| Background:Stroke is a acute onset of disease of brain blood circulation obstacle.People in China appear to be at higher risk of stroke than whites in Westernized countries and stroke has become the leading cause of death in China.50%-70% of the survivors suffer from disabilities,which brought heavy burden to family and society.With noninvasive vascular imaging and cerebral imaging technology development,more and more patients with symptomatic cerebrovascular stenosis were found.The latest Chinese intracranial artery stenosis(ICAS)or occlusion study shows that the rate of ischemic stroke or TIA patients with intracranial artery stenosis is as high as 46.6%.Intracranial artery stenosis is the most important reason of stroke occurrence and recurrence.Stroke patients with intracranial artery stenosis have higher risk of recurrence stroke.Some studies reported that stroke recurrence rate of stroke or TIA patients with severe intracranial artery stenosis was 23%.At present,the methods for treatment of intracranial artery stenosis mainly includes the medical treatment,surgical treatment and stenting treatment.Due to the curative effect of the medical treatment is limited and the risk of surgical operation is high,stenting treatment was considered a better new way for the treatment of intracranial artery stenosis.However,the present studies for stenting treatment is contradictory.Some researches indicated that curative effect of stenting treatment is superior to medical treatment(such as multi-centers stents registration study in China).On the contrary,other researches suggested medical treatment is safer than stenting treatment(such as SAMMPRIS study).Therefore,it is urgent and necessary to investigate the optimum treatment for the secondary prevention of stroke patients with intracranial artery stenosis.In recent years,more and more young patients suffer from stroke.The prevention and treatment of stroke in young people has become an urgent problem.Compared with the study of ischemic stroke prevention,the research for the treatment of acute ischemic stroke is still insufficient.The treatment of stroke in acute phase include super-early intravenous thrombolysis,reascularization in the acute phase(artery thrombolysis,remove the embolus),antiplatelet aggregation treatment,statins,surgical treatment and rehabilitation.Randomized controlled studies had approved the curative effect of intravenous thrombolysis and arterial thrombolysis in the acute phase and recommended by guidelines.However,the strict time window(3-4.5 hours and less than 6 hours)made many patients missed the opportunity to receive acute phase treatment.Meanwhile,the intravenous thrombolysis and the acute phase reascularization have strict operation indication and contraindication.Stroke prevention and treatment group recommended ASA treatment plan including antiplatelet treatment,statins and antihypertensive agent.2011 SAMMPRIS research puts forward the concept of aggressive medical management which refers to dual antiplatelet aggregation,high-dose statins and strict blood pressure control.This scheme has a good effect on preventing stroke in patients with symptomatic severe intracranial artery stenosis.Our previous study also found that the scheme has a good effect on secondary prevention to stroke patients with mild carotid artery stenosis.According to the above reasons,our study intends to compare the effect between medical therapy and stent therapy in young stroke patients with severe intracranial artery stenosis.We also aim to investigate the efficacy and safety of the aggressive medical management for acute ischemic stroke and its mechanism.Objective:1?To compare the efficacy and safety between aggressive medical management and stenting treatment for the severe symptomatic atherosclerotic intracranial arterial stenosis(sICAS)in young patients.2?To study the effect and mechanism of neurological functional recovery with aggressive medical management for acute ischemic stroke.Methods:1?Comparative study on the efficacy and safety of aggressive medical management and stent therapy for severe symptomatic atherosclerotic intracranial artery stenosis.2890 patients who underwent cerebral vascular angiography in Southwest Hospital from January 2010 to June 2015 were collected.According to the inclusion and exclusion criterion,83 cases of ischemic stroke with the severe symptomatic atherosclerotic middle cerebral artery(MCA)stenosis were enrolled.The subjects were divided into aggressive medical management group and the stenting treatment group(stenting treatment + aggressive medical management).The observation indexes were based on SAMMPRIS study.The primary end point events refers to the ipsilateral stroke recurrence within 30 days,any stroke,any death,symptomatic cerebral hemorrhage and the ipsilateral stroke recurrence beyond 30 days.The secondary end point events refers to any stroke,any death,myocardial infarction and symptomatic cerebral hemorrhage in follow-up period.The US national institutes of health stroke nerve function damage quantity scale on admission and modified rankin scale(mRS)at 1 year were observed.2?The pilot study of the effect and mechanism about neural functional recovery of the aggressive medical management for acute ischemic stroke.18 cases who met the included criteria and exclusion criteria between November 2015 to December 2016 in the southwest hospital were randomly assigned to general medical treatment group and aggressive medical management group.All subjects receive immediately corresponding treatment and MRI scans including T1 WI,T2WI,DWI,FLAIR,ASL.After 24 hours,all subjects received the same sequence of MRI scans again.The NIHSS score of the subjects on admission,24 hours and 7 days and the mRS Score on 90 days were observed.The change of magnetic resonance perfusion before and after the treatment was analyzed.Results:1?The efficacy and safety study of aggressive medical management versus stenting treatment for the severe symptomatic atherosclerotic intracranial arterial stenosis in young patients.No statistical difference was found between two groups of baseline data of age,risk factors,vascular stenosis degree and the NIHSS score(P>0.05).The ipsilateral stroke recurrence rates of aggressive medical management group(47 cases)and the stenting treatment group(36 cases)within 30 days were 10.64%(5 cases)versus 0%(0 cases),respectively.There was no significant difference between two groups(P>0.05).The incidence of ipsilateral stroke recurrence within 1 year were 21.28%(10 cases)versus 2.78%(1 case),respectively.The recurrence rate of the stenting treatment group was significantly lower than aggressive medical management group(P<0.05).No cerebral hemorrhage and death occurred in both groups.The ratio of mRS ?2 points of patients in two groups were 82.98%(39 cases)versus 97.22%(35 cases),respectively.There was no statistically difference between each group(P>0.05).2?The perspective pilot study of the effect and mechanism about neural functional recovery of the aggressive medical management for acute ischemic stroke.The average NIHSS score of general medical treatment group and aggressive medical management group on admission were 8.11±3.33 versus 6.89±2.20(P>0.05),respectively.No statistical difference was found between two groups of baseline data for risk factors.The average NIHSS score of two groups at 24 hours were 8.22±3.23 versus 6.44±2.01,respectively and there was no statistically significant difference(P>0.05).The average NIHSS score of two groups on 7 days were 7.22±4.15 versus 4.56±2.83 respectively and no significant difference was observed(P>0.05).The average mRS score on 90 days of aggressive medical management group(1.22±1.09)is significantly lower than the general medical treatment group(2.44±1.33).The rate of stroke within 90 days in general medical treatment group and aggressive medical management were 11.11%(1 cases)versus 0%(0 cases),respectively.The aggressive medical management group is lower than the general medical treatment group,but the difference is not statistical(P>0.05).There was no death in the two groups during the follow-up of 90 days.The core infarction area signal intensity observe by ASL before the treatment were-340.78±248.79 versus-384.23±219.59 for each group and there was no difference(P > 0.05).The results after treatment were-182.51±122.71 versus 59.39±312.93,respectively and the difference was statistically significant(P < 0.05).The difference of aggressive medical management group(443.62.51±293.79)is significantly higher than general medical treatment group(158.27±225.33)(P<0.05).The core infarction surrounding area signal intensity observe by ASL before the treatment were 59.01±215.82 versus 212.42±128.02 and there was no difference(P>0.05).The two groups after treatment were 122.19±159.77 versus 372.43±132.39,respectively.The aggressive medical management group is significantly higher than general medical treatment group(P<0.05).the difference in the two groups before and after treatment were 63.18±133.24 versus 160.07±133.76,respectively and no difference was found(P>0.05).Conclusion:1?Stenting treatment for the severe symptomatic atherosclerotic intracranial arterial stenosis in young patients is safe and efficacy which significantly reduce the risk of stroke recurrence in 1 year and has a tendency to improve nerve function.2?The aggressive medical management is better than that of general medical treatment for promoting neural functional recovery in patients with acute ischemic stroke,which may be related to improved lesions and peripheral perfusion. |
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