Clinical Study of Endovascular Treatment of Severe Middle Cerebral Artery Stenosis or Occlusion and Vascular Cognitive Impairment

Objective: It is very important to study the factors affecting the incidence, progress and prognosis of patients with vascular dementia. Methods: 50 cases of severe middle cerebral artery stenosis or occlusion underwent endovascular treatment (25 cases of mild cognitive dysfunction, 25 cases of moderate cognitive dysfunction) were divided into two groups, where a medical drug treatment group and a control group established with 25 cases in each group. The cognitive function of each group of patients was evaluated before operation, 7 days after operation, 30 days after operation, and 180 days after operation. CTP was used to compare the hemodynamic changes in patients before and after operation. Results: The severe stenosis or occlusion of the middle cerebral artery in patients can be improved, and the intracranial blood supply of patients with poorly compensated medial cranial circulation and hypoperfusion can be restored to a certain extent. Meanwhile, improvement of cognitive function was definitive in some patients with cognitive dysfunction. Conclusion: To guide the formulation of treatment plans for patients with severe middle cerebral artery stenosis or occlusion.

Hemodynamic Versus Anatomic Assessment of Symptomatic Atherosclerotic Middle Cerebral Artery Stenosis: the Relationship Between Pressure Wire Translesional Gradient and Angiographic Lesion Geometry

Background: Intracranial cerebral atherosclerosis (ICAS) is a leading etiology of ischemic stroke. The diagnosis and assessment of intracranial stenosis are shifting from anatomic to hemodynamic for better risk stratification. However, the relationships between lesion geometry and translesional pressure gradient have not been clearly elucidated.Methods: Patients with symptomatic unifocal M1 middle cerebral artery (M1-MCA) stenosis were consecutively recruited. The translesional pressure gradient was measured with a pressure wire and was recorded as both mean distal/proximal pressure ratios (Pd/Pa) and translesional pressure difference (Pa–Pd). Lesion geometry measured on angiography was recorded as diameter stenosis, minimal lumen diameter, and lesion length. The correlations between pressure-derived and angiography-derived indices were then analyzed.Results: Forty-three patients were analyzed. A negative correlation was found between Pd/Pa and diameter stenosis (r = −0.371; p = 0.014) and between Pa – Pd and minimal lumen diameter (r = −0.507; p = 0.001). A positive correlation was found between Pd/Pa and minimal lumen diameter (r = 0.411; p = 0.006) and between Pa – Pd and diameter stenosis (r = 0.466; p = 0.002).Conclusions: In a highly selected ICAS subgroup, geometric indices derived from angiography correlate significantly with translesional pressure gradient indices. However, the correlation strength is weak-to-moderate, which implies that anatomic assessment could only partly reflect hemodynamic status. Translesional pressure gradient measured by pressure wire may serve as a more predictive marker of ICAS severity. More factors need to be identified in further studies.

High-Resolution MRI to Evaluate Benefit of Middle Cerebral Artery Stenosis in Secondary Prevention in Patients with Acute Cerebral Infarction

High-resolution magnetic resonance (HRMRI) combined with magnetic resonance angiography (MRA) was used to analyze the correlation between the degree of infarction and the degree of cerebral vascular stenosis, and these patients are all have the trend to contain acute infarction. All patients were examined by CT cerebral angiography, which was analysed by conventional magnetic resonance imaging (MRI), high-Resolution (HRMRI) imaging, and cerebral vascular (MRA) imaging. The infarct size of each patient with cerebral infarction was calculated. The degree of middle cerebral artery stenosis was evaluated. Moreover, agnosis of acute cerebral infarction in middle cerebral artery region was calculated, and the correlation between acute cerebral infarction in middle cerebral artery region and the degree of cerebral vascular stenosis was analyzed. The specificity, sensitivity, and accuracy of magnetic resonance angiography (MRA) in the diagnosis of acute cerebral infarction in the blood supply area of the middle cerebral artery were 90.48%, 94.87%, and 93.94%. The coincidence rates for the degree of middle cerebral artery stenosis were 90.91% for mild stenosis, 92.31% for moderate stenosis, 93.75% for severe stenosis, and 85.71% for vascular occlusion, respectively. The K value was in good agreement with the results of CTA diagnosis (≥0.75). In conclusion, HRMRI can clearly indicated that the location of lesions with acute cerebral infarction, and MRA can show the degree of vascular stenosis, there is a close relationship between them.

A Comparison of Safety and Effectiveness Between Wingspan and Neuroform Stents in Patients With Middle Cerebral Artery Stenosis

Background: Percutaneous transluminal angioplasty and stenting with the Wingspan stent has proven safe and effective in patients with middle cerebral artery stenosis (MCAS), but the off-label use of the Neuroform stent might be an alternative treatment. This study aimed to compare the safety and effectiveness of the above two intracranial stents in patients with MCAS.Methods: We retrospectively analyzed consecutive patients with symptomatic MCAS who had been treated with the Neuroform EZ or the Wingspan stent. A propensity score was generated to control for differences in baseline characteristics. The endpoints were the rate of peri-procedural complications within 30 days after stenting, the in-stent restenosis rate, and any target-vessel-related stroke or deaths during follow-up.Results: After matching for propensity score, the peri-procedural complication rate in the Wingspan group was 7.4% compared with 5.6% in the Neuroform group (p = 1.00), while the follow-up in-stent restenosis rates were 23.3 vs. 14.3%, respectively (p = 0.41). In the restenosis group, the patients tended to be younger (p < 0.01) and the degree of artery stenosis before stenting was higher (p < 0.01).Conclusion: This study indicated that in patients with symptomatic MCAS, Neuroform EZ stents are an alternative to Wingspan. Moreover, younger age and higher degree of artery stenosis before stenting might be a risk factor of in-stent restenosis.

Evaluating the Velocity and Extent of Cortical Venous Filling in Patients With Severe Middle Cerebral Artery Stenosis or Occlusion

Objective: To investigate the velocity and extent of cortical venous filling (CVF) and its association with clinical manifestations in patients with severe stenosis or occlusion of the middle cerebral artery (MCA) using dynamic computed tomography angiography (CTA).Methods: Fifty-eight patients (36 symptomatic and 22 asymptomatic) with severe unilateral stenosis (≥70%) or occlusion of the MCA M1 segment who underwent dynamic CTA were included. Collateral status, antegrade flow, and CVF of each patient were observed using dynamic CTA. Three types of cortical veins were selected to observe the extent of CVF, and the absence of CVF (CVF-) was recorded. Based on the appearance of CVF in the superior sagittal sinus, instances of CVF, including early (CVF1), peak (CVF2), and late (CVF3) venous phases, were recorded. The differences in CVF times between the affected and contralateral hemispheres were represented as rCVFs, and CVF velocity was defined compared to the median time of each rCVF.Results: All CVF times in the affected hemisphere were longer than those in the contralateral hemisphere (p < 0.05). Patients with symptomatic MCA stenosis had more ipsilateral CVF- (p = 0.02) and more delayed CVF at rCVF2 and rCVF21 (rCVF2-rCVF1) (p = 0.03 and 0.001, respectively) compared to those with asymptomatic MCA stenosis. For symptomatic patients, fast CVF at rCVF21 was associated with poor collateral status (odds ratio [OR] 6.42, 95% confidence interval [CI] 1.37–30.05, p = 0.02), and ipsilateral CVF- in two cortical veins was associated with poor 3-month outcomes (adjusted OR 0.025, 95% CI 0.002–0.33, p = 0.005).Conclusions: Complete and fast CVF is essential for patients with symptomatic MCA stenosis or occlusion. The clinical value of additional CVF assessment should be explored in future studies to identify patients with severe MCA stenosis or occlusion at a higher risk of stroke occurrence and poor recovery.

Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke

Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.