A Study Of The Value Of TCD To Predict High Risk Patients Of Cerebral Hyperperfusion Syndrome(CHS) After The Internal Carotid Artery Stenting And Tcm Syndrome Distributions Of CHS

Objective:Evaluating the value of transcranial Doppler(TCD)to predict who is at risk of cerebral hyperperfusion syndrome(CHS)after the internal carotid artery stenting.For traditional Chinese medicine(TCM),we focus on the TCM syndrome distributions and characteristics of CHS for the experience of TCM treatment.Methods:1.In this study,50 cases of hospitalized patients implanting internal carotid artery stent were selected from those who treated in Traditional Chinese Medicine Hospital of Guangdong Province from May 2011 to January 2018.2.Two trained researchers screened patients whose preoperative transcranial doppler showed low velocity and low pulse change(the diagnostic criteria were described below)in middle cerebral artery,and divided them into directly angioplasty group and comprehensive treatment group who were scheduled for staged angioplasty or provided with intraoperative and postoperative TCD monitoring or performed in general anesthesia.3.The diagnosis of CHS and hyperperfusion induced intracranial hemorrhage(HICH)were determined by the operator and two experts or more.Furthermore HICH must be differentiated from the secondary cerebral infarction or bleeding referring to the preoperative imaging(CT or MRI),and intraoperative video.4.Analysis whether there was statistical significance in the incidence of CHS in directly angioplasty group and comprehensive treatment group.5.Analysis the traditional Chinese medicine syndrome differentiation of all CHS patients or HP patients.Results:1.50 patients who carried internal carotid artery stenting were involved in this study,with the preoperative degree of stenosis of more than 70%.There were 13 patients in directly angioplasty group,37 patients in comprehensive treatment group.The analyzed subjects were 42 males(84%)and 8 females(16%).The average age was 64.2±9.82 years old,ranging from 31 to 87 years old.Besides,35 patients(70%)suffered from cerebral infarction or TIA.There were13 patients whose mean velocity was less than or equal to 50cm/s in directly angioplasty group,33 patients in comprehensive treatment group.There were13 patients whose PI×Vm was less than or equal to 36cm/s in directly angioplasty group,35 patients in comprehensive treatment group.There was no statistitally significant difference in sex ratio,or the average age,or the incidence of hypertension,hyperlipidemia,smoking,cardiac disease in either group(P > 0.05).Comparing to the CHS related risk factors,there were no significant statistical differences in preoperative event(stroke or TIA)related ICA stenosis,or the incidence of diabetes,contralateral ICA stenosis,or the internal between the operation and the last occurrence of ischemic symptoms,or the preoperative patient >70 years of age,or the preoperative mean velocity or Vm×PI(P > 0.05).2.The reexamination of cerebral angiography after the CAS showed that the stenosis of the distal blood flow was better than before.CHS occurred in 3 of 50 patients(6%)afer CAS.One CHS patients experienced intracerebral hemorrhage 2 hours after the CAS,after protamine and heparin,mannitol in reducing intracranial pressure,blood pressure control of urapidil,but died eventually.The brain CT scans demonstrated 1.right basal ganglia hemorrhage for about 232 ml,a large number of intraventricular hemorrhage,2.subarachnoid hemorrhage.The other two experienced headache or the reducing of distal flexibility of the left upper limb with no detectable neurological impairments after the strict control of blood pressure,nutrition nerve,and sedation with no detectable neurological impairments.Thus CHS occurred in3 of 50 patients(6%)and the overall mortality rate was 2%(1/50 patients)afer CAS.CHS occurred in 3 of 13 patients(23%)in the directly angioplasty group and no one of 37 patients(0%)in comprehensive treatment group.The comparison of CHS incidence demonstrated a statistical difference between the2 groups(P=0.015<0.05).3.CHS(one intracranial hemorrhage)occurred in 3 of 50 patients afer CAS.Besides HP occurred in 17 patients.14 patients could be diagnosed as wind syndrome,4 patients as fire fever syndrome,18 patients as phlegm syndrome,14 patients as blood stasis syndrome,3 patients as qi deficiency syndrome,5 patients as yin deficiency and Yang hyperactivity syndrome.Howover,compared to the patients who weren't in HP or CHS state,there were no significant statistical differences.Conclusion:1.Strategy of staged CAS,general anesthesia or intraoperative TCD monitoring applying on patients with poor velocity or poor pulsation index showed by preoperative TCD can reduce the incidence of CHS.The MCA low velocity and low pulse index standard we referred can screen the high-risk patients of CHS.The preoperative application of TCD has some certain value to assesse the risk of CHS,which reminds us of paying more attention to MCA's low flow velocity and low pulsation index,and strengthen the perioperative management,such as the general anesthesia,intraoperative or postoperative TCD monitoring,or staged CAS,to prevent the appearance of CHS or even HICH.2.The syndrome type of TCM syndrome of CHS and HP is often seen with wind syndrome,phlegm syndrome and blood stasis syndrome,Neverthless,there were no significant statistical differences compared to the patients who weren't in HP or CHS state.Moreover,the sample size of this study is too small,and the specific syndrome type should be combined with clinical specific analysis.