Acute Serious Ischemic Stroke:Analysis Of Etiology, Endovascular Treatment Medium-term Outcome Of Stroke Subtypes

Objective:To analysis the etiology, clinical feature, characteristic of digital subtraction angiography (DSA) of patients with different subtypes of acute serious ischemic stroke(ASIS) To discuss flowchart for management of ASIS and strategy of endovascular treatment to ASIS on the basis of etiologic subtype, to assess medium-term outcome of patients with different subtypes of ASIS.Methods:Part one:Between January2012and October2013, we analysis and summary clinical data of patients of the PLA general Hospital retrospectively, who presented with acute serious ischemic stroke. Every patient was classified according to the TOAST and modified TOAST on the basis of clinical variables and imaging, we assessed functional outcome at3months via modified Rankin Score (mRS) scale serially. Part two:This was a retrospective, single-center study of36patients with ASIS attributable to a large artery stenosisi and/or occlusion between January2012and January2014, who was treated by endovascular management.Result:Part one:In232patients who meeted a criterion, large-artery atherosclerosis (LAA) counted for53.9%, small artery occlusion (SAO) counted for21.1%, cardioembolism (CE) counted for18.1%, stroke of other demonstrated etiology (SOE) counted for4.7%, stroke of other undemonstrated etiology (SUE) counted for2.2%. The percentage of male in LAA subtype was highest (75.2%), CE subtype was lowest (45.2%). The average age of CE subtype was eldest (61.9±13.2), the SOE subtype was youngest (42.4±11.4). The percentage of hypertetion in SAO subtype was highest (77.6%), SUE subtype was lowest (20.0%). In the LAA subtype, lesion of antier circulation artery counted for72.8%, lesion of posterior circulation artery counted for27.2%, the ASIS patients due to stenosis or occlusion of carotid artery counted for40%, due to stenosis or occlusion of middle cerebral artery(MCA) counted for29.6%. The patients percentage of in CE subtype whose cardiogenic embolus was stopped in MCA was highest (61.9%). In SAO subtype, ASIS due to perforating artery occlution of antier circulation artery counted for63.3%. The9of11cases in SOE subtype was due to artery dissection, everyone of9cases presented with different levels of headache. The National Institutes of Health Stroke Scale (NIHSS) scores of SAO subtype was lowest. The percentage of patients with the favorable functional outcomes (mRS>2) in SAO subtype was highest (73.5%), in CE subtype was lowest (33.3%). The disability rate in LAA subtype was highest (55.2%). The mortality rate in CE subtype was highest (11.9%).Part two:Male:female was28:8, average age was58.2±13.5(22-79years). large-artery atherosclerosis (LAA) counted for63.9%(23cases, male20, average age60.2years); cardioembolism (CE) counted for19.4%(6cases, male3, average age67.0years); artery dissection counted for11.1%(4cases, male4, average age35.3years);1female patents was with big thrombus located in initial of left inter carotid artery (ICA) due to hypereosinophilic syndrome;1male patents had right middle cerebral artery occlusion due to artery-artery embolism from right ICA serious stenosis of extracranial segment, who had none of risk factor to arteriosclerosis. Mean National Institutes of Health Stroke Scale (NIHSS) scores13.9(range,8-31). The mean time from onset to needle puncture of femoral artery was4.7h, The mean time of procedure was1.5h, The mean time from onset to finishment of procedure or complete recanalization was6.3h. Superselective thrombolisis with urokinase via microcatheter:13cases, mechanicalthrombectomy using the Solitaire AB stent system as the single treatment:6cases, mechanical thrombectomy using the Solitaire AB stent system+aspiration+stenting:2cases, mechanical thrombectomy using the Solitaire AB stent system+stenting:7cases, Superselective thrombolisis with urokinase via microcatheter+stenting:4cases, Superselective thrombolisis with urokinase via microcatheter+mechanical thrombectomy using the Solitaire AB stent system:3cases, Superselective thrombolisis with urokinase via microcatheter+aspiration lease. Successful revascularization defined as thrombosis in cerebral ischemia grade2b or3was achieved in27of36(75%) treated vessels.Symptomatic intracranial hemorrhage was found in2(5.5%) patients,3(8.3%) patients died during the90-day follow-up period, and47.2%of patients (17/36) showed good functional outcome at3months (mRS>2).conclusion:The patients with ASIS due to LAA etiology was more than half, and with characteristic of high disability rate and poor prognosis. The average age of CE subtype was eddest, the patients in CE subtype was with highest rate of disability and mortality,hemorraghe after cerebral infarction, and with the most common feature of cardiogenic embolus was easy to stopped in MCA. The hypertension was the major risk factor of SAO subtype patients, but SAO subtype had good prognosis usually. In the SOE subtype, the cerebral artery dissection was most common reason, the most patients of young and middle-aged with ASIS was due to artery dissection. The rational and workables flowchart for management of acute serious ischemic stroke (ASIS) can shorten time from onset to needle puncture of femoral artery. The correct endovascular therapeutic schedule can shorten time of procedure and have good prognosis to patients on the basis of etiology. The results suggest that the Solitaire AB device can rapidly, safely, and effectively retrieve clots from the middle cerebral artery, terminus of ICA and vertebral-basilar artery. The tandem lesion of ICA and MCA due to carotid artery stenosis or occlusion had more long time to revascularize, had poor prognosis compare to other subtype ASIS. The patients of different etiology with ASIS have different time of procedure to revascularization, endovascular therapeutic schedule and prognosis.