| The paper involved two aspects:(1)the clinical significance of evaluating collateral circulation in patients with chronic middle cerebral artery occlusion by vascular ultrasound;(2)correlation between cerebral hemodynamic changes and cerebral infarction volume in patients with chronic middle cerebral artery occlusion.Part Ⅰ:The clinical significance of evaluating collateral circulation in patientswith chronic middle cerebral artery occlusion by vascular ultrasoundObjectiveTo study the clinical significance of transcranial Doppler(TCD)and/or transcranial color-coded sonography(TCCS)in the evaluation of collateral circulation in patients with unilateral chronic middle cerebral artery occlusion(CMCAO).Methods1.Clinical data:From August 2015 to April 2018,fifty-four consecutive patients diagnosed as unilateral CMCAO by TCD and/or TCCS and confirmed by digital subtraction angiography(DSA)from the First Affiliated Hospital of Soochow University were enrolled retrospectively.Inclusion criteria:(1)patients who had good temporal windows for TCD examination were included;(2)patients whose clinical data such as DSA and CT perfusion sufficiently were included;(3)patients who signed informed consent were included.Exclusion criteria:(1)patients who had multiple stenosis of the intracranial artery or severe stenosis or occlusion of the extracranial carotid artery and severe stenosis or occlusion of the contralateral MCA were excluded;(2)patients who either had stenosis or had congenital absence in anterior cerebral artery(ACA)were excluded;(3)patients who had stenosis in posterior cerebral artery(PCA)or embryonic posterior cerebral artery were excluded.2.Grouping criteria:According to the criteria developed by the Chinese Acute Ischemic Stroke Diagnosis and Treatment Guide 2014,they were divided into three groups by the clinical manifestations:(1)27 patients in cerebral infarction(CI)group showed hemiplegia or partial sensory disturbance for more than 24 hours or new infarction found in imaging examinations;(2)19 patients in transient ischemic attack(TIA)group showed transient darkness,diplopia,aphasia,unilateral limb movement or sensory disturbance less than 24 hours;(3)8 patients in the asymptomatic group showed no symptoms of obvious neurological localization or only showed dizziness and headache.3.Method of examination:3.1 TCD and/or TCCS examination:TCD and/or TCCS were used to measure and recordthe mean velocity(MV)of bilateral ACA and PCA according to The chinese Guidelines for Ultrasound Examination of Stroke through temporal windows,and the ratios of ipsilateral MV to the contralateral were calculated(MViACA/MVcACA,MViPCA/MVcPCA).The hemodynamic parameters detected by TCD were used in the statistical data of this study.3.2 The DSA examination:The DSA was used to evaluate the leptomeningeal anastomoses(LMA)grades of unilateral CMCAO patients according to the American Society of Interventional and Therapeutic Neuroradiology/Interventional Radiology(ASITN/SIR)collateral circulation assessment system.The poor collateral circulation was from 0 to 1 grade and the Moderate was 2 grade,and the good was from 3 to 4 grade.3.3 The CTP examination:The CTP was used to assess cerebral perfusion in patients by a semi-quantitative method using relative CT perfusion parameters-ratio of parameters of affected side to the healthy side,including relative cerebral blood flow(rCBF),relative cerebral blood volume(rCBV),and relative mean transit time(rMTT),relative peak time(rTTP).In this study,the temporal lobe was selected as the region of interest(ROI)for perfusion parameter analysis.4.Statistical methods:The hemodynamic parameters of the three groups were compared by one-way ANOVA analysis and The Tukey test was used to compare the two groups.The distribution of the leptomeningeal anastomoses(LMA)grading was analyzed.Kruskal-Wallis H test was used to compare the relative perfusion parameters of temporal lobe and the Bonferroni method was used to correct the significant level of post-operative comparison.Spearman rank correlation analysis was used to analyze the correlation between the hemodynamic parameters of the affected side ACA and PCA and the LMA grading.Results1.Comparison of ultrasound hemodynamic parameters:MViACA,MViPCA and MViACA/MVcACA,MViPCA/MVcPCA in asymtom group and TIA group were higher than those in CI group,and the differences were statistically signifcant(P<0.05).2.LMA grading comparison:The median LMA grading in the asymptomatic and TIA groups was higher than in the CI group(3.5 and 3 vs 2).3.Comparison of relative CTP parameters:Relative cerebral blood flow(rCBF)and relative cerebral blood volume(rCBV)in asymtom group and TIA group were higher than those in CI group,and the differences were statistically signifcant(P<0.05),the relative mean transit time(rMTT)and relative peak time(rTTP)were lower in asymtom and TIA group than in CI group,and the differences were statistically signifcant(P<0.05).4.Correlation analysis:MViACA and MViACA/MVcACA were signifcantly positively correlated(r=0.568,P<0.001;r=0.757,P<0.001);MViPCA and MViPCA/MVcPCA were positively correlated with LMA grades on DSA(r=0.383,P=0.004;r=0.624,P<0.001).Conclusion1.The LMA grade of patients with unilateral CMCAO was higher in the asymptomatic group and the TIA group,indicating that the collateral circulation was significantly associated with the clinical outcomes of the patient.2.The hemodynamic parameters of ACA and PCA on TCD and/or TCCS have significant correlation with the LMA grades on DSA and have good consistency with the CTP results,which play an important role in guiding patients with unilateral CMCAO to select individualized treatment strategies.Part Ⅱ:Correlation between cerebral hemodynamic changes and cerebral infarction volume in patients with chronic middle cerebral artery occlusion ObjectiveTo investigate the characteristics of hemodynamic parameters in MCA region of patients with unilateral chronic middle cerebral artery occusion(CMCAO)and its correlation with cerebral infarction volume.Methods1.Clinical data:From October 2015 to July 2018,43 consecutive patients diagnosed as unilateral CMCAO in neurology and neurosurgery department were enrolled retrospectively,among them,31 patients with unilateral limb movement or sensory disturbance,7 patients with transient ischemia such as transient black sputum,diplopia and aphasia,5 patients with no obvious symptoms but dizziness and headache.Inclusion criteria:(1)patients who were diagnosed unilateral MCA occlusion more than 3 months were included;(2)TCD and/or TCCS,DSA,magnetic resonance diffusion weighted imaging(MRI-DWI)examination,magnetic resonance angiography(MRA),these examinations were all done within 72h;(3)patients who signed informed consent were included.Exclusion criteria:(1)patients who had multiple stenosis of the intracranial artery or severe stenosis or occlusion of the extracranial carotid artery were excluded;(2)patients who were multiple infarcts in DWI were excluded.2.Method of examination and grouping:2.1 TCD and/or TCCS examination:TCD and/or TCCS were used to measure and record the mean velocity(MV)of contralateral and ipsilateral MCA according to The Chinese Guidelines for Ultrasound Examination of Stroke through temporal windows,and the ratios of bilateral MV of MCA were calculated(MVcMCA/MViMCA).The hemodynamic parameters detected by TCD were used in the statistical data of this study.2.2 The DSA examination:The DSA was used to evaluate the leptomeningeal anastomoses(LMA)grades of unilateral CMCAO patients according to the American Society of Interventional and Therapeutic Neuroradiology/Interventional Radiology(ASITN/SIR)collateral circulation assessment system.Grouping criteria:poor LMA group:0-2 grade;good LMA group:3-4 grade.2.3 MRI-DWI examination:According to the results of MRI-DWI,patients who were single cerebral infarction in MCA region were divided into 4 groups,including no infarction group,small volume group,medium volume group and large volume of cerebral infarction group.3.Statistical methods:The measurement data conforming to the normal distribution were compared using the independent sample t test,the Mann-Whitney U test was used for the non-Conformity distribution parameters,the Mann-Whitney rank sum test was used for the comparison between the rank data groups,and the χ2 test or Fisher’s exact probability test was used for the count data,Spearman rank correlation analysis was used to analyze the correlation between MCA flow paramaters and the cerebral infarction volume.Results1.Comparison of symptoms:The proportion of stroke patients in good LMA group was significantly lower than that in poor LMA group,and the proportion of asymptomatic patients in good LMA group was significantly higher than that in poor LMA group(P=0.031).2.Comparison of ultrasound hemodynamic parameters:MViMCA was higher in the good LMA group than in the poor(t=-5.900,P<0.001)and MVcMCA/MViMCA was lower in the good LMA group(Z=-4.434,P<0.001).3.Comparison of brain infarct volume:The proportion of patients with no infarction and small volume infarction in the good LMA group was significantly higher than that in the poor LMA group(84.6%vs 34.3%),and there was significant difference in infract volume distribution between the two groups(Z=-3.518,P<0.001).4.Correlation analysis:The cerebral infarction volume in poor LMA group was highly negatively correlated with MViMCA(r=-0.716,P=0.001),and highly positively correlated with MVcMCA/MViMCA(r=0.770,P<0.001).Conclusion1.The degree of LMA compensation in patients with unilateral CMCAO is significantly correlated with the volume of cerebral infarction and symptoms,indicating that good collateral compensation can decrease the volume of infarct and alleviate the clinical symptoms of patients.2.The increase in MCA velocity on the affected side assessed by TCD and/or TCCS in patients with CMCAO was significantly correlated with LMA compensation and was significantly negatively correlated with cerebral infarction volume. |
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