Evaluation On Safety And Validity Of Interventional Treatment For Intracranial Atherosclerosis Diseases

Part1. Intracranial angioplasty with Gateway-Wingspan system foratherosclerotic stenosis：A Systematic Review and Meta-analysisObject: This system review and meta-analysis planned to evaluate the safety andvalidity of the treatment of intracranial atherosclerosis diseases (ICAD) by using Wingspanstents which can provide the reference for clinical practice and research.Methods: All references for the treatment of ICAD by using Wingspan stents, includingrandomized controlled trials(RCTs), non-randomized controlled trials, case control studies,cohort studies and case series reports and so on, Meanwhile they had been collected bycomputer and search engine,Google Scholar,searching PubMed, The Cochrane Library,EMbase, Cochrane Central Register of Controlled Trials, CBM, CNKI, VIP and the database of grey literature from January1,2005to January10,2014. According to inclusionindependently by two reviewers, after extracting the data and evaluating quality, it wasadopted by RevMan5.2and R softwares, which conducted a meta-analysis,After thereference documents were screened, extracted and done the quality assessment accordingto inclusion criteria independently by two reviewers, they underwent meta-analysis withRevMan5.2and R softwares.Results: A total of34references were selected in the thesis, including3RCTs,22cohort studies, and9case-control studies，involving2511patients. Meta-analysis resultsof RCTs: A comparison of the group with the use of the Wingspan stents and the medicalmanagement group indicates that the second group was superior to the first group in the30day rates of the end point events. Differences between the two groups had statisticalsignificance and1year rates of the end point events had no differences between the twogroups. All the single sample ratios were used by R software to analysis the sample ofvalidity and safety of the Wingspan stent treatment ICAD. There are meta-analysis results:operation success rates reached96.75%, and30day rates of the end point events were8.75%, and1year rates of the end point events were13%, and total mortality was2.98%,and incidence of in-stent restenosis was21.76%, and the ratio of the patients withsymptomatic restenosis and total patients was6.5%, and the ratio of the patients withsymptomatic restenosis and total patients with restenosis was26.06%. Conclusion: According to the analysis of the Wingspan stent group single sample ratios,the treatment of ICAD by using Wingspan stents was an effective and safe method.However, literature information for RCTs is less now, in the future, more and higherquality RCT results will make the conclusion of meta-analysis more accurate. Part2: Treatment of Symptomatic Intracranial Atherosclerotic StenosisWith Taking Medicine and Intervening Treatment: A Single-centerRetrospective StudyObject: To investigate the safety and validity of stenting treatment for patient withsymptomatic intracranial atherosclerotic stenosis.Methods: For a start, it was a retrospective analysis of some patients with TIA orcerebral infarction who were diagnosed as intracranial atherosclerotic stenosis≧70%byDSA in the department of neurology of Lanzhou General Hospital of Lanzhou MilitaryArea Command of Chinese PLA. Furthermore, according to different therapeutic methods,all the patients were divided into two groups, which were the drug treatment group and theendovascular interventional treatment group; through the inquiry of medicial record,outpatient follow-up and telephone follow-up, any cerebrovascular events, death and otherrelated complications were obtained statistically at30day follow-up visits,12monthfollow-up visits and at the end of the follow-up during3specified time periods after onsetof illness.Results: Of220patients,48were assigned to the endovascular interventional treatmentgroup and172to the drug treatment group. Moreover, in the endovascular interventionaltreatment group alone,3patients underwent simple balloon expansion;24underwentballoon expansion mounted stents;21self-expanding stents. There were no significantdifferences between two groups at baseline. Besides, rates of the primary end point eventswithin30days were respectively4/48(8.33%) in the endovascular interventionaltreatment group and14/172(8.14%) in the drug treatment group alone; the occurrence rateof the primary end points within1year were respectively7/48(14.57%) and28/172(16.28%). Meanwhile, rates of the primary end points during the total follow-upperiods were respectively10/48(20.83%) and39/172(22.67%). There was no statisticaldifference between two groups. Data of the primary end points and secondary end pointswere statistically analyzed and calculated by Kaplan-Meier method and Chi-squaretest,which were compared by log-rank test. The results showed us that survival time hadno significant differences between two groups(x2=0.073,0.133;P=0.787,0.716). UsingKaplan-Meier method to analyze rates of the secondary end points, the median survivaltime(95%confidence interval) was47.082(38.509,55.656) in the endovascularinterventional treatment group and55.916(50.096,61.736) in the drug treatment group alone. There was no statistical difference between two groups. Multivariate Cox-regressionanalysis showed that hypertension, hyperlipidemia, peripheral arterial history, strokehistory, heart disease, hemorrhage and diabetes were the independent risk factors for therates of the secondary end points. Furthermore, according to using the accumulatedsurvival function, it could be found out that the endovascular interventional treatment wassuperior to the drug treatment alone in patients with symptomatic intracranialatherosclerotic serious stenosis.Conclusion: Both endovascular interventional treatment and drug treatment alonewere effective treatment methods for patients with symptomatic intracranialatherosclerotic serious stenosis. However, if patients had repeated paroxysm afterreceiving aggressive drug treatment alone, endovascular interventional treatment was asafe and effective method. Part3The Safety Analysis and Evaluation on Interventional treatmentfor Patients with Intracranial atherosclerotic stenosis by3.0Thigh-resolution magnetic resonance imaging before OperationsObject: To analyze and evaluate atherosclerotic plaques of patients with intracranialatherosclerotic stenosis(ICAS), it was adopted by high-resolution magnetic resonanceimaging(HR-MRI) vascular wall imaging technique, which could differentiate thosesubgroups of stroke inpatients. Then, these patients could have operations withinterventional treatment, reducing the risk of complications of endovascular treatment inpatients with intracranial atherosclerotic disease.Methods:48patients were studied prospectively with intracranial atheroscleroticstenosis(＞50%),who were recorded by our hospital from November,2011to February,2013. Then all the patients underwent conventional CT or MR and high-resolutionmagnetic resonance imaging (HR-MRI) vascular wall imaging studies. Besides, All theatherosclerotic plaques of patients were analyzed. Although some patients receivedstandard medical treatment, there was still onset of disease in clinic. The patients wereregarded as low risk by evaluating their atherosclerotic plaques who accepted and signedcorrelative documents, which meant that they were assigned to the endovascularinterventional treatment group. However, those who had high risk by evaluating theiratherosclerotic plaques and refused to sign correlative documents were assigned to thedrug treatment group. Meanwhile, these patients would have1month follow-up andshould observe the complications during perioperation and the relapse of stroke within1month.Results: The study had48patients and52intracranial vessels, including40middlecerebral arteries,12vertebrobasilar arteries among them;40symptomatic lesion vessels,12asymptomatic lesion vessels. Moreover, there were17vessels of17patients whichunderwent interventional operations. The drug control group had got31patients with35lesion vessels. Mean diameter stenosis of52stenosed vessels was78.33±10.67; therewere plaques in the direction of21perforating vessels (concentric stenosed plaques, inthe upper MCA, around AB), accounting for40.4%.11lesion vessels revealed T1W1high signals and30lesion vessels showed enhanced plaques by contrast-enhancedMRA,which are accounting for57.7%. Regarding the plaques in the direction ofperforating vessels as risk factors of operations, the number of lesion vessels in the endovascular interventional treatment group were3/17(17.6%) and those in the drugtreatment group were18/35(51.4%), P=0.034. The number of lesion vessels in twogroups were respectively10/17(58.8) and20/35(57.1%), P=0.908by contrast-enhancedMRA, and2/17(11.8%) and9/35(25.7%), P=0.304by T1high signals.That was to say,there was no significant statistical differences between two groups by contrast-enhancedMRA and by T1high signals. However, the number of plaques in direction ofperforating vessels in the drug treatment group was much more than that in theendovascular interventional treatment group. Besides, according to judging thesymptomatic or asymptomatic lesion vessels, T1high signals were respectively11/40(27.5%) and0/12(0%) P=0.05in the symptomatic group and in the asymptomaticgroup. Moreover, the plaques in direction of perforating vessels were respectively15/40(37.5%) and6/12(50%) P=0.439in the two groups, and the enhancement ofplaques are24/40(60%) and6/12(50%) P=0.539, respectively; Ratio of T1high signalsin the symptomatic group was much higher than that in the asymptomatic group. Ratio ofplaques in direction of perforating vessels had no statistical differences in thesymptomatic group and in the asymptomatic group. Ratio of enhanced plaques in the twogroups also did not. Furthermore, there was a case of perioperative complications within30days in the stent group, the stent releasing early and no covering up the lesion. Thennew clinical symptoms of nervous system did not occur after the operation.17patients inthe stent group did not have stroke recurrence within30days, and patients in the druggroup also did not within30days. There was no statistical differences before operationby applying NIHSS score, mRS score and MMSE score in the operation group and in thedrug group. It was found that mRS score and NIHSS score had no statistical differencesin the two groups and that the operation group was superior to the drug group by MMSEscore, P=0.0230days after admission. By matching t test, it showed that mRS score andNIHSS score had statistical differences before and after treatment in the drug group andthat MMSE score before and after treatment had no statistical differences. The mRSscore before treatment and that after treatment in stent group had no statisticaldifferences, but the NIHSS score and the MMSE score did. The mean time ofpostoperative hospital stay was18.88±5.41and16.94±5.89, P=0.266respectively in thestent group and in the drug group. There were no statistical differences between the twogroups. The hospitalization expenses were respectively79868.4±22434.1and24596.31±2917.7, P<0.000, That was to say, expenditure of patients in operation group was much higher than that in the drug group.Conclusion: The high-resolution magnetic resonance imaging (HR-MRI) vascularwall imagine technique can estimate clearly the composition and stability of plaques inintracranial arteries and can offer the choice of therapeutic strategies by judging thelocation of plaques. Besides, T1high signals are a well-established predictor ofsymptomatic intracranial atherosclerotic stenosis. The high-resolution magneticresonance imaging (HR-MRI) technique is an effective method to distinguish intracranialatherosclerotic subgroups. In general, in order to find out the correlation amongeconomics index, cognitive functions and Barthel Index, data results, it need to beaccumulated during the long-term followed up.