Kehui Dong

Comparison of elective stenting of severe vs moderate intracranial atherosclerotic stenosis

Objective: To test whether symptomatic severe intracranial atherosclerotic stenosis was associated with a higher subsequent stroke risk than moderate stenosis after elective angioplasty with a balloon-expandable stent and to explore which factors were associated with the subsequent stroke. Methods: Between September 2001 and June 2005, there were 220 symptomatic intracranial atherosclerotic stenoses in 213 patients undergoing elective stenting at our institute. Of these stenoses, 126 in 121 patients were ≥70% severe stenoses, and 94 in 92 patients were 50% to 69% moderate stenoses. Primary endpoints included lesion-related ischemic stroke, and symptomatic brain or subarachnoid hemorrhage. Results: Ten primary endpoint events occurred in the severe stenosis group (six within 30 days and four in mean follow-up of 26.0 months after 30 days), and seven occurred in the moderate stenosis group (four within 30 days and three in mean follow-up of 27.6 months after 30 days). There was no significant difference in cumulative probability of primary endpoints between the severe (7.2% at 1 year and 8.2% at 2 years) and moderate (5.3% at 1 year and 8.3% at 2 years) stenosis groups. No single factor was found to be associated with primary endpoints in the moderate stenosis group. Multivariable analysis revealed that stent failure was the only predictor of primary endpoints in the severe stenosis group (hazard ratio 5.31, 95% CI 1.35 to 20.91). Conclusion: Symptomatic severe intracranial atherosclerotic stenosis did not present a higher subsequent stroke risk than moderate stenosis after elective angioplasty with a balloon-expandable stent. Patients with severe stenosis may benefit from successful stent placement, and randomized trials are necessary to demonstrate this possible benefit.

Long-term outcome of elective stenting for symptomatic intracranial vertebrobasilar stenosis.

Seventy-nine consecutive patients with symptomatic atherosclerotic stenosis ≥ 50% of intracranial vertebrobasilar artery (VBA) were treated by elective stenting. There were five strokes within 30 days, and three strokes in the VBA territory after 30 days (mean of 812 days). The annual stroke rate in the VBA territory (including any stroke and death within 30 days) was 4.6%. At the last follow-up time, 73 patients were independent (modified Rankin scale grade ≤ 2). The outcome compares favorably with medical therapy.

Outcomes of tailored angioplasty and/or stenting for symptomatic intracranial atherosclerosis: a prospective cohort study after SAMMPRIS

Background and purpose High periprocedural complication rate is a key limitation of endovascular treatment of intracranial atherosclerotic disease (ICAD), despite potential risk reduction of recurrent stroke. Taking lessons from the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Arterial Stenosis (SAMMPRIS) trial, targeting a selected patient population, we prospectively evaluated the feasibility and safety of tailored angioplasty and/or stenting for patients with ICAD. Methods From November 2011 to October 2012, 158 patients with symptomatic ICAD caused by hypoperfusion combined with poor collateral flow were consecutively recruited into a prospective single center study. Patients were divided into three groups based on arterial access and lesion morphology: balloon mounted stent group (group BS) for smooth access and Mori A lesion, angioplasty plus self-expanding stent group (group AS) for tortuous access and Mori B or C lesion, and angioplasty group (group AG) for tortuous access and Mori A lesion. The primary endpoints were successful procedure rate and any vascular event within 30 days. Results Overall technical success rate was 96.3% (154/158). There were significant differences in the technical success rate: 89.7% (35/39) in group AG compared with 97.5% (79/81) in group BS and 100% (38/38) in group AS (p=0.042). The 30 day composite stroke, myocardial infarction, or death rate was 4.4% (7/158). Stroke within 30 days occurred in four patients in group BS and in three patients in group AS. Conclusions Individualized treatment of ICAD using tailored devices according to arterial access and lesion morphology was feasible and safe in symptomatic patients caused by hypoperfusion with poor collateral flow.

External Validation of the ASTRAL Score to Predict 3- and 12-Month Functional Outcome in the China National Stroke Registry

Background and Purpose— The ASTRAL score was recently introduced as a prognostic tool for acute ischemic stroke. It predicts 3-month outcome reliably in both the derivation and the validation European cohorts. We aimed to validate the ASTRAL score in a Chinese stroke population and moreover to explore its prognostic value to predict 12-month outcome. Methods— We applied the ASTRAL score to acute ischemic stroke patients admitted to 132 study sites of the China National Stroke Registry. Unfavorable outcome was assessed as a modified Rankin Scale score >2 at 3 and 12 months. Areas under the curve were calculated to quantify the prognostic value. Calibration was assessed by comparing predicted and observed probability of unfavorable outcome using Pearson correlation coefficient. Results— Among 3755 patients, 1473 (39.7%) had 3-month unfavorable outcome. Areas under the curve for 3 and 12 months were 0.82 and 0.81, respectively. There was high correlation between observed and expected probability of unfavorable 3- and 12-month outcome (Pearson correlation coefficient: 0.964 and 0.963, respectively). Conclusions— ASTRAL score is a reliable tool to predict unfavorable outcome at 3 and 12 months after acute ischemic stroke in the Chinese population. It is a useful tool that can be readily applied in clinical practice to risk-stratify acute stroke patients.

The Association between Serum Uric Acid Levels and the Prevalence of Vulnerable Atherosclerotic Carotid Plaque: A Cross-sectional Study

Little is known about the associations between serum uric acid (SUA) levels and atherosclerotic carotid plaque vulnerability. The aim of this study was to assess the associations of SUA levels with the prevalence of vulnerable atherosclerotic carotid plaque in a community-based cohort. In the Asymptomatic Polyvascular Abnormalities Community (APAC) study, cross-sectional data from 2860 Chinese residents who underwent SUA measurement and ultrasonographic assessment of carotid plaque were analyzed. Multivariable logistic regression models were used to assess the associations of SUA levels with presence of vulnerable carotid plaque. After adjustment for potential confounders, SUA levels were significantly associated with the prevalence of vulnerable plaque amongst the middle-aged adults (odds ratio [OR] = 1.19, 95% confidence interval [CI]: 1.11–1.28). Compared to the lowest quartile, quartiles 2, 3 and 4 had a prevalence OR of 1.33 (1.02–1.74), 1.70 (1.27–2.27) and 2.05 (1.53–2.75), respectively, for the presence of vulnerable carotid plaque (p for trend across quartiles < 0.001). In the APAC study, elevated SUA levels were independently associated with the prevalence of vulnerable carotid plaque in middle-aged adults.

Persistence and predictors of abnormal glucose metabolisms in patients after acute stroke

Abstract Objectives: To determine the persistence of newly recognized abnormal glucose metabolism in patients following acute ischemic stroke and delineate the possible predictive factors for this persistence. Methods: A prospective observational study was performed. One hundred and twenty-three patients with acute first-ever ischemic stroke and no previous diagnosis of diabetes mellitus were enrolled consecutively. Information from baseline and laboratory tests was recorded. A standard oral glucose tolerance test was performed on the fourteenth day after onset and 3 months later, respectively. Results: One hundred and seven patients completed the study. Thirty-nine patients (36·3%) were diagnosed as having newly recognized diabetes on the 14th day and 28 patients (26·1%) after 3 months. Among the patients diagnosed as having diabetes or impaired glucose tolerance during hospitalization, 68·6% remained to present with abnormal glucose metabolism 3 months later. Lower post-load plasma glucose on the fourteenth day was detected as a predictor for aggravated glucose metabolism after 3 months of onset. Conclusion: Majority of newly recognized abnormal glucose metabolism during hospitalization persisted 3 months later. Patients with lower post-load glucose level on the fourteenth day had higher risk for aggravated glucose metabolism 3 months later. Those with higher fasting glucose concentration on admission or higher 2 hour post-load plasma glucose on the fourteenth day had significantly high risk for diabetes after 3 months.

Do patients with basilar or vertebral artery stenosis have a higher stroke incidence poststenting

Background and aim Posterior circulation stenosis may be a risk factor associated with stroke after intracranial stenting as compared with anterior circulation stenosis. Our aim was to test our hypothesis that there was no difference in clinical outcome poststenting between patients with severe stenosis of the basilar artery (BA) and intracranial vertebral artery (VA). Methods Using the Cox proportional hazards regression model adjusted for prespecified factors (qualifying event, and timing of stenting after the qualifying event), we compared primary endpoint (ischemic stroke in the vertebrobasilar territory, including any stroke or death within 30 days of stenting) between patients with severe symptomatic atherosclerotic BA and VA stenosis who underwent elective stenting in our prospective database. Analysis was by intention-to-treat principle. Results Primary endpoint event occurred in 13 (18.8%) of 69 patients with BA stenosis during a mean 23.4 months (9 within 30 days and 4 afterward) and 3 (4.3%) of 70 patients with VA stenosis during a mean 26.4 months (2 within 30 days and 1 afterward). Patients with BA stenosis had a significantly higher risk of the primary endpoint (adjusted HR=4.87, 95% CI 1.37 to 17.29; p=0.014) or any stroke or death within 30 days of stenting (adjusted HR=5.13, 95% CI 1.10 to 23.96; p=0.038) than those with VA stenosis. Conclusion A significantly higher stroke risk poststenting exists in patients with severe BA stenosis than those with VA stenosis. The discrepancy in clinical outcome after stenting between patients with BA and VA stenosis should be considered in clinical practice and stenting trials.

Imaging-based thrombolysis trial in acute ischemic stroke-II (ITAIS-II)

BACKGROUND Intravenous (i.v.) recombinant tissue plasminogen activator (rtPA) remains the only approved therapy for acute ischemic stroke. However, the use of i.v. thrombolysis is restricted to a minority of patients by the rigid 3-h time window. Modern imaging-based selection algorithms that can identify penumbra have been proposed as methods to extend the window and to select patients more likely to respond favorably or unfavorably to i.v. thrombolysis. AIMS We aim to compare the safety and efficacy of multiparametric computed tomography (CT)-based i.v. thrombolysis after 3-9 h of symptom onset with standard CT-based thrombolysis within 3 h and with CT-based thrombolysis or placebo after 3-6 h from the pooled data of the large stroke rtPA trials. DESIGN The imaging-based thrombolysis trial in acute ischemic stroke-II study is a prospective, multicenter and assessor-blind controlled study. The primary efficacy outcome will be a favorable outcome at 90 days defined as a modified Rankin Scale and reperfusion improvement 24-36 h after treatment; the primary safety end-point outcome will be intracerebral hemorrhage 24-36 h after treatment. We aim to include 200 patients by 2010. It is registered with IRCTN number: ISRCTN12033002.

Relationship between leukoaraiosis and cerebral large artery stenosis

Abstract Objectives: We carried out this cross-sectional study to explore the association between cerebral large artery lesions and leukoaraiosis in Chinese patients with stroke. The relationship between leukoaraiosis and risk factors of cerebral vascular disease was also investigated. Methods: Data were prospectively collected from patients with ischemic stroke within 7 days of symptom onset. All patients underwent three-dimensional time of flight magnetic resonance angiography (MRA) and contrast-enhanced MRA for evaluating intracranial and extracranial stenosis. Leukoaraiosis grading was performed according to age-related white matter changes rating scale. Results: One hundred and eighty-five patients with acute ischemic stroke were enrolled. Of these, 121 patients (65.4%) had significant stenosis or occlusion. The frequency of distinct leukoaraiosis between the mild or no stenosis group and the significant stenosis or occlusion group was not significantly different (odd ratios: 0.97; 95% confidence interval: 0.46–2.07). In the subgroup analysis, distinct leukoaraiosis was more frequently observed in the multiple lesions group than in the single lesion group (odd ratios: 4.15; 95% confidence interval: 1.32–13.05). Age (odd ratios: 2.659; 95% confidence interval: 1.217–5.809), hypertension (odd ratios: 4.690; 95% confidence interval: 0.947–23.242), smoking (odd ratios: 4.039; 95% confidence interval: 1.340–12.174) and the level of low-density lipoprotein (odd ratios: 0.438; 95% confidence interval: 0.215–0.891) were independently associated with distinct leukoaraiosis. Conclusion: There is a lack of a relationship between cerebral large artery stenosis and leukoaraiosis, but multiple large artery stenoses may increase the risk of leukoaraiosis.

Risk Assessment of Deep‐Vein Thrombosis After Acute Stroke: a Prospective Study Using Clinical Factors

Deep‐vein thrombosis (DVT) represents a serious complication in acute stroke patients with pulmonary embolus (PE) as a potential outcome. Prediction of DVT may help with formulating a proper prevention strategy. To assess of the risk of deep venous thrombosis (DVT) in acute stroke patients, we developed and validated a clinical score in a cohort study.