Incidence Of Cerebral Hemorrhage Research Articles

Clinical analysis of 15 pregnant women complicated with moyamoya disease

Objective: To explore the effects of pregnancy complicated with moyamoya disease on maternal and fetal outcomes. Methods: The general clinical data and maternal and fetal outcomes of 20 pregnancies of 15 patients with moyamoya disease admitted to the First Affiliated Hospital of Zhengzhou University from January 2012 to October 2022 were retrospectively analyzed. Results: (1) General information: among the 20 pregnancies of 15 clearly diagnosed pregnant women complicated with moyamoya disease, 12 were diagnosed before pregnancy (60%, 12/20), 3 were diagnosed during pregnancy (15%, 3/20), and 5 were diagnosed during puerperal period (25%, 5/20). There were 7 cases of primipara (35%, 7/20) and 13 cases of multipara (65%, 13/20). (2) Pregnancy complications and maternal and infant outcomes: among the 20 pregnancies of 15 pregnant women with moyamoya disease, there were 9 pregnancy complications (45%, 9/20), including 5 gestational hypertension (25%, 5/20), 2 severe pre-eclampsia (10%, 2/20), 1 hyperlipidemia and 1 gestational diabetes mellitus (5%, 1/20). There were 2 case of drug abortion in the first trimester, 3 cases of labor induction in the second trimester, and 15 cases of delivery during the third trimester. All the 15 deliveries were cesarean section, of which 11 (11/15) were cesarean sections with medical indications, and 4 (4/15) were cesarean sections caused by personal factors. General anesthesia was used in 5 cases (5/15), epidural block anesthesia in 7 cases (7/15), and combined spinal and epidural anesthesia in 3 cases (3/15). The median gestational age of 15 neonates was 37.2 weeks (34.0 to 40.8 weeks), with 10 cases (10/15) were full-term infants, and 5 (5/15) were preterm infants (3 of which were associated with hypertensive disorder complicating pregnancy). The birth weight of 15 neonates was (2 853±454) g. Four neonates were admitted to neonatal intensive care unit (NICU), of which 3 cases were admitted to NICU due to premature delivery and 1 case was admitted to NICU due to neonatal jaundice. There was no neonatal asphyxia or death. All neonates were followed up from 4 months to 6 years after birth, and all grew well. (3) Neurological symptoms during pregnancy: 8 cases (40%, 8/20) had neurological symptoms during pregnancy, and 6 cases (30%, 6/20) had hemorrhagic symptoms, of which 3 cases occurred during the puerperal period (3/6). There were 2 cases of ischemic symptoms (10%, 2/20), all of which occurred during the puerperal period (2/2). (4) Analysis of factors related to the occurrence of cerebral hemorrhage: the incidence of cerebral hemorrhage in patients with moyamoya disease diagnosed before pregnancy was significantly lower than that in those without a clear diagnosis, and the incidence of cerebral hemorrhage in women with moyamoya disease was lower than that in primipara (all P<0.01). The incidence of cerebral hemorrhage in moyamoya patients without hypertensive disorder complicating pregrancy was lower than that in patients with hypertensive disorder complicating pregrancy, but the difference was not statistically significant (P>0.05). Conclusions: Pregnancy combined with moyamoya disease has adverse effects on maternal and infant outcomes, and the incidence of pregnancy complications increases. Cerebral hemorrhage occurres in prenatal and puperium, while cerebral ischemia occurres mainly in puperium.

Meta-Analysis of Prognostic Correlation of Thrombectomy for Cerebral Infarction Based on Intelligent Medical Treatment.

A meta-analysis is used to investigate the correlation between the status of collateral circulation assessed by head CT angiography (CTA) and the outcome of thrombectomy for cerebral infarction. Meta-analysis is conducted. The experimental results show that the National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin Scale (mRS) score, incidence of cerebral hemorrhage, and mortality in the group with good collateral circulation are significantly lower than those in the group with bad collateral circulation, and the rate of good prognosis is significantly higher (P < 0.05). The evaluation and treatment of patients with cerebral infarction and their prognosis based on CTA intelligent medical technology are related to collateral circulation, and the effect of effectively reducing the risk of death, cerebral hemorrhage, and neurological function injury and improving the prognosis is more obvious in each collateral circulation.

Identification of vasospasm biomarkers for cerebral hemorrhage via bio-informatics analysis.

The incidence of cerebral hemorrhage has rapidly increased over time, and vascular dysfunction has a significant influence on the pathogenesis and outcome of these patients. This is also the case for vasospasm in cerebral hemorrhage, but there is no method to assess this. We conducted this study to find molecular biomarkers of vasospasm in cerebral hemorrhage patients. Raw data of GSE37924 was downloaded from the Gene Expression Omnibus (GEO) database, including 66 samples with cerebral vasospasm and 62 samples without cerebral vasospasm. Differentially expressed genes (DEGs) between samples with cerebral vasospasm and those without cerebral vasospasm were analyzed using the limma package in R software. To determine the functions of DEGs, we conducted functional enrichment analysis of DEGs through the clusterProfiler package in R. The protein-protein interaction (PPI) network of DEGs was constructed through STRING (https://string-db.org/) and generated via Cytoscape software. To understand the correlation between DEGs and immune-related genes, immune-related cerebral vasospasm genes were obtained via intersecting immune-related genes and cerebral vasospasm DEGs. We also compared the infiltration of 28 immune cells between cases with cerebral vasospasm and those without cerebral vasospasm. Finally, we constructed a model to perform the validation experiments. Of the DEGs, there were 24 upregulated and 21 downregulated genes in the vasospasm samples compared to the no-vasospasm samples. Functional enrichment analysis showed that these genes play key roles in several biological processes and signaling pathways such as the bone morphogenetic protein (BMP) signaling pathway, cellular response to BMP stimulus, natural killer cell chemotaxis, negative regulation of transmembrane receptor protein serine/threonine kinase signaling pathway, MHC protein complex binding, and receptor ligand activity, among others. CCL4, HLA-DQA1, IGF2, NTS, and so on were the significant immune-related genes. Furthermore, the immune cell infiltration results showed that there were differences between patients with vasospasm and those without vasospasm. Finally, we found that CCL4 had significantly higher expression in patients with vasospasm than those without vasospasm. CCL4 is an important regulator of vascular dysfunction in cerebral hemorrhage.

Systematic review and meta-analysis of the effect of continuous cerebrospinal fluid drainage on keyhole surgery during the perioperative period.

Lumbar continuous drainage of fluid (LCDF) has become more widely used in the diagnosis and treatment of neurological diseases in recent years. The use of LCDF can enable a better understanding of the patient's condition and reduce the incidence of related complications. LCDF can also affect complications of perforation surgery, including mortality during hospitalization, cerebral vasospasm (CVS), bleeding, and aneurysmal subarachnoid hemorrhage (aSAH). Articles published from library construction to April 2021 were searched for in the English-language databases PubMed, Cochrane Library, and Embase. All randomized controlled trials (RCTs) with LCDF and hole locking surgery were meta-analyzed using the Cochrane Collaboration's RevMan 5.3 software. Ten RCTs involving 1,092 patients (continuous drainage group, n=585; control group, n=507) were included in the meta-analysis. For the statistical different in incidence of perioperative cerebral infarction in the two groups, the odds ratio (OR) was 5.42 [95% confidence interval (CI): (2.71, 10.83); P<0.00001], and for the statistical difference in the incidence of cerebral hemorrhage, the OR was 4.76 [95% CI: (2.11, 10.76); P=0.0002]. Perioperative complications were fewer in the LCDF-treated drainage group than in the conventional group. This meta-analysis of 10 RCTs confirmed that LCDF compared with other treatments is associated with a lower incidence of perioperative complications, such as cerebral hemorrhage, hydrocephalus, and cerebral infarction, as well as increased Glasgow Outcome Scale (GOS).

Efficacy and safety comparison between pro-urokinase and reteplase in the treatment of patients with acute ST elevation myocardial infarction

Objective: To compare the efficacy and safety of pro-urokinase and reteplase in the treatment of patients with acute ST elevation myocardial infarction (STEMI). Methods: STEMI patients, who received intravenous thrombolytic therapy in Henan STEMI registry between September 2016 and August 2018, were eligible for this study. A total of 5479 patients from 66 hospitals were screened and patients were divided into pro-urokinase group (n=638) and reteplase group (n=702) according to thrombolytic drugs. Data including patient demographics, risk factors, medical histories, patient information at admission, in-hospital treatment, time delays, and clinical events were collected. The clinical recanalization rate, in-hospital mortality, in-hospital death or treatment withdrawal, in-hospital main adverse cardiovascular and cerebrovascular events (MACCE, death or treatment withdrawal, congestive heart failure, reinfarction and ischemic stroke) and post-thrombolysis bleeding were compared between the two groups. Bleeding events were evaluated with Bleeding Academic Research Consortium (BARC) criteria. Results: The median age [61.8 (53.2, 69.0) vs. 62.6 (52.1, 69.8), P=0.833] or the proportion of women [23.0% (147/638) vs. 25.1% (176/702), P=0.385] were similar between the pro-urokinase and reteplase groups. Clinical recanalization rates were similar between the pro-urokinase and reteplase groups [82.1% (524/638) vs. 84.9% (596/702), P=0.172], and there was no difference in the median time from onset to thrombolysis [194.5 (135.0,290.0) min vs. 190 (126.0,292.0) min, P=0.431] and the median recanalization time [95 (67.5,120.0) min vs. 95 (71.0,119.0) min, P=0.561] between the two groups. There was no significant difference in in-hospital mortality [5.5% (35/638) vs. 5.1% (36/702), P =0.770], in-hospital all-cause mortality, treatment withdrawal [8.9% (57/638) vs.7.7% (54/702), P=0.410], and in-hospital MACCE [13.0% (83/638) vs. 10.4% (73/702), P=0.137] between pro-urokinase and reteplase groups. However, the incidence of post-thrombolysis bleeding was significantly higher in reteplase group than in pro-urokinase group [7.8% (55/702) vs. 3.8% (24/638), P=0.002]. Further analysis found that the incidence of oral bleeding and the BARC grades 1-2 bleeding were significantly higher in reteplase group than in pro-urokinase group, whereas the incidence of cerebral hemorrhage was similar between the two groups [0.6% (4/638) vs. 0.4% (3/702), P=0.715]. The comparison of efficacy and safety outcomes between the two groups after adjusting for baseline characteristics using general linear mixed models was consistent with those before the adjustment. There was no significant difference in in-hospital mortality, in-hospital death or treatment withdrawal, in-hospital MACCE after adjusting for baseline characteristics and post-thrombolysis bleeding between the two groups. Conclusions: Pro-urokinase and reteplase have similar clinical efficacy in the treatment of STEMI. In terms of safety, the incidence of cerebral hemorrhage is similar, while the incidence of BARC grades 1-2 bleeding and oral bleeding is higher in reteplase group than in pro-urokinase group, which has no impact on in-hospital outcomes.

Mechanical thrombectomy reduces the gap in treatment outcomes of ischemic stroke between hospital levels of care: analysis of a Korean nationwide data

BackgroundMechanical thrombectomy (MT) of ischemic stroke was demonstrated to be effective in clinical trials and was reported to have favorable outcomes in real clinical settings since 2015. We aimed to determine the national trends of MT and compare the outcomes between the different levels of treating hospital.MethodsWe obtained data from the nationwide database from 2008 to 2017. Patients with ischemic stroke who received MT were identified using the International Classification of Disease Codes. Good outcome was defined as discharge to home, and a poor outcome was defined as cerebral hemorrhage, physical disability, or death. The study period was divided into three (off-label MT, transitional, MT period). Hospital groups where MT was performed were divided into tertiary and non-tertiary hospitals.ResultsIn MT period, 47.0% of the MT procedures were performed in non-tertiary hospitals compared with 36.1% in off-label MT period. Comparison of the 3-month mortality between patients who were treated in tertiary vs. non-tertiary hospitals revealed significant lower mortality in tertiary hospital through all period. The incidence of cerebral hemorrhage and physical disability did not differ between hospital groups. However, the percentage of patients discharged home was 41.4% for tertiary hospitals and 42.4% for non-tertiary hospitals, which was not statistically different in MT period (P=0.4671).ConclusionsAnalysis of the nationwide data confirmed that the extent of increase in MT was higher in non-tertiary hospitals than tertiary hospitals. In addition, no significant difference was revealed in the number of favorable clinical outcome between the hospital groups during MT period.

A novel COL4A1 variant associated with recurrent epistaxis and glioblastoma

COL4A1-related disorders are characterized by a higher incidence of cerebral hemorrhage than other hereditary cerebral small vessel diseases. Accumulating data have shown broad phenotypic variations, and extracerebral hemorrhages have been linked to these disorders. Moreover, the coexistence of neural tumors has been described. Here, we report a Japanese family with a novel COL4A1 variant, including a patient with recurrent epistaxis and glioblastoma.

Predictive value of DWI-FLAIR Mismatch in patients with Ischemic Stroke and receiving Endovascular treatment beyond Time Window.

Objective:To investigate the efficacy and safety of endovascular treatment in patients having acute ischemic stroke with over-time window under DWI-FLAIR mismatch.Methods:From January 2018 to January 2020, 80 patients who met the research criteria in the First Central Hospital of Baoding, China were selected. According to the time of onset, they were divided into test group and control group, with 40 cases in each group. Forty patients in the test group were beyond time window (6~24h) and the MRI showed a DWI-FLAIR mismatch. Forty patients in the control group were within the time window (< 6h). All patients received endovascular treatment (EVT). The mRS, NIHSS and infarct volume of patients in the test group were compared and analyzed before and 30 and 90 days after treatment, as well as the indicators of both groups of patients before and after treatment, to determine therapeutic effect in patients receiving EVT beyond time window. Meanwhile, the recanalization of the blood vessel and the incidence of cerebral hemorrhage of patients in both groups were compared to determine the safety in patients receiving EVT beyond time window under DWI-FLAIR mismatch.Results:The mRS, NIHSS and infarct size in the test group were significantly improved before and 30 and 90 days after treatment (p<0.05). The test group showed no significant difference in mRS, NIHSS and other indicators when compared with the control group (p>0.05). There was no significant difference in the rate of recanalization of the blood vessel and intracranial hemorrhage after treatment between both groups (p>0.05).Conclusion:DWI-FLAIR mismatch can be used as an objective imaging basis for intravascular interventional therapy in patients with stroke with over-time window and large vessel occlusion. It has the advantages of short examination time, non-invasiveness, no need for contrast agents, simple implementation, clear guidance.

Management of acute ischemic stroke in the practice of anesthesiologist

Background. Stroke is a major cause of severe disability. Working capacity is restored only in 10-20 % of stroke survivors. Stroke mortality in Ukraine is twice as high as in Western Europe. About 87 % of all strokes are ischemic strokes (II). Leading risk factors for stroke include hypertension, hypercholesterolemia, smoking, obesity, and diabetes.&#x0D; Objective. To describe the management of acute IS (AIS) in the practice of an anesthesiologist.&#x0D; Materials and methods. Analysis of literature data on this issue.&#x0D; Results and discussion. The ideal therapeutic approach for AIS should include reperfusion, inhibition of inflammatory processes, cytoprotection, prevention of complications and their treatment. Extreme caution should be exercised during thrombolytic therapy, as thrombolysis increases the risk of intracerebral hemorrhage. However, a meta-analysis by Y. Shoujiang et al. (2018) found that symptomatic intracerebral hemorrhage occurs in 1.9 % of patients who had received intravenous recombinant tissue plasminogen activator. These hemorrhages did not increase mortality. Excellent treatment results were observed in 74.8 % of patients with AIS. According to the analysis of the VISTA database, the end result of thrombolytic therapy can be predicted based on the initial severity of stroke on the NIHHS scale. Interestingly, hemorrhagic transformation after thrombolysis is associated with lower serum calcium. Lower blood calcium levels are associated with an increased incidence of cerebral hemorrhage in patients with AIS due to atrial fibrillation or rheumatic heart disease. In the treatment of patients with AIS it is advisable to use Neurocytin (“Yuria-Pharm”), which contains citicoline and a balanced isotonic electrolyte solution. Neurocytin helps to avoid hypocalcemia and, consequently, brain hemorrhages. Citicoline is a multimodal agent with neuroprotective and neuroregenerative properties. Citicoline has a wide therapeutic window, as this substance is effective at different time and biochemical stages of the ischemic cascade. The maximum effect of citicoline is observed in cases when it is administered as early as possible after AIS in patients who cannot undergo reperfusion therapy. Citicoline is able to reduce the size of the ischemic focus in the brain. Intensive blood pressure (BP) control also reduces the risk of intracranial hemorrhages without increasing mortality, although previous studies have suggested that a rapid decrease in BP may exacerbate cerebral ischemia. Endovascular treatment of AIS in the most acute phase involves selective thrombolysis, or mechanical thrombextraction, or thromboaspiration. The therapeutic window for the last two procedures for vessels of the carotid pool is 6 hours. When deciding to perform thromboaspiration, it is mandatory to perform and evaluate computed tomography-perfusiography of the brain. About 80-85 % of patients with AIS do not meet the selection criteria for revascularization therapy. There is also no effective therapy for such patients in the acute period. In recent years, it has been proposed to replace the term “neuroprotection” with the term “brain cell cytoprotection”, as the former does not reflect the direction of the impact on all components of the neurovascular unit and white matter. A separate aspect of brain cytoprotection is protection against ischemic reperfusion injury. For this purpose, edaravon (Ksavron, “Yuria-Pharm”) is used, which eliminates free radicals, reduces calcium flow into the cells, prevents cell adhesion to the endothelium, enhances the release of nitric oxide and inhibits the inflammatory response, neutralizing all stages and consequences of ischemic stroke. In Japan, edaravon has been included into AIS treatment guidelines since 2009. T. Yamaguchi et al. (2017) found that co-administration of edaravon and recombinant tissue plasminogen activator within 4.5 hours after AIS led to less intracranial hemorrhages and better treatment outcomes. Early use of edaravon also reduces mortality. S. Kono et al. (2013) also state that edaravon may be a good adjunct to alteplase to enhance recanalization and reduce the likelihood of hemorrhagic transformation. With the administration of edaravon within the first 24 hours after stroke, one in three patients has no post-stroke sequelae, and 70 % of patients have a significant improvement in general neurological status. If edaravon is prescribed within the first 72 hours after AIS, the general condition improves significantly in half of the patients. Edaravon (Ksavron) increases the frequency of early recanalization during thrombolysis.&#x0D; Conclusions. 1. Citicoline is a multimodal agent with neuroprotective and neuroregenerative properties. 2. Edaravon (Ksavron) is an ischemic cascade blocker for the empirical treatment of AIS or transient ischemic attacks. 3. The combination of edaravon (Ksavron) and citicoline (Neurocytin) as part of comprehensive therapy allows to each the advanced protection of the neurovascular unit in AIS.

Isolated diastolic hypertension as defined by the 2017 American College of Cardiology/American Heart Association blood pressure guideline and incident cardiovascular events in Chinese.

The new arterial hypertension guidelines by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) changed the definition of isolated diastolic hypertension (IDH). We assessed and compared in a Chinese population the IDH prevalence, newly defined by the 2017 ACC/AHA guidelines versus the former definition by the Joint National Committee 7 (JNC7) criteria, and examined longitudinal associations of IDH with cardiovascular disease (CVD) outcomes. The prospective community-based Kailuan Study included participants aged 18-98 years who underwent a detailed medical examination at baseline in 2006/2007 and who were biennially re-examined till 2017. History of antihypertensive medication at baseline was an exclusion criterion. The study population consisted of 87 346 individuals (mean age: 50.9 years; range: 18-98 years). Prevalence of IDH was 7.79% [95% confidence interval (CI): 7.62, 7.97] by JNC7 guidelines and 24.72% (95% CI: 24.43, 25.01) by 2017 ACC/AHA criteria [difference: 19.93% (95% CI: 16.81, 17.04)]. Applying the 2017 ACC/AHA guidelines, the prevalence of IDH-recommended antihypertensive therapy was 7.73% (95% CI: 7.55, 7.90). In multivariable analysis, IDH by JNC7 criteria was significantly associated with incident myocardial infarction [n = 93 events; hazard ratio: 1.30 (95 CI: 1.02, 1.66)], cerebral hemorrhage [n = 73 events; hazard ratio: 1.79 (95% CI: 1.35, 2.38)], and total CVD [n = 373 events; hazard ratio: 1.15 (95% CI: 1.02, 1.30)], when compared with normotension. IDH based on 2017 ACC/AHA guidelines was associated with incident cerebral hemorrhage [n = 129 events; hazard ratio: 1.47 (95% CI: 1.12, 1.94)] and total CVD [n = 828 events; hazard ratio: 1.13 (95% CI: 1.02, 1.26)]. In this adult Chinese community, 2017 ACC/AHA-defined IDH was associated with the incidence of cerebral hemorrhage and total CVD, and as compared with JNC7-defined IDH, it was more prevalent.

Analysis of factors influencing the complications of Solitaire AB stent mechanical thrombectomy in patients with acute intracranial artery occlusion

[Abstract] Objective: To investigate the influence factors of hemorrhage and stroke with retriever with Solitaire AB stent in patients with acute intracranial artery occlusion. Methods: A retrospective of 43 cases of patients with acute intracranial artery occlusion for endovascular treatment with Solitaire AB stent enrolled from March 2016 to June 2018 in our hospital, combining the characteristics of the patients of our city, through the clinical baseline data statistical analysis, complications screening of risk factors of complications. Results: There were 81.4% of patients who were dredged totally. The incidences of cerebral hemorrhage and infarction were 18.6% and 16.3%, cerebral hemorrhage group compared with control group, diabetes, blood pressure, revascularized time, NIHSS score, ASPECTS score had statistically significant differences, when infarction group compared with control group, age, opening time, ASITN_SIR score and grade of mTICI had statistically significant differences. Conclusion: Mechanical thrombectomy with Solitaire AB stent in patients with acute intracranial artery occlusion, the occurred of complications associated with various clinical factors, and the occurrence of complications seriously affect the prognosis of patients, therefore, selecting the indications strictly, and adopt individualized treatment to reduce complications.

Abstract TP129: The Combination of Tissue Plasminogen Activatorand Vepoloxamer Results in Sustained Neuroprotection in Aged Rats After Embolic Stroke

Stroke is a leading cause of death and disability worldwide, mainly affecting the elderly. To date, tissue plasminogen activator (tPA), the only FDA approved treatment agent, is of limited use in stroke patients mainly due to its narrow therapeutic window and hemorrhage complication. Vepoloxamer is a highly purified proprietary amphipathic copolymer, which has potent anti-thrombotic and rheological properties for treating various thrombotic disorders. In an effort to increase the efficacy and safety of tPA thrombolytic therapy, the present study evaluated the neuroprotective effect of combination treatment with Vepoloxamer and a low dose of tPA in aged rats after embolic middle cerebral artery occlusion (MCAO). Male aged rats (18 month) subjected to MCAO were randomly divided into the following groups (n=10/group): tPA alone (5mg/kg, IV) at 2h; tPA (5mg/kg, IV) at 2h in combination withVepoloxamer (300mg/kg at 2h, IV; followed by a 12h IV infusion of 100 mg/kg/hr starting at 10h); or saline at 2h as control. An array of behavioral tests were performed weekly for 4 weeks. Infarct volume was measured 4 weeks after MCAO. The combination treatment with tPA and Vepoloxamer significantly (p&lt;0.05) reduced infarct volume (20±3%) compared with rats treated with saline (31±2%) or tPA alone (32±2%). In addition, the rats treated with tPA in combination with Vepoloxamer exhibited sustained improvements in neurological function up to 4 weeks starting at 1d after MCAO, when compared with rats treated with saline or tPA monotherapy. However, tPA monotherapy failed to reduce neurological functional deficits compared with the saline control. The combination of tPA and Vepoloxamer did not increase the mortality rate nor the incidence of cerebral hemorrhage compared with saline or tPA monotherapy. In conclusion, our data demonstrated that the adjuvant treatment with Vepoloxamer and tPA amplifies the therapeutic efficacy of low-dose tPA in aged rats after embolic stroke without increasing the incidence of hemorrhagic transformation.

Analysis on the gender-specific risk factors of new-onset cerebral hemorrhage

Objective: To explore the gender-specific risk factors of new-onset cerebral hemorrhage. Methods: In this prospective cohort study,a total of 98 961 participants((51.1±12.6)years old), who underwent the 2006 to 2007 physical examination and met the inclusion criteria, were enrolled from the Kailuanstudy cohort. There were 78 908 (79.7%) male,and 20 053 (20.3%) female.The incidence of cerebral hemorrhage was observed once per year until December 31, 2016.The difference on the incidence of cerebral hemorrhage between male and female was compared. Multivariate Cox regression analysis was applied to analyze therisk factors of cerebral hemorrhage events among different genders. Results: The participants were followed up for(10.00±0.73) years,and 860 cerebral hemorrhage events were recorded during follow up. The incidence of cerebral hemorrhage in the population was 86.90/10 million person years (standardized incidence rate of 47.85/10 million person years). The incidence of cerebral hemorrhage was significantly higher in male (49.61/10 million person years) than in female (34.07/10 million person years, P<0.05). Multivariate Cox regression analysis showed that 45-59 years old, ≥ 60 years old, diabetes,and waist-hip ratio were more strongly related to new-onset of cerebral hemorrhage events in female than in male, and the hazard ratios(95%CI) were 2.33 (1.23-4.43) ,2.71 (1.30-5.66) ,2.16 (1.24-3.74) and 8.79 (1.42-54.32) in female versus 1.55 (1.21-1.97) ,2.16 (1.68-2.78) ,1.19 (0.93-1.53) and 3.21 (1.09-9.41) in male, respectively. The risk of male cerebral hemorrhage increased by 29% (HR=1.29, 95%CI 1.19-1.40) in male and 24% (HR=1.24, 95%CI 1.20-1.28) in female,when the systolic blood pressure increased 10 mmHg (1 mmHg=0.133 kPa). Conclusions: The incidence of cerebral hemorrhage is higher in male than in female in this cohort.The association between systolic blood pressure and cerebral hemorrhage is stronger in male than that in female.The associations between age, waist-hip ratio, diabetes and cerebral hemorrhage are stronger in female than in male. Trial Registration: Chinese Clinical Trail Registry, ChiCTR-TNC-11001489.

Prevention of cardiovascular events in Asian patients with ischaemic stroke at high risk of cerebral haemorrhage (PICASSO): a multicentre, randomised controlled trial

The optimal treatment for patients with ischaemic stroke with a high risk of cerebral haemorrhage is unclear. We assessed the efficacy and safety of cilostazol versus aspirin, with and without probucol, in these patients. In this randomised, controlled, 2 × 2 factorial trial, we enrolled patients with ischaemic stroke with a history of or imaging findings of intracerebral haemorrhage or two or more microbleeds from 67 centres in three Asian countries. Patients were randomly assigned (1:1:1:1) to receive oral cilostazol (100 mg twice a day), aspirin (100 mg once a day), cilostazol plus probucol (250 mg twice a day), or aspirin plus probucol with centralised blocks stratified by centre. Cilostazol versus aspirin was investigated double-blinded; probucol treatment was open-label, but the outcome assessor was masked to assignment. The co-primary outcomes were incidence of the composite of stroke, myocardial infarction, or vascular death (efficacy) and incidence of haemorrhagic stroke (safety), which were assessed in intention-to-treat and modified intention-to-treat populations. Efficacy was analysed with a non-inferiority test and a superiority test if non-inferiority was satisfied. Safety was assessed with a superiority test only. This trial is registered with ClinicalTrials.gov, NCT01013532. Between Aug 1, 2009, and Aug 31, 2015, we randomly assigned 1534 patients to one of the four study groups, of whom 1512 were assessed for the co-primary endpoints. During a median follow-up of 1·9 years (IQR 1·0-3·0), the incidence of composite vascular events was 4·27 per 100 person-years in patients who received cilostazol and 5·33 per 100 person-years in patients who received aspirin (HR 0·80, 95% CI 0·57-1·11; non-inferiority p=0·0077; superiority p=0·18). Incidence of cerebral haemorrhage was 0·61 per 100 person-years in patients who received cilostazol and 1·20 per 100 person-years in those who received aspirin (HR 0·51, 97·5% CI 0·20-1·27; superiority p=0·18). The incidence of vascular events was 3·91 per 100 person-years in the probucol group compared with 5·75 per 100 person-years in the non-probucol group (HR 0·69, 95% CI 0·50-0·97; superiority p=0·0316). The incidence of cerebral haemorrhage was 0·72 per 100 person-years in the probucol group and 1·11 per 100 person-years in the non-probucol group (HR 0·65, 97·5% CI 0·27-1·57; p=0·55). Adverse events were similar across the four study groups; the most common events were dizziness, headache, diarrhoea, and constipation. In patients with ischaemic stroke at high risk of cerebral haemorrhage, cilostazol was non-inferior to aspirin for the prevention of cardiovascular events, but did not reduce the risk of haemorrhagic stroke. Addition of probucol to aspirin or cilostazol could be beneficial for reducing the incidence of cardiovascular events. Korea Otsuka Pharmaceutical.

ACTR-38. SAFETY AND EFFECTIVENESS OF BEVACIZUMAB IN JAPANESE PATIENTS WITH MALIGNANT GLIOMA: POST-MARKETING SURVEILLANCE RESULTS

OBJECTIVES In Japan, when bevacizumab was approved for malignant glioma patients in 2013, there were limited data on Japanese patients. In the global P3 AVAglio study, the incidence of cerebral hemorrhage, including tumor-related bleeding, and infections was higher in patients who received bevacizumab. This surveillance study was conducted to assess the safety and effectiveness of bevacizumab in patients with newly diagnosed or recurrent malignant glioma.

血液透析により高血圧と頭痛が増悪し痙攣に至ったposterior reversible encephalopathy syndromeの1例(Posterior reversible encephalopathy syndrome in a hemodialysis patient with seizure secondary to aggravated hypertension and headache during hemodialysis)

症例は35歳男性。19歳で左腎移植を受けたが，徐々に移植腎の機能が低下し，入院6週間前に血液透析を導入された。その後，透析中に血圧が上昇し頭痛を繰り返し訴えていた。入院前日も透析中に血圧が上昇し頭痛を訴え，翌日痙攣を発症し当院へ搬送された。来院後に降圧薬，抗痙攣薬を投与して気管挿管し，人工呼吸管理とした。来院時の頭部CTには異常を認めなかったが，第3病日のMRIでは脳の血管原性浮腫を認め，posterior reversible encephalopathy syndrome（PRES）と診断した。本症例は体液過剰による高血圧と血管内皮細胞の脆弱性から血液透析中にPRESを発症したものと思われた。保存的加療にて軽快し，第17病日に退院した。PRESは脳の血管原性浮腫により頭痛，意識障害，視覚障害，痙攣などの症状を呈する症候群である。一般に予後は良好であるが，脳出血を合併し不良となる場合もある。また血液透析患者は脳出血を発症すると重篤化しやすい。血液透析患者が透析中に高血圧，頭痛を呈している場合はPRESの発症に留意し血圧を管理するべきである。 A 35–year–old man with a history of renal transplant 16 years ago was admitted to our hospital with seizure and hypertension one day after hemodialysis. Hemodialysis had been induced 6 weeks previously, and he had experienced headache and exacerbation of hypertension at every dialysis session since then. We administered anticonvulsants and a vasodepressor and initiated artificial respiration. Computed tomography (CT) of the brain at admission did not show any abnormalities. However, magnetic resonance imaging (MRI) on hospital day 3 showed vasogenic cerebral edema, and the patient was diagnosed with posterior reversible encephalopathy syndrome (PRES). We surmised that the main cause of PRES in this case was aggravated hypertension secondary to excessive fluid retention during hemodialysis. The patient responded well to medical therapy and supportive care and had a full recovery without sequelae. He was discharged 17 days after admission. PRES generally has a good prognosis. However, the prognosis may be poor in patients complicated with cerebral hemorrhage. The incidence of cerebral hemorrhage among hemodialysis patients is quite high, and they tend to have poorer prognosis. Clinicians should be aware that exacerbation of hypertension and headache during hemodialysis are indicative of PRES and appropriate management of blood pressure is essential. PRESは急性期に頭痛，意識障害，視覚障害や痙攣などの神経症状を伴い，画像所見で脳の血管原性浮腫を呈する症候群である 1。急激な血圧上昇や薬剤などが原因で起こる血管内皮細胞障害がその病態と考えられている 1, 2。大部分の患者の予後は良好だが、不可逆的な脳出血を合併する場合もある 1, 2。とくに血液透析（hemodialysis: HD）患者では脳出血を合併した場合の予後は不良であり，PRESの発症に留意すべきである。 今回HDにより高血圧と頭痛が増悪し痙攣を呈したPRESの1例を経験したので報告する。 患 者：35歳の男性 主 訴：痙攣 現病歴：入院6週間前にHDを導入した。血圧はHD導入前より170～200/90～120mmHgと高く，透析の前後で収縮期，拡張期とも5～10mmHg程度上昇していた。普段よりHD中に頭痛を訴え，入院の前日もHD中に頭痛を訴えていた。当日患者の居室で物音がし，家族が様子を見に行くと患者が意識朦朧としていたため救急車を要請した。救急隊による観察中に，全身性痙攣を来し，当院へ搬送された。 既往歴：膀胱尿管逆流症により腎不全となり，19歳で左腎移植を受けた。しかし，慢性活動性抗体関連型拒絶反応により移植腎も機能低下し，35歳でHD導入となった。 常用薬は以下のような免疫抑制薬と降圧薬を中心とした薬剤を服用していた。 タクロリムス3mg分2 プレドニゾロン5mg分1 オルメサルタン10mg分1 アムロジピン5mg分1 アルファカルシドール0.5μg分1 沈降炭酸カルシウム1.5g分3 セベラマー塩酸塩3g分3 現 症：血圧197/117mmHg，心拍数140/分，呼吸数27/分，鼓膜温36.8℃，意識レベルはGlasgow coma scale E4V4M6で顔面・四肢に麻痺を認めなかった。顔面，胸部，両上肢に小さな打撲痕が散在していた。 血液検査：WBC 15,900/μL，HB 12.5g/dL，Plt 12.7×104/μL，AST 19IU/L，ALT 12IU/L，Glu 130mg/dL，BUN 51mg/dL，Crea 11.6mg/dL，Na 144mEq/L，K 4.7mEq/L，CK 123IU/L，CRP 2.1mg/dL，PT–INR 0.96，APTT 27.8sec 動脈血液ガス：リザーバーマスクで酸素6L/分で投与しpH 7.195，PCO2 26.9mmHg，PO2 138mmHg，HCO3– 25.3mmol/L，BE –16.6mmol/L，Lac 12.4mmol/L 画像所見：頭部CTでは異常所見を認めなかった（Fig. 1a, b）。胸部X線ではCTRが63%と拡大し，胸部CTでは心嚢液が著明に貯留していた。 a, b: Head CT scan on admission. The CT is normal; there are no signs of edema and no low–density areas. c, d: Head CT on hospital day 3. There are no abnormalities on CT except for the small subdural hematoma (SDH) (arrowhead). 経 過：ICUへ入室後まもなく，再び痙攣を呈した。このためジアゼパム10mg，プロポフォール50mg投与にて鎮静した後，気管挿管を実施し，人工呼吸管理を開始した。また，ニカルジピン持続投与による降圧を実施した。フェニトインも投与し，以降痙攣の再発は認められなかった。血液検査，心電図，頭部CT，髄液検査からは痙攣の原因は不明であった。 第2病日より入院前に週3回行っていたHDを再開した。当院に搬送される前は，膜面積1.2mm2のポリスルホンダイアライザーを用い血流量150mL/hで4時間かけて行われていた。dry weight は63.0kgに設定され，1回除水量は1.0Lから2.0L程度であった。入院中の透析は膜面積1.1mm2のポリスルホンダイアライザーを用い，血流量150mL/hで4時間かけて行った。入院中，体液過剰と判断し，dry weightは60.5kgに下げて設定し，1回除水量は1.4Lから2.0L程度とした。第2病日の透析後は意識清明となり，同日抜管した。 降圧治療は，収縮期血圧160mmHg台を目標に，オルメサルタン10mg/日，アムロジピン10mg/日，カルベジロール10mg/日の経口投与を実施した。 腎移植後から維持投与されているタクロリムスおよびプレドニン，腎性貧血に対するエリスロポエチン製剤（遺伝子組換えダルベポエチンアルファ）については，臨床経過からも高血圧の被疑薬ではないと判断された。 第3病日に脳波検査を行ったが，痙攣の原因となる異常所見は認めなかった。同日のMRIでは，T2強調画像およびfluid attenuated inversion recovery（FLAIR）像で，両側の後頭葉と前頭葉に高信号領域が認められた（Fig. 2a, b）。一方同部位は拡散強調画像（diffusion weighted image: DWI）で高信号を示さなかった（Fig. 2c, d）。よって，同部位の所見は血管原性浮腫と診断した。MRIでは，さらにFLAIR像で右側の大脳半球に沿って少量の硬膜下血腫を疑う高信号域を認めた。同日実施した頭部CT検査でも，急性硬膜下血腫が確認された（Fig. 1c, d）。これは痙攣の際に転倒し受傷したものと考えた。その後嘔吐，頭痛，意識障害など頭蓋内圧の亢進を示唆する症状は現れず，経時的なCT検査でも血腫の増大や脳実質の異常所見は認めなかった。 a–d: Brain MRI on hospital day 3. a: FLAIR imaging shows high–intensity cortical and subcortical signals in both occipital lobes (arrows). There is a small SDH on the right (arrowhead). b: FLAIR imaging shows high–intensity subcortical signals in both frontal lobes (arrows). The small SDH is visible on the right (arrow head). c: There are no high–intensity signals in the brain parenchyma on DWI. d: Low–intensity cerebral parenchyma on DWI. The SDH is visible on the right (arrowhead). e–h: Brain MRI on hospital day 16. e: There are no visible high–intensity cortical or subcortical signals in the occipital lobes on FLAIR imaging. The small SDH remains visible on the right (arrowhead). f: FLAIR imaging shows notable reduction of the high–intensity subcortical signals in the frontal lobes. The small SDH remains visible on the right (arrowhead). g–h: There are no high intensity signals on DWI. 第16病日の脳MRIでは血管原性浮腫は改善しており，可逆性変化であったことが明らかであった（Fig. 2e–h）。このMRI所見の推移からPRESと診断した。 本症例は後遺症を残すことなく軽快し，第17病日に退院となった。 HD患者は一般的に高血圧，自己免疫疾患等の合併，またステロイド，免疫抑制薬等の使用などPRESの誘因を複数有している場合が想定される。しかしHD患者におけるPRESの疫学についての報告は少なく，現時点では詳細は明らかではない。Canneyら 2は592人の末期腎不全患者を10年間追跡して調べたところ，PRESを発症した患者は5人（発症率0.84%）で，いずれもHD患者であったと報告している。 HD患者の意識障害，痙攣の原因としてはPRESの他に脳血管障害，脳腫瘍，尿毒症性脳症，電解質異常，低血糖，薬物中毒，脳髄膜炎，血管炎，脱髄疾患などが挙げられる 3, 4。本症例は高血圧，頭痛および痙攣を呈したものの，降圧薬および抗痙攣薬投与して軽快した臨床経過と，脳MRIの所見の推移からPRESと診断した。 我々の渉猟し得た範囲では，慢性腎不全に対しHDを開始した患者でPRESを発症したとする報告は本症例を含め27例であった。内訳はTable 1に示す。うち7例は再発例で初回のepisodeについて記した。年齢は6～60歳，性別は男性13人，女性14人，慢性腎不全の基礎疾患は様々であった。症状は痙攣と頭痛がともに17例と最多で，霧視，視野欠損，複視などの視覚障害11例，せん妄9例，嘔気8例などであった。画像所見はMRIにおいて15例が脳実質の椎骨脳底動脈領域に異常所見が限局していたが，他の12例では椎骨脳底動脈領域以外にも異常信号を認めた。CTで異常所見があったものは6例，なかったものは6例で，他の15例はCT所見が記載されていなかった。予後は2例を除いて良好だった。PRESの誘因として高血圧を挙げたものが22例と最多で，うち体液過剰であったと記載されたものが12例だった 2, 5, 6, 7, 8, 9, 10。他の誘因として不均衡症候群が3例，免疫抑制薬が2例で，血液透析，ダイアライザー，HIV感染症，ミトコンドリア病を挙げたものがそれぞれ1例だった。 高血圧はHDの主要な合併症であるが，その機序として不適切なdry weightの設定による体液過剰に加え，レニン-アンジオテンシン-アルドステロン（RAA）系が亢進する場合やエリスロポエチンの関与などが挙げられる 11。またHD中は除水により血圧が低下することが一般的であるが，本症例では収縮期，拡張期とも上昇傾向にあった。HD中に血圧が上昇する機序は明確にはなっていないが，体液過剰，RAA系の亢進，交感神経系の亢進，血液透析による降圧薬の血中濃度低下，血管内皮細胞の機能不全などの関与が報告されている 12, 13。Agarwalらは，HD中の血圧の上昇は適切なdry weightを設定することで改善されることから，体液過剰を示しているとしている 14。本症例も来院時心嚢液が貯留していたことや，入院後dry weightを下げて血圧が低下したことから体液過剰が高血圧およびHD中の血圧上昇の主因と思われた。またPRESの病態として血管内皮細胞障害がある。血管内皮細胞が障害されると，血管拡張作用があるnitric oxide（NO）の分泌が低下し，血管収縮作用があるendothelin–1の分泌が上昇することで血圧上昇を来す 12, 13。HD中に血圧上昇を来す患者は血管内皮細胞が脆弱とされる 13。本症例は体液過剰を主因として高血圧となり，血管内皮細胞の脆弱性を背景としてHD中にPRESを発症したことが考えられた。さらにPRESによる頭痛の症状が交感神経系を刺激して高血圧が持続したため，病態が進行し痙攣に至ったものと考えられた。 一般的に，HD患者は脳出血発症率が高く，予後も不良である。前述のCanneyら 2が報告したPRES 5例のうち2例は脳出血を合併して，死亡している。Table 1からは，CTで異常を指摘されていない症例も散見される。すなわちHD患者の脳出血合併例の中にはMRIを行わずPRESの発症が見過ごされている例も少なくないと思われ，PRESの発症に留意する必要がある。HD中に患者の血圧が上昇し，頭痛を訴える場合はPRESを発症している可能性がある。このような場合は，降圧薬や除水により適切に血圧を管理すべきである。 HDにより高血圧と頭痛が増悪し，痙攣に至ったPRESの1例を経験した。本症例は体液過剰を主因として高血圧となり，血管内皮細胞の脆弱性を背景としてHD中にPRESを発症したことが考えられた。HD中に血圧が上昇し，頭痛を訴える場合はPRESも念頭において血圧を管理すべきである。 本論文に開示すべき利益相反関係はありません。

The Relationship between Neutrophil-to-Lymphocyte Ratio and Intracerebral Hemorrhage in Type 2 Diabetes Mellitus

Chronic systematic inflammation has been suggested to be associated with the occurrence and development of cardiovascular events. Low-grade systematic inflammation persists in type 2 diabetes mellitus (T2DM) patients. In addition, the risk of cerebral hemorrhage in these patients is increased compared with non-diabetic patients. Neutrophil-to-lymphocyte ratio (NLR) is the ratio derived by dividing the neutrophil count with the lymphocyte count from a peripheral blood sample. This study aimed to explore the relation between NLR and cerebral hemorrhage, and to prove that NLR is an independent risk factor of cerebral hemorrhage in T2DM patients. In total, 429 cases of T2DM patients were included. The patients were divided into two groups depending on the presence of cerebral hemorrhage: the cerebral hemorrhage group (n = 87) and the control group (n = 342). Based on clinical and laboratory data of diabetes diagnosis, this article investigates the relationship between NLR and the risk of cerebral hemorrhage. Increase in NLR was positively correlated with the incidence of cerebral hemorrhage in T2DM patients and might serve as an independent risk factor of cerebral hemorrhage in T2DM patients (OR: 4.451, 95% CI: 2.582-7.672). NLR >2.58 might be useful in predicting the threshold value of cerebral hemorrhage risk in newly diagnosed T2DM patients (area under the curve: .72, 95% CI: .659-.780, P < .001) CONCLUSION: As an indicator of the degree of systematic inflammation, NLR is an independent risk factor of cerebral hemorrhage in T2DM patients.

Brain Infarct and Abscess—A Very Common Disease and a Rare Association

To explore the effectiveness of superficial temporal artery–to–middle cerebral artery (STA-MCA) anastomosis in treating moyamoya disease (MMD).A total of 30 patients with MMD (hemorrhagic type, n = 13; ischemic type, n = 17) who had undergone STA-MCA anastomosis were enrolled in this study (anastomosis group). Cerebral blood flow was evaluated before and after surgery using cerebral angiography and computed tomography (CT) perfusion imaging. In addition, 27 patients with MMD (hemorrhagic type, n = 11; ischemic type, n = 16) who had received only conservative treatment were enrolled as the control group. Patients in both the anastomosis group and the control group were followed up for 5 years, and the incidences of cerebral hemorrhage and cerebral ischemia were analyzed. Blood samples were collected in both groups before and after treatment. Mononuclear cells were separated by density gradient centrifugation. After labeling with 3 direct fluorescent antibodies (CD133, CD34, and vascular endothelial growth factor receptor 2), the number of endothelial progenitor cells (EPCs) was detected using flow cytometry.Cerebral blood flow was remarkably improved after STA-MCA anastomosis. The incidences of cerebral hemorrhage and cerebral ischemia were significantly lower in the anastomosis group than in the control group. The number of EPCs showed no significant change before and after treatment in the control group; in contrast, it was decreased significantly after surgery in the anastomosis group.STA-MCA anastomosis can reduce the number of EPCs in MMD patients, lower the risk of rebreeding, and improve cerebral ischemic attacks.

SY 08-2 HYPERTENSION MANAGEMENT FOR SECONDARY PREVENTION OF STROKE

Stroke is known to frequently recur in patients with a history of cerebrovascular disease, and the control of hypertension is extremely important for the treatment of those patients. The robust relationship between the recurrent cerebrovascular disease and blood pressure control has been demonstrated in large-scale clinical studies. The antihypertensive drug therapy significantly reduces the recurrence rate of all types of cerebrovascular disease, incidences of myocardial infarction and all vascular events. Evidence suggests that any class of antihypertensive drugs including diuretics, Ca channel blockers, ARBs, and ACE inhibitors are shown to be similarly effective for the secondary prevention of stroke, except in some small study such as MOSES. Thus, most of the benefit obtained from drugs can be ascribed to a decrease in blood pressure. Then, how far should blood pressure be lowered? Target of blood pressure control has been somewhat controversial, since an excessive reduction of blood pressure might exacerbate cerebral ischemia in the area perfused by cerebral artery with a significant stenosis. In fact, some Japanese clinical study has shown that in patients with impaired perfusion demonstrated by PET-CT, the risk of recurrent stroke was high when the systolic blood pressure was There have been very few studies which have primarily investigated the optimum blood pressure level in the secondary prevention of stroke. The sub-analysis of the large clinical trial, PROGRESS, indicated that the incidences of cerebral hemorrhage and cerebral infarction were lower in patients in whom blood pressure was controlled at a lower level (a systolic blood pressure of about 120 mmHg). In the Bleeding with Antithrombotic Therapy (BAT) Study in Japan, 4,009 patients taking antithrombotic drugs for the prevention of recurrent cerebrovascular or heart disease were prospectively enrolled, and hemorrhagic events were investigated over 19 months. The results suggest that the incidence of cerebral hemorrhage is lower when the blood pressure immediately before/after onset is lower, suggesting that blood pressure should be reduced to In the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, a randomized comparative study was conducted in patients with chronic-phase lacunar infarction by dividing them into two groups: a group with a systolic blood pressure of We have been conducting a multicenter, randomized, open-label study (RESPECT study; Clinical Trials.gov Identifier: NCT01198496) since 2010, in which hypertensive patients with a history of strokes are randomly assigned to either a standard therapy group (£140/90 mmHg; if having current DM/CKD/MI, £130/80 mmHg) or a strict therapy group (BP lowering target: £120/80 mmHg). The patients were treated with stepwise multi-drug therapy using an angiotensin-receptor antagonist, diuretic, calcium channel blocker and additional other classes of drug if necessary. The recurrent stroke rates in both groups will be compared from various aspects, and whether strict BP management is useful for the prevention of recurrent strokes will be verified. The first interim analysis of this study has been recently performed. At present, in the JSH2014 Guidelines, the target of blood pressure control for patients with chronic-phase cerebral infarction is established as

Effectiveness of Superficial Temporal Artery-to-Middle Cerebral Artery Anastomosis in Treating Moyamoya Disease by Reducing Endothelial Progenitor Cells

To explore the effectiveness of superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis in treating moyamoya disease (MMD). A total of 30 patients with MMD (hemorrhagic type, n= 13; ischemic type, n= 17) who had undergone STA-MCA anastomosis were enrolled in this study (anastomosis group). Cerebral blood flow was evaluated before and after surgery using cerebral angiography and computed tomography (CT) perfusion imaging. In addition, 27 patients with MMD (hemorrhagic type, n= 11; ischemic type, n= 16) who had received only conservative treatment were enrolled as the control group. Patients in both the anastomosis group and the control group were followed up for 5 years, and the incidences of cerebral hemorrhage and cerebral ischemia were analyzed. Blood samples were collected in both groups before and after treatment. Mononuclear cells were separated by density gradient centrifugation. After labeling with 3 direct fluorescent antibodies (CD133, CD34, and vascular endothelial growth factor receptor 2), the number of endothelial progenitor cells (EPCs) was detected using flow cytometry. Cerebral blood flow was remarkably improved after STA-MCA anastomosis. The incidences of cerebral hemorrhage and cerebral ischemia were significantly lower in the anastomosis group than in the control group. The number of EPCs showed no significant change before and after treatment in the control group; in contrast, it was decreased significantly after surgery in the anastomosis group. STA-MCA anastomosis can reduce the number of EPCs in MMD patients, lower the risk of rebreeding, and improve cerebral ischemic attacks.