Background:Early neurological deterioration (END) often leads to poor long-term outcomes in patients with acute ischemic stroke (AIS). This study aimed to investigate the association between comprehensive collateral circulation status and END. Methods:We retrospectively analyzed data from patients with AIS treated between January 2020 and December 2022. END was defined as an increase of ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) at 24 hours after endovascular thrombectomy (EVT) compared with baseline. Collateral circulation was assessed according to the cerebral collateral cascade (CCC), a composite framework integrating arterial collateral assessed by the Tan score, tissue-level collateral quantified by the hypoperfusion intensity ratio (HIR), and venous outflow (VO) evaluated by the Cortical Vein Opacification Score (COVES). Based on these assessments, patients were classified into three groups: CCC- group (poor arterial, venous, and tissue-level collaterals), CCC+ group (good arterial, venous, and tissue-level collaterals), and CCCmixed (the remainder of the patients). Logistic regression was used to determine whether CCC provides additional value for predicting END compared with single collateral evaluation methods. Sensitivity analyses were performed under alternative HIR and COVES thresholds and repeated in patients without hemorrhagic transformation. Results:A total of 293 patients were included, of whom 64 (21.8%) developed END. The incidence of END was highest in the CCC- group (46.8%), followed by the CCCmixed (22.7%) and CCC+ (2.9%) groups (P<0.001). Multivariate logistic regression identified the independent predictors of END to be CCC- [adjusted odds ratio (aOR) =13.46; 95% confidence interval (CI): 2.55-70.98; P=0.002], CCCmixed (aOR =8.01; 95% CI: 1.76-36.47; P=0.007), and COVES <3 (aOR =2.74; 95% CI: 1.40-5.38; P=0.003). The CCC model demonstrated superior predictive performance [area under the curve (AUC) =0.824; 95% CI: 0.766-0.882] compared with models based on VO (AUC =0.808; 95% CI: 0.746-0.871) or clinical parameters alone (AUC =0.793; 95% CI: 0.727-0.860). In the sensitivity analyses, CCC- remained an independent predictor and achieved the highest predictive accuracy. Conclusions:CCC could effectively predict END after thrombectomy and outperformed clinical variables and single collateral measures in this regard. Its predictive value remained significant even in unexplained END, supporting its potential in early risk assessment.

Futile recanalization is a recognized challenge in acute ischemic stroke (AIS) patients after endovascular treatment (EVT). Our purpose was to develop and validate a predictive model for futile recanalization after EVT by integrating arterial-venous collateral assessment with clinical parameters. This study included 392 AIS patients with acute anterior circulation large vessel occlusion who underwent EVT (March 2016-June 2024). Patients were stratified into training (n = 160), internal validation (n = 69), and completely independent external validation (n = 163) cohorts collected from a separate medical center. Predictors were identified using Boruta algorithm and LASSO regression. Multiple machine learning models were evaluated through discrimination, calibration, and decision curve analyses, with SHAP analysis for feature importance. Three independent predictors were identified: age (OR: 1.06, 95% CI: 1.02-1.11), whole-brain arterial collateral status (OR: 0.30, 95% CI: 0.18-0.50), and whole-brain venous collateral status (OR: 0.78, 95% CI: 0.67-0.90). The model demonstrated excellent discrimination in the training cohort (AUC: 0.914, 95% CI: 0.866-0.963), internal validation cohort (AUC: 0.918, 95% CI: 0.844-0.991), and notably maintained robust performance in the completely independent external validation cohort (AUC: 0.755, 95% CI: 0.678-0.832). Calibration plots showed good agreement between predicted and observed outcomes. SHAP analysis further confirmed the importance of arterial and venous collateral status assessments. The integration of whole-brain arterial-venous collateral assessment with clinical parameters shows potential value in predicting futile recanalization after EVT. This model, validated across multiple cohorts, may provide additional information to support clinical decision-making.

Rationale and Objectives: A significant complication of endovascular treatment (EVT) is hemorrhagic transformation (HT), which can worsen the outcomes of patients with acute ischemic stroke (AIS). This study aimed to evaluate the predictive value of venous collateral circulation on HT in patients with AIS undergoing EVT. Materials and Methods: We retrospectively analyzed 126 patients with AIS who received EVT. The four-dimensional computed tomography angiography-based venous collateral score (4D-VCS) and arterial collateral circulation score (4D-ACS) were used to assess venous and arterial collaterals, respectively. Significant variables were identified using the least absolute shrinkage and selection operator algorithm. Logistic regression analysis, receiver operating characteristic (ROC) analysis, and DeLong's test were conducted. Results: HT occurred in 41.3% (52/126) of patients. Higher clot burden score (CBS; odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.71-0.95, p = 0.009), better arterial collateral circulation (OR: 0.59, 95% CI: 0.42-0.83, p = 0.003), and better venous collateral circulation (OR: 0.85, 95% CI: 0.73-0.97, p = 0.020) were significantly associated with reduced HT risk. The area under the curve (AUC) values for CBS, 4D-ACS, and 4D-VCS were 0.730, 0.772, and 0.795, respectively. Model 1 (4D-VCS+CBS) achieved AUC of 0.820, significantly improving over CBS alone ( p = 0.0133). Model 2 (4D-VCS+4D-ACS) had an AUC of 0.829, significantly higher than 4D-ACS alone ( p = 0.0271). Model 3 (4D-ACS+CBS) had an AUC of 0.790. Model 4 (4D-VCS+4D-ACS+CBS) showed highest AUC of 0.851. Significant correlations were found between 4D-VCS and ischemic core volume ( r = -0.684, p < 0.001) and between 4D-VCS and mismatch ratio ( r = 0.558, p < 0.001). Conclusion: Evaluating venous collateral circulation using 4D-VCS could improve HT risk prediction in patients with AIS after EVT. When combined with other predictors, 4D-VCS may potentially enhance diagnostic performance, which suggests the potential role of venous collateral circulation in predicting HT risk.

ObjectiveThrombectomy may provide superior results compared to best medical care for acute posterior circulation strokes (PCS). Contact aspiration (CA), stent retriever (SR), and combined SR + CA (SRA) are commonly employed as first-line techniques. However, the optimal strategy and the role of SRA remain uncertain.MethodsSystematic searching was conducted in three databases (PubMed, Embase, and Cochrane). Network meta-analyzes were performed using random-effects models. The reperfusion and clinical outcomes were compared. Pooled outcomes were presented as odds ratios (OR) with 95% confidence intervals (CI). Rankograms with surface under the cumulative ranking curve (SUCRA) were calculated.ResultsSeventeen studies were included, involving a total of 645 patients who received first-line CA, 850 patients who received SR, and 166 patients who received SRA. Regarding final recanalization outcomes, both first-line SRA (OR = 3.2, 95%CI 1.4–11.0) and CA (OR = 2.1, 95%CI 1.3–3.7) demonstrated superiority over SR in achieving successful reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3], with values of SUCRA 91.1, 58.5, and 0.4%, respectively. In addition, first-line SRA showed an advantage in achieving final mTICI 2c/3 compared to CA (OR = 3.6, 95%CI 0.99–16.0) and SR (OR = 6.4, 95%CI 1.3–35.0), with SUCRA value of 98.0, 44.7, and 7.2%, respectively. Regarding reperfusion outcome after the first pass, SRA also achieved a higher rate of mTICI 3 than SR (OR = 4.1, 95%CI 1.3–14.0), while CA did not (SUCRA 97.4, 4.6, 48.0%). In terms of safety outcomes, first-line CA was associated with a lower incidence of symptomatic intracranial hemorrhage (sICH) compared to SR (OR = 0.38, 95%CI 0.1–1.0), whereas the SRA technique did not (SUCRA 15.6, 78.6, 55.9%). Regarding clinical prognosis, first-line CA achieved a higher proportion of functional independence (modified Rankin Scale (mRS) 0–2) at 90 days than SR (OR = 1.4, 95%CI 1.1–1.9), whereas SRA did not (SUCRA 90.5, 17.4, 42.1%).ConclusionFor acute PCS, a first-line CA strategy yielded better results in terms of final successful reperfusion and 90-day functional independence compared to SR. As the combined technique, first-line SRA was associated with superior first-pass and final reperfusion outcomes compared to SR. However, no significant difference was observed in functional independence achieved by first-line SRA compared to the other two strategies. Further high-quality studies are warranted.

Purpose: The aim of this study was to verify the value of collateral circulation and B-type natriuretic peptide (BNP) in predicting clinical outcomes of patients with acute ischemic stroke (AIS) and their biomarker value for stroke subtypes before endovascular treatment (EVT). Patients and Methods: In this retrospective study, 182 patients who underwent EVT for unilateral anterior circulation large-vessel occlusion between March 2016 and January 2022 were analyzed. The modified collateral circulation scoring system on four-dimensional computed tomography angiography (4D CTA-CS) was used to assess collateral status, and stroke subtypes were determined according to the TOAST classification criteria. Patients were divided into good (mRS ≤ 2) and poor outcome (mRS > 2) groups based on their modified Rankin Scale (mRS) score at 3 months. Results: 4D CTA-CS was an independent predictor of the clinical outcome for all AIS patients (odds ratio = 0.253; 95% CI, 0.147–0.437; p < 0.001), CE stroke patients (odds ratio = 0.513; 95% CI, 0.280–0.939; p = 0.030), and LAA stroke patients (odds ratio = 0.148; 95% CI, 0.049–0.447; p = 0.001). The BNP was a biomarker for clinical outcome prediction in CE (odds ratio = 1.004; 95% CI, 1.001–1.008; p = 0.005) but not in LAA patients. Combined with BNP, 4D CTA-CS improved predictive values for clinical outcomes (p < 0.05). Conclusion: Collateral status and BNP could be used as independent predictors of clinical outcomes in AIS patients and could determine stroke subtypes (CE stroke or LAA stroke). In addition, the model of 4D CTA-CS combined with BNP was the most effective in predicting clinical outcomes compared with collateral status or BNP alone.

目的 探讨320排宽体探测器CT全模型迭代重建算法(FIRST)与混合迭代重建算法(AIDR 3D)在头颈部CT血管成像(CTA)扫描中对辐射剂量和图像质量的影响.资料与方法 收集2021年8—11月于北京医院放射科因头颈部血管疾病接受头颈动脉CTA检查患者70例,采用随机数字表法平均分为A、B组,每组35例.A、B组分别使用AIDR 3D算法和FIRST算法进行重建.比较两组图像头颈部主要血管(主动脉弓、颈总动脉、椎动脉、颈内动脉、大脑中动脉、大脑前动脉)、背景(肌肉、脑组织)的平均CT值、噪声值、信噪比、血管对比噪声比及辐射剂量.由2名医师以5分法对图像质量进行主观评分.结果 B组有效辐射剂量显著低于A组[(0.56±0.02)mSv比(0.78±0.03)mSv,P<0.001],B组较A组辐射剂量降低28％.B组各血管CT值、信噪比和对比噪声比均显著高于A组(P<0.001),噪声值显著低于A组(P<0.001).B组背景(胸锁乳突肌、脑组织)CT值、噪声值显著低于A组(P<0.001),信噪比高于A组(P<0.001).A、B组图像主观评分差异无统计学意义(P>0.05),B组图像诊断医师接受度更高.结论 在头颈部CTA扫描中,应用FIRST算法较常规AIDR 3D算法可以降低28％的辐射剂量,并获得更好的图像质量.

Objectives To evaluate the application of black-blood CT (BBCT) in carotid artery wall imaging and its accuracy in disclosing stenosis rate and plaque burden of carotid artery. Methods A total of 110 patients underwent contrast-enhanced CT scan with two phases, and BBCT images were obtained using contrast-enhancement (CE)-boost technology. Two radiologists independently scored subjective image quality on black-blood computerized tomography (BBCT) images using a 4-point scale and then further analyzed plaque types. The artery stenosis rate on BBCT was measured and compared with CTA. The plaque burden on BBCT was compared with that on high-resolution intracranial vessel wall MR imaging (VW-MR imaging). The kappa value and intraclass correlation coefficient (ICC) were used for consistency analysis. The diagnostic accuracy of BBCT for stenosis rate and plaque burden greater than 50% was evaluated by AUC. Results The subjective image quality scores of BBCT had good consistency between the two readers (ICC = 0.836, p < 0.001). BBCT and CTA had a good consistency in the identification of stenosis rate ( p < 0.001). There was good consistency between BBCT and VW-MR in diagnosis of plaque burden ( p < 0.001). As for plaque burden over 50%, BBCT had good sensitivity (93.10%) and specificity (73.33%), with an AUC of 0.950 (95%CI 0.838–0.993). Compared with CTA, BBCT had higher consistency with VW-MR in disclosing low-density plaques and mixed plaques (ICC = 0.931 vs 0.858, p < 0.001). Conclusions BBCT can not only display the carotid artery wall clearly but also accurately diagnose the stenosis rate and plaque burden of carotid artery. Clinical relevance statement Black-blood CT, as a novel imaging technology, can assist clinicians and radiologists in better visualizing the structure of the vessel wall and plaques, especially for patients with contraindication to MRI. Key Points • Black-blood CT can clearly visualize the carotid artery wall and plaque burden. • Black-blood CT is superior to conventional CTA with more accurate diagnosis of the carotid stenosis rate and plaque burden features.

Objective:To explore the significance of four-dimensional CT angiography(4D CTA) and CT perfusion (CTP) imaging in evaluating collateral circulation grades in patients with moyamoya disease and moyamoya syndrome and their relationship with cerebral hemodynamics.Methods:The clinical and imaging data of 32 patients with moyamoya disease and moyamoya syndrome in Beijing Hospital from January 2017 to January 2022 were retrospectively analyzed. All patients underwent 4D CTA-CTP imaging. Collateral circulation was scored on CTA images by using Alberta stroke program early CT score system, and on digital subtraction angiography (DSA) images by using American society of interventional and therapeutic neuroradiology/Society of interventional radiology score system, respectively. The patients were divided into Ⅰ-Ⅲ circulation compensation grades based on collateral circulation score. Regions of interest were delineated at basal ganglia on perfusion maps and the perfusion parameters were obtained including cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), mean transit time (TTP) and delay time (DLY). The Kruskal-Wallis test was used to compare the perfusion parameters in different collateral circulation grades, and pairwise comparison was performed with Bonferroni correction. Kappa and Spearman tests were used to analyze the consistency and correlation of 4D CTA and DSA in the classification of collateral circulation.Results:4D CTA and DSA had a moderate consistency (Kappa=0.693, P<0.001) and a strong correlation ( r=0.805, P<0.001) in evaluating collateral grades. There were statistically significant differences in CBF, MTT and TTP among collateral compensation grade Ⅰ, grade Ⅱ and grade Ⅲ ( H values were 7.91, 11.69, 8.93; P values were 0.019, 0.003 and 0.012, respectively). Further pairwise comparison showed that the CBF of collateral compensation grade Ⅰ was lower than that of grade Ⅲ ( P=0.015), MTT of grade Ⅱ was higher than that of grade Ⅲ ( P=0.005), and TTP of grade Ⅰ was higher than that of grade Ⅲ ( P=0.015). There was no statistical significance of other indicators in pairwise comparison. There were no significant differences in CBV and DLY among collateral compensation grade Ⅰ, grade Ⅱ and grade Ⅲ ( P>0.05). Conclusions:4D CTA-CTP is equivalent to DSA in evaluating collateral circulation in patients with moyamoya disease and moyamoya syndrome. It can also evaluate the cerebral hemodynamics comprehensively, which has high clinical significance for disease monitoring.

Objective:To investigate the risk factors of infarct growth rate of elderly acute ischemic stroke(AIS)patients with endovascular treatment(EVT)and its influence on prognosis.Methods:Elderly AIS patients who underwent EVT at Beijing hospital from June 2016 to October 2020 were retrospectively included.Infarct growth rate(ml/h)=infarct core volume(ml)/time from stroke onset to CTP examination(h).Based on the rate of infarct growth and the patient's clinical severity, ROC curve was established, and the cut-off value of the ROC curve was obtained.By the cut-off value of the rate of infarct growth, the patients were divided into cerebral infarct slow-growth group and rapid-growth group.Predictors of rapid growth in infarct were analyzed by univariate and multivariate analysis.The patients were divided into good prognosis group(mRS score 0-2)and poor prognosis group(mRS score 3-6)according to the mRS score at the day 90 and the predictors of poor prognosis were analyzed separately.Results:A total of 67 elderly AIS patients were included with age ranging from 65-96 years and an average of(78.8±7.6)years.(1)The cut-off value of the optimal infarct growth rate for patients with good and poor prognosis was 8.89 ml/h.The patients were divided into fast-growth group(26 patients)and slow-growth group(41 patients)according the cut-off value.(2)Multivariate logistic regression showed that only poor collateral circulation was an independent predictor for fast infarct growth( OR=0.162, 95% CI: 0.053-0.489).(3)Faster infarct growth rate( OR=1.173, 95% CI: 1.044-1.318)and high NIHSS score( OR=1.146, 95% CI: 1.018-1.291)were predictors of poor prognosis. Conclusions:Collateral circulation status is a major influencing factor for the infarct growth rate, and a faster infarct growth rate is a predictor of poor prognosis for elderly AIS patients after endovascular treatment.

目的探讨基于多模态CT及LASSO-Logistic回归的急性缺血性卒中患者血管内治疗术后发生恶性大脑中动脉梗死(MMI)的预测价值,并构建Nomogram预测风险评分系统.资料与方法回顾性分析2016年3月—2021年6月于北京医院急诊行一站式多模态CT血管造影-CT灌注扫描并进行血管内治疗的120例前循环闭塞的急性缺血性卒中患者,根据是否发生MMI分为MMI组24例及非MMI组96例.对临床及影像学资料行LASSO-Logistic回归方法筛选变量,探讨相关因素在MMI中的预测价值,并建立Nomogram图预测模型.建立受试者工作特征曲线及校准曲线验证其效能.结果与非MMI组比较,MMI组患者基线美国国立卫生研究院卒中量表评分更高(Z=?4.071,P<0.001)、颈内动脉闭塞更多见(χ2=5.335,P=0.021)、再通不良占比更高(P<0.001)、梗死核心体积更大(Z=?6.672,P<0.001)、基线Alberta卒中项目早期CT评分更低(Z=?3.693,P<0.001)、4D CTA侧支循环评分更低(Z=?6.085,P<0.001)、血栓负荷评分更低(Z=?2.853,P=0.004).通过LASSO-Logistic回归筛选出MMI的独立预测因子为改良脑梗死溶栓分级(OR=22.098,95％CI 3.100～157.503,P=0.002)、梗死核心体积(OR=1.022,95％CI 1.008～1.037,P=0.002)及4D CTA侧支循环评分(OR=0.288,95％CI 0.128～0.647,P=0.003);基于三者构建的Nomogram模型的曲线下面积为0.965(95％CI 0.915～0.990,P<0.001).校准曲线及Hosmer-Lemeshow检验(P=0.878)显示该模型具有较好的预测符合度.结论未成功再通、较大梗死核心体积及低4D CTA侧支评分的急性缺血性卒中患者行血管内治疗后更易发生MMI,基于三者构建的Nomogram风险预测模型可以判断其MMI风险,指导医师的临床决策.

Background: To establish a novel cortical venous collateral score based on four-dimensional computed tomography angiography (4D CTA) and to assess the relationship between the score and clinical outcomes in patients with acute ischemic stroke (AIS) after endovascular treatments (EVTs). Methods: This was a retrospective case-control study designed to evaluate all consecutive patients with large vessel occlusion in unilateral anterior circulation who underwent EVTs at a single institution. Two independent neuroradiologists evaluated venous collaterals using different venous collateral scores: a cortical venous collateral score based on 4D CTA (4D-VCS), the prognostic evaluation based on cortical vein score difference in stroke (PRECISE) score, and the cortical vein opacification score (COVES). Spearman correlation analysis was used to analyze the correlation of different venous collateral scoring systems with final infarct volume (FIV), modified Rankin Scale (mRS) score, and artery collateral score. Multivariate logistic regression analysis was used to identify the prognostic value of each model. The areas under the curve (AUC) of the receiver operating characteristic (ROC) curve of the 6 models were compared by the DeLong test. Results: A total of 107 patients were enrolled in the study. The AUC of 4D-VCS was 0.92 [95% confidence interval (CI): 0.85 to 0.96; P<0.0001]. The 4D-VCS was highly correlated with FIV (r=-0.615; 95% CI: -0.737 to -0.473; P<0.001), mRS score (r=-0.706; 95% CI: -0.789 to -0.602; P<0.001), and arterial collateral score (r=0.769; 95% CI: 0.678 to 0.838; P<0.001). There were statistically significant differences between model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 2 (AUC, 0.94; 95% CI: 0.88 to 0.98) (P=0.025), model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 3 (AUC, 0.93; 95% CI: 0.87 to 0.97) (P=0.045), model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 6 (AUC, 0.95; 95% CI: 0.89 to 0.98) (P=0.011), and model 2 (AUC, 0.94; 95% CI: 0.88 to 0.98) and model 5 (AUC, 0.89; 95% CI: 0.82 to 0.94) (P=0.032). Conclusions: The findings of this study suggested that 4D-VCS, a novel measurement of venous enhancement based on 4D CTA, may be accurately used to identify AIS patients with high risk of poor clinical outcome after EVTs.

Background:The aim of the study was to find the potential roles of B-type natriuretic peptide (BNP) and imaging markers on distinguishing cardioembolic (CE) stroke from non-CE stroke, so as to provide useful information for making individualized endovascular treatment (EVT) plan for the patients with acute ischemic stroke (AIS). Methods:The patients with unilateral anterior circulation large vessel occlusion who underwent EVT between March 2016 and December 2021 were analyzed in this study, retrospectively. The risk factors, laboratory test indicators, imaging parameters, and other factors were compared between the CE group and non-CE group. Logistic regression was used to analyze the risk factors of CE stroke. ROC curves were used to assess the values of different parameters on distinguishing CE stroke from non-CE stroke. The relationships between BNP and imaging parameters were assessed using the Spearman correlation analysis. Results:160 patients were enrolled in the study and divided into the CE group (n = 66) and non-CE group (n = 94). BNP (odds ratio (OR) = 1.004; 95% CI, 1.001-1.009; p = 0.038), MMR (OR = 0.736; 95% CI, 0.573-0.945; p = 0.016), NIHSS (OR = 1.150; 95% CI, 1.022-1.294; p = 0.020), and AF (OR = 556.968; 95% CI, 51.739-5995.765; p < 0.001) were the independent predictive factors of CE stroke. The area under the curve (AUC) of BNP and mismatch ratio (MMR) were 0.846 (95% CI (0.780-0.898), p < 0.001) and 0.636 (95% CI (0.633-0.779), p < 0.001), respectively. The cut-off value of BNP was 249.23 pg/mL with the sensitivity of 74.24% and the specificity of 82.98%. BNP combined with MMR improved the predictive value for CE stroke. The AUC of the combination was 0.858 with the sensitivity of 84.85% and the specificity of 73.40%. BNP was correlated with 4D CTA collateral score, MMR, clot burden score, final infarct volume, infarct core volume, and ischemic penumbra volume (all, p < 0.05). Conclusion:BNP on admission combined with MMR is valuable for the risk prediction of CE stroke, which will promote the further screening of the high-risk patients with CE stroke and provide more diagnostic information for clinicians.

目的 以一站式CT血管造影(CTA)-CT灌注(CTP)观察烟雾病(MMD)/烟雾综合征(MS)常春藤征与脑血流动力学及侧支循环的关系.方法 纳入43例MMD/MS患者,基于MR液体衰减反转恢复序列判断常春藤征,记录存在缺血灶/出血灶脑区(阳性区域);于CTP参数图测量688个脑区的脑血容量(CBV)、脑血流量(CBF)、平均通过时间(MTT)、达峰时间(TTP)及延迟时间(DLY).以CTA评估侧支循环评分,观察常春藤征(IS)与侧支循环的关系.结果688个脑区中,166个(166/688,24.13％)可见(IS组)、522个(522/688,75.87％)未见常春藤征(NIS组);较常见IS脑区依次为基底节区、半卵圆中心层面大脑中动脉供血区及半卵圆中心层面大脑前动脉供血区.IS组内阳性区域占比高于NIS组(17.47％vs.8.05％,P=0.001).相比 NIS 组,IS 组 CBV 增加,MTT、TTP及 DLY 均延长(P均＜0.001)而侧支循环分级较低(P=0.006).结论 MMD/MS患者出现常春藤征提示存在更严重脑灌注损害及侧支循环不良,具有潜在脑缺血/出血风险.

Objective:To assess the prognostic value of the collateral status and clot burden score based on four-dimensional computed tomography angiography(4D CTA)in anteriorcir culation is chemics troke patients with large ischemic core after endovascular treatment.Methods:Clinical and imaging data of 36 anterior circulation ischemic stroke patients with large infarct core (infarct core≥50.0 ml) after endovascular treatment at our institution from March 2016 to September 2020 were retrospectively reviewed. According to the modified Rankin Scale (mRS) score, patients were divided into the good outcome (mRS score 0-2) and poor outcome (mRS score 3-6) groups. Mann-Whitney U and Fisher tests were used to compare the 4D CTA collateral circulation score, clot burden score, and baseline clinical data between the good and poor outcome groups. Multivariate logistic regression was used to analyze the risk factors associated with the poor outcome (mRS score 3-6) and mortality in patients with large infarct core stroke. Finally, based on the 90-day outcome, a ROC curve was used to obtain the cut-off values for poor prognosis (mRS 3-6) and death, respectively. Results:Ten patients (27.8%) had good outcome and 26 (72.2%) had poor outcome. The patients in the poor outcome group had older median age, higher blood glucose, lower 4D CTA collateral circulation score, lower clot burden score, larger infarct core volume, and higher hemorrhagic transformation and brain hernia (all P<0.05). Multivariate logistic regression showed that the poor collateral circulation score on 4D CTA( OR=0.18, 95% CI: 0.03-0.99, P<0.05)and clot burden score( OR=0.64, 95% CI: 0.44-0.93, P<0.05) were independent predictors of the poor prognosis. The ROC curves revealed that the cut-off value of infarct core for distinguishing between good prognosis and poor prognosis was 63.7 ml, while that for distinguishing between survival and death was 130.3 ml. Conclusions:Endovascular treatment may improve the prognosis of patients with large infarct core of anterior circulation is chemic stroke if the patients have good 4D CTA collateral circulation score and high clot burden score.

We have identified the enzyme responsible for erythritol utilization and its reaction product in the yeast Lipomyces starkeyi CBS 1807. The enzyme, a polyol dehydrogenase requiring NAD+ as a coenzyme, was induced by erythritol in this yeast. We confirmed that the enzyme product was L-erythrulose by MS, NMR, and polarimeter analyses, meaning that we clarified the first step of erythritol utilization in yeasts for the first time. In the case of the oxidative reaction, D-threitol, (2R,3R)-2,3-butanediol, and erythritol were much better substrates than 21 other polyols tested. These three substrates are tetroses and have an R configuration at C-3, and whose third carbon results in easiest oxidation in this enzyme. The research of the substrate specificity in the reductive reaction demonstrated that L-erythrulose and dihydroxyacetone were better substrates, that D-acetoin was inactive and L-erythrose (aldose) was slightly active.

Background: Clot composition could impact recanalization outcomes of thrombectomy, and preoperative imaging markers may help know about the histological components of thrombus. Methods: Consecutive patients who underwent thrombectomy from June 2017 to December 2019 were reviewed. The mean Hounsfield unit (HU) of thrombus (aHU) and contralateral artery (cHU) were recorded based on nonenhanced CT. The relative thrombus density was calculated (dHU=aHU-cHU). Hyperdense artery sign (HAS) was identified if dHU> 4HU. The clot perviousness was evaluated via thrombus attenuation increase (8HU) on contrast-enhanced CT compared to non-enhanced CT. Pervious clots were identified when 8HU> 11HU. Tissue quantification for thrombus was based on Martius Scarlet Blue staining, using the Orbit Imaging Analysis Software. Spearman rank correlations was used to detect the association between imaging markers and clot composition. The differences in clinical characteristics were compared according to the presence of HAS or pervious clots. Results: Fifty-three patients were included. The dHU was positively correlated with erythrocyte fractions (r = 0.337, p = 0.014), while there was no significant association between aHU and erythrocyte components (r = 0.146, p = 0.296). HAS (+) patients showed a comparable proportion of modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3 (94.6% vs. 87.5%, p = 0.740) and modified Rankin Scale score (mRS) 0-2 (35.1% vs. 56.3%, p = 0.152) compared with those HAS (-). Forty-seven cases were available for the analysis of clot perviousness. Clot perviousness was negatively associated with platelet fractions (r = -0.577, p < 0.001). Patients with pervious clots also showed a comparable proportion of mTICI 2b-3 (86.2% vs. 100%, p = 0.283) and mRS 0-2 (37.9% vs. 50.0%, p = 0.416) compared with impervious clots. Conclusions: This study suggests that relative thrombus density was positively correlated with erythrocyte fractions, while clot perviousness showed a negative relationship with platelet components. Yet, the presence of HAS or pervious clots did not show significant associations with recanalization and clinical outcomes. The conclusions should be drawn with caution.

Objective:To explore the safety and efficacy of endovascular mechanical thrombectomy in treatment of acute anterior circulation large vessel occlusive stroke (AACLVOS) of patients with the Alberta Stroke Program Early CT Score (ASPECTS) <6.Methods:A retrospective study was conducted on the clinical data of a total of 30 patients with AACLVOS and baseline ASPECTS <6 who underwent mechanical thrombectomy at Department of Neurosurgery, Beijing Hospital from July 2015 to January 2020. The median preoperative National Institute of Health stroke scale (NIHSS) score was 17 (range: 7-37), and the average ASPECTS was 3.8±1.0. Preoperative DSA demonstrated that the occlusion sites were MCA in 13 cases (M1 segment in 11 cases and M2 segment in 2), ICA in 13 cases, and tandem occlusion of ICA and MCA in 4 cases. Successful recanalization was defined by a modified thrombolysis in cerebral infarction (mTICI) score of 2b-3 assessed at the end of the procedure. Hemorrhagic transformation was graded according to the European Cooperative Acute Stroke Study Ⅱ, and the safety of endovascular treatment was evaluated according to the incidence of type Ⅱ parenchymal hematoma. Follow-up was conducted at 90 days post operation through outpatient clinic visits or telephone enquiry, and a favorable neurological outcome was defined as an mRS (modified Rankin scale) score of 0-2, while a poor outcome was defined as an mRS score of 3-6.Results:Successful recanalization was achieved in 24 patients (24/30, 80.0%). Two patients (2/30, 6.7%) had type Ⅱ parenchymal hematomas after the procedure. At 90-day clinical follow-up, ten patients (10/30, 33.3%) achieved favorable outcomes, including 9 re-perfused patients (9/24, 37.5%) and 1 non-perfused patient (1/6). Ten patients (10/30, 33.3%) died, including 7 re-perfused patients (7/24, 29.2%) and 3 non-perfused patients (3/6). For patients with baseline ASPECTS of 3-5, the rate of 90-day favorable outcome was 37.0% (10/27)and the mortality rate was 25.9% (7/27). For patients with baseline ASPECTS of 0-2, the proportion of favorable outcome was 0/3 and the mortality rate was 3/3.Conclusion:Preliminary observational study has demonstrated that mechanical thrombectomy in patients with AACLVOS and baseline ASPECTS of 3-5 may be relatively safe and effective, while the outcome may remain poor in those with baseline ASPECTS of 0-2.

Objectives: To develop an efficient and quantitative assessment of collateral circulation on time maximum intensity projection CT angiography (tMIP CTA) in patients with acute ischemic stroke (AIS). Methods: Eighty-one AIS patients who underwent one-stop CTA-CT perfusion (CTP) from February 2016 to October 2020 were retrospectively reviewed. Single-phase CTA (sCTA) and tMIP CTA were developed from CTP data. Ischemic core (IC) volume, ischemic penumbra volume, and mismatch ratio were calculated. The Tan scale was used for the qualitative evaluation of collateral based on sCTA and tMIP CTA. Quantitative collateral circulation (CCq) parameters were calculated semi-automatically with software by the ratio of the vascular volume (V) on both hemispheres, including tMIP CTA VCCq and sCTA VCCq. Spearman correlation analysis was used to analyze the correlation of collateral-related parameters with final infarct volume (FIV). ROC and multivariable regression analysis were calculated to compare the significance of the above parameters in clinical outcome evaluation. The analysis time of the observers was also compared. Results: tMIP CTA VCCq (r = 0.61, p < 0.01), IC volume (r = 0.66, p < 0.01), Tan score on tMIP CTA (r = 0.52, p < 0.01) and mismatch ratio (r = 0.60, p < 0.01) showed moderate negative correlations with FIV. tMIP CTA VCCq showed the best prognostic value for clinical outcome (AUC = 0.93, p < 0.001), and was an independent predictive factor of clinical outcome (OR = 0.14, p = 0.009). There was no difference in analysis time of tMIP CTA VCCq among observers (p = 0.079). Conclusion: The quantitative evaluation of collateral circulation on tMIP CTA is associated with clinical outcomes in AIS patients with endovascular treatments.

Objective: Although the benefits of good collateral circulation on infarct volume and outcomes have been confirmed in previous studies, few studies have investigated the relationship between hemorrhagic transformation (HT) and collateral circulation in acute ischemic stroke (AIS). This study aimed to assess whether collateral circulation is an essential factor of HT after endovascular treatments (EVTs). Methods: In total, 71 consecutive AIS patients who underwent EVTs between July 2015 and February 2019 were retrospectively studied. The correlations among HT, collateral vessels on 4D CT angiography (4D CTA), and other predictive factors for HT (e.g., National Institutes of Health Stroke Scale (NIHSS) score, age, sex, serum glucose, and atrial fibrillation history) were evaluated by logistic regression analysis. Results: The rate of hemorrhagic transformation was 42.3% (30/71) in AIS patients. Multivariate logistic regression showed that a good collateral status (OR 0.76, 95% CI 0.73–0.80) was associated with a lower risk of HT. History of atrial fibrillation (OR 2.35, 95% CI 1.96–2.82), baseline NIHSS scores (OR 2.00, 95% CI 1.72–2.32), and higher serum glucose levels (OR 1.70, 95% CI 1.57–1.85) were all independent risk factors of HT. Conclusions: Patients with poor collateral circulation are at a higher risk of HT after receiving endovascular therapy. Thus, variations in collateral circulation based on 4D CTA may be an important factor for personalized clinical treatments. In addition, high blood glucose, atrial fibrillation and the baseline NIHSS score are all important independent predictors of HT.

OBJECTIVE:Secondary embolism (SE) is a common adverse event during mechanical thrombectomy (MT) for acute intracranial large vessel occlusion, which could lead to incomplete revascularization and increased maneuvers. However, the mechanisms behind SE are still unclear. In this study, we aimed to investigate the risk factors of SE, with a focus on clot composition.PATIENTS AND METHODS:Consecutive patients with retrieved clots were reviewed. Histologic examination for thrombus included Hematoxylin and eosin, Martius Scarlet Blue, immunohistochemistry for von Willebrand factor (VWF). Patients included were assigned to SE or no SE group. The differences in histological composition and clinical characteristics were compared, and logistic regression was conducted for predictors of SE.RESULTS:Fifty-four patients were included, of which 19 were identified as having an SE. For patients with SE, there was more history of stroke or transient cerebral ischemia (TIA) (57.9 % vs. 28.6 %, p = 0.035), more occlusion located in terminal internal carotid artery (ICA) (63.2 % vs. 25.7 %, p = 0.007), relatively more contact aspiration used as frontline strategy (68.4 % vs. 45.7 %, p = 0.110), and less eTICI2c-3 recanalization achieved (52.6 % vs. 91.4 %, p = 0.003). As for histologic composition, the clots in SE group showed a higher proportion of erythrocyte fractions (42.9 % vs. 26.8 %, p = 0.045), while the other components were comparable with the non-SE group. Multivariate analysis suggested that a history of stroke or TIA (OR 6.45, 95 %CI 1.41-29.44, p = 0.016) and ICA occlusion (OR 8.05, 95 %CI 1.80-36.10, p = 0.006) could independently predict SE.CONCLUSION:History of TIA or stroke and occlusion in the terminal ICA were found to be independent predictors for SE. Thrombus with a higher erythrocyte fractions might be more fragile. Further studies are needed.