Dong Zhang

Aims: This study aimed to investigate the characteristics, predictors, and clinical significance of periventricular anastomosis (PA) regression following revascularization in moyamoya disease (MMD). Methods: We conducted a longitudinal cohort study involving patients with MMD treated at our hospital between 2019 and 2023. Demographic, radiological findings, and clinical outcomes were recorded. C‐terminal region of ring finger protein 213 ( RNF213 ) was sequenced. Additionally, structural changes of the RNF213 variants were evaluated using a three‐dimensional model of the human RNF213 protein. Results: Of 305 eligible patients, 103 experienced postoperative PA regression. Among the subtypes of PA, those derived from the lenticulostriate, anterior choroidal, and thalamotuberal arteries exhibited significant regression. Multivariate analysis identified age ( p = 0.030), Suzuki stage (III‐IV) ( p = 0.043), preoperative PA score ( p < 0.001), RNF213 p.R4810K variant ( p = 0.019), other RNF213 rare variants ( p = 0.004), and postoperative Matsushima grading ( p < 0.001) were associated with postoperative PA regression. The risk of future hemorrhage was significantly higher in the non‐PA regression group ( p = 0.040). 80% of rare variants without structural changes did not exhibit PA regression. Conclusions: RNF213 variants in the C‐terminal region are associated with PA regression, underscoring a broader genotype–phenotype correlation. Furthermore, PA regression might be considered a potential radiological marker to predict the risk of future hemorrhage in MMD patients.

Background: This study aimed to explore the association between the rim sign and intraplaque hemorrhage (IPH) based on imaging‐histology analysis. Methods: Patients with carotid plaque were prospectively recruited and underwent computed tomography angiography (CTA) and vessel wall magnetic resonance imaging examination. CTA characteristics were evaluated qualitatively or quantitatively. IPH was determined through vessel wall magnetic resonance imaging assessment. The receiver operating characteristic curve and area under the curve were performed to assess the diagnostic performance of CTA features in the identification of IPH. Additionally, the histological subgroup analysis was performed on plaque specimens obtained from carotid endarterectomy procedures. Results: In total, 81 patients who underwent unilateral carotid endarterectomy and 143 plaques were included in the analysis. Plaques with IPH exhibited more severe stenosis, greater soft and total plaque thickness, and a higher proportion of rim signs compared with plaques without IPH ( P <0.05 for all comparisons). Multivariate logistic regression analysis showed that the rim sign was associated with the presence of IPH. In the subgroup analysis based on histology, the rim sign was independently correlated with the presence of IPH. The rim sign demonstrated diagnostic performance for magnetic resonance imaging‐determined IPH, with an area under the curve of 0.85 (95% CI, 0.78–0.92), with a sensitivity of 85.9% and a specificity of 84.1%. Conclusions: The rim sign in carotid plaque is associated with the presence of IPH and may be a potential CTA feature for the evaluation of IPH on CTA images. This imaging marker may provide additional value for risk stratification of carotid plaques.

Background: To summarize the clinical and radiological outcomes of a novel cerebral revascularization technique based on the superficial temporal artery patency concept (STAPC) in patients with moyamoya disease (MMD). Methods: A retrospective review was conducted of adult patients with MMD treated at Beijing Hospital and Nanjing Drum Tower Hospital between January 2019 and December 2021. The cohort comprised 170 patients who underwent superficial temporal artery–middle cerebral artery bypass with encephalo-duro-arterio-synangiosis (EDAS) (STA-MCA/EDAS), and 133 who underwent EDAS alone. Radiological follow-up included computed tomography (CT) angiography (CTA) to assess bypass patency and CT perfusion (CTP) for hemodynamic staging at 3 and 12 months post-revascularization. Clinical follow-up recorded perioperative complications and recurrent stroke events that occurred > 12 months postoperativerly. Results: Of the 303 patients, 37 cases (12.21%) had perioperative complications including 27 cases (15.9%) in the STA-MCA/EDAS group and 10 cases (7.5%) in the EDAS group. Perfusion improvement was observed in 23.76% of patients (25.7% in the STA-MCA/EDAS group and 17.8% in the EDAS group) at 3 months postsurgical, and in 40.17% of patients (48.68% in the STA-MCA/EDAS group and 24.39% in the EDAS group) at 12 months postsurgical. Bypass patency was observed in 95.29% of patients (96.1% in the STA-MCA/EDAS group and 93.5% in the EDAS group) at 3 months postoperative, and in 96.43% patients (95.2% in the STA-MCA/EDAS group and 97.1% in the EDAS group) at 12 months postoperative. Of the 249 patients with a median follow-up period of 50 months (range 12–70 months), 40 cases (16.06%, 3.85% per year) had recurrent stroke events including 22 (15.41%, 3.69% per year) in the STA-MCA/EDAS group and 18 (16.67%, 3.91% per year) in the EDAS group. Conclusions: Cerebral revascularization using STAPC is an acceptable surgical strategy for preventing stroke recurrence in patients with MMD.

Although limited to case report, the role of extracranial-intracranial bypass without aneurysm trapping in resolving complex intracranial aneurysms (CIAs) remained unclear. The aim was to investigate clinical and hemodynamic features of CIAs underwent cerebral revascularization without aneurysm trapping. To the authors' knowledge, this was the first and largest series reported to date. The author prospectively recruited patients with CIAs not passing balloon occlusion test (BOT) or harboring important perforators from Jan. 2019 to Dec 2022. Cerebral revascularization without aneurysm trapping was performed, of which four-dimensional flow (4D-flow) MRI and computational fluid dynamics (CFD) based on CT angiography were utilized. The patients' demographic information and clinical course were obtained from reviewing medical records. Of 15 cases enrolled, CIAs disappeared, unchanged, and enlarged in 4, 8, and 3 cases. The 4D-flow results showed donor vessel had a trend of first increasing and then decreasing in flow and velocity after bypass, with a turning point (TP) that might occur one week after revascularization. The velocity and flow of parent artery (PA) after TP was discrepant with a decrease tendency for aneurysm disappeared, but an increase tendency for aneurysm enlarged. For cases with aneurysm disappeared, CFD analysis revealed postoperative streamline velocity and wall shear (WS) of aneurysm decreased significantly compared to preoperative values. Otherwise, streamline velocity and WS of aneurysm still existed or even increased. Cerebral revascularization without aneurysm trapping was not an ideal option for CIAs, achieving hemodynamic TP of postoperative one week and an uncertain future.

To present results of complex intracranial aneurysms (CIAs) underwent extracranial-intracranial (EC-IC) bypass with one-stage and two-stage aneurysm trapping in anterior circulation and share our experience. The author retrospectively reviewed 53 patients with CIAs underwent EC-IC bypass with different therapies of aneurysm trapping from Jan. 2018 to Dec 2020. Ballon occlusion testing (BOT) was performed to assess collateral circulation. In general, CIAs was operated by one-stage trapping, which was characterized by simultaneous implementation of aneurysm trapping and EC-IC bypass. However, CIAs failing to BOT or harboring important perforators was performed by two-stage trapping, which involved subsequent delay in performing aneurysm trapping based on CIAs change after EC-IC bypass. Clinical variables, postoperative complications, and follow-up outcomes were presented. Of the 53 patients, 28 patients completed the one-stage aneurysm trapping, and 25 patients completed two-stage aneurysm trapping. There was significant difference in patients experiencing new cerebral infarction between patients with one-stage and two-stage aneurysm trapping (21.4% vs. 4.0%, P = 0.049). When discharged, there was significant difference in CIAs disappeared between patients with one-stage and two-stage aneurysm trapping (100.0% vs. 24.0%, P < 0.001). CIAs without one-stage aneurysm trapping achieved complex aneurysm changes after revascularization, including aneurysm disappeared, unchanged, and enlarged in 6 cases, 9 cases, and 10 cases. Out of 18 CIAs demanding two-staged aneurysm trapping, aneurysm disappeared in 17 cases and got smaller in 1 case. At the final follow-up with average of 58 months, there was no significant difference in aneurysm change between patients with one-stage and two-stage aneurysm trapping (P = 0.312). No new ischemic and hemorrhagic events developed. EC-IC bypass with one-stage aneurysm trapping was an effective option for CIAs although with high risk of operation-related infarction. EC-IC bypass with two-stage aneurysm trapping was an alternative treatment for selected CIAs.

Background: Alkaline phosphatase (ALP) has played a pivotal role in vascular diseases in recent years. However, the association between ALP level and postoperative complications of moyamoya disease (MMD) has not been studied.Patients and methods: Blood samples were collected from recruited patients with MMD. The serum ALP concentrations of the patients were determined using non-frozen specimens via an automated enzymatic assay. Patients were then divided into two groups according to the median, and a comparative analysis was performed. Patients were stratified into two cohorts for statistical evaluation based on the occurrence of postoperative stroke events. We employed a nomogram to identify risk factors for postoperative events. We also created a Cox model to analyze the risk factors for postoperative stroke events, including ALP. Furthermore, we plotted a restricted cubic spline (RCS) of ALP concentration vs. postoperative stroke events.Results: We could find that the ALP concentration of non-postoperative stroke group and postoperative stroke group was 68.70 U/L and 71.15 U/L. This nomogram showed that ALP was a risk factor for postoperative events, and the Hosmer–Lemeshow goodness-of-fit test was employed, suggesting that the model was reliable (χ² = 8.507, p = 0.386). And it also could obverse that there was a statistically positive correlation from the RCS between ALP concentration and postoperative stroke events Cox analysis (HR = 1.006, 95% CI = 1.002–1.010, p = 0.008).Conclusions: ALP levels may predict the short-term postoperative outcomes of MMD patients undergoing surgical treatment.

Acute ischemic stroke (AIS) is a common cerebrovascular disease characterized by high incidence and disability rates, placing a significant burden on global healthcare systems. Various cell types, including microglia, astrocytes, oligodendrocytes, and peripheral immune cells, interact in the pathological process of AIS, profoundly influencing the disease's prognosis. This review, for the first time, summarizes the biological functions and interaction mechanisms of microglia, astrocytes, oligodendrocytes, their subgroups, and infiltrating peripheral immune cells at different time points and spatial distributions following AIS, from the perspective of spatial single-cell omics. Spatial transcriptomics technology combines high-resolution gene expression information with tissue spatial architecture, enabling researchers to precisely identify the spatial distribution and dynamic crosstalk between CNS-resident cells and peripheral immune cell subsets. Intervening in the interactions between cell subgroups or different cell types and effectively targeting specific subgroups in the target area, may help minimize the negative effects of harmful subsets while enhancing the functions of beneficial ones. The application of spatial single-cell transcriptomics provides an unprecedented perspective for understanding the complex intercellular interactions following stroke, laying the foundation for precision interventions and targeted therapies.

Metals in circulation and urine had been implicated in atherosclerosis progression, but spatial distribution of metals within plaques and their association with plaque stability remained unclear. This study aimed to clarify differences of metal deposition between symptomatic and asymptomatic carotid plaques and metal spatial distribution within atherosclerotic plaques. We enrolled 15 asymptomatic and 53 symptomatic atherosclerotic plaque specimens during carotid endarterectomy. Each plaque was divided into the plaque core and thickened intimal area. We analyzed the difference of metals within plaques between symptomatic and asymptomatic groups and correlations between age and metal deposition. Besides, 12 additional symptomatic atherosclerotic plaques were used to map metal element distribution by laser ablation inductively coupled plasma mass spectrometry to analyze relative abundance of metal across pathological characteristics of plaques. Significantly higher levels of vanadium, iron, copper, molybdenum, and cadmium were found in the core area of symptomatic plaques compared to asymptomatic plaques, while no difference was observed in plaque thickened intimal area. Copper and lead deposition in core region of symptomatic plaques significantly increased with age. Spatial mapping indicated distinct metal distribution patterns: copper was primarily localized in necrotic and calcified regions, iron was in intraplaque hemorrhage, and calcium and zinc were in calcified areas. Elevated metal accumulation and distinct spatial distribution of metal elements within atherosclerotic plaques might contribute to plaque instability. Our findings highlighted the potential role of metal elements in plaque progression and value of spatial localization methods in studying the pathological roles of metal elements.