Duplex ultrasound and cross-sectional imaging in carotid artery occlusion diagnosis.

OBJECTIVE: Investigations into imaging modalities in the diagnosis of extracranial carotid artery occlusion (CAO) have raised questions about the inter-modality comparability of duplex ultrasound (DUS) and cross-sectional imaging (CSI). This study examines the relationship between DUS and CSI diagnoses of extracranial CAO. METHODS: This single-institution retrospective analysis studied patients with CAO diagnosed by DUS from 2010 to 2021. Patients were identified in our office-based accredited vascular laboratory database. Imaging and clinical data was obtained via our institutional electronic medical record. Primary outcome was discrepancy between DUS and CSI modalities. Secondary outcomes included incidence of stroke and intervention subsequent to CAO diagnosis. RESULTS: Of our 140-patient cohort, 95 patients (67.9%) had DUS follow-up (mean, 42.7 ± 31.3 months). At index duplex, 68.0% of individuals (n = 51) were asymptomatic. Seventy-five patients (53.6%) had CSI of the carotids after DUS CAO diagnosis; 18 (24%) underwent magnetic resonance imaging and 57 (76%) underwent computed tomography. Indications for CSI included follow-up of DUS findings of carotid stenosis/occlusion (44%), stroke/transient ischemic attack (16%), other symptoms (12%), preoperative evaluation (2.7%), unrelated pathology follow-up (9.3%), and outside institution imaging with unavailable indications (16%). When comparing patients with CSI and those without, there were no differences with regard to symptoms at diagnosis, prior neck interventions, or hypertension. There was a significant difference between cross-sectionally imaged and non-imaged patients in anti-hypertensive medications (72% vs 53.8%; P = .04). Despite initial DUS diagnoses of carotid occlusion, 10 patients (13.3%) ultimately had CSI indicating patent carotids. Four of these 10 patients had stenoses of ∼99% (with 1 string sign), four of 70% to 99%, one of 50% to 69%, and one of less than 50% on CSI. The majority of patients (70%) had CSI within 1 month of the index ultrasound. There were no significant relationships between imaging discrepancies and body mass index, heart failure, upper body edema, carotid artery calcification, and neck hardware. Eight individuals (10.7%) underwent ipsilateral revascularization; 62.5% (n = 5) were carotid endarterectomy procedures, and the remaining three procedures were a transcervical carotid revascularization, subclavian to internal carotid artery bypass, and transfemoral carotid artery stenting. Eight patients (10.7%) underwent contralateral revascularization, with the same distribution of procedures as those ipsilateral to occlusions. Two of the 10 patients with discrepancies underwent carotid endarterectomy, and one underwent carotid stenting. CONCLUSIONS: In our experience, duplex diagnosis of CAO is associated with a greater than 10% discordance when compared with CSI. These patients may benefit from closer surveillance as well as confirmatory computed tomography or magnetic resonance angiography. Further work is needed to determine the optimal diagnostic modality for CAO.

Comparison of the treatment strategies for symptomatic chronic internal carotid artery occlusion.

OBJECTIVE: The best management of symptomatic chronic internal carotid artery occlusion (CICAO) has been controversial. This systematic review and meta-analysis were to compare the outcomes of different treatment strategies for symptomatic CICAO. METHODS: Two independent researchers conducted a search of articles on the treatment of CICAO published between January 2000 and October 2023 in PubMed, Web of Science, Embase, and The Cochrane Library. Twenty-two articles were eligible for meta-analysis using a random effects model to combine and analyze the data for the pooled rates of stroke and death, and the rates of procedural success and significant restenosis/occlusion. RESULTS: A total of 1193 patients from 22 publications were included in this study. Six of them had bilateral internal carotid artery occlusion. The 30-day stroke and death rates were 1.1% (95% confidence interval [CI], 0%-4.4%) in the best medical treatment (BMT) group, 4.1% (95% CI, 0.7%-9.3%; I2 = 71.4%) in the extracranial-intracranial (EC-IC) bypass group, 4.4% (95% CI, 2.4%-6.8%; I2 = 0%) in the carotid artery stenting (CAS) group, and 1.2% (95% CI, 0%-3.4%; I2 = 0%) in the combined carotid endarterectomy (CEA) and stenting (CEA + CAS) group. During follow-up of 16.5 (±16.3) months, the stroke and death rates were 19.5%, 1.2%, 6.6%, and 2.4% in the BMT, EC-IC, CAS, and CEA + CAS groups respectively. The surgical success rate was 99.7% (95% CI, 98.5%-100%; I2 = 0%) in the EC-IC group, 70.1% (95% CI, 62.3%-77.5%; I2 = 64%) in the CAS group, and 86.4% (95% CI, 78.8%-92.7%; I2 = 60%) in the CEA + CAS group. The rate of post-procedural significant restenosis or occlusion was 3.6% in the EC-IC group, 18.7% in the CAS group, and 5.7% in the CEA + CSA group. The surgical success rate was negatively associated by the length of internal carotid artery (ICA) occlusion. Surgical success rate was significantly higher in the patients with occlusive lesion within C1 to C4 segments, compared with those with occlusion distal to C4 segment (odds ratio, 11.3; 95% CI, 5.0-25.53; P < .001). A proximal stump of ICA is a favorable sign for CAS. The success rate of CAS was significantly higher in the patients with an ICA stump than that in the patients without (odds ratio, 11.36; 95% CI, 4.84-26.64; P < .01). However, the success rate of CEA + CAS was not affected by the proximal ICA stump. CONCLUSIONS: For the management of symptomatic CICAO, BMT alone is associated with the highest risk of mid- and long-term stroke and death. EC-IC bypass surgery and CEA + CAS should be considered as the choice of treatment based on operator's expertise and patient's anatomy. CAS may be employed as an alternative option in high surgical risk patients, especially when proximal ICA stump exists.

Safety and Efficacy of Hybrid Surgery in Chronic Internal Carotid Artery Occlusion: A Systematic Review and Meta-Analysis.

INTRODUCTION: Chronic internal carotid artery occlusion (CICAO) is a common cause of stroke and ischemia recurrence. An increasing number of reports have highlighted the potential of hybrid surgery for treating CICAO. There are few studies, specifically nonrandomized controlled trials, on the safety and effectiveness of hybrid surgery for the treatment of CICAO, so in this study, we hypothesized that hybrid surgery would be safe, have an acceptable complication rate and a high success rate. METHODS: MEDLINE, Embase, Cochrane Library, and Web of Science databases were searched for relevant studies published up to January 30, 2023. The primary endpoint was recanalization rates of occluded vessels, and the secondary endpoint was perioperative death and procedure-related complications. Subgroup analysis focused on the recanalization rates of endovascular intervention (EI) and hybrid surgery, as well as the rates of recanalization below the clinoid segment and at the clinoid segment and beyond. The follow-up visit was conducted at least 3 months after surgery, and stenosis or occlusion recurrence was confirmed by review of CTA or DSA scan. RESULTS: The databases were searched and 1,709 records were identified, of which 16 articles were used in the meta-analysis, and 464 CICAO patients with complete data who underwent hybrid surgery were enrolled. Hybrid surgery was associated with higher success rates (RD = 0.87, 95% CI [0.84-0.91], p < 0.00001) than EI (OR = 4.71, 95% CI [2.32-9.56], p < 0.0001). The procedural success rate in the below-clinoid segment group was significantly higher than that in the clinoid segment and beyond group (OR = 13.76, 95% CI [5.31-35.66], p < 0.00001). The total periprocedural complication rate was low (RD = 0.11, 95% CI [0.07-0.15], p < 0.00001 and RD = 0.04, 95% CI [0.00-0.07], p = 0.03). Target vessel restenosis or reocclusion occurred in 35 patients (8%) during the follow-up period (RD = 0.08, 95% CI [0.04-0.12], p < 0.0001). CONCLUSION: Hybrid surgery is the combination of the advantages of open surgery and EI, has a high success rate and a low risk of recurrence of stenosis and occlusion in the long term. Randomized controlled trials on hybrid surgery for internal carotid artery occlusion are necessary.

Evaluation of collateral circulation in patients with internal carotid artery occlusion: A clinical and ultrasonographic multicenter study.

BACKGROUND: Internal carotid artery (ICA) occlusion is the major cause of ischemic stroke. The effect of collateral vessels on cerebral hemodynamics in ICA occlusion remains unclear. This study investigated the correlation between collateral vessels and the peak systolic velocity of the middle cerebral artery (MCA) in patients with ICA occlusion. METHODS: The relevant collateral vessels included the anterior communicating (ACoA), posterior communicating (PCoA), and internal-external carotid (IECCA) arteries, respectively. Patients with unilateral ICA occlusion (n = 251) underwent transcranial Doppler imaging to detect the peak systolic velocity (PSV) of the MCA and other intracranial arteries. The clinical symptoms were assessed using the National Institutes of Health Stroke Scale (NIHSS). RESULTS: Patients with ACoA collaterals had significantly higher PSVMCA scores and significantly lower NIHSS scores than those without ACoA collaterals (p < 0.001). Patients without any notable collaterals and those with only IECCA had the lowest PSVMCA and highest NIHSS scores. The PSVMCA and NIHSS scores were negatively correlated (r = -0.566, p < 0.001). CONCLUSION: Collateral circulation patency in unilateral ICA occlusion was closely associated with clinical symptoms, and patients with ACoA collaterals may have favorable outcomes. (ClinicalTrials.gov Identifier: NCT02397655).

Effects of schisandrin B on hypoxia-related cognitive function and protein expression in vascular dementia rats.

Vascular dementia (VD) a heterogenous group of brain disorders in which cognitive impairment is attributable to vascular risk factors and cerebrovascular disease. A common phenomenon in VD is a dysfunctional cerebral regulatory mechanism associated with insufficient cerebral blood flow, ischemia and hypoxia. Under hypoxic conditions oxygen supply to the brain results in neuronal death leading to neurodegenerative diseases including Alzheimer's (AD) and VD. In conditions of hypoxia and low oxygen perfusion, expression of hypoxia-inducible factor 1 alpha (HIF-1α) increases under conditions of low oxygen and low perfusion associated with upregulation of expression of hypoxia-upregulated mitochondrial movement regulator (HUMMR), which promotes anterograde mitochondrial transport by binding with trafficking protein kinesin 2 (TRAK2). Schisandrin B (Sch B) an active component derived from Chinese herb Wuweizi prevented ß-amyloid protein induced morphological alterations and cell death using a SH-SY5Y neuronal cells considered an AD model. It was thus of interest to determine whether Sch B might also alleviate VD using a rat bilateral common carotid artery occlusion (BCAO) dementia model. The aim of this study was to examine the effects of Sch B in BCAO on cognitive functions such as Morris water maze test and underlying mechanisms involving expression of HIF-1α, TRAK2, and HUMMR levels. The results showed that Sch B improved learning and memory function of rats with VD and exerted a protective effect on the hippocampus by inhibition of protein expression of HIF-1α, TRAK2, and HUMMR factors. Evidence indicates that Sch B may be considered as an alternative in VD treatment.

A nomogram predicting the relationship between recanalization time and successful endovascular recanalization of non-acute internal carotid artery occlusion in a Chinese population.

Different recanalization times for endovascular interventions may affect the success of non-acute internal carotid artery occlusion procedures. Nomograms can provide personalized and more accurate risk estimates based on predictive values. Therefore, we developed a nomogram to predict the probability of success of endovascular recanalization procedures for non-acute internal carotid artery occlusion. We performed a single-center retrospective analysis of data collected from patients who underwent endovascular treatment for non-acute internal carotid artery occlusion between January 2015 and December 2022. Multifactorial logistic regression analyses were performed to identify independent predictors affecting the success rate of non-acute internal carotid artery occlusion procedures and to create nomograms. The model was differentiated and calibrated using the area under the ROC curve (AUC-ROC) and calibration plots. Internal validation of the model was performed by using resampling (1000 replications). In total, 46 patients were identified and a total of 39 patients met the study criteria. Predictors in the nomogram included vascular occlusion proximal morphology, reversed flow of the ophthalmic artery, and recanalization time. The model showed good resolution with an ROC area of 0.917 (95% CI: 0.814-0.967). The nomogram can be used to personalize, visualize, and accurately predict the surgical success of endovascular treatment of non-acute internal carotid artery occlusion.

Hybrid Surgery for symptomatic chronic internal carotid artery occlusion: a single-center experience.

BACKGROUND: Patients with symptomatic chronic internal carotid artery occlusion (ICAO) face a high risk of recurrent stroke despite receiving aggressive medical therapy. This study aimed to evaluate the effectiveness and safety of hybrid surgery in treating symptomatic chronic ICAO. METHODS: This retrospective case series was conducted at a single center. From January 2019 to December 2022, patients with symptomatic chronic ICAO who underwent hybrid surgery were included. We collected baseline data, lesion characteristics, revascularization rates, perioperative complications, and follow-up outcomes. RESULTS: The study enrolled 27 patients, comprising 22 males and 5 females, with symptomatic chronic ICAO. The hybrid surgery achieved a technical success rate of 100% for revascularization (n = 27), with a perioperative complication rate of 14.8% (n = 4). Following a median follow-up of 6.0 months (IQR, 4-10), 21 patients underwent a DSA or CT angiography reexamination, confirming a vascular patency rate of 90.5% (n = 19). One patient required surgery for severe in-stent restenosis, and another experienced asymptomatic occlusion. Clinical follow-ups were conducted for all 26 patients; no new strokes were reported in the qualifying artery territory, with 13 patients scoring 0, 12 scoring 1, and 1 scoring 2 on the mRS. CONCLUSION: Although hybrid surgery represent a promising option for treating chronic ICAO, they are also associated with a relatively high incidence of treatment-related complications. The application of composite surgery should be based on standardized technical guidelines and the careful selection of patients who are genuinely at high risk for recurrent strokes.

Carotid-carotid artery crossover bypass using the Saphenous Vein Graft for symptomatic common carotid artery occlusion: how I do it.

BACKGROUND: Common carotid artery occlusion (CCAO) is rare, where a revascularization procedure might be needed in symptomatic or recurrent ischemic events. In this study, we describe the carotid-carotid artery crossover bypass technique for Riles type 1 A CCAO. METHODS: The procedure was conducted via bilateral neck incisions utilizing the saphenous vein graft. The graft was patent after surgery, along with substantial improvement in cerebral perfusion, resulting in a stroke-free postoperative period. CONCLUSION: The carotid-carotid crossover bypass is effective for CCAO patients requiring revascularization. However, individual bypass options and vascular grafts should be carefully considered.

Short jump vein graft for the treatment of symptomatic Riles type 1A occlusion of common carotid artery: case report and review of literature.

A 62-year-old man was presented with transient ischemic attack 1 day after percutaneous coronary intervention. Magnetic resonance imaging demonstrated fresh cerebral infarction in the left hemisphere. Digital subtraction angiography showed left Riles type 1A common carotid artery occlusion (CCAO). Blood flow in the internal carotid artery (ICA) was derived from the external carotid artery, which came through the anastomosis between the left occipital artery and a muscular branch of left vertebral artery. We performed short jump graft from CCA to ICA using saphenous vein, followed by ligation of CCA. The graft remained patent at the 1-year follow-up.

Acute ischemic stroke: The role of emergency carotid endarterectomy in isolated extracranial internal carotid artery occlusion.

OBJECTIVES: The treatment of choice for acute and isolated extracranial internal carotid artery (eICA) occlusion remains, to date, controversial. Although intravenous thrombolysis is recommended, its effectiveness is generally low. This retrospective study aims to assess the clinical outcome and the role of CT perfusion in symptomatic patients who underwent carotid endarterectomy (CEA) for acute occlusion of the eICA. MATERIALS AND METHODS: All the 21 patients presented with stroke-in-evolution, complete patency of intracranial circulation, no evidence of hemorrhagic transformation at CT and a minimum ASPECTS of 6. Clinical improvement was assessed by evaluating the variation of NIHSS and the mRS. We investigated the relationship between NIHSS and the timing of the surgery, the ASPECT score, and the volume of ischemic penumbra at CT perfusion. RESULTS: Median NIHSS on admission was 9 (range 1-24) and it decreased to 4 (range 0-35) 24 h after surgery, improving in 76.2% of patients. Patients with an ASPECTS of 6 (3 patients) showed an improvement of 66.7%, while it was of 81.8% in those starting with a score of 9 or 10 (11 patients). A mRS between 0 and 2 after 3 months was achieved in 12 out of 21 patients. The average time elapsing between surgery and symptom onset was 410 min (range 70-1070 min). Fourteen patients treated within 8 h from symptoms onset showed a clinical improvement of 85.7%, compared to a 57.1% for those which underwent later surgery. Four patients underwent thrombolytic therapy before CEA showing postoperative clinical improvement and no intracranial hemorrhage. Among the 14 patients who underwent CT perfusion, the median ischemic penumbra volume was 112 cc in those with clinical improvement (10 patients) and only 84 cc in those with worse clinical outcomes (4 patients). CONCLUSIONS: Emergency CEA in isolated eICA occlusion has proved to be a safe and effective treatment option in selected patients. CT perfusion, imaging the ischemic penumbra and quantifying the tissue suitable for reperfusion, offers a valid support in the diagnostic-therapeutic workup. Indeed, we can infer that the area of the ischemic penumbra is directly proportional to the margin of clinical improvement after revascularization, supposing that the appropriate intervention timing is respect.

Accuracy of contrast-enhanced ultrasound in diagnosing extracranial carotid occlusion: A meta-analysis.

AIM: This study aimed to assess the accuracy of contrast-enhanced ultrasound (CEUS) in detecting extracranial carotid artery occlusion. MATERIALS AND METHODS: A systematic literature search was conducted in the Cochrane, PubMed, and EMBASE databases. Prospective or retrospective studies that reported sensitivity and specificity of CEUS for the diagnosis of carotid artery occlusion were selected. Eight studies (354 arteries) were included in the meta-analysis. A bivariate random-effect model was used to estimate overall sensitivity and specificity. The results were also summarized by developing a summary receiver operating characteristic (SROC) curve. RESULTS: The overall sensitivity, specificity, positive, and negative likelihood ratios were 0.99 (95% CI: 0.83-1.00), 0.97 (95% CI: 0.90-0.99), 30.0 (95% CI: 9.8-91.4), and 0.01 (95% CI: 0.00-0.21), respectively; the odds ratio for diagnosis was 4,796 (95% CI: 119-192,584). CONCLUSION: The diagnostic test accuracy suggests that CEUS is a reliable tool for diagnosis of extracranial carotid artery occlusion.

Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions.

OBJECTIVES: Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. MATERIALS AND METHODS: We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. RESULTS: 36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). CONCLUSIONS: IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.

Low NIHSS score large vessel occlusion caused by infective endocarditis treated with thrombectomy.

OBJECTIVES: Large vessel occlusion (LVO)-related acute ischemic stroke due to infective endocarditis (IE) is a rare condition. At onset, most patients are severely ill, whereas on rare occasion, they develop mild neurological symptoms. As far as we are aware, this is the first report of IE related internal carotid artery (ICA) occlusion with low National Institutes of Health Stroke Scale (NIHSS) (<6) score treated with endovascular thrombectomy. CASE PRESENTATION: A 24-year-old woman had undergone dental treatment 3 weeks before and had a persistent low-grade fever for a week. She presented to the emergency department with a chief complaint of motor weakness of the right upper limb after waking up. She had only mild paralysis of the right upper limb (NIHSS score 1). Magnetic resonance imaging showed scattered infarcts in the left frontal lobe and cerebral angiography showed that the left ICA had been occluded immediately distal to its origin. The symptom disappeared after the occluded artery was completely recanalized by mechanical thrombectomy. On postoperative day 1, blood cultures were positive and echocardiography was performed, which revealed a verrucous mitral valve and a diagnosis of IE. On postoperative day 2, the patient underwent cardiac surgery for valve replacement. Thereafter, there was no recurrence of cerebral infarction, and the patient was discharged home on day 50 with a modified Rankin Scale 0. CONCLUSIONS: Early endovascular thrombectomy for low NIHSS score LVO due to IE resulted in a good treatment course. IE should be part of the differential diagnosis of LVO in the young patients.

The relationship between occlusion patterns and outcomes after thrombectomy in patients with acute internal carotid artery occlusion.

BACKGROUND AND PURPOSES: Ischemic stroke caused by acute internal carotid artery occlusions (AICO) is usually associated with high disability and mortality. We aimed to investigate whether occlusion patterns significantly influence clinical outcome in patients receiving endovascular thrombectomy (EVT). PATIENTS AND METHODS: We performed a retrospective analysis of databases from two comprehensive stroke centers and consecutively investigated patients who had underwent EVT. AICO was defined as acute internal carotid artery occlusions (cervical segment to terminal segment). The clinical characteristics, intervention parameters, and prognosis data were collected. Leptomeningeal collaterals (LMC) were assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale (ASITN/SIRs), graded on a 5-point scale. The occlusion patterns based on Willisian collaterals were categorized into I-type, L-type, and T-type by contralateral carotid artery injections at digital subtraction angiography. Multivariate regression models were applied to evaluate the relationship between occlusion patterns and the prognosis of patients at 90 days after stroke. RESULTS: A total of 213 patients were included in the study. Of those,142 (66.7%) achieved successful reperfusion and 64 (30.0%) achieved favorable outcomes at 90 days. Overall, 26 (12.2%), 117 (54.9%), and 70 (32.9%) cases respectively suffered from I-type, L-type, and T-type occlusion. In addition, patients with I-type occlusions had a higher percentage of complete LMC compared with L-type or T-type occlusions (88.5% versus 30.8% versus 27.1%, P< 0.0167). In multivariable logistic regression, we found T-type occlusion was no longer an independent predictor of poor functional outcomes in AICO after adjusting LMC (T versus I, OR, 2.555, 95%CI: 0.717-9.103, P = 0.148; L versus I, OR, 0.815, 95%CI: 0.258-2.574, P = 0.727). CONCLUSIONS: For ACIO, occlusion patterns are still a topic that needs attention. Furthermore, compensatory LMC may affect the association between occlusion patterns and functional prognosis in AICO. Occlusion patterns and LMC status distinguish the nature and impact of AICO on expected EVT and subsequent clinical outcomes.

Amentoflavone attenuates oxidative stress and neuroinflammation induced by cerebral ischemia/reperfusion in rats by targeting HMGB1-mediated TLR4/NF-κB signaling pathway.

Surveys indicated that stroke classified among the leading cause of death as well as combined death and disability worldwide resulting in a great loss for the global economy. The present study aims to evaluate the neuroprotective potential of the biflavonoid amentoflavone (AMNT) in alleviating cerebral ischemia/reperfusion (IR) injury in rats, and to elucidate the possible underlying mechanism of an experimental condition with similar circumstances to stroke. Cerebral ischemia was achieved through left common carotid artery occlusion for 60 min, followed by blood flow restoration. Sham-operated control rats subjected to the same surgical process except for brain IR. Rats were orally administered AMNT/ or vehicle for three days' prior surgical operation, and for another three days after left brain IR. Rats of all groups were assessed for neurological deficits 24 h following brain IR. Each group was divided into two subgroups one for the rotarod testing and biochemical assessment while the other subgroup to perform the activity cage testing, histopathological study, immunohistochemistry, and gene expression analysis. AMNT enhanced brain levels of GSH and CAT activities, suppressed neuroinflammation via reducing the inflammatory cytokines in the serum, and enhanced brain contents of TBK1 and IFNß. AMNT downregulated TLR4-/NF-κB signaling pathway as a result of the HMGB1 suppression. Moreover, AMNT blocked apoptotic cell death by suppressing the NF-κB signaling pathway and reducing the activation of caspase-3. These findings revealed that AMNT attenuates I/R-induced cerebral injury possibly by regulating the HMGB1-mediated TLR4/NF-kB pathway. Thus, AMNT could provide potential preventive and therapeutic option for cerebral stroke.

Triptolide protects against white matter injury induced by chronic cerebral hypoperfusion in mice.

White matter injury is the major pathological alteration of subcortical ischemic vascular dementia (SIVD) caused by chronic cerebral hypoperfusion. It is characterized by progressive demyelination, apoptosis of oligodendrocytes and microglial activation, which leads to impairment of cognitive function. Triptolide exhibits a variety of pharmacological activities including anti-inflammation, immunosuppression and antitumor, etc. In this study, we investigated the effects of triptolide on white matter injury and cognitive impairments in mice with chronic cerebral hypoperfusion induced by the right unilateral common carotid artery occlusion (rUCCAO). We showed that triptolide administration alleviated the demyelination, axonal injury, and oligodendrocyte loss in the mice. Triptolide also improved cognitive function in novel object recognition test and Morris water maze test. In primary oligodendrocytes following oxygen-glucose deprivation (OGD), application of triptolide (0.001-0.1 nM) exerted concentration-dependent protection. We revealed that the protective effect of triptolide resulted from its inhibition of oligodendrocyte apoptosis via increasing the phosphorylation of the Src/Akt/GSK3ß pathway. Moreover, triptolide suppressed microglial activation and proinflammatory cytokines expression after chronic cerebral hypoperfusion in mice and in BV2 microglial cells following OGD, which also contributing to its alleviation of white matter injury. Importantly, mice received triptolide at the dose of 20 µg·kg-1·d-1 did not show hepatotoxicity and nephrotoxicity even after chronic treatment. Thus, our results highlight that triptolide alleviates whiter matter injury induced by chronic cerebral hypoperfusion through direct protection against oligodendrocyte apoptosis and indirect protection by inhibition of microglial inflammation. Triptolide may have novel indication in clinic such as the treatment of chronic cerebral hypoperfusion-induced SIVD.

Narirutin-rich fraction from grape fruit peel protects against transient cerebral ischemia reperfusion injury in rats.

Objective: Ischemic stroke is one of the leading causes of disability in adults worldwide. The present study was aimed to evaluate the efficacy of Narirutin-rich fraction (NRF), obtained from grape fruit peel, on cerebral ischemia/reperfusion injury in rats.Methods: Male Wistar rats (180-200 g) were subjected to bilateral carotid artery occlusion for 30 min followed by reperfusion for 24 h to induce cerebral ischemia/reperfusion injury. NRF (150, 300 mg/kg, oral) was administered for 7 days continuously before animals were subjected to ischemia/reperfusion injury. Various behavioral tests (for measurement of motor coordination, locomotor activity, and spatial memory), biochemical parameters (lipid peroxidation, superoxide dismutase, and catalase activity), and histopathological alterations were assessed.Results: Seven-day NRF (150 and 300 mg/kg) pretreatment significantly improved neurobehavioral alterations and histological findings as compared to the disease control group. Further NRF treatment significantly reduced oxidative damage as indicated by improved lipid peroxidation, superoxide dismutase, and catalase activity as compared to disease control animals.Conclusion: The present study demonstrated the protective effect of NRF against cerebral ischemia/reperfusion injury in rats. The results suggest that NRF can be a potential pretreatment option against cerebral ischemia/reperfusion injury.

Segmented carotid endarterectomy for treatment of Riles type 1A common carotid artery occlusion.

OBJECTIVE: Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. Symptomatic lesions are resistant to medical treatment and revascularization is often required, but there is no consensus on the treatment of CCAO at present. Riles type 1A CCAO is most likely to benefit from revascularization because it has patent outflow tract (internal carotid artery) which was supplied by patent external carotid artery (ECA) from collateral circulation. We described a novel surgical technique improved on the basis of the carotid endarterectomy (CEA) for treatment of Riles type 1A CCAO. METHODS: We rigorously screened ten patients with symptomatic Riles type1A CCAO for surgery from January 2017 to May 2019 and performed a full preoperative assessment of the inadequate collateral circulation compensation. Moreover, we retrospectively reviewed our experience of the segmented CEA in the treatment of them in our single center. RESULTS: Segmented CEA was performed on the left side in four cases and on the right side in six cases. The technical success rate of the procedure was 100%. Primary suture was used in nine cases. Only one patient (right CCAO) who had a history of neck radiotherapy was treated by the patch CEA. The mean temporary blocking time during surgery was 52.8 ± 9.15 min. The mean temporary blocking time for treating the upper segment of the common carotid artery (CCA) was 11.1 ± 2.64 min. In the postoperative period, cerebral perfusion on the ipsilateral site improved in all patients, myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another. No ischemic events or re-occlusion or restenosis (> 50%) of the treated CCA occurred during the mean follow-up of 32.6 ± 9.3 months. The preoperative mean modified Rankin Scale (mRS) score was 1.9 (range, 1-3; median, 2). At last follow-up for all patients, the mRS score was 1 (range, 0-3; median, 1). CONCLUSION: Segmented CEA, which utilizes the compensatory effect of collateral circulation, is an effective and safe technique to treat patients suffering from Riles type 1A CCAO with hemodynamic cerebrovascular compromise.

New-Onset Pediatric Diabetes Complicated By Diabetic Ketoacidosis and Invasive Rhinocerebral Mucormycosis With Internal Carotid Artery Occlusion.

BACKGROUND: Diabetic ketoacidosis (DKA) has increased in prevalence in the emergency department (ED) in recent years. The complications of DKA are life threatening and necessitate rapid identification and management. Pediatric complications include cerebral edema, venous thrombosis, acute kidney injury, and severe infections including necrotizing fasciitis and mucormycosis. Rhinocerebral mucormycosis carries a high mortality rate and requires early treatment with antifungals and surgical debridement. CASE REPORT: A 16-year-old boy with no significant past medical history presented to the ED with new-onset DKA complicated by hypothermia, hyperosmolar hyperglycemic state, cerebral edema, and multifactorial shock. During a complicated pediatric intensive care unit admission, he was found to have fatal invasive rhinocerebral mucormycosis, causing internal carotid artery occlusion with evidence of both direct and hematogenous spread into his brain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early identification of shock and appropriate management with intravenous fluids, vasopressors, and reversal of the underlying process is key in hypotensive children. In pediatric DKA, the emergency physician must consider cerebral edema, appropriate fluid resuscitation, and identify the likely precipitants leading to the onset of DKA. Thorough workup for potential precipitants should be initiated in the ED, searching for etiologies including infection, intoxication, insulin deficiency, inflammation, and ischemia. We must remember that pediatric patients, especially those with new DKA, are susceptible to life-threatening infection, including mucormycosis. Mucormycosis is a rare diagnosis, and management includes antifungal therapies and involvement of otorhinolaryngology.

Early Recurrence in Patients with Symptomatic, Non-Cardioembolic, Internal Carotid Artery Occlusion.

INTRODUCTION: There are limited data on the clinical course of patients with non-cardioembolic, mostly atherosclerotic, internal carotid artery occlusion (ICAO). The purpose of this study was to elucidate the frequency and underlying pathogenesis of early recurrent ischemic stroke in symptomatic non-cardioembolic ICAO. MATERIALS AND METHODS: Consecutive patients with symptomatic non-cardioembolic ICAO were retrospectively reviewed. Those who had a tandem occlusion of the proximal middle cerebral artery (MCA) or underwent endovascular thrombectomy were excluded. Early recurrent stroke was defined as deterioration of the NIHSS score by ≥1 point with new lesions on magnetic resonance (MR) diffusion-weighted imaging (DWI) in the ipsilateral territory of the ICAO within 30 days of the index stroke onset. Patients were classified into two groups on carotid ultrasonography: cervical occlusion and intracranial occlusion. The presumed pathogenesis of recurrent stroke was categorized as embolic or hemodynamic according to the topographical features of subsequent lesions on DWI. RESULTS: Of 36 consecutive medically treated patients with symptomatic non-cardioembolic ICAO without tandem MCA occlusion, 23 patients had cervical occlusion, and 13 had intracranial occlusion. Early recurrent stroke occurred in 16 patients (44.4%), which happened much more with intracranial occlusion than with cervical occlusion (69.2% vs 30.4%, p<0.02). Focusing on the presumed pathogenesis, hemodynamic was more common than embolic (68.8% vs 31.2%), especially with intracranial occlusion (77.8%). CONCLUSIONS: Early recurrent stroke occurs at a high frequency in symptomatic non-cardioembolic ICAO, and intracranial occlusion may be a risk factor for early recurrent stroke. The pathogenesis of recurrence is more often hemodynamic than embolic.