| Stroke is one of the most lethal and disabling diseases in the world.The incidence rate is increasing year by year,and the absolute number of stroke population continues to grow.Stroke not only seriously threatens the life and health of patients,but also brings heavy economic burden to patients’ family and society.Stroke is divided into two types: ischemic stroke and hemorrhagic stroke.The proportion of ischemic stroke in the total number of stroke patients is as high as 85%.As we all know,carotid artery stenosis is one of the most common causes of ischemic stroke.According to the current guidelines,surgical treatment should be considered for asymptomatic patients with stenosis greater than or equal to 70% or symptomatic patients with stenosis greater than or equal to 50%.Surgical treatments for carotid stenosis include carotid endarterectomy(CEA)and carotid angioplasty stenting(CAS).For a long time,although CEA is the gold standard for the treatment of carotid artery stenosis,CAS has some advantages that CEA lacks,such as: 1.minimally invasive,short hospital stay and fast postoperative recovery;2.it can deal with high internal carotid artery stenosis;3.it can deal with part of carotid artery tandem stenosis.Therefore,CAS is also widely used in clinic.It has been reported that after CAS,about 1.1%-6.8% of patients with carotid artery stenosis will develop cerebral hyper perfusion syndrome(CHS),which will lead to brain parenchyma swelling and even intracranial hemorrhage(ICH).The pathophysiological mechanism of CHS is the rapid increase of cerebral blood flow caused by the dysfunction of cerebral autoregulation(CA).In this case,hypotensive therapy after CAS can reduce the risk of CHS.However,excessive lowering of blood pressure may further reduce the perfusion of brain tissue which is already in the ischemic state,and even lead to cerebral infarction(CI).Therefore,the strategy of blood pressure control after CAS has been full of controversy,lack of specific and safe evidence recommendation.After carotid revascularization,the arterial blood pressure of CAS patients is not stable.Some patients’ blood pressure increases significantly,while some decreases.These two states are collectively referred to as hemodynamic instability(HI).This may be due to the stimulation of carotid sinus baroreceptor by radial force produced by stent placement during carotid revascularization.HI may persist after CAS and increase the risk of CHS and ischemic stroke.Then,what are the risk factors of HI,and whether it will affect the long-term prognosis of patients with carotid artery stenosis are still unknow.Studies have shown that carotid artery stenosis can lead to cognitive dysfunction in patients,mainly manifested as the decline of understanding and judgment ability,recent memory decline and so on,which can gradually progress to dementia.This may be related to the long-term low perfusion state of the brain,leukosis,multiple lacunar infarction.CAS can reduce the risk of ischemic stroke in patients with carotid artery stenosis,thereby reducing the mortality and disability rate.Although it can significantly improve cerebral blood flow,surgical procedures may increase the risk of micro-thrombotic events.Therefore,whether CAS can improve cognitive function in patients with carotid artery stenosis is controversial.On the other hand,although the number of hemorrhagic stroke is relatively small,the disease development is more rapid,the mortality is high,and the clinical outcome is worse.Spontaneous cerebellar hemorrhage(SCH)is the representative.Because of the narrow space of the posterior fossa,even a small amount of bleeding can cause obstructive hydrocephalus,brain stem compression,and even hernia formation,resulting in rapid deterioration of clinical symptoms,with a mortality rate of 18%-75%.Therefore,spontaneous cerebellar hemorrhage needs more active surgical hematoma removal.But not all patients can benefit from it,there are still a considerable number of patients with poor prognosis.This may be related to the volume of perihematomal edema(PHE).Therefore,for this kind of patients,it is particularly necessary to study the factors leading to different prognosis.In order to solve the above clinical problems,we collected the clinical and imaging data of patients with carotid artery stenosis who underwent CAS in our center,and followed up the patients.Through different statistical methods,we preliminarily studied and analyzed the safety of different blood pressure control strategies during the perioperative period of CAS;the impact of HI on the long-term prognosis of patients after CAS and its risk factors;the changes of cognitive function and risk factors after CAS.It provides evidence recommendation for clinical treatment of patients with carotid artery stenosis.On the other hand,we included the perioperative imaging characteristics of SCH patients into the study to explore the risk factors that affect the prognosis of these patients.This study is divided into the following four parts:1.The influence of different blood pressure management strategies on the short-term prognosis of patients with carotid artery stenosis during the perioperative period of CAS.2.The effect of hemodynamic instability on the long-term prognosis of patients with carotid stenosis after CAS.3.The change of cognitive function after CAS and the influence of different blood pressure control strategies on cognitive function during perioperative period.4.Analysis of risk factors for poor prognosis in patients with spontaneous cerebellar hemorrhage after hematoma removal.Part Ⅰ The influence of different blood pressure management strategies on the short-term prognosis of patients with carotid artery stenosis during the perioperative period of CASMethods A total of 173 patients with carotid stenosis who underwent CAS in our hospital from January 2016 to April 2019 were included,including 140 males and 33 females.The clinical and imaging data were retrospectively analyzed.Patients were grouped according to different blood pressure(systolic blood pressure < 120 mm Hg,120 – 130 mm Hg,> 130 mm Hg)before and 24 hours after CAS,and the short-term clinical prognosis indexes of patients in different groups were compared.The primary endpoint was incidence rate of secondary cerebral infarction(CI)and intracranial hemorrhage(ICH)after CAS.The secondary endpoint were the incidence of unexpected discharge and in-hospital death.Unexpected discharge was defined as the modified Rankin Scale(m RS)score of 3-5 at discharge.Results After CAS,there was no difference in the incidence rate of secondary CI(P=0.410)or ICH(P=0.803)among patients with different blood pressure before operation.There was no difference in the incidence rate of secondary CI between patients with different blood pressure after operation(P=0.174).However,systolic blood pressure(SBP)> 130 mm Hg within 24 hours after operation was an independent risk factor for ICH(P < 0.0001),with odds ratio(OR)37.67 and 95% confidence interval(CI)6.79-209.01.Secondary ICH was an independent risk factor for in-hospital death(OR 26.33,95% CI 2.23-311.69,P = 0.009)and unexpected discharge(OR 31.40,95% CI 5.13-192.59,P < 0.0001).Conclusion Baseline blood pressure in patients with carotid stenosis was not associated with secondary ICH and CI after CAS,but mean blood pressure of 24-hour post CAS > 130 mm Hg significantly increased the risk of secondary ICH,while the risk of in-hospital death or unexpected discharge was significantly increased in patients with secondary ICH.Therefore,systolic blood pressure should be controlled below 130 mm Hg within 24 hours after CAS.Part Ⅱ The effect of hemodynamic instability on the long-term prognosis of patients with carotid stenosis after CASMethods 286 patients with carotid stenosis who underwent CAS with complete clinical data in our hospital from January 2016 to April 2019 were included.The clinical data were analyzed retrospectively.According to whether hemodynamic instability(HI)occurred after CAS,all patients were divided into HI group and non-HI group.The long-term clinical prognosis indexes of different groups were compared.And logistic regression model was used to analyze the risk factors of long-term neurological prognosis and HI.The main endpoint was the prognosis of neurological function(m RS score)in 1 year after CAS operation,in which the poor prognosis of neurological function was defined as 3-6 points of the m RS score,and the secondary endpoint was the all-cause mortality rate in 1 year after CAS.Results After CAS,the recurrence rate of ischemic stroke(36.0% vs.12.3%,P < 0.001)and the long-term poor prognosis rate of neurological function(26.2% vs.12.3%,P = 0.004)in the HI group were significantly higher than those in the non-HI group,and there was no significant difference in mortality between the two groups(P = 0.363).Multivariate logistic regression analysis showed that HI after CAS was an independent risk factor for poor long-term prognosis of neurological function(OR 2.257,95% CI 1.142-4.457,P = 0.019);there was a significant correlation between age and HI after CAS(OR 1.029,95% CI 0.997-1.061,P = 0.075),and good control of blood pressure after CAS was an independent protective factor to avoid HI(OR 0.228,95% CI 0.125-0.415,P < 0.001).Conclusion Hemodynamic instability(HI)in patients with carotid stenosis after CAS is an independent predictor of poor long-term neurological prognosis.The older the patient,the higher risk of HI after CAS.Good blood pressure control after CAS can significantly reduce the risk of HI.Part III The change of cognitive function after CAS and the influence of different blood pressure control strategies on cognitive function during perioperative periodMethods 49 patients with severe carotid stenosis underwent CAS in our hospital From October 2019 to June 2020 were included.The general cognitive function(orientation,memory,attention and calculation,language)were assessed by Mini-Mental State Exam(MMSE)before and after CAS operation,and 3 months after operation.Compare and evaluate the changes of cognitive function in patients with CAS in different periods before and after operation,and analyze the influencing factors of cognitive function improvement in patients with CAS by logistic regression model.The main endpoint was MMSE score in different periodsResults Compared with the preoperative cognitive function score,the total MMSE score of patients with carotid stenosis at 3 days after CAS was significantly increased(P = 0.001),and the recall ability score was significantly increased(P = 0.022).At 3 months after operation,the scores of orientation(P < 0.001),memory(P = 0.103),attention and calculation(P < 0.001),recall ability(P = 0.001),as well as language ability(P = 0.003)increased significantly.Logistic regression analysis showed that there was no correlation between age and postoperative blood pressure control and postoperative cognitive function.Conclusion CAS can significantly improve the general cognitive function in patients with carotid artery stenosis,but the improvement of cognitive function has nothing to do with the control of blood pressure.Part Ⅳ Analysis of risk factors for poor prognosis in patients with spontaneous cerebellar hemorrhage after hematoma removalMethods Retrospectively analyze clinical and radiological characteristics of 71 consecutive SCH patients in our hospital from January 2015 to January 2020.Clinical outcomes were 6-month mortality and 6-month modified Rankin Scale(m RS)score(0-6),of which poor neurological functional outcome was defined as mRS score 3-6.Results Of 71 patients with SCH(mean [SD] age 61.0 ± 10.2,28 [43.1%] women),16(24.62%)died.Multivariate logistic regression shows that residual hematoma volume 1 day post-surgery ≥ 6 ml was associated with higher risk of 6-month mortality(OR 4.052,95% CI 1.064 to 15.433),and the association persisted after adjustment for all confounding factors.PHE volume 1 day post-surgery was associated with higher risk of 6-month poor functional outcome(OR 1.334,95% CI 1.132 to 1.573),and the association persisted after adjusting for all confounding factors(OR 1.325,95% CI 1.009 to 1.740).The PHE plus residual hematoma volume 1 day post-surgery ≥ 18 ml was associated with higher risk of 6-month poor functional outcome,and the association persisted after adjustment for all confounding factors(OR 6.069,95% CI 1.001 to 36.843).Conclusion In SCH patients who underwent surgical hematoma evacuation,residual hematoma volume ≥ 6 ml is an independent predictor of 6-month mortality.PHE volume,as well as the PHE plus residual hematoma volume ≥ 18 ml,is an independent predictor of 6-month poor functional outcome. |
