Yunfei Han

From clinical to tissue-based dual TIA Validation and refinement of ABCD3-I score

Objective: To investigate whether dual tissue-defined ischemic attacks, defined as multiple diffusion-weighted imaging lesions of different age and/or arterial territory (dual DWI), are an independent and stronger predictor of 90-day stroke than dual clinical TIAs (dual TIA). Methods: Consecutive patients with clinically defined TIA were enrolled and assessed clinically and by MRI within 3 days. The predictive ability of the ABCD clinical factors, dual TIA, and dual DWI was evaluated by means of multivariate logistic regression. Results: Among 658 patients who were included in the study and completed 90 days of follow-up, a total of 70 patients (10.6%) experienced subsequent stroke by 90 days. Multivariate logistic regression indicated that dual DWI was an independent predictor for subsequent stroke (odds ratio 4.64, 95% confidence interval 2.15–10.01), while dual TIA was not (odds ratio 1.18, 95% confidence interval 0.69–2.01). C statistics was higher when the item of dual TIA in ABCD3-I score was replaced by dual DWI (0.759 vs 0.729, p = 0.035). The net reclassification value for 90-day stroke risk was also improved (continuous net reclassification improvement 0.301, p = 0.017). Conclusion: Dual DWI independently predicted future stroke in patients with TIA. A new ABCD3-I score with dual DWI instead of dual clinical TIA may improve risk stratification for early stroke risk after TIA.

Validation of NINDS-CSN neuropsychological battery for vascular cognitive impairment in Chinese stroke patients

BackgroundThe NINDS-Canadian Stroke Network (NINDS-CSN) recommended a neuropsychological battery of three protocols to diagnose vascular cognitive impairment (VCI), however, due to culture and language differences, the battery cannot be directly used in China. Validation of the battery in mandarin Chinese is lacking. Our study investigated the reliability and validity of the adapted Chinese versions of the battery in stroke patients with high probability of VCI.MethodsFifty mild stroke patients (median of National Institute of Health Stroke Scale [NIHSS] score, 2) and 50 stroke-free normal controls were recruited. All subjects’ demographics, clinical history, and stroke severity were recorded. The NINDS-CSN neuropsychological protocols were adapted into the Chinese versions. External validity, defined as the ability of the protocol summary scores to differentiate stroke patients from controls, was determined using the area under the curve (AUC) of the receiver operating characteristics curve. We also evaluated internal consistency and intra-rater reliability.ResultsStroke patients performed significantly poorer than controls on all three protocols (F statistics between 24.9 and 31.4, P < 0.001). External validity evaluated by AUCs was 0.88 (95% confidence interval [CI], 0.81-0.95), 0.88 (95% CI, 0.81-0.94), and 0.86 (95% CI, 0.79-0.94) for the 60-min, 30-min and 5-min protocols, respectively. Cronbach’s alpha of the cognitive tests was 0.87 for all subjects. Intra-rater reliability was acceptable with intraclass correlation coefficients 0.90, 0.83 and 0.75 for the 60-min, 30-min and 5-min protocols, respectively.ConclusionsThe adapted Chinese versions of three NINDS-CSN neuropsychological protocols were valid and reliable for assessing VCI in Chinese patients with mild stroke.

Prediction of favorable outcome by percent improvement in patients with acute ischemic stroke treated with endovascular stent thrombectomy

Our objective was to investigate a method for assessing early improvement and its predictive value for 3-month functional outcome in patients treated with EST. A total of 97 consecutive AIS patients undergoing EST were prospectively collected and retrospective reviewed. Data on demographics, vascular risk factors, admission National Institutes of Health Stroke Scale (NIHSS) score, 24-h NIHSS score, reperfusion and collateral formation were collected. Percent improvement was defined as ([baseline NIHSS score-24-h NIHSS score]/baseline NIHSS score×100%), while absolute improvement was calculated by the difference between scores (baseline NIHSS score-24-h NIHSS score). A 3-month functional outcome was assessed using the modified Rankin Scale (mRS). Favorable outcome was defined as a mRS score of 0-2. Areas under the receiver-operating characteristic (ROC) curve (AUC) for percent improvement and absolute improvement in predicting favorable outcome was compared. Finally, we investigated the independent predictors of improvement at 24h after EST and its relationship with favorable outcome. Pairwise comparison of ROC curves revealed that percent improvement had larger AUC than absolute improvement (p=0.004). Rapid neurological improvement (RNI), defined as percent improvement ⩾30%, was a powerful predictor of favorable outcome (odds ratio [OR] 7.63, confidence interval [CI]: 2.65-21.96; p<0.001). Good collaterals (OR 2.86; 95% CI: 1.11-7.38; p=0.030) and short onset-to-reperfusion time (ORT) (OR 3.02, 95% CI: 1.17-7.80; p=0.022) were independent predictors of RNI. RNI predicted 3-month favorable outcome in AIS patients treated with EST. Good collaterals and short ORT are independent predictors of RNI.

Severity assessment of intracranial large artery stenosis by pressure gradient measurements: A feasibility study.

Fractional flow reserve (FFR)‐guided revascularization strategy is popular in coronary intervention. However, the feasibility of assessing stenotic severity in intracranial large arteries using pressure gradient measurements still remains unclear.

Association of C7673T polymorphism in apolipoprotein B gene with ischemic stroke in the Chinese population: a meta-analysis

Background: Epidemiological studies have evaluated the association between the C7673T polymorphism in apolipoprotein B (apoB) gene and ischemic stroke (IS), but the results are still debatable even in the Chinese population. This meta-analysis was therefore designed to clarify these controversies. Methods: All of the relevant studies were identified from PubMed, Embase, Chinese National Knowledge Infrastructure database and Chinese Wanfang database up to 31 October 2014. Statistical analyses were conducted with Revman 5.2 and STATA 12.0 software. Odds ratio (OR) with 95% confidence interval (CI) values were applied to evaluate the strength of the association. A fixed or random effect model was selected for pooling data based on the heterogeneity test. Publication bias was assessed by Beggs test and Eggers test. Results: A significant association was found between the C7673T polymorphism in apoB gene and IS under the heterozygous genetic model (OR = 1.868, 95% CI = 1.160–3.007) and the allelic genetic model (OR = 1.742, 95% CI = 1.294–2.346), respectively. In the subgroup analysis by the geographic region, T allele could increase the risk of IS in northern Chinese (OR = 2.359, 95% CI: 1.425–3.907), but not in southern Chinese individuals (OR = 1.485, 95% CI: 0.778–2.832). Further stratification for source of controls showed that statistical significance was found among the population-based studies. Conclusion: Our meta-analysis revealed that C7673T polymorphism in apoB gene was significantly associated with increased IS risk in the Chinese population.

Correlation study between small vessel disease and early neurological deterioration in patients with mild/moderate acute ischemic stroke

Aims: Cerebral small vessel disease (SVD) refers to a group of pathological processes that affect small arteries, arterioles, venules, and capillaries of the brain. We hypothesized that imaging markers of SVD could be associated with neurological deterioration during acute phase of mild/moderate ischemic stroke. Methods: We performed a prospective cohort with 687 consecutive patients with acute ischemic stroke and also with admission NIHSS score below 12 points. Imaging markers of SVD include silent lacunar infarction, deep cerebral microbleeds (CMBs), brain atrophy, periventricular and semiovale white matter hyperintensities, basal ganglia and semiovale enlarged perivascular spaces as well as SVD burden rating scale, which were evaluated and calculated, respectively. Early neurology deterioration (END) was defined as an increment of NIHSS score ≥2 points in the first 72 h after admission. Results: None of these imaging markers and rating scale of SVD significantly correlated with END after adjusted for major confounders. Post hoc analysis indicated similar negative results in different age, TOAST classification and infarction location subgroups. Only silent infarction (OR 2.42, 95%CI 1.33–5.10) and deep CMBs (OR 2.10, 95%CI 1.08–3.72) seemed to be predictors for END in female patients. However, due to the increased type I error in multiple comparisons, these relationships should not be regarded as statistically significant. Conclusion: In patients with mild/moderate acute ischemic stroke, imaging markers of SVD did not correlate with END.

Relationship between Cellular Apoptosis and the Expression of p75 Neurotrophin Receptor and Tyrosine Kinase A Receptor in Tissue Surrounding Haematoma in Intracerebral Haemorrhage

Cellular apoptosis and the expression of p75 neurotrophin receptor (p75NTR) and tyrosine kinase A receptor (TrkA) were investigated in the tissues surrounding haematoma in patients with intracerebral haemorrhage. Specimens of tissue from near the haematoma (haemorrhagic samples) and tissue from a distant site (control samples) were collected from 14 patients with basal ganglia haemorrhage undergoing surgical intervention. Cellular apoptosis was determined by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelling (TUNEL), and p75NTR TrkA location, protein and gene expression were studied using immunohistochemistry, Western blot and real-time polymerase chain reaction, respectively. The percentage of apoptotic cells and expression of p75NTR, but not of TrkA, were significantly higher in the haemorrhagic samples than in the control samples. There was a positive correlation between the percentage of TUNEL-positive cells and the percentage of p75NTR-positive cells. These results suggest that the p75NTR-dependent signal transduction pathway plays an important role in apoptosis after intracerebral haemorrhage.

Total time of operation is a risk factor of stroke-associated pneumonia in acute ischemic stroke patients with intra-arterial treatment.

Background and purpose:Stroke-associated pneumonia (SAP) is associated with poor functional outcome in patients with acute ischemic stroke (AIS). The objective of this study was to identify predictors of SAP in patients underwent intra-arterial treatment (IAT). Methods:Consecutive patients with AIS within 6 h from the symptom onset underwent IAT were enrolled. Independent predictors of in-hospital SAP after AIS were obtained using multivariable logistic regression. Kaplan–Meier survival curves were calculated and compared by the log-rank test. Results:Of 165 patients with AIS in the study period, 102 (61.8%) underwent IAT. Twenty-two (21.6%; 95% confidence interval [CI], 14.7–29.4) experienced SAP. Patients with SAP were older (69.2 vs 62.9 years, respectively; P = 0.011), more severely affected (National Institutes of Health Stroke Scale score, 18 vs 9, respectively; P = 0.004), more likely to underwent symptom of dysphagia (86.4% vs 15%, respectively; P < 0.001), lower Glasgow Coma Scale score (9 vs 13, respectively; P < 0.001), and longer operation time (149.5 vs 123, respectively; P < 0.001) than those without SAP. Only symptom of dysphagia (adjust odds ratio [OR], 12.051; 95% CI, 3.457–50.610; P < 0.001) and total time of operation (adjust OR, 1.040; 95% CI, 1.009–1.071; P < 0.001) were identified as independent predictors of SAP. Patients with SAP had stable or improved deficits after AIS with IAT (P < 0.001). Conclusions:Besides dysphagia, total time of operation is a risk factor of SAP in patients with AIS with IAT.

Management of acute tandem occlusions: Stent-retriever thrombectomy with emergency stenting or angioplasty

Objective To compare outcomes following intracranial stent retriever-based intracranial thrombectomy (SRT) with emergency extracranial internal carotid artery (EICA) stenting or angioplasty alone in patients presenting with acute stroke due to tandem occlusions of the ICA. Methods Consecutive patients with acute anterior tandem occlusion who received an endovascular intervention within 6h of symptom onset between January 2013 and June 2016 were included in this prospective study. Demographic, radiological, procedural and clinical outcome data were compared between the stenting and the angioplasty alone groups. Results Of the 37 patients eligible for the study, 18 had angioplasty alone and 19 underwent stent placement. Successful recanalization rate was statistically significantly higher in the stenting group than in angioplasty alone group (74% vs. 39%) and although not statistically significant, more patients in the stenting group than in the angioplasty alone group had favourable outcomes (63% vs. 50%). There was no significant difference between groups in rates of symptomatic intracranial haemorrhage (SICH), cerebral herniation or mortality. Conclusion This study in a small sample size suggests that among patients with acute anterior tandem occlusion, SRT with EICA stenting tended to achieve higher recanalization and improved clinical outcomes at three months compared with SRT and angioplasty alone with a similar rate of SICH and mortality.

Emergent Loading Dose of Antiplatelets for Stenting after IV rt-PA in Acute Ischemic Stroke: A Feasibility Study

ABSTRACT Background: A loading dose of antiplatelets reduces in-stent thrombosis after stent implantation. However, whether it is safe in patients undergoing acute stenting after intravenous recombinant tissue plasminogen activator (rt-PA) is unclear. Methods: A case series of acute ischemic stroke patients treated with intravenous rt-PA followed by emergent stenting were prospectively included in Jinling Hospital Stroke Unit. An emergent loading dose of antiplatelets (aspirin 300 mg and clopidogrel 300 mg) were administered to all patients through a nasogastric tube immediately before stenting. Clinical and angiographic outcomes were evaluated in these patients. Results: A total of 12 patients were included. The median of NIHSS score on admission was 15 points (interquartile range 11–19). The median of time from stroke symptom onset to start IV rt-PA and stent placement was 172 min (interquartile range 123.75–189) and 311.5 min (interquartile range 285.5–349.5), respectively. All patients reached complete or partial recanalization (TICI ≥2a). One patient occurred hemorrhagic transformation at 24 h following the emergent loading dose of antiplatelets. A favorable outcome as defined by mRS ≤2 at 90 days was obtained in 58.3% (7/12) of all patients. Conclusion: Our finding preliminary suggested that an emergent loading dose of antiplatelets may be safe and feasible for acute stenting after IV rt-PA.