[Endovascular interventions for stenoses and occlusions of the brachiocephalic trunk]

The study was undertaken to evaluate the efficacy and safety of endovascular interventions in the treatment of stenoses and occlusions of the brachiocephalic trunk (BCT). Described in the article are the results of retrospectively analysing the efficacy of endovascular interventions performed in a total of forty-five patients presenting with lesions of the BCT. Depending on the type of the BCT lesion, the patients were divided into 2 groups: Group One consisted of 28 patients diagnosed with stenoses of the BCT and Group Two included 17 patients found to have occlusions of the BCT. The outcomes of the interventions were assessed with due regard for the findings obtained by angiography, ultrasonographic duplex scanning of the brachiocephalic vessels, as well as by the examination of the patient's neurological status. The remote results were evaluated at follow-up terms ranging from 6 months to 4 years. No ischaemic strokes, myocardial infarctions, nor lethal outcomes were observed during 30 days after the intervention. In the early postoperative period, there occurred 1 (3.6%) case of transitory ischaemic attack in Group One, with also 1 (5.9%) case thereof encountered in Group Two. Within the time frame of the follow-up period (48 months), recurrent occlusion of the stented segment of the BCT was registered in 2 (7.1%) patients from Group One and in 1 (5.8%) patient from Group Two (p=0.87). The primary patency rate at 4 years in Group One and Group Two patients amounted to 86.8 and 88.3%, respectively (p=0.84). A conclusion thus drawn was as follows: endovascular intervention for stenoses and occlusions of the BCT is an effective and safe method of preventing acute cerebral circulation impairments in the vertebrobasilar basin.

Restenosis rates following vertebral artery origin stenting: does stent type make a difference?

OBJECTIVES

To compare our experience with sirolimus and paclitaxel-eluting stents (drug-eluting stents [DES]) and non-drug-eluting stents (NDES) for treatment of vertebral artery (VA) origin stenosis and review the literature.

METHODS

A retrospective review of our prospectively collected database was performed. Clinical and radiologic follow up was obtained by reviewing office records and radiology. Data collected included demographics, comorbidities, presenting symptoms, stenosis severity, contralateral VA stenosis and/or carotid stenosis, type of stent used, angioplasty before or after stenting, post-treatment residual stenosis, clinical and radiological follow up and retreatment. Patients with symptomatic > 60% stenosis or asymptomatic > 70% stenosis and/or a hypoplastic or occluded contralateral VA or significant carotid occlusion were chosen for revascularization.

RESULTS

Thirty-five patients treated with NDES and 15 treated with DES for management of VA origin stenosis were identified. The technical success rate of the procedure was 100%. There were no procedural complications. There were 7 asymptomatic patients (NDES Group-4, DES Group-3). In the NDES Group, 9 patients had pre-stent angioplasty; 2 had post-stent angioplasty. In the DES group, 4 patients had post-stent angioplasty. Symptoms resolved in 30/31 (96.8%) patients treated with NDES and 11/12 (91.7%) treated with DES. Thirty-six patients had radiologic follow up (median 21.3 months); in-stent restenosis was documented in 11 patients (NDES 9/24 [38%], DES 2/12 [17%]). Among patients receiving NDES, re-stenotic lesions required angioplasty in 7 patients. No patients in the DES group required angioplasty.

CONCLUSIONS

DES for treatment of VA origin stenosis may decrease the incidence of restenosis when compared to NDES. Validation in prospective, randomized, multicenter trials is necessary.

Anesthetic implications for the patient with osteogenesis imperfecta

Osteogenesis imperfecta is an inherited disorder of the connective tissue stemming from gross abnormalities in collagen formation and structure. Affected patients fall into 4 classifications each displaying the similar properties of easily fractured bones, hypermobile joints, blue or gray sclera, skeletal deformities, and fragile skin. More severe forms of the disease may manifest platelet dysfunction, cardiac anomalies, hypermetabolic syndromes, respiratory compromise, and/or basilar invagination. Treatment of osteogenesis imperfecta is mainly supportive, consisting of prompt surgical treatment of fractures to prevent deformity and maintaining mobility to lessen the chance of pulmonary or cardiovascular complications. These treatment modalities make anesthesia of paramount importance. Current literature exposes many potential anesthetic complications associated with osteogenesis imperfecta. The research shows that implications range from simply positioning the patient on the operating room table to management of rare occurrences such as malignant hyperthermia and basilar invagination. Commonly encountered complications include a difficult airway, intraoperative bleeding due to platelet dysfunction, respiratory compromise due to skeletal deformity, and congenital cardiac anomalies. Proper preparation and preoperative assessment is important, as is the choice of anesthetic technique. Correct identification of risk factors and optimization of health before surgery should lead to an uneventful anesthetic course.

Safety, feasibility, and short-term follow-up of drug-eluting stent placement in the intracranial and extracranial circulation

BACKGROUND AND PURPOSE

The use of bare metal stents to treat symptomatic intracranial stenosis may be associated with significant restenosis rates. The advent of drug-eluting stents (DESs) in the coronary circulation has resulted in a reduction of restenosis rates. We report our technical success rate and short-term restenosis rates after stenting with DESs in the intracranial and extracranial circulation.

METHODS

This study was a retrospective review of the period between April 1, 2004, and April 15, 2006, of 59 patients with 62 symptomatic intracranial or extracranial atherosclerotic lesions at 2 medical centers (University of Pittsburgh and Borgess Medical Center).

RESULTS

The mean age of our cohort was 61+/-12 years. The location of the 62 lesions was as follows: extracranial vertebral artery 31 (50%), intracranial vertebral artery or basilar artery 18 (29%), extracranial internal carotid artery (ICA) near the petrous bone 5 (8%), and intracranial ICA 8 (13%). There were 2 (3%) periprocedural complications: 1 non-flow-limiting dissection and 1 disabling stroke. Fifty vessels were available for follow-up angiography or computed tomography angiography at a median time of 4.0+/-2 months. A total of 2 of 36 extracranial stents (7%) and 1 of 26 intracranial stents (5%) were found to have restenosis > or = 50% at follow-up.

CONCLUSIONS

This report demonstrates that DES delivery in the intracranial and extracranial circulation is technically feasible. A small percentage of patients developed short-term in-stent restenosis. Longer-term follow-up is required in the setting of a prospective study to determine the late restenosis rates for DESs in comparison with bare metal stents.

Atherosclerosis in the vertebral artery: an intrinsic risk factor in the use of spinal manipulation?

The presence of atherosclerotic plaques and their influence on the vertebral artery is of clinical importance within the scope of spinal manipulation. Manipulation may stimulate the development of atherosclerotic plaques, could detach an embolus with ensuing infarction, injure the endothelium or may directly cause a dissection in the presence of atherosclerotic plaques. In order to identify the sites and frequency of atherosclerotic plaques and to determine its relation to the tortuous course of the vertebral artery, a cadaveric study was performed. The vertebral arteries of 57 human cadavers were studied. The vertebral artery was virtually divided into four segments: the pre-vertebral (V1), the vertebral (V2), the atlanto-axial (V3), and the intracranial segment (V4). Abnormalities in the origin and course of the vertebral artery were noted, along with any associated osseous, or cartilaginous anomalies in the neck. After dissection, the artery was opened and macroscopically screened for the presence of atherosclerotic plaques. In 22.8% of the cases, no atherosclerotic plaques were present. In 35.1% of the cases, the atherosclerotic plaques were unilateral, of which 60.0% was on the left side, 40.0% on the right side, and in 42.1%, the occurrence was bilateral. Atherosclerotic plaques were significantly more present in the V3 segment than in the V1 (0.007) and V2 segment (0.049). In the V1 (P=0.008) and V2 segment (P=0.002), there was a correlation between a tortuous course of the vessel and the occurrence of atherosclerotic plaques. In individuals with marked atherosclerotic disease, stretching and compression effects of rotational manipulative techniques on atherosclerotic vessels impose a further risk factor for vertebrobasilar insufficiency. As direct evidence of atherosclerotic plaques are rarely available, therapists should avoid manipulative techniques at all levels of the cervical spine in the presence of any indirect sign of atherosclerotic disease or in the presence of calcified arterial walls or tortuosities of the vessels visible on routinely available X-ray images of the cervical or thoracic spine. It is strongly recommended, that if any doubt exists about the nature of a clinical presentation, vigorous manual procedures should be avoided until either the diagnosis is definitive or gentle manual therapy has proven effective.

Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report

BACKGROUND

Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described.

CASE DESCRIPTION

A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence.

CONCLUSIONS

Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.

[Multiple ischemic vertebrobasilar lesions in temporal arteritis]

We report a 73-year-old patient with giant cell arteritis who presented with right arm paresis and dysarthria. Vasculitis of the vertebral arteries induced multiple ischemic cerebral lesions in the vertebrobasilar territory, ultimately leading to death despite intensive immunosuppressive therapy. This case illustrates that prompt relief from symptoms of giant cell arteritis upon steroid treatment does not correspond to a remission of the vasculitic process itself. Clinicians should therefore be aware of the possible occult involvement of the vertebral or other major arteries.

[Early manifestation and dynamics of the development of vertebrobasilar circulation disorder associated with cervicovertebral dysfunction, directions of the prophylaxis and treatment]

206 children and young patients have been observed to diagnose the origin and dynamics of the development of vertebrobasilar circulation disturbances. The great importance was given to detail data collection by questionnairing and studying outpatient medical records of the patients since early childhood. The obtained data were compared with those of healthy people of similar age. Risk factors and the development of symptoms of the disease with age were analyzed in the article. Genetical and constitutional factors are of great importance in the development of vascular and musculoskeletal systems pathologies. The intensity of the pathologic process and dynamics of its development connected directly with the number and pathologic factors duration. Early manifestation of vertebrobasilar disturbances is considered in practice as vegetovascular dystonia. Taking into account a reflex factor in the development of the pathology, reflex therapeutic methods will be pathogenetically justified.

Iatrogenic vertebrobasilar insufficiency after surgery of the subclavian or brachial artery: review of three cases

OBJECTIVE AND IMPORTANCE

Vertebrobasilar insufficiency resulting from disease of the subclavian artery is well recognized. Usually, this occurs as the "subclavian steal" syndrome in the context of chronic subclavian stenosis and is consequently well tolerated because of collateralization. Acute disruption of the hemodynamics of the aortic arch vessels, however, can produce disastrous sequelae.

CLINICAL PRESENTATION

We present three cases of iatrogenic vertebrobasilar insufficiency sustained as complications of surgery of the left subclavian artery or its distal continuation. The cases were chosen from a review of approximately 400 emergency neurosurgery consultations requested at the Los Angeles County Hospital between November 1995 and February 1996.

INTERVENTION

The first patient underwent repair of a traumatic brachial artery occlusion and awoke postoperatively with bilateral cortical blindness, right hemiparesis, and multiple cranial nerve deficits that were most likely caused by acute subclavian steal. The second underwent removal of a subclavian embolus and developed bilateral cerebellar infarction leading to persistent coma, possibly from inadvertent embolization of the vertebral artery during surgery. The third underwent resection and bypass grafting of a subclavian aneurysm. Good backflow was reported when the vertebral artery was disarticulated from the subclavian artery, and this vessel was not reimplanted into the graft. The patient suffered massive cerebellar infarction leading rapidly to brain death.

CONCLUSION

There are myriad ways in which the inherent redundancy of the vertebrobasilar system may be jeopardized, and when this protective mechanism fails, the results can be disastrous. Flow through the vertebral arteries may be compromised by thrombosis, embolization, dissection, inappropriate ligation, excessive head rotation, hypotension, vasospasm, or acute subclavian steal. These examples illustrate the importance of understanding the complex physiology of posterior fossa circulation as the basis of pre-, intra-, and postoperative management of patients undergoing surgery of the subclavian artery.

Results of isolated carotid surgery in patients with vertebrobasilar insufficiency

The purpose of this study was to establish whether carotid-revascularized patients who had preoperative vertebrobasilar insufficiency (VBI) displayed distinctive characteristics and whether a particular prognosis would ensure. From January 1985 to December 1993, 1022 carotid revascularizations were performed, of which 114 (11%) were for high-grade stenosis associated with VBI. The group with VBI and the group without VBI were compared according to a set of 121 prospectively collected variables. Of all the demographic and risk-factor variables, only female prevalence (42% vs. 27%) and hypertension (77% vs. 27%) distinguished the group with VBI, who also exhibited a significantly higher proportion of significant contralateral carotid lesions (27.2% vs. 8.9%) and vertebrosubclavian lesions (38.6% vs. 24.8%). Following isolated carotid surgery, there was no statistically significant difference between the two groups as to their cumulative rate of permanent neurological mortality and morbidity (2.6% in the group with VBI vs. 3.4% in the group without it). With an average follow-up of 60 months, VBI was cured in 82.4% and improved condition shown in 6.5% of patients. However, the proportion of good results fell to 65% in patients with a nonfunctional circle of Willis. Out of 13 cases of failure to control VBI, cure was finally effected by means of contralateral revascularization in 3 cases and by means of vertebrosubclavian revascularization in 5 cases out of 6. At 5 years, the actuarial rates of neurological event-free intervals and survival were not different from one group to another. In most cases, isolated carotid surgery is sufficient to bring vertebrobasilar insufficiency under control, except when significant vertebrosubclavian lesions and a nonpatent circle of Willis call for simultaneous carotid and vertebral artery surgery.

Antiplatelet therapy is effective in the prevention of stroke or death in women: subgroup analysis of the European Stroke Prevention Study (ESPS)

Previous stroke prevention studies have suggested that the efficacy of antiplatelet therapy may be less in women than in men. This however, could be due to the small number of women in these trials and the low incidence of cases among female subjects. The European Stroke Prevention Study was a multicenter trial comparing the effect of a combination of dipyridamole 75 mg t.i.d and acetylsalicylic acid 330 mg t.i.d. to placebo in the secondary prevention of stroke or death after one or more recent attacks of TIA (transient ischemic attack), RIND (reversible ischemic neurological deficit) or stroke of atherothrombotic origin. From the 2500 patients recruited, 1307 patients were from a single center, Kuopio, East Finland. Forty-five percent of the patients were women. The number of end-point events (stroke or death from any cause) in women was one-third lower than that in men. End-point reduction in the treatment group was about 50% in women and about 40% in men, significantly lower than in the placebo group in both sexes. Thus, in the relatively randomly selected patient population from one Finnish center, a combination of dipyridamole and acetylsalicylic acid is as effective in women as in men in the prevention of stroke or death. It is unclear, however, whether this beneficial effect in both sexes is due to aspirin only or to the combination therapy of aspirin and dipyridamole.

[Prevention of cerebral complications during thoracic aortic aneurysms operation: study of preoperative selective cerebral arteriography]

Preoperative selective cerebral arteriography is carried out in order to determine if the circle of Willis is intact in the cases of the thoracic aortic aneurysms. As regard to the bilateral vertebrobasilar communications, 26 of 30 patients (86.7%) have good condition, 4 of 30 patients (13.3%) have poor, and in 2 cases the left vertebral artery supplied broad area of posterior cranial fossa. We believe that in the cases in whom the left vertebral artery is dominant, and cross collateral circulation is absent, perfusion of the left subclavian artery is necessary to prevent vertebrobasilar ischemia during aortic aneurysms operation under normothermia.