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Cerebral ischemia/reperfusion (I/R) injury refers to an aggravated brain tissue damage caused by the restoration of blood supply after acute ischemia for a period of time. Its pathogenesis is complex, including oxidative stress, inflammatory response, and excitatory amino acid toxicity. The effective clinical treatments of cerebral I/R injury after ischemic stroke (IS) are limited. Nuclear factor E 2-related factor 2 (Nrf2), the most critical antioxidant transcription factor in cells, can coordinate multiple cytoprotective factors to inhibit oxidative stress. Since Nrf2 signaling pathway is considered to be one of the most important cellular defense mechanisms against oxidative stress, targeting Nrf2 intervention has become an attractive therapeutic strategy in the prevention and treatment of cerebral I/R injury. This review focuses on the structure, regulation and function of Nrf2 signaling pathway, as well as its activation and potential therapeutic targets in cerebral I/R injury. The important role and future potential of Nrf2 pathway in the pathogenesis of cerebral I/R injury were discussed.
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Objective:To investigate the effect of thrombus burden on the clinical outcome of endovascular recanalization in large vessel occlusive stroke.Methods:Patients with acute anterior circulation occlusion who underwent endovascular treatment within 24 hours after onset in Zhengzhou University People′s Hospital from January 2018 to December 2019 were retrospectively collected. According to the clot burden score (CBS) of DSA, total objectives were divided into CBS≥6 group (24 cases) and CBS<6 group (38 cases). Clinical data of the two groups were collected and the modified Rankin scale (mRS) was used to evaluate the clinical outcome at 90 days after surgery. Independent sample t-test, Wilcoxon rank sum test and χ 2 test were used to compare the clinical data between the two groups. Independent risk factors affecting the clinical outcome were analyzed by binary logistic regression. Results:There were no statistically significant differences in basic demographic data, stroke risk factors and other factors between the CBS≥6 group and CBS<6 group ( P>0.05).The proportion of using tirofiban after surgery in the CBS≥6 group (63.2%, 24/38) was lower than that in the CBS<6 group (87.5%, 21/24) (χ2=4.380, P=0.044). The discharge NIHSS score of the CBS≥6 group was [5.0 (3.3, 7.8) points] lower than CBS<6 group [8.5 (1.8, 14.5) points] ( Z=5.221, P=0.022). The proportion of postoperative mRS 0-2 was (91.7%, 22/24) in the CBS≥6 group higher than CBS<6 group(39.5%, 15/38) (χ2=20.486, P=0.001), there were no statistically significant differences between the two groups ( P<0.05). The results of binary logistics regression analysis showed the CBS groups (OR=0.042, 95%CI 0.007-0.244 , P=0.001) was an independent risk factor affecting good outcome. Subgroup analysis of whether tirofiban was used or not showed there was no statistically significant difference in clinical prognosis between the two groups ( P>0.05). Conclusions:The clinical outcome of CBS≥6 group is significantly better than that of CBS<6 group, and patients with small thrombus burden are more likely to get a good clinical outcome of 90 days.
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Objective:To investigate the efficacy and safety of endovascular recanalization treatment for acute vertebral basilar artery occlusion (AVBAO) underlying intracranial atherosclerotic disease (ICAD) using a balloon-mounted stent.Methods:A total of 16 cases of consecutive AVBAO patients who underwent endovascular treatment with the balloon-mounted stent within 24 h after onset were retrospectively enrolled in Henan Provincial People′s Hospital from February 2017 to August 2019. And the recanalization rate, operation-related complications, symptomatic intracranial hemorrhage, the improvement of 1 week National Institutes of Health Stroke Scale (NIHSS) score and 3 months modified Rankin Scale (mRS) after treatment were recorded.Results:In all of the 16 patients, 4 patients underwent direct stenting angioplasty, 12 patients received salvage stenting. Stent placement was successful in all 16 patients. Balloon-mounted stent were implanted in basilar artery of 4 cases, in intracranial segment of vertebral artery of 8 cases, and in origination segment of vertebral artery of 4 cases. Recanalization was successful (thrombolysis in cerebral infarction grade 2b and 3) in 15 patients. The time between arterial puncture and recanalization was 79.0 (72.3, 109.3) min. One patient experienced distal thrombosis during surgery. Two patients suffered symptomatic intracranial hemorrhage within 48 h after surgery. The scores of the NIHSS were improved more than 4 points at 1 week after operation in 8 patients. At 3 months follow-up, 9 patients had a good outcome (mRS 0-3 points) and 4 patients died.Conclusion:Selective stenting angioplasty treatment with a balloon-mounted stent seems to be feasible and safe for AVBAO patients underlying ICAD.
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Objective To evaluate the feasibility of transvenous embolization treatment for cerebral arteriovenous malformations(bAVM). Methods From November 2016 to April 2017, the information of 6 patients with brain arteriovenous malformation in our center accepting the intravenous radical embolization were collected, who were ruptured bAVM, bAVM with a single drainage vein, not suitable for surgery confirmed by neurosurgeon consultation or explicitly refused craniotomy. The modified Rankin Scale score of five patients were smaller than three before treatment.The location of draining vein flowing venous sinus was shown by rotational DSA and 3D reconstructed images.A liquid embolic agent was injected via Sonic catheter to completely embolism the brain arteriovenous malformation under controlling blood pressure and blocking the blood provisionally.The perioperative complications and modified Rankin Scale score were observed and recorded 30 days after treatment. Results The transvenous embolization treatment was successfully performed in six patients with 7 embolization procedures.There were no definite operation-related complications. the mRS of all cases were ≤1 within 30 days after operation. Conclusion The embolization technique via the internal jugular vein is feasible for bAVM patients with a single drainage vein,while the long-term outcome need more evaluations.
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Objective To compare the perioperative complications of prophylactic use of three antiplatelet strategies in unruptured intracranial aneurysms treated by stent assisted coiling. Methods A total of 203 consecutive patients were brought into this retrospective study including the following three groups:the loading group (n=54), with a loading dose of 300 mg to 600 mg clopidogrel at 2 h to 24h before the stenting; tirofiban group (n=50), a loading dosage of tirofiban (8 μg/kg/min over 3 min) followed by a 0.1μg/kg/min maintenance dosage; dual antiplatelet group (n=99), dual oral antiplatelet drugs (clopidogrel 75 mg + aspirin 100 mg) pretreated for 3-5 days before the operation. Events of hemorrhage and thromboembolism were recorded and the complications were compared to assess the safety and efficacy of various antiplatelet strategies. Chi-square or Fisher exact tests were used for categorical variables. Results The hemorrhagic rates were 11.1% in loading group, 2.0% in dual antiplatelet group, and 0% in tirofiban group, respectively, while the thromboembolic rates were 7.4% in loading group, 4.0% in dual antiplatelet group, and 0% in tirofiban group, respectively. For total complications, significant difference (P0.05). The hemorrhagic rate in loading group was significantly higher than that of the dual group (P=0.023) and tirofiban group (P=0.027), while there was no significant difference between tirofiban group and dual antiplatelet group (P>0.05). In subgroup analysis of the loading group, the postoperative thromboembolic rate was significantly higher in those exposed to low molecular weight heparin than those not (P=0.039) with no increase of hemorrhagic events (P>0.05). Conclusions When compared with the dual antiplatelet strategy, tirofiban strategy may be used as a new prophylactic protocol in unruptured intracranial aneurysms treated by stent assisted coiling. Those treated by low molecular weight heparin postoperatively after receiving dual antiplatelet therapy may increase the hemorrhagic risk, although there was a significant decrease in thromboembolic events postoperatively.
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Objective To discuss the perioperative complications of self-expanding Wingspan stent angioplasty for symptomatic basilar atherosclerotic stenosis.Methods A total of 91 consecutive patients with severe basilar atherosclerotic stenosis, who were admitted to the Interventional Radiology Department of Zhengzhou University People’s Hospital during the period from July 2007 to April 2013 to receive Wingspan stent angioplasty, were included in this study.The clinical data were retrospectively analyzed.Based on the operator’s experience, 30 patients who received treatment in the early stage of the period were defined as group A, 30 patients who received treatment in the middle stage of the period were defined as group B, and 31 patients who received treatment in the recent stage of the period were defined as group C.The incidence of perioperative complications, the risk factors and the prevention measures were analyzed.Results Wingspan stent angioplasty was successfully accomplished in all patients.The mean basilar atherosclerotic stenosis ratio was reduced from preoperative (82.2±5.8)%to postoperative (15.9±5.7)%.During the perioperative period of 30 days, strokes occurred in 13 patients (14.3%, 13/91), including perforating branch strokes in 8 patients (8.8%, 8/91); thrombosis occurred in 4 patients (4.4%, 4/91) and subarachnoid hemorrhage in 1 patient (1.1%, 1/91).Lethal and disabling stroke was seen in 2 patients (2.2%, 2/91), resulting in death (n=1) and severe disability (n=1).No other non-stroke-related complications occurred.Statistical analysis indicated that the incidence of ischemic strokes bore a parallel correlation with the following factors: involvement of the middle segment of basilar artery (P=0.049), the longer affected arterial segment (P=0.002) and severe degree of stenosis(P=0.001); while the incidence of ischemic strokes showed no definite correlation with the operator’s experience (P=1.000).Conclusion In treating symptomatic severe basilar atherosclerotic stenosis, self-expanding Wingspan stent angioplasty carries a relatively higher incidence of perioperative complications.Patients with the middle segment stenosis of basilar artery and severe longer segmental stenosis are more prone to develop complications, but the incidence of lethal and disabling stroke is rather lower.
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Objective To retrospectively evaluate the cerebrovascular complications from stenting for symptomatic intracranial stenosis and to detect the factors associated with complications.Methods Medical records of Wingspan stenting were reviewed for 306 cases with symptomatic intracranial stenosis from July 2007 to February 2012,including transient ischemic attack,ischemic stroke,death and intracranial hemorrhage as clinical in-hospital complications.The location of lesions included middle cerebral artery level M1 (114 lesions),intracranial portion of the internal carotid artery (50 lesions),vertebral artery 4(75 lesions),venebro-basilar artery (14 lesions),basilar artery (76 lesions).Complications were evaluated and analyzed to find out whether they were associated with patient-or stenosis-related risk factors using x2test.Results The technical success rate was 99％ (303/306).Cerebrovascular complications rate was 6.9％ (21/303),with 1.6％ (14/303) of disabling stroke events and 0.7％ (2/303) of deaths.Hemorrhagic events were consisted of procedure-related events (3 cases),hyperperfusion (3 cases),ischemic events of perforator stroke (8 cases),transient ischemic attack (3 cases),embolization (2 cases),thrombosis in stent (2 cases).Hemorrhagic events were associated with significantly higher morbidity and mortality rates(x2 =2.908,P ＜ 0.05) and occurred more frequently after treatment of middle cerebral artery stenosis than other lesions(x2 =1.168,P ＜ 0.05).Perforating branches were detected to be affected mainly in the basilar artery than other locations (x2 =4.263,P ＜ 0.05).Conclusion The complication rates in the study are preliminary consistent with the previously published data.Hemorrhagic events are prone to occur in the treatment of middle cerebral artery stenosis,while perforating branches are affected mainly in the basilar artery.
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Objective To evaluate the technical feasibility,safety and treatment effect of endovascular revascularization of symptomatic sub-acute and chronic intracranial vertebrobasilar artery occlusion.Methods Twenty-one consecutive patients with symptomatic sub-acute and chronic intracranial vertebrobasilar occlusion underwent endovascular revascularization.Perioperative complications and recurrent events during the follow-up period were recorded. The modified Rankin scale ( mRS ) scores and blood stream thrombolysis in myocardial infarction (TIMI) scores for all patients preoperatively,postoperatively and at follow-up were evaluated.The results were analyzed using Wilcoxon rank sum test and Fisher exact test.Results All 21 patients but 1 (95.2％,20/21 ) obtained successful recanalization. After the procedure,9 patients showed improvements,10 were stable,and 2 worse. The decline of median mRS scores,which was 4 preoperatively [ inter-quartile range ( IR ) 2.5-5.0 ] and 4 ( IR 1.0-5.0 ) on discharge from the hospital respectively,showed significant statistical difference (Z =2.810,P ＜ 0.01 ).Three ( 14.3％ ) patients suffered periprocedural complications,namely basal arterial dissection,intra-stent thrombosis and postoperatively acute occlusion in each one.There was no death,stoke or recurrent transient ischemic attack (TIA) occurring 30 days after the procedure. During the 7 months after operation,which was the mean clinical follow-up duration,TIA and recurrent stoke occurred in one patient respectively,and two patients died of systemic complications. The median mRS scores were 2.0 (IR 1.0-4.0 )in all 21 patients and 1 ( IR 1.0-4.0) in the surviving subjects.Conclusions Endovascular revascularization for the recanalization of symptomatic sub-acute and chronic vertebrobasilar artery occlusion is technically feasible,and helps to prevent ischemic events and improve disability recovery. However,its exact effect needs further verification by future random controlled studies.
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Objective To evaluate the incidence,potential hazards and effective countermeasure for perforator stroke (PS) resulting from stent angioplasty of symptomatic intracranial artery stenosis.Methods Peri-operation PS complications of 258 patients receiving Gateway balloon-Wingspan stenting for severe symptomatic intracranial stenosis were analyzed.The incidence,clinical course,and prognosis of PS resulting from stenting were recorded.Special attention was given to the anatomical features,clinical manifestation and video materials of patients with PS.x2 test was used for statistics.Results Two hundred and fifty-five patients received stent angioplasty successfully and 7 patients had PS ( incidence rate 2.7％ ).The patients with basilar artery stenosis had a higher incidence of PS resulting from intracranial stenting (6.1％,4/66) than patients with middle cerebral artery stenosis (2.5％,3/118) (x2 =2.320,P =0.025 ).The potential hazards for PS included preoperative perforator stroke adjacent to the stenotic segment and prominent dissection during operation.Six patients presented symptoms after awake from general anaesthesia and one had symptoms 3 hours after stenting.One deteriorated gradually and the others reached the maximum deficit almost at once.At the follow-up of 3 months,3 patients were disabled and scored one,two,two by mRS respectively.Conclusion The incidence of PS resulting from intracranial stenting was low and the prognosis was not disastrous.Stenosis at basilar artery and preoperative perforator stroke adjacent to the stenotic segment were potential risk factors for PS complication.Proper maneuver of angioplasty may decrease the incidence of PS and improve the prognosis.
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Objective To assess the safety, feasibility, short-and mid-term efficacy of wingspan stent for treating patients with symptomatic intracranial artery stenosis. Methods A total of 113 patients with severe symptomatic intracranial stenosis were enrolled and Gateway-wingspan stenting were performed on all patients. The technical success, the pre- and post-stenting stenosis, perioperative complications, clinical outcome and restenosis rates were recorded, and chi-square test was used for analysis of complication rate by comparing our results with the results of Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study and NIH multi-center Wingspan stenting trial. Results The technical success rate was 99. 1% ( 112/113). The mean pre and post-stent stenoses were (80.7 ± 9.3)% and (27.7 ± 9.7)% (χ2 =9.397,P < 0. 05 ). The total complication rate was 4.4% (5/113 ) during the follow-up ( mean 14. 5 months, range 1-28 months), and the frequency of restenosis was 12. 5% (5/40) at 6 months. The primary endpoint events, ischemic stroke, and lesion-related ischemic stroke were lower in our study (4.5%, 3.5%,3.5% ) compared with the results of WASID trial (21.1%, 20. 4%, 15.0% ,P<0. 05). For those with poor outcome in the three high-risk sub-groups which were with more than 70% stenosis, or last event from the treatment was less than 17 days, or NIHSS was above 1, a better outcome was observed in our group (4. 5% ,4. 7% and 2. 0% in our study, 19.0%, 17.0% and 19. 6% in previous study, P < 0. 05). The medium-term efficacy in this group (4. 5% ) significantly improved compared with NIH study ( 14. 0% ,P <0. 05 ). Conclusions Wingspan stenting for symptomatic intracranial arterial stenosis is with good safety,feasibility and low perioperative stroke rate and mortality. The incidence of primary endpoint events and the ischemic events are lower than those of medication group, and the efficacy of stenting is significantly better than medication even in high-risk population.
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he improvement of operation skill and stent system, a better outcome in the future could be achieved.
