Clinical Study of Symptomatic Nonacute Intracranial Large Arterial Occlusion with Endovascular Recanalization.

Objectives This study reported a single-center clinical trial of endovascular treatment for symptomatic nonacute occlusion of the intracranial large artery (NA-ILAO). The aim of this study was to evaluate the safety, feasibility, and clinical effect of simple balloon dilatation and stent implantation. Methods The patients diagnosed with symptomatic NA-ILAO were enrolled. A total of 40 cases were included in this study. While recanalization failed in 4 patients, it was successful in 36 patients, who were then divided into two groups for further analysis: balloon dilatation group ( n = 24) and stent implantation group ( n = 12). The perioperative complications, clinical outcome, and follow-up results were analyzed. Results Perioperative complications in the stent implantation group were significantly higher than those in the simple balloon dilatation group ( p < 0.05). There were 21 and 10 cases of 90-day good clinical outcome (modified Rankin scale [mRS] ≤ 2) in the balloon and stent groups, respectively ( p = 0.518). All patients with successful recanalization underwent digital subtraction angiography (DSA) or CT angiography (CTA) during an average follow-up of 14 months. There were two cases of restenosis in the balloon dilatation group and one in the stent implantation group ( p = 1.000). There were two cases of re-occlusion in the stent group and none in the balloon dilatation group ( p < 0.001). Stroke recurred in two cases in the stent group and in one case in the simple balloon dilatation group ( p = 0.013). Conclusion Endovascular recanalization is safe and feasible for patients with symptomatic NA-ILAO. Compared with stent implantation, simple balloon dilation may be a better recanalization method, but larger randomized controlled trials are needed to confirm it.

Association between triglyceride-glucose index and intracranial/extracranial atherosclerotic stenosis: findings from a retrospective study.

OBJECTIVE: The association of the triglyceride-glucose (TyG) index with intracranial atherosclerotic stenosis (ICAS) and extracranial atherosclerotic stenosis (ECAS) is unclear. This study aimed to investigate the relationship of TyG index with the distribution and severity of ICAS and ECAS. METHOD: Patients who underwent digital subtraction angiography (DSA) for evaluating ICAS/ECAS in Zhongnan Hospital of Wuhan University from January 2017 to October 2021 were retrospectively enrolled in our study. Clinical characteristics, DSA data, blood routine, lipid profile and fasting glucose were recorded. The association of TyG index and ICAS/ECAS status were investigated in four aspects: location and distribution of stenosis, stenosis severity and whether stenosis is symptomatic. Logistic regression models were used to evaluate the association. Restricted cubic splines were constructed to model the non-linear relationship between the TyG index and different arterial stenosis status. RESULTS: Among 1129 included patients, the median age was 62 (IQR 55-68) years, and 71.3% were male. The median TyG index was 8.81 (8.40, 9.21). Elevated TyG index was significantly associated with ICAS, combined ICAS/ECAS, anterior circulation stenosis, posterior circulation stenosis, combined anterior/posterior circulation stenosis, severe stenosis, both asymptomatic and symptomatic stenosis. This association was maintained after adjusting for age, sex, smoking, drinking, medical history of hypertension and stroke, platelet, total cholesterol, high-density lipoprotein, and low-density lipoprotein. Multivariable-adjusted spline regression models showed that a progressively increasing risk of arterial stenosis was related to an elevated TyG index. CONCLUSION: Elevated TyG index was associated with ICAS/ECAS. TyG index might be a useful indicator of ICAS and severe stenosis.

Successful hybrid endovascular treatment for refractory cerebral venous sinus thrombosis in pregnancy: A case report.

Background: Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway. Case presentation: A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery. Conclusion: Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.

Associations of neutrophil-to-lymphocyte ratio with intracranial and extracranial atherosclerotic stenosis.

Background: Neutrophil-to-lymphocyte ratio (NLR) has been shown to be an important inflammatory maker. This study aims to investigate the association of NLR with intracranial and extracranial atherosclerotic stenosis. Methods: We retrospectively recruited patients who underwent digital subtraction angiography (DSA) for evaluating intracranial/extracranial stenosis in the Zhongnan Hospital of Wuhan University from January 2017 to October 2021. Clinical characteristics, DSA data, blood routine, and lipid profile were recorded. Logistic regression was used to evaluate the association of NLR and intercranial/extracranial atherosclerotic stenosis in three aspects: distribution of stenosis, whether the stenosis is symptomatic, and degree of stenosis. Results: A total of 1,129 patients were included in our analysis, with a median age of 62 y (interquartile range 55-68), and a median admission NLR of 2.39 (interquartile range 1.84-3.42). A total of 986 patients presented intracranial and/or extracranial atherosclerotic stenosis. Increased NLR were associated with intracranial stenosis [odds ratio (OR), 1.54; 95% CI, 1.27-1.85; p < 0.001], extracranial stenosis (OR, 1.56; 95% CI, 1.25-1.96; p < 0.001), and combined intracranial/extracranial stenosis (OR, 1.61; 95% CI, 1.28-2.03; p < 0.001). After adjustment of potential factors, higher NLR were independently associated with symptomatic stenosis (OR, 1.16; 95% CI, 1.05-1.27; p = 0.003) and degree of stenosis (OR, 1.32; 95% CI, 1.17-1.49; p < 0.001). Compared with the first quartile NLR, the second, third, and fourth quartiles NLR were independent risk factors for symptomatic stenosis and stenosis degree (both p for trend <0.001). Conclusion: Increased NLR is an important factor associated with both intracranial and extracranial atherosclerotic stenosis. Patients with symptomatic intracranial/extracranial atherosclerotic stenosis or a more severe degree of stenosis presented elevated NLR levels.

Contrast agent retention sign in angiography predicts acute internal carotid artery embolic occlusion.

BACKGROUND: Identification of acute internal carotid artery embolism (ICAE) and internal carotid artery atherosclerotic stenosis (ICAAS) in acute ischemic stroke patients is important for selection of treatment. The presence of contrast agent retention on pre-procedural angiographic images is more common in patients with ICA occlusion caused by embolism compared to patients with ICA atherosclerotic stenosis. This study aimed to evaluate effectiveness of contrast agent retention sign for predicting ICAE. METHODS: Sixty-five patients with ICA occlusion who underwent emergency endovascular treatment from September 2014 to September 2020 were included in this retrospective analysis. Patients were divided into ICAE (n = 46) and ICAAS (n = 19) groups. Clinical characteristics, imaging data and ICA contrast agent retention signs of patients were collected. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnosis accuracy of contrast agent retention sign were conducted. RESULTS: The positive ICA contrast agent retention sign was significantly more common in patients with ICAE (60.87% vs 0.00%, P < 0.001) than that of patients with ICAAS, but significantly lower in male patients (53.57% vs 81.08%, P = 0.017). There were significantly more patients with positive sign had occlusion in C6 segment (64.29% vs 13.51%, P < 0.001) and no outflow tract (85.71% vs 5.41%, P < 0.001) compared with negative sign group. There were significantly fewer patients with postive sign had occlusion in C1 segment (0.00% vs 40.54%, P < 0.001) compared with negative sign group. The sensitivity, specificity, PPV, NPV and diagnosis accuracy of contrast agent retention sign for predicting ICAE occlusion were 60.87%, 100%, 100%, 51.35% and 72.31%, respectively. CONCLUSION: The ICA contrast agent retention sign has very high specificity and moderate sensitivity for detection of acute ICAE.

Successful endovascular therapy for an adolescent patient with cerebral venous sinus thrombosis: A case report.

RATIONALE: Cerebral venous sinus thrombosis associated with protein S deficiency is rare in adolescent patients and has high disability and fatality.Patient concerns: A 15-year-old male student presented in the hospital with sudden headache, nausea, and vomiting and was diagnosed with protein S deficiency by gene testing. DIAGNOSES: Cerebral venous sinus thrombosis due to protein S deficiency was diagnosed in this adolescent patient, who underwent successful endovascular therapy (EVT). INTERVENTIONS: The patient was treated with standard anti-coagulation therapy including low-molecular-weight heparin (90 IU/kg/Q12 h) and dehydrant (mannitol 125 mL Q8 h); however, the symptoms were not alleviated. Successful EVT was implemented. OUTCOMES: Both the superior sagittal sinus and bilateral transverse sinus were recanalized after thrombus clearance. The patient achieved a complete recovery without any other stroke recurrence during follow-up. LESSONS: EVT can be performed with favorable and effective clinical outcomes in adolescent cerebral venous sinus thrombosis patients with protein S deficiency. EVT associated with standard anti-coagulation therapy may improve the prognosis and reduce mortality among such patients.

Efficacy of Stent Thrombectomy Alone or Combined With Intermediate Catheter Aspiration for Severe Cerebral Venous Sinus Thrombosis: A Case-Series.

OBJECTIVE: To assess the safety and efficacy of stent thrombectomy alone or combined with intermediate catheter aspiration for severe cerebral venous sinus thrombosis. METHOD: We retrospectively collected the clinical data of 7 patients with severe CVST who received endovascular treatment at our hospital from January 2017 to June 2020. The patients had at least one adverse prognostic factor (mental status disorder, comatose state, intracerebral hemorrhage, or thrombosis of the deep venous system). RESULTS: The median age was 51 years. Three patients were women. Two or more venous sinuses were in involved in 5 patients. All patients received systemic anticoagulant therapy before endovascular therapy. Neurological deterioration was the main reason for patients with cerebral venous sinus thrombosis undergoing intravascular therapy. The median time from admission to intravascular therapy was 3 days (1-9 days). Primary endpoints: 6 patients (85.7%) had a modified Rankin scale score of 0 at day 90, and 1 patient (14.3%) had a modified Rankin scale score of 2 at day 90. Secondary endpoints: complete recanalization was achieved in 4 cases (57.1%) and partial recanalization in 3 cases (42.9%). CONCLUSION: Stent thrombectomy, combined with intermediate catheter aspiration, balloon dilation, and regional thrombolysis/anticoagulation treatment, is an effective strategy to treat severe cerebral venous sinus thrombosis patients who had inadequate response to anticoagulant therapy. This strategy can quickly eliminate the occluded venous sinus and improve prognosis of severe cerebral venous sinus thrombosis.

Application of pigtail catheter tailing combined with long-wire swapping technique in cerebral angiography via the right radial artery.

The safety and feasibility of transradial approach for cerebral angiography has been confirmed previously. However, this approach has been limited used due to the difficulty during the procedure. This study aimed to introduce a pigtail catheter tailing and long-wire swapping technique to improve the success rate without increasing complications.From August 2015 to December 2018, 560 patients who underwent cerebral angiography via transradial approach were recruited. The data including the type of aortic arch, type of Simmon catheter were collected.The loop was successfully constructed in 553 patients using Simmon-2 or Simmon-1 catheter. Of these patients, 72 patients successfully underwent cerebral and renal angiography, while 481 patients underwent cerebral angiography. The time for angiography was 52.87 ±â€Š11.23 minutes and 47.8 ±â€Š11.8 minutes, respectively. There were 369 (66.7%), 135 (24.4%), and 49 (8.9%) patients with type I, type II, and type III aortic arches, respectively, and their success rates of looping using Simmon-2 catheter were 97.8%, 97.0%, and 89.8%, respectively. The success rates of angiography in the right internal carotid artery, right vertebral artery, left internal carotid artery, and left vertebral artery were 100%, 100%, 98.9%, and 98.9%, respectively. No serious complications were observed in all patients.The pigtail catheter tailing and long guidewire swapping is considered as a safe procedure with high success rate for loop construction using a Simmon-2 catheter through the right radial artery, subsequently improving the success rate as well as the efficiency of angiography.

Factors associated with prolonged viral shedding and impact of lopinavir/ritonavir treatment in hospitalised non-critically ill patients with SARS-CoV-2 infection.

BACKGROUND: The duration of viral shedding is central to the guidance of decisions about isolation precautions and antiviral treatment. However, studies regarding the risk factors associated with prolonged shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the impact of lopinavir/ritonavir (LPV/r) treatment on viral shedding remain scarce. METHODS: Data were collected from all SARS-CoV-2 infected patients who were admitted to isolation wards and had reverse transcription PCR conversion at the No. 3 People's Hospital of Hubei province, China, between 31 January and 9 March 2020. We compared clinical characteristics and SARS-CoV-2 RNA shedding between patients initiated with LPV/r treatment and those without. Logistic regression analysis was employed to evaluate the risk factors associated with prolonged viral shedding. RESULTS: Of 120 patients, the median age was 52 years, 54 (45%) were male and 78 (65%) received LPV/r treatment. The median duration of SARS-CoV-2 RNA detection from symptom onset was 23 days (interquartile range 18-32 days). Older age (OR 1.03, 95% CI 1.00-1.05; p=0.03) and the lack of LPV/r treatment (OR 2.42, 95% CI 1.10-5.36; p=0.029) were independent risk factors for prolonged SARS-CoV-2 RNA shedding. Patients who initiated LPV/r treatment within 10 days from symptom onset, but not initiated from day 11 onwards, had significantly shorter viral shedding duration compared with those without LPV/r treatment (median 19 days versus 28.5 days; log-rank p<0.001). CONCLUSION: Older age and the lack of LPV/r treatment were independently associated with prolonged SARS-CoV-2 RNA shedding in patients with coronavirus disease 2019 (COVID-19). Earlier administration of LPV/r treatment could shorten viral shedding duration.

Protective roles of intra-arterial mild hypothermia and arterial thrombolysis in acute cerebral infarction.

OBJECTIVE: Herein, we evaluated the efficacy and safety of intra-arterial mild hypothermia in combination with arterial thrombolysis to treat acute cerebral infarction due to middle cerebral artery occlusion. METHODS: A total of 26 patients with acute middle cerebral artery occlusion were divided into a normothermia group (n = 15) and a mild hypothermia group (n = 11). The infarct volumes at 24 h and 7 days after the operation were compared between the normothermia group and the mild hypothermia group. Additionally, we compared neurological deficit scores between the two groups at 24 h, 7 days, and 1 mo after the operation. RESULTS: The infarct volumes and neurological deficit scores of the mild hypothermia group were significantly reduced compared to those in the normothermia group (p < 0.05). Furthermore, no adverse reactions or complications occurred in the mild hypothermia group. CONCLUSION: Intra-arterial mild hypothermia reduced infarct volume after ischemia-reperfusion injury in the arterial thrombolysis of an acute cerebral infarction. Additionally, it improved the prognosis of patients with an acute middle cerebral artery occlusion, suggesting that this procedure is safe and effective for treating acute cerebral infarction.