Jiangang Duan

Low-Dose Tirofiban Improves Functional Outcome in Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy

Background and Purpose— Chinese patients largely experience acute ischemic stroke (AIS) because of large artery atherosclerosis rather than cardioembolism, and whether tirofiban is safe and effective in these patients treated with endovascular thrombectomy (ET) is unknown. This study evaluated the safety and efficacy of tirofiban in Chinese patients with AIS treated with ET. Methods— This observational study is based on a single-center prospective registry study. Patients with AIS undergoing ET with second-generation stent retrievers from January 2013 to February 2017 were treated with ET alone or ET plus low dose of tirofiban. The primary outcome was symptomatic intracerebral hemorrhage (sICH). The secondary outcomes included rate of early reocclusion, any ICH, fatal ICH, and 3-month and long-term functional outcomes. Results— One hundred eighty AIS subjects were included in the analysis, including 90 subjects treated with tirofiban and 90 subjects without tirofiban. Sixty-three subjects (35%) had any ICH, 19 of them (11%) were sICH, and 9 of them (5%) were fatal ICH. Ten subjects (11%) treated with tirofiban experienced sICH and 9 subjects (10%) not given tirofiban experienced sICH, not a significant difference (P=0.808). Early reocclusion happened in 4 of 90 subjects (4.4%) treated with tirofiban and 8 of 90 subjects (8.9%) not treated with tirofiban (P=0.370). One hundred sixty-one subjects (89%) completed long-term follow-up, subjects treated tirofiban were associated with lower odds of death (23% versus 44%, P=0.005) when compared with those who were not treated. Additionally, tirofiban was associated with better odds of long-term functional independence (adjusted odds ratio, 4.37; 95% confidence interval, 1.13–16.97; P=0.033). Conclusions— In patients with AIS undergoing ET, tirofiban is not associated with higher sICH, it seems to lead to lower odds of deaths and better odds of long-term functional independence. Further investigations are needed to determine the efficacy of tirofiban in preventing early reocclusion, the underlying mechanisms, and its optimal treatment protocol.

Intracranial hypertension induced by internal jugular vein stenosis can be resolved by stenting

Idiopathic intracranial hypertension (IIH) is characterized by abnormally elevated intracranial pressure (ICP) without identifiable etiology. Recently, however, a subset of patients with presumed IIH have been found with isolated internal jugular vein (IJV) stenosis in the absence of intracranial abnormalities.Background: Idiopathic intracranial hypertension (IIH) is characterized by abnormally elevated intracranial pressure (ICP) without identifiable etiology. Recently, however, a subset of patients with presumed IIH have been found with isolated internal jugular vein (IJV) stenosis in the absence of intracranial abnormalities. A cc ep te d A rt ic le This article is protected by copyright. All rights reserved. Methods: Fifteen consecutive patients were screened from 46 patients suspected as IIH and were finally confirmed as isolated IJV stenosis. The stenotic IJV was corrected with stenting when a trans-stenotic mean pressure gradient (∆MPG) was equal or higher than 5.44 cmH2O. Dynamic MRV/CTV/DSA of IJV, ∆MPG, ICP, Headache Impact Test-6 (HIT-6) and Frisén papilledema grade (FPG) score before and after stenting were compared. Results: All the stenotic IJVs were corrected by stenting. ∆MPG decreased and the abnormal collateral veins disappeared or shrank immediately. Headache, tinnitus, papilledema and ICP were significantly ameliorated at 14 ± 3 days of follow-up (all p < 0.01). At 12 ± 5.6 months of outpatient follow-up, headache disappeared in 14 out of 15 patients (93.3%), visual impairments were recovered in 10 from 12 patients (83.3%) and tinnitus resolved 10 out of 11 patients (90.9%). In 12 out of 15 cases, the FPG scores declined to 1 (0-2). The stented IJVs in all 15 patients kept to sufficient blood flows on CTV follow-up with stenting related adverse events. A cc ep te d A rt ic le This article is protected by copyright. All rights reserved. Conclusions: Non-thrombotic IJV stenosis may be a potential etiology of IIH. Stenting seems to be a promising option to address the issue of intracranial hypertension from etiological level, particularly after medical treatment failure.

Long-term outcomes of acute ischemic stroke patients treated with endovascular thrombectomy: A real-world experience

BACKGROUND AND PURPOSE Long-term follow-up of large trials have confirmed the superiority of endovascular thrombectomy (ET) for treating acute ischemic stroke (AIS). However, it is still unknown whether these results can be generalized to clinical practice. In this study, we aimed to determine the long-term outcomes of AIS post-ET in the real-world clinical practice. METHODS This observational study is based on a single-center prospective registry study. AIS patients were treated with second-generation stent retrievers from December 2012 to April 2016. The primary outcome was modified Ranks scale (mRS) at the time of the latest assessment. Favorable outcome was defined as mRS scores 0-2, and the unfavorable outcome was defined as mRS scores 3-6. RESULTS Eighty-nine AIS subjects with large artery occlusion in anterior circulation undergoing ET were eligible for analysis. Median follow-up duration was 20 months (interquartile range 6-32), and 47 subjects (53%) achieved favorable outcome whereas 17 subjects (19%) were functional dependence and 25 subjects (28%) died. Independent predicators for long-term unfavorable outcome were higher baseline National Institutes of Health Stroke Scale (NIHSS) score (odd ratio:1.21;95% confidence interval 1.09-1.35; p < 0.001) and symptomatic intracerebral hemorrhage (sICH) (odd ratio:16.45;95% confidence interval 1.34-193.44; p = 0.026). More subjects of large-artery-atherosclerosis underwent permanent intracranial stenting (22%vs.10%) as compared with those of cardioembolism, while subjects of cardioembolism were more likely to experience sICH (13%vs.8%) and died (32%vs.16%). CONCLUSIONS Over half of AIS patients can achieve favorable long-term outcomes post-ET. Higher baseline NIHSS scores and sICH are independently associated with unfavorable outcome. Overall, clinical practice in this single canter can replicate the long-term outcomes from the published endovascular clinical trials.

Remote limb ischemic conditioning treatment for intracranial atherosclerotic stenosis patients

Objective The recurrence rate of ischemic stroke remains high among symptomatic intracranial atherosclerotic stenosis patients with either ischemic stroke or transient ischemic attack. The aim of our study is to evaluate whether remote limb ischemic conditioning (RLIC) prevents cerebral ischemic events in symptomatic intracranial atherosclerotic stenosis patients. Methods Symptomatic intracranial atherosclerotic stenosis patients with either ischemic stroke or transient ischemic attack will be recruited from more than 60 hospitals in China to participate in a randomized, double-blind, parallel-controlled clinical trial that will compare the efficacy and safety of RLIC for the prevention of recurrent stroke. Following randomization, patients allocated to the RLIC group (n = 1500) will receive RLIC once daily for 12 months, with treatment consisting of five cycles of 5 min of pressure treatment at 200 mm Hg, followed by 5 min of reperfusion. The sham group (n = 1500) will be treated identically, with the exception of pressure treatment at 60 mm Hg. Results The primary endpoint will be an ischemic stroke event during the study period. Secondary endpoints will include composite fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, and transient ischemic attack. Patients will be assessed periodically over a approximate 3-year study period using the modified Rankin Scale, National Institutes of Health Stroke Scale, and Barthel Activities of Daily Living Index. Conclusion We predict that RLIC treatment for 12 months will safely reduce the ischemic stroke recurrence rate.

Safety, feasibility, and potential efficacy of intraarterial selective cooling infusion for stroke patients treated with mechanical thrombectomy.

This is a prospective non-randomized cohort study of 113 consecutive patients to investigate the safety and efficacy of a short-duration intraarterial selective cooling infusion (IA-SCI) targeted into an ischemic territory combined with mechanical thrombectomy (MT) in patients with large vessel occlusion-induced acute ischemic stroke (AIS); 45/113 patients underwent IA-SCI with 350 ml 0.9% saline at 4℃ for 15 min at the discretion of the interventionalist. Key parameters such as vital signs and key laboratory values, symptomatic and any intracranial hemorrhage, coagulation abnormalities, pneumonia, urinary tract infections and mortality were not significantly different between the two groups. Final infarct volume (FIV) was assessed on noncontrast CT performed at three to seven days. After an adjusted regression analysis, the between-group difference in FIV (19.1 ml; 95% confidence interval (CI) 3.2 to 25.2; P = 0.038) significantly favored the IA-SCI group. At 90 days, no differences were found in the proportion of patients who achieved functional independence (mRS 0–2) (51.1% versus. 41.2%, adjusted odd ratio (aOR) 1.9, 95% CI 0.8–2.6, P = 0.192). Combining short-duration IA-SCI with MT was safe. There was a smaller FIV and trend towards clinical benefit that will need to be further evaluated in randomized control trials.

Severe Hyperhomocysteinemia with Two Novel Mutations of c.154T>C and c.457G>A in Cystathionine Beta-Synthase Gene

To the Editor: Hyperhomocysteinemia (HHcy) is an important risk factor for atherothrombotic disease and venous thrombosis.[1] Normally, homocysteine (Hcy) is either remethylated to methionine (Met) by a Vitamin B12‐dependent reaction or betaine as the methyl donor, or trans‐sulfurated to cysteine through a pyridoxine‐dependent reaction. Based on plasma level of total Hcy, HHcy is typically classified into three groups as follows: mild (tHcy 15–30 μmol/L), moderate (tHcy 30–100 μmol/L), and severe (tHcy >100 μmol/L).[2] Severe HHcy is rare and most commonly caused by inherited deficiency of cystathionine beta‐synthase (CBS), or less frequently, of methylenetetrahydrofolate reductase (MTHFR) genes. The presentations of this metabolic disorder include developmental delay, intellectual disability, epilepsy, ectopia lentis, myopia, hypopigmentation of the skin and hair, marfanoid habitus, and thromboembolic disorders.[3] These manifestations are often overlooked in the early stage until the occur of thrombotic events like cerebral venous sinus thrombosis (CVST).

Remote ischemic conditioning for acute stroke patients treated with thrombectomy

Remote ischemic conditioning (RIC) has been demonstrated to be safe and feasible for patients with acute ischemic stroke (AIS), as well as for those receiving intravenous thrombolysis. We assessed the safety and feasibility of RIC for AIS patients undergoing endovascular treatment (ET).

Nephrotic Syndrome May Be One of the Important Etiologies of Cerebral Venous Sinus Thrombosis.

OBJECTIVE Thrombosis is a common complication of nephrotic syndrome (NS). However, cerebral venous sinus thrombosis (CVST) secondary to NS is rarely reported. Here we report a case series study of 5 cases of CVST with NS, so as to make a better understanding and management of this disorder. METHODS A retrospective study was performed in 5 consecutive patients with CVST in combination with NS between 2009 and 2015. The clinical manifestations, laboratory and radiological findings, treatment, and clinical outcomes were analyzed. RESULTS This cohort of case series consists of 1 woman and 4 men, aged 16-49 years. All patients complained initially of an acute or subacute headache. CVST attacked during NS occurrence in 3 patients, and during NS recurrence in 2 patients. The median duration of signs and symptoms prior to clinical diagnosis and treatment was 12.80 ± 7.53 days. In all patients, it was magnetic resonance venography that detected the thrombosis in the cerebral venous sinus, with the most common site of CVST to be the superior sagittal sinus (5 of 5 patients). Two or more segments of sinus were involved simultaneously in 4 patients. The treatment of CVST in NS involved therapy of CVST in the general population. All the 5 patients had full recovery, and no one relapsed with a follow-up of 26.60 ± 29.75 months. CONCLUSIONS NS may be one of the important etiologies of CVST. When patients with NS had progressing headache, seizure, or other unexplained neurological symptoms, CVST should be considered.