OBJECTIVES:This study aimed to investigate the outcomes and effectiveness of different antithrombotic regimens at discharge in nonvalvular atrial fibrillation (NVAF) patients with acute ischemic stroke (AIS) and competing large artery atherosclerosis (LAA) mechanisms. METHODS:In an observational study, we retrospectively analyzed the clinical and follow-up data of NVAF patients with AIS from January 2018 to December 2021 (NCT04080830). The subjects were grouped into 2 groups based on the presence or absence of competing LAA mechanisms. Stroke severity, short-term prognosis, and ischemic recurrence (a composite of ischemic stroke/TIA, myocardial infarction, or systemic embolism after index stroke), were compared between the 2 groups. Antithrombotic regimens at discharge were further categorized into antiplatelet and anticoagulant subgroups to analyze their effectiveness. RESULTS:Five hundred-one NVAF patients with AIS (129 with and 372 without competing LAA mechanisms) were included. Compared with the other group, the group with competing LAA mechanisms had a higher proportion of patients with a nondisabling mRS score (P <0.001), lower mortality rates at the 90-day follow-up ( P =0.048), and higher 180-day ischemic outcomes ( P =0.023). Subgroup analysis showed that the ischemic outcomes were not significantly different ( P =0.166) between the anticoagulant and antiplatelet subgroups in patients with competing LAA mechanisms. In contrast, it was numerically higher in the anticoagulant subgroup. CONCLUSION:NVAF patients with AIS due to competing LAA mechanisms had mild severity and a comfortable short-term prognosis; however, these patients had a higher risk of ischemic events. The optimal antithrombotic regimens in these patients remain unclear, and stroke mechanisms should be considered.

目的 探讨既往接受口服抗凝治疗的非瓣膜性心房颤动(NVAF)患者发生急性缺血性卒中(AIS)的临床特征.方法 回顾性分析单中心患者登记研究(NCT04080830)中2016年1月至2021年12月在首都医科大学宣武医院神经内科住院的合并NVAF的AIS患者数据,根据发病前抗凝状态将患者分为未抗凝组、充分抗凝组和抗凝不足组,比较3组患者的临床特征.结果 共纳入749例合并NVAF的AIS患者,其中未抗凝组661例,充分抗凝组33例,抗凝不足组55例.充分抗凝组出现大面积脑梗死的比例、初始和出院时的美国国家卫生研究院卒中量表评分均低于未抗凝组[15.2%(5/33)比34.2%(226/666)、4.00(1.00,7.50)分比8.00(3.00,15.00)分、2.00(0,5.00)分比4.00(1.00,12.00)分],出院时改良Rankin量表评分≤2分的比例高于未抗凝组[66.7%(22/33)比44.0%(226/666)],差异均有统计学意义(均P＜0.05).充分抗凝组和抗凝不足组的静脉溶栓比例低于未抗凝组[3.0%(1/33)、3.6%(2/55)比5.6%(37/666)],差异有统计学意义(P＜0.01).充分抗凝组存在心源性/大动脉粥样硬化性卒中型的AIS病因的患者比例高于未抗凝组和抗凝不足组[42.4%(14/33)比21.8%(144/666)、16.4%(9/55)],差异有统计学意义(P＜0.01).结论 既往充分抗凝治疗与NVAF患者发生AIS后卒中严重程度较低和出院时功能预后较好相关,竞争性大动脉动脉粥样硬化性AIS发生机制可能是充分抗凝治疗未能有效防控NVAF患者AIS风险的原因之一.

心脑梗死(cardio-cerebral infarction,CCI)是同时或短时间内相继发生的急性心肌梗死和急性缺血性脑卒中临床综合征,严重影响患者生存和预后.目前对于CCI的病因及病理生理学认识不足,临床治疗管理策略缺乏证据和权威指南指导,疾病的诊疗空白和争议颇多,亟待更全面的研究和探讨.本文综述国内外相关研究,探讨关于CCI概念、流行病学、发病原因及机制、急性期和长期治疗策略、预后转归等方面的最新研究进展.

Objectives: We aimed to analyze the characteristics and mechanisms of acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) who received prior anticoagulant therapy. Methods: We retrospectively analyzed the data of patients with NVAF and AIS between January 2016 and December 2021. Patients were divided into non-anticoagulant, adequate anticoagulant, and insufficient anticoagulant groups according to their prior anticoagulant status. Patients with prior anticoagulant therapy were further divided into warfarin and direct oral anticoagulant groups. Results: A total of 749 patients (661 without anticoagulants, 33 with adequate anticoagulants, and 55 with insufficient anticoagulants) were included. Patients with adequate anticoagulant had a milder National Institute of Health Stroke Scale at presentation (P=0.001) and discharge (P=0.003), a higher proportion of Modified Rankin Scale (mRS) ≤2 at discharge (P=0.011), and lower rates of massive infarction (P=0.008) than patients without anticoagulant. Compared with the non-anticoagulant group, the proportion of intravenous thrombolysis was significantly lower in the adequate anticoagulant (P<0.001) and insufficient anticoagulant (P=0.009) groups. Patients in the adequate anticoagulant group had higher rates of responsible cerebral atherosclerotic stenosis (P=0.001 and 0.006, respectively) and competing large artery atherosclerotic mechanisms (P=0.006 and 0.009, respectively) than those in the other 2 groups. Compared with warfarin, direct oral anticoagulant was associated with higher rates of Modified Rankin Scale ≤2 at discharge (P=0.003). Conclusions: Adequate anticoagulant therapy may be associated with milder stroke severity and better outcomes at discharge in patients with NVAF. Competing large artery atherosclerotic mechanisms may be associated with anticoagulant failure in patients with NAVF with prior adequate anticoagulant therapy.

Aim: Cervicocephalic atherosclerosis (AS) of patients with large-artery atherosclerotic (LAA) stroke might be more closely correlated to the functional outcome than patients with stroke of other etiologies. We aimed to investigate whether a whole-scope evaluation of cervicocephalic AS condition was better at predicting the 90-day functional outcome of LAA stroke than evaluation of intracranial or cervical AS condition alone.Methods: Patients with LAA stroke were consecutively enrolled in this study. Computed tomography angiography was performed to evaluate AS condition of various cervicocephalic arterial segments. AS conditions ranging from no AS plaque to complete arterial occlusion scored 0-4 points. Intracranial atherosclerotic burden (IAB) and cervical atherosclerotic burden (CAB) were in respective the sums of AS scores of all intracranial arterial segments and all cervical arterial segments. And the sum of them was intracranial and cervical atherosclerotic burden (ICAB). Relationships of these three scores with the 90-day unfavorable functional outcome (modified Rankin Scale[mRS] score >2 points) were compared.Results: Of 172 patients who finished 90-day follow-up, only ICAB (adjusted odds ratio[OR]=1.10, 95% confidence interval[CI]:1.00-1.21, p=0.044) predicted 90-day unfavorable functional outcome independently of clinical factors, National Institutes of Health Stroke Scale (NIHSS) and mRS scores at admission. ICAB (adjusted hazard ratio[HR]=1.16, 95%CI:1.02-1.32, p=0.029) was related to 90-day recurrent ischemic stroke/ death independently of clinical factors and was independently, positively correlated with NIHSS score at admission (r=0.16, p=0.047), whereas IAB and CAB were not. Conclusion: A whole-scope evaluation of cervicocephalic AS condition using ICAB outperformed evaluation of intracranial or cervical AS condition alone in predicting 90-day functional outcome of patients with LAA stroke.

BackgroundSymptomatic intracranial hemorrhage (sICH) is a devastating complication of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) and is associated with high risk of disability and mortality. This study intended to evaluate the predictors of sICH after EVT in patients with large vessel occlusion (LVO)-induced AIS.MethodsWe conducted a retrospective review on consecutive AIS patients who underwent EVT in our University hospital between January 2019 and August 2020. The patients were classified into two groups based upon the occurrence of sICH. The main outcomes were the occurrence of sICH using the Heidelberg Bleeding Classification and functional condition at 90 days. Multivariate logistic regression analysis and receiver operating characteristics (ROC) curves were used to identify independent predictors of sICH after EVT.ResultsThree hundred and 69 patients were enrolled in the study, of which 16.8% (n = 62) developed sICH. Favorable neurological outcome was lower in patients with sICH than in patients without sICH (6.5 vs. 43.3%; P < 0.001), with the overall mortality being 112 (30.4%) at 90 days post- EVT. Results from univariate analysis showed significant differences between the two groups in the prevalence of diabetes, initial Alberta Stroke Program Early CT Score (ASPECTS) score, National Institutes of Health Stroke Scale (NIHSS) score after operation, the levels of fasting blood glucose (FBG), neutrophil to lymphocyte ratio (NLR), platelets (PLT), and thrombin time (TT) at admission. Multivariate logistic regression analysis showed that FBG ≥ 7.54 mmol/L (OR: 2.765; 95% confidence interval [CI]: 1.513–5.054), NLR ≥ 5.48 (OR: 2.711; 95% CI: 1.433–5.128), TT at admission ≥ 16.25 s (OR: 2.022; 95% CI: 1.115–3.667), and NIHSS score within 24 h after the operation ≥ 10 (OR: 3.728; 95% CI: 1.516–9.170) were independent predictors of sICH. The combination of NLR ≥ 5.48, FBG ≥ 7.54 mmol/L, TT at admission ≥ 16.25 s, and NIHSS score within 24 h after the operation ≥ 10 generated an optimal prediction model (AUC: 0.723).ConclusionHigher levels of FDG, NLR, TT at admission, and NIHSS score after operation were associated with sICH after EVT in patients with LVO-induced AIS.

OBJECTIVES:We sought to explore the trends and influencing factors of the use of anticoagulants in patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) at discharge in the era of novel oral anticoagulants (NOACs). METHODS:We recruited consecutive inpatients with acute ischemic stroke and NVAF in a registered study (NCT04080830) from January 2016 to December 2021. The relevant data of patients were collected. We compared the proportions of anticoagulant treatment at discharge before and after NOACs entered China's medical insurance system. The proportion of each antithrombotic status as well as anticoagulant agents at discharge in every year were calculated, and the trends during the study period were analyzed. The relevant factors affecting anticoagulant use at discharge were further analyzed. RESULTS:The proportion of anticoagulation at discharge increased significantly after NOACs entered China's medical insurance system in 2018 versus before (χ2 = 42.828, P < 0.001). There were statistically significant differences in antithrombotic status (χ2 = 69.954, P < 0.001) and in the proportion of different anticoagulant drugs (χ2 = 63.049, P<0.001) by year. Anticoagulant therapy (χ2 = 1.55, P = 0.671) and NOACs (χ2 = .178, P = 0.243) increased over 2016-2018 but was relatively stable during 2018-2021. Multivariate logistic regression analysis showed that age ≥75 years, coexisting cerebral artery stenosis, massive cerebral infarction and hemorrhagic transformation were independent risk factors affecting anticoagulants use (all P < 0.05). CONCLUSION:NOACs have indeed improved anticoagulants use in patients with acute ischemic stroke and NVAF at discharge. However, some specific factors affect anticoagulation therapy use at discharge and hinder further improvement even in the NOACs era.

目的 分析急性缺血性卒中合并非瓣膜性心房颤动(NVAF)患者出院时口服抗凝药物使用情况及其影响因素.方法 连续回顾性纳入急性缺血性卒中合并心房颤动患者登记研究(NCT04080830)中2016年1月至2020年12月首都医科大学宣武医院神经内科收治的急性缺血性卒中合并NVAF的住院患者702例,CHA2 DS2-VASc评分[NVAF卒中风险评分:C为充血性心力衰竭,H为高血压,A2为年龄≥75岁计2分,D为糖尿病,S2为卒中或短暂性脑缺血发作计2分,V为血管性疾病,A为年龄65～74岁,Sc为性别(女性)]≥2分,收集患者的一般情况(性别、年龄、体质量指数)、既往史[下肢血管狭窄或闭塞、急性期下肢静脉血栓或肺栓塞、心功能不全、脑梗死和(或)短暂性脑缺血发作、肝病史和(或)肝功能异常]、心脑血管疾病危险因素(冠心病、高血压病、高脂血症、糖尿病、吸烟、饮酒)、相关实验室检查(血红蛋白≤90 g/L、血肌酐≥200μmol/L等)、量表评分[NVAF卒中风险评分、出血风险评分、美国国立卫生研究院卒中量表(NIHSS)评分、改良Rankin量表(mRS)评分]、出院时抗栓药物使用情况以及有无大面积脑梗死、梗死后出血转化、共存颅内外血管狭窄、急性期非主要出血、急性期大出血、医疗保险报销范围等.依据年份分层,即2016、2017、2018、2019、2020年,对各年份急性缺血性卒中合并NVAF患者出院时抗栓药物使用占比及趋势进行比较.根据新型口服抗凝药(NOACs)纳入医疗保险系统分为医保前(2016—2017年)组与医保后(2018—2020年)组,对相关数据进行对比分析.分析急性缺血性卒中合并NVAF患者出院时抗凝药物使用情况及其变化趋势,并分析NOCAs进入医疗保险系统后,对影响出院时口服抗凝药物使用情况的相关因素.比较不同抗凝药物出血事件发生率.医疗保险范围包括农村合作医疗报销、城镇医疗保险报销和职工医疗保险报销.抗栓治疗包括抗凝及抗血小板聚集治疗.CHA2 DS2-VASc评分≥2分者均首选抗凝治疗,包括口服华法林、NOACs及低分子肝素;对于应首选抗凝治疗,但因年龄>80岁、出血风险高的患者,经与其沟通表示拒绝抗凝治疗或对抗凝药物过敏者则给予抗血小板聚集治疗,包括口服阿司匹林肠溶片、硫酸氢氯吡格雷片.经沟通拒绝抗栓治疗、对抗栓药物过敏、出院时仍有症状性出血转化、致命性出血等以上症状之一者,不予抗栓治疗.结果 (1)2016、2017、2018、2019、2020年抗栓药物治疗使用占比分别为66.1％(74/112)、75.3％(113/150)、84.9％(107/126)、83.9％(161/192)、77.9％(95/122),不同年份急性缺血性卒中合并NVAF患者出院时抗栓药物使用占比的差异有统计学意义(χ2=29.83,P<0.05).抗凝药物的使用率大幅度上升,从2016年22.3％(25/112)至2018年50.0％(63/126),之后趋于平稳;无抗栓药物使用占比呈下降趋势;抗血小板聚集药物的使用趋于平稳状态.(2)2016、2017、2018、2019、2020年抗凝药物使用占比分别为22.3％(25/112)、40.7％(61/150)、50.0％(63/126)、47.9％(92/192)、44.3％(54/122),5年间不同抗凝药物的使用的变化趋势有统计学意义(χ2=66.87,P<0.05),2016年至2018年NOACs呈大幅上升,从2016年的36.0％(9/25)至2018年的88.9％(56/63),之后趋于平稳;低分子肝素及华法林的使用呈大幅下降,2018年后均处于平稳状态.(3)2018年NOACS进入医疗保险,对比医疗保险前后抗栓占比差异有统计学意义(χ2=18.37,P<0.01),抗凝药物从32.8％(86/262)提高到47.5％(209/440);抗凝药物种类占比亦有统计学意义(χ2=62.90,P<0.01),NOACS在由39.5％(34/86)提高到83.3％(174/209).(4)多因素Logistic回归分析结果显示,年龄≥75岁(OR=2.315,P<0.01)、共存颅内外血管狭窄(OR=1.674,P=0.016)、大面积梗死比例(OR=1.914,P=0.014)、梗死后出血转化(OR=3.374,P<0.01)和急性期非主要出血(OR=2.872,P=0.020)是出院时使用抗凝药物的独立影响因素.3种抗凝药物应用后的出血事件发生率均较低,且差异无统计学意义(P>0.05).结论 自2018年NOACs进入医疗保险后,NOACs的应用可以明显提高急性缺血性卒中合并NVAF患者出院时的抗凝药物使用率及NOACs在抗凝药物中的占比.高龄、共存颅内外血管狭窄、大面积梗死比例、梗死后出血转化及急性期非主要出血是不利于出院时抗凝药物使用的主要因素,加强出院患者随访是将来提升急性缺血性卒中合并NVAF患者的二级预防管理的重要因素.

新型口服抗凝药又称直接口服抗凝药,与传统口服抗凝药华法林相比,起效快,半衰期短,与食物、药物相互作用小,无需频繁监测凝血指标.对于心房颤动相关卒中的预防,新型口服抗凝药抗凝效果不劣于华法林,出血(尤其是颅内出血)风险低,安全性更高,成为目前抗凝领域研究的热点.在隐源性卒中、颈部动脉夹层、脑静脉系统血栓形成、进展性卒中和高危非致残性卒中等脑血管病的治疗过程中,尽管支持应用抗凝的证据强弱不等,但是鉴于新型口服抗凝药拥有更高的安全性,相关探索性研究不断出现.该文对近年来新型口服抗凝药在脑血管病领域中应用的相关研究展开阐述,探讨其未来的研究热点和方向.

Background and Purpose: Systolic blood pressure falling by 10-20% of daytime values during the night constitutes a physiological night-dipping pattern. Blunted (<10%) systolic blood pressure night-dipping (SBPN) is a risk factor of acute ischemic stroke (AIS), but the prognostic value of SBPN for patients with AIS remains unclear. Severe (≥70%) cervicocephalic atherosclerotic stenosis (SCAS), different from the mild or moderate stenosis, renders the cerebral perfusion more vulnerable to variations of blood pressure is prevalent in AIS, and may consequently change the relationship of SBPN with AIS outcomes. We sought to examine the association between SBPN and AIS functional recovery, respectively in patients with and without SCAS. Methods: Patients with AIS within 6 days were consecutively enrolled and divided into SCAS group and non-SCAS group according to whether there was SCAS on CT angiography. SBPN was evaluated by the night-to-day dipping percentage using 24-hour ambulatory blood pressure monitoring on the 6 th day after the symptom onset. A reduction in modified Rankin scale score (mRS) after 3 months compared to mRS at admission was defined as functional recovery. Results: Among 247 AIS patients, 194 (78.5%) had blunted SBPN, and the mean SBPN percentage was 3.12% ± 7.83% (minimal: -24%, median: 3%, maximal: 22%). AIS patients with blunted SBPN were less likely to have the functional recovery than those with normal SBPN (63.9% vs. 81.1%, p=0.018). There was significant interaction between the SBPN percentage and the presence of SCAS for predicting the functional recovery (p=0.026). In AIS patients with SCAS (n=146), rather than in those without (n=101), the SBPN percentage could serve as an indicator of 3-month functional recovery independently of age, sex, National Institute of Health stroke scale score at admission and traditional risk factors (adjusted odd ratio=1.06 for per percent increase of SBPN, 95% confidential interval: 1.01-1.11). Conclusions: Blunted SBPN was frequent among patients with AIS. Adverse effects exerted by lower SBPN on AIS functional recovery were more considerable in patients with SCAS. For AIS patients with SCAS, evaluating SBPN was important to assess their prognosis.

Objective Vertebral artery dissection (VAD) combined with congenital craniovertebral junction malformation (CVJM) is rare. This study aimed to analyze the etiology, clinical and imaging features, treatment, and prognosis of VAD with CVJM. Methods Four new cases of VAD with congenital CVJM and 28 similar cases found in the literature were included. Detailed clinical data from all cases were retrospectively analyzed. Results A total of 32 patients (28 men, four women; mean age 19.01±12.53 years) were included. Seventeen of 32 cases (53.1%) had had multiple ischemic episodes. The most common neurological symptoms were limb numbness/weakness (20/32), ataxia (15/32), and dizziness/vertigo (12/32). In sum, 31 of 32 cases had multiple infarcts scattered throughout the posterior circulation area on cranial computed tomography or resonance imaging. Dissection had occurred in the V3 segment of the VA in 29/31 cases (93.5%). The most common congenital CVJMs were atlantoaxial dislocation and atlantoaxial subluxation (found in 20/32 cases [62.5%]), while 27/32 cases (84.3%) had multiple combined abnormalities. Seven of eleven cases (63.6%) with initial antiplatelet treatment and one of eleven (9.1%) with initial anticoagulation treatment experienced stoke recurrence. Fusion or vertebral fixation was performed in 16 patients and aneurysm resection in one patient. There was no reported recurrence after surgery in 13 patients with follow-up data. Conclusion Underlying CVJM is a rare but overlooked etiology in VAD, and is prone to induce recurrent ischemic stroke. Patients with VAD, especially that localized in the V3 segment, should be examined for CVJM. Timely assessment is critical for determining the specific cause and to provide targeted intervention.

Background: The treatment of post-stroke depression (PSD) with anti-depressant drugs is partly practical. Transcranial alternating current stimulation (tACS) offers the potential for a novel treatment modality for adult patients with PSD. In this study, we will assess the efficacy and safety of tACS for treating PSD and explore its effect on gamma and beta-oscillations involving in emotional regulation. Methods: The prospective study is an 8-week, double-blind, randomized, placebo-controlled trial. Seventy eligible participants with mild to moderate PSD aged between 18 years and 70 years will be recruited and randomly assigned to either active tACS intervention group or sham group. Daily 40-minute, 77.5-Hz, 15-mA sessions of active or sham tACS targeting the forehead and both mastoid areas on weekdays for 4 consecutive weeks (week 4), and an additional 4-week observational period (week 8) will be followed up. The primary outcome is the proportion of participants having an improvement at week 8 according to the Hamilton Depression Rating Scale 17-Item (HAMD-17) score, including the proportion of participants having a decrease of >= 50% in HAMD-17 score or clinical recovery (HAMD-17 score <= 7). Secondary outcomes include neurological function, independence level, activities of daily living, disease severity, anxiety, and cognitive function. The exploratory outcomes are gamma and beta-oscillations assessed at baseline, week 4, and week 8. Data will be analyzed by logistical regression analyses and mixed-effects models. Discussion: The study will be the first randomized controlled trial to evaluate the efficacy and safety of tACS at a 77.5-Hz frequency and 15-mA current in reducing depressive severity in patients with PSD. The results of the study will present a base for future studies on the tACS in PSD and its possible mechanism. Trial registration number: NCT03903068, pre-results.

Background: Bow hunter's syndrome (BHS), also known as rotational vertebral artery occlusion syndrome, is rare. Occasionally, it combines with dissection/pseudoaneurysm of the ipsilateral VA. Methods: We report a case of BHS combined with ipsilateral VA dissection/pseudoaneurysm and review eight similar cases reported in the literature. Their aetiology, clinical and imaging features, treatment, and prognosis were analysed. Results: Nine patients (seven male, two female; average age 22.0 +/- 4.5 years) were enrolled. Visual symptoms comprised the most common clinical finding (66.7%, 7/9). Clinical symptoms were not related to neck rotation in seven patients (77.8%). Eight patients (88.9%) had multiple, scattered, new and old infarctions of the posterior circulation revealed on computed tomography/magnetic resonance imaging (CT/MRI) scans. Dissection/pseudoaneurysm was found in the ipsilateral VA - usually subtle and localised in the atlas, axis, and occipital bone - in all nine patients. Seven patients (66.7%) had special causes for the syndrome (i.e. congenital bone dysplasia). Altogether, 87.5% (7/8) experienced recurrence with cerebral infarction after antithrombotic therapy alone. Aetiologically targeted treatment, including surgical decompression or vertebral fixation, was performed in seven patients (77.8%). Conclusion: Young patients presenting with cryptogenic stroke in the posterior circulation and localised, subtle dissection/pseudoaneurysm of the ipsilateral VA around the atlanto-axial joint should undergo carotid ultrasonography with a neck rotation test or dynamic CT angiography/MR angiography/digital subtraction angiography, if necessary, to rule out/diagnose BHS.

Objective: To investigate preliminary efficacy and safety of intravenous recombinant human pro-urokinase (rhpro-UK) in patients with acute ischemic stroke (AIS). Methods: In the 23-center phase IIa, time window stratified, randomized, open, positive controlled, clinical trial, patients within 6 hours after the onset of AIS were stratified into two therapeutic time windows. Patients within 4.5 h were randomized to receive intravenous rhpro-UK 50mg, 35mg, or recombinant tissue plasminogen activator (rt-PA; 0.9 mg/kg, maximum 90 mg). Patients within 4.5-6 h were randomized to receive rhpro-UK 50mg or 35mg. Primary outcome was a modified Rankin scale (mRS) score ≤1at 90 days. Secondary outcome was the treatment response based on ≥ 4-point reduction from the baseline National Institutes of Health stroke scale score at 24 hours after treatment. Safety outcomes included symptomatic intracerebral hemorrhage (sICH), death due to any cause, and other serious adverse events. Results: We enrolled 190 patients (Figure 1A). Within 4.5 h, the proportion of patients with a mRS score ≤1 at 90 days did not differ significantly among groups (57.9%, 55.6% and 52.6%, P=0.92). Similarly, there was no statistical significance among groups in term of treatment response at 24 hours (P=0.85). In the 4.5-6 h time window, the rates of functional independence of rhpro-UK 50mg and 35mg were 59.0% and 69.2% (P=0.34). The proportion of patients with functional response to treatment were 28.2% and 33.3% (P=0.62) (Figure1B, 1C). sICH occurred in one patient in the 50mg rphro-UK group within 4.5 h within 30 days after the intervention. There was no significant difference among the five groups in death and rate of other serious adverse events. Conclusion: As compared with rt-PA, intravenous rhpro-UK at two dose within the 4.5 hours after onset of symptoms showed similar efficacy and safety profiles in patients withAIS. Similarly, these two dose groups did not differ in efficacy and safety between 4.5-6.0 hours.

Background and Purpose: Complex aortic plaque (CAP) in the proximal thoracic aorta can be an embolic source for acute ischemic cerebrovascular disease (AICVD), while culprit cervicocephalic atherosclerotic stenosis may coexist. However, the associations between proximal CAP and possible symptomatic cervicocephalic atherosclerotic stenosis (PS-CAS) remain unclear. We aimed at testing whether CAP tended to distribute in the proximal thoracic aorta in AICVD patients with PS-CAS, offering potential risk of aortogenic cerebral embolism. Methods: Patients ≥45 years old with AICVD were consecutively enrolled and underwent CT angiography of cervicocephalic arteries and thoracic aorta. Thoracic aorta was divided into proximal and distal parts by the ostium of the left subclavian. Plaques with thickness ≥4 mm, associated ulcer or mural thrombus were considered to be CAP. Distributing patterns of CAP in the thoracic aorta included proximal only (PO), distal only (DO) and proximal + distal (PD). Extracranial and intracranial atherosclerotic stenosis which could be the potential cause of the cerebral ischemia with luminal stenosis ≥50% was defined as PS-CAS. Results: Within 285 patients with AICVD, 55 had CAP-PO (19.3%), 37 had CAP-DO (13.0%), 72 had CAP-PD (25.3%). Extracranial and intracranial PS-CAS were detected in 62 and 143 patients (21.8% and 50.2%) respectively. AICVD patients with PS-CAS were more likely to have CAP-PO and CAP-PD than those without (51.9% vs. 35.2%, p=0.005). Regardless of age, sex and vascular risk factors, CAP-PO was associated with extracranial PS-CAS (adjusted OR=5.39, 95%CI: 2.18-13.36) and intracranial PS-CAS (adjusted OR=2.59, 95%CI: 1.25-5.38), whereas CAP-DO bored no relationship with them. CAP-PD was independently related to extracranial PS-CAS (adjusted OR=6.59, 95%CI: 2.53-17.15) but not intracranial PS-CAS. Conclusions: AICVD patients with PS-CAS were more likely to have CAP in the proximal thoracic aorta. The risk of potential aortogenic cerebral embolism might be higher when PS-CAS, especially the extracranial ones, was identified in patients with AICVD.

Background and Purpose . Recently, several studies indicated the c.14576G>A variant on the ring finger protein 213 (RNF213), a founder variant of moyamoya diseases (MMD), was associated with non-MMD intracranial major artery stenosis/occlusion (non-MMD ICASO). We proposed that RNF213 variant-related ICASO including MMD might be a special entity with its own characteristics based on a genetic background. The aim of the study was to learn the clinical and vascular features of RNF213 variant-related ICASO. Moreover, we tried to explore the clinical significance of a testing variant in ICASO patients in China. Methods . Clinical material and routine image data were collected in 160 Chinese patients with ICASO, including 41 verified MMD and 119 non-MMD. DNA samples were extracted, and the c.14576G>A variant on RNF213 was genotyped. Then, the clinical and vascular features were compared between the patients with and without a relevant variant. Furthermore, the patients with RNF213 mutation were performed with high resolution magnetic resonance imaging (HR-MRI) examination to conclude features of the artery wall. Results . There were 16 (10%) patients (including 9 MMD and 7 non-MMD ICASO) presenting a heterozygous c.14576G>A variant while none of homozygote was found. Compared to the patients without the c.14576G>A variant, the variant group had more female, less symptomatic patients, and more possibility of having collateral vessels in vascular imaging. In the symptomatic subgroup, there is no significant difference in clinical presentation (p>0.05) between two groups. However, RNF213 variant-related ICASO had lower scores in NIHSS (1.0±3.0 vs. 3.9±5.0, p<0.05) but not in mRS. In the symptomatic subgroup, in addition, most of the HR-MRI images of variant ICASO (77.8%, 7 of 9) were characterized by a shrunken outer diameter, concentric thickening vessel wall, and collateral vessel structures on the stenotic portion, which was prone to be diagnosed as HR-MMD (a MMD diagnosis diagnosed by HR-MRI). The rest of the two variants showed a relatively eccentric luminal narrow, normal outer diameter without collateral vessel findings, identified as HR-ICAD (intracranial atherosclerotic disease diagnosed by HR-MRI). Conclusions . Our study demonstrated that the c.14576G>A variant on RNF213 may be a biomarker to good outcome of ICASO in Chinese. The variant-related ICASO was characterized by both features of MMD and ICAD diagnosed by HR-MRI.

旋转性椎动脉闭塞综合征又称弓猎人综合征(BHS),指在头颈旋转或伸展过程中导致椎动脉机械性闭塞或狭窄的一种罕见临床综合征,其后循环缺血症状多在头部旋转时发生,并在中立位置时迅速改善.在少数情况下,BHS可因椎动脉反复挤压内膜受损继发血栓形成致动脉-动脉栓塞性梗死.作者报道了1例弓猎人综合征致反复后循环梗死的青年女性病例,该患者以突发反应迟钝、记忆力下降、右侧肢体活动不利起病,既往无明确血管危险因素,临床症状与转颈活动无相关性.颈动脉超声转颈试验示左侧椎动脉颈部右转时出现血流减弱逆转,头颈部CT血管成像(CTA)和DSA检查示左侧椎动脉V3、V4交界处局部突起,考虑为夹层或假性动脉瘤;转颈CTA示右侧转头时左侧椎动脉出枢椎横突孔之后未见显影;高分辨率MR示左侧椎动脉V3、V4交界区血管内一膜样结构突入管腔.提示BHS临床症状可以与转颈无关,仅表现为后循环区域梗死,可以合并同侧椎动脉范围非常局限的夹层或假性动脉瘤损害表现.临床医师如果缺乏相应的认识,可能会造成漏诊和误诊.因此遇到隐源性后循环青年卒中患者,应仔细分析后循环血管形态改变,必要时行颈动脉超声转颈试验或动态DAS明确有无合并BHS.

This paper expounds receiving access system,pre-service training,various forms of teaching way and so on,combined with the special experience of clinical education for refresher physicians majoring in cerebrovascular disease (CVD) in the neurology department of Xuanwu Hospital,Capital Medical University,in order to explore the methods and effects of clinical teaching in neurology department.It focuses on the application of the teaching model based on the combination of the cases in the three-level teaching rounds.At the same time,it emphasizes the combination of professional training lectures,difficult case discussion,self-learning ability training and continuing education learning class.Through the clinical teaching of the above comprehensive method,the refresher physicians majoring in CVD had made great progress in the standardized diagnosis and treatment of cerebrovascular disease system,and the clinical teaching effect is relatively ideal.

BACKGROUND AND PURPOSE:The ring finger protein 213 (RNF213) gene R4810K variant, a susceptibility locus for moyamoya disease (MMD), has recently been identified to be associated with intracranial major artery stenosis/occlusion (ICASO) without satisfying the diagnostic criteria of MMD in the Japanese population. However, further studies are needed to determine whether this variant is associated with ICASO in other populations and whether R4810K variant-related ICASO could be categorized as MMD. The aim of this study is to elucidate whether the R4810K variant was associated with ICASO among the Han Chinese population and potential histopathology of R4810K variant-related ICASO. MATERIALS AND METHODS:We conducted a case-control study to evaluate association and performed high-resolution (HR) magnetic resonance imaging (MRI) to investigate arterial wall feature of ICASO. The R4810K variant was genotyped in 114 ICASO patients and 268 controls. Then, patients with R4810K variant-related ICASO were subjected to HR MRI examination and presumptively diagnosed based on the characteristics thus observed. STATISTICAL ANALYSIS:The relationship between R4810K variant and ICASO was evaluated by Fisher's exact test with odds ratios (OR) and 95% confidence interval (CI). RESULTS:The R4810K variant was associated with ICASO and increased the risk for ICASO (P < 0.01; OR: 20.2; 95% CI: 2.5-163.11). Presumptive MMD was diagnosed in all female patients with R4810K variant. However, presumptive intracranial atherosclerotic stenosis was diagnosed in one of three males harboring this variant. CONCLUSIONS:The R4810K variant is a genetic risk factor for ICASO among the Han Chinese population and that R4810K variant-related ICASO should be identified as MMD in female but not uncertain in male patients.

Introduction: Remote ischemic conditioning (RIC) has been investigated for its protective effect for heart disease, stroke prevention, etc. However, the safety and tolerability of RIC have not been systematically investigated. We aimed to conduct a systematic review to evaluate the RIC-related adverse effects. Methods: We searched PubMed up to June 2017 using the following keywords: “remote ischemic postconditioning”; “remote ischemic preconditioning”; “remote ischemic conditioning” and “remote ischemic preconditioning”. We included any clinical studies with adult subjects. Exclusion criteria were conditioning not performed on remote limbs and not ischemic conditioning. We extracted adverse effects from each study, and summarize the rate of these adverse effects. Results: 131 studies with 8,895 subjects were included. Six disease conditions were investigated. Only 10 studies reported RIC related adverse effects in the manuscripts while 47 studies stated no RIC-related adverse effects were observed. The highest pressure was 600 mmHg, and lowest pressure was 15 mmHg above systolic blood pressure. The median duration for each session is 5 minutes and the median number of sessions is 4. “Skin petechiae” was the most common adverse effects (50, 0.56%); followed by “discomfort or pain around limbs” (22, 0.24%) and deep-venous thrombosis (2, 0.02%). Sixteen (0.18%) patients did not tolerate the procedure and discontinued from the study. Conclusions: Our system review concluded that, in general, RIC was well tolerated and its related adverse events are minor with low incidence rates.