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Objective To investigate the relationship between cerebral atrophy and total burden of cerebral small vessel disease in patients with recent small subcortical infarct(RSSI).Methods A total of 194 elderly RSSI patients admitted to Department of Neurology of Changzhou Second People's Hospital Affiliated to Nanjing Medical University from September 2021 to November 2022 were recruited in this study.All patients completed cranial MRI examination and were divid-ed into a non-mild group 1(97 cases)and a moderate to severe group 1(97 cases)based on the to-tal burden of cerebral small vessel diseases(CSVD)imaging.Visual assessment scale was used to assess the severity of brain atrophy in the whole brain and various regions of the brain.According to the global cortical atrophy scale(GCA)score,all patients were divided into a non-mild group 2(88 cases)and a moderate to severe group 2(106 cases).Brain atrophy in various regions,medial temporal lobe atrophy(MTA)score,frontal temporal lobe atrophy(FTA)score,and posterior cortical atrophy(PA)score were evaluated.Their general clinical and imaging data were collected,multivariate logistic regression analysis was employed to analyze the relationship between GCA score and total burden of CSVD imaging in RSSI patients,and Spearman correlation analysis was further adopted to explore the correlation of GCA score and different parts of brain atrophy with total burden of CSVD imaging.Results When compared with the non-mild group 1,the moderate to severe group 1 had significantly larger proportions of having GCA score of 2-3 points,PA score of 2-3 points,MTA score of 2-4 points and FTA score of 2-4 points(P＜0.01).The ra-tio of having 2-4 points in total imaging burden score of CSVD was obviously higher in the mod-erate to severe group 2 than the non-mild group 2(P＜0.01).Multivariate logistic regression anal-ysis showed that age and total burden of CSVD imaging were independent risk factors for brain atrophy in RSSI patients(OR=1.184,95％CI:1.099-1.276,P=0.000;OR=3.537,95％CI:1.664-7.518,P=0.001).Spearman correlation analysis revealed that the total burden score of CSVD imaging was positively correlated with GCA,MTA,FTA and PA scores in RSSI patients(r=0.518,r=0.382,r=0.471,r=0.388,P=0.000).Conclusion The total burden of CSVD is an independent risk factor for GCA in elderly RSSI patients.The more serious the total burden of CSVD is,the higher the grade of GCA is.The total burden of CSVD is related to the whole brain and brain atrophy in other different regions of the brain.
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Cerebral small vessel disease (CSVD) is one of the main causes of cognitive impairment and decreased the quality of daily life in the elderly. Researches have shown that CSVD is closely associated with autonomic nervous function. Patients with CSVD may be accompanied by cardiovascular, endocrine, gastrointestinal, urination, sleep disorders and other autonomic dysfunction.
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Objective:To investigate the relationship between the degree and location of cerebral microbleeds (CMBs) and the early neurological deterioration (END) within 72 h after admissionin in patients with acute small artery occlusive stroke (SAO).Methods:Patients with first-onset SAO hospitalized in Changzhou Second People′s Hospital from July 2020 to January 2021 were retrospectively enrolled. All patients completed the head magnetic resonance imaging including susceptibility weighted imaging. Collected baseline data, and evaluated the National Institutes of Health Stroke Scale (NHISS) scores before admission and within 72 h after onset. Patients were divided into END group and no END group according to whether NIHSS scores increased by ≥3 within 72 h after admission. The baseline characteristics were compared between these two groups. Moreover, the correlation between the degree and location of CMBs and END were analyzed by multivariate Logistic regression.Results:A total of 163 first-episode SAO patients were enrolled. There were 47 patients (28.83%) with END. In END group, there were 35 patients (74.47%) with CMBs which was higher than those in non-END group [42 patients (36.21%)]. In END group, there were 21 patients (44.68%) with severe CMBs, 11 patients (23.41%) with basal ganglia CMBs, 16 patients (34.04%) with mixed CMBs, which were all higher than those in non-END group [5 patients (4.31%) with severe CMBs, 9 patients (7.76%) with basal ganglia CMBs, and 13 patients (11.21%) with mixed CMBs]. The difference was statistically significant ( P<0.05). After adjusting for triglyceride, location of infarcated lesions, and the degree of WMHs, further Logistic regression analysis revealed that severe CMBs ( OR = 6.139, 95% CI 1.377 - 27.375, P = 0.017), basal ganglia CMBs ( OR = 5.253, 95% CI 1.105 - 24.975, P = 0.037) and mixed CMBS ( OR = 5.098, 95% CI 1.197 - 21.704, P = 0.028) were independent risk factors of END in SAO patients. Conclusions:The location and degree of CMBs are closely related to the occurrence of END in patients with SAO. Severe CMBs, basal ganglia CMBs and mixed CMBs may be the effective predictors of END in patients with SAO.
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Objective To explore the correlation between the total imaging burden of cerebral small vessel disease(CSVD)and heart rate variability(HRV)in elderly patients with hypertension.Methods A total of 256 elderly patients with hypertension admitted to Department of Neurolo-gy,Changzhou Second People's Hospital form September 2021 to December 2022 were consecu-tively recruited in this study.According to the total brain MRI burden,they were divided into scored 0-2 group(180 cases)and 3-4 group(76 cases).Their general clinical data and HRV parameters were compared between the two groups.Multivariate logistic regression analysis was used to analyze the relationship between HRV and total CSVD burden in these patients,and Spearman correlation analysis was employed used to analyze the correlation between HRV and to-tal CSVD burden,and between blood pressure variability and HRV.Results Older age,longer course of hypertension,and higher homocysteine level were observed in the group of scored 3-4 than the group of 0-2(P＜0.01).The former group had significantly lower SDNN,SDANN,ASDNN,rMSSD,PNN50,LF and HF when compared with the latter group(all P＜0.01).But there was no statistical difference in LF/HF ratio between the two groups(P＞0.01).Multivariate logistic regression analysis indicated that SDNN(OR=0.989,95％CI:0.979-0.999,P=0.034),SDANN(OR=0.988,95％CI:0.977-0.999,P=0.039)and rMSSD(OR=0.965,95％CI:0.938-0.994,P=0.016)were independent risk factors for total burden of severe CSVD in elderly hypertensive patients.Spearman correlation analysis showed that SDNN,SDANN,ASDNN,rMSSD,PNN50,LF and HF were negatively correlated with the total CSVD burden(P＜0.01);the standard deviation of 24-h SBP was negatively correlated with SDNN,SDANN and rMSSD(P＜0.01);the coefficient of variation of 24-h SBP was negatively correlated with SDNN,SDANN and rMSSD(P＜0.01).Conclusion HRV is an independent risk factor for total burden of severe CSVD in elderly hypertensive patients,and HRV parameters are negatively correlated with the to-tal CSVD burden.
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Objective To explore the relationship between optic nerve tissue thickness and enlarged perivascular space(EPVS)in patients with recent small subcortical infarct(RSSI).Methods A total of 72 RSSI patients admitted to Department of Neurology of Changzhou Second People's Hospital affiliated to Nanjing Medical University from November 2021 to December 2022 were re-cruited in this study.All patients underwent cranial MRI,optical coherence tomography(OCT)and fundus photography.The thickness of retinal nerve fiber layer(RNFL)and ganglion cell-inner plexiform layer(GCL-IPL)were measured by software semi-automatic segmentation,and fundus lesions such as fundus hemorrhage and exudation were observed through fundus photography.The severity of EPVS was graded by visual quantitative evaluation,and then the patients were divided into no to mild EPVS group(32 cases)and moderate to severe EPVS group(40 cases).Basal gan-glia EPVS(BG-EPVS)and semioval center EPVS(CSO-EPVS)were further graded and grouped into no to mild BG-EPVS group(31 cases)and moderate and severe BG-EPVS group(41 cases),and no to mild CSO-EPVS group(39 cases)and moderate and severe CSO-EPVS group(33 cases).The clinical data of each group were compared separately.Results There were statistical differences in age,ratio of hypertension and thicknesses of RNFL and GCL-IPL between the no to mild EPVS group and the moderate to severe EPVS group(P＜0.05,P＜0.01),between the no to mild BG-EPVS and the moderate to severe BG-EPVS group(P＜0.01).Multivariate logistic re-gression analysis showed that age(OR=1.207,95％CI:1.028-1.416,P=0.021),hypertension(OR=7.264,95％CI:1.079-11.929,P=0.042),RNFL thickness(OR=0.753,95％CI:0.617-0.915,P=0.004)and GCL-IPL thickness(OR=0.848,95％CI:0.758-0.949,P=0.004)were independent factors of BG-EPVS grade.Spearman correlation analysis indicated that the thicknes-ses of RNFL and GCL-IPL were negatively correlated with BG-EPVS grade(r=-0.571,r=-0.649,P＜0.01).Conclusion RNFL and GCL-IPL thicknesses are independent factors for BG-EPVS grade and negatively correlated with BG-EPVS grade.OCT has important clinical value in assessing the severity of EPVS lesions in RSSI patients.
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Arterial spin labeling imaging (ASL) is a noninvasive, quantitative magnetic resonance perfusion imaging technique with unique values in early diagnosis, lesion assessment, and prognoses of cerebral small vessel diseases. This paper reviews the principle and classification of ASL, characteristics and essential parameters of ASL, new techniques of ASL, and application of ASL in evaluating, treating and prognosing cerebral small vessel diseases, to evaluate and prevent cerebral small vessel diseases.
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Intracranial arterial dolichoectasia (IADE), also known as dilated cerebral artery disease, is manifested as an increase in the length and diameter of one or more intracranial arteries, the affected arteries being enlarged and dilated significantly, or even with winding and tortuosity. The diagnosis and prognostic evaluation of IADE are mainly based on the diameter and curvature of the intracranial artery. IADE can be manifested as ischemic stroke, transient ischemic attack, hydrocephalus, and hemorrhagic stroke. The review focuses on IADE, including the concept, diagnostic criteria, etiology, pathogenesis, pathology, clinical manifestations, treatment, and prognosis.
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Cerebral small vessel disease (CSVD) is the most common cerebrovascular disease in the elderly, which is closely related to ischemic stroke and cognitive impairment. Early neuroimaging assessment of CSVD is of great clinical significance. With the development of medical imaging technology, it has gradually developed from visual rating assessments to quantitative volumetric assessments; therefore, it can evaluate the severity of CSVD reasonably and efficiently. This review focuses on application of some quantitative neuroimaging assessment techniques in CSVD, in order to provide new evaluation methods and ideas for clinical and basic research of CSVD.
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Objective:To identify the influencing factors for cognitive impairment in patients with recent small subcortical infarct (RSSI), and explore the relationship between enlarged perivascular space (EPVS) and executive function in patients with RSSI.Methods:From February to December 2021, 115 patients with RSSI accepted treatment in Department of Neurology, Changzhou Second People's Hospital Affiliated to Nanjing Medical University were enrolled. According to Montreal cognitive assessment (MoCA) scores, these patients were divided into normal cognitive function group (MoCA scores≥26, n=45) and cognitive impairment group (MoCA scores<26, n=70); univariate analysis was used to analyze the differences of general clinical data and EPVS volume between the two groups; multivariate Logistic regression analysis was used to identify the independent influencing factors for RSSI combined with cognitive impairment. Patients were further divided into EPVS non-mild group and EPVS moderate-severe group according to EPVS visual assessment; the differences of scores of different executive function domains were compared between the two groups; Spearman correlation analysis was used to observe the relationships of EPVS grading and volume with executive function. Results:Patients in the cognitive impairment group had significantly older age, significantly higher serum creatinine level, proportion of patients with moderate-severe basal ganglia EPVS (BG-EPVS) and BG-EPVS volume, and significantly lower years of education as compared with those in the normal cognitive function group ( P<0.05). Multivariate Logistic regression analysis showed that BG-EPVS volume ( OR=1.421, 95%CI: 1.028-1.965, P=0.034) was an independent risk factor for RSSI combined with cognitive impairment. MoCA total scores, scores of visual space and executive function domains in patients of the BG-EPVS moderate-severe group were significantly lower than those in patients of the BG-EPVS non-mild group, while Z-scores of Stroop color word test (SCWT) and trail making test (TMT), and total Z-scores of executive function were significantly higher than those in patients of the BG-EPVS non-mild group ( P<0.05). Spearman correlation analysis showed that BG-EPVS grading and volume were positively correlated with total Z-scores of executive function in RSSI patients with cognitive impairment ( r=0.439, P=0.001; r=0.410, P=0.001). Conclusion:BG-EPVS volume is an independent risk factor for cognitive impairment, and both BG-EPVS grading and volume are correlated with impairment degrees of executive function in cognitive function in RSSI patients.
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Intracranial arterial dolichoectasia (IADE), also known as dilated cerebral artery disease, is a kind of disease in which the diseased arteries are lengthened, enlarged, and tortuous due to various reasons. Cerebral small vessel disease (CSVD) refers to a series of clinical, imaging and pathological syndromes caused by various etiologies affecting cerebral arterioles, venules and capillaries. Its main imaging manifestations include lacunar infarction, cerebral microbleeds, enlargement of perivascular space, white matter hyperintensities, and brain atrophy. In recent years, more and more studies have shown that IADE is closely associated with the occurrence and development of CSVD. This article reviews the correlation between IADE and CSVD.
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With the aging of population, cerebral small vessel disease has attracted more and more attention. A growing body of literature has confirmed that retinal vascular changes can be used as a potential marker for the prediction of cerebral small vessel disease. The retina is recognized as a window into cerebrovascular and systemic vascular conditions. Combining traditional fundus photograph and fundus fluorescein angiography with optical coherence tomography angiography, the retinal vascular system of patients with cerebral small vessel disease can be comprehensively analyzed. This paper summarizes and analyzes the application of retinal angiography technology in different image types of cerebral small vessel disease and makes a review, in order to provide reference for the early diagnosis and prevention of cerebral small vessel disease.
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Objective:To investigate the relationship between renal function and the total cerebral small vessel disease(CSVD)score in elderly patients with a mild stroke.Methods:Patients with a mild stroke(National Institutes of Health Stroke Scale score≤3)and aged 60 years and above hospitalized in our hospital from March to December 2019 were consecutively enrolled.Total CSVD scores were evaluated based on enlarged perivascular spaces, cerebral microbleeds, white matter hyperintensities of presumed vascular origin and lacunes of presumed vascular origin.The estimated glomerular filtration rate(eGFR)was derived by using the formula of chronic kidney disease epidemiology collaboration based on serum creatinine(CKD-EPI Scr). The relationship between eGFR and the total CSVD score was analyzed. Results:Of the 152 patients enrolled, 35, 38, 39, 28 and 12 had total CSVD scores of 0, 1, 2, 3 and 4, respectively.The age of patients increased and eGFR decreased with the increase of total CSVD scores(CSVD from 0 to 4, [(67.43±6.59), (68.42±6.83), (72.18±7.94), (76.46±7.75) vs.(79.92±6.17)years old, F=12.018, P<0.001]; [(92.94±12.45)ml·min -1·1.73m -2, (90.52±8.62)ml·min -1·1.73m -2, (89.45±8.48)ml·min -1·1.73m -2 and(83.90±7.19)ml·min -1·1.73m -2vs.(79.16±7.77)ml·min -1·1.73m -2, F=7.210, P<0.001]. Spearman correlation analysis showed that eGFR was negatively correlated with the total CSVD score( r=-0.399, P<0.001). After adjusting for risk factors including age, gender and hypertension, multivariate ordinary regression analysis showed that decreased eGFR was an independent risk factor for the total CSVD score( OR=0.957, 95% CI: 0.924-0.990, P=0.012). Conclusions:In elderly patients with a mild stroke, eGFR is an independent risk factor for the total CSVD score, which shows an increased burden as eGFR decreases.
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Objective:To investigate the relationship between enlarged perivascular space (EPVS) and retinal vessel abnormalities in transient ischemic attack (TIA) and mild stroke patients.Methods:TIA and mild cerebral infarction (National Institutes of Health Stroke Scale score≤3) patients were enrolled from March to August 2019 in Changzhou Second People′s Hospital. Magnetic resonance imaging and retinal fundus photography were performed in all patients. Retinal arteriovenous diameter was semi-automatically measured, and retinal arteriosclerosis grades, vascular curvature, hemorrhages, microangioma, hard exudation, soft exudation, arteriovenous nicking and venous beads were assessed. Patients were divided into two groups according to the existence of EPVS: EPVS group and non-EPVS group. The baseline data of the two groups were compared and further multivariate Logistic regression was carried out. After normal transformation of the number of EPVS, the correlation between the grades of EPVS and converted EPVS was analyzed. The relationship between the number of converted EPVS and the grades and retinal fundus vascular lesions was further analyzed.Results:A total of 123 patients were included, including 99 patients with cerebral infarction, 24 patients with TIA; 52 patients without EPVS and 71 patients with EPVS. The EPVS group was more than the non-EPVS group in age ((68.61±12.71) years and (63.37±13.53) years, t=-2.198, P=0.030), history of hypertension (52 (73.2%) and 25 (48.1%), χ 2=8.118, P=0.004), hemangioma (17 (23.9%) and 5 (9.6%), χ 2=4.196, P=0.041), arteriovenous nicking (50 (70.4%) and 8 (15.4%), χ 2=36.488, P<0.05) and arteriosclerosis grades (1 (1, 2) and 0 (0, 1), Z=-7.454, P<0.05), and less than the non-EPVS group in central retinal artery equivalent (CRAE; (106.31±15.02) mm and (113.89±11.86) mm, t=3.014, P=0.003) and arteriole-to-venule ratio (AVR; 0.54±0.07 and 0.59±0.05, t=4.553, P<0.05). Multivariate Logistic regression analysis showed arteriosclerosis grades ( OR=7.781, 95 %CI 2.876-21.055, P<0.05) and hypertension ( OR=3.203, 95 %CI 1.049-9.777, P=0.041) were related factors for EPVS. Adjusting for age, sex, hypertension and diabetes, the normally transformed EPVS was found positively correlated with arteriovenous nicking ( B=0.556, 95 %CI 0.203-0.910, P=0.003) and arteriosclerosis grade ( B=0.417, 95 %CI 0.259-0.576, P<0.05), and negatively correlated with AVR ( B=-4.213, 95 %CI-6.712--1.714, P=0.001). The grades of EPVS were positively correlated with arteriosclerosis ( r=0.764, P<0.05), and negatively correlated with CRAE ( r=-0.287, P<0.05) and AVR ( r=-0.422, P<0.05). Conclusions:Hypertension and retinal arteriosclerosis are related factors of EPVS in mild stroke and TIA patients. EPVS is correlated with retinal vessel abnormalities. The more serious of EPVS is, the more serious of retinal arteriosclerosis is, the higher ratio of arteriovenous nicking is, the smaller of CRAE and AVR are.
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Objective To investigate the effect of repeated application of low-frequency transcranial magne-tic stimulation ( rTMS) when combined with hyperbaric oxygen ( HBO) in the treatment non-fluent aphasia after a stroke. Methods Forty-eight stroke survivors with non-fluent aphasia were randomly assigned to a control group, an HBO group or an observation group, each of 16. All received conventional rehabilitation therapy consisting of drug therapy, speech training and conventional physical exercises, while the HBO and observation groups were additionally given HBO and rTMS combined with HBO respectively. The 1 Hz rTMS was applied over the Broca's homologues of the unaffected hemisphere. Before and after 4 weeks of treatment, the Western Aphasia Battery ( WAB) was used to evaluate the subjects' language function and the Modified Barthel Index ( MBI) was used to assess their ability in the activities of daily living. Results There was no significant difference in the average WAB scores among the three groups before the treatment. After 4 weeks of treatment the average WAB and MBI scores of the HBO group and the observation group had improved significantly, and there was then a significant difference among the three groups. The observation group was performing significantly better than the HBO group and the control group in spontaneous speech, auditory comprehension, repetition, naming, AQ score and MBI score. Pairwise comparisons showed that the observation group's average WAB score, spontaneous speech, auditory comprehension, repetition, naming, AQ score and MBI score were the best, followed by those of the HBO group and then those of the control group. All of the differences were statistically significant. Conclusions Low-frequency rTMS combined with HBO can significantly improve the language function and the quality of life of patients with non-fluent aphasia. Such combined therapy is worthy of clinical promotion and application.
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Objective To investigate the influence of estimated glomerular filtration rate (eGFR) in rehabilitation of motor function and short-term prognoses in patients with acute middle cerebral artery (MCA) infarction. MethodsSeventy-four patients with acute MCA infarction, admitted to Department of Neurology from March 2016 to September 2018, and then, accepted rehabilitation training for 4 weeks in Department of Rehabilitation medicine, were recruited. Modification of Diet in Renal Disease was used to evaluate the eGFR instead of renal function; according to the results, these patients were divided into normal renal function group and mild-moderate renal dysfunction group. National Institute of Health Stroke Scale (NIHSS) was used to assess the neurologic function. Fazekas scale was used to assess degrees of leukoaraiosis. Fugl-Meyer Motor Function Assessment (FMA) was used to assess motor functions before rehabilitation treatment and 90 d after onset. Modified Barthel Index (MBI) was used to assess activity of daily living 90 d after onset. According to MBI scores, the patients were divided into good prognosis group (MBI scores>60) and poor prognosis group (MBI scores≤60); multivariate Logistic regression analysis was used to confirm the risk factors affecting prognoses 90 d after onset.ResultsAmong 74 enrolled patients, 40 were classified as normal renal function group and 34 as mild-moderate renal dysfunction group; patients in the mild-moderate renal dysfunction group had significantly higher level of blood urea nitrogen, proportion of silent lacunar cerebral infarction and Fazekas scale scores, and had statistically lower FMA scores and MBI 90 d after onset than normal renal function group (P<0.05). Among the 74 patients, good prognosis was found in 32 patients and poor prognosis in 42 patients; multivariate Logistic regression analysis found that age, eGFR (OR=0.944,P= 0.011, 95％CI: 0.903-0.987), baseline NIHSS scores, and Fazekas scale scores were risk factors affecting prognoses 90 d after onset.ConclusionIn acute MCA infarction patients, eGFR can influence the rehabilitation of motor function and short-term prognoses.
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Objective To investigate the effect of intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis on patients with middle cerebral artery (MCA) infarction of different lesions and to analyze the influencing factors of clinical prognoses.Methods Seventy-five patients with acute infarction in the MCA territory were consecutively collected in our hospital from January 2013 to December 2016,and all patients underwent intravenous rt-PA thrombolysis within 4.5 h time window.The sites of MCA were classified into origin of the MCA (type Ⅰ),MCA trunk distal to the lenticulostriate arteries (type Ⅱ) and branches of the MCA (type Ⅲ).Early symptom improvement was defined as 24 h National Institutes of Health Stroke Scale (NIHSS) scores decreased≥4 or down to 0 after intravenous thrombolysis.Clinical data,NIHSS scores on admission and after intravenous thrombolysis,ratio of patients enjoying early symptom improvement,ratio of hemorrhagic transformation,mortality rate within 7 d of intravenous thrombolysis and modified Rankin scale (mRS) scores 90 d after intravenous thrombolysis were obtained and compared among the three groups.And according to mRS scores 90 d after intravenous thrombolysis,the patients were divided into good prognosis group and poor prognosis group;Logistic regression analysis was used to confirm the different prognoses of patients with MCA infarction of different lesions.Results Among the 75 enrolled patients,22 (29.3％) were classified as type Ⅰ,16 (21.3％) as type Ⅱ and 37 (49.3％) as type Ⅲ.Type Ⅰ patients (n=6,27.3％) had significantly lower ratio of patients with early symptom improvement than type Ⅱ patients (n=l 1,68.8％) and type Ⅲ patients (n=25,67.5％,P＜0.05).Type Ⅰ patients had significantly higher ratio of symptomatic intracranial hemorrhage,higher mortality rate within 7 d of intravenous thrombolysis and higher mRS scores 90 d after intravenous thrombolysis than type Ⅱ patients and type Ⅲ patients (P＜0.05).After 90 d of follow up,good prognosis was found in 56 patients (74.7％) and poor prognosis in 19 patients (25.3％);the sites of MCA lesions,thrombolysis time,and NIHSS scores on admission and 24 h after intravenous thrombolysis between the two groups were significantly different (P＜0.05).Multivariate Logistic analysis revealed that sites of MCA lesions (OR=2.633,95％CI:1.119-6.197,P=0.027),thrombolysis time (OR=7.603,95％ CI:1.561-37.043,P=0.012),and NIHSS scores on admission (OR=3.622,95％CI:1.068-12.285,P=0.039) were the risk factors of prognoses.Conclusions Different lesion sites of MCA may indicate different effects and prognoses in patients with intravenous thrombolysis.And,MCA lesion sites,thrombolysis time and NIHSS scores on admission are independent risk factors for prognoses in cerebral infarction patients with intravenous thrombolysis.
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The incidence of ischemic stroke in the middle cerebral artery (MCA )territory is high.Despite intravenous thrombolytic therapy with recombinant tissue type plasminogen activator (rt-PA )can be used at the early stage ,the patients seldom gain benefits from that ,and the morbidity and mortality stay high. In order to provide evidence for optimizing early identification and clinical treatment of patients at high risk of ischemic stroke ,this article reviewed the current state of science and technology regarding prognosis-influencing factors for ischemic stroke of the middle cerebral artery territory ,such as stroke pathogenesis ,the length and site of vessel occlusion ,the collateral circulation and lesion patterns ,initial symptoms and clinical intervention ,and other related indexes after thrombolysis.
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Objective To investigate the effect of the location of middle cerebral artery (MCA) occlusion on outcomes after intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke.Methods The consecutive patients with stroke of acute MCA occlusion treated with rtPA intravenous thrombolysis within 4.5 h after onset were included.The locations of MCA occlusion were divided into either a proximal MCA segment (proximal M1 segment) or a distal MCA segment (distal M1 segment,M2 segment and more distally).Early neurological improvement was defined as National Institutes of Health Stroke Scale (NIHSS) score improvement ≥4 points from baseline or NIHSS 0 point at 24 h after thrombolysis.They were divided into a good outcome group (0-2) and a poor outcome group (3-6) according to the modified Rankin Scale (mRS) scores.Results A total of 70 patients with MCA occlusion were enrolled in the study,including 22 (31.4％) with proximal MCA occlusion and 48 (68.6％) with distal MCA occlusion;52 (74.3％) with good outcome and 18 (25.7％) with poor outcome.The proportion of atrial fibrilhtion (x2 =4.541,P =0.033),the NIHSS scores on admission (t =5.192,P =0.026) and 24 h after thrombolysis (t =5.365,P =0.024) in the proximal MCA occlusion group were higher than those in the distal MCA occlusion group.The proportion of early neurological improvement in the proximal MCA occlusion group was significantly lower than that in the distal MCA occlusion group (x2 =9.434,P =0.002),and the incidence of symptomatic intracranial hemorrhage (x2 =9.563,P =0.002)and the mortality rate within 7 d (x2 =14.491,P ＜0.001) were significantly higher than those in the distal MCA occlusion group.The time from onset to thrombolysis (t =6.346,P =0.014),NIHSS scores on admission (t =4.498,P =0.038) and at 24 h after thrombolysis (t =4.866,P =0.028),and the proportion of proximal MCA occlusion (x2 =18.710,P ＜0.001) in the poor outcome group were significantly longer or higher than those in the good outcome group.Multivariatelogistic regression analysis showed that the proximal MCA occlusion (odds ratio [OR] 14.385,95％ confidence interval [CI] 2.525-81.925;P =0.003),longer time from onset to thrombolysis (OR 12.927,95％ CI 2.624-61.748;P =0.002),higher NIHSS score at 24 h after thrombolysis (OR 3.492,95％ CI 1.027-11.880;P=0.045) were the independent predictors for poor outcome at 90 d.Conclusions There are differences in the outcomes after intravenous thrombolysis in patients with MCA occlusion at different locations.The locations of MCA occlusion,time from onset to thrombolysis,and NIHSS score at 24 h after thrombolysis,and age are the independent predictors for the outcomes after intravenous thrombolysis in patients with acute MCA ischemic stroke.
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Objective To investigate the effect of the location of middle cerebral artery (MCA) occlusion on outcomes after intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke.Methods The consecutive patients with stroke of acute MCA occlusion treated with rtPA intravenous thrombolysis within 4.5 h after onset were included.The locations of MCA occlusion were divided into either a proximal MCA segment (proximal M1 segment) or a distal MCA segment (distal M1 segment,M2 segment and more distally).Early neurological improvement was defined as National Institutes of Health Stroke Scale (NIHSS) score improvement ≥4 points from baseline or NIHSS 0 point at 24 h after thrombolysis.They were divided into a good outcome group (0-2) and a poor outcome group (3-6) according to the modified Rankin Scale (mRS) scores.Results A total of 70 patients with MCA occlusion were enrolled in the study,including 22 (31.4％) with proximal MCA occlusion and 48 (68.6％) with distal MCA occlusion;52 (74.3％) with good outcome and 18 (25.7％) with poor outcome.The proportion of atrial fibrilhtion (x2 =4.541,P =0.033),the NIHSS scores on admission (t =5.192,P =0.026) and 24 h after thrombolysis (t =5.365,P =0.024) in the proximal MCA occlusion group were higher than those in the distal MCA occlusion group.The proportion of early neurological improvement in the proximal MCA occlusion group was significantly lower than that in the distal MCA occlusion group (x2 =9.434,P =0.002),and the incidence of symptomatic intracranial hemorrhage (x2 =9.563,P =0.002)and the mortality rate within 7 d (x2 =14.491,P ＜0.001) were significantly higher than those in the distal MCA occlusion group.The time from onset to thrombolysis (t =6.346,P =0.014),NIHSS scores on admission (t =4.498,P =0.038) and at 24 h after thrombolysis (t =4.866,P =0.028),and the proportion of proximal MCA occlusion (x2 =18.710,P ＜0.001) in the poor outcome group were significantly longer or higher than those in the good outcome group.Multivariatelogistic regression analysis showed that the proximal MCA occlusion (odds ratio [OR] 14.385,95％ confidence interval [CI] 2.525-81.925;P =0.003),longer time from onset to thrombolysis (OR 12.927,95％ CI 2.624-61.748;P =0.002),higher NIHSS score at 24 h after thrombolysis (OR 3.492,95％ CI 1.027-11.880;P=0.045) were the independent predictors for poor outcome at 90 d.Conclusions There are differences in the outcomes after intravenous thrombolysis in patients with MCA occlusion at different locations.The locations of MCA occlusion,time from onset to thrombolysis,and NIHSS score at 24 h after thrombolysis,and age are the independent predictors for the outcomes after intravenous thrombolysis in patients with acute MCA ischemic stroke.
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Objective To investigate the influence of moderate to severe leukoaraiosis (LA) on hemorrhagic transformation and prognosis of patients after intravenous recombinant tissue plasminogen activator thrombolysis for acute ischemic stroke and analyze influencing factors of the clinical prognosis.Methods We consecutively collected patients with acute infarct on anterior circulation (n =78) in Department of Neurology or Emergency of our hospital between January 2014 and March 2017,and all patients received intravenous thrombolysis therapy within the 4.5-hour time window.All patients processed brain MRI after intravenous thrombolysis therapy.According to the degree of LA,all subjects were classified into two groups;LA group (moderate to severe) vs no LA group (absent to mild).Clinical data were obtained and compared among patients with different grades of LA.Logistic regression analysis was used to confirm the relevant factors of prognosis 90 days after stroke.Results Among 78 enrolled patients,24 (30.8％) were classified as LA and 54 (69.2％) as no LA.In the group of LA,33.3％ (8/24) patients conducted hemorrhagic transformation,whereas 11.1％ (6/54) patients also underwent hemorrhagic transformation in the group of no LA.There was a significant difference between the two groups (x2 =5.571,P =0.018).But symptomatic intracranial hemorrhage accounted for 16.7％ (4/24) and 5.6％ (3/54) respectively in the two groups without significant difference (x2 =2.304,P =0.129).Three-month recurrence of stroke in the groups of LA and no LA was 20.8％ (5/24) and 5.6％ (3/54) respectively,also without significant difference between the two groups (x2 =3.850,P =0.050).Age ((73.7 ± 6.7)years vs (61.3 ± 10.6) years,t =6.567,P =0.012),90 d Fugl-Meyer Scale (FMS) score (92.3 ± 3.4 vs 72.9 ± 7.8,t =22.345,P ＜ 0.01) and proportion of 90 d modified Rankin Scale score 0-2 (83.3％(45/54) vs 50.0％ (12/24),x2 =9.383,P =0.002) were significantly different between the two groups.Follow-up 90-day after onset showed that the good outcome was found in 57 cases (73.1％),poor outcome in 21 patients (26.9％) and death in six cases (7.7％).The grade of LA (57.1％ (12/21) vs 21.1％ (12/57),x2 =9.383,P =0.002),silent lacunar infarction (66.7％ (14/21) vs 35.1％ (20/57),x2 =6.224,P =0.013),age ((72.8 ± 7.9) vs (61.5 ± 11.7) years,t =4.423,P =0.039),proportion of thrombolysis within 3.0-4.5 hours (71.4％ (15/21) vs 38.6％ (22/57),x2 =6.634,P =0.010),vascular occlusion size (66.7％ (14/21) vs 38.6％ (22/57),x2 =4.865,P =0.027),infarction size (52.4％ (11/21) vs 12.3％ (7/57),x2 =14.053,P =0.001) and baseline NIHSS score (16.9 ±6.7 vs 9.5 ± 4.5,t =5.426,P =0.022) were significantly different between the two groups.After adjusting for age,thrombolysis time,baseline NIHSS score,infarction size,vascular occlusion size and silent lacunar infarction,multivariate analysis revealed that moderate to severe LA (OR =4.564,95％ CI 1.199-67.724,P =0.033) was risk factor for worse outcome of patients after intravenous thrombolysis.Conclusions Acute ischemic stroke patients with moderate to severe LA have high hemorrhagic transformation after intravenous thrombolysis and may have poor 90-day FMS score.And moderate to severe LA was found to be an independent risk factor for prognosis in cerebral infarction patients with intravenous thrombolysis.