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Du H, Zheng J, Li X, Bos D, Yang W, Cheng Y, Liu C, Wong LKS, Hu J, Chen X. The correlation between intracranial arterial calcification and the outcome of reperfusion therapy. Ann Clin Transl Neurol 2023; 10:974-982. [PMID: 37088543 PMCID: PMC10270261 DOI: 10.1002/acn3.51780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/07/2023] [Accepted: 04/07/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE Intracranial arterial calcification (IAC) is a risk factor of ischemic stroke. However, the relationship between IAC patterns and clinical outcome of ischemic stroke remains controversial. We aimed to investigate the correlation between IAC patterns and the effects of reperfusion therapy among acute stroke patients. METHODS Consecutive acute ischemic stroke patients who underwent reperfusion therapy were included. IAC was categorized as intimal or medial. Based on its involvement, IAC was further classified as diffuse or focal. Neurologic dysfunction was assessed by the National Institute of Health stroke scale (NIHSS). Clinical outcome including favorable neurologic outcome (FNO) and early neurologic deterioration (END) were assessed. RESULTS Of 130 patients, 117 had IAC. Intimal IAC was identified in 74.6% of patients and medial IAC was present in 64.6% of patients. Diffuse IAC was present in 31.5% of patients. All diffuse IACs were medial pattern. Diffuse IAC was associated with higher baseline NIHSS (p = 0.011) and less FNO (p = 0.047). Compared with patients with focal or single diffuse IAC, patients with multiple diffuse IAC had higher baseline NIHSS (p = 0.002) and less FNO (p = 0.024). Multivariable linear regression (p < 0.001) and logistic regression (p = 0.027) suggested that multiple diffuse IAC was associated with higher baseline NIHSS and less FNO. No significant association was found between END and different IAC patterns. INTERPRETATION Multiple diffuse medial IAC may predict severer neurologic dysfunction and less favorable neurologic outcome after reperfusion therapy in acute stroke patients.
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Affiliation(s)
- Heng Du
- Department of Health Technology and InformaticsThe Hong Kong Polytechnic UniversityKowloonHong Kong SARChina
| | - Jianrong Zheng
- Department of NeurologyPeking University Shenzhen HospitalShenzhenChina
| | - Xuelong Li
- Department of Health Technology and InformaticsThe Hong Kong Polytechnic UniversityKowloonHong Kong SARChina
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Department of EpidemiologyErasmus MC University Medical CenterRotterdamNetherlands
- Department of Clinical EpidemiologyHarvard TH Chan School of Public HealthBostonMassachusettsUSA
| | - Wenjie Yang
- Department of Diagnostic Radiology and Nuclear MedicineUniversity of Maryland School of MedicineBaltimoreUSA
| | - Yajing Cheng
- Department of NeurologyPeking University Shenzhen HospitalShenzhenChina
| | - Cong Liu
- Department of NeurologyPeking University Shenzhen HospitalShenzhenChina
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, Prince of Wales HospitalThe Chinese University of Hong KongHong KongChina
| | - Jun Hu
- Department of NeurologyPeking University Shenzhen HospitalShenzhenChina
| | - Xiangyan Chen
- Department of Health Technology and InformaticsThe Hong Kong Polytechnic UniversityKowloonHong Kong SARChina
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Xiong L, Chen X, Liu J, Wong LKS, Leung TW. Cerebral Augmentation Effect Induced by External Counterpulsation Is Not Related to Impaired Dynamic Cerebral Autoregulation in Ischemic Stroke. Front Neurol 2022; 13:784836. [PMID: 35592467 PMCID: PMC9110640 DOI: 10.3389/fneur.2022.784836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Dynamic cerebral autoregulation is impaired after ischemic stroke. External counterpulsation (ECP) augments the cerebral blood flow of patients with ischemic stroke by elevation of blood pressure (BP). We aimed to investigate if cerebral augmentation effects during ECP were associated with impaired dynamic cerebral autoregulation in patients after acute ischemic stroke. Methods Forty patients with unilateral ischemic stroke and large artery atherosclerosis in the anterior circulation territory within 7 days from symptom onset and eighteen healthy controls were recruited. We monitored changes in mean flow velocity over both middle cerebral arteries (MCA) by transcranial Doppler (TCD) before, during, and immediately after ECP. Cerebral augmentation index was MCA mean flow velocity increase in percentage during ECP compared with baseline to evaluate the augmentation effects of ECP. Spontaneous arterial BP and cerebral blood flow velocity in both bilateral MCAs were recorded using a servo-controlled plethysmograph and TCD, respectively. Transfer function analysis was used to derive the autoregulatory parameters, including phase difference (PD), and gain. Results The cerebral augmentation index in patients with stroke was significantly higher on both the ipsilateral and contralateral sides than that in controls, while the PD in patients with stroke was significantly lower on both sides than those in controls (all P < 0.05). The cerebral augmentation index did not correlate with PD and gain on either the ipsilateral or contralateral side of patients with stroke or in controls (all P > 0.05). The cerebral augmentation index of patients with stroke was significantly related to mean BP change on the ipsilateral side (R2 = 0.108, P = 0.038). Conclusion The degree of ECP-induced cerebral augmentation effects as measured by the cerebral augmentation index did not correlate with the magnitude of impaired dynamic cerebral autoregulation.
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Affiliation(s)
- Li Xiong
- Clinical Trials Centre, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Li Xiong
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Shatin, Hong Kong SAR, China
- Xiangyan Chen
| | - Jia Liu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Thomas W. Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Du H, Li J, Yang W, Bos D, Zheng L, Wong LKS, Leung TW, Chen X. Intracranial Arterial Calcification and Intracranial Atherosclerosis: Close but Different. Front Neurol 2022; 13:799429. [PMID: 35211084 PMCID: PMC8861312 DOI: 10.3389/fneur.2022.799429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose Intracranial arterial calcification (IAC) may be present in the intimal or medial arterial layer. This study aimed to elucidate the link between the calcification and atherosclerotic disease in the intracranial vasculature. Methods Consecutive patients with acute ischemic stroke were included. Bilateral intracranial segment of the internal carotid artery, M1 segment of the middle cerebral artery, intracranial segment of the vertebral artery, and the basilar artery were visualized by the multi-detector computed tomography (CT) and vessel-wall magnetic resonance imaging (vwMRI) within 14 days after stroke onset. IAC was into the intimal or medial pattern. Subsequently, on the vwMRI, we assessed the luminal stenosis, eccentricity, plaque burden, and intraplaque hemorrhage (IPH) as markers of atherosclerosis at each IAC site. Results Among 69 patients with stroke, IAC was identified in 35% of (161/483) artery segments, of which 61.5% were predominantly intimal calcification and 38.5% were predominantly medial calcification. About 79.8% of intimal calcifications and 64.5% of medial calcifications co-existed with atherosclerotic plaques. Intimal calcification was associated with luminal stenosis (p = 0.003) caused by atherosclerotic lesions. Compared with the medial IAC, intimal IAC was more often accompanied by eccentric plaques (p = 0.02), larger plaque burden (p = 0.001), and IPH (p = 0.001). Conclusion Our multimodal imaging-based comparison study on intracranial arteriosclerosis demonstrated that intimal IAC, compared with medial IAC, was more often accompanied by the luminal stenosis, larger plaque burden, eccentricity, and IPH, providing strong evidence for clinical evaluation on the mechanism, risk, and prognosis of ischemic stroke.
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Affiliation(s)
- Heng Du
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Jia Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjie Yang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Clinical Epidemiology, Harvard TH Chan School of Public Health Boston, Cambridge, MA, United States
| | - Lu Zheng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
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Uchiyama S, Toyoda K, Lee BC, Liou CW, Wong LKS, Grauer C, Brueckmann M, Taniguchi A, Urano Y, Easton JD. Dabigatran or Aspirin in East Asian Patients With Embolic Stroke of Undetermined Source: RE-SPECT ESUS Subgroup Analysis. Stroke 2021; 52:1069-1073. [PMID: 33588594 DOI: 10.1161/strokeaha.120.031891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We assessed the outcomes of dabigatran versus aspirin in a prespecified subgroup analysis of East Asian patients with embolic stroke of undetermined source in the RE-SPECT ESUS trial (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source). METHODS Patients with a recent embolic stroke of undetermined source were randomized to dabigatran (150 or 110 mg BID) or aspirin (100 mg QD). The primary efficacy outcome was recurrent stroke; the primary safety outcome was major bleeding. The East Asia cohort was compared with patients from all other countries (non-East Asia cohort). RESULTS Overall, 988 of 5390 patients (18%) were randomized in East Asia. During a median follow-up of 18.8 months, there was no statistically significant difference in recurrent stroke (hazard ratio, 0.65 [95% CI, 0.41-1.03]) or major bleeding (hazard ratio, 1.04 [95% CI, 0.57-1.91]) in East Asian patients receiving dabigatran versus aspirin. Death from any cause occurred more often in the dabigatran versus the aspirin group (hazard ratio, 3.98 [95% CI, 1.32-12.01]). CONCLUSIONS The treatment effect of dabigatran versus aspirin was consistent between cohorts, with no apparent superiority for dabigatran over aspirin in preventing recurrent stroke in patients with embolic stroke of undetermined source. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239120.
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Affiliation(s)
- Shinichiro Uchiyama
- Clinical Research Centre for Medicine, International University of Health and Welfare, Tokyo, Japan (S.U.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym Neurological Institute, Hallym University College of Medicine, Seoul, South Korea (B.-C.L.)
| | - Chia-Wei Liou
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan (C.-W.L.)
| | - Lawrence Ka Sing Wong
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin (L.K.S.W.)
| | - Claudia Grauer
- Clinical Operations Global, Boehringer Ingelheim Pharma GmbH K.G., Biberach, Germany (C.G.)
| | - Martina Brueckmann
- Department of Cardiometabolic Medicine, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany (M.B.)
| | - Atsushi Taniguchi
- Biostatistics and Data Sciences (A.T.), Nippon Boehringer Ingelheim Co, Ltd, Tokyo, Japan
| | - Yasuhisa Urano
- Primary Care Medicine (Y.U.), Nippon Boehringer Ingelheim Co, Ltd, Tokyo, Japan
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco (J.D.E.)
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Wu X, Bos D, Ren L, Leung TWH, Chu WCW, Wong LKS, Abrigo J, Chen XY. Intracranial Arterial Calcification Relates to Long-Term Risk of Recurrent Stroke and Post-stroke Mortality. Front Neurol 2020; 11:559158. [PMID: 33162927 PMCID: PMC7581678 DOI: 10.3389/fneur.2020.559158] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Intracranial arterial calcification (IAC) is highly prevalent in ischemic stroke patients. However, data on the association of IAC with stroke recurrence and mortality remains limited. We examined the effect of IAC on the long-term recurrence of stroke and the risk of post-stroke mortality. Methods: Using a prospective stroke registry, we recruited 694 patients (mean age 71.6 ± 12.4; male sex 50.3%) since December 2004. IAC was visualized using the computed tomography exam that was made at hospital admission and was quantified with the Agatston method. All patients were regularly followed up till July 2016. The impacts of IAC on stroke recurrence and mortality were assessed using Cox-regression models with adjustments for age, sex, and relevant cardiovascular risk factors. Results: During a median follow-up period of 8.8 years, 156 patients (22.5%) suffered a recurrent stroke and 84 died (12.1%). We found that a higher IAC Agatston score related to a higher risk of stroke recurrence (HR per 1-SD increase in IAC: 1.30; 95% CI, 1.08–1.56, p = 0.005) and a higher risk of post-stroke mortality (HR per 1-SD increase, 1.44; 95% CI, 1.06–1.96, p = 0.019). After investigating etiology-specific risks of stroke-recurrence, we found that a higher IAC Agatston score specifically associated with small-vessel occlusive stroke. Conclusions: IAC is a strong risk factor for recurrent stroke and post-stroke mortality. Among stroke subtypes, IAC relates to higher risk of stroke recurrence among patients with small-vessel disease, which indicates chronic calcification detected in large cerebral arteries may have potential effects on the cerebrovascular beds extending to small vessels.
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Affiliation(s)
- Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands.,Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Thomas Wai-Hong Leung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Winnie Chiu-Wing Chu
- Department of Imaging and Interventional Radiology, Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Chinese University of Hong Kong, Hong Kong, China
| | - Xiang Yan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
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Soo YO, Abrigo J, Chu W, Leung KT, Fong WC, Li SH, Li R, Ng PW, Wong KK, Wong LKS, Leung TWH. Risk of intracerebral haemorrhage in patients with cerebral microbleeds taking warfarin for atrial fibrillation: a prospective study. Hong Kong Med J 2019; 25 Suppl 5:6-8. [PMID: 31416977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Affiliation(s)
- Y O Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - J Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - W Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - K T Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - W C Fong
- Department of Medicine, Queen Elizabeth Hospital
| | - S H Li
- Department of Medicine, North District Hospital
| | - R Li
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital
| | - P W Ng
- Department of Medicine and Geriatrics, United Christian Hospital
| | - K K Wong
- Department of Medicine, Yan Chai Hospital
| | - L K S Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - T W H Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong
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Leung TWH, Fan SY, Ip HL, Lau AYL, Siu DYW, Dai EYL, Wong LKS, Liebeskind DS. Effects of collateral circulation on haemodynamic flow status in intracranial artery stenosis depicted by computational fluid dynamics. Hong Kong Med J 2019; 25 Suppl 5:18-21. [PMID: 31416981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Affiliation(s)
- T W H Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - S Y Fan
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - H L Ip
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - A Y L Lau
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - D Y W Siu
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - E Y L Dai
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - L K S Wong
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
| | - D S Liebeskind
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong
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Xiong L, Tian G, Leung HW, Chen XY, Lin WH, Leung TWH, Soo YO, Siu DYW, Wong LKS. Autonomic dysfunction as measured by Ewing battery test to predict poor outcome after acute ischaemic stroke. Hong Kong Med J 2019; 25 Suppl 5:9-11. [PMID: 31416978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Affiliation(s)
- L Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - G Tian
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - H W Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - X Y Chen
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - W H Lin
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - T W H Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - Y O Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - D Y W Siu
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
| | - L K S Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong
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Xiong L, Tian G, Wang L, Lin W, Chen X, Leung TWH, Soo YOY, Wong LKS. External Counterpulsation Increases Beat-to-Beat Heart Rate Variability in Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1487-1492. [PMID: 28396189 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/29/2017] [Accepted: 03/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion in ischemic stroke. However, the response of beat-to-beat heart rate variability (HRV) in patients with ischemic stroke during ECP remains unknown. METHODS Forty-eight patients with unilateral ischemic stroke at the subacute stage and 14 healthy controls were recruited. Beat-to-beat heart rate before, during, and after ECP was monitored. The frequency components of HRV were calculated using power spectral analysis. Very low frequency (VLF; <.04 Hz), low frequency (LF; .04-.15 Hz), high frequency (HF; .15-.40 Hz), total power spectral density (TP; <.40 Hz), and LF/HF ratio were calculated. RESULTS In stroke patients, although there were no statistical differences in all of the HRV components, the HRV at VLF showed a trend of increase during ECP compared with baseline in the left-sided stroke patients (P = .083). After ECP, the HRV at LF and TP remained higher than baseline in the right-sided stroke patients (LF, 209.4 versus 117.9, P = .050; TP, 1275.6 versus 390.2, P = .017, respectively). Besides, the HRV at TP also increased after ECP compared with baseline in the left-sided stroke patients (563.0 versus 298.3, P = .029). CONCLUSIONS Irrespective of the side of the ischemia, patients showed an increased beat-to-beat HRV after ECP. Additionally, sympathetic and parasympathetic cardiac modulations were increased after ECP in patients after right-sided subacute stroke.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Ge Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Li Wang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie Oi Yan Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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He W, Au-Yeung SYS, Mak M, Leung TWH, Leung H, Wong LKS. The potential synergism by combining external counterpulsation with intermittent theta burst stimulation in post-stroke motor function recovery. Med Hypotheses 2016; 93:140-2. [PMID: 27372874 DOI: 10.1016/j.mehy.2016.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 05/22/2016] [Indexed: 11/16/2022]
Abstract
Upper limb weakness and incoordination is a common disability following ischemic stroke. Previous studies have showed that the single application of external counterpulsation (ECP) and intermittent theta burst stimulation (iTBS) can effectively enhance the cortical motor excitability and facilitate recovery. However, it remains uncertain if sequential application of these therapies would further augment the recovery. We hypothesize a synergistic effect of ECP followed by iTBS to upper limb function may happen through improvements in both cerebral perfusion and neuron excitability.
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Affiliation(s)
- Weijia He
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Margaret Mak
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Howan Leung
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Lawrence Ka Sing Wong
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong.
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Tian G, Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. External Counterpulsation Reduces Beat-to-Beat Blood Pressure Variability When Augmenting Blood Pressure and Cerebral Blood Flow in Ischemic Stroke. J Clin Neurol 2016; 12:308-15. [PMID: 27095525 PMCID: PMC4960215 DOI: 10.3988/jcn.2016.12.3.308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE External counterpulsation (ECP) is a noninvasive method used to enhance cerebral perfusion by elevating the blood pressure in ischemic stroke. However, the response of the beat-to-beat blood pressure variability (BPV) in ischemic stroke patients during ECP remains unknown. METHODS We enrolled recent ischemic stroke patients and healthy controls. Changes in the blood flow velocities in bilateral middle cerebral arteries and the continuous beat-to-beat blood pressure before, during, and after ECP were monitored. Power spectral analysis revealed that the BPV included oscillations at very low frequency (VLF; <0.04 Hz), low frequency (LF; 0.04-0.15 Hz), and high frequency (HF; 0.15-0.40 Hz), and the total power spectral density (TP; <0.40 Hz) and LF/HF ratio were calculated. RESULTS We found that ECP significantly increased the systolic and diastolic blood pressures in both stroke patients and controls. ECP decreased markedly the systolic and diastolic BPVs at VLF and LF and the TP, and the diastolic BPV at HF when compared with baseline. The decreases in diastolic and systolic BPV reached 37.56% and 23.20%, respectively, at VLF, 21.15% and 12.19% at LF, 8.76% and 16.59% at HF, and 31.92% and 23.62% for the total TP in stroke patients, which did not differ from those in healthy controls. The change in flow velocity on the contralateral side was positively correlated with the total TP systolic BPV change induced by ECP (r=0.312, p=0.035). CONCLUSIONS ECP reduces the beat-to-beat BPV when increasing the blood pressure and cerebral blood flow velocity in ischemic stroke patients. ECP might be able to improve the clinical outcome by decreasing the beat-to-beat BPV in stroke patients, and this should be explored further in future studies.
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Affiliation(s)
- Ge Tian
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Lin
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jinghao Han
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie Oi Yan Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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Xiong L, Chen XY, Leung TWH, Wong LKS. Combined external counterpulsation and endovascular stenting treatment for symptomatic vertebrobasilar artery stenosis: two case reports. Oxf Med Case Reports 2015; 2015:333-6. [PMID: 26568838 PMCID: PMC4626627 DOI: 10.1093/omcr/omv049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 11/23/2022] Open
Abstract
Symptomatic vertebrobasilar artery (VBA) stenosis has a poor prognosis. Intravascular stents provide a new therapeutic approach, but the long-term outcome of stenting compared with medical outcome is controversial. External counterpulsation (ECP) is a noninvasive method to improve perfusion of vital organs. We report two cases of this combination with ECP treatment in addition to receiving endovascular stenting. Two patients experienced posterior ischemic stroke. Digital subtraction angiography revealed a severe basilar or vertebral artery stenosis. Computed tomographic perfusion revealed significantly decreased perfusion of posterior artery territories. Both of them underwent combined ECP treatment and endovascular stenting of the stenosed basilar or vertebral artery, without recurrent stroke within 30 days after stenting. The two patients were independent (modified Rankin scale ≤2) at the 12-month follow-up time. Combined ECP treatment and endovascular stent placement may be effective and safe for patients with symptomatic VBA stenosis who failed aggressive medical treatment.
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Affiliation(s)
| | | | | | - Lawrence Ka Sing Wong
- Correspondence address. Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China. Tel: +852-2632-3144; Fax: +852-2649-3761; E-mail
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Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. A retrospective pilot study of correlation of cerebral augmentation effects of external counterpulsation with functional outcome after acute ischaemic stroke. BMJ Open 2015; 5:e009233. [PMID: 26351195 PMCID: PMC4563223 DOI: 10.1136/bmjopen-2015-009233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral blood flow of patients with ischaemic stroke via induced hypertension. We aimed to explore the correlation between the cerebral blood flow augmentation effects induced by ECP and clinical outcome after acute ischaemic stroke. METHODS We retrospectively analysed our ECP registry of patients with ischaemic stroke who were enrolled within 7 days after stroke onset. Bilateral middle cerebral arteries of patients were monitored using transcranial Doppler (TCD). Flow velocity changes before, during and after ECP were, respectively, recorded for 3 min. The cerebral augmentation index (CAI) was the increase in percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. TCD data were analysed based on the side ipsilateral or contralateral to the infarct. The modified Rankin Scale (mRS) (good outcome: mRS 0∼2; poor outcome: mRS 3∼6) was evaluated 6 months after the index stroke. RESULTS 72 patients were included (mean age, 63.8±10.7 years; 87.5% males). At month 6 after stroke onset, univariate analysis showed that the National Institutes of Health Stroke Scale at recruitment was significantly higher and ECP therapy duration was longer in the poor outcome group, while the ipsilateral CAI was significantly lower in the good outcome group than that in the poor outcome group (3.71±4.94 vs 7.73±7.66, p=0.044). Multivariate logistic regression showed that ipsilateral CAI was independently correlated with an unfavourable functional outcome after adjusting for confounding factors. CONCLUSIONS The higher degree of cerebral blood flow velocity augmentation on the side ipsilateral to the infarct induced by ECP is independently correlated with an unfavourable functional outcome after acute ischaemic stroke.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Oi Yan Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Yu SCH, Leung TWH, Lee KT, Wong LKS. Angioplasty and stenting of intracranial atherosclerosis with the Wingspan system: 1-year clinical and radiological outcome in a single Asian center. J Neurointerv Surg 2014; 6:96-102. [PMID: 23512176 PMCID: PMC3933179 DOI: 10.1136/neurintsurg-2012-010608] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/13/2013] [Accepted: 02/25/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND This study aimed to evaluate the 1-year clinical and angiographic outcome of angioplasty and stenting of intracranial atherosclerosis using Wingspan and Gateway system. METHODS In this prospective study, patients with symptomatic lesions were treated and followed clinically and angiographically by digital subtraction angiography (DSA) for 1 year. The two primary endpoints were recurrent ipsilateral ischemic stroke and in-stent restenosis (ISR) at 1 year. Secondary endpoints included periprocedural death or stroke and all strokes at 1 year. Potential factors correlated with ISR were studied using univariate and multivariate analysis. RESULTS Treatment was attempted in 65 patients and successfully completed in 61 (93.8%). Fifty-nine patients (44 men, 15 women) aged 62.86 ± 11.38 years with 66 stenoses (average degree of stenosis 71.78 ± 11.23%) underwent clinical and DSA follow-up at 1 year. There were 66 stenotic lesions. ISR occurred in 11 of the 66 lesions (16.7%). Luminal gain occurred in 32 of the lesions (48.5%), an unchanged lumen in 4 (6%) and luminal loss in 30 (45.4%). The periprocedural stroke or death rate was 6.1% (4/65), including three hemorrhagic and one ischemic stroke, all of which occurred at the corresponding site and resulted in death. There were no interval strokes between the periprocedural time and the 1-year follow-up. The occurrence of ISR was correlated with the degree of stenosis before treatment and was not correlated with patient age or sex, vessel diameter, location of stenosis or failure to control risk factors for atherosclerosis. CONCLUSIONS One-year clinical and angiographic outcomes of angioplasty and stenting are promising for symptomatic intracranial atherosclerosis.
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Affiliation(s)
- Simon Chun Ho Yu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kwok Tung Lee
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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15
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Lin W, Han J, Chen X, Xiong L, Leung HW, Leung TW, Soo Y, Wong LKS. Predictors of good functional outcome in counterpulsation-treated recent ischaemic stroke patients. BMJ Open 2013; 3:bmjopen-2013-002932. [PMID: 23794561 PMCID: PMC3686252 DOI: 10.1136/bmjopen-2013-002932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES External counterpulsation (ECP) is a non-invasive method being investigated for ischaemic stroke. We aimed to explore predictors of good functional outcome for ECP-treated ischaemic stroke patients who completed a minimum of 10 sessions. METHODS We analysed our ECP registry of ischaemic stroke patients with cerebral large artery stenosis who underwent ECP therapy at the Prince of Wales Hospital from 2004 to 2010. We included 155 patients who completed at least 10 sessions of ECP and had 3-month follow-up data as well as 52 medical controls. Functional outcomes were dichotomised into good outcome (modified Rankin Scale (mRS) 0-2) and bad outcome (mRS 3-6). We compared the differences in two groups in terms of demographics, medical history and parameters of ECP treatment. RESULTS At 3 months after stroke, 70.5% of patients who finished the whole course of ECP had a good outcome (only 46.5% in the unfinished group and 38.5% in the medical group). Among all 207 recruited cases, 119 (57.5%) patients had a good outcome at 3 months after stroke. Compared with the bad outcome group, patients in the good outcome group were younger and had a lower baseline National Institutes of Health Stroke Scale (NIHSS) and longer ECP therapy duration. Multivariate logistic regression showed that ECP duration (OR 1.032), baseline NIHSS (OR 0.734) and age (OR 0.961) were independent predictors for a favourable outcome. CONCLUSIONS Duration of ECP therapy is first found to be an important predictor for good outcome of ECP-treated ischaemic stroke patients, in addition to the well-known prognostic factors such as age and NIHSS.
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Affiliation(s)
- Wenhua Lin
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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16
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Abstract
Background Symptomatic brain hemorrhage was a significant cause of periprocedural stroke or death following stenting in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, which called into question the safety of Wingspan stenting for intracranial atherosclerosis. This study analyzed the role of a learning curve in the safety and outcome of Wingspan stenting from the experience of 95 consecutive patients at a single center. Methods In this prospective study the endpoints were major stroke or death (modified Rankin Scale score >3) within 30 days, other neurological complications, technical procedural problems, technical success in completion of angioplasty and stenting and recurrent ischemic stroke in the corresponding vascular territory after 30 days. Data splitting into quarters was used for learning curve analysis. Results The periprocedural major stroke or death rate was 4.2% (4/95), minor stroke rate was 5.3% (5/95), total 9.5% (9/95). The technical procedural problem rate was 11.6% (11/95) and the technical success rate was 93.7% (89/95). The 89 patients were followed for 38.9±22.7 months (median 40.8, range 0.2–72, 3463 patient-months) after stenting. The risk of recurrent ischemic stroke in the corresponding vascular territory was 0.7% per patient per year (2/3463 patient-months). Guidewire- or angioplasty-related hemorrhage was the major cause of periprocedural major stroke or death (3/4, 75%) and did not occur in the last quarter. Periprocedural intracerebral hemorrhage was uncommon and perforator stroke did not occur. Conclusions There may be a learning curve for mastering the safety precautions of Wingspan stenting for intracranial atherosclerosis.
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Affiliation(s)
- Simon Chun Ho Yu
- Department of Imaging and Interventional Radiology, Vascular and Interventional Radiology Foundation Clinical Science Center, The Chinese University of Hong Kong, Hong Kong, China
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Yu SCH, Leung TWH, Hung EHY, Lee KT, Wong LKS. Angioplasty and stenting for intracranial atherosclerotic stenosis with nitinol stent: factors affecting technical success and patient safety. Neurosurgery 2012; 70:104-13. [PMID: 21849921 DOI: 10.1227/neu.0b013e3182320bb0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Angioplasty and stenting using nitinol stents is a recognized treatment option for intracranial atherosclerosis. OBJECTIVE To identify procedure-related factors that may affect patient safety and technical outcome. METHODS In this prospective study of 57 consecutive patients, the primary end points were intraprocedural technical problems, periprocedure morbidity, and complications. Major periprocedure complication was defined as all stroke or death at 30 days. Technical failure was defined as the inability to complete the procedure because of technical or safety problems. Procedure failure was defined as a procedure outcome of technical failure or major periprocedure complication. Secondary end points were procedure-related factors that may affect patient safety and technical outcome. RESULTS Procedure failure rate was 12.3% (7/57) (major periprocedure complication rate, 5.3% [3/57]; technical failure rate, 7% [4/57]). Initial failure in tracking of balloon or stent occurred in 20 patients, other technical problems occurred in 11 patients, including kinking or trapping of balloon catheter (2 cases), difficulty in unsheathing of stent (3 cases), forward migration of stent during deployment (4 cases), trapping of nose cone after stent deployment (1 case), fracture of delivery system (2 cases), and guidewire fracture (1 case). Unfavorable vascular morphology signified by the presence of 2 or more reverse curves along the access path was found to associate with initial failure in the tracking of instruments (OR = ∞), and occurrence of other technical problems (OR = 25). CONCLUSION Procedure-related factors could be identified and lead to improvements in patient safety and technical outcome. Tortuous vascular morphology is a key factor to be overcome.
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Affiliation(s)
- Simon Chun Ho Yu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, The New Territories, Hong Kong.
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18
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Yu SCH, Leung TWH, Lee KT, Hui JWY, Wong LKS. Angioplasty and stenting of atherosclerotic middle cerebral arteries with Wingspan: evaluation of clinical outcome, restenosis, and procedure outcome. AJNR Am J Neuroradiol 2011; 32:753-8. [PMID: 21436335 DOI: 10.3174/ajnr.a2363] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MCA is a common location of intracranial stenosis. It is relatively more peripherally located and of a smaller caliber, and could therefore be a site technically more challenging and risky for angioplasty and stenting. The study aimed to evaluate the clinical outcome, restenosis rate, and procedural safety of Wingspan stent placement for atherosclerosis in the MCA compared with stenosis in other arteries. MATERIALS AND METHODS Patients who underwent Wingspan stent placement for symptomatic intracranial stenosis of ≥70% (or stenosis of ≥50% for recurrent ischemia despite medical therapy) were recruited prospectively and allocated into a study group (MCA stenosis, n=35) and a control group (other stenosis, n=25). Primary end points were the following: 1) all stroke or death rate at 1 year, and 2) significant in-stent restenosis rate at 1 year. Secondary end points were the following: 1) periprocedural complications within 24 hours, rate of TIA during the procedure, all stroke or death rate within 30 days; and 2) the inability to complete the procedure due to technical problems. RESULTS Results of study group versus the control group were the following: degree of stenosis, 78.4 ± 10.9% versus 72.5 ± 11.2% (P value=.0456); diameter of stenosis, 0.6 ± 0.3 versus 1.0 ± 0.5 mm (P=.0017); all stroke or death rate at 1 year, 14.3% versus 12% (OR=1.22); in-stent restenosis rate at 1 year, 10% versus 10.5% (OR=1.05); periprocedural complication rate at 24 hours, 2.9% versus 4% (OR=0.70); TIA rate during the procedure, 8.6% versus 4% (OR=2.25); all stroke or death rate at 30 days, 5.7% versus 12% (OR=0.44); and technical failure rate, 2.9% versus 0%. CONCLUSIONS In this study, there were no significant differences in procedural safety, patient outcome, and restenosis rates of stent placement between the group with MCA stenosis and the group with stenoses located at other sites.
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Affiliation(s)
- S C H Yu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing St, Shatin, Hong Kong, China.
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Abstract
OBJECTIVE Based on its efficacy in treating neuropathic pain, gabapentin may be effective for the treatment of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the efficacy of gabapentin for symptom relief in CTS. METHODS We conducted a randomized, double-blinded, placebo-controlled trial recruiting patients with newly diagnosed idiopathic CTS of more than a period of three months. Diagnosis was based on characteristic symptoms with electrophysiological confirmation. Patients were randomly assigned to an active group receiving gabapentin (starting dose 300 mg once daily to a target of 900 mg daily) or a placebo group. Primary end-point was the global symptom score (GSS), which was measured at baseline, two, and eight weeks. RESULTS There was no significant difference in baseline variables between the two treatment groups. Hundred and forty patients were enrolled in the study, of whom 71 were randomly assigned to gabapentin group and 69 assigned to placebo group. Both gabapentin and placebo produced significant improvement in symptoms at two and eight weeks. The GSS at 2 and 8 weeks was 16.4 (SD 9.4) and 13.4 (SD 9.7), respectively, in the active group versus 14.9 (SD 9.0) and 12.5 (SD 8.9) in the control group (P < 0.01). But by eight weeks, the mean reduction in symptom severity of patients on gabapentin [-10.4 (SD 10.8)] was not significant when compared with placebo [-8.7 (SD 8.1), P < 0.39]. Adverse events were not severe and included dizziness, somnolence, and headache. CONCLUSIONS Gabapentin did not produce a significant reduction in symptom severity compared with placebo over an eight-week period.
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Affiliation(s)
- A C F Hui
- Department of Medicine, Electrodiagnostic Unit, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong.
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Lau AYL, Soo YOY, Graham CA, Woo WK, Wong EHC, Leung H, Chan AYY, Au LWC, Ip VHL, Leung CSF, Hui V, Shum WC, Abrigo J, Siu DYW, Yu SCH, Wong LKS, Leung TW. An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis. Hong Kong Med J 2010; 16:455-462. [PMID: 21135422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
OBJECTIVES To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment. DESIGN Prospective study. SETTING A university teaching hospital in Hong Kong. PATIENTS Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009. MAIN OUTCOME MEASURES Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality. RESULTS During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient. CONCLUSION A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.
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Affiliation(s)
- A Y L Lau
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
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21
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Soo Y, Singhal AB, Leung T, Yu S, Mak H, Hao Q, Leung H, Lam W, Wong LKS. Reversible Cerebral Vasoconstriction Syndrome with Posterior Leucoencephalopathy after Oral Contraceptive Pills. Cephalalgia 2009; 30:42-5. [DOI: 10.1111/j.1468-2982.2009.01868.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset recurrent ‘thunderclap’ headaches with reversible multifocal narrowing of the cerebral arteries, often associated with focal neurological deficits from ischaemic or haemorrhagic stroke. It has been associated with exposure to vasoconstrictive drugs, pregnancy, migraine, and a variety of other conditions. Whereas the pathophysiology of RCVS remains unclear, changes in the levels of female hormones are considered important because RCVS predominantly affects women and is frequently associated with pregnancy. We report a patient with angiographically confirmed RCVS whose MRI showed reversible brain oedema, suggesting an overlap between RCVS and the reversible posterior leucoencephalopathy syndrome. The only identified risk factor was oral contraceptive pills started 1 month prior to onset, supporting a role for female reproductive hormones in precipitating this overlap syndrome.
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Affiliation(s)
- Y Soo
- Division of Neurology,
Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong
| | - AB Singhal
- Department of Neurology,
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T Leung
- Division of Neurology,
Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong
| | - S Yu
- Department of Diagnostic Radiology & Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - H Mak
- Department of Diagnostic Radiology & Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - Q Hao
- Division of Neurology,
Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong
| | - H Leung
- Division of Neurology,
Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong
| | - W Lam
- Department of Diagnostic Radiology & Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - LKS Wong
- Division of Neurology,
Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong
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Yu SCH, Leung TWH, Lam JSY, Lam WWM, Wong LKS. Symptomatic Ostial Vertebral Artery Stenosis: Treatment with Drug-eluting Stents—Clinical and Angiographic Results at 1-year Follow-up. Radiology 2009; 251:224-32. [PMID: 19332854 DOI: 10.1148/radiol.2511081057] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Simon Chun Ho Yu
- Department of Diagnostic Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing St, Shatin, New Territories, Hong Kong.
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Lau KK, Yu ITS, Chan ACK, Wong LKS, Tam CM, Sheng B, Li HL. A registry of tuberculous meningitis in Hong Kong. Int J Tuberc Lung Dis 2005; 9:1391-7. [PMID: 16466063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND A prospective observational study of the presentation, diagnosis, treatment and outcome of tuberculous meningitis (TBM). METHODS Demographic characteristics, clinical information, treatment and progress of TBM patients were followed. Their outcomes were ascertained every 6 months for 3 years after diagnosis. Prognostic factors associated with death or full recovery were examined using multivariate Cox's and logistic regression models, respectively. RESULTS Between 1993 and 2000, 166 TBM patients were recruited. Their mean age was 42.9, 153 were Chinese and 81 were males; 92% received HRZS (H = isoniazid; R = rifampicin; Z = pyrazinamide; S = streptomycin), HRZE (E = ethambutol) or HRZES. Steroids were given to 105 patients, with no significant effect on outcome. After 3 years of follow-up, 110 patients had completely recovered, 20 survived with disability and 26 died. Death was significantly associated with older age, lower cerebrospinal fluid (CSF) lymphocyte and poorer consciousness levels at the time of presentation, while full recovery was associated with younger age, being female and absence of complications. CONCLUSIONS Relatively good outcomes of TBM cases were documented in this Hong Kong study with a case-fatality ratio of 15.7% (26/166) up to 3 years. Early recognition, diagnosis and administration of effective treatment regimens were probably the most important factors in reducing mortality and morbidity.
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Affiliation(s)
- K K Lau
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Kwai Chung, Hong Kong.
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Hui ACF, Ng KC, Tong PY, Mok V, Chow KM, Wu A, Wong LKS. Bacterial meningitis in Hong Kong: 10-years’ experience. Clin Neurol Neurosurg 2005; 107:366-70. [PMID: 16023529 DOI: 10.1016/j.clineuro.2004.10.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Revised: 09/29/2004] [Accepted: 10/04/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We studied the etiology, clinical features and outcome of patients with bacterial meningitis from an urban Chinese city over a 10-years period. METHODS We reviewed the files of all persons aged 15-years old or above diagnosed with community-acquired bacterial meningitis from a regional hospital. The clinical findings, relevant laboratory and imaging results as well as outcome were recorded in cases with microbiological evidence of meningitis. Neurosurgical and pediatric patients were excluded. RESULTS Sixty-five patients between the ages of 15 and 86 years of age (mean 52 years) were identified of whom 18 (28%) died. The four most common causes were Mycobacteria tuberculosis (46%), Streptococcus pneumoniae (11%), Streptococcus suis (9%) and Klebsiella pneumoniae (8%). Neisseria meningitidis and Haemophilus influenzae were rare pathogens. The annual incidence of community-acquired bacterial meningitis was 1.27/100,000 adults. Delay in treatment was associated with a poorer prognosis (p<0.001, OR=38.84, CI=7.33-205.80). CONCLUSION The causative organisms found in this region of China differ from that reported from Europe and the US; tuberculous meningitis is the most common cause of bacterial meningitis.
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Affiliation(s)
- A C F Hui
- Department of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Ngan Shing Street, New Terriotories, Shatin, Hong Kong SAR.
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25
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Lam WWM, Leung TWH, Chu WCW, Yeung DTK, Wong LKS, Poon WS. Early computed tomography features in extensive middle cerebral artery territory infarct: prediction of survival. J Neurol Neurosurg Psychiatry 2005; 76:354-7. [PMID: 15716525 PMCID: PMC1739552 DOI: 10.1136/jnnp.2003.035055] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND To assess the predictive value of prognosis of different computed tomography (CT) features and National Institutes of Health Stroke Scale score (NIHSS) in acute extensive middle cerebral artery (MCA) infarct. METHODS Fifty five patients with acute extensive MCA infarct had the CT performed within 24 hours of the onset of symptoms. A total of 11 CT features were analysed. The age distribution, presence of risk factors, presence of individual CT feature, the total CT score, and the NIHSS were correlated with the 30 day mortality. RESULTS Single explanatory variable analysis showed NIHSS, presence of midline shift, midline shift of more than 1 cm, extent of infarct, presence of hydrocephalus, effacement of subarachnoid space/cella media, attenuation of corticomedullary differentiation, and total CT score were associated with the 30 day mortality. Both extent of infarct >67% and attenuation of corticomedullary differentiation gave a sensitivity and specificity of 93% and 95%, respectively, for the prediction of survival. Logistic regression analysis showed that the extent of infarct and NIHSS were the only independent predictors. CONCLUSIONS CT features and admission NIHSS are important parameters for prediction of survival in extensive MCA infarct.
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Affiliation(s)
- W W M Lam
- Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, c/o Rm 27029, X-ray Department, Prince of Wales Hospital, Ngan Shing Street, Shatin, N.T., Hong Kong.
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Lau KK, Wong LKS, Li LSW, Chan YW, Li HL, Wong V. Epidemiological study of multiple sclerosis in Hong Kong Chinese: questionnaire survey. Hong Kong Med J 2002; 8:77-80. [PMID: 11937660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE To study the epidemiology of multiple sclerosis in Hong Kong Chinese. DESIGN Cross-sectional questionnaire survey. SETTING Neurology and paediatric neurology departments in Hong Kong from January through June 1999. PARTICIPANTS All confirmed multiple sclerosis patients. MAIN OUTCOME MEASURES Demographic data, investigation results, Kurtzke's Expanded Disability Status Scale during the last follow-up visit, number of relapses between 1997 and 1998, and treatments used/currently in use. RESULTS Fifty-three Chinese multiple sclerosis patients were identified. The prevalence was thus estimated to be 0.77 per 100,000 population. This low prevalence was also noted in other multiple sclerosis studies from South-East Asia (range, 0.8-4 per 100,000 population). The female to male ratio among the Chinese multiple sclerosis sufferers was 9.6:1, a figure somewhat higher than that reported in the other studies from South-East Asia (range, 3.2-6.6:1). The Chinese multiple sclerosis patients in this study also had a high spinal cord involvement (66%) and a low presence of cerebrospinal fluid oligoclonal banding (40%). These findings were different from those in Caucasian multiple sclerosis patients. CONCLUSION Multiple sclerosis in Hong Kong Chinese has a low prevalence, a high female to male ratio, and a low cerebrospinal fluid oligoclonal banding presence.
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Affiliation(s)
- K K Lau
- Department of Medicine and Geriatrics, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Hong Kong
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