| ObjectiveIntracranial atherosclerosis stenosis is the leading cause of ischemic stroke and TIA in our country, clinically, intracranial atherosclerotic stenosis with occurrence of TIA or cerebral infarction is defined as symptomatic intracranial arterial stenosis, which is the risk of recurrence of TIA and ischemic stroke, therefore the main point of secondary prevention. The pathogenesis of symptomatic intracranial arterial stenosis is related to distal hemodynamic disorder, thrombosis or embolus dislodgement due to unstable plaque, perforator occlusion, etc. Treatment strategies include Medical treatment (Western medicine treatment and Integrative Chinese and Western medicine treatment) and Surgical treatment (Mainly Endovascular treatment and vascular anastomosis). Western medicine treatment has a rather high recurrent stroke rate, while Endovascular treatment is facing the risk of perioperative complication and post procedure restenosis in stent. Due to the difficulties of accurate analysis of the pathogenesis of symptomatic intracranial arterial stenosis in clinical practices, the choice of a safe and effective treatment approach for secondary prevention remained controversial. Xenon computed tomography (Xenon-CT) is a quantitative determinable, safe, reliable and low cost means to evaluate cerebral perfusion, and high-resolution MRI (HR-MRI) has an advantage in analyzing the feature of plaque. With the application of the Xeon-CT and HR-MRI for symptomatic intracranial arterial stenosis, understanding and analyzing of the feature of plaque in site and distal hemodynamic changes should be achieved, combined with other imaging findings, could allow to analyze the pathogenesis of symptomatic intracranial arterial stenosis. On the other hand, the many years of practice of encephalopathy center of Guangdong Provincial Hospital has shown that Integrative Chinese and Western medicine treatment is safe and effective as a secondary prevention strategy of ischemic stroke, and can significantly improve prognosis, especially for patients with symptomatic intracranial arterial stenosis. This study was designed to analysis the pathogenesis of symptomatic intracranial arterial stenosis under the guidance of the Xenon-CT and the HR-MRI, and to evaluate the safeness and effectiveness of Integrative Chinese and Western medicine treatment.Methods20patients with symptomatic intracranial arterial stenosis patients (administrated from January2010to February2012), with stenosis rate greater than or equal to50%, were engaged with Xenon-CT and HR-MRI examination. Based on the test result, the patients were divided into Integrative Medical Treatment group and Endovascular Treatment group. Patients within Integrative Medical Treatment group were given Traditional Chinese Medicine besides western medicine treatment (double antiplatelet regimen, intensive hypolipemic treatment and active controll of risk factors), treatment period lasted for3weeks, while patients within Endovascular treatment group underwent intravascular stenting of target vessel with WINSPAN stent system. Then analysis the recurrent stroke rate and mortality rate and mordality rate within30days and beyond30days during follow-up period.Result1. Of20patients with symptomatic intracranial arterial stenosis,7cases presented with TIA,11cases with acute infraction and2cases with Vertebrobasilar insufficiency. Number of male and female patient is14and6separately, age ranging from41-87, with an average of64.75±8.96. of17cases located in the anterior circulation,3cases was located at Intracranial internal carotid artery,12cases Ml section of MCA,1case M2section of MCA and1case A1section of ACA. And the other3cases located in the posterior circulation,1case was located at intracranial segment of vertebral artery,2cases basilar artery. Amoung them, there are11cases with moderate stenosis (stenosis rate up to50～69%), all located in the anterior circulation, and9cases with severe stenosis (stenosis rate up to more than70%),6located in the anterior circulation, the other3located in the posterior circulation. 2.17cases with intracranial arterial stenosis in the anterior circulation received Xenon-CT examination, and4of17cases received HR-MRI examination. Xenon-CT showed normal regional cerebral blood flow in12cases, and abnormal plaque signal of vessel wall was detected via HR-MRI in3cases. Xeon-CT showed showed a decrease of CBF in related brain area in5cases, and HR-MRI showed arterial dissection in1case of5cases. The other3cases with intracranial arterial stenosis in the posterior circulation received HR-MRI examination, which showed mixed plaque (unstable plaque) in the patient with intracranial segment of vertebral stenosis, and of the other2cases of basilar artery stenosis, eccentic plaque formation (not in close relation with perforating branches) was seen in one case, and severe negative reconstruction of vessel wall in the other case. There is a significant difference of CBF value between moderate and severe stenosis of target vessel (P<0.05), which demonstrated that for patients with moderate stenosis, hemodynamic dysfunction is not the primary pathogenesis. There is also a significant difference of TIA attack incidence between patients with normal and abnormal Xenon-CT result (P<0.05), which demonstrated that the incidence of TIA in the anterior circulation is related to distal hemodynamic disorder.2cases from Endovascular treatment group showed significant increase of CBF after operation compared to that before operation (P<0.05), and this result allow to support the theory that endovascular treatment can improve distal blood supply. Kruskal Wallis test showed that HR-MRI has a favorable outcome of reliability in detecting morphology of plaque, relationship of plaque with perforators, reconstruction, enhancement, dissection and pseudostenosis, while not reliable in analysis about characteristic of plaque.3.14cases were selected for the Integrative Medical treatment group, among them2cases with a decrease in CBF in related brain area shown by Xenon-CT (originally included into the Endovascular treatment group, but transfered into Integrative Medical treatment group due to declination to operation), and1case of basilar stenosis (HR-MRI showed severe negative reconstruction) was included into Integrative Medical treatment group due to the consideration on high operative risk.9cases of them were regarded as the "Yin" kind of Traditional Chinese Medicine, while the other5the "Yan" kind.6cases were selected for Endovascular treatment group, and of6cases3cases of MCA stenosis with a decrease in CBF in related brain area shown by Xenon-CT,1 case of MCA stenosis with normal CBF in related brain area shown by Xenon-CT (underwent recurrent ipsilateral ischemic stroke while receiving standard western medicine treatment), and1case of basilar artery stenosis (HR-MRI show eccentric plaque formation, not in close relation with perforating branches) and1case of vertebral artery stenosis.5cases of them were regarded as the "Yin" kind of Traditional Chinese Medicine, while the other1the "Yan" kind.4. Within30days, no cases of recurrent stroke and death in the Integrative Medical treatment group, and infarction of pons occurred in1case(basilar artery stenosis) from the endovascular treatment group postopratively without neurological dysfunction after treatment. During the Follow-up period ranges from3months to10months with an average of6.5months,1case from the Integrative Medical treatment group suffered from ipsilateral ischemic stroke (4month after discharge)without neurological dysfunction after treatment, and1case from the Endovascular treatment group suffered from ipsilateral stroke(2months after operation)with mild neurological dysfunction after treatment. If to exclude the2cases with decrease in CBF in related brain area (originally included into the Endovascular treatment group, but transfered into Integrative Medical treatment group due to declination to operation), among the12cases from Integrative Medical treatment group, within the follow-up period of an average of7.4months, none of ipsilateral recurrent stroke took place, comparing with1case from Endovascular treatment group suffered from ipsilateral recurrent stroke (2months after operation) with mild neurological dysfunction after treatment. In the term of End Event (recurrent stroke rate and morality and modality within30days and beyond30days), the result of Integrative Medical treatment group in our study was lower than the medical treatment group in SAMMPRIS study.Conclusion1. Xenon-CT can filter out hemodynamic disorder in the patients with sympomatic intracranial arterial stenosis of anterior circulation, and to determinate the appropriate treatment and evaluate hemodynamic changes after treatment and effectiveness of endovascular treatment. HR-MRI can detect morphology of plaque, relation of plaque with perforators, reconstruction, which allow to evaluate the risk of endovascular treatment. Hemodynamic disorder is not the primary pathogenesis of moderate symptomatic intracranial arterial stenosis of the anterior circulation. TIA caused by symptomatic intracranial arterial stenosis in the anterior circulation is related to distal hemodynamic disorder.2. Xenon-CT and HR-MRI combined with conventional imaging had significant direction in formulating a individual and safe treatment strategy with desirable short term efficacy.3. Analysis of short term result suggest that Integrated Chinese and Western Medicine treatment might promote conversion of the unstable plague into stable plaque, so as to reduce the rate of recurrent ischemic stroke. The low ipsilateral recurrent ischemic stroke rate from the Integrated Chinese and Western Medicine group might be related to the stabilization of plaque and inhibition to thrombosis, thrombus dislodgement, which suggest that Tradition Chinese Medicine might play a positive role in this process.4. Further research is needed to determine the efficacy of Integrative Chinese and Western Medicine treatment on high risk patients (complicated with hypoperfusion and unstable plaque). The medium and long term efficacy of this study still needs further validation from long term follow-ups or clinical randomized controlled trials. |
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