Decompressive craniectomy guided by cerebral microdialysis and brain tissue oxygenation in a patient with meningitis

Bacterial meningitis remains a life-threatening disease mainly due to intracranial hypertension. However, decompressive craniectomy (DC) and the use of cerebral microdialysis (MD) and brain tissue oxygen pressure measurement (pTiO(2) ) are poorly described in this disease. We report a case of a 56-year-old woman admitted for severe bacterial meningitis complicating mastoiditis. Despite maximal medical treatment, intracranial pressure increased above 30 mmHg, with a decline in pTiO(2) and MD results indicating cerebral ischaemia. A bilateral DC was performed. Neurological outcome was favourable, and on discharge, the patient was able to live independently. This is the first report of DC in meningitis guided by cerebral MD and pTiO(2) . Invasive multimodal neuromonitoring should be used in severe meningitis and DC could be considered in the case of refractory intracranial hypertension.

[Effects of adipose-derived stem cells transplantation on the neuronal apoptosis and the expression of Bcl-2 and caspase-12 in the brain post focal cerebral ischemia in rats]

AIM

To investigate the effects of adipose-derived stem cells (ADSCs) transplantation on neuronal apoptosis in the brain after focal cerebral ischemia in rats.

METHODS

72 male adult Sprague-Dawley rats were randomly divided into 4 groups: Sham-operated group , Middle cerebral artery occlusion (MCAO) group, Vehicle group and ADSC-treated group (n=18). MCAO model was established with the modified Longa's method. One day after right MCAO, 30 μL of cell suspension containing 1×10(6); cells were injected into the lateral ventricle of ADSC-treated group and the same dose of PBS was given to the vehicle group. At 4 d, 7 d and 14 d after MCAO, the apoptosis of neuron was detected by terminal deoxynucleotidyl transferase-mediated DNA nick-end labeling (TUNEL) method and the expression of Bcl-2 and caspase-12 in ischemic region was detected by immunohistochemistry and RT-PCR.

RESULTS

TUNEL-positive cells in ischemic region of ADSC-treated group were less than that in MCAO group and Vehicle group at 4 d, 7 d and 14 d post MCAO (P<0.05). Compared with MCAO group and Vehicle group, the expression of Bcl-2 significantly up-regulated while caspase-12 expression significantly decreased in ADSC-treated group at any time point post MCAO (P<0.05).

CONCLUSION

The transplantation of ADSCs can reduce neuronal apoptosis of rats with cerebral ischemic injury partly by promoting the expression of Bcl-2 which participates in apoptotic signals after mitochondrial damage and inhibiting the expression of caspase-12 which mediates endoplasmic reticulum (ER) stress-induced apoptosis.

Effect of human neural precursor cell transplantation on endogenous neurogenesis after focal cerebral ischemia in the rat

Little is known about the relationship between neuronal cell transplantation and endogenous neurogenesis after experimental stroke. We found previously that transplantation of neuronal precursors derived from BG01 human embryonic stem cells reduced infarct volume and improved behavioral outcome after distal middle cerebral artery occlusion (MCAO) in rats. In this study, transplantation was performed 14 days after distal MCAO and doublecortin (Dcx)-expressing cells in the subventricular zone (SVZ) and subgranular zone of dentate gyrus (SGZ) were counted 60 days post-transplant. Transplantation increased neurogenesis (Dcx expression) in ipsilateral SVZ, but not in contralateral SVZ or either SGZ, in both young adult (3-month-old) and aged (24-month-old) rats. These findings suggest that cell-based therapy for stroke may be associated with changes in endogenous adaptive processes, including neurogenesis.

Long-term survival of human neural stem cells in the ischemic rat brain upon transient immunosuppression

Understanding the physiology of human neural stem cells (hNSCs) in the context of cell therapy for neurodegenerative disorders is of paramount importance, yet large-scale studies are hampered by the slow-expansion rate of these cells. To overcome this issue, we previously established immortal, non-transformed, telencephalic-diencephalic hNSCs (IhNSCs) from the fetal brain. Here, we investigated the fate of these IhNSC's immediate progeny (i.e. neural progenitors; IhNSC-Ps) upon unilateral implantation into the corpus callosum or the hippocampal fissure of adult rat brain, 3 days after global ischemic injury. One month after grafting, approximately one fifth of the IhNSC-Ps had survived and migrated through the corpus callosum, into the cortex or throughout the dentate gyrus of the hippocampus. By the fourth month, they had reached the ipsilateral subventricular zone, CA1-3 hippocampal layers and the controlateral hemisphere. Notably, these results could be accomplished using transient immunosuppression, i.e administering cyclosporine for 15 days following the ischemic event. Furthermore, a concomitant reduction of reactive microglia (Iba1+ cells) and of glial, GFAP+ cells was also observed in the ipsilateral hemisphere as compared to the controlateral one. IhNSC-Ps were not tumorigenic and, upon in vivo engraftment, underwent differentiation into GFAP+ astrocytes, and β-tubulinIII+ or MAP2+ neurons, which displayed GABAergic and GLUTAmatergic markers. Electron microscopy analysis pointed to the formation of mature synaptic contacts between host and donor-derived neurons, showing the full maturation of the IhNSC-P-derived neurons and their likely functional integration into the host tissue. Thus, IhNSC-Ps possess long-term survival and engraftment capacity upon transplantation into the globally injured ischemic brain, into which they can integrate and mature into neurons, even under mild, transient immunosuppressive conditions. Most notably, transplanted IhNSC-P can significantly dampen the inflammatory response in the lesioned host brain. This work further supports hNSCs as a reliable and safe source of cells for transplantation therapy in neurodegenerative disorders.

[Effects of electroacupuncture on the expression of nestin in endogenous neural stem cell in hippocampus in rats with focal cerebral ischemia-reperfusion]

OBJECTIVE

To explore the mechanism of electroacupuncture for treating focal cerebral ischemia-reperfusion injury.

METHODS

Seventy-five Wistar rats were randomly divided into a control group, a model group and an electroacupuncture group, 25 cases in each group. The model of focal cerebral ischemia-reperfusion was established by inserting nylon thread into the internal carotid artery except the control group which was only separated of the carotid artery without occlusion. Electroacupuncture group was treated with electroacupuncture at "Baihui (GV 20)" and "Dazhui (GV 14)" and the other groups without electroacupuncture treatment. The number of nestin positive cells expression at 1st, 3rd, 7th, 14th and 21st days after focal cerebral ischemia reperfusion was observed by use of immunohistochemistry method.

RESULTS

The number of nestin positive cells in electroacupuncture group at ischemia side was significantly more than that in the model group at 3rd, 7th, 14th and 21st days (P < 0.05, P < 0.01), and at contralateral ischemia side, the number of nestin positive cells in the electroacupuncture group was significantly more than that in the model group only at 7th day (P < 0.05).

CONCLUSION

Electroacupuncture at "Baihui (GV 20)" and "Dazhui (GV 14)" in rats can increase the number of nestin positive cells in hippocampus after focal cerebral ischemia-reperfusion, which may be one of the important mechanisms of electroacupuncture in treating acute cerebral ischemic diseases.

Human umbilical cord blood stem cells: rational for use as a neuroprotectant in ischemic brain disease

The use of stem cells for reparative medicine was first proposed more than three decades ago. Hematopoietic stem cells from bone marrow, peripheral blood and human umbilical cord blood (CB) have gained major use for treatment of hematological indications. CB, however, is also a source of cells capable of differentiating into various non-hematopoietic cell types, including neural cells. Several animal model reports have shown that CB cells may be used for treatment of neurological injuries. This review summarizes the information available on the origin of CB-derived neuronal cells and the mechanisms proposed to explain their action. The potential use of stem/progenitor cells for treatment of ischemic brain injuries is discussed. Issues that remain to be resolved at the present stage of preclinical trials are addressed.

Clinical features and outcome in North American adults with idiopathic basal arterial occlusive disease without moyamoya collaterals

OBJECTIVE

To define the clinical characteristics and outcome of patients with idiopathic stenosis or occlusion of the basal arteries, without moyamoya collateral vessel formation.

METHODS

We identified patients who presented to our institution from 1996 to 2005 with occlusive disease of the distal internal carotid artery or the proximal middle or anterior cerebral arteries demonstrated by digital subtraction cerebral angiography. We excluded those with evidence of atherosclerotic disease, systemic vasculitis, moyamoya phenomenon, or any other condition that could otherwise explain their arterial occlusive disease. Medical records were reviewed for presenting symptoms and clinical characteristics. Outcome was determined from chart review and phone interviews.

RESULTS

Twelve patients were identified. All presented with transient ischemic attack or stroke. Eleven were women. Age at presentation ranged from 34 to 71 years. Nine had a history of hypertension; 5 had unilateral intracranial disease. Recurrent stroke on medical therapy occurred in none of the 5 during an average follow-up of 29 months. Seven had bilateral disease. Ischemic stroke occurred between 2 and 107 months after the initial event in 5 of 8 medically treated hemispheres. Moyamoya collateral vessels developed in 1 patient as shown on follow-up angiography.

CONCLUSION

The clinical features and outcome of these patients are similar to those reported in large case series of North American patients with moyamoya phenomenon. These data suggest a common etiology for the basal arterial occlusive process and a variable ability to form moyamoya collateral vessels.

Prophylaxis for venous thrombo-embolism in neurocritical care: a critical appraisal

Venous thrombo-embolism (VTE) is frequently encountered in critically ill neurological and neurosurgical patients admitted to intensive care units. This patient population includes those with brain neoplasm, intracranial hemorrhage, ischemic stroke, subarachnoid hemorrhage, pre- and post-operative patients undergoing neurosurgical procedures and those with traumatic brain injury, and acute spinal cord injury (SCI). There is a wide variability in clinical practice for thromboprophylaxis in these patients, in part due to paucity of data based on randomized clinical trials. Here, we review the current literature on the incidence of VTE in the critically ill neurological and neurosurgical patients as well as appraise available data to support particular practice paradigms for specific subsets of these patients. Data synthesis was conducted via search of Medline, Cochrane databases, and manual review of article bibliographies. Critically ill neurological and neurosurgical patients have higher susceptibility to VTE. Intermittent compression devices with or without anti-thrombotics is generally the method of choice for thromboprophylaxis. Low molecular weight heparin is the method of choice in certain patient subgroups such as those with SCI and ischemic stroke. Inferior vena cava filters may play a role in thromboprophylaxis in selected cases. Without clear guidelines that can be universally applied to this diverse group of patients, prophylaxis for VTE should be tailored to the individual patient with cautious assessment of benefits versus risks. There is a need for higher level evidence to guide VTE prophylaxis in certain subgroups of this patient population.

Surgical treatment of brachiocephalic vessel involvement in Takayasu's arteritis

BACKGROUND

Takayasu's arteritis (TA) is a chronic idiopathic inflammatory disease that affects large and medium size arteries. The brachiocephalic trunk is the most frequently involved site in TA, and multi-vessel lesions are common. Surgical treatment includes vessel reconstruction surgery and percutaneous transluminal angioplasty (PTA). Herein, we report our preliminary experience with surgical treatment of cerebral ischemia caused by cervical arterial lesions due to TA.

METHODS

From January 2000 to December 2007, 38 patients with cerebral ischemia caused by cervical arterial occlusive lesions due to TA were treated surgically. There were three males and 35 females, with an age range of 15 - 42 years (mean 26.5 years). All patients had operative repairs undertaken. Twenty eight patients received bypass operation and 10 patients received percutaneous transluminal angioplasty. One case with coronary stenosis received coronary artery bypass simultaneously. Patients were followed up for 11 months to eight years.

RESULTS

There were no peri-operative deaths in cerebrovascular reconstruction patients. Symptoms of cerebral ischemia were improved or cured in 25 of 38 patients. There was a low incidence of cerebral reperfusion syndrome. Two patients died at five and seven years after surgery due to heart failure. Another 8 patients (20%) required further surgery for stenosis (5 patients) or anastomotic aneurysms (3 patients). Percutaneous transluminal angioplasty was performed successfully for treatment of aortic and renal lesions. Repeated angioplasty for revascularization was performed in six PTA cases with restenosis after 5 - 24 months.

CONCLUSIONS

When cerebral perfusion has potential to be affected by TA, a definitive corrective procedure is advised when the patient is relatively stable. Although the recurrence rate is very high, percutaneous transluminal angioplasty is the first choice procedure. Bypass operation is optimal for brachiocephalic-vessel involvement in TA. Cerebral reperfusion syndrome can be avoided by careful selection of the operation method and improved post-operative treatment.

New mechanical recanalization devices - the future in pediatric stroke treatment?

OBJECTIVE

To evaluate the recanalization rate and clinical outcome in children with acute ischemic stroke following treatment with innovative mechanical thrombectomy devices.

PATIENTS AND METHODS

Three subjects aged 7-16 years presenting with acute cerebral vascular occlusions (thrombolysis in myocardial infarction [TIMI] 0) were treated with either the Penumbra System, operating on an aspiration platform, or the Phenox clot retriever device, a flexible wire compound with perpendicularly-oriented polyamid microfilaments. Target vessels were the internal carotid artery, the middle cerebral artery and the basilar artery.

RESULTS

Successful recanalization (TIMI 3) was attained in all cases. No device-related complications or intracranial hemorrhage occurred. Follow up was conducted for up to 30 days. A 10- to 26-point improvement in the National Institutes of Health Stroke Scale (NIHSS) score was achieved.

CONCLUSIONS

Mechanical thrombectomy devices possess a dual advantage whereby they can achieve instant recanalization as well as minimize the number of bleeds that customarily accompany intravenous and intra-arterial therapy. These new devices could contribute greatly to treatment decisions in a field not yet clearly defined by current guidelines.

Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage--an outcome and secondary insults study

PURPOSE

The aim was to study the outcome and the occurrence of secondary brain insults in elderly patients with severe subarachnoid hemorrhage (SAH) in comparison to younger patients.

METHODS

Ninety-nine patients with severe SAH requiring a ventriculostomy and management at the neurointensive care unit with at least 120 h of multimodality monitoring data during the first 240 h following SAH were included. Data were continuously recorded for intracranial pressure (ICP), cerebral perfusion pressure, blood pressure, oxygen saturation, and temperature. Secondary insult levels were defined and quantified as percent of good monitoring time at insult level. Outcome according to the Glasgow Outcome Scale was evaluated at 6 months after the SAH. Age-dependent differences in occurrence of secondary insults and clinical characteristics were analyzed with multiple regression analysis.

RESULTS

Good recovery or moderate disability was achieved in 24.1% of the elderly and in 42.9% of the younger patients. The frequency of severe disability was 41.4% in the elderly and 37.1% in the younger patients. The occurrence of ICP insults was lower and the occurrence of hypertensive, hypotensive, and hypoxemic insults were higher in the elderly patients.

CONCLUSIONS

An independent outcome was achieved in a substantial proportion of the elderly with severe SAH, and the proportion of severe disability was not greater than among the younger patients, which justifies neurointensive care also in elderly patients. The occurrence of secondary insults was age dependent. Future studies of multimodality monitoring may provide age-specific secondary insult levels necessary for a tailored neurointensive care specific for elderly patients with severe SAH.

Microglia transplantation attenuates white matter injury in rat chronic ischemia model via matrix metalloproteinase-2 inhibition

Chronic cerebral ischemia is thought to induce white matter lesions (WMLs), which contribute to subcortical vascular dementia. Although glial activation and protease upregulation are believed to modify WML pathology, effective therapy remains elusive. Here, we compare the efficacy of microglial cell transplantation and mesenchymal stem cell (MSC) transplantation in protecting against WML development in a chronic cerebral hypoperfusion rat model. A microglial cell line (HMO6), MSC cell line (B10) or vehicle (phosphate-buffered saline; PBS) was intravenously injected, and the appearance and severity of WMLs were evaluated. Transplanted HMO6 and B10 cells migrated to sites of WMLs, including the corpus callosum (CC) and caudoputamen (CP), reduced the severity of WMLs, and inhibited the accumulation and activation of microglia and astrocytes. Transplantation of both cell types reduced the level of matrix metalloproteinase (MMP)-2 mRNA in microglia of the CC. MMP-2 protein level and activity were also both greatly reduced in the same region. Our results indicate that transplantation of either microglial cells or mesenchymal stem cells could inhibit chronic cerebral ischemia-induced WML formation by decreasing MMP-2 expression in microglia and decreasing MMP-2 activity in the CC region.

[The effects of adipose-derived stem cell transplantation on the expression of IL-10 and TNF-alpha after cerebral ischaemia in rats]

AIM

To explore the effects of adipose-derived stem cell (ADSC) transplantation on the expression of IL-10 amd TNF-alpha after cerebral ischaemia in Middle cerebral artery occlusion (MCAO) rats.

METHODS

72 male adult Sprague-Dawley rats were randomly divided into 4 groups: sham group, MCAO group, Vehicle group and ADSC group (n=18). Rat's cerebral ischemia model was established by MCAO with Longa's method. ADSC were labeled by DAPI before transplantation. One day after MCAO, 30 microL of cell suspension containing 1 x 10(6); ADSCs were injected into the lateral ventricle of ADSC group and the same dose of PBS was given to the Vehicle group. At day 4, day 7 and day 14 after MCAO, the rats were decapitated to detect the expression of IL-10 and TNF-alpha in ischaemic rat's brain by ELISA, immunohistochemistry and RT-PCR.

RESULTS

Compared with sham group, the expression of IL-10 and TNF-alpha significantly up-regulated at 4 d, 7 d of MCAO group(P<0.05). There was no statistical difference of IL-10 and TNF-alpha expression between MCAO and vehicle group ant any time point(P>0.05). Compared with Vehicle group, the expression of IL-10 significantly up-regulated while TNF-alpha expression significantly decreased of ADSC-treated group at any timepoint post MCAO(P<0.05).

CONCLUSION

The transplantation of ADSC could up-regulate the expression of IL-10 and down-regulate the expression of TNF-alpha in MCAO rat's brain, which might contribute to its protective role upon cerebral ischaemia.

Performance and training standards for endovascular ischemic stroke treatment

Stroke is the third-leading cause of death in the United States, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, 750,000 new strokes occur each year, resulting in 200,000 deaths (or 1 of every 16 deaths) per year in the United States alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intra-arterial (IA) thrombolysis in selected patients. IA thrombolysis has been studied in 2 randomized trials and numerous case series. Although 2 devices have been granted FDA 3 approval with an indication for mechanical stroke thrombectomy, none of these devices has demonstrated efficacy in improving patient outcomes. This report defines what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and identifies the performance standards that should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies that historically have been directly involved in the medical, surgical, and endovascular care of patients with acute stroke, including the Neurovascular Coalition and its participating societies: the Society of NeuroInterventional Surgery; American Academy of Neurology; American Association of Neurological Surgeons, Cerebrovascular Section; and Society of Vascular & Interventional Neurology.

Fractalkine and CX3CR1 are involved in the migration of intravenously grafted human bone marrow stromal cells toward ischemic brain lesion in rats

Recent research has shown that transplanted bone marrow stromal cells (MSCs) migrate to the injured regions and exert their therapeutic effects in cases of intracranial trauma, stroke, inflammation and degenerative disease. The specific mechanisms involved in their migration to lesions are still to be fully elucidated. In the present study, a rat model of transient middle cerebral artery occlusion (MCAO) was established. At 24 h after reperfusion, human bone marrow stromal cells (hMSCs) were transplanted by intravenous injection to explore the effects of fractalkine/CX3CR1 on the migration of transplanted MSCs to lesions. In vitro study using real-time PCR and western blot revealed that CX3CR1, the only known receptor of fractalkine, was expressed in cultured hMSCs. The expression of fractalkine in the ischemic brain was significantly increased. The directional migration of transplanted hMSCs to the damaged region was observed through detection of green fluorescence protein (GFP). The results indicated the cells were mainly distributed in the ischemic boundary zone with high fractalkine expression. In a further study, lentivirus-mediated RNA interference of CX3CR1 expression was employed. The results of these experiments indicated that CX3CR1 knock-down dramatically decreased the migration of hMSCs to the ischemic brain. The present study suggests that fractalkine and its specific receptor CX3CR1 are involved in the directional migration of transplanted MSCs to the ischemic damaged brain region.

Waiting times for carotid endarterectomy in UK: observational study

OBJECTIVES

To assess timeliness of carotid endarterectomy services in the United Kingdom.

DESIGN

Observational study with follow-up to March 2008.

SETTING

UK hospitals performing carotid endarterectomy.

PARTICIPANTS

UK surgeons undertaking carotid endarterectomy from December 2005 to December 2007.

MAIN OUTCOME MEASURES

Provision and speed of delivery of appropriate assessments of patients; carotid endarterectomy and operative mortality; 30 day postoperative mortality.

RESULTS

240 (61% of those eligible) consultant surgeons took part from 102 (76%) hospitals and trusts. Of 9913 carotid endarterectomies recorded on hospital episode statistics, 5513 (56%) were included. Of the patients who underwent endarterectomy, 83% had a history of transient ischaemic attack or stroke. Of these recently symptomatic patients, 20% had their operation within two weeks of onset of symptoms and 30% waited more than 12 weeks. Operative mortality was 0.5% during the inpatient stay and 1.0% (95% confidence interval 0.7% to 1.3%) by 30 days.

CONCLUSION

Only 20% of symptomatic patients had surgery within the two week target time set by the National Institute for Health and Clinical Excellence (NICE). Although operative mortality rates are comparable with those in other countries, some patients might experience disabling or fatal stroke while waiting for surgery and hence not be included in operative statistics. Major improvements in services are necessary to enable early surgery in appropriate patients in order to prevent strokes.

3D cross sectional view to investigate the morphology of internal carotid artery plaques. Is 3D ultrasound superior to 2D ultrasound?

PURPOSE

Previous studies have demonstrated that plaques from the internal carotid artery with lower median grayscale values are associated with higher complication rates in the perinterventional course. A repeatedly cited limitation of ultrasound is that the single plane used to calculate the median grayscale value is only two dimensional. The goal of this study was to compare the median grayscale value as determined using two dimensional cuts versus three dimensional data sets.

MATERIALS AND METHODS

Seventy-one cuts of 24 thromboendarterectomy samples from 19 patients were analyzed using 3D data sets. The ultrasound data sets were obtained using a 10 MHz probe in 3D mode in a special chamber and were evaluated by two investigators. Additionally, a longitudinal view of the samples was made using B mode according to a standardized protocol.

RESULTS

There was a significant correlation between the 2D and 3D data as assessed by two observers (p < 0.001, intraclass correlation [ICC] > 0.895) and at different times (p < 0,001, ICC > 0.935). Comparison of the 3D transverse cuts with the longitudinal B mode cuts also showed a highly significant association between the two methods (p < 0.001, R = 0.800). 97.2 % of the measured values were within the limits of agreement, reflecting the concordance of the both methods.

CONCLUSION

The superiority of three dimensional ultrasound with respect to two dimensional ultrasound was not able to be demonstrated using this standardized in vitro procedure to examine the echolucency in extracranial internal carotid artery plaques.

[Treatment of severe cerebral ischemia in Takayasu's disease with arterial reconstruction]

OBJECTIVE

To evaluate the effect of surgical bypass and to explore the role of transcranial doppler (TCD) during the bypass operation.

METHODS

From March 2003 to February 2008, sixteen patients (4 male and 12 female) with mean age of 32 years old and mean disease course of 7.5 years were treated by surgical procedures. The main clinical presentations were dizziness, headache, vertigo, and visional dysfunction. Variated degree of artery stenoses in the 4 arteries (bilateral carotid and vertebral arteries) were revealed by color doppler ultrasonography and DSA. Eight patients underwent aorto-bi-subclavian arteries prosthetic graft bypass. Three patients underwent aorto-bi-subclavian artery prosthetic graft bypass and graft-unilateral carotid artery bypass with autologous great saphenous vein. Three patients underwent aorta-unilateral subclavian artery-unilateral carotid artery prosthetic graft bypass. Two patients underwent aorta carotid artery bypass with autologous great saphenous vein, of which one patient underwent aortocoronary artery bypass simultaneously. Cerebral blood supply was monitored in 14 patients with transcranial doppler. Unilateral subclavian carotid and femoral carotid artery shunt was used respectively to avoid cerebral ischemia during operation in 2 patients.

RESULTS

Symptoms and signs of cerebral ischemia improved in all patients with effective rate of 100% apart from deflected tongue-protrusion in 3 patients which recovered in 2 weeks after operation. All patients survived and no symptoms recurred at the end of a 2.2 year's follow-up. Unfortunately, two patients developed aneurysm at the anastomosis within 4 years after operation.

CONCLUSIONS

Arterial reconstruction is an effective method for Takayasu's disease with severe cerebral ischemia. TCD monitoring plays an important role during the bypass operation. It can help to determine the revision of blood pressure and prevent postoperative brain reperfusion injury.

[Endovascular interventional treatment for symptomatic stenosis of middle cerebral artery]

OBJECTIVE

To study the feasibility, security and validity of percutaneous angioplasty (PTA) or percutaneous angioplasty and stenting (PTAS) for symptomatic stenosis of middle cerebral artery.

METHODS

The results of treatment and follow-up of 39 cases with symptomatic stenosis of middle cerebral artery who had either recurrent transient ischemic attacks (TIAs) or resistant to medical therapy and were performed PTA or PTAS were studied retrospectively.

RESULTS

Among the 39 cases with stenosis of middle cerebral artery (23 in left, 13 in right, 3 in bilateral side and 5 cases combining with stenosis of carotid artery) PTA were successfully performed in 9 cases and PTAS in 30 (whose post-operative residual stenosis were less than 10%). After operation the patients were administrated with antiplatelet drugs. The clinic symptom and sign of ischemia were improved obviously after operation. During the procedure the contrast could be seen outside the vessel in 2 cases, the patients had no obvious symptom of hemorrhage and got well rapidly. But in another case her consciousness changed 1 h after PTAS and the limbs could not move in right side. Emergency CT scan showed cerebral hemorrhage in left basic node area. The patient suffered language barrier and incomplete hemiplegy in right side. No complication was occurred in the others. During 5 to 60 months follow-up, the symptom of weakness in right arm reoccurred but lighter than before in only one case. TCD rechecked in 26 cases and demonstrated the blood beam speed was faster than normal in two case. DSA rechecked in 14 cases showed restenosis in-stent in the 2 cases and they were treated by medicine.

CONCLUSIONS

PTA and PTAS is a feasible, safe and effective therapeutic method for the patients with symptomatic stenosis of middle cerebral artery. Further study in large number of patients is needed for long-term outcome.