
Objective To investigate the risk factors for abnormal cardiac function in patients with hepatolenticular degeneration (also known as Wilson disease ,WD) using cardiac magnetic resonance imaging (CMR), and to identify indicators with a value for early diagnosis. Methods Patients diagnosed with WD were randomly selected to undergo CMR examination, and based on CMR findings, they were divided into abnormal group and normal group. A univariate analysis was used to obtain potential risk factors, then a multivariate logistic regression analysis was performed for variables with a significant difference, and finally the receiver operating characteristic (ROC) curve analysis was performed for the independent risk factors identified. Results A total of 42 WD patients were enrolled, with 21 in the abnormal CMR group and 21 in the normal CMR group. Compared with the normal CMR group, the abnormal CMR group had a significantly higher age and significantly higher levels of total bilirubin, serum copper, and peak 24-hour urinary copper during treatment. The multivariate Logistic regression analysis showed that white blood cell count (WBC) (OR=2.927, 95%CI 1.127‒7.839, P=0.028), serum copper(OR=3.822, 95%CI 1.108‒13.178, P=0.034), and type Ⅳ collagen (OR=1.097, 95%CI 1.011‒1.191,P=0.027) were independent risk factors for CMR abnormalities in WD patients. The ROC curve analysis showed that among the above three indicators used alone, serum copper had the highest diagnostic value with an area under the ROC curve (AUC) of 0.713, followed by WBC(AUC=0.651) and type Ⅳ collagen (AUC=0.644), and the combination of these three indicators had significantly higher diagnostic efficacy (AUC=0.869). Conclusion Serum copper is the single indicator with the highest diagnostic efficacy for CMR abnormalities in WD patients, but the combination of serum copper, WBC, and type Ⅳ collagen has a significantly better diagnostic value in identifying abnormal cardiac function in WD patients.
Objective To quantitatively analyze the volumetric characteristics of each subregion of the basal ganglia in patients with hepatolenticular degeneration (also known as Wilson disease ,WD) using brain magnetic resonance imaging (MRI) and brain segmentation technology, to explore the specific imaging findings of choreiform symptoms, and to assess the clinical value of caudate nucleus atrophy as an imaging indicator for this symptom. Methods A retrospective analysis was performed for 40 WD patients with choreiform symptoms and 40 patients without choreiform symptoms from June 2023 to June 2025, and clinical indicators were compared between the two groups. In addition, the two groups were compared in terms of the volume of the basal ganglia after estimated total intracranial volume (eTIV) correction, and the correlation between the volume of differential brain regions and the chorea subscale score of Unified Wilson's Disease Rating Scale (UWDRS) was explored. Results There were no significant differences in baseline data between the two groups. UWDRS scores showed that the choreiform group had a higher neurological function score (P=0.005), a significantly higher chorea subscale score (P<0.01), and a lower hepatic function score (P<0.01). The choreiform group had a significantly smaller caudate nucleus volume than the non-choreiform group (P<0.001), suggesting severe subregional atrophy, and in contrast, the choreiform group had a significant increase in thalamus volume (P=0.002). Caudate nucleus volume ratio was significantly negatively correlated with chorea subscale score in the choreiform group (P<0.001). Conclusion Caudate nucleus atrophy is a specific imaging finding of choreiform symptoms in WD patients, and a quantitative analysis of caudate nucleus volume is expected to become an objective imaging indicator for assessing the severity of choreiform symptoms and monitoring disease progression in WD.
Objective To investigate the cranial magnetic resonance imaging (MRI) features of patients with hepatolenticular degeneration (also known as Wilson disease,WD) and epilepsy, and to identify the neuroimaging risk factors for seizures in WD patients. Methods A total of 69 WD patients with epilepsy who were hospitalized in Affiliated Hospital of Neurology Institute, Anhui University of Chinese Medicine, from January 2018 to November 2025 were enrolled as study group, while 80 WD patients without seizures, matched for sex and age, during the same period of time were randomly selected as control group. Cranial MRI findings were compared between the two groups. Results There were 69 WD patients (43 male patients and 26 female patients) in the study group, with a mean age of (29.46±8.58) years at the time of attending the hospital, and all these patients had abnormal electroencephalogram (EEG) findings. There were no significant differences between the two groups in age of onset,disease duration, WD subtype, and serum copper. Cranial MRI showed that the putamen was the most common site of brain injury (47 patients, 68.1%), followed by the frontal lobe (40 patients,58.0%) and the parietal lobe (31 patients,44.9%), and there was a significantly higher probability of epilepsy in patients with abnormal lesions in the frontal, temporal, or parietal lobes (P<0.05). Conclusion While the putamen is the most common site of brain injury in WD patients with epilepsy, frontal or temporal lobe injuries are neuroimaging risk factors for seizures in such patients.
Objective To compare the clinical and cranial magnetic resonance imaging (MRI) features of neurological hepatolenticular degeneration (also known as Wilson disease,WD) with two different ATP7B gene mutations, and to investigate the association between the clinical and cranial MRI features in patients with the two mutation types of neurological WD. Methods The neurological WD patients with p.Arg778Leu or p.Pro992Leu homozygous mutation who were hospitalized in Affiliated Hospital of Neurology Institute, Anhui University of Chinese Medicine, from May 2014 to May 2025 were enrolled, and a retrospective analysis was performed for their demographic data, clinical manifestations, serological markers, and cranial MRI data to compare the differences between the two mutation types of neurological WD. Results A total of 103 neurological WD patients were enrolled, among whom there were 65 patients with p.Arg778Leu-mutant WD and 38 patients with p.Pro992Leu-mutant WD. There were no significant differences in demographics, clinical manifestations, and most serological markers between the two mutation types of WD, while there was a significant difference in cranial MRI findings between two groups, with significant differences in the damage of the thalamus (χ2=17.834,P<0.001),the midbrain (χ2=12.579, P<0.001), and the pons (χ2=10.605, P=0.001) between the patients with p.Arg778Leu-mutant WD and those with p.Pro992Leu-mutant WD, and the multivariate analysis also showed significant differences in the above indicators (P<0.05). Conclusion Demographic data, clinical manifestations, and serological markers are not associated with gene mutation types in neurological WD, while cranial MRI manifestations are associated with gene mutation types, among which p.Arg778Leu mutation of the ATP7B gene is more likely to involve the thalamus, the midbrain, and the pons.
Objective To investigate the value of plasma glial fibrillary acidic protein (GFAP) and homocysteine (Hcy) in the diagnosis of hepatolenticular degeneration (also know as Wilson disease, WD) and the differential diagnosis of the hepatic and neurological forms of WD. Methods A total of 120 WD patients who were admitted to Encephalopathy Center of our hospital from January 2023 to January 2025 were enrolled, among whom there were 63 patients with neurological WD and 57 patients with hepatic WD, and 30 healthy volunteers who underwent physical examination during the same period of time were enrolled as control group. ELISA was used to measure the plasma levels of GFAP and Hcy, and the differences between groups were analyzed. The receiver operating characteristic(ROC) curve analysis was performed, and the Spearman correlation analysis was used to investigate the correlation of the plasma levels of GFAP and Hcy with Unified Wilson Disease Rating Scale (UWDRS) score, 24-hour urinary copper, and the serum level of ceruloplasmin (CER). Results The patients with hepatic or neurological WD had a significantly higher plasma level of GFAP than the control group(P<0.05), and the patients with neurological WD had a significantly greater increase than those with hepatic WD(P<0.05). The patients with hepatic or neurological WD also had a significant increase in the plasma level of Hcy(P<0.05), but with no significant difference between the patients with hepatic WD and those with neurological WD.Plasma GFAP had an area under the ROC curve(AUC) of 0.861 in the diagnosis of neurological WD, with a cut-off value of 135.71 pg/ml, a sensitivity of 68.3%,and a specificity of 82.3%;plasma GFAP had an AUC of 0.695 in the diagnosis of hepatic WD, with a cut-off value of 129.84 pg/ml, a sensitivity of 64.7%, and a specificity of 83.3%; in the differential diagnosis of hepatic and neurological WD, plasma GFAP had an AUC of 0.75, with a cut-off value of 151.12 pg/ml,a sensitivity of 73.9%, and a specificity of 87.8%. Plasma Hcy had an AUC of 0.788 in the diagnosis of WD, with a cut-off value of 15.59 μmol/L, sensitivity of 77.9%, and specificity of 66.7%. The Spearman correlation analysis showed that in the patients with hepatic or neurological WD, the plasma levels of GFAP and Hcy were positively correlated with UWDRS score and 24-hour urinary copper (P<0.05), but they were not significantly correlated with the level of CER (P>0.05). Conclusion The plasma levels of GFAP and Hcy are closely associated with the degree of neurological and hepatic impairment in WD, which provides a certain clinical value for the early diagnosis of WD and the differential diagnosis of hepatic and neurological WD.
Objective Hepatolenticular degeneration(also know as Wilson disease ,WD) is a copper metabolic disorder caused by ATP7B gene mutation, often involving the liver and the central nervous system and leading to death in severe cases. At present, there is a lack of systematic studies on the cause of death and related risk factors in WD patients. Therefore, this study aims to investigate the common causes of death and related risk factors in WD patients. Methods A retrospective analysis was performed for the clinical data of 87 WD patients who died and 113 WD patients who survived in our hospital from January 2011 to January 2022. The common causes of death in WD patients were analyzed, and the Cox proportional-hazards regression model analysis was used to investigate the risk factors for death. Results The death group had a median age of 32.00 (27.00,41.00) years and a median course of disease of 144.00 (72.00,228.00) months, and the survival group had a median age of 31.00 (25.00,37.00) years and a median course of disease of 132.00 (72.00,214.00) months. The main causes of death included liver failure (33 patients), infection (23 patients), sudden death (8 patients), gastrointestinal bleeding (8 patients), and liver cancer (4 patients). There were significant differences between the death group and the survival group in sex, pattern of disease onset, low copper diet, liver ultrasound classification, splenectomy, clinical classification, treatment regimens, and various laboratory markers (such as white blood cell count, total bilirubin, and albumin)(P<0.05). The multivariate Cox regression analysis showed that the risk of death was doubled for every 100 μg/24 h increase in urinary copper at baseline (HR=1.22,95%CI 1.11-1.34) and the presence of liver cirrhosis (HR=2.55,95%CI 1.02-6.36). Conclusion Liver failure is the main cause of death in WD patients, and a high level of urinary copper at baseline and the presence of liver cirrhosis significantly increase the risk of death. The risk of death in patients with a urinary copper level of 400 μg/24 h (reference value<100 μg/24 h) was increased by 3.8 times compared with the value at baseline (HR=3.8,P<0.001).The results of this study provide an important basis for the prognosis evaluation and clinical intervention of WD patients.
Objective To investigate the changing trend of sleep disturbance in patients with hepatolenticular degeneration and the bidirectional relationship between sleep disturbance and depression through a cross-lagged regression analysis. Methods A total of 80 patients who met the diagnostic criteria for WD from January to June 2024 were enrolled in this longitudinal study and were followed up for 3 months.Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality, and Beck Depression Inventory (BDI) was used to assess the severity of depression, at the time of enrollment (T0), at 1 month after enrollment (T1),and at 2 months after enrollment (T3). An unconditional growth model was used to analyze the trajectory of sleep disturbance, and a cross-lagged regression model was used to investigate the temporal relationship between sleep disturbance and depression. Results From T0 to T2, there were significant increases in PSQI and BDI scores in all WD patients(P<0.05). The variance of the intercept factor (the initial status of sleep disturbance) was estimated at 10.83(P<0.01),and the variance of the slope factor (the rate of change in sleep disturbance) was 1.20 (P<0.01),with a significant negative correlation between the intercept and the slope (r=-0.25,P<0.01). The correlation analysis of PSQI and BDI scores across the three time points revealed a positive correlation between PSQI and BDI scores (r∈[0.19,0.96],P<0.01).The cross-lagged model analysis showed that sleep disturbance significantly predicted subsequent depression (P<0.01),with standardized regression coefficients (β) of 0.392 and 0.347, respectively; meanwhile, depression also significantly predicted subsequent sleep disturbance (P<0.01), with β of 0.273 and 0.372, respectively. These findings suggested a bidirectional predictive relationship between sleep disturbance and depression in WD patients over time. Conclusion There is a bidirectional relationship between sleep disturbance and depression in patients with WD, and depression has a more pronounced influence on sleep disturbance. Therefore, clinical interventions should focus on both sleep and psychological state, and combined management should be performed to improve the effect of disease control.
Hepatolenticular degeneration (HLD) is an autosomal recessive genetic disorder characterized by copper metabolism impairment, and it is one of the few treatable neurogenetic diseases. A retrospective analysis was performed for the clinical data of four patients with HLD who attended Beijing Ditan Hospital, Capital Medical University, from November 2023 to October 2024, and the genetic testing results of three patients were analyzed, along with a literature review. Among the four patients, there was one female patient and three male patients. All patients had the initial symptoms of dysarthria and limb tremors, and physical examination showed positive K-F rings, normal liver enzyme levels, a reduction in serum ceruloplasmin, and an increase in 24-hour urinary copper excretion. Three patients underwent ATP7B genetic testing, among whom two had compound heterozygous mutations, and one had a heterozygous mutation. In addition, two patients underwent cranial magnetic resonance imaging, and the results showed symmetrical long T1 and long T2 signals. All four patients received copper-chelating therapy and achieved a good outcome. This article reports the diagnosis and treatment of four patients with HLD and identifies a case of HLD resulting from a rare heterozygous mutation site, thereby expanding the variation spectrum of the ATP7B gene.
Objective To investigate the imaging characteristics of patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)carrying cysteine-altering versus non-cysteine-altering NOTCH3 mutations. Methods A retrospective analysis was performed for 19 patients with CADASIL who attended Department of Neurology,The Affiliated Hospital of Guizhou Medical University, among whom there were 16 patients with cysteine-altering mutations and 3 with non-cysteine-altering mutations, and PubMed database was searched to obtain 192 cases (158 patients with cysteine-altering mutations and 34 with non-cysteine-altering mutations). The impact of these two types of mutations on lesion distribution in the temporal pole and external capsule was analyzed. Results The cysteine-altering mutation group had a significantly higher risk of temporal pole lesions compared with the non-cysteine-altering mutation group (OR=2.99,95%CI 1.37‒6.51,P=0.006), and there was no significant difference in external capsule lesions between the two groups (OR=2.31,95%CI 0.75‒6.48,P=0.12). External capsule lesions were associated with age (OR=1.04,95%CI 1.01‒1.07, P=0.02).Sex showed no significant influence on lesion distribution(OR=1.72,95%CI 0.67‒4.67,P=0.27;temporal pole:OR=0.54,95%CI 0.27‒1.05, P=0.07). Conclusion Cysteine-altering NOTCH3 mutations are an independent risk factor for temporal pole lesions,while external capsule lesions are closely associated with age. This suggests that temporal pole lesions might be a specific imaging marker for cysteine-altering mutations, whereas external capsule lesions can reflect age-related disease progression.
Objective Observational studies have shown an association between Parkinson disease (PD) and mental illness, but further studies are needed to explore the causal relationship between them. This study aims to investigate such causal relationship using the method of two-sample Mendelian randomization (MR). Methods Related data were extracted from GWAS, and summary statistics associated with PD, depression, sleep disorders, and anxiety phenotype-variants were obtained. Single nucleotide polymorphisms (SNPs) for PD were selected as instrumental variables, and MR-PRESSO was used to exclude outliers. Inverse variance weighting was used as the main method to assess causal effect estimates, and MR Egger, weighted median, simple mode, and weighted mode were used to verify the robustness of the findings. A sensitivity analysis was used to validate the reliability of the results, including the Cochran Q test, the MR-Egger intercept test, funnel plots, and the leave-one-out method. Results A total of 21 SNPs associated with PD were identified. The MR analysis showed that PD had a causal relationship with depression (OR=0.974,95%CI 0.934‒1.015, P=0.210), sleep disorders (OR=1.056, 95%CI 0.970-1.149, P=0.211), and anxiety (OR=0.998, 95%CI 0.996‒1.001, P=0.118), with no statistical significance. Different MR analyses and sensitivity analyses showed that PD did not directly contribute to the development of mental illness. Conclusion There is no direct causal relationship between PD and depression/sleep disorders/anxiety. In clinical practice, healthcare professionals should pay attention to the mental health of patients with PD. Randomized controlled studies should be conducted in the future to further validate the results of this study.
Objective To investigate the causal effect of major depression, schizophrenia, bipolar affective disorder, and insomnia on the risk of ischemic stroke using the two-sample Mendelian randomization method. Methods Eligible single nucleotide polymorphism data of four distinct mental disorders and stroke were obtained from genome-wide association studies. The random effects IVW method, the MR-Egger method, and the weighted median method were used to perform two-sample Mendelian randomization analyses, and heterogeneity test, horizontal pleiotropy analysis, and sensitivity analysis were also performed. Results IVW results showed a positive causal effect between major depression (OR=1.226,95%CI 1.046-1.436, PIVW=0.012, PFDR=0.047) with the risk of ischemic stroke. For heterogeneity test, the Cochran’s Q test using the IVW method showed a Q value of 44.198(P=0.379) for major depression. In the pleiotropy test, the intercept of MR-Egger regression showed a P-value of 0.667, and the sensitivity analysis yielded robust results, indicating that there was no significant heterogeneity or pleiotropy. These findings suggested that major depression was a risk factor for ischemic stroke. Schizophrenia (OR=1.005,95%CI 0.967‒1.045,PIVW=0.810,PFDR=0.810), bipolar disorder (OR=0.946,95%CI 0.847‒1.055,PIVW=0.318,PFDR=0.424), and insomnia (OR=0.773, 95%CI 0.483‒1.237,PIVW=0.283,PFDR=0.424) had no causal relationship with the onset of ischemic stroke. Conclusion There is a positive causal relationship between major depression and the risk of ischemic stroke, and screening and prevention for ischemic stroke should be enhanced for patients with major depression, so as to reduce their risk of developing ischemic stroke.
Objective Approximately 10% of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) present with mild stroke, and about 20% of the patients with mild stroke who do not receive reperfusion treatment will experience early neurological deterioration. This study aims to investigate the imaging indicators for predicting the onset of early neurologic deterioration (END) in patients with mild stroke due to LVO in the anterior circulation based on magnetic resonance imaging. Methods A total of 84 hospitalized patients who were diagnosed with acute anterior circulation infarction within 72 hours after disease onset in Henan Provincial People’s Hospital from January 1, 2021 to December 30, 2024 were enrolled,and 3.0 T magnetic resonance imaging was used to perform perfusion-weighted imaging (PWI) and diffusion-weighted imaging(DWI) for all patients with acute cerebral infarction. All patients had a baseline National Institutes of Health Stroke Scale(NIHSS) score of ≤5 within 24 hours after admission, and none of them received endovascular treatment. PWI and DWI imaging findings were collected from all patients to analyze regional cerebral blood flow (rCBF), regional cerebral blood volume, mean transit time, and time to peak. The receiver operating characteristic curve was plotted to analyze the value of PWI parameters in predicting END in patients with mild stroke due to LVO in the anterior circulation who did not receive endovascular treatment. Continuous variables were stratified based on the optimal cut-off value of Youden index, and the multivariate logistic regression analysis was used to investigate the independent risk factors for END. Results The incidence rate of END was 31.0%, with the proportion of rCBF as the imaging indicator,cut-off value 29.3%. The proportion of rCBF was an independent risk factor for END (OR=14.41, 95%CI 7.00‒37.33). Conclusion The proportion of rCBF≥29.3% has a certain value in predicting END in patients with mild stroke due to LVO in the anterior circulation and is an independent risk factor.
Objective To investigate the influencing factors for hemorrhagic transformation (HT) after intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) in plateau areas. Methods A retrospective analysis was performed for AIS patients who were admitted to our hospital from February 2019 to April 2024 and received IVT with urokinase or recombinant tissue plasminogen activator, and according to the presence or absence of HT after IVT, they were divided into HT group and non-HT group. The multivariate Logistic regression analysis was used to investigate the independent risk factors for HT after IVT in AIS patients. Results A total of 437 AIS patients who underwent IVT were included in this study, among whom 45 (10.3%) experienced HT. There were significant differences between the HT group and the non-HT group in the proportion of patients with a past history of atrial fibrillation, systolic blood pressure on admission, NIHSS score before thrombolysis, neutrophil-to-lymphocyte ratio (NLR), and blood glucose before thrombolysis (all P<0.05). The above factors were included in a multivariate logistic regression model, and the results showed that blood glucose on admission(OR=1.122,95%CI 1.007~1.251,P<0.05) and history of atrial fibrillation (OR=3.896,95%CI 1.632~9.303,P<0.05)were independent risk factors for HT after IVT. Conclusion History of atrial fibrillation, systolic blood pressure on admission, NIHSS score before thrombolysis, blood glucose level on admission, and NLR level before treatment are influencing factors for HT after IVT in AIS patients in plateau areas, among which history of atrial fibrillation and blood glucose level before thrombolysis are independent risk factors.
Anti-leucine-rich glioma-inactivated 1 (anti-LGI1) antibody autoimmune encephalitis is a relatively common type of limbic encephalitis,and its etiology remains unclear. It is rare for two individuals with a blood relationship to both suffer from encephalitis with positive anti-LGI1 antibodies. This article reports two sisters who lived in different counties and were diagnosed with anti-LGI1 antibody autoimmune encephalitis successively. The two sisters were diagnosed at an age of 64 and 65 years, respectively. During the course of the disease, both patients had epileptic seizures and slow response, but with different clinical manifestations. They had similar results of cranial magnetic resonance imaging and positive anti-LGI1 antibodies in cerebrospinal fluid and serum. The two patients were treated with glucocorticoid shock therapy and gamma globulin infusion during hospitalization,and both patients had a good prognosis. Recent studies have shown that anti-LGI1 antibody encephalitis is associated with genetic susceptibility.For patients with anti-LGI1 antibody encephalitis, it is necessary to inquire about family history and summarize the features of this type of disease, in order to provide better help for clinical practice.
To explore the clinical characteristics, imaging features, diagnostic approaches, effective treatment methods, and prognosis of labyrinthine infarction caused by anterior inferior cerebellar artery (AICA) occlusion.A retrospective analysis was conducted on the detailed clinical data of a patient with labyrinthine infarction caused by AICA occlusion, including medical history, symptoms and signs, auxiliary examination results, therapeutic interventions, and follow-up process. The characteristics of this condition were summarized through a review of the relevant literature.Following a comprehensive treatment regimen, including anti-platelet aggregation, lipid regulation, circulation improvement, nerve nutrition, anti-inflammation, and blood pressure and blood sugar regulation, the symptoms of the nervous system were relieved to a certain extent.Labyrinthine infarction caused by AICA occlusion is rare in clinical practice and its diagnosis is difficult. Early and accurate diagnosis and timely and standardized treatment are of great significance for improving the prognosis of patients. Attention should be paid to the management of high-risk factors.
Translocator protein 18 kDa(TSPO),as a key biomarker for neuroinflammation, has attracted widespread attention in the research on the pathogenesis of stroke in recent years. Stroke is a severe neurological disease, in which neuroinflammation plays a crucial role. TSPO exhibits multiple functions in regulating the activation and polarization of microglial cells and modulating neuroprotective responses, making it an important entry point for understanding the pathological mechanism of stroke.With the continuous development of TSPO-PET imaging technology, this technology has been widely used in clinical and experimental studies, providing a powerful tool for real-time monitoring of intracerebral inflammation and evaluation of therapeutic outcomes. This article systematically reviews the research advances in TSPO in neuroinflammation associated with ischemic and hemorrhagic stroke and explores its potential neuroprotective mechanisms and application prospects,in order to provide theoretical support and research directions for the optimization and innovation of stroke treatment strategies in the future.
Intracranial atherosclerosis (ICAS) is an important etiology of ischemic stroke and has a complex pathogenesis. Iron is an essential trace element for maintaining normal physiological functions of the human body, and the regulation of iron homeostasis is of great significance for ensuring proper physiological activities. Studies in recent years have shown that iron metabolism disorder plays a pivotal role in the development and progression of intracranial atherosclerotic cerebral infarction, involving various pathological processes such as inflammatory response, cell death, lipid metabolism, and blood-brain barrier dysfunction. This article systematically elaborates on the mechanisms through which iron overload promotes ICAS, including oxidative stress, inflammatory response, and lipid peroxidation,with a focus on the key role of related molecular mechanisms (including glutathione depletion, inhibition of GPX4 activity, and lipid peroxide accumulation)in intracranial atherosclerotic cerebral infarction, in order to provide new ideas for the prevention and treatment of intracranial atherosclerotic disease.