Vertebrobasilar artery elongation in migraine-a retrospective cross-sectional study

BACKGROUND

Numerous but inconclusive findings have sparked an ongoing debate about whether the arteries of migraine patients undergo vascular alterations. The outlet angle of the superior cerebellar artery (SUCA) and the lateral displacement of basilar arteries are good surrogate parameters for determining elongation of the vertebrobasilar arteries.

METHODS

We retrospectively determined the SUCA outlet angle and the lateral displacement of the basilar artery in 63 patients with migraine (30.6 ± 8.9 years, 84% women, 16% chronic migraine, 60% migraine with aura) and compared these with 126 age- and sex-matched control subjects.

RESULTS

In patients with migraine, the SUCA outlet angle was lower (159 ± 26° vs. 169 ± 29°, p = 0.020) and the lateral displacement of the basilar artery was greater (3.7 ± 2.7 mm vs. 2.8 ± 2.4 mm, p = 0.020) than in the control subjects. Age, gender, migraine characteristics and presence of any cardiovascular risk factors did not affect the SUCA outlet angle or lateral displacement of the basilar artery.

CONCLUSION

Migraine patients exhibited a lower SUCA outlet angle and greater lateral displacement of the basilar arteries. Both may be attributable to the elongation of the vertebrobasilar arteries, which is an indication of arterial wall pathology in migraine.

[Dolichoectasia of the basilar artery caused by cystic medial degeneration, as a cause of neurovascular conflict with damage to the trigeminal, facial and vestibulocochlear nerves]

Cystic medial degeneration (Gsell-Erdheim syndrome, cystic medial necrosis) is considered to be a nonspecific histological manifestation of a group of diseases characterized by degenerative changes in the media, affecting primarily the aorta and adjacent branches, which leads to destruction of the vessel wall, followed by its expansion and, possibly, rupture. The authors describe a case of a 65-year-old female patient with a neurovascular conflict of the three cranial nerves with dolichoectatic basilar artery due to cystic medial degeneration. As a result, the patient has clinical manifestations in the form of hemifacial spasm, trigeminal neuralgia and vestibular paroxysmia. Data from instrumental studies and treatment provided are presented. Neurovascular conflict can be identified in various diseases and is characterized by the complex etiology. The most common clinical manifestations of neurovascular conflict are trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and vestibular paroxysmia.

Microvascular decompression for trigeminal neuralgia caused by persistent trigeminal artery associated with craniosynostosis: a case report

BACKGROUND

Persistent trigeminal artery (PTA) is a rare arterial anastomosis between the basilar artery (BA) and internal carotid artery (ICA). It plays an indispensable role in a number of neurological disorders, including trigeminal neuralgia (TN).

CASE PRESENTATION

We report a unique case of a 58-year-old Han female patient with TN caused by PTA associated with craniosynostosis. Preoperative three-dimensional time-of-flight (3D-TOF) magnetic resonance (MR) and 3D constructive inference in steady state (3D-CISS) imaging showed that the PTA run though Meckel's cave. Complete pain relief was immediately achieved after microvascular decompression (MVD), without facial numbness and other complications. No recurrence was recorded at the 1-year follow up.

CONCLUSIONS

Microvascular decompression is a feasible option for the treatment of complex TN combined with other abnormalities. For patients deemed suitable for percutaneous balloon compression, PTA should be ruled out. Preoperative 3D-TOF and 3D-CISS MR imaging were essential to identify PTA neurovascular conflicts.

Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review

We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.

Basilar Artery Bands: Anatomic and Histologic Study with Application to Coiling and Stenting Procedures

BACKGROUND

Internal bands of the basilar artery (BA) have been rarely studied. Because bands could have obvious consequences in patient diagnosis and care, the present multiinstitutional cadaveric study was performed.

METHODS

The intraluminal bands of BAs were studied in 80 cadaveric specimens derived from India (Group 1) and the United States (Group 2). Their orientation within the vessel was recorded. Measurements included the length of the BA, diameter of the BA, intraluminal band length and thickness, and distance of the band to the vertebrobasilar junction. Selected bands were submitted for histologic analysis.

RESULTS

In Group 1, an intraluminal band (all vertically oriented) was identified in 16.6%. The mean length and thickness of the bands were 2.04 mm and 1.33 mm, respectively. These bands were located at a mean distance of 1.74 mm superior to the vertebrobasilar junction. In Group 2, an intraluminal band was identified in 6%. One band was vertically positioned, and 2 were horizontally positioned. The mean length and thickness of the bands were 2.5 mm and 0.9 mm, respectively. These latter bands were located at a mean distance of 2.23 mm superior to the vertebrobasilar junction. Histologically, the bands were essentially extensions of the tunica media and interna of the artery.

CONCLUSIONS

To our knowledge, this study is the first multiethnic study of the prevalence and morphometry of the BA bands. A better understanding of these bands may help reveal their relationship to thrombus and aneurysmal formation and their impact on endovascular procedures.

The Longitudinal Distribution and Stability of Curved Basilar Artery Plaque: A Study Based on HR-MRI

AIMS

This study aims to evaluate the differences in the characteristics of atherosclerotic plaques in the proximal, curved, and distal segments of the curved basilar artery (BA) through high-resolution magnetic resonance imaging(HR-MRI).

METHODS

The imaging and clinical data of 146 patients were retrospectively analyzed. On the basis of three-dimensional (3D) time -of -flight magnetic resonance angiography (3D-TOF-MRA), 51 patients with BA curvature were selected for the study. The BA plaque is divided into three groups: proximal, curved, and distal. Plaques were identified and analyzed according to spin echo acquisition imaging via T1-weighted 3D volumetric isotropic Tse acquisition (T1W-3D -VISTA), and compare the differences in clinical related factors and plaque characteristics between groups. Diffusion-weighted imaging (DWI) and/or T2WI identified brainstem infarction. The patients were divided into symptomatic and asymptomatic groups. The correlation between plaque location and symptoms was identified and analyzed.

RESULTS

Among 51 patients, a total of 376 plaques were detected. Plaques in the proximal and curved segments are more common than those in the distal segments. Proximal plaques are more likely to have intraplaque hemorrhage ( P=0.002 ＜0.05). There was no significant difference in the distribution of criminal plaques and non-criminal plaques between each group (P=0.36 ＞0.05).

CONCLUSION

Plaques in the proximal and curved segments of the BA are more common than those in the distal segments. The proximal plaque is more prone to intraplaque hemorrhage.

Involvement of Supraoptic Astrocytes in Basilar Artery Occlusion-Evoked Differential Activation of Vasopressin Neurons and Vasopressin Secretion in Rats

Vasopressin (VP) is a key factor in the development of brain injury in ischemic stroke. However, the regulation of VP secretion in basilar artery occlusion (BAO) remains unclear. To clarify the regulation of VP secretion in BAO and the underlying mechanisms, we performed this study in a rat model of BAO with (BC) or without common carotid artery occlusion (CCAO). The results showed that BAO and BC time-dependently increased neurological scores and that BC also increased water contents in the medulla at 2 h and in the pontine at 8 h. Moreover, plasma VP level increased significantly at BAO-8 h, CCAO and BC-2 h but not at BC-8 h; however, VP expressions increased in the supraoptic nucleus (SON) at BC-8 h. The neurological scores were highly correlated with pontine water contents and plasma VP levels. The number of phosphorylated extracellular signal-regulated protein kinase1/2-positive VP neurons increased significantly in the SON at BC-8 h. Similarly, the number of c-Fos-positive VP neurons increased significantly in the SON at BAO-8 h and BC-8 h. In addition, the length of glial fibrillary acidic protein (GFAP) filaments increased significantly in BC compared to BAO only. Aquaporin 4 (AQP4) puncta around VP neurons increased significantly at BC-8 h relative to BC-2 h, which had negative correlation with plasma VP levels. These findings indicate that BAO facilitates VP secretion and increases VP neuronal activity in the SON. The peripheral VP release is possibly under a negative feedback regulation of central VP neuronal activity through increasing GFAP and AQP4 expression in astrocytic processes.

Depletion of microglia mitigates cerebrovascular dysfunction in diet-induced obesity mice

Obesity is frequently associated with cerebrovascular dysfunction; however, the underlying mechanism remains less well understood. In this study, by using pharmacological approaches, we show that neuroinflammation involving microglia plays an important role in obesity-related cerebrovascular dysfunction. PLX3397 treatment, which leads to depletion of microglia, reduced the wall thickness and collagen deposition in the basilar artery of diet-induced obesity (DIO) mice. Besides, the phosphorylation of endothelial nitric oxide synthase (eNOS) at Ser1177 was enhanced, suggesting improved endothelial function of the basilar artery. The wire myography data show that acetylcholine-elicited relaxation of basilar artery isolated from DIO mice was improved after the treatment with PLX3397. Moreover, our data demonstrate that brain administration of IL-18 impaired cerebrovascular function in mice with normal body weight. Together, these data suggest that neuroinflammation involving microglia is important in obesity-related vascular dysfunction in the brain.NEW & NOTEWORTHY We reported that microglia, the resident immune cells in the brain, contribute to obesity-related cerebrovascular dysfunction in mice. Moreover, we showed that excessive IL-18 can lead to vascular dysfunction in mouse brain.

Free-floating and spinning thrombus of the basilar artery: A case report

RATIONALE

Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.</abstract>.

PATIENT CONCERNS

A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis.

DIAGNOSES

Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis.

INTERVENTIONS

We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days.

OUTCOMES

No thrombus was observed on the third follow-up digital subtraction angiography.

LESSONS

No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.

Morphological variables associated with ruptured basilar tip aneurysms

Morphological factors of intracranial aneurysms and the surrounding vasculature could affect aneurysm rupture risk in a location specific manner. Our goal was to identify image-based morphological parameters that correlated with ruptured basilar tip aneurysms. Three-dimensional morphological parameters obtained from CT-angiography (CTA) or digital subtraction angiography (DSA) from 200 patients with basilar tip aneurysms diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were evaluated. We examined aneurysm wall irregularity, the presence of daughter domes, hypoplastic, aplastic or fetal PCoAs, vertebral dominance, maximum height, perpendicular height, width, neck diameter, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine statistical significance. In multivariable analysis, presence of a daughter dome, aspect ratio, and larger flow angle were significantly associated with rupture status. We also introduced two new variables, diameter size ratio and parent-daughter angle ratio, which were both significantly inversely associated with ruptured basilar tip aneurysms. Notably, multivariable analyses also showed that larger diameter size ratio was associated with higher Hunt-Hess score while smaller flow angle was associated with higher Fisher grade. These easily measurable parameters, including a new parameter that is unlikely to be affected by the formation of the aneurysm, could aid in screening strategies in high-risk patients with basilar tip aneurysms. One should note, however, that the changes in parameters related to aneurysm morphology may be secondary to aneurysm rupture rather than causal.

Three-dimensional morphology of the superior cerebellar artery running in trigeminal neuralgia

The superior cerebellar artery (SCA) is the most frequent offending vessel in trigeminal neuralgia. This study aims to elucidate the patterns of the SCA running in 34 patients with typical trigeminal neuralgia using three-dimensional computer graphics. The SCA which runs in the medial aspect of the trigeminal nerve compressed predominantly the root entry zone at the distal segment of the caudal loop. Meanwhile, the SCA which runs in the cranial or lateral aspect of the trigeminal nerve compressed predominantly the mid-third portion at the proximal segment of the caudal loop. The site of neurovascular compression differed depending on the shape of the initial segment of SCA. Transposition methods could not be performed in several patients with arch-shaped SCA. Three-dimensional computer graphics revealed different characteristics of the SCA running in trigeminal neuralgia depending on the site of neurovascular compression and shape of the SCA. These differences might affect procedures for microvascular decompression.

Surrounding vascular geometry associated with basilar tip aneurysm formation

Hemodynamic stress is thought to play an important role in the formation of intracranial aneurysms, which is conditioned by the geometry of the surrounding vasculature. Our goal was to identify image-based morphological parameters that were associated with basilar artery tip aneurysms (BTA) in a location-specific manner. Three-dimensional morphological parameters obtained from CT-angiography (CTA) or digital subtraction angiography (DSA) from 207 patients with BTAs and a control group of 106 patients with aneurysms elsewhere to control for non-morphological factors, who were diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016, were evaluated. We examined the presence of hypoplastic, aplastic or fetal PCoAs, vertebral dominance, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine statistical significance. Sensitivity analyses with small (≤ 3 mm) aneurysms only and with angles excluded, were also performed. In multivariable analysis, daughter-daughter angle was directly, and parent artery diameter and diameter size ratio were inversely associated with BTAs. These results remained significant in the subgroup analysis of small aneurysms (width ≤ 3 mm) and when angles were excluded. These easily measurable and robust parameters that are unlikely to be affected by aneurysm formation could aid in risk stratification for the formation of BTAs in high-risk patients.

Acute basilar artery occlusion with recurrent shivering: A case report

RATIONALE

Shivering is an important physiological response of the body that causes muscle tremors to maintain temperature homeostasis. Traumatic brain injuries that affect the hypothalamus cause hypothermia, and physical removal of suprasellar tumors causes thermoregulation imbalance. However, no study has reported shivering due to ischemic stroke.

PATIENT CONCERNS

A 58-year-old male patient was admitted to our emergency department to evaluate severe stenosis of the basilar artery. While waiting for further examination, he exhibited coarse shivering and severe dysarthria.

DIAGNOSIS

Brain computed tomography angiography revealed occlusion of the entire basilar artery, and cerebral hypoperfusion was diagnosed in that area.

INTERVENTIONS

Transfemoral cerebral angiography (TFCA) was immediately performed, followed by thrombectomy of the basilar artery.

OUTCOMES

Neurological deficits, including shivering, were rapidly reversed. The same symptom reoccurred 5 hours later, and TFCA was performed for thrombectomy and stenting, and neurological symptoms immediately reversed. The patient's neurological symptoms did not worsen during hospitalization.

LESSONS

Patients with acute basilar artery occlusion need prompt management because they have a higher mortality rate than those with other intracranial artery occlusions. When a patient exhibits neurological deficits accompanied by abrupt shivering for no specific reason, basilar artery occlusion must be considered.

Endovascular treatment combined with vertebral artery endarterectomy for patients with acute tandem vertebrobasilar artery occlusion

PURPOSE

To evaluate the safety and efficacy of endovascular treatment combined with vertebral artery endarterectomy in patients with acute tandem vertebrobasilar artery occlusion.

METHODS

From April 2017 to March 2019, three patients with acute basilar artery occlusion combined with ostial vertebral occlusion in our institution were enrolled in the study. They underwent endovascular treatment combined with vertebral artery endarterectomy. The clinical, technical and functional outcomes of the patients were retrospectively analysed.

RESULTS

All three patients in the study underwent complete recanalization. The modified Thrombolysis in Cerebral Infarction (mTICI) grade was 2b/3 in all patients. The modified Rankin Scale (mRS) score was 0-2 for the three patients at 3 months. Follow-up CT scans revealed no cerebral haemorrhage, and no patients died during follow-up. All patients achieved good clinical outcomes after the combined treatment.

CONCLUSION

Endovascular treatment combined with vertebral artery endarterectomy is a feasible method to treat patients with acute basilar artery occlusion combined with ostial vertebral occlusion, especially when the guidewire cannot pass through the ostium of the dominant vertebral artery occlusion.

Plaque features and vascular geometry in basilar artery atherosclerosis

Hemodynamic changes occurring at the segments of arterial bifurcations, up and down stream of stenotic vessels appear to play a critical role in the development of atherosclerosis. Therefore, we hypothesized that basilar artery (BA) geometry may be related to the distribution of atherosclerotic plaque.In this retrospective cross-sectional study, all patients hospitalized with ischemic stroke and intracranial atherosclerotic disease were sifted from March 2017 to October 2017. Sixty-seven patients with intracranial atherosclerotic disease (39 with and 28 without BA atherosclerosis) were analyzed. Magnetic resonance imaging, magnetic resonance angiography, and high-resolution black-blood MRI were performed within 7 days after symptoms onset. BA tortuosity, plaque location, and plaque enhancement were assessed. Plaque burden and vascular remodeling were measured.Of the 39 patients with BA atherosclerosis, plaques preferred to be formed at the inner arc than the outer arc (27/39, 69% vs 12/39, 31%) in the tortuous BA. In addition, patients with BA plaque had a greater vascular tortuosity compared with those without plaque (113.1 ± 10.2 vs 107 ± 4.6; P = .034). Finally, patients with apparent BA plaque had greater plaque enhancement (14/21, 67% vs 5/18, 28%; P = .017) and plaque burden (0.76 ± 0.15 vs 0.70 ± 0.09; P = .036) compared with those with minimal plaque.Plaque may be more likely to form at the inner arc of tortuous BA with atherosclerotic disease, and increased BA tortuosity is associated with its likelihood to form plaque.

Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study

OBJECTIVE

Posterior circulation ischemic stroke (PCiS) constitutes 20-30% of ischemic stroke cases. Detailed information about differences between PCiS and anterior circulation ischemic stroke (ACiS) remains scarce. Such information might guide clinical decision making and prevention strategies. We studied risk factors and ischemic stroke subtypes in PCiS vs. ACiS and lesion location on magnetic resonance imaging (MRI) in PCiS.

METHODS

Out of 3,301 MRIs from 12 sites in the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Genetics Network (SiGN), we included 2,381 cases with acute DWI lesions. The definition of ACiS or PCiS was based on lesion location. We compared the groups using Chi-squared and logistic regression.

RESULTS

PCiS occurred in 718 (30%) patients and ACiS in 1663 (70%). Diabetes and male sex were more common in PCiS vs. ACiS (diabetes 27% vs. 23%, p < 0.05; male sex 68% vs. 58%, p < 0.001). Both were independently associated with PCiS (diabetes, OR = 1.29; 95% CI 1.04-1.61; male sex, OR = 1.46; 95% CI 1.21-1.78). ACiS more commonly had large artery atherosclerosis (25% vs. 20%, p < 0.01) and cardioembolic mechanisms (17% vs. 11%, p < 0.001) compared to PCiS. Small artery occlusion was more common in PCiS vs. ACiS (20% vs. 14%, p < 0.001). Small artery occlusion accounted for 47% of solitary brainstem infarctions.

CONCLUSION

Ischemic stroke subtypes differ between the two phenotypes. Diabetes and male sex have a stronger association with PCiS than ACiS. Definitive MRI-based PCiS diagnosis aids etiological investigation and contributes additional insights into specific risk factors and mechanisms of injury in PCiS.

Unusual clinicopathological presentation of nontraumatic cerebral fat embolism: Two-case report

RATIONALE

Fat embolism syndrome (FES) is characterized by the classical triad of cerebral, respiratory, and cutaneous manifestations. In contrast, cerebral fat embolism (CFE), corresponding to incomplete pure type FES, is much rarer and usually follows trauma. CFE typically shows a "starfield" pattern on diffusion-weighted magnetic resonance imaging due to the involvement of multiple small arteries. We report 2 unusual cases of CFE that showed a nontraumatic etiology and the involvement of a single dominant cerebral artery.

PATIENT CONCERNS

Case 1 was a 33-year-old woman without a history of trauma who visited the emergency room due to hemiparesis and hemisensory deficits. She was a heavy smoker and had used oral contraceptives for several years. Most importantly, she had 2 experiences of autologous fat grafting 2 months previously. Magnetic resonance angiography (MRA) revealed acute occlusion of the right middle cerebral artery. Case 2 was an 80-year-old man suddenly presented with dizziness, ataxia, and left-sided sensorimotor dysfunction. He had a history of hypertension, untreated atrial fibrillation, and chronic alcoholism. MRA demonstrated the occlusion of the distal basilar artery.

DIAGNOSIS

Case 1: Microscopic findings demonstrated variable sized fat vacuoles intermixed with moderate amounts of thrombi. Case 2: Histologically, mature adipocytes were intermingled with fibrin, blood cells, and a fragment of entrapped soft tissue resembling the vessel wall.

INTERVENTION

Case 1 and 2 underwent aspirational thrombectomy guided by transfemoral cerebral angiography.

OUTCOME

Case 1 recovered well but Case 2 still suffers from gait ataxia.

LESSONS

CFE can rarely occur in various nontraumatic conditions, with or without evident etiology. Furthermore, it may not show characteristic clinicopathological manifestations. Therefore, careful follow up of those who have undergone procedures that are likely to trigger FES or who have hemodynamic or hypercoagulable risk factors is needed.

The effects of Cinnamaldehyde on early brain injury and cerebral vasospasm following experimental subarachnoid hemorrhage in rabbits

The neuroprotective and vasodilatory effects of cinnamaldehyde have been widely studied and documented. On the basis of these findings, we hypothesized that cinnamaldehyde exhibits therapeutic effects on subarachnoid hemorrhage-induced early brain injury and cerebral vasospasm. Thirty-two adult male New Zealand white rabbits were randomly divided into four groups of eight rabbits: control, subarachnoid hemorrhage, subarachnoid hemorrhage + vehicle, and subarachnoid hemorrhage + cinnamaldehyde. An intraperitoneal dose of 50 mg/kg cinnamaldehyde was administered 5 min following an intracisternal blood injection, followed by three further daily injections at identical doses. The animals were sacrificed 72 h after subarachnoid hemorrhage was induced. The cross-sectional areas and arterial wall thicknesses of the basilar artery were measured and hippocampal degeneration scores were evaluated. Treatment with cinnamaldehyde was effective in providing neuroprotection and attenuating cerebral vasospasm after subarachnoid hemorrhage in rabbits. It effectively increased the cross-sectional areas of the basilar artery and reduced the arterial wall thickness; in addition, hippocampal degeneration scores were lower in the cinnamaldehyde group. The findings of this study showed, for the first time to our knowledge, that cinnamaldehyde exhibits neuroprotective activity against subarachnoid hemorrhage-induced early brain injury and that it can prevent vasospasm. Potential mechanisms underlying the neuroprotection and vasodilation were discussed. Cinnamaldehyde could play a role in subarachnoid hemorrhage treatment.

Role of ATP-sensitive potassium channels and inflammatory response of basilar artery smooth muscle cells in subarachnoid hemorrhage of rabbit and immune-modulation by shikonin

OBJECTIVE

To investigate the role of inflammatory response, oxidative damage and changes of ATP-sensitive potassium channels (sK_ATP) in basilar artery (BA) smooth muscle cells (SMCS) of rabbits in subarachnoid hemorrhage (SAH) model.

METHODS

Time course studies on inflammatory response by real-time PCR, oxidative process and function of isolated basilar artery after SAH in New Zealand White rabbits were performed. Basilar artery smooth muscle cells (BASMCs) in each group were obtained and whole-cell patch-clamp technique was applied to record cell membrane capacitance and K_ATP currents. The morphologies of basal arteries were analyzed. Protective effect of shikonin were also determine by same parameters.

RESULTS

Inflammatory cytokines levels were highest at 24h compare to 72h after SAH whereas the oxidative damage and cell death marker were at highest peak at 72h. Oxidative damage peak coincided with significant alterations in cell membrane capacitance, K_ATP currents and morphological changes in basilar arteries. Shikokin pretreatment attenuated early inflammatory response at 24h and associated oxidative damage at 72h. Finally, shikonin attenuated morphological changes in basilar arteries and dysfunction.

CONCLUSION

Currents of ATP-sensitive potassium channels in basilar smooth muscle cells decreased after SAH by putative oxidative modification from immediate inflammatory response and can be protected by shikonin pretreatment.

Clinical application of high-resolution MRI in combination with digital subtraction angiography in the diagnosis of vertebrobasilar artery dissecting aneurysm: An observational study (STROBE compliant)

Vertebrobasilar artery dissecting aneurysm (VBA-DA) is associated with serious complications and poor prognosis in patients. High-resolution magnetic resonance imaging (HR-MRI) is a noninvasive method for the diagnosis of VBA-DA.VBA-DAs were classified according to the feature of HR-MRI in combination with digital subtraction angiography (DSA), and the clinical outcomes of different types of VBA-DAs were analyzed. Thirty-nine patients with 42 VBA-DAs were included and underwent HR-MRI, including three-dimensional T1 weighted image, three-dimensional T2 weighted image (3D-T2WI), three-dimensional time of flight MRA (3D-TOF-MRA), and three-dimensional fast imaging employing steady state acquisition (3D-FIESTA), and hematoma and flaps were compared. The follow-up was 3 to 25 months. The VBA-DAs were classified based on the images of HR-MRI and DSA, and the prognosis was analyzed.VBA-DAs more frequently occurred on the vertebral artery, especially on the dominant vertebral artery. 3D-TOF-MRA showed high signal from hematoma, and 3D-FIESTA showed high signal from flaps. Based on HR-MRI images in combination with DSA, VBA-DAs were classified into 4 types: classical, stenosis, spiral, and hemorrhagic. The patients with the classical VBA-DAs had a higher improvement rate and a lower exacerbation rate. The patients with spiral and hemorrhagic VBA-DAs had poor clinical outcomes. The patients with stenosis VBA-DAs had poorer clinical outcomes than classical types and better clinical outcomes than spiral and hemorrhagic types.The detection of intramural hematoma and dissection flap using HR-MRI provides basic information for the diagnosis of VBA-DA. Individualized therapeutic strategies can be designed for the treatment of VBA-DAs with different features of DSA and HR-MRI.

Effects of 2-Aminoethyl Diphenylborinate, a Modulator of Transient Receptor Potential and Orai Channels in Subarachnoid Hemorrhage: An Experimental Study

BACKGROUND

Cerebral vasospasm remains a serious problem affecting morbidity and mortality in patients with subarachnoid hemorrhage (SAH) during neurosurgery. We aimed to demonstrate the role of the transient receptor potential channel and other channels for Ca²⁺ in the etiology of cerebral vasospasm using 2-aminoethyl diphenylborinate (2-APB) and the effective dose range of an unstudied pharmacological agent, which can limit vasospasm.

METHODS

We performed an experimental study using 32 Sprague-Dawley rats divided into 4 groups: sham group (n = 8), SAH group (n = 8), 2-APB group (SAH rats intraperitoneally administered with 0.5 mg/kg 2-APB; n = 8), and 2-APB-2 group (SAH rats intraperitoneally administered with 2 mg/kg 2-APB; n = 8). The rats were sacrificed after 24 hours, and superoxide dismutase, glutathione peroxidase, malondialdehyde, tumor necrosis factor-α, and interleukin-1β in the brain tissue and serum were measured. The histopathological investigation of brain tissue included measurement of the luminal diameter and wall thickness of the basilar artery (BA), and apoptotic cells in the hippocampus were counted after caspase staining.

RESULTS

Autologous arterial blood injection into the cisterna magna caused vasospasm in rats. 2-APB treatment increased the BA wall thickness and reduced the BA lumen diameter, inducing significant vascular changes. 2-APB also alleviated cell apoptosis at 24 hours after SAH.

CONCLUSION

In experimental SAH in rats, 2-APB treatment increased the BA wall thickness and reduced the BA lumen diameter, inducing significant vascular changes. 2-APB also alleviated cell apoptosis at 24 hours after SAH.

Therapy for acute basilar artery occlusion: a systematic review and meta-analysis

Purpose: This study aims to analyse the efficacy of different treatment methods for acute basilar artery occlusion, with an emphasis placed on evaluating the latest treatment methods. Method:  A systematic review and meta-analysis was performed to analyse the current data on the therapies available for treating acute basilar artery occlusion. Results: A total of 102 articles were included. The weighted pooled rate of mortality was 43.16% (95% CI 38.35-48.03%) in the intravenous thrombolysis group, 45.56% (95% CI 39.88-51.28) in the intra-arterial thrombolysis group, and 31.40% (95% CI 28.31-34.56%) for the endovascular thrombectomy group. The weighted pooled rate of Modified Ranking Score (mRS) 0-2 at 3 months was 31.40 (95% CI 28.31-34.56%) in the IVT group, 28.29% (95% CI 23.16-33.69%) in the IAT group, and 35.22% (95% CI 32.39-38.09%) for the EVT group. Meta-analyses were also done for the secondary outcomes of recanalization and symptomatic haemorrhage. There was no difference between stent retriever and thrombo-aspiration thrombectomy on subgroup analysis in both clinical outcome and safety profile. Limitations: The included studies were observational in nature. There was significant heterogeneity in some of the outcomes. Conclusions:  Superior outcomes and better recanalization rates for acute basilar occlusion were seen with patients managed with endovascular thrombectomy when compared with either intravenous and/or intraarterial thrombolysis. No superiority of stent-retrievers over thrombo-aspiration thrombectomy was seen.

Ruptured intrameatal anterior inferior cerebellar artery aneurysm associated with obstructed internal auditory artery in a patient with sudden hearing loss and vertigo

BACKGROUND

Intrameatal aneurysms arising from the meatal loop of the anterior inferior cerebellar artery (AICA) are extremely rare.

CASE PRESENTATION

We report a 60-year-old man presenting with severe vertigo and sudden left hearing loss associated with subarachnoid hemorrhage caused by rupture of a saccular aneurysm arising from the meatal loop of the AICA, which was entirely buried in the meatus. Intraoperatively, we identified the occluded internal auditory artery arising from the meatal loop of the AICA, where the aneurysm originated, and performed neck clipping.

CONCLUSION

These findings suggest that internal auditory artery occlusion is a potential cause of loss of auditory and vestibular functions.

Icariin ameliorates angiotensin II-induced cerebrovascular remodeling by inhibiting Nox2-containing NADPH oxidase activation

Cerebrovascular smooth muscle cells (SMCs) hyperplasia is an important contributor to cerebrovascular remodeling during hypertension. The aim of present study was to investigate the effects of Icariin on cerebrovascular SMCs proliferation and remodeling and the underlying mechanisms. The results revealed that Icariin administration attenuated the enhanced basilar artery constriction in angiotensin II (AngII)-induced hypertension rat model, as well as the inhibition of basilar artery diameter reduction in response to AngII and phenylephrine. In addition, histological analyses showed that Icariin also significantly ameliorated basilar artery remodeling in AngII hypertensive rats. In human brain vascular SMCs (HBVSMCs), AngII-induced cell proliferation, migration and invasion were markedly inhibited by Icariin treatment. Moreover, Icariin treatment largely limited AngII-induced the increase of reactive oxygen species (ROS) production in HBVSMCs, which was closely associated with cell proliferation. Analysis of the mechanisms showed that Icariin decreased ROS production via inhibiting NADPH oxidase activity but not mitochondria-derived ROS production. Further, Icariin promoted Nox2 degradation and consequently reduced its protein expression. In conclusion, these findings demonstrate that Icariin attenuates cerebrovascular SMCs hyperplasia and subsequent remodeling through inhibiting Nox2-containing NADPH oxidase activation, suggesting Icariin may be a potential therapeutic agent to prevent the onset and progression of stroke.

Extracranial and Intracranial Ultrasonographic Findings in Posterior Circulation Infarction

OBJECTIVES

Patients with posterior circulation infarction are at higher risk of early recurrent stroke, especially those with vertebrobasilar stenosis or hypoplasia. The clinical presentations of this condition vary over a broad range, making diagnosis and treatment a challenge. Hemodynamic changes and stenosis detected by ultrasonography (US) are sensitive and important indicators for further evaluation. In this study, we correlated extracranial and intracranial US characteristics with brain magnetic resonance imaging (MRI) in patients with posterior circulation infarction.

METHODS

Inpatients with acute ischemic stroke who received both MRI and US were enrolled. Baseline characters, underlying disorders, the ischemic territory, and vascular stenosis on MRI were recorded. Series of US data, including flow volume, diameter, mean velocity, and pulsatility index, were analyzed. Patients with new infarction over the medulla, pons, midbrain, or cerebellum were enrolled as the posterior circulation infarction group. Patients with pure anterior circulation infarction were also enrolled.

RESULTS

A total of 210 patients with anterior circulation infarction (mean age ± SD, 66.24 ± 12.88 years) and 143 with posterior circulation infarction (mean age, 65.82 ± 11.39 years) were enrolled. Significant higher frequencies of vertebral artery hypoplasia and decreased intracranial vertebrobasilar velocity in the posterior circulation infarction group (44.75% and 64.33%, respectively) were documented (P < .0001; P = .035). Ischemic lesion distributions were correlated with vertebral artery hypoplasia (55.56 %) and low vertebral and basilar artery velocities (44.44% and 25.53%), as documented by US. A low vertebrobasilar velocity was highly correlated with MRI-documented vascular stenosis (53.06%).

CONCLUSIONS

Vertebral artery hypoplasia and a low velocity in the intracranial vertebrobasilar system on US might change the treatment of patients with posterior circulation infarction for primary and secondary prevention.

Ipsiversive Ocular Torsion, Skew Deviation, and Hearing Loss as Initial Signs of Anterior Inferior Cerebellar Artery Infarction

A 67-year-old man with hypertension and type 2 diabetes mellitus was admitted to our hospital because of left hearing loss and vertical diplopia. A neurological examination showed ocular torsion, skew deviation, and sensorineural hearing loss in the left ear. Brainstem and cerebellar neurological signs were not observed. Left middle cerebellar peduncle infarction was evident on magnetic resonance imaging. He was treated with antiplatelet, however, the infarct progressed after this administration. Ocular tilt reaction (OTR) involves the triad of ocular torsion, skew deviation, and head tilt. Ipsiversive OTR components associated with hearing loss can be early diagnostic signs of anterior inferior cerebellar artery infarction.

ClC-2 knockdown prevents cerebrovascular remodeling via inhibition of the Wnt/β-catenin signaling pathway

BACKGROUND

Mishandling of intracellular chloride (Cl-) concentration ([Cl-]i) in cerebrovascular smooth muscle cells is implicated in several pathological processes, including hyperplasia and remodeling. We investigated the effects of ClC-2-mediated Cl- efflux on the proliferation of human brain vascular smooth muscle cells (HBVSMCs) induced by angiotensin II (AngII).

METHODS

Cell proliferation and motility were determined using the CCK-8, bromodeoxyuridine staining, wound healing and invasion assays. ClC-2, PCNA, Ki67, survivin and cyclin D1 expression, and β-catenin and GSK-3β phosphorylation were examined using western blotting. Histological analyses were performed using hematoxylin and eosin staining and α-SMA staining.

RESULTS

Our results showed that AngII-induced HBVSMC proliferation was accompanied by a decrease in [Cl-]i and an increase in ClC-2 expression. Inhibition of ClC-2 by siRNA prevented AngII from inducing the efflux of Cl-. AngII-induced HBVSMC proliferation, migration and invasion were significantly attenuated by ClC-2 downregulation. The inhibitory effects of ClC-2 knockout on HBVSMC proliferation and motility were associated with inactivation of the Wnt/β-catenin signaling pathway, as evidenced by inhibition of β-catenin phosphorylation and nuclear translocation, and decrease of GSK-3β phosphorylation and survivin and cyclin D1 expression. Recombinant Wnt3a treatment markedly reversed the effect of ClC-2 knockdown on HBVSMC viability. An in vivo study revealed that knockdown of ClC-2 with shRNA adenovirus ameliorated basilar artery remodeling by inhibiting Wnt/β-catenin signaling in AngII-treated mice.

CONCLUSION

This study demonstrates that blocking ClC-2-mediated Cl- efflux inhibits AngII-induced cerebrovascular smooth muscle cell proliferation and migration by inhibiting the Wnt/β-catenin pathway. Our data indicate that downregulation of ClC-2 may be a viable strategy in the prevention of hyperplasia and remodeling of cerebrovascular smooth muscle cells.

Successive occurrence of vertebrobasilar dolichectasia induced trigeminal neuralgia, vestibular paroxysmia and hemifacial spasm: A case report

RATIONALE

Study reported an extremely rare case of trigeminal neuralgia, vestibular paroxysmia, and hemifacial spasm successively occurring in a patient with vertebrobasilar dolichoectasia (VBD).

PATIENT CONCERNS

A 66-year-old female patient presented with episodic vertigo for 20 days before she was admitted to our hospital. Vertigo suddenly occurred when the patient rotated her head 20 days ago, the symptoms of vertigo were improved after continuous 1 to 3 seconds, and similar symptoms were repeated in sleep and rest, with a frequency of 30 to 40 times per day. The patient had a history of hypertension with poor blood pressure control for more than 20 years.

DIAGNOSES

The final diagnosis was vertebrobasilar dolichectasia, right trigeminal neuralgia, and vestibular paroxysmia.

INTERVENTIONS

Vitamin B1 (10 mg), methylcobalamin (0.5 mg), and carbamazepine (0.1 g) were given orally 3 times a day to relieve the symptoms.

OUTCOMES

On the seventh day of drug treatment, the symptoms of paroxysmal vertigo and trigeminal neuralgia were completely relieved, but occasional episodes occurred during the follow-up period. Five months after discharge, right hemifacial spasm appeared in the patient, which did not affect the quality of life of the patient, so the patient did not choose further treatment. Six months after discharge, the patient was lost to follow-up.

LESSONS

Comprehensive treatment to control VBD risk factors, delay the progression of VBD, and improve clinical symptoms may have a better effect on such patients. However, further research is needed.

Reverse Locked-In Syndrome

BACKGROUND

Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria, and limited communication via eye movements. Here, we describe an uncommon stroke syndrome associated with endovascular recanalization of the top of the basilar artery: "reverse locked-in syndrome."

METHODS

We report the case of a patient with atypical neurological deficits caused by acute ischemic stroke of the midbrain tegmentum. We perform neuroanatomic localization of the patient's infarcts by mapping the magnetic resonance imaging (MRI) data onto a brainstem atlas.

RESULTS

A 61-year-old man presented with acute coma and quadriplegia due to top of the basilar artery occlusion. He underwent emergent endovascular thrombectomy, with successful recanalization of the basilar artery at 4 h and 43 min post-ictus. The patient regained consciousness and purposeful movement in all four extremities, but the post-procedure neurological examination demonstrated bilateral ptosis with complete pupillary and oculomotor paralysis. MRI revealed infarction of the bilateral oculomotor nuclei in the midbrain tegmentum. At 9-month follow-up, he had anisocoria and dysconjugate gaze, but was living at home and required minimal assistance in performing all activities of daily living.

CONCLUSIONS

Since the patient's deficits were the exact opposite of those described in locked-in syndrome, we propose the term "reverse locked-in syndrome" to describe this neurological entity characterized by bilateral ptosis, non-reactive pupils, and ophthalmoplegia with preservation of consciousness and extremity motor function.

Why does my patient's basilar artery continue to grow? A four-year case study of a patient with symptoms of vertebrobasilar dolichoectasia

BACKGROUND

Vertebrobasilar dolichoectasia (VBD) is a clinical entity associated with ischemic stroke, compression of cranial nerves or brainstem, and hydrocephalus. There have been relatively few studies following the progression of VBD in patients presenting with a variety of diverse clinical features.

CASE PRESENTATION

Here, we report a case study of a male with progressive VBD who was followed from November 2012 to December 2016. The patient had diagnosed hypertension for several years and suffered from left peripheral facial paralysis, recurrent ischemic attacks in the brainstem and cerebellum, obstructive hydrocephalus and frequent pneumonia. A series of cranial CT and multi-modal MRI scans were performed to explore the brain imaging features of the patient during follow-up.

CONCLUSIONS

The presented case study suggests that aging, uncontrolled hypertension, arterial dissection and infection may contribute to the exacerbation of VBD and recurrent ischemic stroke.

Multiple blood flow measurements before and after carotid artery stenting via phase-contrast magnetic resonance imaging: An observational study

After carotid artery stenting, the procurement of information about blood flow redistribution among brain-feeding arteries and its time trend is essential to understanding a patient’s physiological background and to determine their care regimen. Cerebral blood flow has been measured twice following carotid artery stenting in few previous studies, with some discrepancies in the results. The purpose of this study was to measure cerebral blood flow at multiple time points after carotid artery stenting, and to elucidate the time trend of cerebral blood flow and redistribution among arteries. Blood flow rates in 11 subjects were measured preoperatively, at one day, one week, and about three months, respectively after carotid artery stenting by using phase-contrast magnetic resonance imaging. The target vessels were the bilateral internal carotid arteries, the basilar artery, and the bilateral middle cerebral arteries. Lumen was semi-automatically defined using an algorithm utilizing pulsatility. The results showed that blood flow rates in the stented internal carotid artery and the ipsilateral middle cerebral artery increased following carotid artery stenting. Blood flow rates in the contralateral internal carotid artery and the basilar artery gradually declined, and they were lower than the preoperative values at three months after stenting. The sum of blood flow rates of the bilateral internal carotid arteries and the basilar artery increased after carotid artery stenting, and then decreased over the next three months. There was no significant change in the blood flow rate in the contralateral middle cerebral artery. From these results, it was concluded that redistribution among the bilateral internal carotid arteries and the basilar artery occurs after carotid artery stenting, and that it takes months thereafter to reach another equilibrium.

Multiple congenital anomalies of carotid and vertebral arteries in a patient with an ischemic stroke in the vertebrobasilar territory. Case report and review of the literature

The congenital anomalies of the supra-aortic arteries and their branches as potential risk factors for cerebrovascular insufficiency are not yet fully investigated and clarified. This report describes the case of a 68-year-old man who was admitted in our Clinic for an acute ischemic stroke in the vertebrobasilar territory. Extracranial color-coded duplex sonography (CCDS) and computed tomography angiography revealed a combination of congenital anomalies of the neck arteries: left internal carotid artery hypoplasia, left common carotid artery hypoplasia, right vertebral artery hypoplasia and the emergence of the left vertebral artery directly from the aortic arch. The aim of this article is to emphasize the value of CCDS as an accurate, non-invasive method of assessing the neck arteries and, also, the importance of the morphological anomalies of the carotid and vertebral arteries in the cerebral hemodynamics.

Flanking the fenestration: circumferential limb-to-limb stent-assisted coiling of a basilar artery fenestration aneurysm

A man aged 61 years with a history of a ruptured basilar fenestration aneurysm underwent unassisted coiling in 1997 and repeat intervention for a recurrence at the aneurysm mouth in 2011. At repeat intervention, the decision was made to intentionally leave some filling at the base to preserve the parent vessels. Stent-assisted coil embolization, although technically feasible, was not pursued given the relative risks of the procedure. In 2017, the patient returned for repeat surveillance and further coil compaction was found at the aneurysm base. With the advent of more compliant woven stents deliverable through 0.017 microcatheters, stent-assisted coiling was possible. This case demonstrates hereto unseen agility afforded by novel low-profile stents allowing a circumferential approach to a basilar artery fenestration aneurysm and resultant limb-to-limb stent-assisted coiling. Techniques described here may be extended to more common anatomic variants that require stent-assisted coiling.

[Relationship between dynamic CT angiography-based collateral flow evaluation and outcome of patients with stroke induced by acute basilar artery occlusion]

OBJECTIVE

To evaluate the collateral flow in patients with ischemic stroke due to acute basilar artery occlusion by dynamic CT angiography and to predict the outcome after reperfusion therapy.

METHODS

Forty-five patients with stroke due to acute basilar artery occlusion undergoing reperfusion treatment in the Second Affiliated Hospital of Zhejiang University School of Medicine during January 2012 and August 2016 were retrospectively reviewed. Univariate and binary logistic regression model were used to identify the independent predictors of patient's outcome, and the receiver operating characteristic (ROC) curve was used to determine the optimal threshold of the posterior circulation collateral score (PC-CS) in predicting the prognosis of the patients.

RESULTS

Binary logistic regression analysis indicated that the baseline National Institutes of Health Stroke Scale (NIHSS) score (OR=0.886, 95% CI:0.802-0.979, P<0.05) and PC-CS (OR=1.962, 95%CI:1.026-3.752, P<0.05) were independent predictors of patient's outcome, and PC-CS 4.5 was the optimal threshold (AUC:0.837, sensitivity of 68.2%, specificity of 87.0%).

CONCLUSIONS

Dynamic CT angiography based on CT perfusion imaging can be used to evaluate collaterals in posterior circulation, and to predict clinical outcome after reperfusion therapy in patients with acute basilar artery occlusion.

Study on the expression and mechanism of inflammatory factors in the brain of rats with cerebral vasospasm

OBJECTIVE

We investigated the significance of IL-1 and ICAM-1 in rat's subarachnoid hemorrhage (SAH) cerebral vasospasm (CVS) model.

MATERIALS AND METHODS

A total of 30 Sprague-Dawley (SD) rats were randomly divided into the SAH group and the Sham group. Cisterna magna auto blood injection was used to prepare the CVS models. We studied and compared changes in the basilar arteries diameters before and after SAH. We measured the cerebrovascular inner diameter before and after SAH modeling using the ultrasound. ELISA method was used to measure the expression of IL-1 and ICAM-1 in peripheral blood. The expression of MAPK and P38 in the brain was tested using Western blot. Brain cells apoptosis was studied using TUNEL method.

RESULTS

Cerebrovascular inner diameter reduced significantly in the SAH group as compared to the control group. The expression of IL-1 and ICAM-1 increased significantly after 48 hours. Compared to the Sham group, p-38 and p-MAPK expression levels in the SAH group increased significantly after 48 hours. Results showed that 48 hours after the operation, the level of apoptosis was significantly higher in the SAH group. IL-1 and ICAM-1 expression levels were associated with a P38-MAPK signal pathway in the brain. p38 and MAPK activation were closely related to apoptosis in the cortex.

CONCLUSIONS

We suggest that the cerebral basilar vasospasm was occurred in rats 48 hours after ASH onset, with an increase in IL-1 and ICAM-1 expression and brain cells apoptosis.

Vertebrobasilar system computed tomographic angiography in central vertigo

The incidence of vertigo in the population is 20% to 30% and one-fourth of the cases are related to central causes. The aim of this study was to evaluate computed tomography angiography (CTA) findings of the vertebrobasilar system in central vertigo without stroke.CTA and magnetic resonance images of patients with vertigo were retrospectively evaluated. One hundred twenty-nine patients suspected of having central vertigo according to history, physical examination, and otological and neurological tests without signs of infarction on diffusion-weighted magnetic resonance imaging were included in the study. The control group included 120 patients with similar vascular disease risk factors but without vertigo. Vertebral and basilar artery diameters, hypoplasias, exit-site variations of vertebral artery, vertebrobasilar tortuosity, and stenosis of ≥50% detected on CTA were recorded for all patients. Independent-samples t test was used in variables with normal distribution, and Mann-Whitney U test in non-normal distribution. The difference of categorical variable distribution according to groups was analyzed with χ and/or Fisher exact test.Vertebral artery hypoplasia and ≥50% stenosis were seen more often in the vertigo group (P = 0.000, <0.001). Overall 78 (60.5%) vertigo patients had ≥50% stenosis, 54 (69.2%) had stenosis at V1 segment, 9 (11.5%) at V2 segment, 2 (2.5%) at V3 segment, and 13 (16.6%) at V4 segment. Both vertigo and control groups had similar basilar artery hypoplasia and ≥50% stenosis rates (P = 0.800, >0.05).CTA may be helpful to clarify the association between abnormal CTA findings of vertebral arteries and central vertigo.This article reveals the opportunity to diagnose posterior circulation abnormalities causing central vertigo with a feasible method such as CTA.

Differences in Hemodynamics and Rupture Rate of Aneurysms at the Bifurcation of the Basilar and Internal Carotid Arteries

BACKGROUND AND PURPOSE

Cerebral aneurysms in the posterior circulation are known to have a higher rupture risk than those in the anterior circulation. We sought to test the hypothesis that differences in hemodynamics can explain the difference in rupture rates.

MATERIALS AND METHODS

A total of 117 aneurysms, 63 at the tip of the basilar artery (27 ruptured, 36 unruptured, rupture rate = 43%) and 54 at the bifurcation of the internal carotid artery (11 ruptured, 43 unruptured, rupture rate = 20%) were analyzed with image-based computational fluid dynamics. Several hemodynamic variables were compared among aneurysms at each location and between ruptured and unruptured aneurysms at each location.

RESULTS

On average, aneurysms at the basilar tip had more concentrated inflow (P < .001), a larger inflow rate (P < .001), a larger maximum oscillatory shear index (P = .003), more complex flows (P = .033), and smaller areas under low wall shear stress (P < .001) than aneurysms at the bifurcation of the internal carotid artery. In general, ruptured aneurysms had larger inflow concentration (P = .02), larger shear concentration (P = .02), more complex flows (P < .001), and smaller minimum wall shear stress (P = .003) than unruptured aneurysms.

CONCLUSIONS

High flow conditions, characterized by large and concentrated inflow jets, complex and oscillatory flow patterns, and wall shear stress distributions with focalized regions of high shear and large regions of low shear, are associated with aneurysm rupture, especially for basilar tip aneurysms. The higher flow conditions in basilar tip aneurysms could explain their increased rupture risk compared with internal carotid bifurcation aneurysms.

Childhood acute basilar artery thrombosis successfully treated with mechanical thrombectomy using stent retrievers: case report and review of the literature

INTRODUCTION

Acute basilar artery occlusion (ABAO) is an infrequent but potentially fatal cause of strokes in both adults and children, and it is usually due to vertebral artery dissection (VAD). VAD has been found to be usually a consequence of traumatic vertebral artery injury. ABAO usually presents with symptoms of acute ischemic stroke (AIS) of the posterior circulation or transient ischemic attack (TIA). It may lead to death or long-term disability if not promptly recanalized. Basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents.

CLINICAL PRESENTATION

We report the case of a 23-month old baby that came to the emergency room of our hospital for progressive impairment of consciousness associated with widespread stiffness and plaintive cry, appeared after accidental fall from stroller. An emergency brain CT scan was obtained showing multiple infarction lesions in the brainstem and left cerebellum suggestive of acute stroke in posterior circulation territories. An MR scan with angiography and diffusion-weighted sequences confirmed the multiple infarction lesions and demonstrated poor representation of the flow signal at the V3 segment of the left vertebral artery and absent representation of the flow signal at the distal segment of the basilar artery suggestive of acute thrombotic occlusion. The patient was immediately referred to interventional neuroradiology unit, and digital subtraction angiography showed complete basilar artery occlusion and left vertebral artery dissection at extracranial V2-V3 segment. The patient underwent intra-arterial thrombectomy using stent retrievers and occlusion of the V2-V3 segment of the left vertebral artery. The patient survived and long-term outcome was excellent.

CONCLUSIONS

To our knowledge, only nine cases of ABAO in children treated with intra-arterial thrombectomy have been previously reported in the literature. In only three cases, the Solitaire stent was applied. Our case is the first case of basilar artery occlusion treated with Solitaire stent, in a child under 24 months. The reports that are available so far indicate that basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents.

Delay in Diagnosis of Basilar Artery Stroke

BACKGROUND

Basilar artery stroke causes substantial morbidity and mortality. Although its unusual clinical presentation potentially contributes to a delay in diagnosis, this problem has not been systematically studied. We compared intervals between symptom onset, initial presentation, and diagnosis in stroke due to basilar artery (BA) versus left middle cerebral artery (LMCA) occlusion to determine the presence of and potential reasons for diagnostic delay in BA stroke.

METHODS

We retrospectively identified 21 consecutive adult patients diagnosed with BA stroke between 2009 and 2011 from our hospital's prospective stroke registry. Patients were age-, sex-, and race-matched with 21 LMCA stroke patients from the same period. All subjects had confirmed clinical and radiographic diagnosis of stroke due to occlusion or stenosis of the BA, LMCA, or left internal carotid artery. Time to diagnosis was determined independently by two investigators through medical record review. The pre-specified primary outcome was latency from emergency department (ED) arrival to stroke diagnosis.

RESULTS

Median time from ED arrival to diagnosis was 8 h 24 min (IQR: 2:43-26:32) for BA and 1 h 23 min (IQR: 0:41-1:45; p < 0.001) for LMCA. Median time from symptom onset to ED arrival was 7 h 44 min (IQR 1:23-21:30) for BA and 1 h 2 min (IQR 0:36-9:41; p = 0.06) for LMCA. Four of 21 (19 %) BA patients were diagnosed within a 4-h time frame to make intravenous thrombolysis possible compared to 13 of 21 (62 %) LMCA patients (p = 0.01).

CONCLUSIONS

Our results suggest that both pre-hospital and in-hospital processes cause substantial, clinically significant delays in the diagnosis of BA stroke.

Dementia resulting from expansion of basilar artery aneurysm: two case reports and a review of the literature

BACKGROUND

Dementia places a large burden on the economy, with financial and emotional costs incurred by patients, caregivers and the health sector.

METHODS AND RESULTS

We report the first published case series of giant basilar aneurysm leading to progressive cognitive and functional decline. We review the literature regarding giant aneurysms and their association with dementia and the possible underlying pathophysiological mechanism.

CONCLUSIONS

This report highlights a number of therapeutic considerations when determining the best management strategy for these difficult lesions.

Flatness of the infratentorial space associated with hemifacial spasm

BACKGROUND

Whether a difference in morphology of the infratentorial space is associated with hemifacial spasm is not well understood. The aim of this study was to analyze the three-dimensional conformation of the infratentorial space and evaluate any possible contribution of morphological characteristics to the development of neurovascular compression leading to hemifacial spasm.

METHODS

We enrolled 25 patients with hemifacial spasm and matched them by age and sex to controls. The extent of the three-dimensional axes and the volume of the infratentorial space were measured using image analysis software for three-dimensional MRI. We evaluated the correlation between a morphological difference in the infratentorial space and changes in vascular configuration in the brain stem.

RESULTS

We found no statistical difference in volumetric analyses. The mean aspect ratio on the coronal plane (the ratio of the Z to X extent) of the infratentorial space in patients with hemifacial spasm was significantly lower (p < 0.01) than that in controls, as was the mean aspect ratio on the sagittal plane (the ratio of Z to Y extent, p < 0.01). A smaller sagittal aspect ratio was correlated (p < 0.05) with greater lateral deviation of the basilar artery.

CONCLUSIONS

Our results suggest that flatness of the superior-inferior dimension of the infratentorial space is an anatomical feature that characterizes patients with hemifacial spasm. We hypothesize that this unique structural variation may exaggerate the lateral deviation of the vertebrobasilar arteries due to arteriosclerosis and exacerbate the space competition among vessels and cranial nerves.

Vascular Analysis of Individuals with Drop Attacks

The authors used magnetic resonance angiography to examine the intracranial and cervical vascular structures of individuals who suffer from drop attacks. Normal structural configurations of the circle of Willis and the vertebrobasilar arterial system were compared to the vascular patterns of 10 subjects with these episodic tonic or atonic attacks. Overall, multiple areas of arterial occlusion, stenosis, or hypoplasia were visualized in the images of 8 of the 10 subjects. Specific anomalies of the vertebral and basilar arteries were identified in 4 individuals, and 8 images depicted nonvisualization of the posterior communicating arteries. We suggest that the pathological aberrations in the regional circulation of the hindbrain support the hypothesis that a transient hypovolemic episode may have an impact upon the neural activity involved in maintenance of motor tone and postural stability.

High dietary fructose does not exacerbate the detrimental consequences of high fat diet on basilar artery function

The objective of the study was to determine the effects of a high fat (HF) diet alone or with high fructose (HF/F) on functional and structural changes in the basilar arteries and cardiovascular health parameters in rats. Male Sprague Dawley rats were fed either a HF (30%) or HF/F (30/40%) diet for 12 weeks. The basilar artery was cannulated in a pressurized system (90 cm H2O) and vascular responses to KCl (30 - 120 mM), endothelin (10(-11) - 10(-7) M), acetylcholine (ACh) (10(-10) - 10(-4) M), diethylamine (DEA)-NONO-ate (10(-10) - 10(-4) M), and papaverine (10(-10) - 10(-4) M) were evaluated. Rats were also monitored for food intake, body weight, blood lipids, blood pressure, and heart rate. At death, asymmetrical dimethyl arginine level (ADMA) and leptin were assayed in serum. Although there was no significant difference in weight gain and food intake, HF and HF/F diets increased body fat composition and decreased the lean mass. HF/F diet accelerated the development of dyslipidemia. Although resting blood pressure remained unchanged, stress caused a significant elevation in blood pressure and a modest increase in heart rate in HF fed rats. Both HF and HF/F diet resulted in decreased response to endothelium-dependent and -independent relaxation, whereas increased basilar artery wall thickness was observed only in HF group. Serum leptin levels positively correlated with wall thickness. Moreover serum ADMA was increased and eNOS immunofluorescence was significantly decreased with both diets. These data suggest that the presence of high fructose in a HF diet does not exacerbate the detrimental consequences of a HF diet on basilar artery function.

Intravenous Recombinant Tissue Plasminogen Activator Therapy for Acute Basilar Artery Ischemic Stroke Following Transfemoral Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) can now be considered a standard of care for inoperable and high-risk surgical patients with severe aortic stenosis, and its uptake worldwide is rapidly increasing. Indeed, many centers performing the procedure have now moved towards treating intermediate-risk patients with TAVI rather than referring them for surgical aortic valve replacement. Although the incidence of peri-procedural acute and subacute stroke following TAVI has fallen to 2-5%, its occurrence can be life-threatening and life-changing, and every effort must be made to improve patient outcome should stroke occur. Many cardiologists would not instinctively consider the use of thrombolytic therapy for post-transfemoral TAVI ischemic stroke because of concern about the risk of major bleeding from the access site, despite it being a standard of care for ischemic stroke in other circumstances. The present case highlights the benefit of using intravenous thrombolytic therapy for an acute basilar artery thrombotic stroke after transfemoral TAVI (TF-TAVI) that would otherwise have almost certainly resulted in the patient's death. The case may also prompt interventional cardiologists to consider performing TF-TAVI under conscious sedation rather than general anesthesia, as this can result in an earlier detection of acute stroke and allow an earlier intervention with thrombolytic agents, with an improved outcome.

Cerebral vasospasm and corticospinal tract injury induced by a modified rat model of subarachnoid hemorrhage

OBJECTIVE

Double-hemorrhage rat models of subarachnoid hemorrhages (SAH) are most effective at simulating delayed cerebral vasospasms (CVS). The present study modified the models to minimize additional trauma and investigated injury of the corticospinal tract (CST) using diffusion tensor imaging (DTI).

METHODS

On the first day, 0.3ml of autologous arterial blood was collected by puncturing the caudal artery and injected into the cisterna magna via percutaneous puncture; and the operation was repeated on the third day. The diameters of the basilar artery (BA), middle cerebral artery (MCA), and anterior cerebral artery (ACA) were measured by magnetic resonance angiography on days 3, 5, 7, 9, and 11 post-SAH. Meanwhile, on days 3, 7, 11, 15 and 19, DTI was performed to evaluate the injury of the CST at cerebral peduncle (CP) and pyramidal tract (Py) by measuring fractional anisotropy (FA) value.

RESULTS

Blood was deposited mainly in the basal cistern. Diameters of BA, MCA, and ACA were significantly reduced. FA value of the CP was lower in the SAH group than in the control group; but FA value of Py wasn't different between the two groups.

CONCLUSION

This is a minimally-invasive and high performance rat model of SAH. Additionally, the occurrence of CVS is firm and the axons in CP are injured.

Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score Using Hypointense Vessels on Susceptibility Weighted Imaging Independently Predicts Outcome in Patients with Basilar Artery Occlusion

PURPOSE

Appearance of hypointense vessels on susceptibility weighted imaging (SWI) has been reported to correlate with outcome in patients with ischemia of the anterior circulation. This study investigates the correlation between the appearance of hypointense vessels on SWI after recanalization therapy and outcome in patients with basilar artery occlusion.

METHODS

Patients with basilar artery occlusion who were treated with endovascular recanalization or intravenous alteplase and received an MRI including SWI after therapy were retrieved from the hospital database for retrospective analysis. Posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pcASPECTS) was calculated based on regions displaying hypointense vessels on SWI and compared to lesions on diffusion weighted imaging (DWI). Subsequently, SWI based pcASPECTS was correlated with outcome determined with modified Rankin Scale (mRS), categorized as favorable outcome (mRS 0-2) or unfavorable outcome (3-6).

RESULTS

Twenty-two MRI of patients with basilar artery occlusion were analyzed. In seven out of eight areas of the pcASPECTS hypointense vessels on SWI were significantly correlated to areas of restricted diffusion on DWI. In univariate analysis median pcASPECTS on SWI was significantly higher in patients with favorable outcome (7.5 vs. 5, p=0.02). In a multivariate analysis pcASPECTS on SWI was an independent predictor of favorable outcome (OR 2.02; CI [1.02;3,99]; p=0.04).

CONCLUSION

pcASPECTS based on hypointense vessels on SWI after therapy predicts outcome in patients with basilar artery occlusion and might potentially be used as an additional imaging biomarker in the management of patients with stroke in the posterior circulation. This needs to be confirmed in larger prospective clinical trials.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Various endovascular techniques have been applied to the treatment of vertebrobasilar dissecting aneurysms, including parent artery preservation with coiling, stent placement or flow diverter placement, and trapping and proximal occlusion. We performed a systematic review and meta-analysis to study clinical and angiographic outcomes of patients undergoing endovascular treatment of vertebrobasilar dissecting aneurysms.

MATERIALS AND METHODS

We performed a comprehensive literature search for studies on the endovascular treatment of vertebrobasilar dissecting aneurysms. From each study we abstracted the following data: immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. We performed subgroup analyses of patients undergoing deconstructive-versus-reconstructive techniques. Meta-analysis was performed by using a random effects model.

RESULTS

Seventeen studies with 478 patients were included in this analysis. Sixteen studies had at least 6 months of clinical/angiographic follow-up. Endovascular treatment was associated with high rates of long-term occlusion (87.0%; 95% CI, 74.0%-94.0%) and low recurrence (7.0%; 95% CI, 5.0%-10.0%) and retreatment rates (3.0%; 95% CI, 2.0%-6.0%). Long-term good neurologic outcome was 84.0% (95% CI, 65.0%-94.0%). Deconstructive techniques were associated with higher rates of long-term complete occlusion compared with reconstructive techniques (88.0%; 95% CI, 35.0%-99.0% versus 81.0%; 95% CI, 64.0%-91.0%; P < .0001). Deconstructive and reconstructive techniques were both associated with high rates of good neurologic outcome (86.0%; 95% CI, 68.0%-95.0% versus 92.0%; 95% CI, 86.0%-95.0%; P = .10).

CONCLUSIONS

Endovascular treatment of vertebrobasilar dissecting aneurysms is associated with high rates of complete occlusion and good long-term neurologic outcomes. Deconstructive techniques are associated with higher occlusion rates. There was no statistical difference in neurologic outcomes between groups, possibly due to low power.

Preconditioning with pitavastatin, an HMG-CoA reductase inhibitor, attenuates C-Jun N-terminal kinase activation in experimental subarachnoid hemorrhage-induced apoptosis

BACKGROUND

Accumulating results have disclosed that early brain injury (EBI) may play a major role in the determination of the outcome of aneurysmal subarachnoid hemorrhage (SAH) patients. This study is of interest to examine the efficacy of pitavastatin, a 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMG-CoA reductase) inhibitor, on SAH-induced apoptosis.

METHODS

A rodent double SAH model was employed. Pitavastatin was administered orally. CSF IL-1β, IL-6, IL-8 and TNF-α were measured (rt-PCR). Basilar arteries were harvested for C-Jun N-terminal kinase p46/p55 (cJNK (p46/p55)), matrix metallopeptidase-9 (MMP-9) (Western blot), caspase and Bcl-2 (rt-PCR) evaluation.

RESULTS

Pitavastatin reduced the bioexpression of cJNK p55 compared with the SAH groups. Cleaved caspase-9a was significantly reduced in the pitavastatin-preconditioned group compared with the SAH group (p > 0.05). IL-1β and TNF-α levels were reduced in the pitavastatin-preconditioned group. Pretreatment with pitavastatin significantly reduced activated MMP-9, capsase-9a and B-cell lymphoma 2(Bcl) mRNA.

CONCLUSION

Preconditioning with pitavastatin exerts its neuroprotective effect through the dual action of inhibiting cJNK(p46/p55) activation and reducing cleaved caspase-9a expression. Besides, the bioinhibition of MMP-9 may partially contribute to the neuroprotective effect. This study lends credence to the theory that statins, especially in the preconditioning status, may attenuate SAH-induced neuron apoptosis.

The Infarct Shape Predicts Progressive Motor Deficits in Patients with Acute Lacunae-sized Infarctions in the Perforating Arterial Territory

OBJECTIVE

This study was performed to analyze the lesion patterns of lacunae-sized infarctions on diffusion-weighted imaging (DWI) findings in the perforating arterial territory, and to determine whether this pattern of satellite lesions affected progressive motor defect (PMD).

METHODS

Seventy-five patients with acute lacunae-sized infarctions in the perforating arterial territory (pons or territory of the lenticulostriate arteries), which was confirmed by cranial magnetic resonance image (MRI), were enrolled in this study. These patients were divided into PMD (n=30) and non-progressive motor defect (NPMD) (n=45) groups according to the dynamic scores of the National Institutes of Health Stroke Scale (NIHSS) within 7 days after stroke. The lesion patterns of lacunae-sized infarctions were divided into single oval or satellite lesions signs based on DWI. The risk factors of stroke and the clinical characteristics of all the subjects, including neurological deficits, infarction lesion patterns in image, and the condition of the basilar artery, were comparatively analyzed.

RESULTS

The constituent ratio of satellite lesions signs [20/30 (66.7%)] in the PMD group was higher than that [10/45 (22.2%)] of the NPMD group (χ(2)= 6.1, p=0.013). Mean NIHSS scores in the PMD group on admission were higher than that of the NPMD group (4.60±1.40 vs. 3.75±1.2, t=2.81, p=0.003). A logistic regression analysis showed that the pattern of satellite lesions was associated with PMD. 〔odds ratio (OR): 3.0, 95% confidence interval (CI) 1.25-7.17, p=0.014〕.

CONCLUSION

Satellite lesions are one of the features of lacunae-sized infarctions patterns, which might be an independent predictor in DWI findings for PMD in patients with lacunae-sized infarctions in the perforating arterial territory.