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Feng X, Chan KL, Lan L, Abrigo J, Ip VHL, Soo YOY, Leung TW, Leng X. Translesional Pressure Gradient Alters Relationship Between Blood Pressure and Recurrent Stroke in Intracranial Stenosis. Stroke 2020; 51:1862-1864. [PMID: 32312220 DOI: 10.1161/strokeaha.119.028616] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- There is debate over an optimal systolic blood pressure (SBP) in secondary stroke prevention of patients with symptomatic intracranial atherosclerotic stenosis (sICAS). We investigated whether translesional pressure gradient across sICAS would alter the relationship between SBP and risk of recurrent stroke in such patients. Methods- We recruited patients with sICAS (50%-99% stenosis) confirmed in computed tomography angiography. We simulated blood flow across sICAS with computed tomography angiography-based computational fluid dynamics models. Translesional pressure ratio (PR=Pressurepost-stenotic/Pressurepre-stenotic) was calculated in each case. Pressure ratio (PR) ≤ median was defined as low PR, indicating larger translesional pressure gradient across sICAS. All patients received optimal medical treatment. We investigated the interaction of translesional PR and mean SBP during follow-up (SBPFU) in determining the risk of the primary outcome, recurrent ischemic stroke in the same territory within 1 year. Results- Among 157 patients with sICAS, the median PR was 0.93. Multivariate Cox regression revealed significant PR-SBPFU interaction on the primary outcome (P=0.008): in patients with normal PR, risk of primary outcome significantly decreased with lower SBPFU (hazard ratio for 10 mm Hg decrement =0.46; P=0.018); however, in those with low PR, SBPFU≤130 mm Hg was associated with significantly increased risk of primary outcome, compared with 130<SBPFU<150 mm Hg (hazard ratio=5.08; P=0.043). Conclusions- Low SBP level may be associated with increased risk of stroke recurrence in patients with sICAS with a large translesional pressure gradient. Translesional PR by computational fluid dynamics models may yield a promising indicator to guide more individualized blood pressure management in patients with sICAS, warranting future studies.
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Affiliation(s)
- Xueyan Feng
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Lung Chan
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China.,Department of Neurology, First Affiliated Hospital, Jinan University, Guangzhou, China (K.L.C.)
| | - Linfang Lan
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China.,Department of Neurology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (L.L.)
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology (J.A.), Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent H L Ip
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yannie O Y Soo
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China
| | - Thomas W Leung
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinyi Leng
- From the Department of Medicine and Therapeutics (X.F., K.L.C., L.L., V.H.L.I., Y.O.Y.S., T.W.L., X.L.), Chinese University of Hong Kong, Hong Kong SAR, China
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Xiong L, Tian G, Leung H, Soo YOY, Chen X, Ip VHL, Mok VCT, Chu WCW, Wong KS, Leung TWH. Autonomic Dysfunction Predicts Clinical Outcomes After Acute Ischemic Stroke: A Prospective Observational Study. Stroke 2017; 49:215-218. [PMID: 29203690 DOI: 10.1161/strokeaha.117.019312] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/23/2017] [Accepted: 11/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Central autonomic dysfunction increases stroke morbidity and mortality. We aimed to investigate whether poststroke autonomic dysfunction graded by Ewing battery can predict clinical outcome. METHODS In this prospective observational study, we assessed autonomic function of ischemic stroke patients within 7 days from symptom onset by Ewing battery. On the basis of the magnitude of autonomic dysfunction, we stratified patients into significant (definite, severe, or atypical) or minor (normal or early) autonomic function impairment groups and correlated the impairment with the 3-month modified Rankin Scale score (good outcome: modified Rankin Scale score 0≈2; poor outcome: modified Rankin Scale score 3≈6). RESULTS Among the 150 patients enrolled (mean age, 66.4±9.9 years; 70.7% males), minor autonomic dysfunction was identified in 36 patients (24.0%), and significant autonomic dysfunction was identified in 114 patients (76.0%) based on Ewing battery. In 3 months, a poor functional outcome was found in 32.5% of significant group patients compared with 13.9% in the minor group (P=0.031). Crude odds ratios of the magnitude of autonomic dysfunction and 3-month unfavorable functional outcome after acute ischemic stroke were 2.979 (95% confidence interval, 1.071-8.284; P=0.036). After adjusting for confounding variables with statistical significance between the 2 functional outcome subgroups identified in univariate analysis (including sex and National Institutes of Health Stroke Scale score on admission), the magnitude of autonomic dysfunction still independently predicted an unfavorable outcome, with an odds ratio of 3.263 (95% confidence interval, 1.141-9.335; P=0.027). CONCLUSIONS Autonomic dysfunction gauged by Ewing battery predicts poor functional outcome after acute ischemic stroke.
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Affiliation(s)
- Li Xiong
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Ge Tian
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Howan Leung
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Yannie O Y Soo
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Xiangyan Chen
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Vincent H L Ip
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Vincent C T Mok
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Winnie C W Chu
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Ka Sing Wong
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.)
| | - Thomas W H Leung
- From the Division of Neurology, Department of Medicine and Therapeutics (L.X., H.L., Y.O.Y.S., X.C., V.H.L.I., V.C.T.M., K.S.W., T.W.H.L.) and Department of Imaging and Interventional Radiology (W.C.W.C.), The Chinese University of Hong Kong; and Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China (G.T.).
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Leng X, Lan L, Ip VHL, Liu H, Abrigo J, Liebeskind DS, Wong LKS, Leung TW. Noninvasive fractional flow in intracranial atherosclerotic stenosis: Reproducibility, limitations, and perspectives. J Neurol Sci 2017; 381:150-152. [PMID: 28991669 DOI: 10.1016/j.jns.2017.08.3239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | - Linfang Lan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | - Vincent H L Ip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | - Haipeng Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, China
| | - David S Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology, University of California, Los Angeles, CA, USA
| | - Lawrence K S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China.
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Lan L, Leng X, Abrigo J, Fang H, Ip VHL, Soo YOY, Leung TWH, Yu SCH, Wong LKS. Diminished Signal Intensities Distal to Intracranial Arterial Stenosis on Time-of-Flight MR Angiography Might Indicate Delayed Cerebral Perfusion. Cerebrovasc Dis 2016; 42:232-9. [PMID: 27173386 DOI: 10.1159/000445842] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intracranial arterial stenosis (ICAS) is a predominant cause of ischemic stroke in Asia. Changes in the signal intensities (SIs) across ICAS lesions on time-of-flight magnetic resonance angiography (TOF-MRA) have been indicated to partially reflect the hemodynamic significance of the lesions, which we aimed to verify by correlating it with cerebral perfusion features provided by CT perfusion (CTP) imaging. METHODS Ischemic stroke or transient ischemic attack patients with unilateral symptomatic stenosis (≥50%) of intracranial internal carotid artery or middle cerebral artery (MCA) were included in this study. Change of SIs across an ICAS lesion on TOF-MRA was calculated by the distal and proximal SI ratio (SIR). Cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) within the MCA territory of ipsilateral and contralateral hemispheres were evaluated on the CTP images at the basal ganglia level. Relative CBV, CBF and MTT were defined as ratios of the values obtained from ipsilateral and contralateral hemispheres. The relationships between SIR and CTP parameters were analyzed. RESULTS Fifty subjects (74% male, mean age 62) were recruited. Overall, the mean SIR was 0.77 ± 0.17. SIR of ICAS was significantly, linearly and negatively correlated with ipsilateral CBV (r = -0.335, p = 0.017), ipsilateral MTT (r = -0.301, p = 0.034), and ipsilateral/contralateral MTT ratio (r = -0.443, p = 0.001). CONCLUSIONS Diminished SIs distal to ICAS on TOF-MRA might be associated with delayed ipsilateral cerebral perfusion. Changes of the SIs across ICAS lesions on TOF-MRA may be a simple marker to reflect cerebral perfusion changes in patients with symptomatic ICAS.
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Affiliation(s)
- Linfang Lan
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Chan NH, Ip VHL, Au L, Siu D, Leung T, Xiong L, Wong KS. Moyamoya disease in a patient with neuromyelitis optica. Oxf Med Case Reports 2015; 2014:13-5. [PMID: 25988010 PMCID: PMC4369969 DOI: 10.1093/omcr/omu006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 02/20/2014] [Revised: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 11/15/2022] Open
Abstract
Moyamoya disease can be associated with autoimmune disease such as thyrotoxicosis, but there has been only one report of association with neuromyelitis optica (NMO). We report another case of this combination with the presence of anti-SSA antibody in addition to the NMO-immunoglobulin G. The patient presented limb weakness along with unsteady gait and numbness. A magnetic resonance imaging (MRI) of the spine showed extensive intramedullary hyperintense signals at C2 to T3 levels. On the other hand, no lesions were found on the MRI of the brain. The patient tested positive for anti-aquaporin-4 antibody and anti-SSA antibody which confirms the diagnosis of NMO. A magnetic resonance angiography scan of the brain revealed a bilateral distal occlusion of the internal carotid arteries (ICAs) as well as occlusions of the middle cerebral arteries (MCAs) with fine collaterals in the region which confirms the diagnosis of moyamoya disease. This report suggests that autoimmunity may be an important factor in the pathogenesis of moyamoya disease in some patients.
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Affiliation(s)
- Nathan H Chan
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Vincent H L Ip
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Lisa Au
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Deyond Siu
- Department of Imaging & Interventional Radiology , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Thomas Leung
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Li Xiong
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
| | - Ka Sing Wong
- Department of Medicine & Therapeutics , Chinese University of Hong Kong, Prince of Wales Hospital , Shatin , Hong Kong
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Leung TW, Wang L, Soo YOY, Ip VHL, Chan AYY, Au LWC, Fan FSY, Lau AYL, Leung H, Abrigo J, Wong A, Mok VCT, Ng PW, Tsoi TH, Li SH, Man CBL, Fong WC, Wong KS, Yu SCH. Evolution of intracranial atherosclerotic disease under modern medical therapy. Ann Neurol 2015; 77:478-86. [PMID: 25557926 DOI: 10.1002/ana.24340] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/26/2014] [Accepted: 12/07/2014] [Indexed: 01/05/2023]
Affiliation(s)
- Thomas W. Leung
- Division of Neurology, Department of Medicine and Therapeutics
| | - Lily Wang
- Division of Neurology, Department of Medicine and Therapeutics
| | | | | | - Anne Y. Y. Chan
- Division of Neurology, Department of Medicine and Therapeutics
| | - Lisa W. C. Au
- Division of Neurology, Department of Medicine and Therapeutics
| | | | - Alex Y. L. Lau
- Division of Neurology, Department of Medicine and Therapeutics
| | - Howan Leung
- Division of Neurology, Department of Medicine and Therapeutics
| | - Jill Abrigo
- Department of Diagnostic and Interventional Radiology; Prince of Wales Hospital, Chinese University of Hong Kong
| | - Adrian Wong
- Division of Neurology, Department of Medicine and Therapeutics
| | | | - Ping Wing Ng
- Department of Medicine and Geriatrics; United Christian Hospital
| | - Tak Hong Tsoi
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital
| | - Siu Hung Li
- Department of Medicine; North District Hospital
| | | | - Wing Chi Fong
- Department of Medicine; Queen Elizabeth Hospital; Hong Kong
| | - Ka Sing Wong
- Division of Neurology, Department of Medicine and Therapeutics
| | - Simon C. H. Yu
- Department of Diagnostic and Interventional Radiology; Prince of Wales Hospital, Chinese University of Hong Kong
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Chan AYY, Yeung JHM, Mok VCT, Ip VHL, Wong A, Kuo SH, Chan DTM, Zhu XL, Wong E, Lau CKY, Wong RKM, Tang V, Lau C, Poon WS. Subthalamic nucleus deep brain stimulation for Parkinson's disease: evidence for effectiveness and limitations from 12 years' experience. Hong Kong Med J 2014; 20:474-80. [PMID: 25345997 DOI: 10.12809/hkmj144242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/05/2022] Open
Abstract
OBJECTIVE To present the result and experience of subthalamic nucleus deep brain stimulation for Parkinson's disease. DESIGN Case series. SETTING Prince of Wales Hospital, Hong Kong. PATIENTS A cohort of patients with Parkinson's disease received subthalamic nucleus deep brain stimulation from September 1998 to January 2010. Patient assessment data before and after the operation were collected prospectively. RESULTS Forty-one patients (21 male and 20 female) with Parkinson's disease underwent bilateral subthalamic nucleus deep brain stimulation and were followed up for a median interval of 12 months. For the whole group, the mean improvements of Unified Parkinson's Disease Rating Scale (UPDRS) parts II and III were 32.5% and 31.5%, respectively (P<0.001). Throughout the years, a multidisciplinary team was gradually built. The deep brain stimulation protocol evolved and was substantiated by updated patient selection criteria and outcome assessment, integrated imaging and neurophysiological targeting, refinement of surgical technique as well as the accumulation of experience in deep brain stimulation programming. Most of the structural improvement occurred before mid-2005. Patients receiving the operation before June 2005 (19 cases) and after (22 cases) were compared; the improvements in UPDRS part III were 13.2% and 55.2%, respectively (P<0.001). There were three operative complications (one lead migration, one cerebral haematoma, and one infection) in the group operated on before 2005. There was no operative mortality. CONCLUSIONS The functional state of Parkinson's disease patients with motor disabilities refractory to best medical treatment improved significantly after subthalamic nucleus deep brain stimulation. A dedicated multidisciplinary team building, refined protocol for patient selection and assessment, improvement of targeting methods, meticulous surgical technique, and experience in programming are the key factors contributing to the improved outcome.
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Affiliation(s)
| | - Anne Y Y Chan
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jonas H M Yeung
- Division of Neurology, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Vincent C T Mok
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Vincent H L Ip
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Adrian Wong
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - S H Kuo
- Neurological Institutes of New York, Columbia University, United States
| | - Danny T M Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - X L Zhu
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Edith Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Claire K Y Lau
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Rosanna K M Wong
- Department of Occupational Therapy, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Venus Tang
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Clinical Psychology, Prince of Wales Hospital, Hospital Authority, Hong Kong
| | - Christine Lau
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - W S Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Yu SCH, Zou WXY, Soo YOY, Wang L, Hui JWY, Chan AYY, Lee KT, Ip VHL, Fan FSY, Chan ALC, Wong LKS, Leung TW. Evaluation of carotid angioplasty and stenting for radiation-induced carotid stenosis. Stroke 2014; 45:1402-7. [PMID: 24699055 DOI: 10.1161/strokeaha.113.003995] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate the procedural safety, clinical, and angiographic outcome of carotid angioplasty and stenting for high-grade (≥70%) radiation-induced carotid stenosis (RIS) using atherosclerotic stenosis (AS) as a control. METHODS In this 6-year prospective nonrandomized study, we compared the carotid angioplasty and stenting outcome of 65 consecutive patients (84 vessels) with RIS with that of a control group of 129 consecutive patients (150 vessels) with AS. Study end points were 30-day periprocedural stroke or death, ipsilateral ischemic stroke, technical success, procedural characteristics, instent restenosis (ISR; ≥50%) and symptomatic ISR. RESULTS The median follow-up was 47.3 months (95% confidence interval, 26.9-61.6). Imaging assessment was available in 74 vessels (RIS) and 120 vessels (AS) in 2 years. Comparing RIS group with AS group, the rates of periprocedural stroke or death were 1.5% (1/65) versus 1.6% (2/129; P=1); ipsilateral ischemic stroke rates were 4.6% (3/65) versus 4.7% (6/129; P=1); the annual risks of ipsilateral ischemic stroke were 1.2% (3 patient/254.7 patient year) versus 1.2% (6 patient/494.2 patient year; P=0.89); technical success rates were both 100%. Stenting of common carotid artery and the use of multiple stents was more common in the RIS group (P=0 in both cases); ISR rates were 25.7% (19/74) versus 4.2% (5/120; P<0.001); symptomatic ISR rates were 6.8% (5/74) versus 0.8% (1/120; P=0.031). CONCLUSIONS The safety, effectiveness, and technical difficulty of carotid angioplasty and stenting for RIS are comparable with that for AS although it is associated with a higher rate of ISR. CLINICAL TRIAL REGISTRATION This trial was not registered as enrollment started in 2006.
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Affiliation(s)
- Simon C H Yu
- From the Department of Imaging and Interventional Radiology, Prince of Wales Hospital (S.C.H.Y., J.W.Y.H., K.T.L.), Vascular and Interventional Radiology Foundation Clinical Science Center (S.C.H.Y., J.W.Y.H., K.T.L., T.W.L.), and Department of Medicine and Therapeutics, Prince of Wales Hospital (W.X.Y.Z., Y.O.Y.S., L.W., A.Y.Y.C., V.H.L.I., F.S.Y.F., A.L.C.C., L.K.S.W., T.W.L.), The Chinese University of Hong Kong, Hong Kong, China
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Zou WXY, Leung TW, Yu SCH, Wong EHC, Leung SF, Soo YOY, Ip VHL, Chan AYY, Lam WWM, Siu DYW, Abrigo J, Lee KT, Liebeskind DS, Wong KS. Angiographic features, collaterals, and infarct topography of symptomatic occlusive radiation vasculopathy: a case-referent study. Stroke 2013; 44:401-6. [PMID: 23306321 DOI: 10.1161/strokeaha.112.674036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes. METHODS We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern. RESULTS ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P<0.05). With comparable rates of vascular anomaly, ORV patients showed more established collateral circulations through leptomeningeal arteries, anterior communicating artery, posterior communicating artery, suboccipital/costocervical artery, and retrograde flow in ophthalmic artery. In terms of infarct topography, the frequencies of cortical or subcortical watershed infarcts were similar in both groups. CONCLUSIONS ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV.
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Affiliation(s)
- Winnie X Y Zou
- Department of Medicine and Therapeutics, Division of Neurology, Prince of Wales Hospital, 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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