embolization combined with endovascular stenting for treatment of intracranial pseudoaneurysms].

OBJECTIVE: To evaluate the therapeutic effect of embolization combined with endovascular stenting in the for treatment of intracranial pseudoaneurysms. METHODS: Seventeen patients with intracranial pseudoaneurysms received endovascular treatment with coil placement, NBCA glue embolization and endovascular stenting, and the therapeutic effect was evaluated according to the findings in immediate postoperative and follow-up angiography. RESULTS: Fatal aneurysm rupture occurred in 1 case during embolization, and the surgical procedures were carried out smoothly in the remaining 16 cases. The aneurysm cavity dense coil packing ratio was 50% in coil embolization group and 42.9% in stent-assisted coil embolization group. In the follow-up for 3 months to 2 years, 2 patients in coil embolization group experienced pseudoaneurysm recurrence and were managed successfully with additional embolization with coils and stent. Aneurysms were not found postoperatively in stent-assisted coil embolization group. CONCLUSION: Embolization combined with endovascular stenting is a safe and effective treatment of intracranial pseudoaneurysms with minimized risk of recurrence.