BACKGROUND: Previous trials have failed to demonstrate the benefits of extracranial-intracranial (EC-IC) bypass surgery for patients with carotid or middle cerebral artery occlusion. However, little evidence has focused on the effect of age on prognosis. This study aimed to explore whether EC-IC bypass surgery can provide greater benefits than medical therapy alone in specific age groups. METHODS: A post hoc analysis was performed of the CMOSS (Carotid or Middle Cerebral Artery Occlusion Surgery Study), which was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China between June 2013 and March 2018. A total of 324 patients with internal carotid artery or middle cerebral artery occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency were randomized into a surgical group (n=161) that underwent EC-IC bypass surgery with medical therapy, and a medical group (n=163) that received antiplatelet therapy and stroke risk factor control alone. The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days up to 2 years after randomization. Receiver operating characteristic curves were drawn to explore the optimal age boundary, and survival analyses were used to explore differences between groups. RESULTS: Among the 324 patients (median age, 52.7 years; 79.3% men), an age cutoff of 55.5 years predicted the primary outcome in the surgical group (area under the curve, 0.649 [95% CI, 0.530-0.769]). Patients were further divided into an older group (>55.5 years) and a younger group (<= 55.5 years). Younger patients who underwent bypass surgery showed a lower risk of the primary outcome (log-rank P=0.001) than older patients. Patients who underwent EC-IC bypass surgery had a lower risk than patients with medical therapy alone in the younger group (3.2% versus 11.6%; hazard ratio, 0.255 [95% CI, 0.071-0.916]; P=0.036), but not in the older group (17.5% versus 13.3%; adjusted hazard ratio, 0.597 [95% CI, 0.225-1.580]; P=0.298). CONCLUSIONS: In patients aged 55.5 years or younger with symptomatic atherosclerotic occlusion of the internal carotid artery or middle cerebral artery and hemodynamic insufficiency, the addition of EC-IC bypass surgery to medical therapy significantly improved prognosis. These findings suggest that the clinical application of EC-IC bypass surgery needs more research to explore refined patient selection criteria incorporating more clinical features.

Background: Prior randomised trials have shown no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis (ICAS). But the potential for stenting to provide benefits over a longer time horizon remains to be explored. We aimed to directly compare the long-term effect of stenting versus medical therapy alone in a randomised trial. Methods: We extended the follow-up of subjects enrolled in a multicentre, open-label, randomised trial conducted at 8 centres in China. Patients with TIA or ischaemic stroke (mRS 0-2) attributed to severe symptomatic ICAS (70%-99%) were enrolled. Eligible patients were randomised in a 1:1 ratio to stenting plus medical therapy vs. medical therapy alone. The primary outcome was a composite of stroke or death within 30 days or stroke in territory of qualifying artery beyond 30 days. Other secondary outcomes included stroke in territory of qualifying artery, as well as disabling stroke or death after enrollment. This trial was registered in ClinicalTrials.gov with identifier NCT01763320. Findings: 358 patients (stenting 176 vs. medical 182) were recruited from Mar 5, 2014 and followed up till Jan 22, 2024. The median duration of follow-up was 7·4 years (IQR 6·0-8·0). The primary outcome was not significantly different (stenting 14·8% vs. medical 14·3%; HR, 1·02 [95% CI, 0·58-1·77]; P = 0·97). No significant difference was found between groups for the secondary outcomes: stroke in territory of qualifying artery (14·8% vs. 14·3%; HR, 1.02 [95% CI, 0·58-1·77]; P = 0·97), disabling stroke or death (16·5% vs. 14·3%; HR, 1·12 [95% CI, 0·66-1·91]; P = 0·70) and death (9·1% vs. 7·1%; HR, 1·22 [95% CI, 0·58-2·58]; P = 0·60). Interpretations: This study provides compelling evidence that, even over prolonged observed periods, the addition of stenting to medical therapy does not confer additional benefits to medical therapy alone in patients with symptomatic severe ICAS. These results underscore the importance of medical therapy as the cornerstone of long-term stroke prevention in this patient population. Trial Registration: This trial was registered in ClinicalTrials.gov with identifier NCT01763320. Funding: This work was supported by a research grant (2011BAI08B04) from the National Health Commission of the People’s Republic of China. Stryker Neurovascular (Stryker neurovascular, Fremont, CA, USA) provided supplemental funding for third-party site monitoring and auditing. This work was supported by a research grant (2011BAI08B04) from the National Health Commission of the People’s Republic of China. Stryker Neurovascular (Stryker neurovascular, Fremont, CA, USA) provided supplemental funding for third-party site monitoring and auditing. Declaration of Interest: CPD reports consultancy to the Penumbra, NoNO, and Euphrates Vascular Inc. Dr Jiao reported receiving grants from the Ministry of Science and Technology of the People’s Republic of China (2011BAI08B04) and Stryker Neurovascular during the conduct of the study, as well as grants from Ministry of Science and Technology of the People’s Republic of China (SQ2016YFSF110141) outside the submitted work. No other disclosures were reported. All other authors declare no competing interests. Ethical Approval: The institutional review board of Xuanwu Hospital reviewed and approved the study ([2013]013).

Background The authors aimed to elucidate the relationship between latest ischemic event and the incidence of subsequent ischemic stroke in patients with symptomatic artery occlusion. Methods and Results We analyzed the association between qualifying event—the latest ischemic event (transient ischemic attack [TIA] or stroke)—and the incidence of ipsilateral ischemic stroke in patients with symptomatic artery occlusion treated with medical therapy alone in CMOSS (Carotid or Middle Cerebral Artery Occlusion Surgery Study). The incidence of CMOSS primary outcomes, including any stroke or death within 30 days after randomization or ipsilateral ischemic stroke between 30 days and 2 years, between the bypass surgical and medical groups, stratified by qualifying events, was also compared. Of the 165 patients treated with medical therapy alone, 75 had a TIA and 90 had a stroke as their qualifying event. The incidence of ipsilateral ischemic stroke did not significantly differ between patients with a TIA and those with a stroke as their qualifying event (13.3% versus 6.7%, P =0.17). In multivariate analysis, the qualifying event was not associated with the incidence of ipsilateral ischemic stroke. There were no significant differences in the CMOSS primary outcomes between the surgical and medical groups, regardless of the qualifying event being TIA (10.1% versus 12.2%, P =0.86) or stroke (6.7% versus 8.9%, P =0.55). Conclusions Among patients with symptomatic artery occlusion and hemodynamic insufficiency, the risk of subsequent ipsilateral ischemic stroke does not appear to be lower in patients presenting with a TIA compared with those with a stroke. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01758614.

Background:To investigate the association between BMI and the incidence of ischemic stroke in patients with symptomatic artery occlusion, and further to evaluate the utility of BMI as a screening tool for identifying candidates for extracranial-intracranial bypass surgery. Materials and Methods:The authors analyzed the relationship between BMI and the occurrence of ipsilateral ischemic stroke (IIS) among patients receiving only medical management in the Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS). Additionally, the authors compared the primary endpoint of CMOSS-stroke or death within 30 days, or IIS after 30 days up to 2 years-among patients with varying BMIs who underwent either surgery or medical treatment. Results:Of the 165 patients who treated medically only, 16 (9.7%) suffered an IIS within 2 years. BMI was independently associated with the incidence of IIS (hazard ratio: 1.16 per kg/m(2); 95% CI: 1.06-1.27). The optimal BMI cutoff for predicting IIS was 24.5 kg/m(2). Patients with BMI >= 24.5 kg/m(2) experienced a higher incidence of IIS compared to those with BMI <24.5 kg/m(2) (17.4 vs. 0.0%, P<0.01). The incidence of the CMOSS primary endpoint was significantly different between the surgical and medical groups for patients with BMI >= 24.5 kg/m(2) (5.3 vs. 19.8%, P<0.01) and those with BMI <24.5 kg/m(2) (10.6 vs. 1.4%; P=0.02). Surgical intervention was independently associated with a reduced rate of the CMOSS primary endpoint in patients with BMI >= 24.5 kg/m(2). Conclusion:Data from the CMOSS trial indicate that patients with BMI >= 24.5 kg/m(2) are at a higher risk of IIS when treated medically only and appear to derive greater benefit from bypass surgery compared to those with lower BMIs. Given the small sample size and the inherent limitations of retrospective analyses, further large-scale, prospective studies are necessary to confirm these findings.

ImportancePrevious randomized clinical trials did not demonstrate the superiority of endovascular stenting over aggressive medical management for patients with symptomatic intracranial atherosclerotic stenosis (sICAS). However, balloon angioplasty has not been investigated in a randomized clinical trial.ObjectiveTo determine whether balloon angioplasty plus aggressive medical management is superior to aggressive medical management alone for patients with sICAS.Design, Setting, and ParticipantsA randomized, open-label, blinded end point clinical trial at 31 centers across China. Eligible patients aged 35 to 80 years with sICAS defined as recent transient ischemic attack (<90 days) or ischemic stroke (14-90 days) before enrollment attributed to a 70% to 99% atherosclerotic stenosis of a major intracranial artery receiving treatment with at least 1 antithrombotic drug and/or standard risk factor management were recruited between November 8, 2018, and April 2, 2022 (final follow-up: April 3, 2023).InterventionsSubmaximal balloon angioplasty plus aggressive medical management (n = 249) or aggressive medical management alone (n = 252). Aggressive medical management included dual antiplatelet therapy for the first 90 days and risk factor control.Main Outcomes and MeasuresThe primary outcome was a composite of any stroke or death within 30 days after enrollment or after balloon angioplasty of the qualifying lesion or any ischemic stroke in the qualifying artery territory or revascularization of the qualifying artery after 30 days through 12 months after enrollment.ResultsAmong 512 randomized patients, 501 were confirmed eligible (mean age, 58.0 years; 158 [31.5%] women) and completed the trial. The incidence of the primary outcome was lower in the balloon angioplasty group than the medical management group (4.4% vs 13.5%; hazard ratio, 0.32 [95% CI, 0.16-0.63]; P < .001). The respective rates of any stroke or all-cause death within 30 days were 3.2% and 1.6%. Beyond 30 days through 1 year after enrollment, the rates of any ischemic stroke in the qualifying artery territory were 0.4% and 7.5%, respectively, and revascularization of the qualifying artery occurred in 1.2% and 8.3%, respectively. The rate of symptomatic intracranial hemorrhage in the balloon angioplasty and medical management groups was 1.2% and 0.4%, respectively. In the balloon angioplasty group, procedural complications occurred in 17.4% of patients and arterial dissection occurred in 14.5% of patients.Conclusions and RelevanceIn patients with sICAS, balloon angioplasty plus aggressive medical management, compared with aggressive medical management alone, statistically significantly lowered the risk of a composite outcome of any stroke or death within 30 days or an ischemic stroke or revascularization of the qualifying artery after 30 days through 12 months. The findings suggest that balloon angioplasty plus aggressive medical management may be an effective treatment for sICAS, although the risk of stroke or death within 30 days of balloon angioplasty should be considered in clinical practice.Trial RegistrationClinicalTrials.gov Identifier: NCT03703635

颅内动脉粥样硬化性狭窄(ICAS)是亚洲人群缺血性卒中发生和复发的主要病因,颅内动脉粥样硬化性疾病(ICAD)的早期预防、精准诊断和治疗是降低疾病社会损害的重要方向.作者以"(ICAD or ICAS)AND(biomarker[Title/Abstract]OR predict[Title/Abstract]OR association[Title/Abstract])"为检索式检索了Medline、Embase数据库,共检出文献403篇,从ICAS的诊断、缺血事件发生及斑块稳定性、缺血性卒中复发预测3个方面分析了ICAD外周血生物标志物的应用价值,同时就所涉及的文献初步比较了各生物标志物与颅内、外动脉粥样硬化性狭窄的相关性,希望为临床应用和研究提供一定的参考.

目的 研究高龄急性大血管闭塞性卒中患者动脉内取栓治疗的特点及疗效.方法 回顾性连续纳入2018年1月至2021年8月解放军战略支援部队特色医学中心神经内科收治的诊断为急性大血管闭塞并接受动脉内取栓治疗的卒中患者.年龄均≥18岁,根据患者年龄分为两组:高龄组(年龄≥80岁)以及低龄组(年龄<80岁).详尽收集患者基线资料[包括性别、年龄、既往病史(高血压病、糖尿病、高脂血症、心房颤动、严重心肺疾病等)、基线美国国立卫生研究院卒中量表(NIHSS)评分、入院改良Rankin量表(mRS)评分、基线前循环Alberta卒中项目早期CT评分(ASPECTS)或基线后循环急性卒中预后早期CT评分(pc-ASPECTS)、急性卒中Org 10172治疗试验(TOAST)病因分型等]、治疗相关信息[是否静脉溶栓、闭塞部位、串联病变、发病至到院时间、到院至穿刺时间、穿刺至再通时间、麻醉方式、侧支循环情况、术中是否球囊扩张或置入支架、取栓次数、术后改良脑梗死溶栓(mTICI)分级、症状性颅内出血等]以及患者术后3个月的预后信息(mRS评分0～2为预后良好,3分以上为预后不良,6分为死亡)等.结果 151例符合入组条件的患者被纳入研究,中位年龄为70.0(57.5,80.0)岁,其中男94例(62.3％).高龄组患者42例[27.8％;中位年龄为83(81,86)岁],低龄组患者109例[中位年龄63(54,72)岁].与低龄组患者比较,高龄组患者基线NIHSS评分更高[19.0(14.3,23.0)分比15.0(12.0,20.0)分,Z=-2.247,P=0.025],心房颤动患者比例更高[81.0％(34/42)比33.9％(37/109),χ2=26.893,P<0.01],更多合并严重心肺疾病[50.0％(21/42)比31.2％(34/109),χ2=4.631,P=0.031].两组患者TOAST分型分布差异有统计学意义(χ2=20.193,P<0.01),低龄组患者以心源性栓塞[45.9％(50/109)]和大动脉粥样硬化型[44.0％(48/109)]为主要病因,高龄组患者以心源性栓塞[85.7％(36/42)]尤为突出.低龄组串联病变患者比例较高龄组高[22.9％(25/109)比4.8％(2/42),χ2=6.820,P=0.009],术中使用球囊扩张或置入支架的比例高于高龄组[32.1％(35/109)比9.5％(4/42),χ2=8.073,P=0.004].高龄组穿刺至再通时间较低龄组患者长[81.0(46.0,131.0)min比54.5(36.8,95.0)min,Z=-2.505,P=0.012],取栓次数也较多[3.0(1.0,4.0)次比2.0(1.0,3.0)次,Z=-2.225,P=0.026].高龄、低龄两组闭塞血管开通比例[88.1％(37/42)比84.4％(92/109)]、取栓后24 h NIHSS评分[12.0(7.0,19.5)分比8.0(4.0,16.0)分]差异均无统计学意义(均P>0.05).高龄组与低龄组患者相比,症状性颅内出血比例[19.0％(8/42)比10.1％(11/109)]、90 d mRS评分[3.0(2.0,5.0)分比3.0(1.0,4.0)分]、90d mRS评分0～2分比例[31.0％(13/42)比47.7％(52/109)]、90 d死亡比例[16.7％(7/42)比15.6％(17/109)]差异均无统计学意义(均P>0.05).结论 对于急性大血管闭塞性卒中患者,年龄≥80岁与年龄<80岁取栓预后无差异.

BACKGROUND:The optimum systolic blood pressure after endovascular thrombectomy for acute ischaemic stroke is uncertain. We aimed to compare the safety and efficacy of blood pressure lowering treatment according to more intensive versus less intensive treatment targets in patients with elevated blood pressure after reperfusion with endovascular treatment. METHODS:We conducted an open-label, blinded-endpoint, randomised controlled trial at 44 tertiary-level hospitals in China. Eligible patients (aged ≥18 years) had persistently elevated systolic blood pressure (≥140 mm Hg for &gt;10 min) following successful reperfusion with endovascular thrombectomy for acute ischaemic stroke from any intracranial large-vessel occlusion. Patients were randomly assigned (1:1, by a central, web-based program with a minimisation algorithm) to more intensive treatment (systolic blood pressure target &lt;120 mm Hg) or less intensive treatment (target 140-180 mm Hg) to be achieved within 1 h and sustained for 72 h. The primary efficacy outcome was functional recovery, assessed according to the distribution in scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Analyses were done according to the modified intention-to-treat principle. Efficacy analyses were performed with proportional odds logistic regression with adjustment for treatment allocation as a fixed effect, site as a random effect, and baseline prognostic factors, and included all randomly assigned patients who provided consent and had available data for the primary outcome. The safety analysis included all randomly assigned patients. The treatment effects were expressed as odds ratios (ORs). This trial is registered at ClinicalTrials.gov, NCT04140110, and the Chinese Clinical Trial Registry, 1900027785; recruitment has stopped at all participating centres. FINDINGS:Between July 20, 2020, and March 7, 2022, 821 patients were randomly assigned. The trial was stopped after review of the outcome data on June 22, 2022, due to persistent efficacy and safety concerns. 407 participants were assigned to the more intensive treatment group and 409 to the less intensive treatment group, of whom 404 patients in the more intensive treatment group and 406 patients in the less intensive treatment group had primary outcome data available. The likelihood of poor functional outcome was greater in the more intensive treatment group than the less intensive treatment group (common OR 1·37 [95% CI 1·07-1·76]). Compared with the less intensive treatment group, the more intensive treatment group had more early neurological deterioration (common OR 1·53 [95% 1·18-1·97]) and major disability at 90 days (OR 2·07 [95% CI 1·47-2·93]) but there were no significant differences in symptomatic intracerebral haemorrhage. There were no significant differences in serious adverse events or mortality between groups. INTERPRETATION:Intensive control of systolic blood pressure to lower than 120 mm Hg should be avoided to prevent compromising the functional recovery of patients who have received endovascular thrombectomy for acute ischaemic stroke due to intracranial large-vessel occlusion. FUNDING:The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Futures Fund of Australia; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.

IntroductionThe safety outcomes of endovascular therapy for intracranial artery stenosis in a real-world stetting are largely unknown. The Clinical Registration Trial of Intracranial Stenting for Patients with Symptomatic Intracranial Artery Stenosis (CRTICAS) was a prospective, multicentre, real-world registry designed to assess these outcomes and the impact of centre experience.Methods1140 severe, symptomatic intracranial arterial stenosis (ICAS) patients treated with endovascular therapy were included from 26 centres, further divided into three groups according to the annual centre volume of intracranial angioplasty and stent placement procedures over 2 years: (1) high volume for ≥25 cases/year; (2) moderate volume for 10–25 cases/year and (3) low volume for <10 cases/year.ResultsThe rate of 30-day stroke, transient ischaemic attack or death was 9.7% (111), with 5.4%, 21.1% and 9.7% in high-volume, moderate-volume and low-volume centres, respectively (p<0.05). Multivariable logistic regression confirmed high-volume centres had a significantly lower primary endpoint compared with moderate-volume centres (OR=0.187, 95% CI: 0.056 to 0.627; p≤0.0001), while moderate-volume and low-volume centres showed no significant difference (p=0.8456).ConclusionCompared with the preceding randomised controlled trials, this real-world, prospective, multicentre registry shows a lower complication rate of endovascular treatment for symptomatic ICAS. Non-uniform utilisation in endovascular technology, institutional experience and patient selection in different volumes of centres may have an impact on overall safety of this treatment.

Purpose: The Tonbridge stent is a novel retriever with several design improvements which aim to achieve promising flow reperfusion in the treatment of acute ischemic stroke (AIS). We conducted a randomized controlled, multicenter, non-inferiority trial to compare the safety and efficacy of the Tonbridge stent with the Solitaire FR. Methods: AIS patients aged 18–85 years with large vessel occlusion in anterior circulation who could undergo puncture within 6 h of symptom onset were included. Randomization was performed on a 1:1 ratio to thrombectomy with either the Tonbridge stent or the Solitaire FR. The primary efficacy endpoint was successful reperfusion using a modified thrombolysis in cerebral infarction score (mTICI) of 2b/3. Safety outcomes were symptomatic intracranial hemorrhage (sICH) within 24 ± 6 h and all-cause mortality within 90 days. A clinically relevant non-inferiority margin of 12% was chosen as the acceptable difference between groups. Secondary endpoints included time from groin puncture to reperfusion, National Institutes of Health Stroke Scale (NIHSS) score at 24 h and at 7 days, and a modified Rankin Scale (mRS) score of 0–2 at 90 days. Results: A total of 220 patients were enrolled; 104 patients underwent thrombectomy with the Tonbridge stent and 104 were treated with the Solitaire FR. In all test group patients, the Tonbridge was used as a single retriever without rescuing by other thrombectomy devices. Angioplasty with balloon and/or stent was performed in 26 patients in the Tonbridge group and 16 patients in the Solitaire group ( p = 0.084). Before angioplasty, 86.5% of those in the Tonbridge group and 81.7% of those in the Solitaire group reached successful reperfusion ( p = 0.343). Finally, more patients in the Tonbridge group achieved successful reperfusion (92.3 vs. 84.6%, 95% CI of difference value 0.9–16.7%, p < 0.0001). There were no significant differences on sICH within 24 ± 6 h between the two groups. All-cause mortality within 90 days was 13.5% in the Tonbridge group and 16.3% in the Solitaire group ( p = 0.559). We noted no significant differences between groups on the NIHSS at either 24 h or 7 days and the mRS of 0–2 at 90 days. Conclusion: The trial indicated that the Tonbridge stent was non-inferior to the Solitaire FR within 6 h of symptom onset in cases of large vessel occlusion stroke. Clinical Trial Registration: ClinicalTrials.gov , number: NCT03210623.

目的 评估应用单纯小球囊亚满意扩张治疗后循环进展性卒中伴基底动脉极重度狭窄的安全性及有效性.方法 回顾性分析战略支援部队特色医学中心2017年1月至2019年1月采用小球囊(Gateway 1.5 mm×9.0 mm或2.0 mm×9.0 mm)亚满意扩张治疗后循环进展性卒中并基底动脉极重度狭窄患者6例的临床及影像学资料.分析患者起病及进展后的美国国立卫生研究院卒中量表(NIHSS)评分、狭窄血管直径、狭窄病变的分型、技术成功率、围手术期并发症、影像及临床随访结果等.结果 6例患者发病后短时间内,症状均有不同程度的进展.狭窄病变Mori分型A型4例,B型2例.狭窄病变术前残余管腔直径(0.15±0.05)mm,狭窄程度平均(93±3)％.采用小球囊亚满意扩张后,狭窄病变残余管腔直径(1.03±0.21)mm,残余狭窄程度平均(50±10)％,与术前比较,差异均有统计学意义(t值分别为11.79、11.74,均P<0.01).围手术期并发症1例,为穿支脑梗死事件,经康复治疗后,症状逐渐改善.临床随访11～23个月,改良Rankin量表(mRS)评分≤2分5例,mRS评分3分1例.结论 对于伴有基底动脉极重度狭窄的后循环进展性卒中应积极进行干预,单纯小球囊亚满意扩张的技术成功率高,围手术期并发症较少,中短期疗效较好,是治疗该类疾病的可选方案.

目的 分析内囊预警综合征(capsular warning syndrome,CWS)的临床特点、影像学特征及治疗预后,以提高对此病的认识.方法 回顾性分析战略支援部队特色医学中心神经内科2013年1月-2018年12月收住院治疗的CWS的临床资料、影像学特征及治疗预后情况.结果 共12例患者,男性8例(66.67％),中位年龄为60岁.高脂血症9例(75.0％),高血压8例(66.67％),糖尿病4例(33.33％),肿瘤病史3例(25.0％).纯运动性卒中4例(33.33％),运动伴有构音障碍者4例(33.33％),运动及感觉性障碍3例(25.00％),纯感觉障碍1例(8.33％).影像学示豆纹动脉供血区新发脑梗死6例(50％).所有患者给予口服双联抗血小板治疗,其中3例症状复发患者又给予静脉溶栓和静脉抗血小板治疗.3个月随访,所有患者均未再出现症状发作,10例m R S评分为0分,2例mRS评分分别为4分及3分.结论 CWS主要表现为运动障碍,发作刻板,常见原因为动脉粥样硬化性.在本组病例中发现双重抗血小板治疗有效,静脉溶栓效果不肯定.

我院收治以脊髓病变为首发表现,并经立体定向脑穿刺活检明确的血管内大B细胞淋巴瘤(intravascular large B-cell lymphoma,IVLBCL)患者1例,诊断过程复杂,早期经甲基泼尼松龙及丙种球蛋白治疗后脊髓病灶缩小,颅内病灶变化多端,症状反复,进行性加重,最终行脑穿刺活检明确诊断,在病程4个月时死亡.对诊断不明确及治疗效果不佳的脊髓病变,需保持较高警醒,最大限度地进行组织活检,以防进入诊断陷阱.

目的 初步分析急性基底动脉闭塞性脑梗死患者不同麻醉方式下行血管内治疗对预后的影响.方法 回顾性连续纳入2015年8月至2019年12月解放军战略支援部队特色医学中心神经内科住院行血管内治疗的急性基底动脉闭塞患者27例,均使用支架或抽吸技术行血管内机械取栓治疗.根据麻醉方式的不同,将27例患者分为全身麻醉组(17例)和清醒镇静麻醉组(10例).记录患者年龄、性别、脑血管疾病危险因素(高血压病、糖尿病、高脂血症、吸烟、饮酒、心房颤动)、既往卒中病史、基线美国国立卫生研究院卒中量表(NIHSS)评分、急性卒中Org10172治疗试验(TOAST)分型(心源性栓塞、大动脉粥样硬化性)、基线后循环急性卒中预后早期CT评分(pc-ASPECTS)、发病时间、到院时间、到达导管室时间、穿刺时间、血管再通时间、术前平均动脉压(MAP)、术中MAP、取栓次数、取栓治疗方式[球囊扩张和(或)支架置入]、改良脑梗死溶栓(mTICI)分级,对术后症状性颅内出血及90 d临床良好预后[改良Rankin量表(mRS)评分≤2分]情况进行评估,并进行组间比较.结果 (1)两组患者年龄、性别、脑血管疾病危险因素、TOAST分型、pc-ASPECTS的差异均无统计学意义(均P>0.05).(2)两组基线NIHSS评分、取栓次数及静脉溶栓、术中使用球囊扩张和(或)支架置入、取栓后mTICI分级≥2b级占比的差异均无统计学意义(均P>0.05);两组术前、术中MAP水平及MAP下降幅度>20％占比的差异均无统计学意义(均P>0.05);两组发病至导管室、穿刺至再通、发病至穿刺及发病至再通时间的差异均无统计学意义(均P>0.05);全身麻醉组导管室至穿刺时间[29.0(15.0,36.5)min]长于清醒镇静麻醉组[13.5(10.8,20.0)min],组间差异有统计学意义(Z=-2.272,P=0.023).(3)术后症状性颅内出血发生率为14.8％(4/27),全身麻醉组与清醒镇静麻醉组症状性颅内出血发生占比的差异无统计学意义(3/17比1/10,P=1.000).27例患者均完成术后90 d随访,其中预后良好(mRS评分≤2分)12例(44.4％),全身麻醉组与清醒镇静麻醉组预后良好占比(7/17比5/10)和mRS评分[3.0(0.5,5.0)分比2.0(0.0,5.0)分,Z=-0.698]的差异均无统计学意义(均P>0.05).结论 对于因急性基底动脉闭塞引起的脑梗死行血管内治疗患者,全身麻醉方式可能延长动脉穿刺时间,对预后的影响与清醒镇静麻醉方式无差别.

目的 比较不同能量评估法制订的营养方案在急性重症缺血性卒中治疗中的差异.方法 前瞻性连续纳入2016年7月-2018年1月入住内蒙古自治区人民医院神经内科重症监护病房的急性重症缺血性卒中患者,根据随机数字法分成经验组、公式组及间接能量测定组,分别采用经验能量估算法、Harris-Benedict校正公式及间接能量测定法测定的日需静息能量代谢值(resting energy expenditure,REE)进行营养支持治疗.观察三组患者营养支持治疗前及治疗后7 d、14 d的上臂肌肉围度、腰围、淋巴细胞计数、前白蛋白、血清白蛋白及血红蛋白水平.结果 最终纳入90例患者,平均年龄71±8岁,男性51例(56.67％),每组各30例.治疗前三组基线资料及营养指标差异均无统计学意义.治疗7 d淋巴细胞计数,以及治疗14 d上臂肌肉围度、血清前白蛋白及白蛋白,三组间差异均具有统计学意义;进一步两两比较,治疗7 d淋巴细胞计数和治疗14 d血清白蛋白水平在各组间差异均具有统计学意义,间接能量测定组高于公式组和经验组.结论 间接能量测定法能更准确地评估急性重症缺血性卒中患者的能量需求,制订的营养方案能更好地改善患者的营养指标.

目的 探讨急性基底动脉闭塞患者使用Solitaire AB型支架血管内机械取栓治疗的安全性和临床疗效.方法 回顾性连续纳入2015年1月至2017年12月解放军战略支援部队特色医学中心(原解放军第306医院)神经内科住院行血管内治疗的急性基底动脉闭塞患者20例,均使用Solitaire AB型支架系统进行血管内机械取栓治疗.根据90 d改良Rankin量表(mRS)评分结果 ,将20例患者分为预后良好(mRS评分≤2分)组和预后不良(mRS评分3～6分)组,各10例.记录患者年龄、性别、危险因素、既往病史、基线美国国立卫生研究院卒中量表(NIHSS)评分、急性卒中Org 10172治疗试验(TOAST)分型(心源性栓塞、大动脉粥样硬化性)、基线后循环急性卒中预后早期CT评分(pc-ASPECTS)、发病时间、到院时间、静脉溶栓时间、穿刺时间、血管再通时间、取栓次数,以及使用球囊扩张或支架置入、血管再通情况,对术后症状性颅内出血、术后24 h NIHSS评分及临床预后进行评估,并进行组间比较.结果(1)两组患者年龄、性别、危险因素、TOAST分型、pc-ASPECTS的差异均无统计学意义(均P>0.05).(2)20例患者中,17例(85.0％)血管内机械取栓后改良脑梗死溶栓(mTICI)分级达2b～3级,3例(15.0％)mTICI分级2a级.基线和术后24 h NIHSS评分中位值分别为21.0(16.0,27.2)分和8.5(0.8,27.2)分,差异有统计学意义(Z=-2.155,P=0.031);预后良好组基线NIHSS评分及术后24 h NIHSS评分均低于预后不良组,组间差异均有统计学意义[基线:17.0(15.2,21.5)分比27.5(21.2,35.2)分,术后24 h:0.5(0.0,1.0)分比27.5(17.0,34.5)分;均P<0.05].两组静脉溶栓、术中使用球囊扩张或支架置入、症状性颅内出血所占比的差异均无统计学意义(均P>0.05),取栓次数、发病至再通时间中位值的差异均无统计学意义(均P>0.05).(3)术后90 d随访,20例患者中,4例(20.0％)死亡(mRS评分6分),6例(30.0％)中重度残疾(mRS评分3～5分),10例(50.0％)预后良好(mRS评分≤2分).结论 部分ABAO患者初步应用Solitaire支架取栓治疗可获得安全有效的临床预后,基线及取栓后24 h NIHSS评分较高可能影响患者的预后.

目的 探讨应用Trevo ProVue支架对前循环脑动脉急性闭塞进行支架取栓治疗的安全性及有效性.方法 回顾本中心13例采用Trevo ProVue支架取栓治疗前循环脑动脉急性闭塞患者的临床资料.应用改良脑梗死溶栓(modified thrombolysis in cerebral infarction,mTICI)分级评估闭塞血管再通情况,比较患者术前及术后24 h美国国立卫生研究院卒中量表(National Institute of Health stroke scale,NIHSS)评分.并于术后90 d进行临床随访,采用改良Rankin量表(modified Rankin scale,mRS)评分评估患者独立生活情况.结果 13例患者中,术后即刻8例获得mTICI分级2b～3级再通,4例mTICI分级2a级再通,1例血管无法开通mTICI分级0级.患者入院时NIHSS评分15.0(9.5～21.0)分,术后24 h NIHSS评分7.0(5.5～16.0)分,比较差异具有统计学意义(t=2.38,P=0.035).90 d临床随访,mRS评分0～2分6例(46.15％),3分2例,4分2例,5分1例,6分(死亡)2例.结论 应用Trevo ProVue支架取栓治疗前循环脑动脉急性闭塞是安全、有效的.

目的 探讨多模式影像学选择的觉醒型缺血性卒中(WUS)患者进行静脉溶栓以及动脉内治疗的临床疗效.方法 解放军第306医院对1例WUS患者进行静脉溶栓桥接动脉取栓并急诊支架成形术治疗,随访90天,将临床资料进行总结与分析.结果 经过静脉溶栓后患者症状部分缓解,很快再次加重,随即进行动脉取栓并发现责任大脑中动脉重度狭窄,取栓后血流不能维持,给予急诊支架植入.病情演变过程复杂,最终结局良好,神经功能缺损改善.90天随访:患者痊愈,NIHSS 0分,mRS 0级.结论 对于WUS患者,通过多模式影像学选择后进行静脉溶栓以及动脉内治疗是安全有效的.

Objective To investigate the related factors of the prognosis of arterial embolectomy of acute cardiogenic cerebral embolism caused by atrial fibrillation.Methods The clinical data of using vein thrombolysis bridging artery embolectomy or arterial embolectomy alone for the treatment of patients with acute cardiogenic cerebral embolism of cerebral large artery occlusion due to atrial fibrillation were analyzed retrospectively.From January 2015 to December 2016,22 consecutive inpatients with cardioembolic cerebral embolism caused by paroxysmal or persistent atrial fibrillation were enrolled,including 10 patients with the 90-day modified Rankin Scale (mRS) score 0-2 (good recovery group) and 12 patients with mRS scores 3-6 (poor recovery group).The clinical features,imaging data,and treatment of the patients in both groups were compared.The factors such as age,gender,preoperative international standardization ratio (INR),embolism position,whether bridging vein thrombolysis before thrombectomy,National Institutes of Health Stroke Scale (NIHSS) score at the onset,time of onset to reperfusion (TOR),whether using tirofiban,times of thrombectomy,modified Thrombolysis In Cerebral Infarction (mTICI) blood flow grade,and postoperative intracranial symptomatic intracerebral hemorrhage were analyzed.Results There were no significant differences in age,gender,preoperative INR,embolism position,the number of intravenous thrombolysis before thrombectomy,the number of using tirofiban in surgery,the proportion of the above mTICI 2b grade,and the proportion of symptomatic cerebral hemorrhage after surgery of the patients between the two groups (P>0.05).The NIHSS score 15.2±2.0 at the onset in the good recovery group was lower than 22.9±8.4 in the poor recovery group.There was significant difference between the two groups (P<0.05).The TOR time (307±86 min) in the good recovery group was less than that of the poor recovery group (426±145 min).There was significant difference between the two groups (P<0.05).Embolectomy was performed 1.5 (0.5,3.0) times in the good recovery group,which was less than the poor recovery group (4.0 [2.0,7.0] times).There was significant difference between the two groups (P<0.05).Conclusions Shortening the time of reperfusion and reducing the number of embolectomy during operation are the important factors for improving the prognosis of patients when atrial fibrillation causes arterial embolectomy in patients with acute cerebral embolism.However,a study of larger sample is needed for further exploration.

随着高通量测序技术的发展,以往许多被认为是"垃圾"的脱氧核糖核酸(RNA)被证实有重要的生物学功能,如长链非编码RNA(即不被翻译成蛋白质的RNA),微小RNA(microRNA),小核RNA等[1].环状RNA是最近几年发现的一种特殊非编码RNA,因其呈封闭环状而得名,其中很大一部分具有一定的保守性与特异性.有研究发现,有一些环状RNA在大脑中呈特异性表达[2].新近诸多研究显示,环状RNA与脑血管疾病的发生、发展密切相关[3-4].笔者对环状RNA的研究进展及其在脑血管疾病中的初步研究进展综述如下.