Subtypes Of Intracranial Anterior Circulation Large Artery Occlusions And Prognoses Of Related Cerebral Infarction

Part One: Subtypes and characteristics of anterior circulation large artery occlusions(AC-LAO)Objective: The aim is to find out the incidence of AC-LAO in the Chinese population,analyze whether certain risk factors can make AC-LAO patients more prone to ischemic stroke or more severe consequences,in hopes of addressing these factors with proper interventions to help improve their prognoses.Methods: 1199 patients admitted to the Second Hospital of Hebei Medical University from June 1,2016 to April 30,2018 were diagnosed by cranial computed tomography angiography(CTA)or magnetic resonance angiography(MRA)in the neck.Inpatients with single or multiple main occlusions of the intracranial arterial(ICA)and/or middle cerebral artery(MCA)were the study subjects.Data were collected from the hospital's internal database for analysis after approval by the ethics committee.Results: The arteries involved in the anterior cranial circulation occlusion can be divided into eight subtypes.Unilateral MCA(UMCA,46.5%,n=558)occlusion is the most common type of AC-LAO,and the others are as follows: unilateral ICA(UICA,27.9%,n=334)occlusion,tandem ICA/MCA(TICA/MCA,11.2%,n=134)occlusion,bilateral MCA(BMCA,5.2%,n=63)occlusion,bilateral ICA combined with bilateral MCA(BICA/BICA,4.3%,n=51)occlusion,bilateral MCA combined with unilateral ICA(BMCA/UICA,2.3%,n=28)occlusion,bilateral ICA(BICA,1.5%,n=18))occlusion,and bilateral ICA combined with unilateral MCA(BICA/UMCA,0.3%,n=3)occlusion.Non-parametric tests were used to analyze the differences between these subgroups.The results showed age(P=0.001),gender(P<0.001),smoking history(P=0.001),heart disease(P<0.001),Apo B(P=0.018),and history of previous ischemic stroke(P<0.001)were significantly different between these groups.Of the 1,199 patients with AC-LAO,a total of 184(15.3%)patients had never experienced an ischemic stroke event(including transient ischemic attack and cerebral infarction).In a further logistic regression model,hyperhomocysteinemia(OR=2.625;95%CI 1.8-3.8)is an independent predictor of ischemic stroke events in patients with anterior circulation aortic occlusion.Conclusions: Different AC-LAO subtypes have significant differences in age,gender,smoking history,history of heart disease,Apo B,history of previous ischemic stroke,and associated acute infarction;hyperhomocysteinemia is independent risk factor for ischemic cerebrovascular events in AC-LAO patients,but the likelihood of suffering from ischemic cerebrovascular events does not increase with increasing homocysteine levels.Part Two: Short-term prognoses and risk factors of ACI patients with AC-LAOObjective: This section studies the clinical characteristics of ACI patients with different subtypes of AC-LAO,and further analyzes the influencing factors of AC-LAO severity and related factors of short-term prognoses of such patients.Methods: A retrospective analysis of 787 consecutive hospitalized ACI patients with AC-LAO in Shijiazhuang,Hebei Province,China.AC-LAO is defined as the complete occlusion of at least one ICA intracranial segment or MCA based on CTA and/or MRA.Data were collected from the hospital's internal database for analysis after approval by the ethics committee.Results: Unilateral MCA occlusion(49.8%,n=392)is the most common type of ACI,followed by unilateral ICA occlusion(24.1%,n=190),tandem ICA/MCA occlusion(12.7%,n=100),bilateral MCA occlusion(5.3%,n=42),bilateral ICA combined with bilateral MCA occlusion(4.2%,n=33),bilateral MCA combined with unilateral ICA occlusion(2.7%,n=21),bilateral ICA occlusion(0.9%,n=7),and bilateral ICA combined with unilateral MCA occlusion(0.3%,n=2).Factors including age(P<0.001),gender(P=0.006),smoking history(P=0.002),history of ischemic stroke(P<0.001),complications(P=0.014),single or multiple infarctions(P=0.006),ASPECTS score(P<0.001),NIHSS score(P<0.001),and m RS score(P<0.001)were different in each group.Compared with unilateral MCA occlusion(P=0.016),unilateral ICA occlusion(P=0.008),and bilateral ICA occlusion(P=0.047),the prognoses of patients with BICA/BMCA combined with ACI are poor.Compared with unilateral MCA occlusion(P=0.001)and unilateral ICA occlusion(P=0.004),the prognoses of patients with TICA/MCA combined with ACI is poor.Long-term hospitalization(OR=1.04;95%CI 1.01-1.07),higher NIHSS score(OR=1.37;95%CI 1.30-1.45),lower ASPECTS score(OR=0.87;95%CI 0.81-0.93),and complication(OR=1.84;95%CI 1.11-3.05)were independent predictors of poor clinical outcome.In terms of age(P=0.001),smoking history(P=0.017),Apo A1 level(P=0.048),ischemic stroke history(P<0.001),ASPECTS(P<0.001),NIHSS(P<0.001),m RS(P<0.001),complications(P<0.001),and infarction subtype(P=0.007),there were differences in patients with different severity of AC-LAO.Age(OR=1.022,95%CI 1.007-1.036)was an independent risk factor for AC-LAO patients to worsen;Apo A1(OR=0.453;95%CI 0.235-0.953)was an independent protective factor.There is a correlation between the AC-LAO subtype and the type of infarction.Conclusions: Compared with patients with UMCA occlusion,the BICA/BMCA occlusion group and TICA/MCA occlusion group have the worst prognosis when ACI occurs.Patients with UICA occlusion are more likely to have cerebral infarction due to hypoperfusion/embolism reduction.Patients with UMCA occlusion are more prone to infarction due to arterial-to-arterial embolism,while patients with BICA/BMCA occlusion are more likely to have infarction due to carrier arterial occlusion and perforation.Age promoted the progression of AC-LAO from single vessel to multiple vessel occlusion,while Apo A1 inhibited this course.Part Three: Long-term prognoses and recurrence of ACI patients with AC-LAOObjective: In this part of the study,we followed up with the above-mentioned patients,observed the long-term prognoses of AC-LAO patients and the recurrence of cerebral infarction,collected case data for analysis,and found out that there is a clearer guiding significance for the long-term prognoses of AC-LAO patients.The related factors aim to provide a new important direction for secondary prevention of ACI patients with AC-LAO.Methods: A total of 241 AC-LAO patients diagnosed with transcranial CTA admitted to the Second Hospital of Hebei Medical University from July 1,2017 to April 30,2018 were collected.Data were collected from the hospital's internal database for analysis,and the patients were followed up via a telephone questionnaire with a median period of 1 year after onset.Results: A total of 87 patients were followed up,of whom 70 had good prognoses(m RS<4),and another 17 had poor prognoses(m RS?4).Patients with good prognoses and poor prognoses are different in terms of age(P=0.001),AF(P=0.036),complications(P=0.028),ASPECTS(P=0.033),whether statins are taken orally after discharge(P<0.001),and whether the oral antiplatelet drugs were regularly administered after discharge(P<0.001).Further analysis showed that age(OR=1.123,95%CI 1.042-1.227)was independent risk factors for poor prognoses;regular intake of statins after discharge(OR=0.023,95%CI 0.002-0.266)is an independent protective factor for prognoses.Conclusions: Age is independent risk factors for poor long-term prognoses;regular statin intake after discharge is an independent protective factor for long-term prognoses in these patients.