A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion

A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion Kai-Jun Zhao, Yi-Ming Chen, Jian-Min Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8501424/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To evaluate the efficacy of treating cryptogenic vertebral artery dissections (CVADs) in patients with middle cerebral artery (MCA) stenosis/occlusion and posterior-circulation symptoms. Methods This retrospective study analyzed three patients who underwent endovascular stent reconstruction for CVADs between February 2024 and July 2025. All had symptomatic CVADs confirmed by dynamic contrast-enhanced computed tomography (DCE-CT), concurrent anterior-circulation lesions, and failed medical therapy. Results CVADs treatment alleviated posterior-circulation symptoms and improved hypoperfusion. Case 1 and 3 required staged treatments for recurring symptoms, while Case 2 improved after one treatment. Notably, parkinsonism-like symptoms in Case 3 improved post-treatment. Conclusions Targeting CVADs in complex cerebrovascular disease can improve clinical outcomes and reduce surgical risks. Further research on combined vascular-neurological therapies is warranted. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Highlights 1. This study innovatively focuses on CVADs in patients with MCA stenosis/occlusion and posterior-circulation symptoms, offering a novel approach for complex cerebrovascular disorders. 2. Managing CVADs effectively alleviates posterior-circulation symptoms, improves hypoperfusion from anterior-circulation issues, and reduces procedural risks. A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion Introduction Symptomatic intracranial atherosclerotic stenosis (ICAS) remains a complex challenge in neurovascular medicine. Randomized trials such as Summparis [ 1 , 2 ], VISSIT[ 3 ], and Cassiss [ 4 ] have demonstrated that surgical intervention does not offer clear superiority over best medical therapy for intracranial stenosis. This highlights the uncertainty surrounding interventional treatment and the complexity of managing cerebral arterial stenosis or occlusion. The CMOSS-FU study [ 5 ] first provided long-term evidence that extracranial-to-intracranial bypass can yield sustained benefits in patients with symptomatic, chronic occlusion of the internal carotid or middle cerebral artery. However, the therapeutic strategy becomes significantly more intricate when anterior circulation lesions are accompanied by posterior-circulation symptoms, as illustrated by the three cases reported here. In such scenarios, surgical correction of anterior-circulation stenosis entails higher procedural risks and renders the prognosis more uncertain. However, we observed that all three patients harbored highly occult CVADs [ 6 , 7 ]. Their presenting symptoms-dizziness, headache, numbness, and limb weakness—were more closely related to the CVADs than to the anterior-circulation stenosis or occlusion. Consequently, addressing these CVADs may prove more meaningful for symptom relief, ameliorating hypoperfusion secondary to anterior-circulation stenosis/occlusion, reducing operative risk, and improving overall outcomes. Herein, we describe three patients with bilateral middle cerebral artery stenosis or occlusion and focus on a management strategy that prioritizes the treatment of CVADs. This approach may offer a more effective and less invasive solution for such complex cerebrovascular disorders. Materials and Methods This retrospective study was approved by the Ethics Committees of **BLINDED** Hospitals, and all written consents provided by patients were stored in hospital databases and used exclusively for research purposes. Patients and CVADs We retrospectively reviewed all patients who underwent endovascular treatment for middle-cerebral-artery stenosis and/or occlusion associated with CVADs between February 2024 and July 2025, with the goal of identifying those whose CVADs were reconstructed with stent(s). CVADs were defined as V3–4 segment lesions with or without involvement of the basilar artery (BA). Inclusion criteria were: (1) symptomatic CVADs confirmed on DCE-CT; (2) concomitant stenosis or occlusion of the ipsilateral internal carotid and/or middle cerebral artery; (3) failure of optimal antiplatelet therapy; (4) refusal of extracranial–intracranial direct or indirect revascularization; and (5) endovascular treatment with stent(s). Patients were excluded if (1) the CVADs were left untreated or (2) they had previously undergone intracranial or extracranial bypass surgery. Three consecutive patients (male : female = 2:1; mean age 47.3 ± 20.6 years, range 26–67) harboring five unilateral intracranial symptomatic CVADs (uis-CVADs) fulfilled the criteria and were enrolled. Clinical, angiographic, and follow-up data were analyzed (Table). Patients and Evolution of symptoms Case 1 A 67-year-old female patient presented with restricted elevation of the right upper limb and an inability to comb her hair. She also developed dysarthria, reduced speech rate, and blurred vision. Stiffness and pain in the right shoulder were also reported. These symptoms persisted despite rest and symptomatic treatment. The patient had a history of hypertension. CTA revealed occlusion of the left MCA M1 segment and mild stenosis of the right MCA M1 segment (Figure 1A). CT perfusion (CTP) demonstrated hypoperfusion in the posterior circulation (Figure 2A) and the left temporoparietal region (Figure 2C, 2E). The patient was diagnosed with left MCA occlusion, mild stenosis of the right MCA origin, and cryptogenic arterial dissection of the bilateral vertebral arteries (Figure 1B-1C). However, the patient refused left MCA recanalization or left external carotid - MCA bypass due to concerns regarding the risks and benefits of the procedures. Given that her symptoms were primarily related to the posterior circulation and closely associated with CVADs, right CVAD reconstruction was performed (Figure 1D-1F), resulting in complete resolution of the symptoms. However, seven months after discharge, three of the symptoms reoccurred (Table 1), along with mental confusion, numbness in the left neck, right hand, and right toes, pain and restricted rotation in the right neck, weakness in the distal part of the right upper limb and unstable grasping, as well as stiffness, crepitus, and inflexibility in the right fingers. Following a second-stage left CVAD reconstruction (Figure 1G-1I), all the symptoms were completely alleviated (Table 1). Case 2 A 26-year-old male with a history of congenital strabismus that was not fully corrected by glasses presented with a long-term compensatory gait due to foot imbalance, causing uneven shoe wear. As a child, he had difficulty walking in a straight line and exhibited speech characterized by slow delivery and low volume. He was also noted to be reticent, socially passive, and had poor eye contact. However, his intellectual development was normal, and he completed higher education and entered the workforce. Over the past two years, his weight decreased from 105 kg to 65 kg. Four months ago, he experienced transient left-sided limb weakness following intense exercise that resolved spontaneously. Two months ago, he developed coughing, headache, and dizziness. The following day, his left-sided weakness worsened, occurring 2-3 times daily. His condition progressively deteriorated, with gait deviation and difficulty, accompanied by dysarthria. CTA revealed bilateral MCA stenosis (Figure 3A). Additionally, there were indicators of CVAD in the right vertebral artery (Figure 3B). Cerebral CTP also demonstrated hypoperfusion (Figure 4A) in the posterior circulation, bilateral temporal lobes (Figure 4C), and the right parieto-occipital region (Figure 4E). After reconstructive treatment for cryptogenic vascular dissection (CVD), the opacification of the vascular tree was significantly increased at the same time point (Figure 3C vs Figure 3D; Figure 3E vs Figure 3F) and hypoperfusion in the posterior circulation, particularly in the right temporoparietal lobes, improved (Figure 4). His clinical symptoms were significantly relieved, and his walking function basically returned (Table 2). Now, he can complete four swimming exercises per week for four days. Case 3 A 49-year-old male first presented with gait instability and a tendency to lean toward the left side while standing and walking two years ago. Around one year later, his condition gradually progressed, leading to blurred vision, muscle tremors, decreased dexterity in his right hand, unnatural movements of his right leg while driving, and weakness in his right limbs, during which period he often felt irritable. The muscle tremors initially began in the right hand, then gradually spread to the lower legs and eventually to various parts of the body, with no discernible pattern. In the past 10 days, the patient's aforementioned symptoms significantly worsened, and he developed new symptoms such as headaches, dizziness, bilateral blepharospasm, difficulty in opening his eyes, generalized weakness, and a sensation of numbness in the left scapular region akin to an electric shock. Previously, the patient had been under conservative treatment, but the symptoms remained unrelieved. It was not until he underwent the first CVAD treatment (Figure 5) that his symptoms were completely alleviated (Table 3). However, about one month after discharge, the patient developed new symptoms. He experienced left-sided head, forehead, and neck pain. He also presented with a "Tyrannosaurus posture," characterized by flexed upper limbs, forward inclination of the body, and difficulty squatting and turning. Since the disease onset, the patient exhibited a sallow complexion, marked dark circles around both eyes, constipation, and sleep disorders. Following contralateral CVAD treatment (Figure 5), the patient's "Tyrannosaurus posture" improved, and he is now capable of engaging in outdoor activities such as playing badminton (Table 3). Diagnosis of CVADs All three patients underwent extensive pre-treatment assessments, including routine cranial CT perfusion and MRI scans. These imaging modalities revealed varying degrees of stenosis and/or occlusion in the anterior circulation, specifically in the middle cerebral arteries (Figure 1, 3, 5). However, the predominant symptoms exhibited by the patients were consistent with posterior circulation deficits (Table 1-3). To further elucidate the underlying pathology, DCE-CT was routinely performed [6, 7]. This advanced imaging technique uncovered the presence of CVADs in the posterior circulation, which were closely associated with the observed hypoperfusion (Figure 2, 4, 6). The identification of these dissections was crucial in guiding the subsequent treatment strategy. Treatment of CVADs Of the three patients, all rejected anterior circulation endovascular treatment or indirect/direct extracranial-intracranial bypass due to uncertain results. They weighed the risks and benefits and decided to first manage the vertebral artery dissections to ease posterior circulation hypoperfusion. This was because treating the CVAD might enhance both posterior and anterior circulation perfusion through compensatory mechanisms. Prior to treatment, all patients were administered a dual antiplatelet regimen, consisting of 300 mg of aspirin and 75 mg of clopidogrel, for at least three days to reduce the risk of thrombotic complications. Under general anesthesia, endovascular stent implantation was performed to reconstruct the affected cerebrovascular segments. The stents were meticulously placed to extend at least 5 mm beyond the edges of the dissections to ensure adequate coverage and secure vessel patency. Postoperatively, patients were closely monitored for any new or recurrent symptoms. Follow-up CT perfusion scans were obtained to assess the effectiveness of the treatment. If new or persistent symptoms were identified, contralateral CVAD reconstruction was considered based on the updated imaging findings. This staged approach allowed for targeted intervention and optimization of clinical outcomes. Results The results of these cases demonstrate the efficacy of targeting CVADs in patients with complex cerebrovascular disease. In Cases 1 and 3, staged treatments were necessary to address the recurrence of symptoms and new manifestations, highlighting the importance of comprehensive follow-up and tailored therapeutic approaches. Case 2 showed a stable and sustained improvement following a single treatment session, emphasizing the potential for durable outcomes with this approach. The overall findings suggest that addressing the underlying posterior circulation pathology through CVAD reconstruction can lead to significant clinical improvements, even in the presence of anterior circulation stenosis and/or occlusion. In this series, Case 2 underwent one treatment, while Cases 1 and 3 received staged treatments. In Case 1, we first treated the right symptomatic CVAD. Post-treatment, symptoms fully improved. However, seven months later, the patient had a recurrence with three symptoms (Table 1), alongside new ones such as mental fogginess, numbness in the left neck, right hand, and right toes, right neck pain, restricted neck movement, distal right upper limb weakness, unsteadiness in holding objects, and right finger stiffness, clicking during movement, and clumsiness. Following subsequent left CVAD reconstructive treatment, all these symptoms resolved. In Case 2, after CVAD treatment, hypoperfusion improved, clinical symptoms markedly eased, and walking function mostly recovered. Now, the patient can swim four times a week for four days. In Case 3, symptoms fully eased only after the initial CVAD treatment. Yet, about a month post-discharge, new symptoms emerged. The patient experienced left-sided head, forehead, and neck pain. He also presented with a "Tyrannosaurus posture," featuring flexed upper limbs, a stooped body, and difficulty squatting and turning. Since the disease onset, the patient had a sallow complexion, pronounced periorbital dark circles, constipation, and sleep issues. After contralateral CVAD treatment, the "Tyrannosaurus posture" improved. The patient can now engage in outdoor activities like badminton. An external PET-CT scan showed reduced DaT distribution in the bilateral anterior and posterior Putamen, and increased FDG metabolism there. With further Parkinson's-directed medical treatment, symptoms such as restlessness and irritability have improved. Discussion The management of patients with ischemic cerebrovascular disease involving both anterior and posterior circulation deficits remains a significant clinical challenge. The presented cases highlight the importance of a targeted approach to treating CVADs in patients with concomitant MCA stenosis and/or occlusion, emphasizing the significance of understanding of the pathophysiology and potential therapeutic targets. Therapeutic Dilemma in MCA Stenosis/Occlusion The limitations of current symptomatic MCA stenosis interventions become particularly evident when considering their inability to effectively address posterior circulation symptoms. Traditional interventions such as intracranial angioplasty, stenting [8] or bypass surgeries often fail to improve posterior circulation perfusion. This is partly due to the limited collateral pathways from the anterior to posterior circulation. Moreover, when patients present with symptoms primarily related to the posterior circulation, such as dizziness[9], imbalance[10], limb weakness [6, 11], headache[12], and pain[7], treating the anterior circulation stenosis or occlusion may not resolve these symptoms. In such cases, the risks associated with anterior circulation interventions may outweigh the potential benefits. Rationale for Targeting CVADs Pathology The posterior circulation plays a crucial role in compensating for anterior circulation hypoperfusion through various communicating arteries[13]. However, when this compensatory mechanism fails, it can lead to a complex clinical presentation where symptoms may seem more related to the posterior circulation. In our cases, we observed that CVADs were closely associated with the posterior circulation symptoms (Table 1-3, Figure 1, 3, 5). These CVADs, though occult, were identified using advanced imaging techniques like DCE – CT [6, 7]. Addressing these CVADs through endovascular stent reconstruction proved to be effective in improving overall cerebral perfusion through compensatory mechanisms (Figure 2, 4, 6) and alleviating symptoms (Table 1-3). Parkinsonism - Like Symptoms and CVADs Treatment Case 3 presents an intriguing scenario where the patient exhibited "Tyrannosaurus posture" and other parkinsonism - like symptoms. The improvement in these symptoms following CVADs treatment and subsequent antiparkinsonian therapy suggests a possible link between CVADs - related hypoperfusion and parkinsonism - like manifestations[14-17]. The PET - CT findings of reduced dopamine transporter (DaT) distribution and increased FDG metabolism in the putamen may indicate that chronic hypoperfusion due to CVAD or MCA stenosis affects the dopaminergic system[17, 18]. Treating CVADs improved cerebral perfusion, which in turn may have positively influenced the dopaminergic system's function. This hypothesis underscores the complex interplay between vascular factors and neurodegenerative - like symptoms and highlights the potential benefits of a combined vascular and neurological approach in certain cases. Conclusion This study demonstrates that targeting posterior-circulation pathology in complex cerebrovascular patients yields better outcomes than standard anterior-circulation treatment. Future work should clarify the mechanisms of CVADs-related symptoms and test combined vascular-neurological therapies. Limitations This was the first study to demonstrate that endovascular treatment of CVAD improved hypoperfusion in patients with middle cerebral artery steno-occlusive disease and thereby alleviated their symptoms. Yet the very novelty of the procedure meant that its promise had to be weighed against a series of methodological and clinical caveats. First, because this was the initial report, the cohort was small and statistical power was correspondingly limited. The absence of a concurrent control group further weakened any firm causal inference between the intervention and neurological improvement, while radiological follow-up remained in its infancy; longer-term observation was therefore required to confirm both efficacy and safety. Second, the permanent implantation of a stent introduced a distinct set of long-term concerns. Once deployed, the device became a lifelong substrate for neointimal hyperplasia, late collapse, and thrombo-embolic events. These risks were compounded by indefinite dual antiplatelet therapy—initiated three days before the procedure and continued without a predefined endpoint—which conferred an annual major bleeding risk of 1–2%, a hazard that would accumulate over decades in a cohort whose mean age was only 47 years. Finally, the retrospective, single-centre design and the absence of blinded endpoint adjudication left the study vulnerable to selection, detection, and reporting bias, limitations that could restrict the external validity of the observed benefits. Declarations The authors confirm that the patient involved in this study provided informed consent for publication of their data and associated information. Written consent was explicitly obtained for any identifiable images or personal details in the manuscript. Informed Consent Written informed consent was obtained from the patient for the publication of these case reports and any accompanying images. The authors affirmed that all ethical standards have been upheld and grant the journal full permission to publish the work. Availability of data and materials All original data supporting the findings of these cases were included in the article and its supplementary materials. For any additional information, please contact the corresponding author(s). Conflicts of interest The authors have no personal financial or institutional interest Funding This project was supported by Pudong New Area Health Commission（PW2022A-28）and Neuroscience Innovation Development Research Project (YXJL-2022-00351-0183) Human Ethics and Consent to Participate declarations In accordance with the Declaration of Helsinki, the study was approved by the Ethics Committees of Shanghai East Hospital [2022] Pre review No. (227) and [EC.D (BG). 016. 02.1] and Shanghai Changhai Hospital Ethics Committee (CHEC-Y2020-003), and written informed consent was obtained from all participants. Contributions Guarantors of integrity of entire study: Kai-Jun Zhao and Jian-Min Liu; Study concepts/study design: all authors; Data acquisition or data analysis/interpretation: all authors; Manuscript drafting or manuscript revision for important intellectual content: all authors; Manuscript editing and final version approval: all authors References Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF et al : Stenting versus aggressive medical therapy for intracranial arterial stenosis . The New England journal of medicine 2011, 365 (11):993-1003. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, Montgomery J, Nizam A, Lane BF, Lutsep HL et al : Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial . Lancet 2014, 383 (9914):333-341. 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Annals of neurology 2024, 95 (2):388-399. Tables Table 1. Patient symptoms, onset time, and changes after intervention No Symptom onset time before discharge+/ Follow-up (M*) Second - stage New onset Recurrence Stable Improved Resolved 1 Right upper limb elevation restricted; unable to reach occiput 6M 5M* + 2M* Y 2 Impaired speech articulation 6M 5M* +/ 2M* Y 3 Reduced speech rate 6M + 8M* N 4 Blurred vision 6M + 8M* N 5 Right shoulder stiffness 6M + 8M* N 6 Right shoulder pain 6M 5M* + 2M* Y 7 Mental confusion 1M ++ +/ 2M* Y 8 Numbness in the left cervical region 1M ++ +/ 2M* Y 9 Pain in the right cervical region 1M ++ +/ 2M* Y 10 Restricted cervical rotation 1M ++ +/ 2M* Y 11 Numbness in the right toes 1M ++ +/ 2M* Y 12 Right distal arm weakness; poor grip. 1M ++ +/ 2M* Y 13 Right middle/ring fingers stiff, crepitant, stiff. 1M ++ +/ 1M* Y 14 Numbness in the right hand 2M ++ + 1M* Y Abbreviations: +: before discharge; ++ ： New onset; *: Follow-up ； BI, Before intervention; Y, yes; N, No Before discharge+: The status before discharge after the first treatment. Follow-up (M*): The status during follow-up after the first or second treatment. Yes represents that the symptom was alleviated in the second phase of treatment; No represents that it was alleviated in the first phase of treatment. Table 2. Patient symptoms, onset time, and changes after intervention No Symptom Onset time before discharge+/ Follow-up (M*) One-stage Stable /Recurrence /Deteriorated Improved Markedly improved /Resolved 1 Strabismus >25Y + 16M* Yes 2 Forefoot-dominant gait >25Y +/ 16M* Yes 3 Inability to walk in a straight line >20Y +/ 16M* Yes 4 Slow speech rate >20Y +/ 16M* Yes 5 Hypophonia >20Y + 16M* Yes 6 Social withdrawal >20Y + 16M* Yes 7 Ocular motility deficit >20Y + 16M* Yes 8 Left-sided paresis with limping >2M +/ 16M* Yes Abbreviations: Y ， years; M, months; +: before discharge; *: Follow-up Before discharge+: The status before discharge after the first treatment. Follow-up (M*): The status during follow-up after treatment. Yes represents that the symptom was alleviated in the first phase of treatment. Table 3. Patient symptoms, onset time, and changes after intervention No. Symptom Onset time before discharge+/ Follow-up (M*) Second - stage New onset Recurrence /Stable Improved Markedly improved / resolved 1 Gait instability 24M +/ 8M N 2 Leftward truncal lean while standing/walking 24M +/ 8M N 3 Blurred vision 12M +/ 8M N 4 Generalized muscle tremors, right-hand onset, irregular 12M +/ 8M N 5 Impaired right-hand dexterity 12M +/ 8M N 6 Involuntary right-leg movements while driving 12M +/ 8M N 7 Right-sided limb weakness 12M +/ 8M N 8 Irritability 12M +/ 8M N 9 Dizziness 10d +/ 8M N 10 Headache 10d +/ 8M N 11 Bilateral blepharospasm 10d +/ 8M N 12 Electric-shock–like numbness, left scapular region 10d +/ 8M N 13 Generalized fatigue 10d +/ 8M N 14 “Tyrannosaurus-rex” posture 1M ++ + +/ 8M Y 15 Sequential pain 1M ++ +/ 8M Y 16 Constipation 1M ++ + +/ 8M Y 17 Sleep disturbance 1M ++ +/ 8M Y Abbreviations: M, Month; d, day; Y, yes; N, not; +:before discharge; ++ ： New onset; *: Follow-up ; Y, yes; N, no Before discharge+: The status before discharge after the first treatment; Follow-up (M*): The status during follow-up after the first or second treatment; Yes represents that the symptom was alleviated in the second phase of treatment; No represents that it was alleviated in the first phase of treatment; “Tyrannosaurus-rex” posture: flexed arms, forward trunk, impaired squat/turn; Sequential pain: left head, forehead, neck Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8501424","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578609651,"identity":"ad674a7e-3bcc-45b0-a1aa-f906311a4bfe","order_by":0,"name":"Kai-Jun 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09:49:24","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116530,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/96e828a6c7f427383adad7bf.html"},{"id":101205481,"identity":"aeff2a40-817d-4af1-ac6f-db9d19093686","added_by":"auto","created_at":"2026-01-27 09:49:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1108596,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStaged Treatment for Symptomatic Bilateral CVADs)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCTA demonstrated occlusion of the left MCA-M1 segment and mild long-segment stenosis of the right M1 segment (A). DCE-CT revealed intracranial CVADs ( B-C). Following stent reconstruction for the right CVAD (D-F), there was a significant increase in blood flow velocity, with enhanced visualization of distal branches (D vs. F). Seven months later, planned flow reconstruction was performed for the left CVAD (G-I) due to recurrent and new-onset symptoms.\u003c/p\u003e","description":"","filename":"Figure1.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/60ec47cbb3a8c52c5717f825.jpg"},{"id":101074158,"identity":"cca673fe-80ca-4d30-bd18-f2ac6fd2a0aa","added_by":"auto","created_at":"2026-01-25 10:20:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1191645,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImprovement of Cerebral Hypoperfusion in Case 1 with Symptomatic CVAD After Reconstructive Treatment (Figure 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-treatment, hypoperfusion in the cerebellar hemisphere (Panel A, red) showed significant improvement (B, white box, green/blue). Hypoperfusion in the left temporal (C vs. D) and parietal lobes (E vs. F) also improved, with a reduction in red hypoperfusion areas (B, D, F).\u003c/p\u003e","description":"","filename":"Figure2.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/8b12038bfd02f2029d30bbba.jpg"},{"id":101205395,"identity":"da09236e-da42-43ec-ab9a-6a6ebcd3b391","added_by":"auto","created_at":"2026-01-27 09:49:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":887830,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTreatment for Right Symptomatic CVADs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCTA demonstrated bilateral MCA stenosis (Panel A), and DCE-CT revealed the characteristic intimal flap of CVAD. Following reconstructive treatment for CVAD, there was a notable increase in the opacification of the posterior circulation vascular tree at the same time point (Panel C vs. Panel D, 1.86 S; Panel E vs. Panel F, 2.91 S).\u003c/p\u003e","description":"","filename":"Figure3.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/c5653eaa3ff6b215f2e04dbc.jpg"},{"id":101074183,"identity":"1cd37641-8484-4fbb-baa5-9c2160bf96ed","added_by":"auto","created_at":"2026-01-25 10:20:10","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1275491,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImprovement of Cerebral Hypoperfusion in Case 2 with Symptomatic Right CVAD After Reconstructive Treatment (Fig. 3)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing reconstructive treatment for the right CVAD, cerebral hypoperfusion improved (indicated by red reduction↓) as follows: posterior circulation (A vs. B), bilateral temporal lobes (C vs. D), and right temporoparietal lobes (E vs. F).\u003c/p\u003e","description":"","filename":"Figure4.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/818fce39d1b18c608ec9dcb7.jpg"},{"id":101205831,"identity":"4b62dc7d-f013-40b6-98dc-96b7275f2e61","added_by":"auto","created_at":"2026-01-27 09:50:21","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1055370,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStaged Treatment for Symptomatic Bilateral CVADs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCTA revealed near-occlusion of the left MCA and moderate-to-severe multifocal stenosis in the M1 segment of the right MCA (A). DCE-CT showed characteristic CVAD intimal flaps in both vertebral arteries (B-C). Reconstructive treatment was first performed for the left CVAD (D-F). One month later, due to new symptoms, reconstructive treatment was also conducted for the symptomatic left CVAD (G-I).\u003c/p\u003e","description":"","filename":"Figure5.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/7752e13c8bcdf3da26493958.jpg"},{"id":101205624,"identity":"bae6226c-9242-4a6f-8495-ff68c5daed6a","added_by":"auto","created_at":"2026-01-27 09:49:58","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1328472,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImprovement of Cerebral Hypoperfusion in Case 3 After Reconstructive Treatment for Bilateral CVADs (Fig. 5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing bilateral CVADs reconstructive treatment, hypoperfusion (indicated by red regions) in the posterior circulation (A vs. B), bilateral temporal lobes (C vs. D), and bilateral parieto-occipital regions (E vs. F) was alleviated, as evidenced by the reduction in red regions.\u003c/p\u003e","description":"","filename":"Figure6.300dpi.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/5960501addc14522ed9f56f6.jpg"},{"id":104779462,"identity":"a9803e91-e513-4e6f-bcb1-e1980cc49b25","added_by":"auto","created_at":"2026-03-17 07:40:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8921615,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8501424/v1/3f2d30cc-ecca-4432-b2dc-9d722682d5ac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion","fulltext":[{"header":"Highlights","content":"\u003cp\u003e1. This study innovatively focuses on CVADs in patients with MCA stenosis/occlusion and posterior-circulation symptoms, offering a novel approach for complex cerebrovascular disorders.\u003c/p\u003e\u003cp\u003e2. Managing CVADs effectively alleviates posterior-circulation symptoms, improves hypoperfusion from anterior-circulation issues, and reduces procedural risks.\u003c/p\u003e\u003cp\u003eA Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSymptomatic intracranial atherosclerotic stenosis (ICAS) remains a complex challenge in neurovascular medicine. Randomized trials such as Summparis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], VISSIT[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and Cassiss [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] have demonstrated that surgical intervention does not offer clear superiority over best medical therapy for intracranial stenosis. This highlights the uncertainty surrounding interventional treatment and the complexity of managing cerebral arterial stenosis or occlusion.\u003c/p\u003e \u003cp\u003eThe CMOSS-FU study [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] first provided long-term evidence that extracranial-to-intracranial bypass can yield sustained benefits in patients with symptomatic, chronic occlusion of the internal carotid or middle cerebral artery. However, the therapeutic strategy becomes significantly more intricate when anterior circulation lesions are accompanied by posterior-circulation symptoms, as illustrated by the three cases reported here.\u003c/p\u003e \u003cp\u003eIn such scenarios, surgical correction of anterior-circulation stenosis entails higher procedural risks and renders the prognosis more uncertain. However, we observed that all three patients harbored highly occult CVADs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Their presenting symptoms-dizziness, headache, numbness, and limb weakness\u0026mdash;were more closely related to the CVADs than to the anterior-circulation stenosis or occlusion. Consequently, addressing these CVADs may prove more meaningful for symptom relief, ameliorating hypoperfusion secondary to anterior-circulation stenosis/occlusion, reducing operative risk, and improving overall outcomes.\u003c/p\u003e \u003cp\u003eHerein, we describe three patients with bilateral middle cerebral artery stenosis or occlusion and focus on a management strategy that prioritizes the treatment of CVADs. This approach may offer a more effective and less invasive solution for such complex cerebrovascular disorders.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This retrospective study was approved by the Ethics Committees of **BLINDED** Hospitals, and all written consents provided by patients were stored in hospital databases and used exclusively for research purposes.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and CVADs\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed all patients who underwent endovascular treatment for middle-cerebral-artery stenosis and/or occlusion associated with CVADs between February 2024 and July 2025, with the goal of identifying those whose CVADs were reconstructed with stent(s). CVADs were defined as V3\u0026ndash;4 segment lesions with or without involvement of the basilar artery (BA). Inclusion criteria were: (1) symptomatic CVADs confirmed on DCE-CT; (2) concomitant stenosis or occlusion of the ipsilateral internal carotid and/or middle cerebral artery; (3) failure of optimal antiplatelet therapy; (4) refusal of extracranial\u0026ndash;intracranial direct or indirect revascularization; and (5) endovascular treatment with stent(s). Patients were excluded if (1) the CVADs were left untreated or (2) they had previously undergone intracranial or extracranial bypass surgery. Three consecutive patients (male : female\u0026thinsp;=\u0026thinsp;2:1; mean age 47.3\u0026thinsp;\u0026plusmn;\u0026thinsp;20.6 years, range 26\u0026ndash;67) harboring five unilateral intracranial symptomatic CVADs (uis-CVADs) fulfilled the criteria and were enrolled. Clinical, angiographic, and follow-up data were analyzed (Table).\u003c/p\u003e \u003c/div\u003e"},{"header":"Patients and Evolution of symptoms","content":"\u003cp\u003e\u003cstrong\u003eCase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 67-year-old female patient presented with restricted elevation of the right upper limb and an inability to comb her hair. She also developed dysarthria, reduced speech rate, and blurred vision. Stiffness and pain in the right shoulder were also reported. These symptoms persisted despite rest and symptomatic treatment. The patient had a history of hypertension. CTA revealed occlusion of the left MCA M1 segment and mild stenosis of the right MCA M1 segment (Figure 1A). CT perfusion (CTP) demonstrated hypoperfusion in the posterior circulation (Figure 2A) and the left temporoparietal region (Figure 2C, 2E). The patient was diagnosed with left MCA occlusion, mild stenosis of the right MCA origin, and cryptogenic arterial dissection of the bilateral vertebral arteries (Figure 1B-1C). However, the patient refused left MCA recanalization or left external carotid - MCA bypass due to concerns regarding the risks and benefits of the procedures. Given that her symptoms were primarily related to the posterior circulation and closely associated with CVADs, right CVAD reconstruction was performed (Figure 1D-1F), resulting in complete resolution of the symptoms. However, seven months after discharge, three of the symptoms reoccurred (Table 1), along with mental confusion, numbness in the left neck, right hand, and right toes, pain and restricted rotation in the right neck, weakness in the distal part of the right upper limb and unstable grasping, as well as stiffness, crepitus, and inflexibility in the right fingers. Following a second-stage left CVAD reconstruction (Figure 1G-1I), all the symptoms were completely alleviated (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 26-year-old male with a history of congenital strabismus that was not fully corrected by glasses presented with a long-term compensatory gait due to foot imbalance, causing uneven shoe wear. As a child, he had difficulty walking in a straight line and exhibited speech characterized by slow delivery and low volume. He was also noted to be reticent, socially passive, and had poor eye contact. However, his intellectual development was normal, and he completed higher education and entered the workforce.\u003c/p\u003e\n\u003cp\u003eOver the past two years, his weight decreased from 105 kg to 65 kg. Four months ago, he experienced transient left-sided limb weakness following intense exercise that resolved spontaneously. Two months ago, he developed coughing, headache, and dizziness. The following day, his left-sided weakness worsened, occurring 2-3 times daily. His condition progressively deteriorated, with gait deviation and difficulty, accompanied by dysarthria. CTA revealed bilateral MCA stenosis (Figure 3A). Additionally, there were indicators of CVAD in the right vertebral artery (Figure 3B). Cerebral CTP also demonstrated hypoperfusion (Figure 4A) in the posterior circulation, bilateral temporal lobes (Figure 4C), and the right parieto-occipital region (Figure 4E). After reconstructive treatment for cryptogenic vascular dissection (CVD), the opacification of the vascular tree was significantly increased at the same time point (Figure 3C vs Figure 3D; Figure 3E vs Figure 3F) and hypoperfusion in the posterior circulation, particularly in the right temporoparietal lobes, improved (Figure 4). His clinical symptoms were significantly relieved, and his walking function basically returned (Table 2). Now, he can complete four swimming exercises per week for four days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 49-year-old male first presented with gait instability and a tendency to lean toward the left side while standing and walking two years ago. Around one year later, his condition gradually progressed, leading to blurred vision, muscle tremors, decreased dexterity in his right hand, unnatural movements of his right leg while driving, and weakness in his right limbs, during which period he often felt irritable. The muscle tremors initially began in the right hand, then gradually spread to the lower legs and eventually to various parts of the body, with no discernible pattern. In the past 10 days, the patient\u0026apos;s aforementioned symptoms significantly worsened, and he developed new symptoms such as headaches, dizziness, bilateral blepharospasm, difficulty in opening his eyes, generalized weakness, and a sensation of numbness in the left scapular region akin to an electric shock. Previously, the patient had been under conservative treatment, but the symptoms remained unrelieved. It was not until he underwent the first CVAD treatment (Figure 5) that his symptoms were completely alleviated (Table 3). However, about one month after discharge, the patient developed new symptoms. He experienced left-sided head, forehead, and neck pain. He also presented with a \u0026quot;Tyrannosaurus posture,\u0026quot; characterized by flexed upper limbs, forward inclination of the body, and difficulty squatting and turning. Since the disease onset, the patient exhibited a sallow complexion, marked dark circles around both eyes, constipation, and sleep disorders. Following contralateral CVAD treatment (Figure 5), the patient\u0026apos;s \u0026quot;Tyrannosaurus posture\u0026quot; improved, and he is now capable of engaging in outdoor activities such as playing badminton (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis of CVADs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll three patients underwent extensive pre-treatment assessments, including routine cranial CT perfusion and MRI scans. These imaging modalities revealed varying degrees of stenosis and/or occlusion in the anterior circulation, specifically in the middle cerebral arteries (Figure 1, 3, 5). However, the predominant symptoms exhibited by the patients were consistent with posterior circulation deficits (Table 1-3). To further elucidate the underlying pathology, DCE-CT was routinely performed\u0026nbsp;[6, 7]. This advanced imaging technique uncovered the presence of CVADs in the posterior circulation, which were closely associated with the observed hypoperfusion (Figure 2, 4, 6). The identification of these dissections was crucial in guiding the subsequent treatment strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment of CVADs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the three patients, all rejected anterior circulation endovascular treatment or indirect/direct extracranial-intracranial bypass due to uncertain results. They weighed the risks and benefits and decided to first manage the vertebral artery dissections to ease posterior circulation hypoperfusion. This was because treating the CVAD might enhance both posterior and anterior circulation perfusion through compensatory mechanisms.\u003c/p\u003e\n\u003cp\u003ePrior to treatment, all patients were administered a dual antiplatelet regimen, consisting of 300 mg of aspirin and 75 mg of clopidogrel, for at least three days to reduce the risk of thrombotic complications. Under general anesthesia, endovascular stent implantation was performed to reconstruct the affected cerebrovascular segments. The stents were meticulously placed to extend at least 5 mm beyond the edges of the dissections to ensure adequate coverage and secure vessel patency.\u003c/p\u003e\n\u003cp\u003ePostoperatively, patients were closely monitored for any new or recurrent symptoms. Follow-up CT perfusion scans were obtained to assess the effectiveness of the treatment. If new or persistent symptoms were identified, contralateral CVAD reconstruction was considered based on the updated imaging findings. This staged approach allowed for targeted intervention and optimization of clinical outcomes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results of these cases demonstrate the efficacy of targeting CVADs in patients with complex cerebrovascular disease. In Cases 1 and 3, staged treatments were necessary to address the recurrence of symptoms and new manifestations, highlighting the importance of comprehensive follow-up and tailored therapeutic approaches. Case 2 showed a stable and sustained improvement following a single treatment session, emphasizing the potential for durable outcomes with this approach. The overall findings suggest that addressing the underlying posterior circulation pathology through CVAD reconstruction can lead to significant clinical improvements, even in the presence of anterior circulation stenosis and/or occlusion.\u003c/p\u003e\n\u003cp\u003eIn this series, Case 2 underwent one treatment, while Cases 1 and 3 received staged treatments. In Case 1, we first treated the right symptomatic CVAD. Post-treatment, symptoms fully improved. However, seven months later, the patient had a recurrence with three symptoms (Table 1), alongside new ones such as mental fogginess, numbness in the left neck, right hand, and right toes, right neck pain, restricted neck movement, distal right upper limb weakness, unsteadiness in holding objects, and right finger stiffness, clicking during movement, and clumsiness. Following subsequent left CVAD reconstructive treatment, all these symptoms resolved.\u003c/p\u003e\n\u003cp\u003eIn Case 2, after CVAD treatment, hypoperfusion improved, clinical symptoms markedly eased, and walking function mostly recovered. Now, the patient can swim four times a week for four days.\u003c/p\u003e\n\u003cp\u003eIn Case 3, symptoms fully eased only after the initial CVAD treatment. Yet, about a month post-discharge, new symptoms emerged. The patient experienced left-sided head, forehead, and neck pain. He also presented with a \u0026quot;Tyrannosaurus posture,\u0026quot; featuring flexed upper limbs, a stooped body, and difficulty squatting and turning. Since the disease onset, the patient had a sallow complexion, pronounced periorbital dark circles, constipation, and sleep issues. After contralateral CVAD treatment, the \u0026quot;Tyrannosaurus posture\u0026quot; improved. The patient can now engage in outdoor activities like badminton. An external PET-CT scan showed reduced DaT distribution in the bilateral anterior and posterior Putamen, and increased FDG metabolism there. With further Parkinson\u0026apos;s-directed medical treatment, symptoms such as restlessness and irritability have improved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe management of patients with ischemic cerebrovascular disease involving both anterior and posterior circulation deficits remains a significant clinical challenge. The presented cases highlight the importance of a targeted approach to treating CVADs in patients with concomitant MCA stenosis and/or occlusion, emphasizing the significance of understanding of the pathophysiology and potential therapeutic targets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTherapeutic Dilemma in MCA Stenosis/Occlusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe limitations of current symptomatic MCA stenosis interventions become particularly evident when considering their inability to effectively address posterior circulation symptoms. Traditional interventions such as intracranial angioplasty, stenting [8] or bypass surgeries often fail to improve posterior circulation perfusion. This is partly due to the limited collateral pathways from the anterior to posterior circulation. Moreover, when patients present with symptoms primarily related to the posterior circulation, such as dizziness[9], imbalance[10], limb weakness [6, 11], headache[12], and pain[7], treating the anterior circulation stenosis or occlusion may not resolve these symptoms. In such cases, the risks associated with anterior circulation interventions may outweigh the potential benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRationale for Targeting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCVADs Pathology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe posterior circulation plays a crucial role in compensating for anterior circulation hypoperfusion through various communicating arteries[13]. However, when this compensatory mechanism fails, it can lead to a complex clinical presentation where symptoms may seem more related to the posterior circulation. In our cases, we observed that CVADs were closely associated with the posterior circulation symptoms (Table 1-3, Figure 1, 3, 5). These CVADs, though occult, were identified using advanced imaging techniques like DCE \u0026ndash; CT [6, 7]. Addressing these CVADs through endovascular stent reconstruction proved to be effective in improving overall cerebral perfusion through compensatory mechanisms (Figure 2, 4, 6) and alleviating symptoms (Table 1-3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParkinsonism - Like Symptoms and CVADs Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase 3 presents an intriguing scenario where the patient exhibited \u0026quot;Tyrannosaurus posture\u0026quot; and other parkinsonism - like symptoms. The improvement in these symptoms following CVADs treatment and subsequent antiparkinsonian therapy suggests a possible link between CVADs - related hypoperfusion and parkinsonism - like manifestations[14-17]. The PET - CT findings of reduced dopamine transporter (DaT) distribution and increased FDG metabolism in the putamen may indicate that chronic hypoperfusion due to CVAD or MCA stenosis affects the dopaminergic system[17, 18]. Treating CVADs improved cerebral perfusion, which in turn may have positively influenced the dopaminergic system\u0026apos;s function. This hypothesis underscores the complex interplay between vascular factors and neurodegenerative - like symptoms and highlights the potential benefits of a combined vascular and neurological approach in certain cases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that targeting posterior-circulation pathology in complex cerebrovascular patients yields better outcomes than standard anterior-circulation treatment. Future work should clarify the mechanisms of CVADs-related symptoms and test combined vascular-neurological therapies.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThis was the first study to demonstrate that endovascular treatment of CVAD improved hypoperfusion in patients with middle cerebral artery steno-occlusive disease and thereby alleviated their symptoms. Yet the very novelty of the procedure meant that its promise had to be weighed against a series of methodological and clinical caveats.\u003c/p\u003e\u003cp\u003eFirst, because this was the initial report, the cohort was small and statistical power was correspondingly limited. The absence of a concurrent control group further weakened any firm causal inference between the intervention and neurological improvement, while radiological follow-up remained in its infancy; longer-term observation was therefore required to confirm both efficacy and safety.\u003c/p\u003e\u003cp\u003eSecond, the permanent implantation of a stent introduced a distinct set of long-term concerns. Once deployed, the device became a lifelong substrate for neointimal hyperplasia, late collapse, and thrombo-embolic events. These risks were compounded by indefinite dual antiplatelet therapy—initiated three days before the procedure and continued without a predefined endpoint—which conferred an annual major bleeding risk of 1–2%, a hazard that would accumulate over decades in a cohort whose mean age was only 47 years.\u003c/p\u003e\u003cp\u003eFinally, the retrospective, single-centre design and the absence of blinded endpoint adjudication left the study vulnerable to selection, detection, and reporting bias, limitations that could restrict the external validity of the observed benefits.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors confirm that the patient involved in this study provided informed consent for publication of their data and associated information. Written consent was explicitly obtained for any identifiable images or personal details in the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of these case reports and any accompanying images. The authors affirmed that all ethical standards have been upheld and grant the journal full permission to publish the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll original data supporting the findings of these cases were included in the article and its supplementary materials. For any additional information, please contact the corresponding author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no personal financial or institutional interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported by Pudong New Area Health Commission（PW2022A-28）and Neuroscience Innovation Development Research Project (YXJL-2022-00351-0183)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn accordance with the Declaration of Helsinki, the study was approved by the Ethics Committees of Shanghai East Hospital [2022] Pre review No. (227) and [EC.D (BG). 016. 02.1] and Shanghai Changhai Hospital Ethics Committee (CHEC-Y2020-003), and written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuarantors of integrity of entire study: Kai-Jun Zhao and Jian-Min Liu; Study concepts/study design: all authors; Data acquisition or data analysis/interpretation: all authors; Manuscript drafting or manuscript revision for important intellectual content: all authors; Manuscript editing and final version approval: all authors\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eStenting versus aggressive medical therapy for intracranial arterial stenosis\u003c/strong\u003e. \u003cem\u003eThe New England journal of medicine \u003c/em\u003e2011, \u003cstrong\u003e365\u003c/strong\u003e(11):993-1003.\u003c/li\u003e\n\u003cli\u003eDerdeyn CP, Chimowitz MI, Lynn MJ, 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Parkinsons Dis \u003c/em\u003e2024, \u003cstrong\u003e10\u003c/strong\u003e(1):221.\u003c/li\u003e\n\u003cli\u003eChun MY, Chung SJ, Kim SH, Park CW, Jeong SH, Lee HS, Lee PH, Sohn YH, Jeong Y, Kim YJ: \u003cstrong\u003eHippocampal Perfusion Affects Motor and Cognitive Functions in Parkinson Disease: An Early Phase (18) F-FP-CIT Positron Emission Tomography Study\u003c/strong\u003e. \u003cem\u003eAnnals of neurology \u003c/em\u003e2024, \u003cstrong\u003e95\u003c/strong\u003e(2):388-399.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Patient symptoms, onset time, and changes after intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eonset time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ebefore discharge+/ Follow-up (M*)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond - stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eNew onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eStable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eResolved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRight upper limb elevation restricted; unable to reach occiput\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5M*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e2M*\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eImpaired speech articulation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eReduced speech rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp; 8M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eBlurred vision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp; 8M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRight shoulder stiffness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp; 8M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRight shoulder pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMental confusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNumbness in the left cervical region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePain in the right cervical region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRestricted cervical rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNumbness in the right toes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRight distal arm weakness; poor grip.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e2M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRight middle/ring fingers stiff, crepitant, stiff.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e1M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNumbness in the right hand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e2M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp; 1M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e+: before discharge; ++\u003c/em\u003e\u003cem\u003e：\u003c/em\u003e\u003cem\u003eNew onset; *: Follow-up\u0026nbsp;\u003c/em\u003e\u003cem\u003e；\u003c/em\u003e\u003cem\u003eBI, Before intervention; Y, yes; N, No\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBefore discharge+: The status before discharge after the first treatment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFollow-up (M*): The status during follow-up after the first or second treatment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes represents that the symptom was alleviated in the second phase of treatment; No represents that it was alleviated in the first phase of treatment.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 586px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Patient symptoms, onset time, and changes after intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnset time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ebefore discharge+/ Follow-up (M*)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne-stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e/Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e/Deteriorated\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarkedly improved\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e/Resolved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eStrabismus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;25Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eForefoot-dominant gait\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;25Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eInability to walk in a straight line\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eSlow speech rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eHypophonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eSocial withdrawal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eOcular motility deficit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eLeft-sided paresis with limping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt;2M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e16M*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 182px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003cem\u003e，\u003c/em\u003e\u003cem\u003eyears; M, months; +: before discharge; *: Follow-up\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBefore discharge+: The status before discharge after the first treatment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFollow-up (M*): The status during follow-up after treatment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes represents that the symptom was alleviated in the first phase of treatment.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 553px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Patient symptoms, onset time, and changes after intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnset time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ebefore discharge+/ Follow-up (M*)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond - stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew onset\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e/Stable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarkedly improved / resolved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eGait instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e24M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eLeftward truncal lean while standing/walking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e24M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eBlurred vision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eGeneralized muscle tremors, right-hand onset, irregular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eImpaired right-hand dexterity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eInvoluntary right-leg movements while driving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eRight-sided limb weakness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eIrritability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eDizziness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHeadache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eBilateral blepharospasm\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eElectric-shock\u0026ndash;like numbness, left scapular region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eGeneralized fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026ldquo;Tyrannosaurus-rex\u0026rdquo; posture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eSequential pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eConstipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eSleep disturbance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e+/\u003c/strong\u003e8M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eM, Month; d, day; Y, yes; N, not; +:before discharge; ++\u003c/em\u003e\u003cem\u003e：\u003c/em\u003e\u003cem\u003eNew onset; *: Follow-up ; Y, yes; N, no\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBefore discharge+: The status before discharge after the first treatment;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFollow-up (M*): The status during follow-up after the first or second treatment;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes represents that the symptom was alleviated in the second phase of treatment;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNo represents that it was alleviated in the first phase of treatment;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Tyrannosaurus-rex\u0026rdquo; posture: flexed arms, forward trunk, impaired squat/turn; Sequential pain: left head, forehead, neck\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8501424/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8501424/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cdiv id=\"ASec1\" class=\"AbstractSection\"\u003e \u003cdiv class=\"Heading\"\u003eObjective\u003c/div\u003e \u003cp\u003eTo evaluate the efficacy of treating cryptogenic vertebral artery dissections (CVADs) in patients with middle cerebral artery (MCA) stenosis/occlusion and posterior-circulation symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"ASec2\" class=\"AbstractSection\"\u003e \u003cdiv class=\"Heading\"\u003eMethods\u003c/div\u003e \u003cp\u003eThis retrospective study analyzed three patients who underwent endovascular stent reconstruction for CVADs between February 2024 and July 2025. All had symptomatic CVADs confirmed by dynamic contrast-enhanced computed tomography (DCE-CT), concurrent anterior-circulation lesions, and failed medical therapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"ASec3\" class=\"AbstractSection\"\u003e \u003cdiv class=\"Heading\"\u003eResults\u003c/div\u003e \u003cp\u003eCVADs treatment alleviated posterior-circulation symptoms and improved hypoperfusion. Case 1 and 3 required staged treatments for recurring symptoms, while Case 2 improved after one treatment. Notably, parkinsonism-like symptoms in Case 3 improved post-treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"ASec4\" class=\"AbstractSection\"\u003e \u003cdiv class=\"Heading\"\u003eConclusions\u003c/div\u003e \u003cp\u003eTargeting CVADs in complex cerebrovascular disease can improve clinical outcomes and reduce surgical risks. Further research on combined vascular-neurological therapies is warranted.\u003c/p\u003e \u003c/div\u003e","manuscriptTitle":"A Novel Therapeutic Strategy for Complex Cerebrovascular Disorders with Anterior Circulation Stenosis/Occlusion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-25 10:20:03","doi":"10.21203/rs.3.rs-8501424/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b6f7f8c-bd80-4f35-ab37-136c07a45b53","owner":[],"postedDate":"January 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-06T13:41:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-25 10:20:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8501424","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8501424","identity":"rs-8501424","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}