| (Part one)Relationship between retention of contrast injected via microcatheter distal to occlusion site and clinical outcome after thrombectomy with stent retrivor in patients with acute ischemic strokeBackground and objective:The incidence of acute ischemic stroke is increasing year by year,which causes heavy burden to the society.The key to the treatment of AIS is to open the occluded vessels as soon as possible,restore the cerebral blood flow,and save the ischemic penumbra tissue,so as to obtain a better prognosis.Several key international multicenter clinical studies have confirmed that mechanical thrombectomy with stent retriever is an effective treatment for acute ischemic stroke.Microcatheter angiography is an important process during thrombectomy:before thrombectomy by stent retriver,microcatheter should slowly pass through the thrombus segment with the assistance of microwire and then microwire is withdrawn.The microcatheter is confirmed to be in the vascular lumen by manual contrast agent injected through microcatheter.At the same time,the location of stenosis and occlusion is judged to help the stent to locate the releasing site,and then the stent retriever will be transported through the microcatheter to occlusion site.In our clinical practice,we found that the prognosis of patients before thrombectomy was usually better if the contrast agent injected from microcatheter was not retained in the cerebral vascular braches;but if the contrast agent was retained,the prognosis of patients was not good.We believe that contrast agent retention is related to higher thrombus load,forward blood flow deficiency even after microcatheter pass through the thrombus,thromboembolic drift and blockage of branches,microthrombosis in the vascular bed leading to diffusing difficulty of contrast agent and poor collateral circulation,and these factors are basically related to poor prognosis of patients after thrombectomy.Therefore,the retention of contrast agent during microcatheterography(i.e.,angiography via microcatheter)may be a predictor of poor clinical prognosis and larger cerebral infarction volume after thrombectomy.It can help the interventionalist to judge the prognosis in time during the operation.In order to confirm our hypothesis,we will observe the relationship between contrast agent retention and prognosis of patients with acute large cerebral artery occlusion of anterior circulation during microcatheter angiography,and preliminarily explore the predictive value of contrast agent retention on clinical efficacy and safety of patients with thrombectomy.Methods:A retrospective analysis is made by reviewing the medical records of AIS patients of anterior circulation who underwent thrombectomy in the Department of Neurology from October 2012 to May 2018 in the thrombectomy database.The patients are selected according to inclusion and exclusion criteria.The patients are divided into two groups according to the diffusion/retension of contrast agent during microcatheter angiography:microcatheter contrast agent retention group and contrast agent non-retention group.Evaluation of contrast agent diffusion during microcatheter angiography and definition of contrast retension:When microcatheters pass through the occluded site,angiography is performed;about 1 ml contrast agent is injected via the microcatheter at a uniform speed.The diffusion of contrast agent in the distal main artery and its branches of the microcatheter is observed.Under normal circumstances,the contrast agent through the microcatheter can flow forward rapidly and continuously in different branches.In this case,we conclude that the microcatheter contrast agent is not retained in the patient;in some other cases,there will be a"blockage"like retention or pause after the contrast agent is pushed by hand(contrast agent retention in the trunk or main branch),or the last injected contrast agent will still be found in the next sequence of fluoroscopy or angiography.Baseline data and clinical data were collected according to the diffusion of contrast agent and collateral circulation group.The data of the different groups were analyzed and compared,and the factors affecting the clinical prognosis,infarct volume and cerebral hemorrhage were explored.Results:A total of 78 patients were enrolled,including 63 patients in the non-retention group,30 of whom were females(47.6%)aged 69.1±12.4 years old.The National Institute of Health stroke scale(NIHSS)score before thrombectomy was 14(10,17).There were 15 cases in contrast agent retention group,7 of them were female(46.7%).The average age of the patients was 73.1±14.9 years old,and the NIHSS score was 17(14,20)before thrombectomy.The NIHSS score at admission in the retention group was significantly higher than that in the non-retention group(P=0.023).In addition,there was no significant difference in gender,preoperative systolic blood pressure,American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology(ASITN/SIR)grade before thrombectomy,modified Thrombolyswas in Cerebral Infarction(m TICI),smoking history,diabetes history and laboratory results(P>0.05).Among all subjects,43.6%(34/78)had good collateral circulation(ASITN/SIR grade3-4);79.5%(62/78)had successful recanalization(m TICI 2b-3);the volume of cerebral infarction in contrast agent retention group was significantly larger than that in non-retention group(164.6 cm~3vs 55.4 cm ~3,P=0.007);and the time from onset to femoral puncture in contrast agent retention group was significantly longer than that in non-retention group(164.6 cm~3vs 55.4 cm~3,P=0.007).The number of thrombectomy in the non-retention group(320 min vs 250 min,P=0.002)was significantly higher than that in the non-retention group(P=0.048).The NIHSS score was 12.0(7.0,17.3)on the 7th day after operation in all the subjects,including 12.0(7.0,16.0)in non-retention group and 15.0(2.0,20.0)in contrast-agent-retention group.In terms of prognosis,12 patients(19.0%)in non-retention group had better prognosis,while 4 patients(37.5%)in retention group had no significant difference(P=0.763).The incidence of intracranial hemorrhage in the retention group was significantly higher than that in the non-retention group(60.0%vs 22.2%,P=0.010);29.5%(23/78)patients died within 90 days after operation;15 cases(23.8%)in the non-retention group and 4 cases(37.5%)in the retention group.Spearman correlation analysis was made between diffusion of contrast agent and m RS score,collateral circulation,m TICI score,thrombectomy times,cerebral infarction volume,time from onset to femoral artery puncture and occurrence of cerebral hemorrhage 90 days after operation.It was found that the times of thrombectomy,intracerebral hemorrhage after thrombectomy and the volume of cerebral infarction were negatively correlated with the time from onset to femoral artery puncture and the diffusion of contrast agent,respectively.Univariate logistic regression analysis showed that NIHSS score(OR=0.874,95%CI:0.785-0.973,95%CI:0.785-0.973,P=0.014),ASITN/SIR score(OR=1.354,95%CI:0.900-2.037,P=0.145),history of atrial fibrillation(OR=0.374,95%CI:0.116-1.205,P=0.100),duration from onsonset to femoral puncture(OR=1.004,95%CI:1.004,95%CI:0.999-1.008,P=0.094)may be the prognostic factor after thrombectomy.These factors were then included in the multivariate logistic regression analysis.The results showed that there was no independent correlated factor affecting the prognosis of thrombectomy(P>0.05).34 cases had good collateral circulation and 44 cases had poor collateral circulation.The good collateral circulation group had higher recanaliztion rate than the poor collateral circulation group(91.2%vs 70.5%,P=0.025).The mortality rate at 90 days after operation in the group with poor collateral circulation was significantly higher than that in the group with good collateral circulation(36.3%vs 8.8%,P=0.005).There was no statistical difference in other clinical data(P>0.05).After univariate linear regression,it was found that the volume of cerebral infarction,NIHSS score before thrombectomy,systolic blood pressure before thrombectomy,history of diabetes mellitus and history of atrial fibrillation(P<0.200)may be the factors related to status of collateral circulation before operation,and the above factors were included in the multivariate linear regression analysis.The results showed that no relevant factors affecting collateral circulation were found(P>0.05).The volume of cerebral infarction was used as a dependent variable for linear regression analysis.After univariate linear regression,we found that the diffusion of contrast agent,number of thrombectomy,the pre-operative Alberta Stroke Proram Early CT Score(ASPECTS)score and the history of diabetes may be the factors affecting the volume of cerebral infarction after thrombectomy.We also included the above factors in multivariate linear regression analysis,and found that diffusion situation of microcatheter contrast agent was an independent factor associated with the volume of cerebral infarction after arterial thrombectomy(P=0.016).After logistic regression,we found that the number of thrombectomy,NIHSS score before thrombectomy and diabetes history may be the factors associated with the status of collateral circulation.We also included the above factors in the multivariate logistic regression analysis.The results showed that there was no independent correlation factor affecting the diffusion of microcatheter contrast agent(P>0.05).Univariate regression analysis showed that age and diffusion situation of microcatheter contrast agent were the related factors of intracerebral hemorrhage after thrombectomy.We included these factors in multivariate logistic regression analysis,and found that diffusion of microcatheter contrast agent was an independent correlation factor of intracerebral hemorrhage after thrombectomy(P=0.011).Conclusion:There was no significant correlation between diffusion of contrast agent and clinical prognosis.However,we confirmed that the diffusion of contrast agent(retention or not)was an independent correlative factor for the volume of cerebral infarction and hemorrhagic transformation after thrombectomy.We also found that collateral circulation was closely related to recanalization rate and mortality.The relationship between microcatheter contrast agent diffusion and clinical prognosis,as well as various parameters,still needs to be confirmed in large sample studies.(Part two)Relationship between onset season and circadian rhythm and prognosis after thrombectomy in patients with acute ischemic strokeBackground and objective: In the past,scholars had done a lot of research on the onset time of acute ischemic stroke,which showed that the onset time of ischemic stroke had a circadian rhythm.At present,there were many studies on the chronobiology of thrombolytic therapy in patients with acute ischemic stroke,but there were no reports on the impact of onset season and day and night time characteristics on the prognosis of mechanical thrombectomy.It was helpful for the public prevention,first aid work plan and hospital stroke team plan of thrombectomy.In this study,patients with acute stroke receiving thrombectomy were grouped according to season and day and night,statistical analysis was conducted to determine the impact of season and day and night factors on the prognosis of thrombectomy patients.Methods: A retrospective analysis was made according to the data of stroke patients who received thrombectomy in the Department of Neurology of our hospital from October 2012 to May 2018.Patients were screened according to inclusion and exclusion criteria.(1)For seasonal group,it was defined as: 1-spring(March-May),2-summer(June-August),3-autumn(September-November),4-winter(December-February)and day-night grouping,defined as: 1-morning(6:00-11:59),2-afternoon(12:00-17:59),3-Night(18:00-23:59),4-morning(0:00-05:59).The gender,age and various vascular risk factors were compared among the four groups.The baseline data of hypertension,diabetes mellitus,recent smoking and drinking history,low density lipoprotein cholesterol,NIHSS score and interventional imaging data were compared between groups.Also we compared the occurrence of hemorrhagic transformation after thrombectomy and the m RS score at 90 days of onset between the two groups.(2)Logistic regression model was used to analyze the correlation between different seasons,circadian time and prognosis of patients with ischemic stroke after thrombectomy.The relationship between different seasons,circadian time and clinical prognosis of patients with ischemic stroke at 90 days after thrombectomy was analyzed.(According to m RS score,the prognosis of patients with ischemic stroke at 90 days was good;m RS > 2 was poor),and the ratio(OR)and the prognosis were used.Its 95%confidence interval(95% CI)was expressed.In order to eliminate the influence of other risk factors,factors such as age,sex,history of hypertension,history of diabetes,smoking and drinking were adjusted in multivariate logistic regression analysis.Results:(1)A total of 93 patients with ischemic stroke were enrolled in this study.The average age was 69.2 ± 13.1 years old,of which 54 were males(58.1%)and 39 were females(41.9%).In the past,58 cases(62.4%)had history of hypertension,19 cases(20.4%)had history of diabetes,28 cases(30.1%)had history of atrial fibrillation,24cases(25.8%)smoked and 7 cases(7.5%)drank in terms of bad habits.(2)According to the season of onset,the subjects were divided into four groups:spring,summer,autumn and winter.The clinical characteristics of the four groups were analyzed and compared,including 25 cases(26.8%)in spring,15 cases(16.1%)in summer,30 cases(32.3%)in autumn and 23 cases(24.5%)in winter.In terms of blood pressure,the systolic blood pressure and diastolic blood pressure of summer onset were higher,but there was no significant difference between groups(P > 0.05);the systolic blood pressure and diastolic blood pressure of winter onset were lower than those of patients with summer onset(P = 0.020).In terms of history of past illness,there were more patients with diabetes mellitus in summer group,but there was no significant difference between groups(P > 0.05);in terms of laboratory examination,level of serum LDL cholesterol in summer patients was significantly higher than that in winter patients(P = 0.034).There were no significant differences in other baseline characteristics,including age,sex,NIHSS score at admission,smoking historyand drinking history,etc.(P > 0.05).(3)According to the specific time distribution of thrombectomy in patients with acute ischemic stroke,the patients were divided into four groups: morning?afternoon?evening and early morning,and the clinical data were analyzed and compared.Among them,33cases(35.4%)had disease onset in the morning,25 cases(26.9%)in the afternoon,23cases(24.7%)in the evening and 12 cases(12.9%)in the morning.The median time from onset to femoral artery puncture was longer in the early morning group than in the late morning group(P < 0.01),and was significantly longer in the early morning group than in the evening group(P = 0.028).There was no significant difference in other clinical features.(4)The prognosis of thrombectomy patients according to the seasonal distribution of onset was compared: 23 patients had better clinical prognosis at 90 days after onset,accounting for 24.7%,while 70 patients had poor prognosis,accounting for 75.3%.The incidence of poor prognosis in summer and autumn was similar(80.0%),while that in spring was similar to that in winter(72.0% vs 69.6%).The mortality rate in spring and summer group was relatively high(24.0% vs 26.7%)while that in winter group was lower(8.7%).There was no significant difference in mortality and clinical prognosis between seasonal groups of ischemic stroke patients with thrombectomy at 90 days after onset(P > 0.05).Logistic regression analysis was carried out with the onset season and other risk factors as independent variables and the prognosis at 90 days of onset as dependent variables.The results showed that there was no significant relationship between the prognosis of patients and onset seasons.(5)When circadian rhythm of onset was used as grouping basis,the poor prognosis rate in the afternoon group was the highest(84.0%),followed by the early morning group(83.3%),and the good prognosis rate in the morning group was the same as that in the evening group(30.0%).Patients of morning and afternoon groups had higher mortality after thrombectomy(24.2% vs 24.0%)and morning group had lower mortality(8.3%).There was no significant difference in the above results between groups(P > 0.05).We analyzed the correlation between the circadian time distribution of thrombectomy and the clinical prognosis of patients with ischemic stroke at 90 days of onset.The results showed that there was no significant difference in the clinical prognosis of patients with thrombectomy between different circadian times.We used circadian time of onset as a single index and logistic regression analysis with other factors and clinical prognosis at90 days after onset.The results showed that there was no significant difference in the prognosis of patients with onset at different time periods(P > 0.05).Conclusion: We found that seasonal and circadian variations were not associated with clinical outcomes after thrombectomy.However,it was found that the time from onset to femoral artery puncture in the evening group was significantly shorter than that in the morning group,while that in the morning group was significantly longer than that in the evening group.At the same time,we also found that the diastolic blood pressure in the winter group was significantly lower than that in the summer group,while the low density lipoprotein cholesterol in the summer group was significantly higher than that in the winter group.In addition,we also observed that the number of thrombectomy patients showed a seasonal and circadian characteristic distribution trend: seasonally,the number of patients receiving thrombectomy in spring and autumn was more;circadian distribution,the early morning group received less thrombectomy patients,while there were more patients received thrombectomy in the morning group.In addition,in terms of prognosis,we found that the adverse prognosis rate was relatively high in the afternoon and early morning groups,but there was no significant difference between groups.These results need to be further clarified and validated in large sample studies.(Part three)Clinical characteristics and prognosis of iatrogenic embolization of ipsilateral anterior cerebral artery during thrombectomy in patients with acute middle cerebral artery occlusionBackground and objective: Iatrogenic occlusion of ipsilateral anterior cerebral artery can be caused after thrombectomy of middle cerebral artery occlusion.At present,the understanding of anterior cerebral artery embolism secondary to middle artery occlusion was still limited;anterior cerebral artery embolism often occurs at the distal segement of the blood vessel.There are technical challenges and higher risks in thrombectomy because of the small diameter,longer route and tortuous blood vessels.Therefore,it was of great significance to explore the pathogenesis,treatment and clinical prognosis of iatrogenic anterior cerebral artery embolism.We plan to enroll patients with acute middle cerebral artery occlusion and received thrombectomy.They were divided into anterior cerebral artery embolism(ACAE)group and no anterior cerebral artery embolism(NACAE)group.The incidence of ACAE was calculated,and the baseline data and characteristics of ACAE were summarized to find out the causes of iatrogenic ACAE,so as to provide a reference for the treatment of iatrogenic ACAE patients during middle cerebral artery occlusion thrombectomy.Methods: A retrospective analysis was made on the medical records of patients with acute ischemic stroke who underwent endovascular treatment in the Department of Neurology of our hospital from October 2012 to May 2018.Inclusion and exclusion criteria were formulated to select patients.For NACAE group and ACAE group,the baseline data of gender,age,various vascular risk factors(hypertension,diabetes mellitus,recent smoking,drinking history,low density lipoprotein cholesterol),NIHSS score and imaging score data were compared between the two groups.Then the prognosis of NIHSS score on 7 days after admission,occurrence of hemorrhagic transformation after thrombectomy,and m RS score on 90 days after onset were compared between the two groups;0-NACAE,1-ACAE were defined as dependent variables,and various risk factors(such as past medical history,laboratory examination,interventional operation data,etc.)that might cause ACAE were assessed by logistic regression analysis.The univariate Logistic regression analysis was used to get the risk factors of P < 0.2,then the conditional backward multifactor logistic regression analysis was used to correct the interaction of the risk factors,and the risk factors of P < 0.05 were obtained.Results: 61 patients were enrolled after according to inclusion and exclusion criteria.The patients in NACAE group were 51(83.6%)and 27(52.9%)women,The median age of the patients was 71(62,82).The NIHSS score at admission was 14(11,18)and the preoperative ASPECTS score was 8.0(7.0,10.0).There were 10(16.4%)patients in ACAE group,including 4(40%)females.The median age of patients was 77.0(69.3,84.3).The NIHSS score was 11(6,16)before thrombectomy,and the ASPECTS score was 8.0(6.0,10.0)before thrombectomy.There was no significant difference in age,sex,preoperative systolic blood pressure,diastolic blood pressure,smoking history,diabetes history and laboratory examination results between the two groups(P > 0.05).Interventional surgery related data: 50.8%(31/61)patients had good collateral circulation(ASITN/SIR3-4)before thrombectomy;84.3%(43/61)patients in NACAE group achieved successful recanalization of middle cerebral artery(m TICI2b-3),while60.0% patients in ACAE group.In addition,4(40%)patients with anterior cerebral artery occlusion achieved vascular recanalization(m TICI2b-3).As far as the recanalization of the responsible artery was concerned,the proportion of the final recanalization of the anterior cerebral artery was lower than that of the middle cerebral artery,but there was no significant difference between the two groups because of the small number of cases.There was no significant difference in ASITN/SIR score,m TICI score,thrombectomy times and infarct volume between the two groups(P > 0.05).Prognosis: The NIHSS score was 12.0(5.0,16.0)at 7 days after operation in all patients,including 12.0(7.0,16.0)in NACAE group and 8.0(2.5,15.0)in ACAE group;4.0(2.0,4.0)in m RS score at 90 days after thrombectomy in all patients,including 4.0(2.0,4.0)in NACAE group and 4.0(2.0,4.3)in ACAE group;the incidence of hemorrhagic transformation and mortality at 90 days after operation in both groups.There was no significant difference of the incidence of hemorrhagic transformation and mortality at 90 days after operation between the two groups(P > 0.05).We also sorted out and summarized the data of ACAE group,and found that almost all patients used local anesthesia(9/10).There were 3 patients who underwent intravenous thrombolysis before operation.The specific occlusion sites of ACAE patients were mostly in segment A2(7).Anterior artery embolism occurred in 6 patients during the placement of the guiding catheter was in place,and 4 patients after thrombectomy for the occluded middle cerebral artery.All the devices used for embolization were Solitaire stents.Three patients achieved good prognosis at 90 days of onset.Conclusion:The incidence of ACAE during middle cerebral artery thrombectomy was about 16.4%.The occurrence of iatrogenic ACAE has no significant effect on prognosis.The successful recanalization rate of ACAE patients was relatively lower than that of MCA occlusion,which may be due to the long and tortuous path and small diameter of the tube.ACAE mostly occurs during the placement of the guiding catheter before thrombectomy.Therefore,it was necessary to pay attention to the fine operation,appropriate use of antithrombotic drugs and other measures to reduce the occurrence of ACAE.The incidence of ACAE was not low,but its successful recanalization rate was low,so it was more necessary to prevent the occurrence of ACAE during operation.These results need to be confirmed by further large sample studies. |
PDF Full Text Request