Intracranial aortic occlusive cerebral infarction, from the cause to the prognosis, is a clinical necessity!

*Only for medical professionals to read for reference.
See what Professor Liu Xiaoyun said? Intracranial aortic occlusion (Large artery occlusion, LAO) is also called intracranial large vessel occlusion (LVO), so these two terms will appear in the following text
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This reason causes cerebral infarction to be more common clinically, which can account for more than 40% of various ischemic strokes, of which about 80% occur in the anterior circulation
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At the 24th National Neurology Conference of the Chinese Medical Association, Professor Liu Xiaoyun from the Second Hospital of Hebei Medical University brought a report on "Different Outcome Prediction of Cerebral Infarction Related to Intracranial Artery Occlusion".
Let us learn together Take a moment
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The concept of intracranial aortic artery occlusion Intracranial aortic artery occlusion is defined as the occlusion of the intracranial carotid artery (ICA) with/without involvement of the terminal bifurcation; specifically includes: M1 and MCA of the middle cerebral artery (MCA) / Or M2 occlusion; A1 and/or A2 occlusion of the anterior cerebral artery (ACA); vertebral artery (VA), basil artery (BA) or posterior cerebral artery ,PCA) P1 and/or P2 are occluded
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Causes of intracranial aortic occlusion Intracranial aortic occlusion can be divided into acute occlusion and chronic occlusion
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The causes of acute occlusion are as follows: in situ occlusion caused by rupture of intracranial atherosclerotic plaque; arterial-arterial embolism, where embolic fragments come from stenosis, ulcers with plaque rupture or dissection of extracranial arteries; from the heart Embolism, the most common cause is atrial fibrillation; cryptogenic or unknown cause is usually considered to be occult paroxysmal atrial fibrillation
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The causes of chronic occlusion are as follows: atherosclerosis is the most common cause; rare causes include malignant tumors, cerebral aneurysms, pituitary stroke, giant cell arteritis, Moyamoya syndrome, trauma, radiation, radiation, and carotid artery surgery
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Taking atherosclerosis as an example, Professor Liu showed everyone a follow-up case.
The imaging examination is shown in Figure 1
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A case of minor stroke patients received regular cranial magnetic resonance angiography since 2015
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It can be seen that the patient's MCA is gradually narrowing, and ACA also appeared stenosis in 2019
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Through this case, we can intuitively see that atherosclerosis is a lifelong disease that continues to progress
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Therefore, the management of atherosclerosis should be the whole process, not only when the patient has ischemic events such as cerebral infarction
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Figure 1 Follow-up imaging changes of a patient (picture from Professor Liu Xiaoyun's PPT) Clinical features of intracranial large artery occlusive cerebral infarction Intracranial large artery occlusive cerebral infarction has the following clinical features: acute LAO-induced ischemic stroke and small vessel stroke There are many of the same symptoms; patients with acute ischemic stroke caused by acute LAO usually show other cortical symptoms, including gaze deviation, visual field defects, vision and sensory loss, aphasia, and agnosia; chronic LAO (such as chronic internal carotid artery) The clinical manifestations of occlusion, chronic internal carotid artery occlusion, CICAO are very different, and many of them are asymptomatic, so we should be alert to the long-term stroke rate of CICAO; CICAO has some special clinical characteristics, such as limb shaking TIA is a rare but rare aspect of CICAO.
Characteristic clinical manifestations; unilateral visual impairment may be a unique symptom of carotid artery disease; non-specific clinical manifestations such as headache and cognitive impairment; vascular dementia may be related to chronic cerebral ischemia caused by CICAO; syncope may be CICAO Of rare symptoms
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Recognition and treatment of large vessel occlusive cerebral infarction Emergency department needs to recognize large vessel occlusive cerebral infarction, because early detection and early prediction can be early intervention to improve the prognosis
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ELVO is the Emergency Large Vessel Occlusion Scale, which is a commonly used scale for identifying large vessel occlusion in the emergency department
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The ELVO scale includes one observation and two questions (Figure 2): Observe the position of the patient’s eye to determine whether there is gaze; the two questions are used to judge aphasia and judge unilateral neglect and hemianopia, respectively
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Any error of the ELVO scale is judged to be positive, indicating that the patient may have large blood vessel occlusion
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The ELVO scale has a sensitivity of 85%, a specificity of 72%, a positive predictive value of 54%, a negative predictive value of 93%, and an accuracy of 76%
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Figure 2 Emergency Large Vessel Occlusion Scale (ELVO) In terms of treatment of large vessel occlusive cerebral infarction, in addition to the conventional treatment according to the guidelines, Professor Liu shared some special experiences and experiences: (1) Patients with large vessel occlusive cerebral infarction The area of ​​cerebral infarction may be large, and attention should be paid to the problems of edema and high intracranial pressure; (2) Patients with large vessel occlusive cerebral infarction may be prone to complications such as post-stroke pneumonia, which requires attention in diagnosis and treatment; (3) Large vessel ischemia Compared with direct thrombolysis, bridging thrombolysis can bring better clinical results, lower 90-day mortality, and higher successful recanalization rate after sexual stroke, without increasing the risk of recent bleeding complications; (4) Patients with good collateral circulation have a higher success rate of reperfusion after receiving endovascular treatment; (5) CICAO patients with hemodynamic disorders may benefit from vascular recanalization
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Prediction of clinical outcome of anterior circulation great vessel occlusion In clinical work, it is indeed found that some patients with anterior circulation-LVO (AC-LVO) are asymptomatic, while some patients have repeated cerebral infarctions
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So for patients with AC-LVO, how to predict the occurrence of acute ischemic stroke (AIS)? Professor Liu’s team applied four representative machine learning algorithms (Figure 3) to model predictions on this problem
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Figure 3 Machine learning methods (picture from Professor Liu Xiaoyun's PPT) The research of Professor Liu's team shows that occlusion of blood vessels, hyperhomocysteinemia, age, diabetes, and atrial fibrillation are the top 5 AIS in patients with AC-LVO Independent risk factors
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The top variables related to disability risk are age, ASPECT score, overweight, and occlusion of blood vessels
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This suggests that clinically, patients with AC-LVO need to pay special attention to the above risk factors
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After investigating the risk factors of AC-LAO for AIS, Professor Liu's team conducted a retrospective analysis of AC-LAO patients, with the purpose of summarizing the subtype classification and outcome of AC-LAO
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The results of the study show that AC-LAO can be divided into eight subtypes as shown in the figure below (Figure 4).
Among them, the MCA occlusion shown in A is the most common type; the least common is the bilateral ICA occlusion shown in F at the same time.
MCA occlusion on one side of the merger
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In terms of prognosis, the results of the study show that the prognosis of bilateral ICA combined with bilateral MCA occlusion and unilateral ICA/MCA continuous occlusion is relatively poor
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Figure 4 The prediction of the clinical outcome of the eight subtypes of AC-LAO (picture from Professor Liu Xiaoyun's PPT).
In addition to AC-LVO, Professor Liu's team also studied the clinical outcome of posterior circulatory occlusion
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Cerebral infarction caused by occlusion of large vessels in the posterior circulation (Figure 5) is characterized by paralysis.
Multiple infarcts are more common, and these patients often have more risk factors
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In terms of prognosis, the results of the study showed that 62.
5% of the patients had a good prognosis, 37.
5% had a poor prognosis, and 10.
4% had a clinical deterioration
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Factors affecting the poor prognosis of discharge include hyperhomocysteinemia, limb numbness, and complications
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Figure 5 Types of vascular occlusion in the posterior circulation (picture from Professor Liu Xiaoyun’s PPT) In addition, Professor Liu Xiaoyun also proposed the concept of vanishing basilar artery syndrome, which refers to the 5 posterior circulation large blood vessels (bilateral vertebral arteries, basilar arteries and bilateral brains).
The posterior artery) has severe stenosis or occlusion, which makes the vascular examination (MRA) basically impossible to develop, as shown in Figure 6
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Figure 6 Vertebrobasilar artery disappearance syndrome (picture from Professor Liu Xiaoyun’s PPT) Professor Liu’s team summarized the clinical characteristics of more than 70 cases of vertebrobasilar artery disappearance syndrome.
The study found that these patients are mainly brainstem and pontine lesions.
There are more risk factors
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Risk factors associated with poor prognosis include diabetes and complications
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Therefore, for these patients, strict blood glucose management is recommended; in terms of examination and evaluation, it is recommended that angiography, a precise vascular examination and evaluation, be further carried out to determine the next treatment plan
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Professor Liu’s lecture explained the basic knowledge of LVO in detail, and demonstrated the difference in clinical manifestations of ischemic stroke caused by anterior circulation and posterior circulation LVO through research
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Studying the risk factors for different prognosis of patients with LVO will help prevent and interfere with ischemic stroke
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 The content of this article is compiled from the lecture of Professor Liu Xiaoyun at the 24th National Neurology Conference of the Chinese Medical Association-"Prediction of Different Outcomes of Cerebral Infarction Related to Intracranial Aortic Occlusion"
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