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BackgroundRecently, several studies have focused on the relationship between blood-brain barrier (BBB) impairment and the etiology of Moyamoya disease (MMD). However, in vivo studies investigating about BBB impairment and cortical perfusion in MMD patients were really rare.MethodsThis study included 16 patients diagnosed with MMD and 9 patients with atherosclerotic cerebrovascular disease (ACVD); all of who were treated with superficial temporal artery–middle cerebral artery (STA-MCA) bypass. Cortical perfusion was assessed using intraoperative indocyanine green (ICG) videoangiography by calculating the blood flow index (BFI). In addition, we used sodium fluorescein (NaFl) to evaluate the permeability of BBB in vivo during operation.ResultsThe results showed that BBB impairment in MMD patients was more significant than that in ACVD patients, whereas, the cortical perfusion was comparable between two groups. BFI was significantly improved after STA-MCA bypass both in the MMD group (post-operation vs pre-operation: 109.2 ± 67.7 vs 64.3 ± 35.0, p = 0.004) and the ACVD group (post-operation vs pre-operation: 137.6 ± 89.6 vs 90.8 ± 58.3, p = 0.015). Moreover, BFI was significantly decreased in the cortex with BBB impairment as compared with that in the cortex with intact BBB (impaired BBB vs intact BBB: 55.7 ± 26.5 vs 87.6 ± 55.1, p = 0.025). Following bypass, the cortical perfusion significantly improved in the area of BBB impairment (post-operation vs pre-operation: 93.8 ± 75.2 vs 55.7 ± 26.5, p = 0.004), which was not observed in the BBB intact area (post-operation vs pre-operation: 92.4 ± 50.4 vs 87.6 ± 55.1, p = 0.58).ConclusionIn summary, we observed that BBB impairment in MMD patients was more significant than that in ACVD patients. This study also demonstrated for the first time that cortical perfusion was significantly decreased in the cortex with BBB impairment as compared with that in the cortex with intact BBB in MMD patients. We also observed that After STA-MCA bypass, the cortical perfusion was significantly improved in the cortex with BBB impairment. These results may provide a new insight for BBB impairment and cortical perfusion in the etiology of MMD.

A significant portion of ischemic stroke is on account of emboli caused by fibrous cap rupture of vulnerable plaque with intraplaque neovascularization as a significant triggering factor to plaque vulnerability. Contrast-enhanced ultrasound (CEUS) could offer detailed information on plaque surface and intraplaque microvascular. This study aims to comprehensively assess the value of CEUS for the detection of plaque rupture and neovascularization in histologically verified plaques that had been removed from the patients who had undergone carotid endarterectomy (CEA). Fifty-one consecutive subjects (mean age, 67.0 ± 6.5 years; 43 [84.3%] men) scheduled for CEA were recruited. Standard ultrasound and CEUS were performed prior to surgery. Based on the direction of the contrast agents that diffuse within the plaques, plaques were divided as “inside-out” direction (contrast agents diffuse from the artery lumen towards the inside of the plaque) and non-inside-out direction. Plaque enhancement was assessed by using a semi-quantitative grading scale (grade 1: no enhancement; grade 2: moderate enhancement; grade 3: extensive enhancement). Plaques were evaluated for histopathologic characteristics according to Oxford Plaque Study (OPS) standard postoperative. Intraplaque neovascularization as manifested by the appearance of CD34-positive microvessels was characterized in terms of microvessel density (MVD), microvessel area (MVA), and microvessel shape (MVS). In 51 plaques, the sensitivity, specificity, positive, and negative predictive values of contrast agent inside-out direction diffusion for the detection of plaque fibrous cap rupture were 87.5%, 92.6%, 91.3%, and 89.3%, respectively. The incidence of cap rupture was significantly higher in contrast agent inside-out direction diffusion than non-inside-out direction diffusion (73.9% vs 25.0%, p  < 0.001), and inside-out direction diffusion did exhibit higher frequency of vulnerable plaques (OPS grades 3–4) (95.7% vs 53.6%, p  = 0.001). Multivariate logistic regression analysis revealed the contrast agent inside-out direction diffusion as an independent correlate to plaque rupture (OR 8.5, 95% CI 2.4–30.1, p  = 0.001). With increasing plaque enhancement, plaque MVD ( p  < 0.001), plaque MVA ( p  = 0.012), and percentage of highly irregular-shaped microvessels increased ( p  < 0.001). Contrast agent inside-out direction diffusion could indicate plaque rupture. The increase in plaque enhancement paralleled increased, larger, and more irregular-shaped microvessels, which may suggest an increased risk of plaque vulnerability.

BackgroundSuperficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with an encephaloduromyosynangiosis (EDMS) had gained significant role in treating chronic cerebral ischemia. Invasiveness and costs of intraoperative digital subtraction angiography (DSA) limited its application in operations.ObjectiveTo find the reliable parameters for determining bypass patency with intraoperative micro-Doppler (IMD) sonography and compare the diagnostic accuracy of indocyanine green (ICG) videoangiography with IMD in combined bypass.MethodOne hundred fifty bypass procedures were included and divided into patent and non-patent groups according to postoperative computed tomography angiography (CTA) within 72 h. The surgical process was divided into four phases in the following order: preparation phase (phase 1), anastomosis phase (phase 2), the temporalis muscle closure phase (phase 3), and the bone flap closure phase (phase 4). The IMD parameters were compared between patent and non-patent groups, and then compared with the patency on CTA by statistical analyses. IMD with CTA, ICG videoangiography with CTA, IMD with ICG videoangiography were performed to assess bypass patency. The agreement between methods was evaluated using kappa statistics.ResultsNo significant differences of baseline characteristics were found between patent and non-patent group. Parameters in the STA were different between patent and non-patent groups in phases 2, 3, and 4. In patent group, Vm was apparently higher and PI was lower in phases 2, 3, and 4 compared with phase 1 (P < .001). In non-patent group, no differences of Vm and PI were found within inter-group. The best cutoff value of IMD in the STA to distinguish patent from non-patent bypasses was Vm in phase 4 > 17.5 cm/s (sensitivity 94.2%, specificity 100%). In addition, the agreement for accessing bypass patency was moderate between ICG videoangiography and CTA (kappa = 0.67), IMD and ICG videoangiography (kappa = 0.73), and good between IMD and CTA (kappa = 0.86).ConclusionICG videoangiography could directly display morphology changes of bypass. IMD could be used for providing half-quantitative parameters to assess bypass patency. Vm in phase 4 > 17.5 cm/s suggesting the patency of bypass on CTA would be good. Also, compared with ICG videoangiography, IMD had more accuracy.

ObjectiveIntraplaque hemorrhage (IPH) and ulceration of carotid atherosclerotic plaques have been associated with vulnerability while calcification has been conventionally thought protective. However, studies suggested calcification size and location may increase plaque vulnerability. This study explored the association between calcium configurations and ulceration with IPH.MethodsOne hundred thirty-seven consecutive symptomatic patients scheduled for carotid endarterectomy were recruited. CTA and CTP were performed prior to surgery. Plaque samples were collected for histology. According to the location, calcifications were categorized into superficial, deep and mixed types; according to the size and number, calcifications were classified as thick and thin, multiple and single.ResultsSeventy-one plaques had IPH (51.8%) and 83 had ulceration (60.6%). The appearance of IPH and ulceration was correlated (r = 0.49; p < 0.001). The incidence of multiple, superficial and thin calcifications was significantly higher in lesions with IPH and ulceration compared with those without. After adjusting factors including age, stenosis and ulceration, the presence of calcification [OR (95% CI), 3.0 (1.1-8.2), p = 0.035], multiple calcification [3.9 (1.4-10.9), p = 0.009] and superficial calcification [3.4 (1.1-10.8), p = 0.001] were all associated with IPH. ROC analysis showed that the AUC of superficial and multiple calcifications in detecting IPH was 0.63 and 0.66, respectively (p < 0.05). When the ulceration was combined, AUC increased significantly to 0.82 and 0.83, respectively. Results also showed that patients with lesions of both ulceration and IPH have significantly reduced brain perfusion in the area ipsilateral to the infarction.ConclusionsSuperficial and multiple calcifications and ulceration were associated with carotid IPH, and they may be a surrogate for higher risk lesions.Key Points• CTA-defined superficial and multiple calcifications in carotid atherosclerotic plaques are independently associated with the presence of intraplaque hemorrhage.• The combination of superficial and multiple calcifications and ulceration is highly predictive of carotid intraplaque hemorrhage.• Patients with lesions of both ulceration and intraplaque hemorrhage have significantly reduced brain perfusion in the area ipsilateral to the infarction.

Abstract Objective Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. Symptomatic lesions are resistant to medical treatment and revascularization is often required, but there is no consensus on the treatment of CCAO at present. Riles type 1A CCAO is most likely to benefit from revascularization because it has patent outflow tract (internal carotid artery) which was supplied by patent external carotid artery (ECA) from collateral circulation. We described a novel surgical technique improved on the basis of the carotid endarterectomy (CEA) for treatment of Riles type 1A CCAO.MethodsWe rigorously screened ten patients with symptomatic Riles type1A CCAO for surgery from January 2017 to May 2019 and performed a full preoperative assessment of the inadequate collateral circulation compensation. Moreover, we retrospectively reviewed our experience of the segmented CEA in the treatment of them in our single center.ResultsSegmented CEA was performed on the left side in four cases and on the right side in six cases. The technical success rate of the procedure was 100%. Primary suture was used in nine cases. Only one patient (right CCAO) who had a history of neck radiotherapy was treated by the patch CEA. The mean temporary blocking time during surgery was 52.8 ± 9.15 min. The mean temporary blocking time for treating the upper segment of the common carotid artery (CCA) was 11.1 ± 2.64 min. In the postoperative period, cerebral perfusion on the ipsilateral site improved in all patients, myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another. No ischemic events or re-occlusion or restenosis (> 50%) of the treated CCA occurred during the mean follow-up of 32.6 ± 9.3 months. The preoperative mean modified Rankin Scale (mRS) score was 1.9 (range, 1–3; median, 2). At last follow-up for all patients, the mRS score was 1 (range, 0–3; median, 1).ConclusionSegmented CEA, which utilizes the compensatory effect of collateral circulation, is an effective and safe technique to treat patients suffering from Riles type 1A CCAO with hemodynamic cerebrovascular compromise.

Background. Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS). Transcatheter closure of PFO is superior to pharmacotherapy for patients with CS or transient ischemic attack (TIA). More evidence is needed to evaluate the efficacy and safety of PFO closure in Chinese patients. Methods. This study enrolled ten CS patients and two TIA patients (mean age of 40.8±9.7 y), including seven males (58%) and five females (42%) who underwent PFO closure in our center from January 2017 to July 2019. Baseline data, imaging data, and RoPE (Risk of Paradoxical Embolism) score were collected retrospectively. The preprocedural assessment and percutaneous transcatheter PFO closure were described in detail. The perioperative complications and follow-ups were recorded from all patients. Results. Among ten patients with CS, eight patients had a RoPE score of >6 and two patients had a RoPE score of 6. MRI confirmed multiple infarcts in seven cases, and infarct involving the cortex in nine cases. Abnormal ECG was found in three patients and abnormal Echo in four patients. Right-to-left shunt (RLS) was detected in all the patients by cTCD or cTTE. To be specific, RLS was observed in nine of the ten TEE-detected patients. No case had PFO complicated with atrial septal aneurysm (ASA). The success rate of PFO closure was 91.6%. No serious perioperative complications were observed. During a mean time of 26.5±8 months (15-41 months) of follow-up, no recurrent cerebral infarction, TIA, or thromboembolism were detected in postoperative patients. Conclusions. PFO closure is safe and effective in the treatment of Chinese patients with CS or TIA.

BackgroundAlteplase before thrombectomy for patients with large vessel occlusion stroke raises concerns regarding an increased risk of intracranial hemorrhage (ICH), but the details of this relationship are not well understood.MethodsThis was a secondary analysis of the DIRECT-MT trial. ICH and its subtypes were independently reviewed and classified according to the Heidelberg Bleeding Classification. The effects of alteplase before thrombectomy on ICH and ICH subtypes occurrence were evaluated using logistic regression. Clinical and imaging characteristics that may modify these effects were exploratorily tested.ResultsAmong 591 patients, any ICH occurred in 254 (43.0%), including hemorrhagic infarction type 1 in 12 (2.1%), hemorrhagic infarction type 2 in 127 (21.7%), parenchymal hematoma type 1 in 34 (5.8%), parenchymal hematoma type 2 in 50 (8.6%), and other hemorrhage types (3a-3c) in 24 (4.1%). Similar ICH frequencies were observed with combined alteplase and thrombectomy versus thrombectomy only (134/292 (45.9%) vs 120/299 (40.1%); OR 1.27, 95% CI 0.91 to 1.75, P=0.16), but patients treated with alteplase had a higher parenchymal hematoma rate (51/287 (17.8%) vs 33/297 (11.1%); OR 1.75, 95% CI 1.08 to 2.85, P=0.024). In the adjusted model, difference in parenchymal hematoma occurrence between groups remained significant (adjusted OR 1.71, 95% CI 1.00 to 2.92, P=0.049). Patients with history of diabetes (Pinteraction=0.048), hypertension (Pinteraction=0.02), antiplatelet therapy (Pinteraction=0.02), anticoagulation therapy (Pinteraction=0.04), and statin administration (Pinteraction=0.02) harbored a higher ICH rate when they received combination therapy.ConclusionsOur data showed that in the DIRECT-MT trial, alteplase did not increase overall ICH for large vessel occlusion patients treated with thrombectomy, but it increased the parenchymal hematoma rate.

The interfacial adhesion between asphalt and steel slag aggregate is a decisive factor in the formation of an asphalt–steel slag mixture and significantly affects the quality stability of steel slag–asphalt mixtures. In this study, the adhesion between an asphalt and steel slag aggregate, the interfacial microstructure, the adsorption and desorption characteristics, and chemical reactions were, respectively, explored by a PosiTestAT–A adhesion puller, a scanning electron microscope, a net adsorption test, an infrared spectrometer, and a dynamic shear rheometer. The mechanism of adhesion between the asphalt and steel slag aggregate was analyzed from the perspectives of physical adsorption and chemical reactions. The results showed that different factors had different effects on the adhesion of asphalt–steel slag aggregate interface. The freeze–thaw cycle and steel slag aggregate particle size had significant effects on interfacial adhesion, while the asphalt heating temperature, water bath time, and stirring time had relatively weak effects on interfacial adhesion. Compared to a limestone aggregate, the steel slag–asphalt mixture had greater adhesion and better adhesion performance because the pits and textures on the surface of the steel slag aggregate produced a skeleton–like effect that strengthened the phase strength of the asphalt–slag aggregate interface, thereby improving the adhesion and increasing the physical adsorption between the asphalt and steel slag aggregate. In addition, due to the N–H stretching vibrations of the amines and amides, as well as SiO–H stretching vibrations, a chemical reaction occurred between the asphalt and steel slag aggregate, thus improving the adhesion performance between the asphalt and steel slag. Based on the shape of the adsorption isotherm, it was determined that the adsorption type was multi–molecular layer adsorption, indicating that the adhesion between the asphalt and steel slag mainly involved physical adsorption.

Phosphogypsum (PG) is not only a solid waste discharged from the phosphate fertilizer industry, but also a valuable resource. After high-temperature heat treatment, it can be decomposed into SO2 and CaO; the former can be used to produce sulfuric acid, and the latter can be used as building materials. In this paper, the catalytic thermal decomposition conditions of phosphogypsum were optimized, and the effects of the reaction temperature, reaction atmosphere, reaction time and carbon powder content on the decomposition of phosphogypsum were studied. The research shows that the synergistic effect of carbon powder and CO reducing atmosphere can effectively reduce the decomposition temperature of phosphogypsum. According to the results of the orthogonal test under simulated suspended laboratory conditions, the factors affecting the decomposition rate of phosphogypsum are temperature, time, atmosphere and carbon powder content in turn, and the factors affecting the desulfurization rate are time, temperature, atmosphere and carbon powder content in turn. Under laboratory conditions, the highest decomposition rate and desulfurization rate of phosphogypsum are 97.73% and 97.2%, and the corresponding reaction conditions are as follows: calcination temperature is 1180 °C, calcination time is 15 min, carbon powder content is 4%, and CO concentration is 6%. The results of thermal analysis of phosphogypsum at different temperature rising rates show that the higher the temperature rising rate, the higher the initial temperature of decomposition reaction and the temperature of maximum thermal decomposition rate, but the increase in the temperature rising rate will not reduce the decomposition rate of phosphogypsum.

Steel slag is an industrial solid waste with the largest output in the world. It has the characteristics of wear resistance, good particle shape, large porosity, etc. At the same time, it has good adhesion characteristics with asphalt. If steel slag is used in asphalt pavement, it not only solves the problem of insufficient quality aggregates in asphalt concrete, but can also give full play to the high hardness and high wear resistance of steel slag to improve the performance of asphalt pavement. In this study, a steel slag aggregate was mixed with road petroleum asphalt to prepare a permeable steel slag–asphalt mixture, which was then compared with the permeable limestone–asphalt mixture. According to the Technical Regulations for Permeable Asphalt Pavement (CJJT 190-2012), the permeability, water stability, and Marshall stability of the prepared asphalt mixtures were tested and analyzed. In addition, the high-temperature stability and expansibility were analyzed according to the Experimental Regulations for Highway Engineering Asphalt and Asphalt Mixture (JTG E20-2011). The chemical composition of the steel slag was tested and analyzed by X-ray fluorescence spectrometer (XRF). The mineral composition of the steel slag was tested and analyzed by X-ray diffractometer (XRD). The asphalt was analyzed by Fourier transform infrared spectroscopy (FTIR). The results show that the steel slag asphalt permeable mixture had good permeability, water stability, and Marshall stability, as well as good high-temperature stability and a low expansion rate. The main mineral composition was ferroferric oxide, the RO phase (RO phase is a broad solid solution formed by melting FeO, MgO, and other divalent metal oxides such as MnO), dicalcium silicate, and tricalcium silicate. In the main chemical composition of steel slag, there was no chemical reaction between aluminum oxide, calcium oxide, silicon dioxide, and asphalt, while ferric oxide chemically reacted with asphalt and formed new organosilicon compounds. The main mineral composition of the steel slag (i.e., triiron tetroxide, dicalcium silicate, and tricalcium silicate) reacted chemically with the asphalt and produced new substances. There was no chemical reaction between the RO phase and asphalt.