Middle Cerebral Artery Stenosis Research Articles

Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Drug-coated balloons (DCBs) have exhibited promising results in coronary and peripheral artery diseases, but conclusive evidence is lacking in intracranial vasculature. We assessed the safety and efficacy of DCBs vs stent angioplasty for symptomatic intracranial atherosclerotic stenosis (sICAS) and initially identified patients who might have benefited most from DCB treatment. A single-center, retrospective cohort study was conducted from June 2021 to May 2022 with 154 patients with sICAS divided into 2 treatment groups: a DCB group (with or without remedial stenting, n = 47) and a stent group (n = 107). The treatment outcomes were compared using 1:2 propensity score matching. The primary safety end point was perioperative stroke or mortality, and the primary efficacy end point was the rate of target vessel restenosis at 12 months. The degree of luminal change was analyzed as a subgroup, defined as the difference between the degree of stenosis at follow-up and immediately after intervention. One hundred eighteen patients were enrolled using propensity score matching, with 43 patients in the DCB group and 75 in the stent group. The incidence of perioperative adverse events was 2.3% in the DCB group and 8.0% in the stent group (P = .420). At a median follow-up of 12 months, the incidence of restenosis (11.9% [5/43] vs 28.0% [21/75], P = .045) and the median degree of stenosis (30% [20%, 44%] vs 30% [30%, 70%], P = .009, CI [0-0.01, 0.2]) were significantly lower in the DCB group than in the stent group. DCB angioplasty effectively prevented adverse events in the target vessel area and significantly reduced the degree of luminal change in the M1 segment of the middle cerebral artery (0 [0, 15%] vs 10% [0, 50%], P = .016). DCB angioplasty might be a safe and effective alternative to stent angioplasty to treat sICAS, particularly among patients with M1 segment of the middle cerebral artery stenosis.

Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study.

Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms. This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition. Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1month post-CABG. Women in this CABG cohort were more likely to have depression at baseline and 1month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Improvement of cerebral blood flow after balloon angioplasty and stenting for symptomatic middle cerebral artery stenosis

Objective Although reports of endovascular treatment for intracranial arterial stenosis have been increasing recently, their efficacy remains to be elucidated. This study aimed to investigate the changes in cerebral hemodynamics of severe middle cerebral artery (MCA) stenosis patients by performing CT perfusion (CTP) after endovascular treatment. Methods Subjects were those who underwent balloon angioplasty and stenting for symptomatic MCA M1 stenosis refractory to medical therapy at our hospital between 2008 and 2022. We included 36 patients (mean age 63.69 ± 15.24 years, 20 males) who underwent CTP before and within three weeks after treatment. The CTP parameters such as relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) were calculated as ipsilateral values divided by contralateral value. Results Endovascular treatment consisted of 26 balloon angioplasty and 10 stenting procedures performed at an average of 1 month from onset. CTP was performed at an average of 5.5 days postoperatively. The mean overall stenosis rate decreased from 79.0% to 30.3%. In the balloon angioplasty group, it decreased from 77.6% to 35.3%, and in the stent group, it decreased from 82.7% to 17.5%. After treatment, rCBF and rMTT measured by CTP improved significantly (both p < 0.001), whereas there was no significant change in rCBV. The improvement rates of rCBF and rMTT were mild higher in the stent group, but not significantly so. Conclusion Balloon angioplasty and stenting for symptomatic MCA improved cerebral hemodynamics, resulting in significantly increased rCBF and decreased rMTT.

Abstract WP142: Investigating the Association of Intracranial Stenosis With Low Wall Shear Stress

Background: Intracranial atherosclerotic disease (ICAD) is associated with high recurrence rates of stroke despite aggressive medical management. Low wall shear stress (WSS) alters endothelial function and changes in WSS within the post-stenotic region of ICAD lesions is a potential driver of stroke recurrence. Methods: Using the SAMMPRIS imaging dataset, we identified medically managed patients with symptomatic middle cerebral artery (MCA) stenosis measured by CTA. WSS was calculated by creating a 3D volumetric mesh from CTA source imaging. Pulsatile flow profile reference standard boundary conditions were applied at pressure outlets to simulate normal hemodynamics. Arterial segments extending from the stenosis to the MCA bifurcation were captured and quantified. Contralateral arterial segments were matched by length and area. The ratio of area with low WSS (<4 dyne/cm 2 ) on both sides was then calculated. Differences in the mean arterial area with low WSS and ratio of area with low WSS were compared using paired Student’s t-test with data presented as mean ± SD. Results: Of 451 cases in SAMMPRIS, the medical management arm had 105 MCA cases of which 47 cases had CTA available and 33 cases were able to be analyzed by computational flow dynamics. Symptomatic ICAD lesions demonstrated significant differences in post stenosis area with low WSS (24.7±43.4 mm 2 vs 2.8±3.4 mm 2 p=0.003) and differences in the low WSS ratio (0.25±0.26 vs0.04±0.05 p<0.001). There was no statistically significant difference in the length and area of the arterial segment post stenosis to the bifurcation and the control length on the contralateral side (11.6±7.4 mm vs 10.6±6.1 mm p=0.566; 80.7±55.0 mm 2 vs 95.4±58.3 mm 2 p=0.298). Conclusion: Area with low WSS after ICAD stenoses is increased in the SAMMPRIS imaging dataset and may be a marker of symptomatic ICAD. Further studies are needed to evaluate the association of post stenotic WSS with symptomatic recurrent stroke.

Diagnostic feasibility of middle cerebral artery stenosis or occlusion evaluated by TCCS and CEUS: Repeatability, reproducibility, and diagnostic agreement with DSA

AimThis study aimed to evaluate the feasibility of transcranial color-coded sonography (TCCS) and contrast-enhanced ultrasound (CEUS) in assessing middle cerebral artery (MCA) stem stenosis or occlusion compared to digital subtraction angiography (DSA). MethodsA total of 48 cases including 96 MCAs suspected stem stenosis or obstruction in the MCA were assessed by TCCS, CE-TCCS, and DSA. The diameters of the most severe stenosis (Ds), proximal normal artery (Dn), and diameter stenosis rate of MCA were measured using both the color doppler flow imaging (CDFI) modality of TCCS or CEUS and the CEUS imaging modality. The intraclass correlation coefficients (ICCs) and 95 % confidence intervals (CI) were evaluated, and a weighted Kappa value was used to evaluate the intra-observer agreement, inter-observer agreement, agreement between CDFI modality and DSA stenosis or occlusion, and agreement between CEUS imaging modality and DSA stenosis or occlusion. ResultsThe ICC results indicated excellent repeatability and reproducibility (all ICCs > 0.75; weighted Kappa values >0.81). Compared with DSA, the weighted Kappa values and 95 % CIs of stenosis (the first measurement was taken by two observers) of CDFI modality and CEUS imaging modality were 0.175 (0.041, 0.308) and 0.779 (0.570, 0.988) for observers A and 0.181 (0.046, 0.316) and 0.779 (0.570, 0.988) for observers B respectively. ConclusionThis study indicates that inter- and intra-observer agreements were good for the direct method of measuring percentages of MCA stenosis by TCCS and CEUS. CEUS imaging modality is a new and reliable imaging modality approach to evaluate the MCAs stenosis and occlusion.

Reduced Likelihood of Infarction in Crescendo Transient Ischemic Attack Caused by Vasculitic Middle Cerebral Artery Stenosis.

A 53-year-old woman was admitted to our hospital because of increasingly frequent transient speech disturbance and left upper limb weakness. Brain magnetic resonance imaging and angiography revealed multiple intracranial stenoses, including the proximal right middle cerebral artery (MCA), without evidence of infarction. The diagnosis of primary angiitis of the central nervous system was established based on circumferential vascular wall thickening with contrast enhancement observed in the right MCA. Following the administration of dual antiplatelet therapy and intravenous methylprednisolone pulse therapy, the patient experienced complete cessation of symptoms, and the stenosis gradually improved without infarction. The risk of infarct development in crescendo transient ischemic attacks may differ between inflammatory vascular stenosis and atherosclerosis.

The Music Within: A Doppler Harmonic Pattern Report in Non-Subarachnoid Hemorrhage Related Cerebral Vasospasm

A 40-year-old male presented an episode of severe thunderclap headache with right hemiparesis. Imaging revealed severe stenosis in the left middle cerebral artery, associated with increased mean velocities detected by Transcranial Doppler Ultrasound (TCD). Notably, a distinctive "tin whistle" sound, known as a doppler harmonic effect, near the highest velocity point was observed during the examination. Extensive workup was performed, including CSF analysis and laboratory investigations, and the diagnosis of Reversible Cerebral Vasoconstriction Syndrome (RCVS) was established. Treatment involving medication and daily monitoring led to a decline in the left MCA's velocity, enabling the patient's discharge with no recurrent headaches or neurological deficits. Notably, a follow-up MRI exhibited the disappearance of the left MCA stenosis. This report discusses the rare occurrence of "musical murmurs" in cerebrovascular diseases, underscoring the potential for early diagnosis using techniques like TCD in emergency settings, particularly in conditions like RCVs.

Fried-Breadstick sign: A novel marker for healthy vasculature in magnetic resonance angiography

The Fried-Breadstick sign is characterized as a continuous signal loss at the center of the intracranial internal carotid artery (ICA) on time-of-flight magnetic resonance angiography (TOF-MRA). In this study, we present a novel imaging marker on TOF-MRA and investigate its potential association with ICA-middle cerebral artery (ICA-MCA) atherosclerosis and ischemic stroke. Vessel wall magnetic resonance imaging data were obtained from patients with recent clinical stroke or asymptomatic patients with suspected middle cerebral artery (MCA) atherosclerosis, covering the period from January 2007 to August 2015. We conducted a comparative analysis of ICA stenosis, MCA atherosclerosis and stenosis degree, and the terminal ICA bifurcation angle between ICA-MCAs with and without the Fried-Breadstick sign, involving a total of 1,005 ICA-MCAs from 553 patients. The Fried-Breadstick sign exhibited a higher prevalence in non-to-mild stenotic ICAs (57.5% vs. 9.8% in severely stenotic ICA, P < 0.001) and plaque-free MCAs (53.2% vs. 26.6% in MCAs with plaque, P < 0.001). Factors independently associated with the presence of the Fried-Breadstick sign included MCA stenosis degree (odds ratio [OR]: 0.85/10% increase, 95% confidence interval [CI]: 0.80 – 0.90), ICA stenosis (compared to non-to-mild stenosis, moderate stenosis: OR: 0.39, 95% CI: 0.28 – 0.54, severe stenosis: OR: 0.10, 95% CI: 0.06 – 0.17), and terminal ICA bifurcation angle (OR: 0.86/10° increase, 95% CI: 0.79 – 0.93). In atherosclerotic MCAs without luminal narrowing, the Fried-Breadstick sign was also less frequently observed than in plaque-free MCAs (34.6% vs. 53.2%, P = 0.012). In conclusion, the presence of the Fried-Breadstick sign is associated with healthier ICA-MCAs devoid of stenosis or plaque. The Fried-Breadstick sign may signify healthy ICA-MCA hemodynamics, serving as a potential screening tool for intracranial atherosclerosis without incurring additional cost or risk.

P103: Middle Cerebral Artery Stenosis is Associated with Severity of Depression in Elderly Patients: Magnetic Resonance Angiography (MRA) Findings

Objective:Vascular abnormalities have been frequently reported in elderly adults as a potential risk factor of late-life depression. However, it is still unclear whether stenosis of cerebral arteries may increase risk of depression in the elderly.Methods:Study participants were 365 patients 65 years or older with depressive disorder who had undergone brain MRI and angiography (MRA) which were assessed by trained radiologists, and the 15-item Geriatric Depression Scale (GDS-15) and the Mini Mental State Examination (MMSE), and blood glucose and lipid profiles.Results:Of the 365 subjects, 108 had at least one location of cerebral artery stenosis (29.59%). Stenosis was associated with age, marital status, infarction, and atherosclerosis. In multivariable linear regression analysis of different locations of stenosis among the whole sample, only bilateral middle cerebral artery (MCA) stenosis was found to have a significant association with higher GDS-15 score (p= 0.0138), and more than 8 scores in the GDS-15 (p= 0.0045), but no significant associations with ACA (anterior cerebral artery), PCA (posterior cerebral artery) or ICA (internal carotid artery). In multivariable linear logistic analysis of different locations among patients with at least one cerebral artery stenosis, left MCA was found to be significantly related to higher GDS-15 scores but not with right MCA (p = 0.0202).Conclusion:MCA stenosis is significantly associated with severity of depression in elderly adults with cerebral artery stenosis, especially in those with left MCA stenosis.Key pointsPatients with cerebral artery stenosis found with brain magnetic resonance angiography (MRA) were associated with higher depression severity.Stenosis of both left and right middle cerebral artery (MCA) was associated with greater depression severity, with left MCA stenosis having a greater influence on depression severity than right MCA stenosis.Higher depression severity in patients with MCA stenosis suggests that depression in elderly patients is mediated at least in part by vascular pathology of MCA supplied regions and careful investigation and management of cerebral artery stenosis and their risk factors may help reduce the severity of depression in elderly patients who visit psychiatrists.

Endovascular stenting to treat an acute stroke caused by severe stenosis of the duplicated middle cerebral artery

BackgroundThe duplicated middle cerebral artery (DMCA), a rare anatomical variant of the middle cerebral artery, arises between the anterior choroidal artery and the distal end of the internal carotid artery. We present the case of a patient who had an acute progressive stroke caused by severe stenosis in the initial segment of the DMCA and was successfully treated with endovascular stenting.Case presentationA 57-year-old man was admitted to our hospital with sudden left extremity weakness for three days. Cranial magnetic resonance imaging revealed multiple fresh infarcts in the right basal ganglia and temporal lobe. Cerebrovascular imaging revealed severe stenosis of the right DMCA’s initial segment. However, despite standard medical therapy, the patient’s limb weakness worsened. Based on the clinical and imaging findings, we speculated that severely stenotic DMCA is responsible for the acute progressive stroke. On the basis of the best medical treatment, the patient successfully underwent endovascular stent implantation under general anesthesia two weeks after the onset. The patient’s condition was stable after interventional therapy, and his postoperative follow-up prognosis was favorable.ConclusionsEndovascular stenting may be a feasible treatment for symptomatic severe stenosis of the DMCA in cases of poor control with standard medications.

Association between arterial tortuosity and early neurological deterioration in lenticulostriate artery infarction

Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57–44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03–1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85–58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37–237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ.

Role of Advanced Hemodynamic Ultrasound Evaluation in the Differential Diagnosis of Middle Cerebral Artery Stenosis: Introducing Morphological Criteria.

The aim of the work described here was to determine the possible impact of the new technique advanced hemodynamic ultrasound evaluation (AHUSE) in identification of severe intracranial stenosis. Transcranial Doppler (TCD) and transcranial color-coded Doppler (TCCD) provide reliable velocimetric data, the indirect analysis of which allows us to obtain information on the patency of vessels and assumed stenosis range. However, very tight stenoses (>95%) cannot be detected with velocimetric criteria because of spectrum drops and the absence of high velocities, so that the right curve of the Spencer equation cannot be solved. Likewise, high velocities are not detected when analyzing morphologically long stenosis. Furthermore, the current classifications based on velocimetric criteria do not provide any categorization on stenoses with multiple acceleration points (MAPs). With this Technical Note we aim to introduce, in addition to velocimetric criteria, more morphological criteria based on TCCD with the algorithm of AHUSE to optimize the characterization of intracranial stenosis (IS). TCCD-AHUSE relies on intensity-based next-generation techniques and can be used to identify IS with MAPs and simultaneously perform a morphological assessment of the stenosis length. We introduce a new technical ultrasound (U) approach that we tested in a sample of four different types of stenoses combining velocimetric data and AHUSE using Esaote Microvascularization (MicroV) technique to the M1 tract of the middle cerebral artery (MCA). The authors believe that a multiparametric evaluation is more sensitive and supports the clinician by introducing the morphological concept, not just the velocimetric concept, to differentiate the IS pattern of MCA. The potential for developing a diagnostic/prognostic algorithm is discussed.

Abstract 167: Surgical treatment for unruptured Anterior communicating artery aneurysm

Introduction We report the results of endovascular surgery as the first‐line treatment for unruptured anterior communicating artery aneurysms. Methods Fifty‐seven patients (F:M, 30:27; mean age, 65.5 years) underwent surgery for unruptured anterior communicating artery aneurysms in our hospital between January 2018 and January 2023. Results The mean aneurysm dome size was 5.29 mm (2–22 mm), and the mean aneurysm neck size was 3.2 mm (1.5–7 mm). Coil embolization was performed for fifty‐four patients using various adjunctive techniques (simple, 7; double catheter, 15; balloon neck remodeling, 7; stent‐assisted, 26 (LVIS Jr., 12; ATLAS, 14). Neck clipping was performed in 3 cases. The surgical results revealed complete coil embolization in 27, neck remnant in 26, and dome filling in 1 patient(s). The reason for 3 patients treated with neck clipping are patient's preference in one, associated with severe Middle cerebral artery stenosis needed TSA MCA anastomosis on one, and difficulty of embolization in one patient. Postoperative thrombotic complications were observed in 1 patient. The modified Rankin scale scores were 0 in 32 (96.5%) patients, 3 in 1 (1.7%) patients, and 6 in 1 (1.7%) patient. Follow‐up was performed in 55 patients, averaging 29.5 months (3–45 months). However, one patient underwent re‐aneurysm embolization for major recanalization of the aneurysm dome, and none of them suffered from rupture of the treated aneurysm. Conclusion Endovascular surgery may be the first choice of treatment for unruptured anterior communicating artery aneurysms.

Cerebral hemodynamics and stroke risks in symptomatic intracranial atherosclerotic stenosis with internal versus cortical borderzone infarcts: A computational fluid dynamics study

There may be different mechanisms underlying internal (IBZ) and cortical (CBZ) borderzone infarcts in intracranial atherosclerotic stenosis. In 84 patients with symptomatic, 50-99% atherosclerotic stenosis of M1 middle cerebral artery (MCA-M1) with acute borderzone infarcts in diffusion-weighted imaging, we classified the infarct patterns as isolated IBZ (n = 37), isolated CBZ (n = 31), and IBZ+CBZ (n = 16) infarcts. CT angiography-based computational fluid dynamics models were constructed to quantify translesional, post-stenotic to pre-stenotic pressure ratio (PR) in the MCA-M1 lesion. Those with IBZ infarcts were more likely to have a low PR (indicating impaired antegrade flow across the lesion) than those without (p = 0.012), and those with CBZ infarcts were more likely to have coexisting small cortical infarcts (indicating possible embolism) than those without (p = 0.004). In those with isolated IBZ or CBZ infarcts, low PR was independently associated with isolated IBZ infarcts (adjusted odds ratio = 4.223; p = 0.026). These two groups may also have different trajectories in the stroke risks under current medical treatment regimen, with a higher risk of same-territory ischemic stroke recurrence within 3 months in patients with isolated IBZ infarcts than isolated CBZ infarcts (17.9% versus 0.0%; log-rank p = 0.023), but similar risks later in 1 year.

Enhanced Gait Recovery in Chronic Post-COVID-19 Stroke: The Role of Combined Physical Rehabilitation

Background: Rehabilitation programs applied in cases of COVID-19-related stroke should counteract not only the effects of the stroke but also the effects of long-term COVID-19. As the molecular processes underlying these cases are still not fully understood, and evidence-based clinical outcomes are scarcely documented, there is a valid need to gather information and develop rehabilitation strategies for these patients. The risks, already clarified in the case of stroke, need to be assessed taking into account the coincidence of the two diseases. Endothelial injuries and emboli that develop after the hypercoagulable state of COVID-19 may take longer to heal, and complications may occur during exercise. This case study attempts to determine what the rehabilitation of a COVID-19-related stroke patient should include. The participant was a 64-year-old male with ischemic right middle cerebral artery stroke, left-side hemiplegia, and middle cerebral artery stenosis, and the CT showed a well-defined area of hypoattenuation in the basal ganglia territory involving the right lentiform nucleus, the anterior and posterior limbs of the internal capsule, and the dorsal part of the external capsule. His NIHSS score was 14, and he registered 15 points on the Barthel index. The patient had a COVID-19 infection two weeks before the stroke event. Methods: Conventional physical therapy was combined with adaptive ballistic strength training, a high-intensity interval training regimen, and manual treatment for myofascial release throughout the chronic recovery phase. Our primary goals were gait rehabilitation, muscle strengthening, weakness management, as well as spasticity reduction, while three different rehabilitation approaches were adopted in a single rehabilitation program to improve the outcome and long-term functional recovery of the patient. Results: The patient progressed in almost every aspect of the assessment criteria. This combined approach’s main success was improved gait speed, gait quality, and improved cardiovascular fitness. Take-away message: In the case of a stroke caused by COVID-19, where the endothelium cells are compromised, HIIT may be questionable due to the poor vascular condition. Based on our results, the low-volume HIIT approach proved appropriate and effective.

Transradial intra-aortic catheter looping in the angioplasty of severe intracranial symptomatic arteriosclerotic diseases.

This study aims to investigate the effect and feasibility of intra-aortic catheter looping via transradial access in angioplasty for symptomatic intracranial severe (>70%) atherosclerotic stenosis or occlusion of large arteries (SISOLAs). Patients with SISOLAs who underwent transradial endovascular angioplasty using the catheter looping technique in the ascending aorta were retrospectively enrolled. The clinical data and treatment outcomes were analyzed. Fifteen patients aged 48-71 years were enrolled in this study. Left vertebrobasilar artery occlusion was present in 1 (6.7%) patient, severe left middle cerebral artery stenosis in 7 (46.7%) patients, severe left internal carotid artery (ICA) stenosis of the ophthalmic segment in 4 (26.7%) patients, severe left ICA stenosis of the cavernous segment in 2 (13.3%) patients, and severe right middle cerebral artery stenosis in 2 (13.3%) patients. The arterial stenosis ranged from 70 to 92% (mean 86%) before stenting. The looping of a guiding catheter in the ascending aorta via transradial access for angioplasty was successful in all patients (100%). The vertebral artery intracranial segment occlusion was successfully recanalized, while severe stenosis in the remaining 14 patients was successfully eliminated. After endovascular recanalization, the residual stenosis was reduced by 12-26% (median 18%). No puncture-related complications or surgical-related neurological complications occurred in these patients. In the follow-up angiography conducted on 10 (66.7%) patients after 6-25 months, no in-stent restenosis was detected. Intra-aortic guiding catheter looping via transradial access for endovascular angioplasty of SISOLAs is technically safe, feasible, and effective, especially when the transfemoral artery approach is difficult or impossible to undertake.

Retracted: Correlation between Lpa, APO-A, APO-B, and Stenosis of Middle Cerebral Artery in Patients with Cerebral Ischemic Stroke.

[This retracts the article DOI: 10.1155/2022/6403645.].

Application of high-resolution magnetic resonance vessel wall image in the treatment of M1 segment stenosis of middle cerebral artery

To investigate the application of high-resolution magnetic resonance vessel wall image (HRMR-VWI) in treating middle cerebral artery (MCA) M1 segment stenosis. We retrospectively analyzed preoperative clinical data, imaging data, preoperative evaluation, stent procedure, and postoperative complications in 35 patients with atherosclerotic stenosis of the MCA M1 segment. And the 30-day postoperative mortality and disability and the 12-month restenosis were followed up. There were 21 males and 14 females, with a median age of 55 and a median duration of 1 month from onset to stenting. DSA confirmed that the stenosis locates in the M1 segment, with a stenosis degree of (75.00±17.15) %, a stenosis length of (4.34±1.51) mm, and a blood vessel diameter of (2.25±0.42) mm. After the operation, there was 1 case of death after a craniotomy to remove hematoma+decompression due to reperfusion hemorrhage. There were two technical complications during the procedure (1 case of asymptomatic occlusion of the A1 segment due to the covering of stent at the initial part of A1, 1 case of intraparenchymal hematoma in the temporal lobe due to penetrating distal small blood vessel with guide wire). HRMR-VWI is of great value in observing plaques' location, morphology, and stability. It can improve the safety and effectiveness of stenting treatment of MCA M1 segment stenosis.

Moyamoya disease mimicking primary central nervous system vasculitis: A case report

Rationale: Both Moyamoya disease (MMD) and primary central nervous system vasculitis (PCNSV) cause cerebrovascular stenosis resulting in similar ischemic neurological events, although therapeutic approaches are distinct from each other. High-resonance vascular wall imaging (HRVWI) with contrast-enhanced magnetic resonance imaging (MRI) is believed to be useful to differentiate PCNSV from MMD by detecting enhancement of cerebral vascular walls. However, recent studies have reported that the vascular walls of major arteries and superficial cerebral arteries are also enhanced by HRVWI in some MMD cases. Patient concerns: A 40-year-old Chinese woman admitted to our hospital with transient weakness of the right hand for a week. A cerebral infarction of the left frontal lobe was detected by diffusion-weighted brain MRI. Magnetic resonance angiography demonstrated severe stenosis of the left middle cerebral artery (MCA) and extensive vascular narrowing. Magnetic resonance angiography incidentally taken 3 years before admission showed only a mild stenosis at the proximal portion of right MCA with intact left internal carotid artery (ICA) and MCA. Moreover, on HRVWI with contrast-enhanced MRI after admission, the wall of ICA was strongly enhanced, and the superficial cerebral arteries were also highly enhanced, which initially suggested PCNSV. Despite these findings, reticular blood vessels were confirmed by digital subtraction angiography, and p.R4810K polymorphism in the ring finger protein 213 gene was detected. Diagnosis: Based on these result, the patient was diagnosed with MMD. Interventions: Bypass surgery was performed. Outcomes: Ischemic events have never been experienced since surgery. Lessons: Our MMD case demonstrated marked asymmetrical progression of cerebral artery stenosis, and enhanced vascular walls of ICA and superficial cerebral arteries by HRVWI, which made differential diagnosis from PCNSV difficult. Genetic analysis of SNP in the ring finger protein 213 gene should be performed to rule out MMD to avoid misdiagnosis of PCNSV particularly in Asian population.

Hemodynamics combined with inflammatory indicators exploring relationships between ischemic stroke and symptomatic middle cerebral artery atherosclerotic stenosis

Background and purposeIntracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke, and high-resolution vessel wall imaging (HR-VWI) can be used to assess the plaque characteristics of ICAS. This study combined HR-VWI, hemodynamics, and peripheral blood inflammatory indicators to investigate the role of these factors in symptomatic intracranial atherosclerotic stenosis (sICAS) and their inter-relationships.MethodsPatients diagnosed with atherosclerotic middle cerebral artery stenosis were recruited retrospectively from June 2018 to July 2022. Plaque enhancement was qualitatively and quantitatively analyzed, and the degree of plaque enhancement was graded according to the plaque-to-pituitary stalk contrast ratio (CR). Computational fluid dynamics models were constructed, and then hemodynamic parameters, including wall shear stress (WSS) and pressure ratio (PR), were measured and recorded. Univariate and multivariable analyses were performed to identify factors that can predict sICAS. In addition, the correlation analysis between the plaque characteristics on HR-VWI, hemodynamic parameters, and peripheral blood inflammatory indicators was performed to investigate the interrelationships between these factors.ResultsThirty-two patients were included. A higher proportion of plaque enhancement, maximum WSS, and WSS ratio (WSSR) were significantly associated with sICAS. The multiple logistic regression analysis showed that only the WSSR was an independent risk factor for sICAS. The correlation analysis revealed that both the CR and plaque burden showed linear positive correlation with the WSSR (R = 0.411, P = 0.022; R = 0.474, P = 0.007, respectively), and showed linear negative correlation with the lymphocyte to monocyte ratio (R = 0.382, P = 0.031; R = 0.716, P < 0.001, respectively).ConclusionsThe plaque enhancement and WSSR were significantly associated with sICAS, WSSR was an independent risk factor for sICAS. Plaque enhancement and plaque burden showed linear correlation with the WSSR and lymphocyte-to-monocyte ratio (LMR). Hemodynamics and inflammation combined to promote plaque progression.