Embolic protection device (EPD) is a well-described adjunct in carotid artery stenting for its benefit of reducing perioperative stroke, but EPD retrieval is sometimes challenging, especially in elderly patients. We described a 73-year-old patient of EPD retrieval difficulty with falling of the guide catheter into hos-tile aortic arch during the right carotid open-cell stent placement under filter device. In this case, type III arch, tortuosity distal to stenosis and calcified plaque resulted in angulated path, made filter wire en-trapped in stent struts, and pulled back guide catheter into aortic arch. A 6-French Sofia intermediate catheter was performed to bail the operator out and retrieve the EPD which was unsuccessfully re-solved by all the other methods. The Sofia intermediate catheter is a valuable and final tool to resolve an EPD retrieval difficulty, especially when the filter wire is trapped in the stent and the guide catheter loses an access to carotid artery in elderly patients.Copyright (c) 2023, Taiwan Society of Geriatric Emergency & Critical Care Medicine.

Background: Cerebral hypoperfusion caused by large-vessel stenosis is an important risk factor for ischemic stroke and vascular cognitive impairment. In vitro, animal and clinic studies demonstrated that DL-3-n-butylphthalide (NBP) can improve the collateral circulation and the cerebral perfusion. In this trial, the benefit of NBP to ameliorate the chronic cerebral hypoperfusion resulting from unilateral internal carotid system stenosis will be explored. Methods: This trial is a randomized, double-blind, placebo-controlled, multicenter clinical study. A total 480 subjects with ≥70% stenosis or occlusion in unilateral internal carotid artery system, cerebral hypoperfusion in the ipsilateral middle cerebral artery (MCA) territory, and no transient ischemic attacks (TIA) or ischemic strokes within 2 weeks will be enrolled in China. Patients will be assigned in a 1:1 ratio to NBP and placebo groups. Patients in NBP or placebo group received 200 mg or 20 mg of NBP capsules three times daily for 4 weeks respectively. The cerebral perfusion will be assessed again after 12 weeks. The primary efficacy outcome is the proportion of patients with cerebral blood flow (CBF) amelioration, stabilization and deterioration after treatment. Conclusions: This trial will provide a high-level of evidence for NBP to treat the cerebral hypoperfusion, and a novel strategy to improve the cerebral hemodynamic impairment due to large intracranial and extracranial atherosclerotic stenosis in the surgical high-risk patients, especially in the aged and Asians. Trial registration: This trial is registered as ChiCTR2100053112 on November 12th, 2021.

Background and Objective: Myasthenia gravis (MG) is an autoimmune neuromuscular disease. Nearly 10-30% of patients with MG are refractory to conventional therapy. Rituximab (RTX), a monoclonal antibody targeting CD20, is increasingly used in autoimmune disorders. We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of RTX for refractory MG. Methods: Studies published between January 1, 2000 and January 17, 2021 were searched in PubMed, EMBASE, Cochrane Library, and ClincalTrails.gov. Primary outcomes included proportion of patients achieving minimal manifestation status (MMS) or better and quantitative MG (QMG) score change from baseline. Secondary outcomes were glucocorticoids (GC) doses change from baseline and proportion of patients discontinuing oral immunosuppressants. Results: A total of 24 studies involving 417 patients were included in the meta-analysis. An overall 64% (95% confidence interval, 49-77%) of patients achieved MMS or better. The estimated reduction of QMG score was 1.55 (95% confidence interval, 0.88-2.22). The mean reduction of GC doses was 1.46 (95% confidence interval, 1.10-1.82). The proportion of patients discontinuing oral immunosuppressants was 81% (95% confidence interval, 66-93%). Subgroup analyses showed that the proportion of patients achieving MMS or better and discontinuing oral immunosuppressants was higher in MuSK-MG group than those in AChR-MG group. Improvement was more pronounced in patients with mild to moderate MG compared to those with severe MG. Moreover, the efficacy appeared to be independent of the dose of RTX. 19.6% of patients experienced adverse events, most of which were mild to moderate. Only one patient developed progressive multifocal leukoencephalopathy. Conclusions: RTX can alleviate the symptom of weakness, decrease QMG score and reduce the doses of steroids and non-steroid immunosuppressive agents in refractory MG. It is well-tolerated with few severe adverse events. Randomized controlled trials are urgently needed to study the efficacy of RTX in treating refractory MG and to identify the characteristics of patients who might respond well to RTX.

Background: DL-3-n-butylphthalide (NBP) was demonstrated to increase the cerebral blood flow (CBF) in the animal models, but there are no clinic studies to verify this. We aimed to explore the effect of NBP on improving cerebral hypoperfusion caused by cerebral large-vessel stenosis.Methods: In this single-center, randomized, double-blind, placebo-controlled study, 120 patients with severe carotid atherosclerotic stenosis and cerebral hypoperfusion in the ipsilateral middle cerebral artery (MCA) were included and randomly assigned into NBP or placebo group as 1:1 radio. Patients in NBP or placebo group received 200mg or 20mg of NBP capsules three times daily for four weeks respectively. Single photon emission computed tomography (SPECT) was used to assess regional CBF (rCBF) in four regions of interest (ROIs) corresponding to MCA before and 12 weeks after the treatment. After therapy, the rCBF change for every ROI and the whole CBF change in MCA territory for every patient were classified into amelioration, stabilization and deterioration respectively.Results: 48 NBP patients (6 with bilateral stenosis) and 46 placebo patients (8 with bilateral stenosis) completed the trial. Overall, both groups had 54 stenotic carotid arteries and 216 ROIs for rCBF change analysis. After therapy, the rCBF in ROIs increased in NBP group (83.5%±11.4% vs. 85.8%±12.5%, p=0.000), whereas no change was found in placebo group (86.9%±11.6% vs. 87.8%±11.7%, p=0.331). Besides, there was higher percentages of ROIs with rCBF amelioration and stabilization in NBP group than in placebo group (93.1% vs. 79.2%, p=0.000). Furthermore, ordinal regression analysis showed that compared with placebo, NBP independently made more patients to have whole CBF amelioration in ipsilateral MCA (Wald-χ2=5.247, OR=3.31, p=0.022).Conclusions: NBP might improve the cerebral hypoperfusion in the patients with carotid artery atherosclerotic stenosis.Trial registration: Chinese Clinical Trial Registry, ChiCTR1900028005, registered December 8th 2019- Retrospectively registered ( http://www.chictr.org.cn/index.aspx ).

Objective Subclavian steal syndrome results from hemodynamic impairment due to stenosis or occlusion of subclavian artery. Therefore, it is important for subclavian steal syndrome patients to assess hemodynamic status during endovascular therapy. Methods Eleven subclavian steal syndrome patients undergoing endovascular therapy attended this study. Pressure wire was used to measure trans-stenosis pressure difference (ΔP). Digital subtraction angiography, Transcranial Doppler and Electronic sphygmomanometer were introduced to assess stenotic rate, steal grade and inter-arm systolic pressure difference, respectively. Clinical symptoms and restenosis were followed up after endovascular therapy. The associations of ΔP with stenotic rate, inter-arm pressure difference, steal degree, clinic symptoms and restenosis were analyzed in this paper. Results Prior to the therapy, ΔP moderately correlated with stenotic rate (r = 0.757, p = 0.007) and inter-arm pressure difference (r = 0.701, p = 0.016). ΔP was ≥6 mmHg in all patients, and 6–9 mmHg for grade 1 steal and ≥10 mmHg for grade 2 and 3 steals. After the therapy, all patients had technique success, and 10 patients had clinic success, and 1 patient appeared restenosis. ΔP was ≤3 mmHg and steal disappeared in the patients with clinical success. ΔP was 18 mmHg and grade 3 steal still existed in one patient without clinical success. One patient with 1 mmHg of ΔP after therapy appeared restenosis in the follow-up. Conclusion The trans-stenosis pressure difference is closely related to steal degree and clinical symptoms. The measurement of hemodynamic status by pressure wire is very useful to guide endovascular therapy in subclavian steal syndrome patients. However, the restenosis may still occur, even though the hemodynamic impairment is improved.

The bilateral and symmetrical Wallerian degeneration (WD) of the middle cerebellar peduncles (MCPs) is rarely reported in pontine hemorrhage. We described a patient with WD of bilateral MCPs secondary to a strip of unilateral and transversal pontine hemorrhage. Magnetic Resonance Imaging showed hyperintensity on T2-weighted, fluid attenuation inversion recovery and diffusion weighted image, and hypointensity on T1-weighted and apparent diffusion co-efficient map, and no enhancement in bilateral MCPs. These abnormal signals existed over 6 months and subsided gradually. The patients didn’t present with new symptoms when WD happened, the initial clinical manifestations related to pontine hemorrhage persisted for more than one year. In conclusion, a single unilateral pontine stroke along “cross” or “trident” line may cause WD of the bilateral MCPs in the below slice. Although this pathological change brings no additional new symptoms, it is related to the short‑term of poor neurological prognosis after pontine stroke. In addition, since this lesion appears restricted diffusion in the imaging, we should avoid misdiagnosing it as new infarction

Purpose/aim of the study:Posterior circulation stroke (PCS) accounts for 20% of ischemic stroke, and vertebrobasilar stenosis is an important cause of PCS. Notably, not all patients with artery stenosis progress to ischemic stroke, and one of the important reason is that collateral circulation construction plays important protection role in this process. Clinical presentation:Here, we present the case of a 71-year-old male who presented with lightheadedness and three episodes of loss of consciousness after bilateral subclavian artery stenting. Digital subtraction angiography (DSA) demonstrated severe stenosis of the left vertebral artery, and the bilateral subclavian artery was kept open. The patient was then given the left vertebral artery stenting in an effort to resolve the vascular stenosis. As expected, he achieved a complete remission after stenting. However, 6 months later the patient suffered from loss of consciousness again. Repeat DSA confirmed restenosis of the left vertebral artery, and revealed a collateral flow to the left vertebral artery which fed by external carotid collateral branches. Then DSA was performed after 12 months, and another collateral circulation involving thyrocervical trunk was also found supplying flow to the left vertebral artery. In this process, the frequency of loss of consciousness gradually decreased as the collateral circulation construction.Conclusion:Through this case, we observe the whole process of the collateral circulation construction. Moreover, this case serves as a testament to the variability and complexity of vertebrobasilar arteriopathies, suggesting promotion of collateral flow offers the opportunity for outcome improvement.

BACKGROUND The aim of this study was to evaluate the effects of carotid artery angioplasty and carotid artery stenting (CAS) on cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) in patients with preoperative cerebrovascular hemodynamic impairment. MATERIAL AND METHODS Seventeen patients with unilateral severe internal carotid artery (ICA) stenosis and ipsilateral CVR impairment underwent CAS. CBF and CVR were measured by single photon emission computed tomography (SPECT) with inhalation of carbon dioxide (CO2) one week before and three months after CAS. Sixty-eight ROIs in the middle cerebral artery (MCA) territory were analyzed in 17 patients. RESULTS Before CAS, CVR was impaired in all ROIs. CBF was impaired in 16 ROIs (23.5%). The percentage of ROIs with impaired CBF was significantly increased in patients with ≥90% carotid artery stenosis (p=0.047) without collateral flow through the circle of Willis (p=0.005). CAS significantly increased CVR in ROIs with a normal preoperative CBF and impaired CVR, indicating mild hemodynamic impairment (0.9±6.7% vs. 4.9±8.6%) (p=0.014). CAS significantly increased CBF in ROIs with preoperative impaired CBF and impaired CVR, indicating severe hemodynamic impairment (79.1±7.5% vs. 86.7±10.0%) (p<0.001). Following CAS, ROIs with normal CBF and impaired CVR had a significantly increased percentage of improved CVR (p=0.047); ROIs with impaired CBF and impaired CVR had a significantly increased percentage of improved CBF (p=0.027). CONCLUSIONS The severity of preoperative hemodynamic impairment, which is related to the degree of carotid artery stenosis and cerebral collateral flow, may influence hemodynamic benefits by CAS.

Purpose/aim of the study: Cerebrovascular reactivity (CVR) reflects the vasodilatory reserve of cerebral resistance vessels, which is an important marker for assessing cerebrovascular disease. The present study is to investigate whether CVR impairment increases adverse long-term outcome risk of patients with 50% symptomatic unilateral middle cerebral artery (MCA) stenosis (ischemic stroke (IS) or transient ischemic attack (TIA)).Material and methods: Digital subtraction angiography (DSA) was used to assess the degree of stenosis, and perfusion CT and 5% CO2 inhalation were adopted to evaluate CVR. Patients with 50% symptomatic unilateral MCA stenosis were assigned to non-CVR impairment group and CVR impairment group according to CVR status. The long-term follow-up endpoint was composite of any IS ( in the territory of the studied MCA) or death within 12 months.Results: Seventy-three patients with 50% symptomatic unilateral MCA stenosis, involving 31 non-CVR impairment cases and 42 CVR impairment cases, were included in the present study. Finally, IS occurred in six CVR impairment patients, and no endpoint happened in the non-CVR impairment group. Therefore, the annual rate of IS was 14.29% in the CVR impairment group and 0% in the non-CVR impairment group (P = 0.035). Besides, further Kaplan-Meier analysis found CVR impairment was closely associated with the IS risk (Kaplan-Meier Log-rank 4.719, P = 0.030).Conclusions: Our results showed that for patients with 50% symptomatic unilateral MCA stenosis, there was significant difference between non-CVR impairment cases and CVR impairment cases in the annual rate of IS. It suggests that CVR impairment increases the risk of adverse long-term outcomes.

Purpose/Aim of the study: Cerebrovascular reactivity (CVR) is an important marker for assessing cerebrovascular disease. This study assessed the CVR by perfusion computed tomography (CT) and CO2 inhalation tests in patients with unilateral middle cerebral artery (MCA) stenosis disease. Materials and Methods: Thirty-one patients with unilateral MCA stenosis disease diagnosed by digital subtraction angiography were studied. Patients were divided into two groups according to the degree of stenosis: severe and moderate. The regional cerebral blood flow (CBF) before and after CO2 inhalation was determined by perfusion CT. Regional CVR values were obtained by the following formula: increase (%) = (post-CBF) -(pre-CBF)/(pre-CBF) x 100%. Results: No significant differences in the mean CBF in the MCA stenosis region were found between the affected and contralateral sides before the CO2 inhalation test; after the test, CBF was more significantly decreased on the affected side than on the contralateral side. The changes in CBF on the affected side were categorized into three types: increased CBF (17 cases), decreased CBF (12 cases) and no change in CBF (2 cases). The rate of CVR impairment among severe stenosis patients (13/19) was higher than that among moderate stenosis patients (3/12). CVR was significantly correlated with the degree of stenosis (r = 0.423, P = 0.018). Conclusion: CVR impairment was found in approximately half of patients with unilateral MCA stenosis. Along with an increase in the degree of stenosis, patients with unilateral MCA stenosis were more likely to exhibit CVR impairment. It is important to assess the CVR in patients with unilateral MCA stenosis, especially those with severe stenosis.

Background: Silent brain infarct (SBI) is associated with symptomatic stroke, but the association between SBI and acute ischemic stroke severity is uncertain. We aimed at investigating the association between SBI number and stroke severity in patients with first-ever ischemic stroke without advanced leukoaraiosis. Methods: This study included 115 patients with first-ever ischemic stroke without advanced leukoaraiosis. National Institutes of Health Stroke Scale (NIHSS) scores were measured. Magnetic resonance imaging (MRI) was performed to detect the acute ischemic infarct and SBI. The location of infarct was divided into anterior and posterior circulations. The size of infarct was divided into large (>= 15 mm) and small (< 15 mm) infarctions. The number of SBIs was divided into single and multiple (r(2)) subgroups. The association between SBI and the NIHSS score was analyzed by stratification of stroke locations. The associations between SBI and the NIHSS score and the size of the acute ischemic infarct were analyzed by logistic regression. Results: Of the 74 patients with SBI, single SBI was 30 (40.5%) and multiple SBIs were 44 (59.5%). Age (odds ratio [OR] = 1.125, P <.001) and hypertension (OR = 3.562, P <.05) were independent risk factors for SBI. When adjusted for all the other vascular risk factors, multiple SBIs had a higher percentage of more than 3 NIHSS scores (OR = 3.59, 95% confidence interval [CI]: 1.00-12.99, P =.048) and a large acute ischemic infarct (OR = 3.71, 95% CI: 1.2311.22, P =.020) than no SBI. Conclusion: Multiple SBIs have severer neurological deficits and larger infarcts for ischemic stroke than no SBI, which may suggest the large-artery or cardiovascular vasculopathy evolution and poor collateral circulation in patients with multiple SBIs.